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Miranda SP, Whitmore RG, Kanter A, Mummaneni PV, Bisson EF, Barker FG, Harrop J, Magge SN, Heary RF, Fehlings MG, Albert TJ, Arnold PM, Riew KD, Steinmetz MP, Wang MC, Heller JG, Benzel EC, Ghogawala Z. Patients May Return to Work Sooner After Laminoplasty: Occupational Outcomes of the Cervical Spondylotic Myelopathy Surgical Trial. Neurosurgery 2024:00006123-990000000-01229. [PMID: 38912784 DOI: 10.1227/neu.0000000000003048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/23/2024] [Indexed: 06/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Return-to-work (RTW) is an important outcome for employed patients considering surgery for cervical spondylotic myelopathy (CSM). We conducted a post hoc analysis of patients as-treated in the Cervical Spondylotic Myelopathy Surgical Trial, a prospective, randomized trial comparing surgical approaches for CSM to evaluate factors associated with RTW. METHODS In the trial, patients were randomized (2:3) to either anterior surgery (anterior cervical decompression/fusion [ACDF]) or posterior surgery (laminoplasty [LP], or posterior cervical decompression/fusion [PCDF], at surgeon's discretion). Work status was recorded at 1, 3, 6, and 12 months postoperatively. For patients working full-time or part-time on enrollment, time to RTW was compared across as-treated surgical groups using discrete-time survival analysis. Multivariate logistic regression was used to assess predictors of RTW. Clinical outcomes were compared using a linear mixed-effects model. RESULTS A total of 68 (42%) of 163 patients were working preoperatively and were analyzed. In total, 27 patients underwent ACDF, 29 underwent PCDF, and 12 underwent LP. 45 (66%) of 68 patients returned to work by 12 months. Median time to RTW differed by surgical approach (LP = 1 month, ACDF = 3 months, PCDF = 6 months; P = .02). Patients with longer length-of-stay were less likely to be working at 1 month (odds ratio 0.51; 95% CI, 0.29-0.91; P = .022) and 3 months (odds ratio 0.39; 95% CI, 0.16-0.96; P = .04). At 3 months, PCDF was associated with lower Short-Form 36 physical component summary scores than ACDF (estimated mean difference [EMD]: 6.42; 95% CI, 1.4-11.4; P = .007) and LP (EMD: 7.98; 95% CI, 2.7-13.3; P = .003), and higher Neck Disability Index scores than ACDF (EMD: 12.48; 95% CI, 2.3-22.7; P = .01) and LP (EMD: 15.22; 95% CI, 2.3-28.1; P = .014), indicating worse perceived physical functioning and greater disability, respectively. CONCLUSION Most employed patients returned to work within 1 year. LP patients resumed employment earliest, while PCDF patients returned to work latest, with greater disability at follow-up, suggesting that choice of surgical intervention may influence occupational outcomes.
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Affiliation(s)
- Stephen P Miranda
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert G Whitmore
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Adam Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Pickup Family Neurosciences Institute, Hoag Specialty Clinic, Los Angeles, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Erica F Bisson
- Department of Neurosurgery Clinical Neurosciences Center, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Fred G Barker
- Brain Tumor Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Subu N Magge
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Robert F Heary
- Department of Neurological Surgery, Hackensack Meridian School of Medicine, Nutley, New Jersey, USA
| | - Michael G Fehlings
- Division of Neurosurgery and Spine Program, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
- Division of Neurosurgery, Krembil Neuroscience Centre, University Health Network, Toronto, Ontario, Canada
| | - Todd J Albert
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York, USA
- Department of Neurosurgery, Weill Cornell Medicine, New York, New York, USA
| | - Paul M Arnold
- Carle Neuroscience Institute, Carle Foundation Hospital, Urbana, Illinois, USA
| | - K Daniel Riew
- Department of Neurosurgery, Weill Cornell Medicine, New York, New York, USA
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, New York, USA
| | | | - Marjorie C Wang
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - John G Heller
- The Emory Orthopaedics & Spine Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Edward C Benzel
- Center for Spine Health, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Zoher Ghogawala
- Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
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Shahrestani S, Brown NJ, Yue JK, Tan LA. Developing Mixed-effects Models to Optimize Prediction of Postoperative Outcomes in a Modern Sample of Over 450,000 Patients Undergoing Elective Cervical Spine Fusion Surgery. Clin Spine Surg 2023; 36:E536-E544. [PMID: 37651572 DOI: 10.1097/bsd.0000000000001512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 07/19/2023] [Indexed: 09/02/2023]
Abstract
STUDY DESIGN A retrospective cohort. OBJECTIVE We utilize big data and modeling techniques to create optimized comorbidity indices for predicting postoperative outcomes following cervical spine fusion surgery. SUMMARY OF BACKGROUND DATA Cervical spine decompression and fusion surgery are commonly used to treat degenerative cervical spine pathologies. However, there is a paucity of high-quality data defining the optimal comorbidity indices specifically in patients undergoing cervical spine fusion surgery. METHODS Using data from 2016 to 2019, we queried the Nationwide Readmissions Database (NRD) to identify individuals who had received cervical spine fusion surgery. The Johns Hopkins Adjusted Clinical Groups (JHACG) frailty-defining indicator was used to assess frailty. To measure the level of comorbidity, Elixhauser Comorbidity Index (ECI) scores were queried. Receiver operating characteristic curves were developed utilizing comorbidity indices as predictor variables for pertinent complications such as mortality, nonroutine discharge, top-quartile cost, top-quartile length of stay, and 1-year readmission. RESULTS A total of 453,717 patients were eligible. Nonroutine discharges occurred in 93,961 (20.7%) patients. The mean adjusted all-payer cost for the procedure was $22,573.14±18,274.86 (top quartile: $26,775.80) and the mean length of stay was 2.7±4.4 days (top quartile: 4.7 d). There were 703 (0.15%) mortalities and 58,254 (12.8%) readmissions within 1 year postoperatively. Models using frailty+ECI as primary predictors consistently outperformed the ECI-only model with statistically significant P -values for most of the complications assessed. Cost and mortality were the only outcomes for which this was not the case, as frailty outperformed both ECI and frailty+ECI in cost ( P <0.0001 for all) and frailty+ECI performed as well as ECI alone in mortality ( P =0.10). CONCLUSIONS Our data suggest that frailty+ECI may most accurately predict clinical outcomes in patients receiving cervical spine fusion surgery. These models may be used to identify high-risk populations and patients who may necessitate greater resource utilization following elective cervical spinal fusion.
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Affiliation(s)
- Shane Shahrestani
- Keck School of Medicine, University of Southern California, Los Angeles
- Department of Medical Engineering, California Institute of Technology, Pasadena
| | - Nolan J Brown
- Department of Neurological Surgery, University of California, Irvine, Orange
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA
| | - Lee A Tan
- Department of Neurological Surgery, University of California, San Francisco, CA
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3
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Ito S, Nakashima H, Yoshii T, Egawa S, Sakai K, Kusano K, Tsutui S, Hirai T, Matsukura Y, Wada K, Katsumi K, Koda M, Kimura A, Furuya T, Maki S, Nagoshi N, Nishida N, Nagamoto Y, Oshima Y, Ando K, Takahata M, Mori K, Nakajima H, Murata K, Miyagi M, Kaito T, Yamada K, Banno T, Kato S, Ohba T, Inami S, Fujibayashi S, Katoh H, Kanno H, Oda M, Mori K, Taneichi H, Kawaguchi Y, Takeshita K, Matsumoto M, Yamazaki M, Okawa A, Imagama S. Deep learning-based prediction model for postoperative complications of cervical posterior longitudinal ligament ossification. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2023; 32:3797-3806. [PMID: 36740608 DOI: 10.1007/s00586-023-07562-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/06/2023] [Accepted: 01/24/2023] [Indexed: 02/07/2023]
Abstract
PURPOSE Postoperative complication prediction helps surgeons to inform and manage patient expectations. Deep learning, a model that finds patterns in large samples of data, outperform traditional statistical methods in making predictions. This study aimed to create a deep learning-based model (DLM) to predict postoperative complications in patients with cervical ossification of the posterior longitudinal ligament (OPLL). METHODS This prospective multicenter study was conducted by the 28 institutions, and 478 patients were included in the analysis. Deep learning was used to create two predictive models of the overall postoperative complications and neurological complications, one of the major complications. These models were constructed by learning the patient's preoperative background, clinical symptoms, surgical procedures, and imaging findings. These logistic regression models were also created, and these accuracies were compared with those of the DLM. RESULTS Overall complications were observed in 127 cases (26.6%). The accuracy of the DLM was 74.6 ± 3.7% for predicting the overall occurrence of complications, which was comparable to that of the logistic regression (74.1%). Neurological complications were observed in 48 cases (10.0%), and the accuracy of the DLM was 91.7 ± 3.5%, which was higher than that of the logistic regression (90.1%). CONCLUSION A new algorithm using deep learning was able to predict complications after cervical OPLL surgery. This model was well calibrated, with prediction accuracy comparable to that of regression models. The accuracy remained high even for predicting only neurological complications, for which the case number is limited compared to conventional statistical methods.
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Affiliation(s)
- Sadayuki Ito
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa Ward, Nagoya, Aichi, 466-8550, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Hiroaki Nakashima
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa Ward, Nagoya, Aichi, 466-8550, Japan.
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan.
| | - Toshitaka Yoshii
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Satoru Egawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Kenichiro Sakai
- Department of Orthopaedic Surgery, Saiseikai Kawaguchi General Hospital, 5-11-5 Nishikawaguchi, Kawaguchishi, Saitama, 332-8558, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Kazuo Kusano
- Department of Orthopaedic Surgery, Kudanzaka Hospital, 1-6-12 Kudanminami, Chiyodaku, 102-0074, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Shinji Tsutui
- Department of Orthopaedic Surgery, Wakayama Medical University, 811-1 KImiidera, Wakayama-city, Wakayama, 641-8510, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Takashi Hirai
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Yu Matsukura
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Kanichiro Wada
- Department of Orthopaedic Surgery, Hirosaki University Graduate School of Medicine, 5 Zaifucho, Hirosaki, Aomori, 036-8562, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Keiichi Katsumi
- Department of Orthopaedic Surgery, Niigata University Medicine and Dental General Hospital, 1-754 Asahimachidori, Chuo Ward, Niigata, Niigata, 951-8520, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Masao Koda
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Atsushi Kimura
- Department of Orthopaedic, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Takeo Furuya
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo Ward, Chiba, Chiba, 260-8670, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Satoshi Maki
- Department of Orthopaedic Surgery, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo Ward, Chiba, Chiba, 260-8670, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Narihito Nagoshi
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku Ward, Tokyo, 160-8582, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Norihiro Nishida
- Department of Orthopaedic Surgery, Yamaguchi University School of Medicine, 111 Minami Kogushi, Ube, Yamaguchi, 755-8505, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Yukitaka Nagamoto
- Department of Orthopaedic Surgery, Osaka Rosai Hospital, 1179-3 Nagasonecho, Sakaishi, Osaka, 591-8025, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Yasushi Oshima
- Department of Orthopaedic Surgery, Faculty of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-Ku, Tokyo, 113-0033, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Kei Ando
- Department of Orthopaedic Surgery, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital, Myokencho 2-9, Showa Ward, Nagoya, Aichi, 466-8650, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Masahiko Takahata
- Department of Orthopaedic Surgery, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Kita 15, Nishi 7, Sapporo, 060-8638, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Kanji Mori
- Department of Orthopaedic Surgery, Shiga University of Medical Science, Tsukinowa-cho, Seta, Otsu, Shiga, 520-2192, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Hideaki Nakajima
- Department of Orthopaedics and Rehabilitation Medicine, Faculty of Medical Sciences, University of Fukui, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Kazuma Murata
- Department of Orthopaedic Surgery, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Masayuki Miyagi
- Department of Orthopedic Surgery, School of Medicine, Kitasato University, 1-15-1 Kitazato, Minami-ku, Sagamiharashi, Kanagawa, 252-0375, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Takashi Kaito
- Department of Orthopaedic Surgery, Graduate School of Medicine, Osaka University, 2-2 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Kei Yamada
- Department of Orthopaedic Surgery, Kurume University School of Medicine, 67 Asahi-machi, Kurume-shi, Fukuoka, 830-0011, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Tomohiro Banno
- Department of Orthopaedic Surgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Hamamatsu, Shizuoka, 431-3125, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Satoshi Kato
- Department of Orthopaedic Surgery, Graduate School of Medical Sciences, Kanazawa University, 13-1 Takara-machi, Kanazawa, 920-8641, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Tetsuro Ohba
- Department of Orthopaedic Surgery, University of Yamanashi, 1110 Shimokato, Chuo Ward, Yamanashi, 409-3898, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Satoshi Inami
- Department of Orthopaedic Surgery, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu-machi, Shimotsuga-gun, Tochigi, 321-0293, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Shunsuke Fujibayashi
- Department of Orthopaedic Surgery, Graduate School of Medicine, Kyoto University, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, 606-8507, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Hiroyuki Katoh
- Department of Orthopaedic Surgery, Surgical Science, Tokai University School of Medicine, 143 Shimokasuya, Isehara, Kanagawa, 259-1193, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Haruo Kanno
- Department of Orthopaedic Surgery, Tohoku University School of Medicine, 1-1 Seiryomachi, Aoba Ward, Sendai, Miyagi, 980-8574, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Masahiro Oda
- Information Strategy Office, Information and Communications, Nagoya University, Furo-cho, Chikusa-ku, Nagoya, Aichi, 464-8601, Japan
| | - Kensaku Mori
- Information Strategy Office, Information and Communications, Nagoya University, Furo-cho, Chikusa-ku, Nagoya, Aichi, 464-8601, Japan
- Department of Intelligent Systems, Nagoya University Graduate School of Informatics, Furo-cho, Chikusa-ku, Nagoya, Aichi, 464-8601, Japan
- Research Center for Medical Bigdata, National Institute of Informatics, 2-1-2 Hitotsubashi, Chiyoda-ku, Tokyo, 101-8430, Japan
| | - Hiroshi Taneichi
- Department of Orthopaedic Surgery, Dokkyo Medical University School of Medicine, 880 Kitakobayashi, Mibu-machi, Shimotsuga-gun, Tochigi, 321-0293, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Yoshiharu Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, 2630 Sugitani, Toyama, Toyama, 930-0194, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Katsushi Takeshita
- Department of Orthopaedic, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjuku Ward, Tokyo, 160-8582, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki, 305-8575, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Atsushi Okawa
- Department of Orthopaedic Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo Ward, Tokyo, 113-8519, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
| | - Shiro Imagama
- Department of Orthopaedic Surgery, Nagoya University Graduate School of Medicine, 65 Tsurumaicho, Showa Ward, Nagoya, Aichi, 466-8550, Japan
- Japanese Multicenter Research Organization for Ossification of the Spinal Ligament, Tokyo, Japan
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Bakare AA, Varela JR, Moss JR, Platt A, O'Toole JE, Fontes RBV, Traynelis VC. Comparison of Perioperative Complications After Anterior-Posterior Versus Posterior-Anterior-Posterior Cervical Fusion: A Retrospective Review of 153 Consecutive Cases. Neurosurgery 2023; 93:373-386. [PMID: 36861985 DOI: 10.1227/neu.0000000000002422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 12/22/2022] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Although published data support the utilization of circumferential fusion to treat select cervical spine pathologies, it is unclear whether the posterior-anterior-posterior (PAP) fusion has increased risks compared with the anterior-posterior fusion. OBJECTIVE To evaluate the differences in perioperative complications between the 2 circumferential cervical fusion approaches. METHODS One hundred fifty-three consecutive adult patients who underwent single-staged circumferential cervical fusion for degenerative pathologies from 2010 to 2021 were retrospectively reviewed. Patients were stratified into the anterior-posterior ( n = 116) and PAP ( n = 37) groups. The primary outcomes assessed were major complications, reoperation, and readmission. RESULTS Although the PAP group was older ( P = .024), predominantly female ( P = .024), with higher baseline neck disability index ( P = .026), cervical sagittal vertical axis ( P = .001), and previous cervical operation rate ( P < .00001), the major complication, reoperation, and readmission rates were not significantly different from the 360° group. Although the PAP group had higher urinary tract infection ( P = .043) and transfusion ( P = .007) rates, higher estimated blood loss ( P = .034), and longer operative times ( P < .00001), these differences were insignificant after the multivariable analysis. Overall, operative time was associated with older age (odds ratio [OR] 17.72, P = .042), atrial fibrillation (OR 158.30, P = .045), previous cervical operation (OR 5.05, P = .051), and lower baseline C1 - 7 lordosis (OR 0.93, P = .007). Higher estimated blood loss was associated with older age (OR 1.13, P = .005), male gender (OR 323.31, P = .047), and higher baseline cervical sagittal vertical axis (OR 9.65, P = .022). CONCLUSION Despite some differences in preoperative and intraoperative variables, this study suggests both circumferential approaches have comparable reoperation, readmission, and complication profiles, all of which are high.
