The Effect of Workers' Compensation Status on Outcomes of Cervical Disc Arthroplasty: A Prospective, Comparative, Observational Study

The Influence of Workers' Compensation Status on Patient-Reported Outcomes after Cervical Disc Arthroplasty at an Ambulatory Surgical Center

INTRODUCTION

Workers' compensation (WC) status tends to negatively affect patient outcomes in spine surgery. This study aims to evaluate the potential effect of WC status on patient-reported outcomes (PROs) after cervical disc arthroplasty (CDR) at an ambulatory surgical center (ASC).

METHODS

A single-surgeon registry was retrospectively reviewed for patients who had undergone elective CDR at an ASC. Patients with missing insurance data were excluded. Propensity score-matched cohorts were generated by the presence or lack of WC status. PROs were collected preoperatively and at 6-week, 12-week, 6-month, and 1-year time points. PROs included the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS-PF), visual analog scale (VAS) neck and arm pain, and Neck Disability Index. PROs were compared within and between groups. Minimum clinically important difference (MCID) achievement rates were compared between groups.

RESULTS

Sixty-three patients were included, with 36 without WC (non-WC) and 27 with WC. The non-WC cohort demonstrated postoperative improvement in all PROs at all time points, with the exception of VAS arm past the 12-week point ( P ≤ 0.030, all). The WC cohort demonstrated postoperative improvement in VAS neck at 12-week, 6-month, and 1-year time points ( P ≤ 0.025, all). The WC cohort improved in VAS arm and Neck Disability Index at the 12-week and 1-year points as well ( P ≤ 0.029, all). The non-WC cohort reported superior PRO scores in every PRO at one or more postoperative time points ( P ≤ 0.046, all). The non-WC cohort demonstrated higher rates of minimum clinically important difference achievement in PROMIS-PF at 12 weeks ( P ≤ 0.024).

CONCLUSION

Patients with WC status undergoing CDR at an ASC may report inferior pain, function, and disability outcomes compared with those with private or government-provided insurance. Perceived inferior disability in WC patients persisted into the long-term follow-up period (1 year). These findings may aid surgeons in setting realistic preoperative expectations with patients at risk of inferior outcomes.

Coexistence of Cervical Disc Herniation and Shoulder Soft Tissue Pathologies and the Effect of Sleeping Positions and Orthopedic Pillows

Background/aim This study investigates the degree of coexistence of cervical disc herniation and shoulder soft tissue pathology, as well as the effect of sleeping positions and orthopedic pillow use. Materials and methods This present study was conducted on 72 patients with shoulder/arm pain operated on for cervical disc herniation. Two groups were examined according to the presence of shoulder soft tissue pathology, four common sleeping positions, and the use of an orthopedic pillow. Preoperative and postoperative shoulder/arm visual analog scale (VAS) scores were compared. Results The preoperative VAS values were 7.35, while the postoperative VAS values were 3.32. Twenty-one patients (29.2%) had a disc at the C3-4 level, a rate equal to that for the C5-6 level. Twenty-four patients (33.3%) had a disc at the C4-5 level. Thirty-two cases (44.4%) slept in a side-lying position on the same side as their disc herniation. Among those with a herniated disc at the C3-4 level, 8 (53.3%) preferred sleeping side-lying on the opposite side of the disc. In contrast, those with a herniated disc at the C4-5 level more frequently (40.6%) slept side-lying on the same side as the disc. Mean VAS scores were significantly higher in cases with shoulder soft tissue pathology and were significantly lower in the group that used orthopedic pillows (p<0.001). Conclusion Shoulder soft tissue pathologies should be considered in postoperative shoulder pain. The use of orthopedic pillows is effective in preoperative and postoperative pain. Sleeping positions do not affect the shoulder/arm pain before and after the operation, but they affect the level of cervical disc herniations.

