RESUMO

STUDY DESIGN: Retrospective observational study. OBJECTIVE: To elucidate racial and socioeconomic factors driving preoperative disparities in spine surgery patients. SUMMARY OF BACKGROUND DATA: There are racial and socioeconomic disparities in preoperative health among spine surgery patients, which may influence outcomes for minority and low socioeconomic status (SES) populations. METHODS: Presenting, postoperative day 90 (POD90), and 12-month (12M) outcome scores (PROMIS global physical and mental [GPH, GMH] and visual analog scale pain [VAS]) were collected for patients undergoing deformity arthrodesis or cervical, thoracic, or lumbar laminotomy or decompression/fusion; these procedures were the most common in our cohort. Social determinants of health for a patient's neighborhood (county, zip code, or census tract) were extracted from public databases. Multivariable linear regression with stepwise selection was used to quantify the association between a patient's preoperative GPH score and sociodemographic variables. RESULTS: Black patients presented with 1 to 3 point higher VAS pain scores (7-8 vs. 5-6) and lower (worse) GPH scores (6.5-10 vs. 11-12) than White patients (P < 0.05 for all comparisons); similarly, lower SES patients presented with 1.5 points greater pain (P < 0.0001) and 3.5 points lower GPH (P < 0.0001) than high SES patients. Patients with lowest-quartile presenting GPH scores reported 36.8% and 37.5% lower (worse) POD-90 GMH and GPH scores than the highest quartile, respectively (GMH: 12 vs. 19, P < 0.0001; GPH: 15 vs. 24, P < 0.0001); this trend extended to 12 months (GMH: 19.5 vs. 29.5, P < 0.0001; GPH: 22 vs. 30, P < 0.0001). Reduced access to primary care (B = -1.616, P < 0.0001) and low SES (B = -1.504, P = 0.001), proxied by median household value, were independent predictors of worse presenting GPH scores. CONCLUSION: Racial and socioeconomic disparities in patients' preoperative physical and mental health at presentation for spine surgery are associated adversely with postoperative outcomes. Renewed focus on structural factors influencing preoperative presentation, including timeliness of care, is essential.Level of Evidence: 3.

Assuntos

Medidas de Resultados Relatados pelo Paciente , Determinantes Sociais da Saúde , Humanos , Morbidade , Dor , Estudos Retrospectivos

RESUMO

STUDY DESIGN: Retrospective cohort study at a single institution. Patients undergoing specific, elective spinal procedures between 2012 and 2018. OBJECTIVE: The aim of thi stsudy was to investigate the relationship between opioid prescriptions during the immediate, post-discharge period, and patient-reported pain outcomes. SUMMARY OF BACKGROUND DATA: Medically prescribed opiates contribute to the opioid crisis, manifesting in significant mortality and economic burden. Although opioids are a mainstay of pain amelioration following spinal surgery, prescription practices are heterogeneous. METHODS: Inclusion criteria included: patients who underwent one of 10 spinal procedures (Table 1); patients with preoperative, postoperative day (POD 1, and POD 30 pain scores reported on the visual analog scale (VAS); patients discharged without a complicated perioperative course. Opioids were converted to morphine milligram equivalents per day (MME/day) using a standard reference table. χ2, Kruskal-Wallis, and logistic regression were utilized to investigate associations between clinical variables and postoperative pain scores. Univariate and multivariable linear regression models with Stepwise selection (cut off: P = 0.05) were employed as appropriate on POD 30 VAS pain scores. RESULTS: Smoking status and postoperative LOS were associated with opioid prescription doses. Patients prescribed opioids <40 MME/day, equivalent to five tablets of 5 mg oxycodone/day, showed no significant difference in POD 30 VAS score (ß coefficient: 0.095, P  = 0.752) when compared to patients who received the highest-dose opioids (>80 MME/day-equivalent to 10 tablets of 5 mg oxycodone/day). Adjusted multivariable logistic regression analysis revealed that postoperative opioid dosage/prescription was not a significant predictor of patients reporting at least 50% pain improvement, suggesting that 40 MME/day is sufficient to maintain patient satisfaction. CONCLUSION: Patients receiving the lowest dosage of opioid prescriptions with sufficient nonopiate analgesics did not report worse pain relief at POD 30 compared to those receiving higher opioid prescriptions. In light of the opioid epidemic, this study supports initial dosing recommendations by the American Society for Addiction Medicine.Level of Evidence: 3.