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Affiliation(s)
- Adewale A Bakare
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois, USA
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Rodrigues AJ, Schonfeld E, Varshneya K, Stienen MN, Veeravagu A. The Impact of Preoperative Myelopathy on Postoperative Outcomes among Anterior Cervical Discectomy and Fusion Procedures in the Nonelderly Adult Population: A Propensity-Score Matched Study. Asian Spine J 2023; 17:693-702. [PMID: 37226379 PMCID: PMC10460652 DOI: 10.31616/asj.2022.0347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/28/2022] [Accepted: 01/20/2023] [Indexed: 05/26/2023] Open
Abstract
STUDY DESIGN Retrospective cohort study. PURPOSE Anterior cervical discectomy and fusion (ACDF) is a common surgical intervention for patients diagnosed with cervical degenerative diseases with or without myelopathy. A thorough understanding of outcomes in patients with and without myelopathy undergoing ACDF is required because of the widespread utilization of ACDF for these indications. OVERVIEW OF LITERATURE Non-ACDF approaches achieved inferior outcomes in certain myelopathic cases. Studies have compared patient outcomes across procedures, but few have compared outcomes concerning myelopathic versus nonmyelopathic cohorts. METHODS The MarketScan database was queried from 2007 to 2016 to identify adult patients who were ≤65 years old, and underwent ACDF using the international classification of diseases 9th version and current procedural terminology codes. Nearest neighbor propensity-score matching was employed to balance patient demographics and operative characteristics between myelopathic and nonmyelopathic cohorts. RESULTS Of 107,480 patients who met the inclusion criteria, 29,152 (27.1%) were diagnosed with myelopathy. At baseline, the median age of patients with myelopathy was higher (52 years vs. 50 years, p <0.001), and they had a higher comorbidity burden (mean Charlson comorbidity index, 1.92 vs. 1.58; p <0.001) than patients without myelopathy. Patients with myelopathy were more likely to undergo surgical revision at 2 years (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.54-1.73) or are readmitted within 90 days (OR, 1.27; 95% CI, 1.20-1.34). After patient cohorts were matched, patients with myelopathy remained at elevated risk for reoperation at 2 years (OR, 1.55; 95% CI, 1.44-1.67) and postoperative dysphagia (2.78% vs. 1.68%, p <0.001) compared to patients without myelopathy. CONCLUSIONS We found inferior postoperative outcomes at baseline for patients with myelopathy undergoing ACDF compared to patients without myelopathy. Patients with myelopathy remained at significantly greater risk for reoperation and readmission after balancing potential confounding variables across cohorts, and these differences in outcomes were largely driven by patients with myelopathy undergoing 1-2 level fusions.
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Affiliation(s)
- Adrian John Rodrigues
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
| | - Ethan Schonfeld
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
| | - Kunal Varshneya
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
| | - Martin Nikolaus Stienen
- Department of Neurosurgery & Spine Center of Eastern Switzerland, Kantonsspital St. Gallen & Medical School of St.Gallen, St. Gallen,
Switzerland
| | - Anand Veeravagu
- Neurosurgery AI Lab & Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA,
USA
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Guo L, Li J, Zhang F, Sun Y, Zhang W. Posterior endoscopic decompression combined with anterior cervical discectomy and fusion versus posterior laminectomy and fusion for multilevel cervical spondylotic myelopathy: a retrospective case-control study. BMC Musculoskelet Disord 2023; 24:578. [PMID: 37454072 DOI: 10.1186/s12891-023-06713-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE To compare the clinical efficacy of surgical treatment for multilevel cervical spondylotic myelopathy (MCSM) between the hybrid procedure, posterior endoscopic decompression (PED) combined with anterior cervical discectomy fusion (ACDF), and posterior cervical laminectomy and fusion (PCLF). METHODS A retrospective analysis was performed on 38 patients who received surgical treatment for MCSM from January 2018 to December 2021, including 19 cases in hybrid procedure group (13 males and 6 females), followed up for 10 to 22 (12.8 ± 10.3) months, and 19 cases in PCLF group (15 males and 4 females), followed up for 10 to 21 (11.7 ± 8.9) months. Perioperative information, including operation time, intraoperative blood loss, length of hospitalization, and complications, were compared between two groups. Visual analogue scale (VAS) of pain, neck disability index (NDI) and Japanese Orthopaedic Association (JOA) score were recorded to evaluate clinical efficacy. Cervical lordosis was calculated by radiographic examination. RESULTS Intraoperative blood loss, length of hospital stay were less in hybrid group than PCLF group, while operation time is longer in hybrid group, with a statistically significant difference (p < 0.05). Increased lordosis was better in hybrid group. There was no significant difference in preoperative VAS, JOA and NDI at pre-operation and final follow-up between two groups. But at post-operation and final follow-up, VAS was less in hybrid group than PCLF group (p < 0.05). There were 2 cases of neurostimulation symptoms in hybrid group, 2 cases of C5 nerve root palsy, 2 cases of subcutaneous fat necrosis and 1 case of dural tear in PCLF group, and all patients relieved with symptomatic treatment. CONCLUSION The hybrid procedure of PED combined with ACDF showed satisfied clinical outcome, with less intraoperative blood loss, shorter length of hospitalization and lower post-operative neck pain than PCLF. It is an effective surgical treatment for MCSM.
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Affiliation(s)
- Lei Guo
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Hebei, China
| | - Jiaqi Li
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Hebei, China
| | - Fei Zhang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Hebei, China
| | - Yapeng Sun
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Hebei, China
| | - Wei Zhang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Hebei, China.
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7
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He Z, Tung NTC, Makino H, Yasuda T, Seki S, Suzuki K, Watanabe K, Futakawa H, Kamei K, Kawaguchi Y. Assessment of Cervical Myelopathy Risk in Ossification of the Posterior Longitudinal Ligament Patients With Spinal Cord Compression Based on Segmental Dynamic Versus Static Factors. Neurospine 2023; 20:651-661. [PMID: 37401084 PMCID: PMC10323351 DOI: 10.14245/ns.2346124.062] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/05/2023] [Accepted: 03/14/2023] [Indexed: 07/05/2023] Open
Abstract
OBJECTIVE Using segmental dynamic and static factors, we aimed to elucidate the pathogenesis and relationship between ossification of the posterior longitudinal ligament (OPLL) and the severity of cervical myelopathy. METHODS Retrospective analysis of 163 OPLL patients' 815 segments. Imaging was used to evaluate each segmental space available for the spinal cord (SAC), OPLL diameter, type, bone space, K-line, the C2-7 Cobb angle, each segmental range of motion (ROM), and total ROM. Magnetic resonance imaging was used to evaluate spinal cord signal intensity. Patients were divided into the myelopathy group (M group) and the without myelopathy group (WM group). RESULTS Minimal SAC (p = 0.043), (C2-7) Cobb angle (p = 0.004), total ROM (p = 0.013), and local ROM (p = 0.022) were evaluated as an independent predictor of myelopathy in OPLL. Different from the previous report, the M group had a straighter whole cervical spine (p < 0.001) and poorer cervical mobility (p < 0.001) compared to the WM group. Total ROM was not always a risk factor for myelopathy, as its impact depended on SAC, when SAC > 5 mm, the incidence rate of myelopathy decreased with the increase of total ROM. Lower cervical spine (C5-6, C6-7) showing increased "Bridge-Formation," along with spinal canal stenosis and segmental instability (C2-3, C3-4) in the upper cervical spine, could cause myelopathy in M group (p < 0.05). CONCLUSION Cervical myelopathy is linked to the OPLL's narrowest segment and its segmental motion. The hypermobility of the C2-3 and C3-4, contributes significantly to the development of myelopathy in OPLL.
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Affiliation(s)
- Zhongyuan He
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
- Innovation Platform of Regeneration and Repair of Spinal Cord and Nerve Injury, Department of Orthopaedic Surgery, The Seventh Affiliated Hospital of Sun Yat-sen University, Shenzhen, China
| | - Nguyen Tran Canh Tung
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
- Department of Trauma and Orthopaedic Surgery, Vietnam Military Medical University, Hanoi, Vietnam
| | - Hiroto Makino
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Taketoshi Yasuda
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Shoji Seki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Kayo Suzuki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Kenta Watanabe
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Hayato Futakawa
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Katsuhiko Kamei
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Yoshiharu Kawaguchi
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama, Toyama, Japan
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8
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Yuh WT, Kim M, Choi Y, Han J, Kim J, Kim T, Chung CK, Lee CH, Park SB, Kim KT, Rhee JM, Park MS, Kim CH. Nationwide sample data analysis of additional surgery rate after anterior or posterior cervical spinal surgery. Sci Rep 2023; 13:6317. [PMID: 37072455 PMCID: PMC10113194 DOI: 10.1038/s41598-023-33588-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 04/15/2023] [Indexed: 05/03/2023] Open
Abstract
Surgical outcomes of degenerative cervical spinal disease are dependent on the selection of surgical techniques. Although a standardized decision cannot be made in an actual clinical setting, continued education is provided to standardize the medical practice among surgeons. Therefore, it is necessary to supervise and regularly update overall surgical outcomes. This study aimed to compare the rate of additional surgery between anterior and posterior surgeries for degenerative cervical spinal disease using the National Health Insurance Service-National Sample Cohort (NHIS-NSC) nationwide patient database. The NHIS-NSC is a population-based cohort with about a million participants. This retrospective cohort study included 741 adult patients (> 18 years) who underwent their first cervical spinal surgery for degenerative cervical spinal disease. The median follow-up period was 7.3 years. An event was defined as the registration of any type of cervical spinal surgery during the follow-up period. Event-free survival analysis was used for outcome analysis, and the following factors were used as covariates for adjustment: location of disease, sex, age, type of insurance, disability, type of hospital, Charles comorbidity Index, and osteoporosis. Anterior cervical surgery was selected for 75.0% of the patients, and posterior cervical surgery for the remaining 25.0%. Cervical radiculopathy due to foraminal stenosis, hard disc, or soft disc was the primary diagnosis in 78.0% of the patients, and central spinal stenosis was the primary diagnosis in 22.0% of them. Additional surgery was performed for 5.0% of the patients after anterior cervical surgery and 6.5% of the patients after posterior cervical surgery (adjusted subhazard ratio, 0.83; 95% confidence interval, 0.40-1.74). The rates of additional surgery were not different between anterior and posterior cervical surgeries. The results would be helpful in evaluating current practice as a whole and adjusting the health insurance policy.
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Affiliation(s)
- Woon Tak Yuh
- Department of Neurosurgery, Hallym University Dongtan Sacred Heart Hospital, 7 Keunjaebong-gil, Hwaseong-si, Gyeonggi-do, 18450, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Minjung Kim
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Yunhee Choi
- Division of Medical Statistics, Medical Research Collaborating Center, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Junghoon Han
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Junhoe Kim
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Taeshin Kim
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Neurosurgery, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Brain and Cognitive Sciences, College of Natural Science, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Republic of Korea
| | - Chang-Hyun Lee
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Neurosurgery, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Sung Bae Park
- Department of Neurosurgery, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Neurosurgery, Seoul National University Boramae Hospital, Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Kyoung-Tae Kim
- Department of Neurosurgery, Kyungpook National University Hospital, 130 Dongdeok-ro, Jung-gu, Daegu, 41944, Republic of Korea
- Department of Neurosurgery, School of Medicine, Kyungpook National University, 680 Gukchaebosang-ro, Jung-gu, Daegu, 41944, Republic of Korea
| | - John M Rhee
- Department of Orthopaedic Surgery, Emory University School of Medicine, Atlanta, GA, 30322, USA
| | - Moon Soo Park
- Department of Orthopedics, Hallym University Dongtan Sacred Heart Hospital, 22 Gwanpyeong-ro 170 Beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, Republic of Korea
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Neurosurgery, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Medical Device Development, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
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9
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Shah AA, Devana SK, Lee C, Olson TE, Upfill-Brown A, Sheppard WL, Lord EL, Shamie AN, van der Schaar M, SooHoo NF, Park DY. Development and External Validation of a Risk Calculator for Prediction of Major Complications and Readmission After Anterior Cervical Discectomy and Fusion. Spine (Phila Pa 1976) 2023; 48:460-467. [PMID: 36730869 PMCID: PMC10023283 DOI: 10.1097/brs.0000000000004531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/22/2022] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN A retrospective, case-control study. OBJECTIVE We aim to build a risk calculator predicting major perioperative complications after anterior cervical fusion. In addition, we aim to externally validate this calculator with an institutional cohort of patients who underwent anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA The average age and proportion of patients with at least one comorbidity undergoing ACDF have increased in recent years. Given the increased morbidity and cost associated with perioperative complications and unplanned readmission, accurate risk stratification of patients undergoing ACDF is of great clinical utility. METHODS This is a retrospective cohort study of adults who underwent anterior cervical fusion at any nonfederal California hospital between 2015 and 2017. The primary outcome was major perioperative complication or 30-day readmission. We built standard and ensemble machine learning models for risk prediction, assessing discrimination, and calibration. The best-performing model was validated on an external cohort comprised of consecutive adult patients who underwent ACDF at our institution between 2013 and 2020. RESULTS A total of 23,184 patients were included in this study; there were 1886 cases of major complication or readmissions. The ensemble model was well calibrated and demonstrated an area under the receiver operating characteristic curve of 0.728. The variables most important for the ensemble model include male sex, medical comorbidities, history of complications, and teaching hospital status. The ensemble model was evaluated on the validation cohort (n=260) with an area under the receiver operating characteristic curve of 0.802. The ensemble algorithm was used to build a web-based risk calculator. CONCLUSION We report derivation and external validation of an ensemble algorithm for prediction of major perioperative complications and 30-day readmission after anterior cervical fusion. This model has excellent discrimination and is well calibrated when tested on a contemporaneous external cohort of ACDF cases.