Differences in Time to Achieve Minimum Clinically Important Difference Between Patients Undergoing Anterior Cervical Discectomy and Fusion and Cervical Disc Replacement

OBJECTIVE

To compare patients undergoing anterior cervical discectomy and fusion (ACDF) versus cervical disc replacement (CDR) for time to minimum clinically important difference (MCID) achievement and predictors of delayed MCID achievement for the patient-reported outcomes (PROs), Patient-Reported Outcomes Measurement Information System Physical Function, Neck Disability Index, Visual Analog Scale (VAS) neck, and VAS arm.

METHODS

PROs of patients undergoing ACDF or CDR were collected preoperatively and postoperatively at 6-week/12-week/6-month/1-year/2-year periods. MCID achievement was calculated through comparison of changes in Patient-Reported Outcomes Measurement to previously established values in literature. Time to MCID achievement and predictors for delayed MCID achievement were determined through Kaplan-Meier survival analysis and multivariable Cox regression, respectively.

RESULTS

One hundred ninety-seven patients were identified, with 118 and 79 undergoing ACDF and CDR, respectively. Kaplan-Meier survival analysis demonstrated faster time to achieve MCID for CDR patients in Patient-Reported Outcomes Measurement Information System Physical Function (P = 0.006). Early predictors of MCID achievement through Cox regression were CDR procedure, Asian ethnicity, elevated preoperative PROs of VAS neck and VAS arm (hazard ratio, 1.16-7.28). Workers' compensation was a late predictor of MCID achievement (hazard ratio, 0.15).

CONCLUSIONS

Most patients achieved MCID in physical function, disability, and back pain outcomes within 2 years of surgery. Patients undergoing CDR achieved MCID faster in physical function. Early predictors of MCID achievement were CDR procedure, Asian ethnicity, and elevated preoperative PROs of pain outcomes. Workers' compensation was a late predictor. These findings may be helpful in managing patient expectations.

Workers compensation patients experiencing depression report meaningful improvement in mental health scores after anterior cervical discectomy and fusion

Background

Mental health has been demonstrated to affect postoperative outcomes. No prior literature has reported the relationship between preoperative mental health on outcomes following anterior cervical discectomy and fusion (ACDF) in the Workers Compensation (WC) population.

Methods

WC claimants who underwent primary ACDF were identified from a single-surgeon retrospective database. Patients were separated by SF-12 MCS score into Depressed (<45.6) or Not Depressed (ND) (≥45.6) cohorts. Patient-reported Outcome Measurement Information System Physical Function (PROMIS PF), SF-12 Physical Component Score (SF-12 PCS), SF-12 MCS, visual analog scale (VAS) neck/arm pain, and Neck Disability Index (NDI) were collected and compared within and between groups. Minimum clinically important difference (MCID) achievement rates were compared between groups.

Results

Depressed patients had greater length of stay (p = 0.007) and postoperative narcotic consumption (p = 0.026). Depressed patients improved at 12-week to 2-year PROMIS PF, 6-month SF-12 PCS, 6-week to 6-month SF-12 MCS, 6-week to 6-month and 2-year VAS neck, all VAS arm, and 6-month NDI (p ≤ 0.045, all). ND patients improved at 12-week to 1-year PROMIS PF, 6-month to 2-year SF-12 PCS, 12-week to 1-year VAS neck, 6-week to 1-year VAS arm, and 12-week to 1-year NDI (p ≤ 0.044, all). Between groups, ND patients reported superior PROMIS PF, SF-12 MCS, VAS neck, VAS arm, and NDI scores at two or more periods (p ≤ 0.045, all). MCID achievement rate regarding SF-12 MCS was greater in the Depressed cohort at all postoperative points up to 1 year (p ≤ 0.020, all).

Conclusion

Depressed patients tended to have a greater length of stay and postoperative narcotic consumption immediately after surgery. Not depressed patients reported more favorable physical and mental function, pain, and disability scores preoperatively and postoperatively. Depressed patients reported greater MCID achievement in mental function following surgery. Depressed patients with WC have a greater likelihood of reporting tangible improvement in mental health scores following ACDF.

Workers' Compensation Association With Clinical Outcomes After Anterior Cervical Diskectomy and Fusion

BACKGROUND

Research has suggested that workers' compensation (WC) status can result in poor outcomes after anterior cervical diskectomy and fusion (ACDF).

