Complications, reoperation rates, and health-care cost following surgical treatment of lumbar spondylolisthesis

Lumbar fusion surgery in the era of an aging society: analysis of a nationwide population cohort with minimum 8-year follow-up

BACKGROUND CONTEXT

Fusions for lumbar spine diseases are widely performed and have a growing incidence, especially in elderly population.

PURPOSE

The goal of this study was to assess national trends of lumbar spinal fusions and examine the risk for reoperations after a lumbar fusion with a focus on 'epidemiologic transition' relating to age.

STUDY DESIGN/SETTING

The prospectively collected Korean Health Insurance Review and Assessment Service (HIRA) nationwide cohort database was retrospectively reviewed.

PATIENT SAMPLE

The total 278,815 patients who underwent lumbar spinal fusions for degenerative spine diseases between 2010 and 2018 were reviewed and used to assess trends in operative incidence. The 37,050 patients who underwent lumbar fusions between 1/2010 and 12/2011 were enrolled to determine 8-year reoperation rates.

OUTCOME MEASURES

The overall number of lumbar spinal fusions were analyzed for the national annual trend. Demographic data, reoperation rates, and confounding clinical factors were evaluated.

METHODS

The overall number of lumbar spinal fusions was analyzed to determine the national annual trend of operative incidence. For the reoperation rate analysis, the primary outcome measured was the cumulative incidence of revision operations within a minimum 8-year follow-up period. Additional outcomes included comparative analyses of the reoperation rate with respect to age, sex, or other underlying comorbidities.

RESULTS

Over time, elderly patients comprised a larger portion of the cohort (2010:24.2%; 2018:37.6%), while operations in younger patients decreased over time (2010:40.3%; 2018:27.0%). In the cohort of patients with a minimum 8-year follow-up (n=37,050), rates of reoperation peaked in patients aged 60-69 years (17.6 per 1000 person-years [HR 2.20 compared to <40years]) and decreased for more elderly patients (14.3 per 1000 person-years [HR 1.80 compared to <40years]). Age was the most significant risk factor for reoperation. Osteoporosis was also a risk factor for reoperation in postmenopausal females.

CONCLUSIONS

Increasing incidence of lumbar fusions in elderly patients was seen however the risk of reoperation decreased in patients aged 70 or more. Lumbar fusion for elderly patients should not be hesitated in the decision-making process because of concerns about reoperation.

Risk Factors for Unexpected Admission Following Lumbar Spine Laminectomy: A National Database Study

Introduction Laminectomy is one of the most common orthopedic spine surgeries performed in the United States. Compared to other spine operations such as fusions, laminectomies in isolation are of lower morbidity. However, complications may arise that result in readmission to an inpatient healthcare facility. The purpose of this study is to identify the demographics and risk factors associated with unplanned 30-day readmission following a laminectomy. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for patients who underwent a laminectomy procedure from 2015 to 2019 using CPT code 63030. This query yielded 61,708 cases. Demographic, lifestyle, comorbidity, and peri-operative factors were recorded. Independent samples Student's t-tests, chi-squared, and, where appropriate, Fisher's exact tests were used in univariate analyses to identify demographic, lifestyle, and peri-operative variables related to 30-day readmission following a laminectomy procedure. Multivariate logistic regression modeling was subsequently performed. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated and reported. Results Of the 61,708 patients included in our sample, 2,359 were readmitted within 30 days of surgery, corresponding to a readmission rate of 3.82%. Results of the univariate analysis revealed statistically significant relationships between readmission status and the following patient variables: patient age, sex, BMI, ASA classification, race, bleeding disorder, chronic obstructive pulmonary disease (COPD), diabetes, hypertension, congestive heart failure (CHF), chronic steroid use, total operative time, and tobacco use (p < 0.05). Multivariate logistic regression modeling confirmed that the following patient variables were associated with statistically significantly increased odds of readmission: age greater than 65 (p < 0.05), female sex (p = 0.013), bleeding disorder (p = 0.011), diabetes (p = 0.006), current smoker (p = 0.010), COPD (p < 0.001), steroid use (p = 0.006), ASA Class II or above (p < 0.05), and total operative time (p < 0.001). Conclusion Unplanned 30-day readmission after laminectomy is infrequent. However, increasing age, female sex, steroid use, current smokers, bleeding disorders, diabetes, COPD, CHF, a higher ASA classification, and longer operative times are independent risk factors for readmission following laminectomy.

Long-Term Clinical and Radiological Evaluation of Low-Grade Lumbar Spondylolisthesis Stabilization with Rigid Percutaneous Pedicle Screws

The armamentarium of surgical treatment options for lumbar spondylolisthesis (LS) includes decompression alone, stabilization with interlaminar devices, or instrumented fusion, through open or minimally invasive approaches. Despite its safe profuse use in distinctive lumbar spine disorders, using percutaneous pedicle screws (PPSs) alone to stabilize LS has never been described before. We performed a retrospective study of prospectively collected data, enrolling 24 patients with LS and scrutinizing clinical and radiological outcomes. A statistically significant decrease in visual analog scale (VAS) scores (p < 0.001) and Oswestry Disability Index (ODI) scores (p < 0.001) was observed, as was a reduction in the intake of acetaminophen after surgery (p = 0.022). In the long-term, PPS effectively reduced the index-level range of motion (p < 0.001), reduced preoperative slippage (p = 0.03), and maintained foraminal height, thus accounting for the positive clinical outcomes. It induced a significant segmental kyphotic effect (p < 0.001) that was compensated for by a favorable increase in the pelvic incidence minus lumbar lordosis (PI-LL) index (0.028).

Early Failures After Lumbar Discectomy Surgery: An Analysis of 62 690 Patients

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To determine the rate of early failures (readmission or reoperation for new or recurrent pain/neurological symptoms) within 30 days after lumbar discectomy and identify associated risk factors.

METHODS

A retrospective cohort study was conducted of patients undergoing lumbar discectomy in the National Surgical Quality Improvement Program database between 2013 and 2017. Rates of readmission for new or recurrent symptoms or reoperation for revision discectomy or fusion within 30 days postoperatively were measured and correlated with risk factors.

RESULTS

In total 62 690 patients were identified; overall rate of readmission within 30 days was 3.3%, including 1.2% for pain or neurological symptoms. Populations at increased risk of readmission were those with 3 or more levels of treatment (2.0%, odds ratio [OR] 2.8%, P < .01), age >70 years (1.8%, OR 1.6, P < .01), class 3 obesity (1.5%, OR 1.4, P = .04), and female gender (1.4%, OR 1.2, P = .02). The overall rate of reoperation within 30 days was 2.2%, including 1.2% for revision decompression or lumbar fusion surgery. Populations at increased risk of reoperation were revision discectomies (1.4%, OR 1.7, P < .01) and females (1.1%, OR 1.4, P < 0.01). Extraforaminal discectomies were associated with lower rates of readmission (0.7%, OR 0.6, P = 0.02) and reoperation (0.4%, OR 0.4, P = .01).

CONCLUSIONS

Early failures after lumbar discectomy surgery are rare. However, certain subpopulations are associated with increased rates of early failure: obesity, multilevel surgery, females, and revision discectomies.