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Affiliation(s)
- Akash A. Shah
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Sai K. Devana
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Changhee Lee
- Department of Artificial Intelligence, Chung-Ang University, Seoul, South Korea
| | - Thomas E. Olson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Alexander Upfill-Brown
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - William L. Sheppard
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Elizabeth L. Lord
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Arya N. Shamie
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Mihaela van der Schaar
- Department of Electrical and Computer Engineering, University of California, Los Angeles, CA
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, United Kingdom
| | - Nelson F. SooHoo
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Don Y. Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
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10
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Lee NJ, Boddapati V, Mathew J, Fields M, Vulapalli M, Kim JS, Lombardi JM, Sardar ZM, Lehman RA, Riew KD. What Is the Impact of Surgical Approach in the Treatment of Degenerative Cervical Myelopathy in Patients With OPLL? A Propensity-Score Matched, Multi-Center Analysis on Inpatient and Post-Discharge 90-Day Outcomes. Global Spine J 2023; 13:324-333. [PMID: 33601898 PMCID: PMC9972269 DOI: 10.1177/2192568221994797] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Retrospective cohort. OBJECTIVE Provide a comparison of surgical approach in the treatment of degenerative cervical myelopathy in patients with OPLL. METHODS A national database was queried to identify adult (≥18 years) patients with OPLL, who underwent at least a 2-level cervical decompression and fusion for cervical myelopathy from 2012-2014. A propensity-score-matching algorithm was employed to compare outcomes by surgical approach. RESULTS After propensity-score matching, 627 patients remained. An anterior approach was found to be an independent predictor for higher inpatient surgical complications(OR 5.9), which included dysphagia:14%[anterior]vs.1.1%[posterior] P-value < 0.001, wound hematoma:1.7%[anterior]vs.0%[posterior] P-value = 0.02, and dural tear:9.4%[anterior]vs.3.2%[posterior] P-value = 0.001. A posterior approach was an predictor for longer hospital length of stay by nearly 3 days(OR 3.4; 6.8 days[posterior]vs.4.0 days[anterior] P-value < 0.001). The reasons for readmission/reoperation did not vary by approach for 2-3-level fusions; however, for >3-level fusions, patients with an anterior approach more often had respiratory complications requiring mechanical ventilation(P-value = 0.038) and required revision fusion surgery(P-value = 0.015). CONCLUSIONS The national estimates for inpatient complications(25%), readmissions(9.9%), and reoperations(3.5%) are substantial after the surgical treatment of multi-level OPLL. An anterior approach resulted in significantly higher inpatient surgical complications, but this did not result in a longer hospital length of stay and the overall 90-day complication rates requiring readmission or reoperation was similar to those seen after a posterior approach. For patients requiring >3-level fusion, an anterior approach is associated with significantly higher risk for respiratory complications requiring mechanical ventilation and revision fusion surgery. Precise neurological complications and functional outcomes were not included in this database, and should be further assessed in future studies.
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Affiliation(s)
- Nathan J. Lee
- Department of Orthopaedics, Columbia
University Medical Center, The Och Spine Hospital at New York-Presbyterian, New
York, NY, USA,Nathan J. Lee, MD, Columbia University
Medical Center, Fort Washington Avenue, New York, NY 10032, USA.
| | - Venkat Boddapati
- Department of Orthopaedics, Columbia
University Medical Center, The Och Spine Hospital at New York-Presbyterian, New
York, NY, USA
| | - Justin Mathew
- Department of Orthopaedics, Columbia
University Medical Center, The Och Spine Hospital at New York-Presbyterian, New
York, NY, USA
| | - Michael Fields
- Department of Orthopaedics, Columbia
University Medical Center, The Och Spine Hospital at New York-Presbyterian, New
York, NY, USA
| | - Meghana Vulapalli
- Department of Orthopaedics, Columbia
University Medical Center, The Och Spine Hospital at New York-Presbyterian, New
York, NY, USA
| | - Jun S. Kim
- Department of Orthopaedics, Columbia
University Medical Center, The Och Spine Hospital at New York-Presbyterian, New
York, NY, USA
| | - Joseph M. Lombardi
- Department of Orthopaedics, Columbia
University Medical Center, The Och Spine Hospital at New York-Presbyterian, New
York, NY, USA
| | - Zeeshan M. Sardar
- Department of Orthopaedics, Columbia
University Medical Center, The Och Spine Hospital at New York-Presbyterian, New
York, NY, USA
| | - Ronald A. Lehman
- Department of Orthopaedics, Columbia
University Medical Center, The Och Spine Hospital at New York-Presbyterian, New
York, NY, USA
| | - K. Daniel Riew
- Department of Orthopaedics, Columbia
University Medical Center, The Och Spine Hospital at New York-Presbyterian, New
York, NY, USA
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11
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A Five-Year Cost-Utility Analysis Comparing Synthetic Cage Versus Allograft Use in Anterior Cervical Discectomy and Fusion Surgery for Cervical Spondylotic Myelopathy. Spine (Phila Pa 1976) 2023; 48:330-334. [PMID: 36730850 DOI: 10.1097/brs.0000000000004526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/12/2022] [Indexed: 02/04/2023]
Abstract
STUDY DESIGN Retrospective cost-utility analysis. OBJECTIVE To conduct a cost-analysis comparing synthetic cage (SC) versus allograft (Allo) over a five-year time horizon. SUMMARY OF BACKGROUND DATA SC and Allo are two commonly used interbody choices for anterior cervical discectomy and fusion (ACDF) surgery. Previous analyses comparative analyses have reached mixed conclusions regarding their cost-effectiveness, yet recent estimates provide high-quality evidence. MATERIALS AND METHODS A decision-analysis model comparing the use of Allo versus SC was developed for a hypothetical 60-year-old patient with cervical spondylotic myelopathy undergoing single-level ACDF surgery. A comprehensive literature review was performed to estimate probabilities, costs (2020 USD) and quality-adjusted life years (QALYs) gained over a five-year period. A probabilistic sensitivity analysis using a Monte Carlo simulation of 1000 patients was carried out to calculate incremental cost-effectiveness ratio and net monetary benefits. One-way deterministic sensitivity analysis was performed to estimate the contribution of individual parameters to uncertainty in the model. RESULTS The use of Allo was favored in 81.6% of the iterations at a societal willing-to-pay threshold of 50,000 USD/QALY. Allo dominated (higher net QALYs and lower net costs) in 67.8% of the iterations. The incremental net monetary benefits in the Allo group was 2650 USD at a willing-to-pay threshold of 50,000 USD/QALY. One-way deterministic sensitivity analysis revealed that the cost of the index surgery was the only factor which significantly contributed to uncertainty. CONCLUSION Cost-utility analysis suggests that Allo maybe a more cost-effective option compared with SCs in adult patients undergoing ACDF for cervical spondylotic myelopathy.
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12
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Elsamadicy AA, Koo AB, Reeves BC, Freedman IG, David WB, Ehresman J, Pennington Z, Laurans M, Kolb L, Sciubba DM. Octogenarians Are Independently Associated With Extended LOS and Non-Routine Discharge After Elective ACDF for CSM. Global Spine J 2022; 12:1792-1803. [PMID: 33511889 PMCID: PMC9609534 DOI: 10.1177/2192568221989293] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim of this study was to determine the impact age has on LOS and discharge disposition following elective ACDF for cervical spondylotic myelopathy (CSM). METHODS A retrospective cohort study was performed using the National Inpatient Sample (NIS) database from 2016 and 2017. All adult patients >50 years old undergoing ACDF for CSM were identified using the ICD-10-CM diagnosis and procedural coding system. Patients were then stratified by age: 50 to 64 years-old, 65 to 79 years-old, and greater than or equal to 80 years-old. Weighted patient demographics, comorbidities, perioperative complications, LOS, discharge disposition, and total cost of admission were assessed. RESULTS A total of 14 865 patients were identified. Compared to the 50-64 and 65-79 year-old cohorts, the 80+ years cohort had a significantly higher rate of postoperative complication (50-64 yo:10.2% vs. 65-79 yo:12.6% vs. 80+ yo:18.9%, P = 0.048). The 80+ years cohort experienced significantly longer hospital stays (50-64 yo: 2.0 ± 2.4 days vs. 65-79 yo: 2.2 ± 2.8 days vs. 80+ yo: 2.3 ± 2.1 days, P = 0.028), higher proportion of patients with extended LOS (50-64 yo:18.3% vs. 65-79 yo:21.9% vs. 80+ yo:28.4%, P = 0.009), and increased rates of non-routine discharges (50-64 yo:15.1% vs. 65-79 yo:23.0% vs. 80+ yo:35.8%, P < 0.001). On multivariate analysis, age 80+ years was found to be a significant independent predictor of extended LOS [OR:1.97, 95% CI:(1.10,3.55), P = 0.023] and non-routine discharge [OR:2.46, 95% CI:(1.44,4.21), P = 0.001]. CONCLUSIONS Our study demonstrates that octogenarian age status is a significant independent risk factor for extended LOS and non-routine discharge after elective ACDF for CSM.
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Affiliation(s)
- Aladine A. Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
- Aladine A. Elsamadicy, Department of
Neurosurgery, Yale University School of Medicine, 333 Cedar Street, New Haven,
CT 06520, USA.
| | - Andrew B. Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Benjamin C. Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Isaac G. Freedman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Wyatt B. David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Jeff Ehresman
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA
| | - Zach Pennington
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA
| | - Maxwell Laurans
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Luis Kolb
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel M. Sciubba
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, USA
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13
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Shah AA, Devana SK, Lee C, Bugarin A, Lord EL, Shamie AN, Park DY, van der Schaar M, SooHoo NF. Machine learning-driven identification of novel patient factors for prediction of major complications after posterior cervical spinal fusion. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1952-1959. [PMID: 34392418 PMCID: PMC8844303 DOI: 10.1007/s00586-021-06961-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/23/2021] [Accepted: 08/08/2021] [Indexed: 01/20/2023]
Abstract
PURPOSE Posterior cervical fusion is associated with increased rates of complications and readmission when compared to anterior fusion. Machine learning (ML) models for risk stratification of patients undergoing posterior cervical fusion remain limited. We aim to develop a novel ensemble ML algorithm for prediction of major perioperative complications and readmission after posterior cervical fusion and identify factors important to model performance. METHODS This is a retrospective cohort study of adults who underwent posterior cervical fusion at non-federal California hospitals between 2015 and 2017. The primary outcome was readmission or major complication. We developed an ensemble model predicting complication risk using an automated ML framework. We compared performance with standard ML models and logistic regression (LR), ranking contribution of included variables to model performance. RESULTS Of the included 6822 patients, 18.8% suffered a major complication or readmission. The ensemble model demonstrated slightly superior predictive performance compared to LR and standard ML models. The most important features to performance include sex, malignancy, pneumonia, stroke, and teaching hospital status. Seven of the ten most important features for the ensemble model were markedly less important for LR. CONCLUSION We report an ensemble ML model for prediction of major complications and readmission after posterior cervical fusion with a modest risk prediction advantage compared to LR and benchmark ML models. Notably, the features most important to the ensemble are markedly different from those for LR, suggesting that advanced ML methods may identify novel prognostic factors for adverse outcomes after posterior cervical fusion.
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Affiliation(s)
- Akash A Shah
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, 90095, USA.
| | - Sai K Devana
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, 90095, USA
| | - Changhee Lee
- Department of Electrical and Computer Engineering, University of California, Los Angeles, CA, USA
| | - Amador Bugarin
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, 90095, USA
| | - Elizabeth L Lord
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, 90095, USA
| | - Arya N Shamie
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, 90095, USA
| | - Don Y Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, 90095, USA
| | - Mihaela van der Schaar
- Department of Electrical and Computer Engineering, University of California, Los Angeles, CA, USA
- Department of Applied Mathematics and Theoretical Physics, University of Cambridge, Cambridge, UK
| | - Nelson F SooHoo
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Los Angeles, 90095, USA
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Jain N, Sharma M, Wang D, Ugiliweneza B, Drazin D, Boakye M. Simulated bundled payments for four common surgical approaches to treat degenerative cervical myelopathy: a consideration to break the clinical equipoise. J Neurosurg Spine 2022; 37:49-56. [PMID: 35171836 DOI: 10.3171/2021.10.spine211105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 10/26/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In degenerative cervical myelopathy (DCM) pathologies in which there exists a clinical equipoise in approach selection, a randomized controlled trial found that an anterior approach did not significantly improve patient-reported outcomes compared with posterior approaches. In this era of value and bundled payment initiatives, the cost profiles of various surgical approaches will form an important consideration in decision-making. The objective of this study was to compare 90-day and 2-year reimbursements for ≥ 2-level (multilevel) anterior cervical discectomy and fusion (mACDF), anterior cervical corpectomy and fusion (ACCF), posterior cervical laminectomy and fusion (LF), and cervical laminoplasty (LP) performed for DCM. METHODS The IBM MarketScan research database (2005-2018) was used to study beneficiaries 30-75 years old who underwent surgery using four approaches (mACDF, ACCF, LF, or LP) for DCM. Demographics, index surgery length of stay (LOS), complications, and discharge disposition were compared. Index admission (surgeon, hospital services, operating room) and postdischarge inpatient (readmission, revision surgery, inpatient rehabilitation), outpatient (imaging, emergency department, office visits, physical therapy), and medication-related payments were described. Ninety-day and 2-year bundled payment amounts were simulated for each procedure. All payments are reported as medians and interquartile ranges (IQRs; Q1-Q3) and were adjusted to 2018 US dollars. RESULTS A total of 10,834 patients, with a median age of 54 years, were included. The median 90-day payment was $46,094 (IQR $34,243-$65,841) for all procedures, with LF being the highest ($64,542) and LP the lowest ($37,867). Index hospital payment was 62.4% (surgery/operating room 46.6%) and surgeon payments were 17.5% of the average 90-day bundle. There were significant differences in the index, 90-day, and 2-year reimbursements and their distribution among procedures. CONCLUSIONS In a national cohort of patients undergoing surgery for DCM, LP had the lowest complication rate and simulated bundled reimbursements at 90 days and 2 years postoperatively. The lowest quartile 90-day payment for LF was more expensive than median amounts for mACDF, ACCF, and LP. If surgeons encounter scenarios of clinical equipoise in practice, LP is likely to result in maximum value because it is 70% less expensive on average than LF over 90 days.