Assuntos

Analgésicos Opioides , Entorpecentes , Assistência ao Convalescente , Humanos , Dor Pós-Operatória/diagnóstico , Dor Pós-Operatória/tratamento farmacológico , Alta do Paciente , Padrões de Prática Médica , Prescrições , Estudos Retrospectivos

RESUMO

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The goal of the present study was to determine whether neck pain responds differently to anterior cervical discectomy and fusion (ACDF) between patients with cervical radiculopathy and/or cervical myelopathy. SUMMARY OF BACKGROUND DATA: Many patients who undergo ACDF because of radiculopathy/myelopathy also complain of neck pain. However, no studies have compared the response of significant neck pain to ACDF. METHODS: Patients undergoing one to three-level primary ACDF for radiculopathy and/or myelopathy with significant (Visual Analogue Scale [VAS] ≥ 3) neck pain and a minimum of 1-year follow-up were included. Based on preoperative symptoms patients were split into groups for analysis: radiculopathy (R group), myelopathy (M group), or both (MR group). Groups were compared for differences in Health Related Quality of Life outcomes: Physical Component Score-12, Mental Component Score (MCS)-12, Neck Disability Index, VAS neck, and VAS arm pain. RESULTS: Two hundred thirty-five patients met inclusion criteria. There were 117 patients in the R group, 53 in the M group, and 65 in the MR group. Preoperative VAS neck pain was found to be significantly higher in the R group versus M group (6.5 vs. 5.5; P = 0.046). Postoperatively, all cohorts experienced significant (P < 0.001) reduction in VAS neck pain, (ΔVAS neck; R group: -2.9, M: -2.5, MR: -2.5) with no significant differences between groups. However, myelopathic patients showed greater improvement in absolute MCS-12 scores (P = 0.011), RR (P = 0.006), and % minimum clinically important difference (P = 0.013) when compared with radiculopathy patients. This greater improvement remained following regression analysis (P = 0.025). CONCLUSION: Patients with substantial preoperative neck pain experienced significant reduction in their neck pain, disability, and physical function following ACDF, whether treated for radiculopathy or myelopathy. However, in this study, only myelopathy patients had significant improvements in their mental function as represented by MCS improvements. LEVEL OF EVIDENCE: 3.

Assuntos

Vértebras Cervicais/cirurgia , Discotomia/tendências , Cervicalgia/cirurgia , Radiculopatia/cirurgia , Doenças da Medula Espinal/cirurgia , Fusão Vertebral/tendências , Adulto , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Cervicalgia/diagnóstico , Cervicalgia/etiologia , Medição da Dor/métodos , Medição da Dor/tendências , Radiculopatia/complicações , Radiculopatia/diagnóstico , Estudos Retrospectivos , Doenças da Medula Espinal/complicações , Doenças da Medula Espinal/diagnóstico , Resultado do Tratamento

RESUMO

STUDY DESIGN: Spine update. OBJECTIVE: The purpose of this study is to provide a review of preoperative clearance and optimization, before elective spine surgery. SUMMARY OF BACKGROUND DATA: Patient optimization preceding elective surgery is critical to ensure the best possible outcome. METHODS: Historical and current literature pertaining to patient clearance and optimization, before elective surgery, was reviewed. These data were then synthesized and assessed to provide a balanced view on current trends in regards to preoperative management and optimization. RESULTS: The American Academy of Cardiology defines spine surgery as "intermediate" risk, and thus patients are permitted to forgo formal cardiac evaluation if they have no active cardiac condition and demonstrate adequate functional capacity; however, those with active or chronic medical conditions require further investigation before elective operations. CONCLUSION: Overall, preoperative screening and optimization of comorbidities are vital to ensure positive outcomes in elective spine surgery, and the aforementioned criteria must be considered on an individual basis. Further research into specific preoperative optimization guidelines would help to ensure successful outcomes for those undergoing spine surgery. LEVEL OF EVIDENCE: N/A.