Preoperative Cognitive Impairment as a Predictor of Postoperative Outcomes in Elderly Patients Undergoing Spinal Surgery for Degenerative Spinal Disease

Cognitive status has been reported to affect the peri-operative and post-operative outcomes of certain surgical procedures. This prospective study investigated the effect of preoperative cognitive impairment on the postoperative course of elderly patients (n = 122, >65 years), following spine surgery for degenerative spinal disease. Data on demographic characteristics, medical history, and blood analysis results were collected. Preoperative cognition was assessed using the mini-mental state examination, and patients were divided into three groups: normal cognition, mild cognitive impairment, and moderate-to-severe cognitive impairment. Discharge destinations (p = 0.014) and postoperative cardiopulmonary complications (p = 0.037) significantly differed based on the cognitive status. Operation time (p = 0.049), white blood cell count (p = 0.022), platelet count (p = 0.013), the mini-mental state examination score (p = 0.033), and the Beck Depression Inventory score (p = 0.041) were significantly associated with the length of hospital stay. Our investigation demonstrated that improved understanding of preoperative cognitive status may be helpful in surgical decision-making and postoperative care of elderly patients with degenerative spinal disease.

Inpatient Outcomes in Dialysis Dependent Patients Undergoing Elective Cervical Spine Surgery for Degenerative Cervical Conditions

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate inpatient outcomes in dialysis dependent patients undergoing elective cervical spine surgery.

METHODS

A total of 1605 dialysis dependent patients undergoing elective primary or revision cervical spine surgery for degenerative conditions were identified from the National Inpatient sample from 2002 to 2012 and compared to 1 450 642 nondialysis-dependent patients undergoing the same procedures. The National Inpatient Sample is a de-identified database; thus, no institutional review board approval was needed.

RESULTS

Dialysis dependence was associated with higher inpatient mortality rates (7.5% vs 1.9%; P < .001) as well as both major (17.3% vs 0.6%; P < .001) and minor (36.8% vs 10.5%; P < .001) complication rates as compared with nondialysis-dependent patients. Dialysis-dependent patients had substantially increased mean lengths of stay (9.8 days compared with 2.0 days; P < .001) and total hospital charges ($141 790 compared with $46 562; P < .001).

CONCLUSION

Dialysis-dependence is associated with drastically increased complication rates, risk of mortality, and represent a significant financial and psychosocial burden to patients undergoing elective cervical spine surgery. Both surgeons and patients should be aware of these risks while planning elective surgeries.

American Society of Anesthesiologists' Status Association With Cost and Length of Stay in Lumbar Laminectomy and Fusion: Results From an Institutional Database

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The objective of this study was to characterize the costs associated with American Society of Anesthesiologists (ASA) class, and to determine the extent to which ASA status is a predictor of increased cost and LOS following lumbar laminectomy and fusion (LLF).

SUMMARY OF BACKGROUND DATA

Spinal fusion accounts for the highest hospital costs of any surgical procedure performed in the United States, and ASA (American Society of Anesthesiologists) status is a known risk factor for cost and length of stay (LOS) in the orthopedic literature. There is a paucity of literature that directly addresses the influence of ASA status on cost and LOS following LLF.

METHODS

This is a retrospective cohort study of an institutional database of patients undergoing single-level LLF at an academic tertiary care facility from 2006 to 2016. Univariate comparisons were made using χ tests for categorical variables and t tests for continuous variables. Multivariate linear regression was utilized to estimate regression coefficients, and to determine whether ASA status is an independent risk factor for cost and LOS.

RESULTS

A total of 1849 patients met inclusion criteria. For every one-point increase in ASA score, intensive care unit (ICU) LOS increased by 0.518 days (P < 0.001), and hospital length of stay increased by 1.93 days (P < 0.001). For every one-point increase in ASA score, direct cost increased by $7474.62 (P < 0.001).

CONCLUSION

ASA status is a predictor of hospital LOS, ICU LOS, and direct cost. Consideration of the ways in which ASA status contributes to increased cost and prolonged LOS can allow for more accurate reimbursement adjustment and more precise targeting of efficiency and cost effectiveness initiatives.

LEVEL OF EVIDENCE

3.

Noninstrumented Lumbar Fusion with Bone Morphogenetic Proteins for Spinal Stenosis with Spondylolisthesis in the Elderly

OBJECTIVE

This study examined the use of noninstrumented posterolateral lumbar fusion with bone morphogenetic protein (BMP) and compared its effectiveness with that of instrumented fusion for the treatment of lumbar spinal stenosis (LSS) with spondylolisthesis in elderly patients.

METHODS

This study was a retrospective review of 93 patients treated in a single-surgeon neurosurgical private practice over a 15-year period. Fifty-nine patients over the age of 65 who underwent noninstrumented posterolateral fusion with rhBMP-2 (Infuse) for LSS with spondylolisthesis were compared with 34 patients who underwent instrumented fusion without rhBMP-2. Outcomes in terms of reoperation rate, pain improvement, Oswestry Disability Index (ODI) score, and number of extra follow-up visits due to persistent problems were characterized by the use of t tests and χ² tests.

RESULTS

The reoperation rate in the noninstrumented rhBMP-2 fusion group was significantly lower than in the instrumented fusion group (17.6% vs. 3.4%, P = 0.048). The mean pain improvement was significantly higher in the noninstrumented rhBMP-2 group at 3 months (8.1 vs. 6.0, P < 0.001, 95% confidence interval [CI] 1.2 to 3.0) and at 1 year (7.25 vs. 5.6, P = 0.030, 95% CI 0.3 to 3.1). The ODI score improvement was significantly higher in the noninstrumented rhBMP-2 group (51 vs. 42.8, P < 0.001, 95% CI 4.7 to 11.6). The mean number of additional follow-up visits per patient was significantly lower in the noninstrumented rhBMP-2 group (0.068 vs. 1.23, P < 0.001, 95% CI 0.59 to 1.75).

CONCLUSION

Noninstrumented posterolateral lumbar fusion with rhBMP-2 in elderly patients with LSS and spondylolisthesis is a viable alternative to instrumented fusion based on clinical outcomes measured in this study.

Increased Proportion of Fusion Surgery for Degenerative Lumbar Spondylolisthesis and Changes in Reoperation Rate: A Nationwide Cohort Study With a Minimum 5-Year Follow-up

STUDY DESIGN

A retrospective cohort study.

OBJECTIVE

The objectives of the present study were to examine the changes in the number of surgeries, surgical methods selected, and reoperation rates between the years 2003 and 2008.

SUMMARY OF BACKGROUND DATA

The selection of the appropriate surgical method between decompression-only (D) and decompression plus fusion (DF) represents a challenging clinical dilemma in patients with degenerative lumbar spinal spondylolisthesis. DF is selected in greater than 90% of patients, mostly due to the associated low reoperation rate. However, the outcomes of D have been improved with minimally invasive decompression surgery techniques.

METHODS

The Health Insurance Review and Assessment Service database was used to create cohorts of all Korean patients who underwent surgery for degenerative lumbar spinal spondylolisthesis in 2003 (2003 cohort, n = 5624) and 2008 (2008 cohort, n = 11,706). All patients were followed up for at least 5 years. Reoperation was defined as the occurrence of any type of second lumbar surgery during the follow-up period. The probabilities of reoperation were calculated using the Kaplan-Meier method.

RESULTS

The number of surgeries increased 2.08-fold in 2008. Patients older than 60 years comprised 38.6% of the 2003 cohort and 52.4% of the 2008 cohort. The proportion of DF surgery was 31.13% in the 2003 cohort but 91.54% in the 2008 cohort. However, the high proportion of fusion surgery failed to reduce the reoperation probability in the 2008 cohort (8.1%) compared with that in the 2003 cohort (6.2%). The cost of DF was US$5264 and that of D was $2719 in 2008. DF decreased the reoperation probability by 1% at the cost of $421/patient in the 2008 cohort.

CONCLUSION

The increased proportion of fusion surgery without improvement in reoperation probability in an aging society may be cautiously addressed in deciding future health policies.