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Affiliation(s)
- Nikhil Jain
- 1Department of Orthopedics, Boston University, Boston, Massachusetts
| | - Mayur Sharma
- 2Department of Neurosurgery, University of Louisville, Kentucky; and
| | - Dengzhi Wang
- 2Department of Neurosurgery, University of Louisville, Kentucky; and
| | | | - Doniel Drazin
- 3Pacific Northwest University of Health Sciences, Yakima, Washington
| | - Maxwell Boakye
- 2Department of Neurosurgery, University of Louisville, Kentucky; and
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Elsamadicy AA, Koo AB, David WB, Freedman IG, Reeves BC, Ehresman J, Pennington Z, Sarkozy M, Laurans M, Kolb L, Shin JH, Sciubba DM. Ramifications of Postoperative Dysphagia on Health Care Resource Utilization Following Elective Anterior Cervical Discectomy and Interbody Fusion for Cervical Spondylotic Myelopathy. Clin Spine Surg 2022; 35:E380-E388. [PMID: 34321392 DOI: 10.1097/bsd.0000000000001241] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 06/23/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE The aim of this study was to investigate patient risk factors and health care resource utilization associated with postoperative dysphagia following elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA There is a paucity of data on factors predisposing patients to dysphagia and the burden this complication has on health care resource utilization following ACDF. METHODS A retrospective cohort study was performed using the Nationwide Inpatient Sample (NIS) database from 2016 to 2017. All adult (above 18 y old) patients undergoing ACDF for cervical spondylotic myelopathy were identified using the ICD-10-CM diagnosis and procedural coding system. Patients were then categorized by whether they had a recorded postoperative dysphagia or no dysphagia. Weighted patient demographics, comorbidities, perioperative complications, length of hospital stay (LOS), discharge disposition, and total cost of admission were assessed. A multivariate stepwise logistic regression was used to determine both the odds ratio for risk-adjusted postoperative dysphagia as well as extended LOS. RESULTS A total of 17,385 patients were identified, of which 1400 (8.1%) experienced postoperative dysphagia. Compared with the No-Dysphagia cohort, the Dysphagia cohort had a greater proportion of patients experiencing a complication (P=0.004), including 1 complication (No-Dysphagia: 2.9% vs. Dysphagia: 6.8%), and >1 complication (No-Dysphagia: 0.3% vs. Dysphagia: 0.4%). The Dysphagia cohort experienced significantly longer hospital stays (No-Dysphagia: 1.9±2.1 d vs. Dysphagia: 4.2±4.3 d, P<0.001), higher total cost of admission (No-Dysphagia: $19,441±10,495 vs. Dysphagia: $25,529±18,641, P<0.001), and increased rates of nonroutine discharge (No-Dysphagia: 16.5% vs. Dysphagia: 34.3%, P<0.001). Postoperative dysphagia was found to be a significant independent risk factor for extended LOS on multivariate analysis, with an odds ratio of 5.37 (95% confidence interval: 4.09, 7.05, P<0.001). CONCLUSION Patients experiencing postoperative dysphagia were found to have significantly longer hospital LOS, higher total cost of admission, and increased nonroutine discharge when compared with the patients who did not. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Isaac G Freedman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Jeff Ehresman
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD
| | - Zach Pennington
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Maxwell Laurans
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - Luis Kolb
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Daniel M Sciubba
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY
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Jain N, Sharma M, Wang D, Ugiliweneza B, Drazin D, Boakye M. Simulated Bundled Payments for 4 Common Surgical Approaches to Treat Degenerative Cervical Myelopathy: A Consideration to Break the Clinical Equipoise. Clin Spine Surg 2022; 35:E636-E642. [PMID: 35344518 DOI: 10.1097/bsd.0000000000001315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/01/2022] [Indexed: 12/16/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE The aim was to compare 90-day and 2-year reimbursements for ≥2-level anterior cervical discectomy and fusion (mACDF), anterior cervical corpectomy and fusion (ACCF), posterior laminectomy and fusion (LF) and laminoplasty (LP) done for degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA In DCM pathologies where there exists a clinical equipoise in approach selection, a randomized controlled trial found that an anterior approach did not significantly improve patient-reported outcomes over posterior approaches. In the era of value and bundled payments initiatives, cost profile of various approaches will form an important consideration for decision making. MATERIALS AND METHODS IBM MarketScan Research Database (2005-2018) was used to study beneficiaries (30-75 y) who underwent surgery (mACDF, ACCF, LF, LP) for DCM. Index hospital stay (operating room, surgeon, hospital services) and postdischarge inpatient, outpatient and prescription medication payments have been used to simulate 90-day and 2-year bundled payment amounts, along with their distribution for each procedure. RESULTS A total of 10,834 patients with median age of 54 years were included. The median 90-day payment was $46,094 (interquartile range: $34,243-$65,841) for all procedures, with LF being the highest ($64,542) and LP the lowest ($37,867). Index hospital was 62.4% (operating room: 46.6) and surgeon payments were 17.5% of the average 90-day bundle. There was significant difference in the index, 90-day and 2-year reimbursements and their distribution among procedures. CONCLUSION In a national cohort of patients undergoing surgery for DCM, LP had the lowest complication rate, and simulated bundled reimbursements at 90 days and 2 years postoperatively. The lowest quartile 90-day payment for LF was more expensive than median amounts for mACDF, ACCF, and LP. If surgeons encounter scenarios of clinical equipoise in practice, LP is likely to result in maximum value as it is on an average 70% less expensive than LF over 90 days.
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Affiliation(s)
- Nikhil Jain
- Department of Orthopedics, Boston University, Boston, MA
| | - Mayur Sharma
- Department of Neurosurgery, University of Louisville, Louisville, KY
| | - Dengzhi Wang
- Department of Neurosurgery, University of Louisville, Louisville, KY
| | | | - Doniel Drazin
- Pacific Northwest University of Health Sciences, Yakima, WA
| | - Maxwell Boakye
- Department of Neurosurgery, University of Louisville, Louisville, KY
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Koo AB, Elsamadicy AA, Sarkozy M, Pathak N, David WB, Freedman IG, Reeves BC, Sciubba DM, Laurans M, Kolb L. Geographic variations in health care resource utilization following elective ACDF for cervical spondylotic myelopathy: A national trend analysis. NORTH AMERICAN SPINE SOCIETY JOURNAL 2022; 9:100099. [PMID: 35141663 PMCID: PMC8819911 DOI: 10.1016/j.xnsj.2022.100099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 12/27/2021] [Accepted: 01/03/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND As health care expenditures continue to increase, standardizing health care delivery across geographic regions has been identified as a method to reduce costs. However, few studies have demonstrated how the practice of elective spine surgery varies by geographic location. The aim of this study was to assess the geographic variations in management, complications, and total cost of elective anterior cervical discectomy and fusion (ACDF) for cervical spondylotic myelopathy (CSM). METHODS The National Inpatient Sample database (2016-2017) was queried using the ICD-10-CM procedural and diagnostic coding systems to identify all adult (≥18 years) patients with a primary diagnosis of CSM undergoing an elective ACDF. Patients were divided into regional cohorts as defined by the U.S. Census Bureau: Northeast, Midwest, South, and West. Weighted patient demographics, Elixhauser comorbidities, perioperative complications, length of stay (LOS), discharge disposition, and total cost of admission were assessed. RESULTS A total of 17,385 adult patients were identified. While the age (p=0.116) and proportion of female patients (p=0.447) were similar among the cohorts, race (p<0.001) and healthcare coverage (p<0.001) varied significantly. The Northeast had the largest proportion of patients in the 76-100th household income quartile (Northeast: 32.1%; Midwest: 16.9%; South: 15.7%; West: 27.5%, p<0.001). Complication rates were similar between regional cohorts (Northeast: 10.1%; Midwest: 12.2%; South: 10.3%; West: 11.9%, p=0.503), as was LOS (Northeast: 2.2±2.4 days; Midwest: 2.1±2.4 days; South: 2.0±2.5 days; West: 2.1±2.4 days, p=0.678). The West incurred the greatest mean total cost of admission (Northeast: $19,167±10,267; Midwest: $18,903±9,114; South: $18,566±10,152; West: $24,322±15,126, p<0.001). The Northeast had the lowest proportion of patients with a routine discharge (Northeast: 72.0%; Midwest: 84.8%; South: 82.3%; West: 83.3%, p<0.001). The odds ratio for Western hospital region was 3.46 [95% CI: (2.41, 4.96), p<0.001] compared to the Northeast for increased cost. CONCLUSION Our study suggests that regional variations exist in elective ACDF for CSM, including patient demographics, hospital costs, and nonroutine discharges, while complication rates and LOS were similar between regions.
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Affiliation(s)
- Andrew B. Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Aladine A. Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Neil Pathak
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, CT, United States
| | - Wyatt B. David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Isaac G. Freedman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Benjamin C. Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Daniel M. Sciubba
- Department of Neurosurgery, John Hopkins School of Medicine, Baltimore, MD, United States
- Department of Neurosurgery, Zucker School of Medicine at Hofstra, Long Island Jewish Medical Center and North Shore University Hospital, Northwell Health, Manhasset, NY, United States
| | - Maxwell Laurans
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Luis Kolb
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
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Dutt R, Mendonca D, Phen HM, Broida S, Ghassemi M, Gichoya J, Banerjee I, Yoon T, Trivedi H. Automatic Localization and Brand Detection of Cervical Spine Hardware on Radiographs Using Weakly Supervised Machine Learning. Radiol Artif Intell 2022; 4:e210099. [PMID: 35391772 DOI: 10.1148/ryai.210099] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 12/13/2021] [Accepted: 12/27/2021] [Indexed: 01/09/2023]
Abstract
Purpose To develop an end-to-end pipeline to localize and identify cervical spine hardware brands on routine cervical spine radiographs. Materials and Methods In this single-center retrospective study, patients who received cervical spine implants between 2014 and 2018 were identified. Information on the implant model was retrieved from the surgical notes. The dataset was filtered for implants present in at least three patients, which yielded five anterior and five posterior hardware models for classification. Images for training were manually annotated with bounding boxes for anterior and posterior hardware. An object detection model was trained and implemented to localize hardware on the remaining images. An image classification model was then trained to differentiate between five anterior and five posterior hardware models. Model performance was evaluated on a holdout test set with 1000 iterations of bootstrapping. Results A total of 984 patients (mean age, 62 years ± 12 [standard deviation]; 525 women) were included for model training, validation, and testing. The hardware localization model achieved an intersection over union of 86.8% and an F1 score of 94.9%. For brand classification, an F1 score, sensitivity, and specificity of 98.7% ± 0.5, 98.7% ± 0.5, and 99.2% ± 0.3, respectively, were attained for anterior hardware, with values of 93.5% ± 2.0, 92.6% ± 2.0, and 96.1% ± 2.0, respectively, attained for posterior hardware. Conclusion The developed pipeline was able to accurately localize and classify brands of hardware implants using a weakly supervised learning framework.Keywords: Spine, Convolutional Neural Network, Deep Learning Algorithms, Machine Learning Algorithms, Prostheses, Semisupervised Learning Supplemental material is available for this article. © RSNA, 2022See also commentary by Huisman and Lessmann in this issue.
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Affiliation(s)
- Raman Dutt
- Department of Computer Science, Shiv Nadar University, Greater Noida, Uttar Pradesh, India (R.D.); Department of Chemical Engineering and Applied Chemistry (D.M.) and Department of Computer Science (M.G.), University of Toronto, Toronto, Canada; and Departments of Radiology (H.M.P., S.B., J.G., T.Y., H.T.) and Biomedical Informatics (I.B.), Emory University, Atlanta, Ga
| | - Dylan Mendonca
- Department of Computer Science, Shiv Nadar University, Greater Noida, Uttar Pradesh, India (R.D.); Department of Chemical Engineering and Applied Chemistry (D.M.) and Department of Computer Science (M.G.), University of Toronto, Toronto, Canada; and Departments of Radiology (H.M.P., S.B., J.G., T.Y., H.T.) and Biomedical Informatics (I.B.), Emory University, Atlanta, Ga
| | - Huai Ming Phen
- Department of Computer Science, Shiv Nadar University, Greater Noida, Uttar Pradesh, India (R.D.); Department of Chemical Engineering and Applied Chemistry (D.M.) and Department of Computer Science (M.G.), University of Toronto, Toronto, Canada; and Departments of Radiology (H.M.P., S.B., J.G., T.Y., H.T.) and Biomedical Informatics (I.B.), Emory University, Atlanta, Ga
| | - Samuel Broida
- Department of Computer Science, Shiv Nadar University, Greater Noida, Uttar Pradesh, India (R.D.); Department of Chemical Engineering and Applied Chemistry (D.M.) and Department of Computer Science (M.G.), University of Toronto, Toronto, Canada; and Departments of Radiology (H.M.P., S.B., J.G., T.Y., H.T.) and Biomedical Informatics (I.B.), Emory University, Atlanta, Ga
| | - Marzyeh Ghassemi
- Department of Computer Science, Shiv Nadar University, Greater Noida, Uttar Pradesh, India (R.D.); Department of Chemical Engineering and Applied Chemistry (D.M.) and Department of Computer Science (M.G.), University of Toronto, Toronto, Canada; and Departments of Radiology (H.M.P., S.B., J.G., T.Y., H.T.) and Biomedical Informatics (I.B.), Emory University, Atlanta, Ga
| | - Judy Gichoya
- Department of Computer Science, Shiv Nadar University, Greater Noida, Uttar Pradesh, India (R.D.); Department of Chemical Engineering and Applied Chemistry (D.M.) and Department of Computer Science (M.G.), University of Toronto, Toronto, Canada; and Departments of Radiology (H.M.P., S.B., J.G., T.Y., H.T.) and Biomedical Informatics (I.B.), Emory University, Atlanta, Ga
| | - Imon Banerjee
- Department of Computer Science, Shiv Nadar University, Greater Noida, Uttar Pradesh, India (R.D.); Department of Chemical Engineering and Applied Chemistry (D.M.) and Department of Computer Science (M.G.), University of Toronto, Toronto, Canada; and Departments of Radiology (H.M.P., S.B., J.G., T.Y., H.T.) and Biomedical Informatics (I.B.), Emory University, Atlanta, Ga
| | - Tim Yoon
- Department of Computer Science, Shiv Nadar University, Greater Noida, Uttar Pradesh, India (R.D.); Department of Chemical Engineering and Applied Chemistry (D.M.) and Department of Computer Science (M.G.), University of Toronto, Toronto, Canada; and Departments of Radiology (H.M.P., S.B., J.G., T.Y., H.T.) and Biomedical Informatics (I.B.), Emory University, Atlanta, Ga
| | - Hari Trivedi
- Department of Computer Science, Shiv Nadar University, Greater Noida, Uttar Pradesh, India (R.D.); Department of Chemical Engineering and Applied Chemistry (D.M.) and Department of Computer Science (M.G.), University of Toronto, Toronto, Canada; and Departments of Radiology (H.M.P., S.B., J.G., T.Y., H.T.) and Biomedical Informatics (I.B.), Emory University, Atlanta, Ga
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Nunna RS, Khalid S, Chiu RG, Parola R, Fessler RG, Adogwa O, Mehta AI. Anterior vs Posterior Approach in Multilevel Cervical Spondylotic Myelopathy: A Nationwide Propensity-Matched Analysis of Complications, Outcomes, and Narcotic Use. Int J Spine Surg 2022; 16:88-94. [PMID: 35314510 PMCID: PMC9519084 DOI: 10.14444/8198] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023] Open
Abstract
BACKGROUND There is unclear evidence regarding the optimal surgical approach for multilevel cervical spondylotic myelopathy (CSM). The objective of this study was to compare complications, outcomes, and narcotic use in anterior discectomy and fusion (ACDF) vs posterior decompression and fusion (PCDF) in CSM patients. STUDY DESIGN Registry-based retrospective cohort analysis. METHODS Patients undergoing 3-level ACDF or PCDF for CSM between 2007 and 2017 were identified from the Humana Claims Database using relevant procedure codes. Propensity score-matched groups were compared in regards to complications, outcomes, and narcotic use. RESULTS Propensity score matching generated equal cohorts of 6124 patients. The posterior fusion group had a higher rate of urinary tract infection (OR 2.47, P < 0.0001), deep vein thrombosis (OR 1.90, P < 0.0001), and pulmonary embolism (OR 1.75, P < 0.0001). In regards to 30-day outcomes, the posterior approach demonstrated higher rates of stroke (OR 1.68, P < 0.0001), wound dehiscence (OR 5.59, P < 0.0001), Surgical site infection (SSI) (OR 4.76, P < 0.0001), wound revision surgery (OR 3.02, P < 0.0001), and all-cause readmission (OR 2.01, P < 0.0001). One-year outcomes revealed higher rates of pseudarthrosis (4.7% vs 2.0%, OR 2.43, P < 0.0001) and revision or extension surgery (OR 2.33, P < 0.0001) in the posterior fusion cohort. These patients also demonstrated significantly higher mean morphine milligram equivalent used at 30 days (OR 1.19, P < 0.0001), as well as 60 (OR 1.20, P < 0.0001), 90 (OR 1.21, P < 0.0001), and 120 (OR 1.21, P < 0.0001) days. CONCLUSIONS This nationwide propensity-matched analysis of multilevel CSM patients found the posterior approach to be associated with increased rates of inpatient complications, wound complications, 30-day readmission, 1-year pseudarthrosis, and 1-year revision or extension surgery. These patients also demonstrated higher levels of narcotic use up to 120 days after surgery. CLINICAL RELEVANCE The posterior approach for treatment of CSM may be associated with increased rates of short- and long-term complications in addition to increased narcotic consumption in comparison to the anterior approach.
