Evolving Trends in the Use of Sacroiliac Fusion From 2015 to 2020

STUDY DESIGN

Retrospective cohort analysis.

OBJECTIVE

To assess the evolution of patients undergoing sacroiliac (SI) fusion with minimally invasive surgery (MIS) relative to open approaches.

SUMMARY OF BACKGROUND DATA

The SI joint can be a contributor to lumbopelvic symptoms. The MIS approach to SI fusion has been shown to have fewer complications compared with the open approach. Recent trends and evolved patient populations have not been well-characterized.

MATERIALS AND METHODS

Data were abstracted from the large, national, multi-insurance, administrative 2015-2020 M151 PearlDiver database. The incidence, trends, and patient characteristics of MIS, as well as open, SI fusions for adult patients with degenerative indications, were determined. Univariable and multivariable analyses were then performed to compare the MIS relative to open populations. The primary outcome was to assess the trends of MIS and open approaches for SI fusions.

RESULTS

In total, 11,217 SI fusions were identified (of which 81.7% were MIS), with a clear increase in numbers over the years from 2015 (n=1318, 62.3% of which were MIS) to 2020 (n=3214 86.6% of which were MIS). Independent predictors of MIS (as opposed to open) SI fusion included: older age (odds ratio [OR] 1.09 per decade increase), higher Elixhauser-Comorbidity Index (OR 1.04 per two-point increase), and geographic region (relative to South, Northeast OR 1.20 and West OR 1.64). As might be expected, 90-day adverse events were lower for MIS than open cases (OR 0.73).

CONCLUSION

The presented data quantify the increasing incidence of SI fusions over the years, with the increase being driven by MIS cases. This was largely related to an expanded population (those who are older and with greater comorbidity), fitting the definition of disruptive technology with lesser adverse events than open procedures. Nonetheless, geographic variation highlights the differential adoption of this technology.

Sponsorship of clinical trials related to the spine: Trends over time and comparative analysis of trial characteristics by sponsorship type

Background

Clinical trials are crucial to advance products and procedures related to the spine. ClinicalTrials.gov is an internet-based registry and results database that catalogs trial characteristics, such as intervention types, phase, randomization, and blinding. Sponsorship trends have not been specifically evaluated for spine-related clinical trials, nor have trial characteristics been compared among spine-related trials sponsored by institutions, industries, and federal agencies. The purpose of this cross-sectional analysis of spine-related clinical trials was to characterize the types and trends of sponsorship for spine-related clinical trials, and compare trial characteristics among trials sponsored by institutions, industries, and federal agencies.

Methods

ClinicalTrials.gov was queried for clinical trials started from the launch of ClinicalTrials.gov (February 29, 2000) through December 31, 2022, using the term "spine." Trial characteristics were abstracted, including start year, intervention type, phase, randomization, and blinding. Univariate and multivariate analyses were performed to determine associations between sponsorship type and other trial characteristics.

Results

A total of 4,484 clinical trials were identified, of which 78 trials were excluded due to incomplete reporting of trial registration data. From 2000 through 2022, the number of spine-related trials initiated annually markedly increased (from 21 to 453, representing an increase of 2,057%). This was predominantly driven by an increase in the number of institutionally sponsored trials. Relative to trials with institutional sponsorship, industry sponsorship was independently associated with different intervention types, phases of study, lack of randomization, and lack of blinding. Relative to trials with institutional sponsorship, federal sponsorship was independently associated with intervention type, and phase of study.

Conclusions

From 2000 through 2022, the number of spine-related clinical trials initiated annually markedly increased, driven by an increase in institutionally sponsored trials. Specific trial characteristics were more or less likely for industrially or federally sponsored trials relative to institutionally sponsored trials suggesting the types of clinical trials are shifting over time.

Racial Disparities in Surgical Versus Nonsurgical Management of Distal Radius Fractures in a Medicare Population

BACKGROUND

As racial/ethnic disparities in management of distal radius fractures (DRFs) have not been well elucidated in the literature, this study sought to evaluate the correlation of race/ethnicity on surgical versus nonsurgical management of DRFs in a Medicare population.

METHODS

The PearlDiver Standard Analytical Files Medicare claims database was used to identify patients ≥65 years old with isolated DRF. Patients with polytrauma or surgery performed for upper extremity neoplasm were excluded. Surgical versus nonsurgical management was compared based on demographics, comorbidity (Elixhauser Comorbidity Index, ECI), race/ethnicity, and whether the fracture was open or closed. Univariate and multivariable analyses were used to assess for independent predictors.