OBJECTIVE

To determine the influence WC status has on postoperative clinical outcomes after ACDF.

METHODS

A surgical database was reviewed for patients undergoing primary or revision single-level ACDF. Patients were grouped into WC vs Non-WC, and differences in baseline characteristics were assessed. Postoperative improvement was assessed for differences in mean scores between WC subgroups for visual analog scale (VAS) arm, VAS neck, 12-item Short Form Physical Composite Score, Patient-Reported Outcomes Measurement Information System physical function (PF), and Neck Disability Index (NDI) at preoperative and postoperative time points. Minimum clinically important difference (MCID) achievement was compared between groups.

RESULTS

The patient cohort included 44 with WC and 95 without. The cohort was 40% female with an average age of 48 years and mean body mass index of 30. Mean VAS arm, VAS neck, NDI, 12-item Short-Form Physical Composite Score, and Patient-Reported Outcomes Measurement Information System PF scores differed between groups; however, the difference was not sustained at the 1-yr time point. MCID achievement among WC subgroups was different for VAS arm (6 wk through 6 mo, P = .005), VAS neck (3 and 6 mo, P < .01), and NDI (3 and 6 mo, P < .05). No statistically significant difference was noted between cohorts for overall rates of MCID achievement for all patient-reported outcome measures collected.

CONCLUSION

WC patients reported similar preoperative and 1-yr postoperative neck and arm pain compared with non-WC patients after ACDF. One-yr MCID achievement rates were similar between cohorts for disability and PF scores.

Does the Predominant Pain Location Influence Functional Outcomes, Satisfaction and Return to Work After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?

STUDY DESIGN

Retrospective review of prospectively-collected registry data.

OBJECTIVES

The aim of this study was to determine how different combinations of preoperative neck pain (NP) and arm pain (AP) influence functional outcomes, patient satisfaction, and return-to-work in patients undergoing anterior cervical discectomy and fusion (ACDF) for degenerative cervical radiculopathy (DCR).

SUMMARY OF BACKGROUND DATA

Surgeons often base decisions on the traditional belief that the predominance of radicular upper extremity symptoms is a stronger indication for cervical spine surgery than axial pain. However, there is a paucity of literature supporting this notion.

METHODS

A prospectively maintained registry was reviewed for all patients who underwent primary ACDF for DCR. Patients were categorized into three groups depending on predominant pain location: AP predominant ([APP]; AP > NP), NP predominant ([NPP]; NP > AP), and equal pain predominance ([EPP]; NP = AP). Patients were prospectively followed for at least 2 years.

RESULTS

In total, 303 patients were included: 27.4% APP, 38.9% NPP, and 33.7% EPP cases. The APP group was significantly older (P = 0.030), although there were no other preoperative differences among the three groups. After adjusting for baseline differences, the SF-36 Physical Component Summary was significantly better in the APP group at 6 months (P = 0.048) and 2 years (P = 0.039). In addition, they showed a trend towards better 6-month Neck Disability Index (P = 0.077) and 2-year SF-36 Mental Component Summary (P = 0.059). However, an equal proportion of patients in each group achieved the Minimal Clinically Important Difference for each outcome, were satisfied, and returned to work 2 years after surgery.

CONCLUSION

Although patients with NPP had slightly poorer function and quality of life, all patients experienced a clinically meaningful improvement in patient-reported outcomes, regardless of the predominant pain location. High rates of satisfaction and return-to-work were also achieved. In the context of proper indications, these findings suggest that ACDF can be equally effective for DCR patients with varying combinations of NP or AP.Level of Evidence: 3.

Do Mid-term Outcomes of Lateral Ankle Stabilization Procedures Differ Between Military and Civilian Populations?