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Affiliation(s)
- Ravi S Nunna
- Department of Neurosurgery, Swedish Medical Center, Seattle, WA, USA
| | - Syed Khalid
- Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Ryan G Chiu
- Department of Neurosurgery, University of Illinois-Chicago Medical Center, Chicago, IL, USA
| | - Rown Parola
- Department of Neurosurgery, University of Illinois-Chicago Medical Center, Chicago, IL, USA
| | - Richard G Fessler
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Owoicho Adogwa
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois-Chicago Medical Center, Chicago, IL, USA
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Spurgas MP, Entezami P, Thomas J, DiRisio DJ. Long Segment Anterior Cervical Discectomy and Fusion, Including C2: Surgical Pearls and Review of Our Experience. Clin Spine Surg 2022; 35:E13-E18. [PMID: 34369912 DOI: 10.1097/bsd.0000000000001245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 06/23/2021] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A retrospective study of thirteen patients undergoing 5-level anterior spinal surgery for cervical myelopathy. OBJECTIVE While limited literature exists in reviewing the treatment of high cervical pathology extending caudally, we believe long segment surgery beginning at C2-3 can be accomplished with good success and is an option more patients may benefit from. We aim to describe the technique in accessing the C2-C3 disk space and efficacy of treating multilevel disease beginning at the C2 vertebral body. This includes an extensive technical report and surgical pearls. SUMMARY OF BACKGROUND DATA Compression at the level of C2 can be daunting to access because of steep approach required. Few studies have described the technique in reaching the C2 level, with less information describing the efficacy of a 5-level anterior fusion starting at C2. METHODS Patients who underwent surgery between 2000 and 2016 were identified utilizing the department billing database and ICD codes. Patients age, operative indications, levels treated, length of hospital stay, fusion outcome, and operative complications were explored. Independent analysis of fusion was performed. RESULTS The average length of hospital stay was 3.9 days. Eight patients reported significant improvement of hand weakness, numbness, and/or gait at 6 months follow-up. The most frequent complication was dysphagia (23%). One patient experienced recurrent symptoms secondary to nonunion, and another patient suffered a postoperative neurological worsening because of anterior spinal artery syndrome. CONCLUSION This retrospective review discusses the technique to visualize and fully decompress C2-C3 spinal segments. In addition, we explored the efficacy and perioperative risk in long segment anterior cervical discectomy and fusion.
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Rogerson A, Aidlen J, Mason A, Pierce A, Tybor D, Salzler MJ. Predictors of Inpatient Morbidity and Mortality After 1- and 2-Level Anterior Cervical Diskectomy and Fusion Based on the National Inpatient Sample Database From 2006 Through 2010. Orthopedics 2021; 44:e675-e681. [PMID: 34590947 DOI: 10.3928/01477447-20210817-08] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Spine procedures, including anterior cervical diskectomy and fusion (ACDF), are more commonly being performed in an outpatient setting to maximize value. Early complications after ACDF are rare but can have devastating consequences. The authors sought to determine risk factors for inpatient complications after 1-and 2-level ACDF by performing a retrospective review of the National Inpatient Sample (NIS) administrative database from 2006 through 2010. A total of 78,771 patients were identified. Multivariate logistic regression analysis was performed to identify preoperative risk factors for medical and surgical complications, including mortality, airway compromise, new neurologic deficit, and surgical-site infection. Inpatient mortality and overall complication rates were 0.074% and 3.73%, respectively. The risk of any medical complication was 3.13%. Airway compromise, neurologic deficit, and surgical-site infection occurred in 0.75%, 0.05%, and 0.04% of cases, respectively. Chronic kidney disease was the strongest predictor of mortality, with an odds ratio (OR) of 11.14 (P<.001). Airway complication was associated with age older than 65 years, male sex, myelopathy, diabetes mellitus, anemia, bleeding disorder, chronic obstructive pulmonary disease, obesity, and obstructive sleep apnea (P<.05). Preoperative diagnosis of myelopathy was most strongly associated with an increased rate of neurologic complication (OR, 6.67; P<.001). Anemia was associated with a significantly increased rate of surgical-site infection, with an OR of 14.34 (P<.001). Age older than 65 years; certain medical comorbidities, particularly kidney disease and anemia; and a preoperative diagnosis of myelopathy are associated with increased risk of early complication following ACDF surgery. Surgeons should consider these risk factors when deciding to perform ACDF surgery in an outpatient setting. [Orthopedics. 2021;44(5):e675-e681.].
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Papavero L, Pietrek M, Marques CJ, Schmeiser G. Cervical Single-Level Pincer Stenosis Causing Myelopathy: A Technical Note and Medium-term Results of a One-Session Microsurgical 360-Degree Treatment. J Neurol Surg A Cent Eur Neurosurg 2021; 83:187-193. [PMID: 34634828 PMCID: PMC8860618 DOI: 10.1055/s-0041-1723811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND STUDY AIMS Single-level circumferential or pincer stenosis (PS) affects few patients with degenerative cervical myelopathy (DCM). The surgical technique and medium-term results of a one-session microsurgical 360-degree (m360°) procedure are presented. PATIENTS Between 2013 and 2018, the data of 23 patients were prospectively collected out of 371 patients with DCM. The m360° procedure comprised a microsurgical anterior cervical decompression and fusion (ACDF), with additional plate fixation, followed by flipping the patient and performing a microsurgical posterior bilateral decompression via a unilateral approach in crossover technique. RESULTS The mean age of the patients was 72 years (range: 50-84); 17 patients were males. The mean follow-up time was 12 months (range: 6-31). The patients filled in the patient-derived modified Japanese Orthopaedic Association (P-mJOA) questionnaire on average 53 months after surgery. One patient received a two-level ACDF. Lesions were mostly (92%) located at the C3/C4 (8/24), C4/C5 (7/24), and C5/C6 (7/24) levels. Functional X-rays showed segmental instability in 10 of 23 patients (44%). All preoperative T2-weighted magnetic resonance imaging (MRI) showed an intramedullary hyperintensity. The median preoperative mJOA score was 13 (range 3), and it improved to 16 (range 3) postoperatively. The mean improvement rate in the mJOA score was 73%. When available, postoperative MRI confirmed good circumferential decompression with persistent intramedullary hyperintensity. There were two complications: a long-lasting radicular paresthesia at C6 and a transient C5 palsy. No revision surgery was required. CONCLUSION The one-session m360° procedure was found to be a safe surgical procedure for the treatment of PS, and the medium-term clinical outcome was satisfactory.
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Affiliation(s)
- Luca Papavero
- Schoen Clinic Hamburg Eilbek, Academic Hospital of the Eppendorf University Medical Center - Clinic for Spine Surgery, Hamburg, Germany,Address for correspondence Luca Papavero, MD, PhD Schoen Clinic Hamburg Eilbek, Academic Hospital of the Eppendorf University Medical Center - Clinic for Spine SurgeryHamburgGermany
| | - Markus Pietrek
- Schoen Clinic Hamburg Eilbek, Academic Hospital of the Eppendorf University Medical Center - Clinic for Spine Surgery, Hamburg, Germany
| | - Carlos J. Marques
- Science Office of the Orthopedic and Joint Replacement Department, Schoen Clinic Hamburg Eilbek, Academic Hospital of the Eppendorf University Medical Center – 2, Hamburg, Germany
| | - Gregor Schmeiser
- Schoen Clinic Hamburg Eilbek, Academic Hospital of the Eppendorf University Medical Center - Clinic for Spine Surgery, Hamburg, Germany
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Cervical Oblique Corpectomy: Revitalizing the Underused Surgical Approach With Step-By-Step Simulation in Cadavers. J Craniofac Surg 2021; 33:337-343. [PMID: 34267143 DOI: 10.1097/scs.0000000000007909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Recently, the World Federation of Neurosurgical Societies Spine committee recommended that additional research on cost-benefit analysis of various surgical approaches for cervical spondylotic myelopathy be carried out and their efficacy with long-term outcomes be compared. Unfortunately, it is highly probable that the oblique corpectomy (OC) will not be included in cost-benefit investigations due to its infrequent application by neurosurgeons dealing with the spine. In this cadaveric study, head and necks of 5 adult human cadavers stained with colored latex and preserved in 70% alcohol solution were dissected under a table-mounted surgical microscope using 3× to 40× magnifications. The OC approach was performed to simulate real surgery, and the neurovascular structures encountered during the procedure and their relations with each other were examined. Oblique corpectomy was performed unilaterally, although neck dissections were performed bilaterally on 10 sides in all 5 cadavers. At each stage of the dissection, multiple three-dimensional photographs were obtained from different angles and distances. For an optimal OC, both the anterior spinal cord must be sufficiently decompressed and sufficient bone must be left in place to prevent instability in the cervical spine. Oblique corpectomy is a valid and potentially low cost alternative to other anterior and posterior approaches in the surgical treatment of cervical spondylotic myelopathy. However, meticulous cadaver studies are essential before starting real surgical practice on patients in order to perform it effectively and to avoid the risks of the technique.
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Wadhwa H, Sharma J, Varshneya K, Fatemi P, Nathan J, Medress ZA, Stienen MN, Ratliff JK, Veeravagu A. Anterior Cervical Discectomy and Fusion Versus Laminoplasty for Multilevel Cervical Spondylotic Myelopathy: A National Administrative Database Analysis. World Neurosurg 2021; 152:e738-e744. [PMID: 34153482 DOI: 10.1016/j.wneu.2021.06.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/11/2021] [Accepted: 06/12/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) is effective for the treatment of single-level cervical spondylotic myelopathy (CSM). However, the data surrounding multilevel CSM have remained controversial. One alternative is laminoplasty, although evidence comparing these strategies has remained sparse. In the present report, we retrospectively reviewed the readmission and reoperation rates for patients who had undergone ACDF or laminoplasty for multilevel CSM from a national longitudinal administrative claims database. METHODS We queried the MarketScan Commercial Claims and Encounters database to identify patients who had undergone ACDF or laminoplasty for multilevel CSM from 2007 to 2016. The patients were stratified by operation type. Patients aged <18 years, patients with a history of tumor or trauma, and patients who had undergone anteroposterior approach were excluded from the present study. RESULTS A total of 5445 patients were included, of whom 1521 had undergone laminoplasty. A matched cohort who had undergone ACDF was identified. The overall 90-day postoperative complication rate was greater in the laminoplasty cohort (odds ratio, 1.48; 95% confidence interval, 1.18-1.86; P < 0.0001). The mean length of stay and 90-day readmission rates were greater in the laminoplasty cohort. The hospital and total payments of the index hospitalization were greater in the ACDF cohort, as were the total payments for ≤2 years after the index hospitalization. CONCLUSIONS In the present administrative claims database study, no difference was found in the reoperation rate between ACDF and laminoplasty. ACDF resulted in fewer complications and readmissions compared with laminoplasty but was associated with greater costs. Additional prospective research is required to investigate the factors driving the higher costs of ACDF in this population and the long-term clinical outcomes.
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Affiliation(s)
- Harsh Wadhwa
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Jigyasa Sharma
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Kunal Varshneya
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Parastou Fatemi
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Jay Nathan
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Zachary A Medress
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Martin N Stienen
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - John K Ratliff
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University Medical Center, Stanford, California, USA.
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Davies BM, Francis JJ, Butler MB, Mowforth O, Goacher E, Starkey M, Kolias A, Wynne-Jones G, Hutton M, Selvanathan S, Thomson S, Laing RJC, Hutchinson PJ, Kotter MRN. Current surgical practice for multi-level degenerative cervical myelopathy: Findings from an international survey of spinal surgeons. J Clin Neurosci 2021; 87:84-88. [PMID: 33863541 DOI: 10.1016/j.jocn.2021.01.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 12/23/2020] [Accepted: 01/29/2021] [Indexed: 12/15/2022]
Abstract
Degenerative cervical myelopathy (DCM) results from compression of the cervical spine cord as a result of age related changes in the cervical spine, and affects up to 2% of adults, leading to progressive disability. Surgical decompression is the mainstay of treatment, but there remains significant variation in surgical approaches used. This survey was conducted in order to define current practice amongst spine surgeons worldwide, as a possible prelude to further studies comparing surgical approaches. METHODS An electronic survey was developed and piloted by the investigators using SurveyMonkey. Collected data was categorical and is presented using summary statistics. Where applicable, statistical comparisons were made using a Chi-Squared test. The level of significance for all statistical analyses was defined as p < 0.05. All analysis, including graphs was performed using R (R Studio). RESULTS 127 surgeons, from 30 countries completed the survey; principally UK (66, 52%) and North America (15, 12%). Respondents were predominantly Neurosurgeons by training (108, 85%) of whom 84 (75%) reported Spinal Surgery as the principal part of their practice. The majority indicated they selected their surgical procedure for multi-level DCM on a case by case basis (62, 49%). Overall, a posterior approach was more popular for multi-level DCM (74, 58%). Region, speciality or annual multi-level case load did not influence this significantly. However, there was a trend for North American surgeons to be more likely to favour a posterior approach. CONCLUSIONS A posterior approach was favoured and more commonly used to treat multi-level DCM, in an international cohort of surgeons. Posterior techniques including laminectomy, laminectomy and fusion or laminoplasty appeared to be equally popular.