RESULTS

Of 54 564 isolated DRFs identified, surgery was performed for 20 663 (37.9%). On multivariable analysis, patients were independently less likely to receive surgical management if they were: older (relative to 65- to 69-year-olds, incrementally decreasing by age bracket up to >85 years where odds ratio [OR] was 0.27, P < .001), higher ECI (per 2 increase OR: 0.96, P < .001), and closed fractures (OR: 0.35, P < .001). For race/ethnicity: black (OR: 0.64, P < .001), Hispanic (OR: 0.71, P < .001), and Asian (OR: 0.60, P < .001) patients were less likely to undergo surgery.

CONCLUSIONS

While age, comorbidities, and fracture type are known to affect surgical decision-making for DRF, race/ethnicity has not previously been reported, and its independent prediction of nonsurgical management for several groups points to a disparity in surgical decision-making/access to care. This highlights the need for increased attention to initiatives that seek to provide equitable care to all patients.

LEVEL OF EVIDENCE

Level III-Retrospective review of national database.

Prospective analysis of home narcotic consumption and management of excess narcotic prescription following adolescent idiopathic scoliosis surgery

PURPOSE

The aim of this study was to identify factors associated with the outpatient narcotic intake of patients following posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS) and to introduce a safe and effective method of disposing of unused narcotics.

METHODS

Following Institutional Review Board approval, retrospective review of prospectively collected data from patients undergoing PSF for AIS took place. Pain scores, narcotic use, patient demographic data, pre-, intra-, and postoperative parameters, and discharge data were gathered via chart review. Patients were divided into two groups according to home narcotic use, high use (top 25th percentiles) and low use (bottom 75th percentiles), and multivariate statistical analysis was conducted. Narcotic surplus was collected during postoperative clinic visits and disposed of using biodegradable bags.

RESULTS

Statistical analysis of 27 patients included in the study showed that patients with a higher home narcotic use correlated with increased length of hospitalization with an average of 3.4 days compared to the lower-use group of 2.8 day (p = 0.03). Higher-use group also showed increased inpatient morphine milligram equivalent than the lower-use group. There was no significant difference of home narcotic use when looking at patient age, height, weight, BMI, levels fused, intraoperative blood loss, or length of surgery. A total of 502 narcotic doses were disposed of in the clinic.

CONCLUSION

Our study suggests that there are not a significant number of patient- or surgical-level factors predisposing patients to increased home narcotic usage following spinal fusion for adolescent idiopathic scoliosis.

LEVEL OF EVIDENCE

Level I, prospective study.

Comparing Race/Ethnicity and Zip Code Socioeconomic Status for Surgical versus Nonsurgical Management of Proximal Humerus Fractures in a Medicare Population

BACKGROUND

This study evaluated the effect of race/ethnicity and socioeconomic status (SES) on surgical utilization after proximal humerus fractures in a large Medicare cohort.

METHODS

The PearlDiver Medicare claims database was used to identify patients aged 65years and older with isolated, closed proximal humerus fractures, for whom race/ethnicity data were available (65.5% of identified fractures). Patients with polytrauma or neoplasm were excluded. Patient demographic, race/ethnicity, comorbidity, and median household income were compared for surgical versus nonsurgical management. Univariate and multivariable logistic regressions were used to determine disparities of surgical utilization based on the abovementioned factors.

RESULTS

Of 133,218 patients with proximal humerus fracture identified, surgery was conducted for 4446 (3.3%). Those less likely to receive surgery were older (incrementally by increasing age bracket up to 85 years and older odds ratio [OR], 0.16, P < 0.001), male (OR, 0.79, P < 0.001), Black (OR, 0.51, P < 0.001) or Hispanic (0.61, P = 0.005), higher Elixhauser Comorbidity Index (per 2 increase OR, 0.86, P < 0.001), and low median household income (OR, 0.79, P < 0.001).

CONCLUSIONS

The independent significance of race/ethnicity and SES point to disparities in surgical decision making/access to care. These findings highlight the need for increased attention on initiatives and policies that seek to eliminate racial disparities and improve health equity independent of SES.

Postoperative spine surgical site infections: high rate of failure of one-stage irrigation and debridement

BACKGROUND CONTEXT

Following spine surgery, postoperative surgical site infection (SSI) is a rare but potentially devastating complication. Previous studies have assessed risk factors for spine SSI and one aimed to develop risk stratification tool to assess management options, but this tool has not been externally validated or regularly used.

PURPOSE

The current study aimed to investigate the rate of SSI following elective spine surgery, surgical management pursued, and success of traditionally utilized one-stage of irrigation and debridement (I&D) with closure over drains.

STUDY DESIGN

Retrospective case-control study.

PATIENT SAMPLE

Adult, elective spine surgeries performed at a single academic institution between 2013 and 2021 were evaluated. Patients who developed SSI requiring surgical intervention were identified.

OUTCOME MEASURES

Those who underwent initial management with I&D and closure over drains were assessed for need of subsequent I&D (considered failure of initial infection management).