LEVEL OF EVIDENCE

4.

Determinants and Variations of Hospital Costs in Patients With Lumbar Radiculopathy Hospitalized for Spinal Surgery

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of this study was to determine hospital costs related to surgery for lumbar radiculopathy and identify determinants of intramural costs based on minimal hospital and claims data.

SUMMARY OF BACKGROUND DATA

Costs related to the initial hospitalization of patients undergoing surgery for lumbar radiculopathy make up the major part of direct health care expenditure in this population. Identifying factors influencing intramural costs can be beneficial for health care policy makers, and clinicians working with patients with lumbar radiculopathy.

METHODS

The following data were collected from the University Hospital Brussels data warehouse for all patients undergoing surgery for lumbar radiculopathy in 2016 (n = 141): age, sex, primary diagnosis, secondary diagnoses, type of surgery, severity of illness (SOI), admission and discharge date, type of hospital admission, and all claims incurred for the particular hospital stay. Descriptive statistics for total hospital costs were performed. Univariate analyses were executed to explore associations between hospital costs and all other variables. Those showing a significant association (P < 0.05) were included in the multivariate general linear model analysis.

RESULTS

Mean total hospital costs were &OV0556; 5016 ± 188 per patient. Costs related to the actual residence (i.e., "hotel costs") comprised 53% of the total hospital costs, whereas 18% of the costs were claimed for the surgical procedure. Patients with moderate/major SOI had 44% higher hospital costs than minor SOI (P = 0.01). Presence of preadmission comorbidities incurred 46% higher costs (P = 0.03). Emergency procedures led to 72% higher costs than elective surgery (P < 0.001). Patients receiving spinal fusion had 211% higher hospital costs than patients not receiving this intervention (P < 0.001).

CONCLUSION

Hospital costs in patients receiving surgery for lumbar radiculopathy are influenced by SOI, the presence of preadmission comorbidities, type of hospital admission (emergency vs. elective), and type of surgical procedure.

LEVEL OF EVIDENCE

3.

Geographic variation in the surgical management of lumbar spondylolisthesis: characterizing practice patterns and outcomes

BACKGROUND CONTEXT

The role of arthrodesis in the surgical management of lumbar spondylolisthesis remains controversial. We hypothesized that practice patterns and outcomes for this patient population may vary widely.

PURPOSE

This study aimed to characterize geographic variation in surgical practices and outcomes for patients with lumbar spondylolisthesis.

STUDY DESIGN/SETTING

A retrospective analysis on a national longitudinal database between 2007 and 2014 was carried out.

METHODS

We calculated arthrodesis rates, inpatient and long-term costs, and key quality indicators (eg, reoperation rates). Using linear and logistic regression models, we then calculated expected quality indicator values, adjusting for patient-level demographic factors, and compared these values with the observed values, to assess quality variation apart from differences in patient populations.

RESULTS

We identified a cohort of 67,077 patients (60.7% female, mean age of 59.8 years (standard deviation, 12.0) with lumbar spondylolisthesis who received either laminectomy or laminectomy with arthrodesis. The majority of patients received arthrodesis (91.8%). Actual rates of arthrodesis varied from 97.5% in South Dakota to 81.5% in Oregon. Geography remained a significant predictor of arthrodesis even after adjusting for demographic factors (p<.001). Marked geographic variation was also observed in initial costs ($32,485 in Alabama to $78,433 in Colorado), 2-year postoperative costs ($15,612 in Arkansas to $34,096 in New Jersey), length of hospital stay (2.6 days in Arkansas to 4.5 in Washington, D.C.), 30-day complication rates (9.5% in South Dakota to 22.4% in Maryland), 30-day readmission rates (2.5% in South Dakota to 13.6% in Connecticut), and reoperation rates (1.8% in Maine to 12.7% in Alabama).

CONCLUSIONS

There is marked geographic variation in the rates of arthrodesis in treatment of spondylolisthesis within the United States. This variation remains pronounced after accounting for patient-level demographic differences. Costs of surgery and quality outcomes also vary widely. Further study is necessary to understand the drivers of this variation.

Postoperative Opioid Use, Complications, and Costs in Surgical Management of Lumbar Spondylolisthesis

STUDY DESIGN

Retrospective analysis on a national longitudinal database (2007-2014).

OBJECTIVE

To determine the association between arthrodesis and complication rates, costs, surgical revision, and postoperative opioid prescription.

SUMMARY OF BACKGROUND DATA

Arthrodesis in patients receiving laminectomy for lumbar spondylolisthesis remains controversial. However, population-level evidence to support the use of arthrodesis remains limited.

METHODS

We identified 73,176 patient records and used coarsened exact matching to create comparable populations of patients who received laminectomy or laminectomy with arthrodesis. We use linear and logistic regression models to analyze the relationship between arthrodesis and postoperative complications, length of stay, costs, readmissions, surgical revisions, and postoperative opioid prescribing.

RESULTS

Patients who underwent arthrodesis spent 1 more day in the hospital on average (P < 0.01), and had higher costs of care at their index visit ($24,126, P < 0.01), which were partially offset by lower costs of care over the 2 years following their procedure ($14,667 less in arthrodesis patients, P = 0.01). Patients with arthrodesis were less likely to have a surgical revision (odds ratio = 0.66, P < 0.01). Patients with arthrodesis used more opioids in the first 2 months following their procedure, but had comparable opioid use to patients undergoing laminectomy without arthrodesis in all other postoperative months over the next 2 years, and were not more or less likely to convert to chronic opioid use. Postoperative opioid prescription varied dramatically across states (P < 0.01); geographic variation in opioid use is substantially greater than differences in opioid use based on procedure performed.

CONCLUSION

Arthrodesis is associated with reduced likelihood of surgical revision and increased use of opioids in the first 2 months following surgery, but not associated with greater or lesser opioid use beyond the initial 2 postoperative months. Geographic variation in opioid use is substantial even after accounting for patient characteristics and for whether patients underwent arthrodesis.

LEVEL OF EVIDENCE

3.

Distribution and Determinants of 90-Day Payments for Multilevel Posterior Lumbar Fusion: A Medicare Analysis

STUDY DESIGN

A retrospective, economic analysis.

OBJECTIVE

The objective of this article is to analyze the distribution of 90-day payments, sources of variation, and reimbursement for complications and readmissions for primary ≥3-level posterior lumbar fusion (PLF) from Medicare data. A secondary objective was to identify risk factors for complications.

SUMMARY OF BACKGROUND DATA

Bundled payments represent a single payment system to cover all costs associated with a single episode of care, typically over 90 days. The dollar amount spent on different health service providers and the variation in payments for ≥3-level PLF have not been analyzed from a bundled perspective.

MATERIALS AND METHODS

Administrative claims data were used to study 90-day Medicare (2005-2012) reimbursements for primary ≥3-level PLF for deformity and degenerative conditions of the lumbar spine. Distribution of payments, sources of variation, and reimbursements for managing complications were studied using linear regression models. Risk factors for complications were studied by stepwise multiple-variable logistic regression analysis.

RESULTS

Hospital payments comprised 73.8% share of total 90-day payment. Adjusted analysis identified several factors for variation in index hospital payments. The average 90-day Medicare payment for all multilevel PLFs without complications was $35,878 per patient. The additional average cost of treating complications with/without revision surgery within 90 days period ranged from $17,284 to $68,963. A 90-day bundle for ≥3-level PLF with readmission ranges from $88,648 (3 levels) to $117,215 (8+ levels). Rates and risk factors for complications were also identified.