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Affiliation(s)
- Benjamin M Davies
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom.
| | - Jibin J Francis
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom
| | - Max B Butler
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Oliver Mowforth
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Edward Goacher
- Department of Musculoskeletal, Spinal Unit, Royal Victoria Infirmary, Newcastle, United Kingdom
| | - Michelle Starkey
- Academic Neurosurgery Unit, Department of Clinical Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Angelos Kolias
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom
| | - Guy Wynne-Jones
- Department of Musculoskeletal, Spinal Unit, Royal Victoria Infirmary, Newcastle, United Kingdom
| | - Mike Hutton
- Royal Devon and Exeter Hospital, United Kingdom
| | | | | | - Rodney J C Laing
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom
| | - Peter J Hutchinson
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom
| | - Mark R N Kotter
- Division of Neurosurgery, Addenbrooke's Hospital and University of Cambridge, Cambridge, United Kingdom; Department of Neurosurgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
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Revision surgery of an older patient with adjacent segment disease (ASD) following anterior cervical discectomy and fusion by PCB: A case report. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2020.100944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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27
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Goyal A, Bhandarkar AR, Alvi MA, Kerezoudis P, Yolcu YU, Habermann EB, Sebastian AS, Bydon M. Cost of Readmissions Following Anterior Cervical Discectomy and Fusion: Insights from the Nationwide Readmissions Database. Neurosurgery 2021; 87:679-688. [PMID: 31642499 DOI: 10.1093/neuros/nyz443] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/18/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Postoperative readmissions are a significant driver of variation in bundled care costs associated with cervical spine surgery. OBJECTIVE To determine the factors predicting the cost of readmission episodes following elective anterior cervical discectomy and fusion (ACDF). METHODS We queried the Healthcare Cost and Utilization Project Nationwide Readmissions Database for patients undergoing elective ACDF during 2012 to 2015. Multivariable linear regression was performed to establish the factors associated with the cost of each 30-/90-d readmission episode. RESULTS A total of 139 877 and 113 418 patients met inclusion criteria for the evaluation of 30- and 90-d readmissions, respectively. Among these, the national rates of 30- and 90-d readmission after an elective ACDF were 3% and 6%, respectively. The median cost of a 30- and 90-d readmission episode was $6727 (IQR: $3844-$13 529) and $8507 (IQR: $4567-$17 460), respectively. Relative predictor importance analysis revealed that the number of procedures at index admission (IA), length of stay at IA, and time elapsed between index surgical admission and readmission were the top predictors of both 30- and 90-d readmission costs (all P < .001). Although cervical myelopathy accounted for only 3.6% of all 30-d readmissions, it accounted for the largest share (8%) of 30-d readmission costs. CONCLUSION In this analysis from a national all-payer database, we determined the factors associated with the cost of readmissions following elective ACDF. These results are important in assisting policymakers and payers with a better risk adjustment in bundled care payment systems and for surgeons in implementing readmission cost-reduction efforts.
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Affiliation(s)
- Anshit Goyal
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Archis R Bhandarkar
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Mayo Clinic Alix School of Medicine, Rochester, Minnesota
| | - Mohammed Ali Alvi
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Panagiotis Kerezoudis
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Yagiz U Yolcu
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
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Patient Risk Factors Associated With 30- and 90-Day Readmission After Cervical Discectomy: A Nationwide Readmission Database Study. Clin Spine Surg 2020; 33:E434-E441. [PMID: 32568863 DOI: 10.1097/bsd.0000000000001030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE The aim of this study was to assess the patient-level risk factors associated with 30- and 90-day unplanned readmissions following elective anterior cervical decompression and fusion (ACDF) or cervical disk arthroplasty (CDA). SUMMARY OF BACKGROUND DATA For cervical disk pathology, both ACDF and CDA are increasingly performed nationwide. However, relatively little is known about the adverse complications and rates of readmission for ACDF and CDA. METHODS A retrospective cohort study was performed using the Nationwide Readmission Database from the years 2013 to 2015. All patients undergoing either CDA or ACDF were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Unique patient linkage numbers were used to follow patients and to identify 30- and 31-90-day readmission rates. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31-90 days (90-R). RESULTS There were a total of 13,093 index admissions with 856 (6.5%) readmissions [30-R: n=532 (4.0%); 90-R: n=324 (2.5%)]. Both overall length of stay and total cost were greater in the 30-R cohort compared with 90-R and Non-R cohorts. The most prevalent 30- and 90-day complications seen among the readmitted cohorts were infection, genitourinary complication, and device complication. On multivariate regression analysis, age, Medicaid status, medium and large hospital bed size, deficiency anemia, and any complication during index admission were independently associated with increased 30-day readmission. Whereas age, large hospital bed size, coagulopathy, and any complication during the initial hospitalization were independently associated with increased 90-day readmission. CONCLUSION Our nationwide study identifies the 30- and 90-day readmission rates and several patient-related risk factors associated with unplanned readmission after common anterior cervical spine procedures. LEVEL OF EVIDENCE Level III.
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Identification of Risk Factors for Readmission in Patients Undergoing Anterior Cervical Discectomy Fusion: A Predictive Risk Scale. Clin Spine Surg 2020; 33:E426-E433. [PMID: 32205517 DOI: 10.1097/bsd.0000000000000962] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE The objective of this study was to analyze readmission rates among patients undergoing anterior cervical discectomy and fusion (ACDF), determine which factors were associated with higher readmission rates, and develop a scale for utilization during surgical planning. SUMMARY OF BACKGROUND DATA ACDF is the most common surgical treatment for many cervical disk pathologies. With the Centers for Medicare and Medicaid Services selecting readmissions as a measure of health care quality, there has been an increased focus on reducing readmissions. MATERIALS AND METHODS There were 114,174 recorded ACDF surgeries in the derivation cohort, the State Inpatient Database (SID) of New York and California between 2006 and 2014. There were 115,829 ACDF surgeries recorded in the validation cohort, the SID from Florida and Washington over the same time period. After identification of risk factors using univariate and multivariate analysis of the derivation cohort, a predictive scale was generated and tested utilizing the validation cohort. RESULTS Overall, readmission rates within 30 days of discharge were 5.87% and 5.52% in the derivation and validation cohorts, respectively. On multivariate analysis of the derivation cohort, age older than 80 years [odds ratio (OR), 1.67] male sex (OR, 1.16), Medicaid insurance (OR, 1.90), Medicare insurance (OR, 1.64), revision ACDF (OR, 1.43), anemia (OR, 1.45), chronic lung disease (OR, 1.23), coagulopathy (OR, 1.42), congestive heart failure (OR, 1.31), diabetes (OR, 1.23), fluid and electrolyte disorder (OR, 1.56), liver disease (OR, 1.37), renal failure (OR, 1.59), and myelopathy (OR, 1.19) were found to be statistically significant predictors for readmission. These factors were incorporated into a numeric scale that, that when tested on the validation cohort, could explain 97.1% of the variability in readmission rate. CONCLUSIONS Overall, 30-day readmission following ACDF surgery was 5%-6%. A novel risk scale based on factors associated with increased readmission rates may be helpful in identifying patients who require additional optimization to reduce perioperative morbidity. LEVEL OF EVIDENCE Level III-prognostic.
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30
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Associated risk factors for extended length of stay following anterior cervical discectomy and fusion for cervical spondylotic myelopathy. Clin Neurol Neurosurg 2020; 195:105883. [DOI: 10.1016/j.clineuro.2020.105883] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 12/27/2022]
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Woodroffe RW, Helland LC, Grossbach AJ, Nourski KV, Hitchon PW. Risk factors associated with reoperation in posterior cervical fusions: A large-scale retrospective analysis. Clin Neurol Neurosurg 2020; 195:105828. [PMID: 32344282 DOI: 10.1016/j.clineuro.2020.105828] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To identify risk factors for reoperation in patients who have undergone posterior cervical fusion (PCF). PATIENTS AND METHODS A retrospective cohort analysis was performed of patients undergoing PCF during a 12-year period at a single institution. Demographic and surgical characteristics were collected from electronic medical records. This study addressed reoperations, from all causes, of PCF. Different strategies, including the addition of anterior fusion, were also compared. RESULTS Of the 370 patients meeting inclusion criteria there were 44 patients (11.9 %) that required a revision and of those 5 required a second revision. The most common reasons for revision were adjacent segment disease and infection, 13 (3.5 %) and 11 patients (3.0 %), respectively. There was not a higher revision rate (for any cause) for patients who had a subaxial fusion and compared with those that included C2 or those that failed to cross the cervicothoracic junction. Of patients who required reoperation, there was a statistically significant higher fraction of smokers (p = 0.023). CONCLUSION The risks and benefits of posterior cervical instrumentation and fusion should be thoroughly discussed with patients. This report implicates smoking as a risk factor for all-cause reoperation in patients who have had this PCF and provides surgeons with additional data regarding this complication. When possible, preoperative optimization should include smoking cessation therapy.
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Affiliation(s)
- Royce W Woodroffe
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | - Logan C Helland
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Andrew J Grossbach
- Department of Neurosurgery, The Ohio State University, Columbus, OH, USA
| | - Kirill V Nourski
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Patrick W Hitchon
- Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Badhiwala JH, Witiw CD, Nassiri F, Akbar MA, Mansouri A, Wilson JR, Fehlings MG. Efficacy and Safety of Surgery for Mild Degenerative Cervical Myelopathy: Results of the AOSpine North America and International Prospective Multicenter Studies. Neurosurgery 2020; 84:890-897. [PMID: 29684181 PMCID: PMC6425462 DOI: 10.1093/neuros/nyy133] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 03/27/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND There is controversy over the optimal treatment strategy for patients with mild degenerative cervical myelopathy (DCM). OBJECTIVE To evaluate the degree of impairment in baseline quality of life as compared to population norms, as well as functional, disability, and quality of life outcomes following surgery in a prospective cohort of mild DCM patients undergoing surgical decompression. METHODS We identified patients with mild DCM (modified Japanese Orthopaedic Association [mJOA] 15 to 17) enrolled in the prospective, multicenter AOSpine CSM-NA or CSM-I trials. Baseline quality of life Short Form-36 version 2 (SF-36v2) was compared to population norms by the standardized mean difference (SMD). Outcomes, including functional status (mJOA, Nurick grade), disability (NDI [Neck Disability Index]), and quality of life (SF-36v2), were evaluated at baseline and 6 mo, 1 yr, and 2 yr after surgery. Postoperative complications within 30 d of surgery were monitored. RESULTS One hundred ninety-three patients met eligibility criteria. Mean age was 52.4 yr. There were 67 females (34.7%). Patients had significant impairment in all domains of the SF-36v2 compared to population norms, greatest for Social Functioning (SMD –2.33), Physical Functioning (SMD –2.31), and Mental Health (SMD –2.30). A significant improvement in mean score from baseline to 2-yr follow-up was observed for all major outcome measures, including mJOA (0.87, P < .01), Nurick grade (–1.13, P < .01), NDI (–12.97, P < .01), and SF-36v2 Physical Component Summary (PCS) (5.75, P < .01) and Mental Component Summary (MCS) (6.93, P < .01). The rate of complication was low. CONCLUSION Mild DCM is associated with significant impairment in quality of life. Surgery results in significant gains in functional status, level of disability, and quality of life.
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Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Muhammad A Akbar
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Alireza Mansouri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Yee TJ, Swong K, Park P. Complications of anterior cervical spine surgery: a systematic review of the literature. JOURNAL OF SPINE SURGERY 2020; 6:302-322. [PMID: 32309668 DOI: 10.21037/jss.2020.01.14] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The anterior approach to the cervical spine is commonly utilized for a variety of degenerative, traumatic, neoplastic, and infectious indications. While many potential complications overlap with those of the posterior approach, the distinct anatomy of the anterior neck also presents a unique set of hazards. We performed a systematic review of the literature to assess the etiology, presentation, natural history, and management of these complications. Following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), a PubMed search was conducted to evaluate clinical studies and case reports of patients who suffered a complication of anterior cervical spine surgery. The search specifically included articles concerning adult human subjects, written in the English language, and published from 1989 to 2019. The PubMed search yielded 240 articles meeting our criteria. The overall rates of complications were as follows: dysphagia 5.3%, esophageal perforation 0.2%, recurrent laryngeal nerve palsy 1.3%, infection 1.2%, adjacent segment disease 8.1%, pseudarthrosis 2.0%, graft or hardware failure 2.1%, cerebrospinal fluid leak 0.5%, hematoma 1.0%, Horner syndrome 0.4%, C5 palsy 3.0%, vertebral artery injury 0.4%, and new or worsening neurological deficit 0.5%. Morbidity rates in anterior cervical spine surgery are low. Nevertheless, the unique anatomy of the anterior neck presents a wide variety of potential complications involving vascular, aerodigestive, neural, and osseous structures.
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Affiliation(s)
- Timothy J Yee
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Kevin Swong
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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Martini ML, Deutsch BC, Neifert SN, Caridi JM. A National Snapshot Detailing the Impact of Parkinson's Disease on the Cost and Outcome Profiles of Fusion Procedures for Cervical Myelopathy. Neurosurgery 2020; 86:298-308. [PMID: 30957147 DOI: 10.1093/neuros/nyz087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 02/25/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Studies suggest a higher prevalence of cervical deformities in Parkinson's Disease (PD) patients who predispose to cervical myelopathy (CM). Despite the profound effect of CM on function and quality of life, no study has assessed the influence of PD on costs and outcomes of fusion procedures for CM. OBJECTIVE To conduct the first national-level study that provides a snapshot of the current outcome and cost profiles for different fusion procedures for CM in PD and non-PD populations. METHODS Patients with or without PD who underwent cervical decompression and fusion anteriorly (ACDF), posteriorly (PCDF), or both (Frontback), for CM were identified from the 2013 to 2014 National Inpatient Sample using International Classification of Disease codes. RESULTS A total of 75 870 CM patients were identified, with 535 patients (0.71%) also having PD. Although no difference existed between in-hospital mortality rates, overall complication rates were higher in PD patients (38.32% vs 22.05%; P < .001). PD patients had higher odds of pulmonary (P = .002), circulatory (P = .020), and hematological complications (P = .035). Following ACDFs, PD patients had higher odds of complications (P = .035), extended hospitalization (P = .026), greater total charges (P = .003), and nonhome discharge (P = .006). Although PCDFs and Frontbacks produced higher overall complication rates for both populations than ACDFs, PD status did not affect complication odds for these procedures. CONCLUSION PD may increase risk for certain adverse outcomes depending on procedure type. This study provides data with implications in healthcare delivery, policy, and research regarding a patient population that will grow as our population ages and justifies further investigation in future prospective studies.