BACKGROUND

Ankle instability is common and previous studies have documented greater than 85% good-to-excellent outcomes based upon both patient-reported outcome measures and subjective evaluation of ability to return to previous activity levels after lateral ankle stabilization in the civilian population. However, patient-reported outcomes and performance may differ in the military population. The military oftentimes requires servicemembers to navigate uneven terrain and ladderwells, which can stress ankles differently than in their civilian counterparts. There has been limited evidence regarding patient outcomes after lateral ankle stabilization within a military population and its elucidation is important in optimizing outcomes for our servicemembers. Furthermore, the potential benefit of fibular periosteum augmentation with lateral ankle stabilization procedures in a military population has not been described. The results of using this extra tissue to reinforce the repair are important in determining whether its routine incorporation is indicated in the military.

QUESTIONS/PURPOSES

In an active-duty military population, we asked: (1) What proportion of patients who underwent lateral ankle stabilization using anatomic repair techniques with or without fibular periosteum augmentation achieved good-to-excellent outcomes based on the Foot and Ankle Disability Index (FADI) score at a minimum follow-up interval of 2 years? (2) Was the proportion of patients who achieved a good-to-excellent FADI score higher among those treated with fibular periosteum augmentation than those treated without? (3) Did the likelihood of achieving a good-to-excellent outcome after lateral ankle stabilization vary based on whether the procedure was performed by a fellowship-trained sports or foot and ankle orthopaedic surgeon versus a podiatrist?

METHODS

Between 2007 and 2017, 15 surgeons (six orthopaedic surgeons and nine podiatrists) performed 502 lateral ankle stabilizations. We excluded 4% (18 of 502) of patients because they were not active-duty at the time of surgery, and we excluded 12% (56 of 502) of lateral ankle stabilizations because they were performed as part of other potentially confounding foot or ankle procedures. We considered 60% (303 of 502) as lost to follow-up because the patients could not be contacted at least 2 years after surgery, they declined to participate, or they did not fully answer the questionnaires. This left 125 patients for analysis. Of those, 79% (99 of 125) had a procedure with fibular periosteum augmentation and 21% (26 of 125) had a procedure without augmentation. During the study period, five fellowship-trained orthopaedic foot and ankle surgeons and two podiatrists always used fibular periosteum augmentation. Orthopaedic surgeons performed 75% (94 of 125) of the procedures, and the other 25% (31 of 125) were performed by podiatrists. Whether a servicemember was treated by one specialty or the other was simply based upon whom they were referred to for care. Orthopaedic surgeons tended to perform procedures with augmentation (five with versus one without) and podiatrists tended to perform procedures without augmentation (two with versus seven without). To help account for this confounding factor, we performed separate analyses for procedures performed with versus without augmentation in addition to procedures performed by orthopaedic surgeons versus podiatrists. We retrospectively contacted each patient to obtain their self-reported overall result, FADI outcome score, and postoperative military capabilities. The minimum follow-up duration was 2 years; overall mean follow-up duration was 7 years. The fibular periosteum augmentation group mean follow-up was 7 ± 4 years and without augmentation was 6 ± 3 years. The orthopaedic surgeons group mean follow-up was 7 ± 3 years and the podiatrists group was 7 ± 3 years. We obtained postoperative FADI scores via phone interview along with data regarding the patients' postoperative military capabilities, but did not have preoperative FADI scores.

RESULTS

Pooling both surgical treatments, 67% (84 of 125) of the patients reported good-to-excellent results and 33% (41 of 125) reported very poor-to-fair results. We found no difference in the proportion of patients treated with fibular periosteal augmentation who achieved a good or excellent score on the FADI than was observed among the patients treated without periosteal augmentation (68% [67 of 99] versus 65% [17 of 26]; odds ratio 1 [95% CI 0 to 2]; p = 0.81). The proportion of patients who achieved a good or excellent score on the FADI did not differ depending on whether the procedure was performed by an orthopaedic surgeon or a podiatric surgeon (66% [62 of 94] versus 71% [22 of 31]; OR 1 [95% CI 1 to 2]; p = 0.66).