CONCLUSIONS

The average 90-day payment per patient from Medicare was $35,878 with several factors such as levels of surgery, comorbidities, and development of complications influencing the cost. The study also identifies the risks and costs associated with complications and readmissions and emphasize the significant effect these would have on bundled payments (additional burden of up to 192% the cost of an average uncomplicated procedure over 90 days).

LEVEL OF EVIDENCE

Level 3.

Transforaminal Endoscopic Decompression for Lumbar Spinal Stenosis: A Novel Surgical Technique and Clinical Outcomes

OBJECTIVE

Transforaminal endoscopic treatment has been reported to be an effective treatment option in patients with lumbar disc herniation. However, it is rarely performed for spinal stenosis because of the limitation of endoscopic working mobility caused by the exiting nerve root and foraminous bony structure. The objective of this study was to describe a novel transforaminal endoscopic decompression technique for spinal stenosis and report the clinical results.

METHODS

From October 2015 to October 2016, 30 consecutive cases were diagnosed as lateral recess stenosis in our institution and underwent transforaminal endoscopic decompression. Visual analog scale (VAS) of back and leg pain and the Oswestry Disability Index (ODI) were measured preoperatively and at follow-up.

RESULTS

The mean ± SD value of preoperative VAS leg pain score was 7.6 ± 1.17. The score improved to 2.2 ± 1.11 at 1 week postoperatively, 1.73 ± 0.96 at 4 weeks postoperatively, and 1.63 ± 0.95 at 26 weeks postoperatively (P < 0.01). The mean ± SD value of the preoperative ODI score was 65.69 ± 14.22. The score improved to 24.29 ± 11.89 at 1 week postoperatively, 21.25 ± 9.25 at 4 weeks postoperatively, and 15.62 ± 10.49 at 26 weeks postoperatively (P < 0.01). There were no patients with postoperative infection, dural tear, delayed neurologic deterioration, or conversion to open surgery.

CONCLUSIONS

Transforaminal endoscopic decompression under local anesthesia could be an effective treatment method for the selected group of patients with spinal stenosis.

Lower complication and reoperation rates for laminectomy rather than MI TLIF/other fusions for degenerative lumbar disease/spondylolisthesis: A review

Background:

Utilizing the spine literature, we compared the complication and reoperation rates for laminectomy alone vs. instrumented fusions including minimally invasive (MI) transforaminal lumbar interbody fusion (TLIF) for the surgical management of multilevel degenerative lumbar disease with/without degenerative spondylolisthesis (DS).

Methods:

Epstein compared complication and reoperation rates over 2 years for 137 patients undergoing laminectomy alone undergoing 2-3 level (58 patients) and 4-6 level (79 patients) Procedures for lumbar stenosis with/without DS. Results showed no new postoperative neurological deficits, no infections, no surgery for adjacent segment disease (ASD), 4 patients (2.9%) who developed intraoperative cerebrospinal fluid (CSF) fistulas, no readmissions, and just 1 reopereation for a (postoperative day 7). These rates were compared to other literature for lumbar laminectomies vs. fusions (e.g. particularly MI TLIF) addressing pathology comparable to that listed above.

Results:

Some studies in the literature revealed an average 4.8% complication rate for laminectomy alone vs. 8.3% for decompressions/fusion; at 5 postoperative years, reoperation rates were 10.6% vs. 18.4%, respectively. Specifically, the MI TLIF literature complication rates ranged from 7.7% to 23.0% and included up to an 8.3% incidence of wound infections, 6.1% durotomies, 9.7% permanent neurological deficits, and 20.2% incidence of new sensory deficits. Reoperation rates (1.6–6%) for MI TLIF addressed instrumentation failure (2.3%), cage migration (1.26–2.4%), cage extrusions (0.8%), and misplaced screws (1.6%). The learning curve (e.g. number of cases required by a surgeon to become proficient) for MI TLIF was the first 33-44 cases. Furthermore, hospital costs for lumbar fusions were 2.6 fold greater than those for laminectomy alone, with overall neurosurgeon reimbursement quoted in one study as high as $142,075 per year.

Conclusions:

The spinal literature revealed lower complication and reoperation rates for lumbar laminectomy alone vs. higher rates for instrumented fusion, including MI TLIF, for degenerative lumbar disease with/without DS.

Lumbar Fusion for Degenerative Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Due to uncertain evidence, lumbar fusion for degenerative indications is associated with the greatest measured practice variation of any surgical procedure.

OBJECTIVE

To summarize the current evidence on the comparative safety and efficacy of lumbar fusion, decompression-alone, or nonoperative care for degenerative indications.

METHODS

A systematic review was conducted using PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (up to June 30, 2016). Comparative studies reporting validated measures of safety or efficacy were included. Treatment effects were calculated through DerSimonian and Laird random effects models.

RESULTS

The literature search yielded 65 studies (19 randomized controlled trials, 16 prospective cohort studies, 15 retrospective cohort studies, and 15 registries) enrolling a total of 302 620 patients. Disability, pain, and patient satisfaction following fusion, decompression-alone, or nonoperative care were dependent on surgical indications and study methodology. Relative to decompression-alone, the risk of reoperation following fusion was increased for spinal stenosis (relative risk [RR] 1.17, 95% confidence interval [CI] 1.06-1.28) and decreased for spondylolisthesis (RR 0.75, 95% CI 0.68-0.83). Among patients with spinal stenosis, complications were more frequent following fusion (RR 1.87, 95% CI 1.18-2.96). Mortality was not significantly associated with any treatment modality.

CONCLUSION

Positive clinical change was greatest in patients undergoing fusion for spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required (PROSPERO International Prospective Register of Systematic Reviews number, CRD42015020153).

Predictive Factors for Postoperative Follow-up: Which Patients are Prone to Loss to Follow-up After Spinal Surgery?

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To find out the predictive factors for the failure to follow-up in patients who underwent spinal surgery.

SUMMARY OF BACKGROUND DATA

Causes for loss to follow-up range from geographical accessibility to dissatisfaction with surgeons. There were few reports that investigated loss to follow-up after spinal surgery.

METHODS

A total of 649 patients who underwent laminectomy and 193 patients who underwent L4-L5 fusion from August 2006 to August 2013 were enrolled in this retrospective study. In each surgical group, demographic data and comorbidities as assessed by the Charlson index were investigated and analyzed for correlation with follow-up. The between-group difference of failure to follow-up was also evaluated.

RESULTS

The fusion group (n=193) was more likely to follow-up and the between-group difference was statistically significant (P=0.047). In the laminectomy group (n=649), 271 patients (41.8%) made regular hospital visits. Those who were male, had a spouse, or had fewer comorbidities were less prone to loss to follow-up (P<0.001). Other parameters including age, number of spinal segments operated on during surgery, distance from home to hospital, income, education level, and whether or not patients exercised were also significantly correlated with follow-up compliance (P>0.05). In contrast, 51.8% (n=100) of patients who underwent fusion had regular follow-ups. The fusion group showed a statistical difference in follow-up rate based only on sex (P=0.002).

CONCLUSIONS

Our study shows that patients who underwent decompression alone were less likely to attend follow-up than were patients who underwent fusion surgery. Whereas the factors correlated with loss to follow-up after laminectomy alone were sex, marital status, and number of comorbidities, the only predictor after fusion was male sex. Sex was the only shared risk factor for loss to follow-up.

LEVEL OF EVIDENCE

Level III.