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Affiliation(s)
- Michael L Martini
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brian C Deutsch
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sean N Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
| | - John M Caridi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York
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Badhiwala JH, Ellenbogen Y, Khan O, Nouri A, Jiang F, Wilson JR, Jaja B, Witiw CD, Nassiri F, Fehlings MG, Wilson JR. Comparison of the Inpatient Complications and Health Care Costs of Anterior versus Posterior Cervical Decompression and Fusion in Patients with Multilevel Degenerative Cervical Myelopathy: A Retrospective Propensity Score–Matched Analysis. World Neurosurg 2020; 134:e112-e119. [DOI: 10.1016/j.wneu.2019.09.132] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/24/2019] [Accepted: 09/25/2019] [Indexed: 10/25/2022]
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Jiang F, Wilson JRF, Badhiwala JH, Santaguida C, Weber MH, Wilson JR, Fehlings MG. Quality and Safety Improvement in Spine Surgery. Global Spine J 2020; 10:17S-28S. [PMID: 31934516 PMCID: PMC6947676 DOI: 10.1177/2192568219839699] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
STUDY DESIGN Review article. OBJECTIVES A narrative review of the literature on the current advances and limitations in quality and safety improvement initiatives in spine surgery. METHODS A comprehensive literature search was performed using Ovid MEDLINE focusing on 3 preidentified concepts: (1) quality and safety improvement, (2) reporting of outcomes and adverse events, and (3) prediction model and practice guidelines. The search was conducted under appropriate subject headings and using relevant text words. Articles were screened, and manuscripts relevant to this discussion were included in the narrative review. RESULTS Quality and safety improvement remains a major research focus attracting investigators from the global spine community. Multiple databases and registries have been developed for the purpose of generating data and monitoring the progress of quality and safety improvement initiatives. The development of various prediction models and clinical practice guidelines has helped shape the care of spine patients in the modern era. With the reported success of exemplary programs initiated by the Northwestern and Seattle Spine Team, other quality and safety improvement initiatives are anticipated to follow. However, despite these advancements, the reporting metrics for outcomes and adverse events remain heterogeneous in the literature. CONCLUSION Constant surveillance and continuous improvement of the quality and safety of spine treatments is imperative in modern health care. Although great advancement has been made, issues with reporting outcomes and adverse events persist, and improvement in this regard is certainly needed.
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Affiliation(s)
- Fan Jiang
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jamie R. F. Wilson
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | - Jetan H. Badhiwala
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | | | | | - Jefferson R. Wilson
- University of Toronto, Toronto, Ontario, Canada,St Michael’s Hospital, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada,Michael G. Fehlings, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, 399 Bathurst Street, Toronto, Ontario, M5T2S8, Canada.
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Abstract
STUDY DESIGN This was a retrospective cohort study. OBJECTIVE To identify the differences in inpatient pain scores, narcotic consumption, and patient-reported outcomes (PROs) between tobacco users and nonusers following an anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA Previous studies have investigated tobacco use as a risk factor for negative postsurgical outcomes following spine surgery; however, few studies have analyzed the effects of tobacco on pain following ACDF. METHODS Patients undergoing primary, 1-level, or 2-level ACDF were retrospectively reviewed and stratified by tobacco use at the time of surgery. Inpatient pain scores and narcotic consumption were collected. Neck Disability Index and Visual Analogue Scale (VAS) neck and arm pain scores were collected preoperatively and at 6-week, 3-month, and 6-month follow-up visits. Differences in demographics and perioperative characteristics were assessed using χ analysis and multivariate linear regression. An association between immediate postoperative pain, narcotics consumption, and long-term PROs was tested for using multivariate linear regression. RESULTS A total of 192 patients were included and stratified by tobacco use: tobacco (n=25) and nontobacco (n=167). There were no significant differences in demographic and perioperative characteristics. No statistical differences were observed in inpatient VAS pain scores and narcotic consumption on postoperative day 0 and postoperative day 1. Preoperative VAS neck pain and arm pain was greater in tobacco users, however, improvements in neck and arm pain were similar in the postoperative period through 6-month follow-up. In addition, no statistical differences in Neck Disability Index were observed preoperatively or at any postoperative time points. CONCLUSIONS Our study suggests that tobacco use does not influence inpatient pain scores, narcotic consumption, and improvements in PROs following ACDF. As such, tobacco users and nonusers should receive similar postoperative pain management protocols following surgery. LEVEL OF EVIDENCE Level III.
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Pennington Z, Mehta VA, Lubelski D, Elliott C, Miller JA, Benzel EC, Mroz TE. Quality of Life and Cost Implications of Pseudarthrosis After Anterior Cervical Discectomy and Fusion and its Subsequent Revision Surgery. World Neurosurg 2019; 133:e592-e599. [PMID: 31568900 DOI: 10.1016/j.wneu.2019.09.104] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 09/14/2019] [Accepted: 09/19/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND More than 120,000 anterior cervical discectomy and fusions (ACDFs) are performed annually. Pseudarthrosis is a potential delayed adverse event that affects up to 33% of patients. The degree to which this adverse event affects both patient quality-of-life (QOL) outcomes and health care costs is poorly understood. METHODS Patients who underwent revision surgery for pseudarthrosis between 2007 and 2012 were identified and matched to controls not experiencing pseudarthrosis in a 1:2 fashion (case/control). Cases and controls were compared regarding total health care costs incurred in the year after the index ACDF and QOL outcomes on the following metrics: EuroQol Five-Dimensions Questionnaire, Patient Health Questionnaire-9, and Pain Disability Questionnaire. RESULTS Of 738 patients who underwent ACDF, 11 underwent surgery for pseudarthrosis. No differences were noted between cases and controls regarding any of the matched variables. Patients in the pseudarthrosis cohort had poorer postoperative scores on the EuroQol Five-Dimensions Questionnaire mobility, usual activities, pain/discomfort, and quality-adjusted life-year dimensions. In addition, 64% of patients with pseudarthrosis had worsened quality-adjusted life-year scores compared with only 9% of controls (P < 0.01). Patients with pseudarthrosis also had poorer mental health (P < 0.01) and pain disability outcomes (P < 0.01) than did controls. Pseudarthrosis was associated with significant increases in direct costs, direct postoperative costs, and total costs (all P < 0.01). CONCLUSIONS This is the first study to characterize the effect of surgical revision for pseudarthrosis on both QOL outcomes and care costs after ACDF. Patients requiring revision experienced significantly poorer QOL outcomes and higher care costs relative to controls.
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Affiliation(s)
- Zach Pennington
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vikram A Mehta
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles Elliott
- Department of Emergency Medicine, University of Arizona, Tucson, Arizona, USA
| | - Jacob A Miller
- Department of Radiation Oncology, Stanford Hospital, Palo Alto, California, USA
| | - Edward C Benzel
- Cleveland Clinic Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA; Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Thomas E Mroz
- Cleveland Clinic Center for Spine Health, Cleveland Clinic, Cleveland, Ohio, USA; Department of Neurological Surgery, Cleveland Clinic, Cleveland, Ohio, USA; Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA.
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Lee CH, Son DW, Lee SH, Lee JS, Sung SK, Lee SW, Song GS. Radiological and Clinical Outcomes of Anterior Cervical Discectomy and Fusion in Older Patients: A Comparative Analysis of Young-Old Patients (Ages 65-74 Years) and Middle-Old Patients (Over 75 Years). Neurospine 2019; 17:156-163. [PMID: 31284342 PMCID: PMC7136094 DOI: 10.14245/ns.1836072.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 02/20/2019] [Indexed: 12/23/2022] Open
Abstract
Objective Anterior cervical discectomy and fusion (ACDF) is the most commonly performed procedure for degenerative cervical spondylosis. Because of its relatively low invasiveness and surgical procedure, old age is not regarded as an exclusion criterion for ACDF. However, very few studies have been conducted on the radiological and clinical outcomes of ACDF in older patients. The purpose of this study was to evaluate the radiological and clinical outcomes of ACDF in older patients.
Methods We retrospectively analyzed 48 patients (> 65 years) who underwent ACDF from January 2011 to December 2015. We divided the patients into 2 groups: young-old age group (65–74 years) and middle-old age group (≥ 75 years). Cervical lateral radiographs taken in the neutral standing position were evaluated preoperatively (PRE), on postoperative day 7 (POST), and at the 1-year follow-up (F/U). The radiological parameters included cervical angle (CA: C2–7 Cobb angle), segmental angle, total intervertebral height, disc height, sagittal vertical axis (SVA), T1 slope (T1s), and range of cervical motion (extension CA minus flexion CA). Postoperative hospital days, comorbidities, complications, and clinical outcomes were also analyzed.
Results We analyzed data from 48 patients (group A: n = 30 patients, 46 segments, mean age, 68.60 ± 3.36 years; group B: n = 18 patients, 23 segments, mean age, 79.22 ± 2.63 years). The surgical levels were as follows: C3/4, 4; C4/5, 7; C5/6, 10; C6/7, 29; and C7/ T1, 6 levels, and there were no significant between-group differences in the distribution. There were no significant between-group differences in the fusion and subsidence rates (fusion rate: group A, 76.2%; group B, 71.4%; p = 0.732; subsidence rate: group A, 34.8%; group B, 26.1%; p = 0.587). There was no longitudinal trend in the repeated-measurements analysis of variance test of the 2 groups of the PRE, POST, and F/U data for each radiological parameter. According to the paired t-test, T1 slope (T1s), SVA, and CA did not differ preoperatively and postoperatively. There was no statistically significant difference in visual analogue scale scores (axial, arm), the Neck Disability Index, or Odom’s criteria between the 2 groups (p = 0.448, p = 0.357, and p = 0.913).
Conclusion There was no significant difference in radiological and clinical outcomes between young-old and middle-old patients. Middle-old age does not seem to be a limitation to ACDF, but larger-scale and longer-term studies are needed to confirm the findings of this study.
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Affiliation(s)
- Chi Hyung Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Dong Wuk Son
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Su Hun Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Jun Seok Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Soon Ki Sung
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Sang Weon Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, Pusan National University School of Medicine, Yangsan, Korea
| | - Geun Sung Song
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.,Department of Neurosurgery, Pusan National University School of Medicine, Yangsan, Korea
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Zakaria HM, Mansour T, Telemi E, Xiao S, Bazydlo M, Schultz L, Nerenz D, Perez-Cruet M, Seyfried D, Aleem IS, Easton R, Schwalb JM, Abdulhak M, Chang V. Patient Demographic and Surgical Factors that Affect Completion of Patient-Reported Outcomes 90 Days and 1 Year After Spine Surgery: Analysis from the Michigan Spine Surgery Improvement Collaborative (MSSIC). World Neurosurg 2019; 130:e259-e271. [PMID: 31207366 DOI: 10.1016/j.wneu.2019.06.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/06/2019] [Accepted: 06/07/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND The Michigan Spine Surgery Improvement Collaborative is a statewide multicenter quality improvement registry. Because missing data can affect registry results, we used MSSIC to find demographic and surgical characteristics that affect the completion of patient-reported outcomes (PROs) at 90 days and 1 year. METHODS A total of 24,404 patients who had lumbar surgery (17,813 patients) or cervical surgery (6591 patients) were included. Multivariate logistic regression models of patient disease were constructed to identify risk factors for failure to complete scheduled PRO surveys. RESULTS Patients ≥65 years old and female patients were both more likely to respond at 90 days and 1 year. Increasing education was associated with greater response rate at 90 days and 1 year. Whites and African Americans had no differences in response rates. Calling provided the highest response rate at 90 days and 1 year. For cervical spine patients, only discharge to rehabilitation increased completion rates, at 90 days but not 1 year. For lumbar spine patients, spondylolisthesis or stenosis (vs. herniated disc) had a greater response rate at 1 year. Patients with leg (vs. back) pain had a greater response only at 1 year. Patients with multilevel surgery had an increased response at 1 year. Patients who underwent fusion were more likely to respond at 90 days, but not 1 year. Discharge to rehabilitation increased response at 90 days and 1 year. CONCLUSIONS A multivariate analysis from a multicenter prospective database identified surgical factors that affect PRO follow-up, up to 1 year. This information can be helpful for imputing missing PRO data and could be used to strengthen data derived from large prospective databases.
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Affiliation(s)
| | - Tarek Mansour
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Edvin Telemi
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Shujie Xiao
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Michael Bazydlo
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Lonni Schultz
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - David Nerenz
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | | | - Donald Seyfried
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ilyas S Aleem
- Department of Orthopedics, University of Michigan, Ann Arbor, Michigan, USA
| | - Richard Easton
- Department of Orthopaedic Surgery, Beaumont Health, Oakland University-William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Jason M Schwalb
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Muwaffak Abdulhak
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Victor Chang
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA.
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Preparing for Bundled Payments in Cervical Spine Surgery: Do We Understand the Influence of Patient, Hospital, and Procedural Factors on the Cost and Length of Stay? Spine (Phila Pa 1976) 2019; 44:334-345. [PMID: 30074974 DOI: 10.1097/brs.0000000000002825] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective, observational study. OBJECTIVE To examine the influence of patient, hospital, and procedural characteristics on hospital costs and length hospital of stay (LOS). SUMMARY OF BACKGROUND DATA Successful bundled payment agreements require management of financial risk. Participating institutions must understand potential cost input before entering into these episodes-of-care payment contracts. Elective anterior cervical discectomy and fusion (ACDF) has become a popular target for early bundles given its frequency and predictability. METHODS A national discharge database was queried to identify adult patients undergoing elective ACDF. Using generalized linear models, the impact of each patient, hospital, and procedures characteristic on hospitalization costs and the LOS was estimated. RESULTS In 2011, 134,088 patients underwent ACDF in the United States. Of these 31.6% had no comorbidities, whereas 18.7% had three or more. The most common conditions included hypertension (44.4%), renal disease (15.9%), and depression (14.7%). Mean hospital costs after ACDF was $18,622 and mean hospital LOS was 1.7 days. With incremental comorbidities, both hospital costs and LOS increased. Both marginal costs and LOS rose with inpatient death (+$17,181, +2.0 days), patients with recent weight loss (+$8351, +1.24 days), metastatic cancer (+$6129 +0.80 days), electrolyte disturbances (+$4175 +0.8 days), pulmonary-circulatory disorders (+$4065, +0.6 days), and coagulopathies (+$3467, +0.58 days). Costs and LOS were highest with the following procedures: addition of a posterior fusion/instrumentation ($+11,189, +0.9 days), revision anterior surgery (+$3465, +0.3 days), and fusion of more than three levels (+$3251, +0.2 days). Patients treated in the West had the highest costs (+$9300, +0.3 days). All P values were less than 0.05. CONCLUSION Hospital costs and LOS after ACDF rise with increasing patient comorbidities. Stakeholders entering into bundled payments should be aware of that certain patient, hospital, and procedure characteristics will consume greater resources. LEVEL OF EVIDENCE 3.
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Zakaria HM, Bazydlo M, Schultz L, Pahuta MA, Schwalb JM, Park P, Aleem I, Nerenz DR, Chang V. Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative. J Neurosurg Spine 2019; 30:602-614. [PMID: 30771759 DOI: 10.3171/2018.10.spine18666] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 10/01/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery. METHODS A total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition. RESULTS Ninety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings. CONCLUSIONS A multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.