METHODS

Of spine surgeries meeting inclusion criteria, those with SSI were identified and management was characterized. For those who did and did not fail attempted one stage I&D with closure over drains, pre-operative and surgical variables from the index procedure as well as infection characteristics were assessed and compared with univariable and multivariable analyses.

RESULTS

Of 11,023 elective spine surgeries, SSI was identified for 76 (0.7%). For initial management, I&D with closure over drains was used for 66 (86.8%) while I&D and wound vacuum management was used 10 (13.2%). Failure of attempted one stage I&D (requiring subsequent I&D procedure) was identified for 18 (27% of those undergoing I&D and closure over drains). Of multiple patient, surgical, and infection characteristics, the only factor identified as independently predictive of one stage I&D failure was presence of bacteremia (odds ratio [OR] 38.3, p=0.0007). Within the sub-cohort of patients with bacteremia, failure of attempted one stage I&D was noted for 80%.

CONCLUSION

Less than one percent of a large cohort of patients undergoing spine surgery were found to develop SSIs. Of those undergoing attempted one stage I&D, most patient, surgical, and infection variables did not influence outcome of the intervention. However, those with bacteremia were at 38.3 times greater odds of failing attempted one-stage I&D. These results suggest considering delayed closure approaches in these cases.

Comparison of postoperative outcomes in patients with and without osteoporosis undergoing single-level anterior cervical discectomy and fusion

Background

Osteoporosis is ubiquitous in elderly populations, such as those undergoing ACDF. Short- and longer-term outcomes might be affected in the setting of osteoporosis related to graft subsidence, bony union, and stresses on adjacent segments. Better understanding the potential correlation of osteoporosis and outcomes after ACDF might affect patient counseling and surgical planning. The current study compares 90-day adverse events and 5-year reoperations following single-level anterior cervical discectomy and fusion (ACDF) between patients with and without osteoporosis.

Methods

Single-level ACDF procedures were identified in a national administrative database. Exclusion criteria included age under 18 years, less than 90 days of follow-up in the database, multi-level procedures, posterior concomitant procedures, and surgeries performed for trauma, neoplasm, or infection. After matching based on patient characteristics, 90-day perioperative adverse events were compared with multivariate analyses and five-year reoperations were compared with log-rank analysis. Reasons for reoperations were also evaluated.

Results

Relative to age, sex, and comorbidity-matched patients without osteoporosis, those with osteoporosis had a small but statistically greater incidence of experiencing any 90-day adverse event (10.9% vs 9.4%, p < 0.001) and 5-year reoperations (19.1% vs 17.0%, p < 0.001). Of those requiring reoperation, those in the osteoporosis group had a greater proportion for nonunion (7.5% vs 5.6% p = 0.003).

Conclusions

Following single-level ACDF, patients with osteoporosis experience slightly greater 90-day adverse events and 5-year reoperations. These results suggest the importance of recognizing osteoporosis in the ACDF population and accounting for this with surgical planning and patient counselling.

Cadaveric Examination of the Radiographic Safe Zone for Open Reduction and Internal Fixation of the Calcaneus Posterior Facet

Background:

The purpose of this study is to define a safe zone for screw placement on a lateral radiograph of the calcaneus taking into account the lateral to medial convexity of the posterior facet. Such findings may serve to improve surgical quality during open reduction and internal fixation (ORIF) of the posterior facet of the calcaneus.

Methods:

Eleven cadaveric calcanei were harvested and the articular margins of the posterior facet were outlined with a radiopaque wire. Lateral radiographs, similar to those used for intraoperative fluoroscopy, of each specimen were obtained and calibrated to a standardized marker. The proximal-to-distal length of the posterior facet was then divided into quadrants. The greatest height difference between the superolateral and inferomedial surfaces outlined by the radiopaque marker were measured in the 2 most posterior quadrants, as screw insertion in this area would be mostly likely to risk screw penetration during ORIF.

Results:

The average distance from the osseous surface to the radiographic marker was 3.3 ± 1.2 mm in the most posterior quadrant (fourth quadrant) and 3.2 ± 1.6 mm in the quadrant just anterior to this (third quadrant). The range for unsafe screw placement was 1.7 to 5.6 mm below the osseous surface in the fourth quadrant and 1.1 to 6.6 mm in the third quadrant.

Conclusion:

Intraoperative radiographic assessment of the safety of subchondral posterior facet screws does not correlate to its osteology. Because of the superolateral to inferomedial convexity of the posterior facet of the calcaneus, overly long screws may appear to be radiographically intraosseous, though in actuality the screw may be intra-articular. On average, screws placed in the fourth quadrant of the facet are at less risk if 3.3 mm inferior to the upper margin of the osseous shadow on fluoroscopic imaging and 3.2 mm inferior in the third quadrant. Though limited by a small sample size, this study sets a foundation for future research into this complex osteology.

Level of Evidence:

Level V, mechanism-based reasoning.