Lumbar Spinal Stenosis Associated With Degenerative Lumbar Spondylolisthesis: A Systematic Review and Meta-analysis of Secondary Fusion Rates Following Open vs Minimally Invasive Decompression

Background

Decompression without fusion is a treatment option in patients with lumbar spinal stenosis (LSS) associated with stable low-grade degenerative spondylolisthesis (DS). A minimally invasive unilateral laminotomy (MIL) for "over the top" decompression might be a less destabilizing alternative to traditional open laminectomy (OL).

Objective

To review secondary fusion rates after open vs minimally invasive decompression surgery.

Methods

We performed a literature search in Pubmed/MEDLINE using the keywords "lumbar spondylolisthesis" and "decompression surgery." All studies that separately reported the outcome of patients with LSS+DS that were treated by OL or MIL (transmuscular or subperiosteal route) were included in our systematic review and meta-analysis. The primary end point was secondary fusion rate. Secondary end points were total reoperation rate, postoperative progression of listhetic slip, and patient satisfaction.

Results

We identified 37 studies (19 with OL, 18 with MIL), with a total of 1156 patients, that were published between 1983 and 2015. The studies' evidence was mostly level 3 or 4. Secondary fusion rates were 12.8% after OL and 3.3% after MIL; the total reoperation rates were 16.3% after OL and 5.8% after MIL. In the OL cohort, 72% of the studies reported a slip progression compared to 0% in the MIL cohort, respectively. After OL, satisfactory outcome was 62.7% compared to 76% after MIL.

Conclusion

In patients with LSS and DS, minimally invasive decompression is associated with lower reoperation and fusion rates, less slip progression, and greater patient satisfaction than open surgery.

Risk Factors for Reoperation in Patients Treated Surgically for Degenerative Spondylolisthesis: A Subanalysis of the 8-year Data From the SPORT Trial

STUDY DESIGN

Retrospective analysis of prospective data from the degenerative spondylolisthesis (DS) arm of the Spine Patient Outcomes Research Trial.

OBJECTIVE

The aim of this study was to identify risk factors for reoperation in patients treated surgically for DS and compare outcomes between patients who underwent reoperation with nonreoperative patients.

SUMMARY OF BACKGROUND DATA

Several studies have examined outcomes following surgery for DS, but few have identified risk factors for reoperation.

METHODS

Analysis included patients with neurogenic claudication (>12 weeks), clinical neurological signs, spinal stenosis, and DS on standing lateral x-rays. Univariate and multivariate analyses were used to investigate patient characteristics and risk factors. Treatment effects (TEs) were calculated and compared between study groups.

RESULTS

Of 406 patients, 72% underwent instrumented fusion, 21% noninstrumented fusion, and 7% decompression alone. At 8 years, the reoperation rate was 22%, of which 28% occurred within 1 year, 54% within 2 years, 70% within 4 years, and 86% within 6 years. The reasons for reoperation included recurrent stenosis or progressive spondylolisthesis (45%), complications such as hematoma, dehiscence, or infection (36%), or new condition (14%). Reoperative patients were younger (62.2 vs. 65.3, P = 0.008). Significant risk factors were use of antidepressants (P = 0.008, hazard ratio [HR] 2.08) or having no neurogenic claudication upon enrollment (P = 0.02, HR 1.82). Patients who were smokers, diabetics, obese, or on workman's compensation were not at greater risk for reoperation. At 8-year follow-up, scores for SF-36 bodily pain (BP), Oswestry Disability Index, American Academy of Orthopaedic Surgeons/Modems version (ODI), and stenosis frequency index were better in nonreoperative patients. TE favored nonreoperative patients for SF-36 BP, physical function, ODI, Stenosis Bothersomeness Index, and satisfaction with symptoms (P < 0.001).

CONCLUSION

The incidence of reoperation for patients with DS was 22% 8 years following surgery. Patients with a history of no neurogenic claudication and patients taking antidepressants were more likely to undergo reoperation. Outcome scores and TE were more favorable in nonreoperative patients.

LEVEL OF EVIDENCE

2.

Emerging Techniques in Degenerative Thoracolumbar Surgery

There continue to be incremental advances in thoracolumbar spine surgery techniques in attempts to achieve more predictable outcomes, minimize risk of complications, speed recovery, and minimize the costs of these interventions. This paper reviews recent literature with regard to emerging techniques of interest in the surgical treatment of lumbar spinal stenosis, fusion fixation and graft material, degenerative lumbar spondylolisthesis, and thoracolumbar deformity and sacroiliac joint degeneration. There continue to be advances in minimal access options in these areas, although robust outcome data are heterogeneous in its support. The evidence in support of sacroiliac fusion appears to be growing more robust in the properly selected patient.

Inpatient Outcomes in Dialysis-dependent Patients Undergoing Elective Lumbar Surgery for Degenerative Lumbar Disease

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To evaluate hospital outcomes in dialysis-dependent patients undergoing elective lumbar surgeries.

SUMMARY OF BACKGROUND DATA

Because of their overall poor health status and concomitant comorbidity burden, spinal surgery in dialysis-dependent patients represents a significant challenge to spine surgeons. Large studies evaluating their immediate postoperative outcomes in elective lumbar surgery are lacking.

METHODS

Utilizing the National Inpatient Sample, an estimated 1834 dialysis-dependent patients undergoing elective lumbar spine surgery for degenerative lumbar conditions were compared to an estimated 2,522,594 non-dialysis-dependent patients undergoing the same procedures between 2002 and 2012. Our primary outcomes measures included postoperative complication rates, hospital length of stay, and total hospital costs.

RESULTS

Mean age of dialysis-dependent patients was 64.2 years compared to 59.9 in the non-dialysis-dependent cohort (P < 0.001). Dialysis-dependent patients had substantially higher inpatient mortality rates (1.8% vs 0.1%; P < 0.001), major complication rates (8.1% vs 1.1%; P < 0.001), and an increased need for blood transfusion (18.3% vs 12.5%; P < 0.001). Multivariate analysis revealed that dialysis dependence independently increased odds of in-hospital mortality (odds ratio = 8.30; 95% confidence interval 5.78-11.93; P < 0.001) and odds of a major postoperative complication (odds ratio = 3.63; 95% confidence interval 3.49-3.89; P < 0.001). Dialysis dependence was associated with an increased mean length of stay of 3.3 days (P < 0.001) and a significant increase in hospital costs when stratified by procedure type.

CONCLUSION

Dialysis dependence is associated with poorer immediate postoperative outcomes and increased hospital costs when compared to non-dialysis-dependent patients. In addition, an increased need for postoperative transfusion should be anticipated in this patient population. Further studies are warranted to confirm these findings.

LEVEL OF EVIDENCE

3.

Comparing Health Care Resource Use between Implant and Autologous Reconstruction of the Irradiated Breast: A National Claims-Based Assessment

BACKGROUND

In the debate on reconstruction of the irradiated breast, there is little information on associated health care resource use. Nationwide data were used to examine health care resource use associated with implant and autologous reconstruction. It was hypothesized that failure rates would contribute the most to higher average cumulative cost with either reconstruction method.

METHODS

From the 2009 to 2013 MarketScan Commercial Claims and Encounters database, irradiated breast cancer patients who underwent implant or autologous reconstruction were selected. In a 24-month follow-up period, the cumulative costs of health care services used were tallied and described. Regression models stratified by reconstruction method were then used to estimate the influence of failure on cumulative cost of reconstruction.

RESULTS

There were 2964 study patients. Most (78 percent) underwent implant reconstruction. The unadjusted mean costs for implant and autologous reconstructions were $22,868 and $30,527, respectively. Thirty-two percent of implant reconstructions failed, compared with 5 percent of autologous cases. Twelve percent of the implant reconstructions had two or more failures and required subsequent autologous reconstruction. The cost of implant reconstruction failure requiring a flap was $47,214, and the cost for autologous failures was $48,344. In aggregate, failures constituted more than 20 percent of the cumulative costs of implant reconstruction compared with less than 5 percent for autologous reconstruction.