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Affiliation(s)
| | | | | | | | | | | | - Ilyas Aleem
- 5Orthopedics, University of Michigan, Ann Arbor, Michigan
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The Impact of Comorbid Mental Health Disorders on Complications Following Cervical Spine Surgery With Minimum 2-Year Surveillance. Spine (Phila Pa 1976) 2018; 43:1455-1462. [PMID: 29579013 DOI: 10.1097/brs.0000000000002651] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective analysis. OBJECTIVE To improve understanding of the impact of comorbid mental health disorders (MHDs) on long-term outcomes following cervical spinal fusion in cervical radiculopathy (CR) or cervical myelopathy (CM) patients. SUMMARY OF BACKGROUND DATA Subsets of patients with CR and CM have MHDs, and their impact on surgical complications is poorly understood. METHODS Patients admitted from 2009 to 2013 with CR or CM diagnoses who underwent cervical surgery with minimum 2-year surveillance were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System. Patients with a comorbid MHD were compared against those without (no-MHD). Univariate analysis compared demographics, complications, readmissions, and revisions between MHD and no-MHD cohorts. Multivariate binary logistic regression models identified independent predictors of outcomes (covariates: age, sex, Charlson/Deyo score, and surgical approach). RESULTS A total of 20,342 patients (MHD: n = 4819; no-MHD: n = 15,523) were included. MHDs identified: depressive (57.8%), anxiety (28.1%), sleep (25.2%), and stress (2.9%). CR patients had greater prevalence of comorbid MHD than CM patients (P = 0.015). Two years postoperatively, all patients with MHD had significantly higher rates of complications (specifically: device-related, infection), readmission for any indication, and revision surgery (all P < 0.05); regression modeling corroborated these findings and revealed combined surgical approach as the strongest predictor for any complication (CR, odds ratio [OR]: 3.945, P < 0.001; CM, OR: 2.828, P < 0.001) and MHD as the strongest predictor for future revision (CR, OR: 1.269, P = 0.001; CM, OR: 1.248, P = 0.008) in both CR and CM cohorts. CONCLUSION Nearly 25% of patients admitted for CR and CM carried comorbid MHD and experienced greater rates of any complication, readmission, or revision, at minimum, 2 years after cervical spine surgery. Results must be confirmed with retrospective studies utilizing larger national databases and with prospective cohort studies. Patient counseling and psychological screening/support are recommended to complement surgical treatment. LEVEL OF EVIDENCE 3.
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Abstract
OBJECTIVE Cervical spondylotic myelopathy is a common cause of neurological disability, especially in aging populations. There are several approaches to decompress the cervical spinal cord, including anterior cervical discectomy and fusion, corpectomy and fusion, arthroplasty, posterior cervical laminectomy with or without fusion, and laminoplasty. Less well described is minimally invasive cervical laminectomy. The authors report their technique and results for minimally invasive cervical laminectomy. MATERIALS AND METHODS The authors describe in detail their surgical technique and results of 30 consecutive cases. Preoperative and postoperative modified Japanese Orthopaedic Association (mJOA) myelopathy scores were recorded. RESULTS In total, 30 cases were included. Mean age was 69 years (range, 57-89 y). Twelve procedures were at C3-4, 4 at C4-5, 5 at C5-6, 4 at C7-T1, 3 at C3-4 and C4-5, 1 at C4-5 and C5-6, and 1 at C5-6 and C6-7. Mean preoperative mJOA score was 12.1 (range, 4-15). Average length of surgery was 142 minutes. Mean follow-up was 27 months (range, 3-64 mo). At 3 months, mean postoperative mJOA score was 14.0 (range, 5-17). Mean mJOA improvement of 1.9 was statistically significant (P<0.001). Seventeen patients had magnetic resonance imaging (MRI) available at 3 months postoperatively (5 patients had no MRI, 3 patients had MRI contraindications, and 5 are pending). No MRI findings led to further surgery. There were no durotomies and no wound infections. A single patient had an unexplained new neurological deficit that resolved over 6 months. CONCLUSIONS Minimally invasive laminectomy for cervical myelopathy is safe and effective and may be an underutilized procedure.
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Postoperative Emergency Department Utilization and Hospital Readmission After Cervical Spine Arthrodesis: Rates, Trends, Causes, and Risk Factors. Spine (Phila Pa 1976) 2018; 43:1031-1037. [PMID: 29215499 DOI: 10.1097/brs.0000000000002518] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective state database analysis. OBJECTIVE To quantify the 30- and 90-day emergency department (ED) utilization and inpatient readmission rates after primary cervical arthrodesis, to stratify these findings by surgical approach, and to describe risk factors and conditions precipitating these events. SUMMARY OF BACKGROUND DATA Limited data exist on ED utilization and hospital readmission rates after cervical spine arthrodesis. METHODS The New York State all-payer health-care database was queried to identify all 87,045 patients who underwent primary subaxial cervical arthrodesis from 1997 through 2012. Demographic data and clinical information were extracted. Readmission data were available for the entire study period, whereas ED utilization data collection began later and was therefore analyzed starting in 2005. Incidences of these events within 30 and 90 days of discharge as well as trends over time were tabulated. The conditions prompting these encounters were also collected. Data were analyzed with respect to surgical approach. RESULTS The hospital readmission rate was 4.2% at 30 days and 6.2% at 90 days postoperatively. Approximately 6.2% of patients were managed in the ED without inpatient admission within 30 days and 11.3% within 90 days of surgery. The most common conditions prompting such events were dysphagia or dysphonia, respiratory complications, and infection. ED utilization and readmission rates were lowest after anterior surgeries. A preoperative Charlson Comorbidity Index of 1 or greater and traumatic pathologies were associated with increased risk of subsequent ED utilization or hospital readmission. Thirty-day hospital readmission rates declined after 2010, whereas 30-day ED utilization continued to increase. CONCLUSION Patient comorbidities, traumatic pathologies, and surgical approach are associated with increased postoperative complications. Anterior procedures carry the lowest risk, followed by posterior and then circumferential. Awareness of these findings should help to encourage development of strategies to minimize the rate of postoperative ED utilization and hospital readmission. LEVEL OF EVIDENCE 3.
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Bartlett RS, Thibeault SL. Insights Into Oropharyngeal Dysphagia From Administrative Data and Clinical Registries: A Literature Review. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2018; 27:868-883. [PMID: 29710238 PMCID: PMC6105122 DOI: 10.1044/2018_ajslp-17-0158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 11/25/2017] [Accepted: 12/27/2017] [Indexed: 06/08/2023]
Abstract
Purpose The call for data-driven health care has been bolstered by the digitization of medical records, quality initiatives, and payment reform. Administrative databases and clinical registries are increasingly being used to study oropharyngeal dysphagia and to facilitate data-driven decision making. The objective of this work was to summarize key findings, etiologies studied, data sources used, study objectives, and quality of evidence of all original research articles that have investigated oropharyngeal dysphagia or aspiration pneumonia using administrative or clinical registry data to date. Method A literature search was completed in MEDLINE, Scopus, and Google Scholar (January 1, 1990, to February 1, 2017). Each study that met inclusion criteria was rated for quality of evidence on a 5-point scale. Results Eighty-four research articles were included in the final analysis (n = 221-1,649,871). Over the past 20 years, the number of new publications in this area has quintupled. Most of the administrative database and clinical registry studies of dysphagia have been retrospective cohort studies and cross-sectional studies and limited to quality of evidence levels of 3-4. In these studies, much has been learned about risk factors for dysphagia and pneumonia in defined populations and health care costs and usage. Little has been gleaned from these studies regarding swallowing physiology or dysphagia management. Conclusions Investigators are just beginning to develop the methods to study oropharyngeal dysphagia using administrative data and clinical registries. Future research is needed in all areas, from the fundamental issue of how to identify individuals with dysphagia with high sensitivity in these data sets to evaluating treatment effectiveness. Supplemental Material https://doi.org/10.23641/asha.6066515.
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Affiliation(s)
- Rebecca S. Bartlett
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Wisconsin-Madison
| | - Susan L. Thibeault
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Wisconsin-Madison
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Vonck CE, Tanenbaum JE, Smith GA, Benzel EC, Mroz TE, Steinmetz MP. National Trends in Demographics and Outcomes Following Cervical Fusion for Cervical Spondylotic Myelopathy. Global Spine J 2018; 8:244-253. [PMID: 29796372 PMCID: PMC5958486 DOI: 10.1177/2192568217722562] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
STUDY DESIGN Retrospective trends analysis. OBJECTIVES Cervical fusion is a common adjunctive surgical modality used in the treatment of cervical spondylotic myelopathy (CSM). The purpose of this study was to quantify national trends in patient demographics, hospital characteristics, and outcomes in the surgical management of CSM. METHODS This was a retrospective study that used the National Inpatient Sample. The sample included all patients over 18 years of age with a diagnosis of CSM who underwent cervical fusion from 2003 to 2013. The outcome measures were in-hospital mortality, length of stay, and hospital charges. Chi-square tests were performed to compare categorical variables. Independent t tests were performed to compare continuous variables. RESULTS We identified 62 970 patients with CSM who underwent cervical fusion from 2003 to 2013. The number of fusions performed per year in the treatment of CSM increased from 3879 to 8181. The average age of all fusion patients increased from 58.2 to 60.6 years (P < .001). Length of stay did not change significantly from a mean of 3.7 days. In-hospital mortality decreased from 0.6% to 0.3% (P < .01). Hospital charges increased from $49 445 to $92 040 (P < .001). CONCLUSIONS This study showed a dramatic increase in cervical fusions to treat CSM from 2003 to 2013 concomitant with increasing age of the patient population. Despite increases in average age and number of comorbidities, length of stay remained constant and a decrease in mortality was seen across the study period. However, hospital charges increased dramatically.
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Affiliation(s)
- Caroline E. Vonck
- Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | - Joseph E. Tanenbaum
- Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
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A Randomized Trial Comparing Clinical Outcomes Between Zero-Profile and Traditional Multilevel Anterior Cervical Discectomy and Fusion Surgery for Cervical Myelopathy. Spine (Phila Pa 1976) 2018; 43:E259-E266. [PMID: 29432408 DOI: 10.1097/brs.0000000000002323] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective randomized study from a single center OBJECTIVE.: The purpose of this study was to compare outcomes between a zero-profile (ZP) anterior cervical discectomy and fusion (ACDF) construct to a traditional ACDF with anterior cervical plate (ACP) in the treatment of multilevel cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA Multilevel cervical spondylotic myelopathy can be treated by a variety of techniques, most commonly with corpectomy, ACDF, posterior cervical fusion, or a combination of the three. Examples in the literature of comparative effectiveness of different anterior approach types are few. METHODS A total of 104 patients with multilevel cervical spondylotic myelopathy were randomized in equal proportion between treated with ACDF and ZP or ACDF with ACP. Clinical efficacy of two groups was evaluated preoperatively and at all postoperative time points through 2 years postoperative by the Japanese Orthopedic Association score and the neck disability index. Radiographic changes from baseline, including disc height and cervical lordosis, were evaluated at the same postoperative time points. Complications were assessed perioperatively and through 2 years postoperatively. RESULTS The ZP and ACP ACDF groups demonstrated substantially equivalent Japanese Orthopaedic Association, neck disability index, disc height, and lordosis improvements from baseline, which were maintained through 2 years postoperatively. Complications occurred in 4% of ZP and 17% of ACP patients (P = 0.052), and zero (0%) ZP and four (8%) ACP patients reported hoarseness or dysphagia. CONCLUSION ZP used in multilevel ACDF may obtain favorable clinical outcomes and a lower postoperative complication. LEVEL OF EVIDENCE 2.
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Cervical Spinal Fusion: 16-Year Trends in Epidemiology, Indications, and In-Hospital Outcomes by Surgical Approach. World Neurosurg 2018; 113:e280-e295. [PMID: 29438790 DOI: 10.1016/j.wneu.2018.02.004] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/31/2018] [Accepted: 02/02/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND The rate of cervical spinal fusion has been increasing significantly. However, there is a paucity of literature describing trends based on surgical approach using complete population databases. We investigated the approach-based trends in epidemiology, indications, and in-hospital outcomes of cervical spinal fusion. METHODS New York's Statewide Planning and Research Cooperative System database was queried to identify patients who underwent primary subaxial cervical fusion from 1997 to 2012. Demographic and clinical information was obtained. Subgroup analyses were performed based on surgical approach: anterior (A), posterior (P), and circumferential (C). RESULTS A total of 87,045 cervical fusions were included. Over the study period, the population-adjusted annual fusion rate increased from 23.7 to 50.6 per 100,000 population (P < 0.001). A fusion was most common (85.2%), followed by P (12.3%), and C (2.5%). Mean ages were 49.8 ± 11.9, 59.9 ± 15.2, and 55.1 ± 14.5 years (P < 0.001), respectively. Although rates remained steady among younger patients, they increased for older patients. Overall, degenerative conditions were the predominant indications for surgery and increased in rate over time. The mean length of stay was: A, 3.1 ± 10.5; P, 9.1 ± 14.1; and C, 14.1 ± 22.5 days (P < 0.001). Rates of in-hospital complications were A, 3.0%; P, 10.5%; and C, 18.9% (P < 0.001), and mortality was A, 0.3%, P, 1.8%, and C, 2.5% (P < 0.001). CONCLUSIONS The rate of subaxial spinal fusions increased 114% from 1997 to 2012 in New York State. Rates remained stable in younger patients but increased in the older population. Preoperative indications and postoperative courses differed significantly among the various approaches, with patients undergoing anterior fusion having better short-term outcomes.
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Abstract
STUDY DESIGN Retrospective database review. OBJECTIVE To determine how demographics and comorbid diagnoses influence hospital costs during admission for anterior cervical fusions (ACFs) in the elderly Medicare population. SUMMARY OF BACKGROUND DATA Elective ACFs to treat degenerative cervical pathology are extremely common within the elderly population. Although it is well known that every patient has a significantly different medical profile that guides treatment and postoperative care, little information is available regarding how hospital costs vary from patient to patient. METHODS Medicare records from the PearlDiver database (2011-2012) were retrospectively queried to select all 65- to 84-year-old patients who underwent primary, 1 to 2 level ACF (International Classification of Diseases, Ninth Revision, Clinical Modification: 81.02) for either cervical spondylosis or cervical disc disease. All patients with corpectomies, posterior cervical fusions, and all other same-day spine fusion surgeries were excluded. The primary outcome of this study was Medicare reimbursement from the full inpatient stay as associated with the selected International Classification of Diseases, Ninth Revision procedure code. The relative contributions of year, age, sex, region, myelopathy diagnosis, and various comorbidities to the total cost were determined with both univariate statistics and multivariate analysis. For all analyses, P < 0.001 was determined to be significant. RESULTS In total, 21,853 patients were selected for analysis. The average reimbursement for the full cohort was $13,648 ± $7306. On multivariate analysis, advanced age ($1083), diagnosis of myelopathy ($2150), diabetes mellitus ($1019), obesity ($651), congestive heart failure ($1523), chronic kidney disease ($1962), and chronic pulmonary disease ($489) were all factors that increased costs. Of note, sex, smoking history, and prior liver disease were not associated with changes in cost. CONCLUSION Medicare reimbursements provide a value means by which determinants of cost can be elucidated. Although multiple comorbidities, older age, and myelopathy diagnosis could be theorized to contribute to increased costs, there is still some uncertainty regarding their relative costs. These data are informative to practicing physicians as health care as a whole transitions to a more value-based approach. LEVEL OF EVIDENCE 4.
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