CONCLUSION

The patient-reported outcome scores after lateral ankle stabilization in our study of military servicemembers at a minimum of 2 years and a mean of 7 years were far lower than have been reported in studies on civilians. Indeed, our findings may represent a best-case scenario because more patients were lost to follow-up than were accounted for, and in general, surgical results among missing patients are poorer than among those who return for follow-up. Variability in the addition of fibular periosteum augmentation and whether an orthopaedic surgeon or podiatrist performed the procedure did not account for these findings. With one third of patients reporting very-poor-to-fair results after these reconstructions, and many patients lost to follow-up, we recommend surgeons counsel their servicemember patients accordingly before surgery. Specifically, that there is a one third chance they will need permanent restrictions or have to leave the military postoperatively; analogously, we believe that our findings may apply to similarly active patients outside the military, and we question whether these procedures may not be serving such patients as well as previously believed.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Employment Status for the First Decade Following Randomization to Cervical Disc Arthroplasty Versus Fusion

STUDY DESIGN

An analysis of employment status data up to 10 years following the Federal Drug Administration (FDA) Investigational Device Exemption (IDE) randomized trial and extension as post-approval study comparing BRYAN cervical disc (Medtronic, Minneapolis, MN) arthroplasty (CDA) versus single-level anterior cervical discectomy and fusion (ACDF) was performed.

OBJECTIVE

Ten-year experience with the BRYAN disc arthroplasty trial provides opportunity to report patient employment data.

SUMMARY OF BACKGROUND DATA

The long-term consequences of arthroplasty remain incomplete, including the occurrence of occupational compromise.

METHODS

Patients' employment status were measured at regular intervals in both groups up to 10 years.

RESULTS

The preoperative employment status proportion was comparable between investigational (BRYAN CDA) and control (ACDF) groups. In the investigational group, 49.2% returned to work at 6 weeks compared with 39.4% of the control group (P = 0.046). At 6 months and 2 years postoperatively, there was a similar likelihood of active employment in both groups. After 2 years at all time points, 10% drop-off seen in control group employment, but not in investigational group. At 10 years, 76.2% CDA patients were employed to 64.1% ACDF patients (P = 0.057). Preoperative variables influencing work status at 10 years following CDA included: preoperative work status, age, and SF-36 Mental Component Score (SF-36 MCS); whereas, no significant preoperative factor identified with ACDF. Time to return to work was influenced in both groups by preoperative work status; and in the ACDF group: reaching age 65 at 10-year visit, preoperative arm pain and NDI score had significant influences.

CONCLUSION

More patients returned to work at 6 weeks after CDA compared with ACDF, although there was no difference by 6 months. After 2 years, a nonsignificant trend toward higher employment rates in the arthroplasty group was evident, but this difference could not be validated due to the very high rate of loss of patients to the follow-up.

LEVEL OF EVIDENCE

2.

Implant complications after one-level or two-level cervical disc arthroplasty: A retrospective single-centre study of 105 patients

The aim of study was to investigate the complications of cervical disc arthroplasty (CDA) and to discuss the factors affecting the mobility of the prosthesis and the measures to prevent these complications. Hundred and five patients who underwent CDA between 2009 and 2016 were enrolled. The clinical and radiographic outcomes were used to assess and the complications were recorded as well.All the patients were followed-up with an average of 41.30 ± 16.90 months with an average age of 47.90 ± 9.22 years. The visual analogue scale (VAS), neck disability index (NDI), and Japanese Orthopaedic Association (JOA) scores improved significantly at the final follow-up (FU) compared with the preoperative values. At the final FU, the overall incidence of heterotopic ossification (HO) was 51.42%. The distribution of different grades of HO was low-level HO (53.7%) and high-level HO (46.3%). No significant differences were found in the NDI, VAS, or JOA scores between patients with HO and those without HO (P > .05). In the high-level HO patients, the range of mobility (ROM) was significantly reduced compared with the low-level HO patients and those without HO (P < .05). The anterior displacement, subsidence, and instability were observed in 1 patient respectively and the segmental kyphosis, adjacent segment degeneration in 3 patients respectively. The patient of CDA instability also suffered severe neck pain and the revision surgery was performed.Postoperative complications in CDA such as HO, segmental kyphosis, and prosthesis displacement are prone to occur, affecting prosthesis mobility. Surgical indications should be strictly controlled, and intraoperative and postoperative treatments should be given great attention in order to reduce prosthesis-related complications.