CONCLUSIONS

More than one in 10 patients who had implant reconstruction in the setting of radiation therapy to the breast eventually required a flap for failure. These findings make a case for autologous reconstruction being primarily considered in irradiated patients who have this option available.

Trends in Surgical Management of Shoulder Instability

Background:

Optimal surgical management of anterior shoulder instability remains controversial. There is a need to assess the most recent trends for primary and revision shoulder stabilization surgery using a national database significantly larger than those previously utilized.

Hypothesis:

Most shoulder stabilization procedures are performed arthroscopically. Examining revision procedures, we hypothesized that open procedures would result in decreased revision stabilizations compared with arthroscopic procedures and that most revision procedures would be open Bankart or bone transfer procedures regardless of the index procedure technique.

Study Design:

Descriptive epidemiology study.

Methods:

The MarketScan Database was searched using International Classification of Diseases–Ninth Revision (ICD-9) and Current Procedural Terminology (CPT) codes to identify patients who underwent any shoulder stabilization procedure between 2008 and 2012. Regression analysis was used to evaluate trends between patient groups. The Cochran-Armitage trend test was used to identify differences in trends seen yearly. Odds ratios (ORs) were calculated to compare the likelihood of undergoing a revision stabilization procedure.

Results:

A total of 66,564 shoulder stabilization procedures were identified from 2008 through 2012: 60,248 arthroscopic stabilization procedures (90.5%) and 6316 open stabilization procedures (9.5%), including 1623 bone block procedures. Arthroscopic stabilization procedures increased in total number and percentage of all procedures in each year of the study. Bone block procedures increased in number each year, although other open procedures decreased during the study period. Males underwent more stabilization procedures, while patients between the ages of 10 and 19 years were most likely to undergo any procedure. Patients who underwent bone block stabilization were significantly less likely to undergo a second stabilization procedure during the study period when compared with open Bankart repair (OR, 0.582; 95% CI, 0.405-0.836; P < .05) and arthroscopic Bankart repair (OR, 0.587; 95% CI, 0.418-0.824; P < .05). No statistically significant difference in revision stabilization was seen when comparing arthroscopic versus open Bankart repair (OR, 0.934; 95% CI, 0.863-1.139).

Conclusion:

Although the number of arthroscopic shoulder stabilization surgeries continues to increase, our data show a consistent increase, not seen in prior studies, in the number of bone block procedures. Contrary to some studies, there was no significant difference in the likelihood of a second procedure between patients initially undergoing arthroscopic compared with open Bankart repair.

A Review of Databases Used in Orthopaedic Surgery Research and an Analysis of Database Use in Arthroscopy: The Journal of Arthroscopic and Related Surgery

PURPOSE

The purpose of this study was to evaluate how database use has changed over time in Arthroscopy: The Journal of Arthroscopic and Related Surgery and to inform readers about available databases used in orthopaedic literature.

METHODS

An extensive literature search was conducted to identify databases used in Arthroscopy and other orthopaedic literature. All articles published in Arthroscopy between January 1, 2006, and December 31, 2015, were reviewed. A database was defined as a national, widely available set of individual patient encounters, applicable to multiple patient populations, used in orthopaedic research in a peer-reviewed journal, not restricted by encounter setting or visit duration, and with information available in English.

RESULTS

Databases used in Arthroscopy included PearlDiver, the American College of Surgeons National Surgical Quality Improvement Program, the Danish Common Orthopaedic Database, the Swedish National Knee Ligament Register, the Hospital Episodes Statistics database, and the National Inpatient Sample. Database use increased significantly from 4 articles in 2013 to 11 articles in 2015 (P = .012), with no database use between January 1, 2006, and December 31, 2012.

CONCLUSIONS

Database use increased significantly between January 1, 2006, and December 31, 2015, in Arthroscopy.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II through IV studies.

Geographic Variation in Diagnostic Ability and Quality of Care Metrics: A Case Study of Ankylosing Spondylitis and Low Back Pain

Studies examining geographic variation in care for low back pain often focus on process and outcome measures conditional on patient diagnosis but generally do not take into account a physician's ability to diagnose the root cause of low back pain. In our case study, we used increased detection of ankylosing spondylitis-a relatively rare inflammatory back disease-as a proxy for diagnostic ability and measured the relationship between ankylosing spondylitis detection, potentially inappropriate low back pain care, and cost. Using 5 years of health insurance claims data, we found significant variation in ankylosing spondylitis detection across metropolitan statistical areas (MSAs), with 8.1% of the variation in detection explained by a region's racial composition. Furthermore, low back pain patients in MSAs with higher ankylosing spondylitis detection had 7.9% lower use of corticosteroids, 9.0% lower use of opioids, and 8.2% lower pharmacy cost, compared with patients living in low-detection MSAs.

Clinical and Radiological Study Focused on Relief of Low Back Pain After Decompression Surgery in Selected Patients With Lumbar Spinal Stenosis Associated With Grade I Degenerative Spondylolisthesis

STUDY DESIGN

A retrospective study.

OBJECTIVE

The aim of the present study was to identify the clinical and radiological features of low back pain (LBP) that was relieved after decompression alone of lumbar spinal stenosis (LSS) associated with grade I lumbar degenerative spondylolisthesis (LDS).

SUMMARY OF BACKGROUND DATA

Although decompression and fusion are generally the recommended surgical treatments of LDS, several authors have reported that some patients with LDS could obtain good clinical results including relief from LBP by decompression alone. The pathogenesis of relief from LBP after decompression is, however, not known.

METHODS

Forty patients with LSS associated with grade I LDS, who underwent a minimally invasive surgical-decompression were enrolled in the present study. All patients complained preoperatively of predominantly leg-related symptoms and LBP (≥ 4 points on Numeric Rating Scale). Clinical and radiological assessments were performed 1 year after surgery (a relief of LBP: Numeric Rating Scale reduction ≥3 points and valuation ≤3 points) and at the last follow-up. We conducted a comparative study between patient groups with and without the relief from LBP (groups R and N, respectively).

RESULTS

Twenty-nine patients were distributed to group R and the remaining 11 patients to group N. Preoperatively, there was a significant difference between the two groups for age and radiographic flexibility for lumbar extension. Postoperatively, there was a positive correlation between improvement in both LBP and leg symptoms. The clinical outcomes of group R were significantly better than those of group N throughout follow-up period (mean 37 mo). In group R, sagittal lumbopelvic radiographic parameters improved significantly after surgery.

CONCLUSION

Although the causes of LBP are varied in each patients, our results show that concomitant LSS itself might cause LBP in some patients with grade I LDS, because it involves impingement of the neural tissue and discordant sagittal lumbopelvic alignment.

LEVEL OF EVIDENCE

3.

Complications associated with the Dynesys dynamic stabilization system: a comprehensive review of the literature

The Dynesys dynamic stabilization system is an alternative to rigid instrumentation and fusion for the treatment of lumbar degenerative disease. Although many outcomes studies have shown good results, currently lacking is a comprehensive report on complications associated with this system, especially in terms of how it compares with reported complication rates of fusion. For the present study, the authors reviewed the literature to find all studies involving the Dynesys dynamic stabilization system that reported complications or adverse events. Twenty-one studies were included for a total of 1166 patients with a mean age of 55.5 years (range 39-71 years) and a mean follow-up period of 33.7 months (range 12.0-81.6 months). Analysis of these studies demonstrated a surgical-site infection rate of 4.3%, pedicle screw loosening rate of 11.7%, pedicle screw fracture rate of 1.6%, and adjacent-segment disease (ASD) rate of 7.0%. Of studies reporting revision surgeries, 11.3% of patients underwent a reoperation. Of patients who developed ASD, 40.6% underwent a reoperation for treatment. The Dynesys dynamic stabilization system appears to have a fairly similar complication-rate profile compared with published literature on lumbar fusion, and is associated with a slightly lower incidence of ASD.