Smoking, unemployment, female sex, obesity, and medication use yield worse outcomes in patellofemoral arthroplasty

PURPOSE

The purpose of this study was to identify effects of psychosocial and demographic factors on patellofemoral arthroplasty (PFA) outcomes.

METHODS

Patients who underwent PFA by a single surgeon between 2002 and 2013 (min. 2 year follow-up) were included. Knee Society scores (KSS), UCLA, and Tegner Scores were prospectively collected in a designated arthroplasty registry. Patient records were retrospectively reviewed and univariate and multivariate statistical analyses were performed to assess the effect of psychosocial factors and demographic variables including patient sex, BMI, smoking and medication use, psychiatric history, and employment status on improvement between pre- and post-operative scores.

RESULTS

Seventy-four knees in 55 patients (88% female) with a mean age of 51.8 (SD 8.8) and mean follow-up of 46.5 (SD 26.9) months were included. Patients showed significant improvement in all functional outcomes (p < 0.001). Mean improvement in KSS-F scores and median improvement in Tegner scores was greater in males compared to females (37.8 vs 16.1, p = 0.007; 3.0 vs 2.0, p = 0.07, respectively). Smokers showed less improvement in KSS-P compared to non-smokers (17.2 vs 30.0, p = 0.028). Retired or employed patients had a greater mean improvement in KSS-F and median improvement in Tegner Scores compared to those were unemployed or on work disability (p = 0.022, p = 0.01). Patients who reported using opioids and/or anti-depressants pre-operatively showed less improvement in UCLA scores (p = 0.006). Obese patients showed less improvement in both KSS-F and Tegner score compared to non-obese patients (p = 0.009, p = 0.004).

CONCLUSION

Psychosocial factors influence the degree of improvement following PFA. Although patients showed overall improvement compared to their baseline scores, obese patients, smokers, unemployed/work disabled, and pre-operative use of opioids and/or anti-depressants were risk factors for decreased improvement… The consideration of psychosocial variables are clinically important when assessing a patient's candidacy for PFA and improve pre-operative patient selection and counselling.

LEVEL OF EVIDENCE

Level IV.

PROMIS PF in the Evaluation of Postoperative Outcomes in Workers' Compensation Patients Following Anterior Cervical Discectomy and Fusion

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

To determine the improvement of clinical outcomes in Workers' Compensation (WC) patients compared with non-WC patients utilizing Patient-reported Outcome Measurement Information System Physical Function (PROMIS PF) following anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND DATA

To our knowledge, there has not been a study to evaluate clinical outcomes of WC patients utilizing the PROMIS PF survey.

METHODS AND MATERIALS

Patients undergoing a primary, 1 to 3-level ACDF were retrospectively reviewed and stratified according to insurance (WC and non-WC). Demographic and perioperative characteristics were compared using χ test and independent t tests. Change in PROMIS PF scores was calculated using paired t tests. Differences in postoperative PROMIS PF scores and changes in PROMIS PF from baseline were compared using linear regression.

RESULTS

In total, 124 1 to 3-level ACDF patients were included: 36 had WC insurance and 88 had non-WC insurance. WC patients were younger and more likely to be obese. WC patients reported significantly lower PROMIS PF scores preoperatively and at 6 weeks, 12 weeks, and 6 months timepoints. However, both cohorts reported comparable PROMIS PF scores at the 1-year timepoint. WC patients demonstrated similar improvements from baseline through 1-year postoperatively compared with non-WC patients. For both non-WC and WC cohort, the change in the postoperative PROMIS PF score from baseline was significant at 3 months, 6 months, and 1 year. However, in both cohorts, the change in the postoperative PROMIS PF score from baseline was not significantly different at 6 weeks.

CONCLUSIONS

In our study, WC patients had worse baseline physical function as indicated by lower preoperative PROMIS PF scores and reported lower PROMIS PF scores postoperatively. However, there were no significant differences when comparing the postoperative change from baseline between the cohorts. Both cohorts experienced significant postoperative improvements from baseline. This study established that PROMIS PF is an effective tool to evaluate recovery of WC patients following ACDF.

Factors Associated With Return-to-Work Following Cervical Spine Surgery in Non-Worker's Compensation Setting

STUDY DESIGN

This study retrospectively analyzes prospectively collected data.

OBJECTIVE

Here in this study we aim to determine the factors which impact a patient's ability to return to work (RTW) in the setting of cervical spine surgery in patients without worker's compensation status.

SUMMARY OF BACKGROUND DATA

Surgical management of degenerative cervical disease has proven cost-effectiveness and shown significant improvement in quality of life. However, the ability to RTW is an important clinical outcome for preoperatively employed patients.

METHODS

All adult patients undergoing elective surgery for cervical degenerative disease at our institution are enrolled in a prospective, web-based registry. A multivariable Cox proportional hazards regression model was built for time to RTW. The variables included in the model were age, sex, smoking status, occupation type, number of levels operated on, ASA grade, body mass index, history of diabetes, history of coronary artery disease (CAD), history of chronic obstructive pulmonary disease (COPD), anxiety, depression, myelopathy at presentation, duration of symptoms more than 12 months, diagnosis, type of surgery performed, and preoperative Neck Disability Index, EuroQol Five Dimensions, and Numeric Rating Scale pain scores for neck pain and arm pain scores.

RESULTS

Of the total 324 patients with complete 3-month follow-up data 83% (n = 269) returned to work following surgery. The median time to RTW was 35 days (range, 2-90 d). Patients with a labor-intensive occupation, higher ASA grade, history of CAD, and history of COPD were less likely to RTW. The likelihood of RTW was lower in patients with a diagnosis of disc herniation compared with cervical stenosis, patients undergoing cervical corpectomy compared laminectomy and fusion and patient with longer operative time.

CONCLUSION

Our study identifies the various factors associated with a lower likelihood of RTW at 3 months after cervical spine surgery in the non-worker's compensation setting. This information provides expectations for the patient and employer when undergoing cervical spine surgery.

LEVEL OF EVIDENCE

3.

Safety and Efficiency of Cervical Disc Arthroplasty in Ambulatory Surgery Centers vs. Hospital Settings

Background

Outpatient surgery has been shown safe and effective for anterior cervical discectomy and fusion (ACDF), and more recently, for 1-level cervical disc arthroplasty (CDA). The purpose of this analysis is to compare the safety and efficiency of 1-level and 2-level CDA performed in an ambulatory surgery center (ASC) and in a hospital setting.

Methods

The study was a retrospective collection and analysis of data from consecutive CDA patients treated in ASCs compared to a historical control group of patients treated in hospital settings who were classified as outpatient (0 or 1-night stay) or inpatient (2 or more nights). Surgery time, blood loss, return to work, adverse events (AEs), and subsequent surgeries were compared.

Results

The sample consisted of 145 ASC patients, 348 hospital outpatients, and 65 hospital inpatients. A greater proportion of 2-level surgeries were performed in hospital than ASC. Surgery times were significantly shorter in ASCs than outpatient or inpatient 1-level (63.6 ± 21.6, 86.5 ± 35.8, and 116.7 ± 48.4 minutes, respectively) and 2-level (92.4 ± 37.3, 126.7 ± 43.8, and 140.3 ± 54.5 minutes, respectively) surgeries. Estimated blood loss was also significantly less in ASC than outpatient and inpatient 1-level (18.5 ± 30.6, 43.7 ± 35.9, and 85.7 ± 98.0 mL, respectively) and 2-level (21.1 ± 12.3, 67.8 ± 94.9, and 64.9 ± 66.1 mL). There were no hospital admissions and no subsequent surgeries among ASC patients. ASC patients had 1 AE (0.7%) and hospital patients had 10 AEs (2.4%). Working patients returned to work after a similar number of days off, but fewer ASC patients had returned to work by the end of the 90-day period.

Conclusions

Both 1- and 2-level CDA may be performed safely in an ASC. Surgeries in ASCs are of shorter duration and performed with less blood loss without increased AEs.