Unplanned Reoperation of Lumbar Spinal Surgery During the Primary Admission: A Multicenter Study Based on a Large Patient Population

STUDY DESIGN

A retrospective study.

OBJECTIVE

The purpose of this study was to identify the rates and reasons, and the risk factors for unplanned reoperation of lumbar spinal surgery during the primary admission in terms of a multicenter and a large patient population study.

SUMMARY OF BACKGROUND DATA

Unplanned reoperation is suggested to be a useful quality indicator for spinal surgery. However, the rates of unplanned reoperation in patients underwent lumbar spinal surgery during the primary admission are not well established.

METHODS

This study was performed to review all the patients who underwent lumbar spinal surgery at three institutions from January 2010 to April 2015. Patients with unplanned reoperations after primary surgery during the same admission were included in this study. The demographics, diagnosis, surgical procedure, and complications of patients were reviewed and statistical analysis was performed to investigate the incidences and risk factors of unplanned revision.

RESULTS

A total of 3936 patients who underwent lumbar spinal surgery from three institutions were reviewed, and 82 (2.08%) required unplanned reoperation during the primary admission because of wound infection (0.94%), screw misplacement (0.53%), cerebrospinal fluid leakage (0.27%), wound hematoma (0.18%), and neurologic deficit (0.15%). For the diagnosis, patients with lumbar spinal spondylolisthesis had a much higher rate of reoperation (4.3%) than those of lumbar stenosis (2.3%), vertebral tumor (2.2%), vertebral fracture (1.2%), and disc herniation (1.1%) with a significant difference (P < 0.001). The revision rate was significantly higher in patients underwent posterior lumbar interbody fusion than those received transforaminal lumbar interbody fusion (P = 0.007).

CONCLUSION

Unplanned reoperation rate of lumbar spinal surgery was 2.08% and the most common reasons for it were wound infection and screw misplacement. Patients with a diagnosis of lumbar spinal spondylolisthesis or who underwent posterior lumbar interbody fusion were more likely to required unplanned reoperation during the primary admission.

LEVEL OF EVIDENCE

4.

Perioperative Outcomes After Cervical Laminoplasty Versus Posterior Decompression and Fusion: Analysis of 779 Patients in the ACS-NSQIP Database

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To compare the short-term outcomes for patients undergoing cervical laminoplasty versus posterior decompression and fusion for multilevel cervical pathology.

SUMMARY OF BACKGROUND DATA

There are conflicting data regarding the merits of cervical laminoplasty and posterior decompression and fusion for the treatment of multilevel cervical pathology.

METHODS

Patients who underwent cervical laminoplasty or posterior decompression and fusion were identified in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2010 to 2012. Baseline patient characteristics were compared using bivariate logistic regression. Propensity-adjusted multivariate regressions were performed to assess differences in postoperative length of stay, adverse events, and 30-day readmission.

RESULTS

A total of 779 patients were included in this study: 437 (56.1%) underwent cervical decompression and fusion and 342 (43.9%) underwent cervical laminoplasty. Decompression and fusion patients were found to be more comorbid at baseline than laminoplasty patients based on increased American Society of Anesthesiologists scores and Charlson Comorbidity Index.Propensity-adjusted multivariate analysis was used to control for differences in baseline patient characteristics, and found that compared with laminoplasty patients, decompression and fusion patients had increased length of stay (+1.2 d, P<0.001), greater rates of any adverse event (OR=1.7, P=0.018), and were more likely to be readmitted (OR=2.3, P=0.028).

CONCLUSIONS

Posterior cervical decompression and fusion patients were found to have moderately worse short-term outcomes than laminoplasty patients. The information provided here can be used to inform patients and surgeons about the likely perioperative experience after they have made the decision to pursue 1 of these 2 procedures.

Medicare payment data for spine reimbursement; important but flawed data for evaluating utilization of resources

BACKGROUND

Medicare data showing physician-specific reimbursement for 2012 were recently made public in the mainstream media. Given the ongoing interest in containing healthcare costs, we analyze these data in the context of the delivery of spinal surgery.

METHODS

Demographics of 206 leading surgeons were extracted including state, geographic area, residency training program, fellowship training, and academic affiliation. Using current procedural terminology (CPT) codes, information was evaluated regarding the number of lumbar laminectomies, lumbar fusions, add-on laminectomy levels, and anterior cervical fusions reimbursed by Medicare in 2012.

RESULTS

In 2012 Medicare reimbursed the average neurosurgeon slightly more than an orthopedic surgeon for all procedures ($142,075 vs. $110,920), but this was not found to be statistically significant (P = 0.218). Orthopedic surgeons had a statistical trend illustrating increased reimbursement for lumbar fusions specifically, $1187 versus $1073 (P = 0.07). Fellowship trained spinal surgeons also, on average, received more from Medicare ($125,407 vs. $76,551), but again this was not statistically significant (P = 0.112). A surgeon in private practice, on average, was reimbursed $137,495 while their academic counterparts were reimbursed $103,144 (P = 0.127). Surgeons performing cervical fusions in the Centers for Disease Control West Region did receive statistically significantly less reimbursement for that procedure then those surgeons in other parts of the country (P = 0.015). Surgeons in the West were reimbursed on average $849 for CPT code 22,551 while those in the Midwest received $1475 per procedure.

CONCLUSION

Medicare reimbursement data are fundamentally flawed in determining healthcare expenditure as it shows a bias toward delivery of care in specific patient demographics. However, neurosurgeons, not just policy makers, must take ownership to analyze, investigate, and interpret these data as it will affect healthcare reimbursement and delivery moving forward.

Database and Registry Research in Orthopaedic Surgery: Part I: Claims-Based Data

The use of large-scale national databases for observational research in orthopaedic surgery has grown substantially in the last decade, and the data sets can be grossly categorized as either administrative claims or clinical registries. Administrative claims data comprise the billing records associated with the delivery of health-care services. Orthopaedic researchers have used both government and private claims to describe temporal trends, geographic variation, disparities, complications, outcomes, and resource utilization associated with both musculoskeletal disease and treatment. Medicare claims comprise one of the most robust data sets used to perform orthopaedic research, with >45 million beneficiaries. The U.S. government, through the Centers for Medicare & Medicaid Services, often uses these data to drive changes in health policy. Private claims data used in orthopaedic research often comprise more heterogeneous patient demographic samples, but allow longitudinal analysis similar to that offered by Medicare claims. Discharge databases, such as the U.S. National Inpatient Sample, provide a wide national sampling of inpatient hospital stays from all payers and allow analysis of associated adverse events and resource utilization. Administrative claims data benefit from the high patient numbers obtained through a majority of hospitals. Using claims, it is possible to follow patients longitudinally throughout encounters irrespective of the location of the institution delivering health care. Some disadvantages include lack of precision of ICD-9 (International Classification of Diseases, Ninth Revision) coding schemes. Much of these data are expensive to purchase, complicated to organize, and labor-intensive to manipulate--often requiring trained specialists for analysis. Given the changing health-care environment, it is likely that databases will provide valuable information that has the potential to influence clinical practice improvement and health policy for years to come.