Reoperation and complications after anterior cervical discectomy and fusion and cervical disc arthroplasty: a study of 52,395 cases

PURPOSE

The aim of this study was to analyze rates of perioperative complications and subsequent cervical surgeries in patients treated for cervical degenerative disc disease with anterior cervical discectomy and fusion (ACDF) and those treated with artificial cervical disc arthroplasty (ACDA) for up to 5-year follow-up.

METHODS

California's Office of Statewide Health Planning and Development discharge database was analyzed for patients aged 18-65 years undergoing single-level ACDF or ACDA between 2003 and 2010. Medical comorbidities were identified with CMS-Condition Categories. Readmissions for short-term complications of the procedure were identified and rates of subsequent cervical surgeries were calculated at 90-day and 1-, 3-, and 5-year follow-up. Multivariate regression modeling was used to identify associations with complications and subsequent cervical surgeries correcting for patient and provider characteristics.

RESULTS

A total of 52,395 eligible cases were identified: 50,926 ACDF and 1469 ACDA. Readmission was less common in the ACDA group (OR: 0.69, 95% CI: 0.48-1.0, p = 0.048). Subsequent cervical spine surgery was more common in the ACDF group in the immediate perioperative period (within 90 days of surgery) (ACDF 3.35% vs. ACDA 2.04%, OR: 0.63, 95% CI: 0.44-0.92, p = 0.015). At 1-, 3-, and 5-year postoperatively, rates of subsequent cervical surgeries were similar between the two cohorts.

CONCLUSIONS

We found no protective benefit for ACDA versus ACDF for single-level disease at up to 5-year follow-up in the largest cohort of patients examined to date. Early complications were rare in both cohorts stressing the value of large cohort studies to study risk factors for rare events. These slides can be retrieved under Electronic Supplementary Material.

Spine Surgery Outcomes in Workers' Compensation Patients

Occupational spine injuries place a substantial burden on employees, employers, and the workers' compensation system. Both temporary and permanent spinal conditions contribute substantially to disability and lost wages. Numerous investigations have revealed that workers' compensation status is a negative risk factor for outcomes after spine injuries and spine surgery. However, positive patient outcomes and return to work are possible in spine-related workers' compensation cases with proper patient selection, appropriate surgical indications, and realistic postoperative expectations. Quality improvement measures aimed at optimizing outcomes and minimizing permanent disability are crucial to mitigating the burden of disability claims.

Worker's Compensation Status and Outcomes Following Anterior Lumbar Interbody Fusion: Prospective Observational Study

BACKGROUND

Anterior lumbar-interbody fusion (ALIF) is a commonly performed procedure for degenerative spinal disorders with reasonable clinical and safety outcomes, although there is limited evidence regarding the impact of ALIF in patients receiving worker's compensation (WC) compared with those without. The aim of our study is to identify whether WC status affects the clinical outcome and rates of complication following ALIF surgery in a prospective cohort.

METHODS

We followed prospectively 114 consecutive patients undergoing ALIF surgery from 2012-2014. Patients were categorized into 2 groups: those with worker's compensation (WC) (n = 24) and those without (n = 90). Patients were evaluated preoperative and postoperatively. Outcome measures included Short Form-12 (SF-12), Oswestry Disability Index (ODI), surgical complications, and subsidence.

RESULTS

In terms of baseline traits, the WC group had a significantly higher proportion of class III/IV obesity patients, who were younger (46.3 vs. 60.2 years) compared with non-WC. There were no significant differences in fusion rates or preoperative or postoperative disk height. No significant differences were found for hospital stay, blood loss, or operation duration. Similar rates of complications were found between WC versus non-WC cohorts. No significant difference was noted in clinical improvement between the 2 cohorts with SF-12 PCS, SF-12 MCS, or ODI (P = 0.232). No significant difference was found in the proportion of patients achieving minimal clinically important difference for SF-12 PCS/MCS or ODI.

CONCLUSIONS

In our prospective cohort, there were no significant differences found between WC versus non-WC patients in terms of fusion rates, complications, clinical outcomes, or proportion of patients achieving minimal clinically important difference.