Comparison of 368 patients undergoing surgery for lumbar degenerative spondylolisthesis from the SPORT trial with 955 from the NSQIP database

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To compare demographics and perioperative outcomes between the Spine Patient Outcomes Research Trial (SPORT) lumbar degenerative spondylolisthesis arm and a similar population from the National Surgical Quality Improvement Program (NSQIP) database.

SUMMARY OF BACKGROUND DATA

SPORT is a well-known surgical trial that investigated the benefits of surgical versus nonsurgical treatment in patients with various lumbar pathologies. However, the external validity of SPORT demographics and outcomes has not been fully established.

METHODS

Surgical degenerative spondylolisthesis cases were identified from NSQIP between 2010 and 2012. This population was then compared with the SPORT degenerative spondylolisthesis study. These comparisons were based on published data from SPORT and included analyses of demographics, perioperative factors, and complications.

RESULTS

The 368 surgical patients with degenerative spondylolisthesis in SPORT were compared with 955 patients identified in NSQIP. Demographic comparisons were as follows: average age and race (no difference; P > 0.05 for each), sex (9.1% more female patients in SPORT; P = 0.002), smoking status (6.6% more smokers in NSQIP; P = 0.002), and average body mass index (1.1 kg/m greater in NSQIP; P = 0.005). Larger differences were noted in what surgical procedure was performed (P < 0.001), with the most notable difference being that the NSQIP population was much more likely to include interbody fusion than the SPORT population (52.4% vs. 12.5%). Most perioperative factors and complication rates were similar, including average operative time, wound infection, wound dehiscence, postoperative transfusion, and postoperative mortality (no differences; P > 0.05 for each). Average length of stay was shorter in NSQIP compared with SPORT (3.7 vs. 5.8 d; P = 0.042).

CONCLUSION

Though important differences in the distribution of surgical procedures were identified, this study supports the greater generalizability of the surgical SPORT degenerative spondylolisthesis study based on similar demographics and perioperative outcomes when compared with patients from the NSQIP database.

LEVEL OF EVIDENCE

3.

Fusion surgery for lumbar degenerative disc disease: still more questions than answers

Yoshihara H, Yoneoka D. National trends in the surgical treatment for lumbar degenerative disc disease: United States, 2000 to 2009. Spine J 2015;15:265-71 (in this issue).

Efficacy of epidural injections in the treatment of lumbar central spinal stenosis: a systematic review

Context:

Lumbar central spinal stenosis is common and often results in chronic persistent pain and disability, which can lead to multiple interventions. After the failure of conservative treatment, either surgical or nonsurgical modalities such as epidural injections are contemplated in the management of lumbar spinal stenosis.

Evidence Acquisition:

Recent randomized trials, systematic reviews and guidelines have reached varying conclusions about the efficacy of epidural injections in the management of central lumbar spinal stenosis. The aim of this systematic review was to determine the efficacy of all three anatomical epidural injection approaches (caudal, interlaminar, and transforaminal) in the treatment of lumbar central spinal stenosis. A systematic review was performed on randomized trials published from 1966 to July 2014 of all types of epidural injections used in the management of lumbar central spinal stenosis. Methodological quality assessment and grading of the evidence was performed.

Results:

The evidence in managing lumbar spinal stenosis is Level II for long-term improvement for caudal and lumbar interlaminar epidural injections. For transforaminal epidural injections, the evidence is Level III for short-term improvement only. The interlaminar approach appears to be superior to the caudal approach and the caudal approach appears to be superior to the transforaminal one.

Conclusions:

The available evidence suggests that epidural injections with local anesthetic alone or with local anesthetic with steroids offer short- and long-term relief of low back and lower extremity pain for patients with lumbar central spinal stenosis. However, the evidence is Level II for the long-term efficacy of caudal and interlaminar epidural injections, whereas it is Level III for short-term improvement only with transforaminal epidural injections.

Perioperative outcomes, complications, and costs associated with lumbar spinal fusion in older patients with spinal stenosis and spondylolisthesis

OBJECT

The purpose of this study was to quantify the perioperative outcomes, complications, and costs associated with posterolateral spinal fusion (PSF) among Medicare enrollees with lumbar spinal stenosis (LSS) and/or spondylolisthesis by using a national Medicare claims database.

METHODS

A 5% systematic sample of Medicare claims data (2005-2009) was used to identify outcomes in patients who had undergone PSF for a diagnosis of LSS and/or spondylolisthesis. Patients eligible for study inclusion also required a minimum of 2 years of follow-up and a claim history of at least 12 months prior to surgery.

RESULTS

A final cohort of 1672 patients was eligible for analysis. Approximately half (50.7%) had LSS only, 10.2% had spondylolisthesis only, and 39.1% had both LSS and spondylolisthesis. The average age was 71.4 years, and the average length of stay was 4.6 days. At 3 months and 1 and 2 years postoperatively, the incidence of spine reoperation was 10.9%, 13.3%, and 16.9%, respectively, whereas readmissions for complications occurred in 11.1%, 17.5%, and 24.9% of cases, respectively. At 2 years postoperatively, 36.2% of patients had either undergone spine reoperation and/or received an epidural injection. The average Medicare payment was $36,230 ± $17,020, $46,840 ± $31,350, and $61,610 ± $46,580 at 3 months, 1 year, and 2 years after surgery, respectively.

CONCLUSIONS

The data showed that 1 in 6 elderly patients treated with PSF for LSS or spondylolisthesis underwent reoperation on the spine within 2 years of surgery, and nearly 1 in 4 patients was readmitted for a surgery-related complication. These data highlight several potential areas in which improvements may be made in the effective delivery and cost of surgical care for patients with spinal stenosis and spondylolisthesis.

Number of recent inpatient admissions as a risk factor for increased complications, length of stay, and cost in patients undergoing posterior lumbar fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To identify risk factors for increased complication rate, hospital charges, and length of stay in patients undergoing posterior lumbar fusion.

SUMMARY OF BACKGROUND DATA

A better understanding of risk factors for perioperative complications in patients undergoing posterior lumbar fusion can aid with patient selection and postoperative monitoring. Previous studies have assessed the impact of factors such as body mass index, age, and American Society of Anesthesiologists physical status classification on complication rate.

METHODS

Data were acquired from the institution's quality improvement data set. Preoperative demographic factors included sex, age, number of inpatient admissions in the prior year, body mass index, Charlson comorbidity score, American Society of Anesthesiologists physical status classification, number of levels fused, operative duration, and medications on admission. Complications recorded included pneumonia, myocardial infarction, venous thromboembolic event, hardware failure, readmission, or unplanned return to the operating room. Multivariate regression was used to identify predictors of increased complication rate, hospital charges, and length of stay.

RESULTS

A total of 462 patients were included. A history of more than 1 admission in the prior year was the only variable significantly associated with increased complication rate (odds ratio 10.56, P < 0.0001). History of more than 1 admission in the prior year (+1.92 d, P < 0.0001), operative duration more than 5 hours (+0.81 d, P = 0.008), and American Society of Anesthesiologists physical status classification 3 or greater (+0.75 d, P = 0.01) were associated with increased length of stay, whereas history of more than 1 admission in the prior year (+$27,798, P < 0.0001), fusion of 4 or more levels (+$38,043, P < 0.0001), and operative duration more than 5 hours (+$40,298, P < 0.0001) were associated with increased total charges.

CONCLUSION

The number of inpatient admissions in the prior year was found to be a more powerful predictor of perioperative risk after lumbar fusion than metrics evaluated in prior studies, such as age, body mass index, and comorbidities.

LEVEL OF EVIDENCE

3.