Assuntos

Procedimentos Cirúrgicos Eletivos , Cuidados Pré-Operatórios , Encaminhamento e Consulta , Idoso , Comorbidade , Feminino , Cardiopatias , Humanos , Masculino , Pessoa de Meia-Idade , Coluna Vertebral/cirurgia

RESUMO

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The goal of this study is to determine if skipping a single level affects the revision rate for patients undergoing multilevel posterior cervical decompression and fusion (PCDF). SUMMARY OF BACKGROUND DATA: A multilevel PCDF is a common procedure for patients with cervical spondylotic myelopathy. With advanced pathology, it can be difficult to safely place screw instrumentation at every level increasing the risk of intraoperative and perioperative morbidity. It is unclear whether skipping a level during PCDF affects fusion and revision rates. PATIENTS AND METHODS: A cervical spine surgeries database at a single institution was used to identify patients who underwent ≥3 levels of PCDF. Inclusion criteria consisted of patients who had screws placed at every level or if they had a single level without screws bilaterally. Patients were excluded if the surgery was performed for tumor, trauma, or infection, and age below 18 years, or if there was <1 year of follow-up. RESULTS: A total of 157 patients met inclusion criteria, with 86 undergoing a PCDF with instrumentation at all levels and 71 that had a single uninstrumented level. Overall mean follow-up was 46.5±22.8 months. In patients with or without a skipped level, the revision rate was 25% and 26%, respectively (P<1.00). Univariate regression analysis demonstrated that proximal fixation level in the upper cervical region, having the fusion end at C7, prior surgery, and myelopathy were significant predictors of revision. Skipping a single level, however, was not predictive of revision. CONCLUSIONS: When performing a multilevel PCDF, there is no increase in the rate of revision surgery if a single level is uninstrumented. Conversely, other surgical factors, including the cranial and caudal levels, affect revision rates. In contrast to other reports, the C2 sagittal vertical axis did not affect reoperation rates. LEVEL OF EVIDENCE: Level IV.

Assuntos

Vértebras Cervicais/cirurgia , Descompressão Cirúrgica , Reoperação , Fusão Vertebral , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Cuidados Pré-Operatórios

RESUMO

STUDY DESIGN: Health Services Research. OBJECTIVE: The purpose of this study is to determine the variability of Medicaid (MCD) reimbursement for patients who require spine procedures, and to assess how this compares to regional Medicare (MCR) reimbursement as a marker of access to spine surgery. SUMMARY OF BACKGROUND DATA: The current health care environment includes two major forms of government reimbursement: MCD and MCR, which are regulated and funded by the state and federal government, respectively. METHODS: MCD reimbursement rates from each state were obtained for eight spine procedures, utilizing online web searches: anterior cervical decompression and fusion, posterior cervical decompression and fusion, posterior lumbar decompression, single-level posterior lumbar fusion, posterior fusion for deformity (less than six levels; six to 12 levels; 13+ levels), and lumbar microdiscectomy. Discrepancy in reimbursement for these procedures on a state-to-state basis, as well as overall differences in MCD versus MCR reimbursement, was determined. Procedures were examined to identify whether certain surgical interventions have greater discrepancy in reimbursement. RESULTS: The average MCD reimbursement was 78.4% of that for MCR. However, there was significant variation between states (38.8%-140% of MCR for the combined eight procedures). On average, New York, New Jersey, Florida, and Rhode Island provided MCD reimbursements <50% of MCR reimbursements in the region. In total, 20 and 42 states provided <75% and 100% of MCR reimbursements, respectively. Based upon relative reimbursement, MCD appears to value microdiscectomy (84.1% of MCR; P = 0.10) over other elective spine procedures. Microdiscectomy also had the most interstate variation in MCD reimbursement: 39.0% to 207.0% of MCR. CONCLUSION: Large disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to fully understand the effect of these significant differences. However, it is likely that these discrepancies lead to suboptimal access to necessary spine care. LEVEL OF EVIDENCE: 4.

Assuntos

Descompressão Cirúrgica , Reembolso de Seguro de Saúde , Medicaid , Procedimentos Ortopédicos , Coluna Vertebral/cirurgia , Descompressão Cirúrgica/economia , Descompressão Cirúrgica/estatística & dados numéricos , Humanos , Reembolso de Seguro de Saúde/economia , Reembolso de Seguro de Saúde/estatística & dados numéricos , Medicaid/economia , Medicaid/estatística & dados numéricos , Procedimentos Ortopédicos/economia , Estados Unidos

RESUMO

BACKGROUND: While some advocate for unicompartmental knee arthroplasty (UKA) for isolated medial compartment osteoarthritis (OA), others favor total knee arthroplasty (TKA). The purpose of this study was to compare the functional outcomes of UKA and TKA performed for patients with unicompartmental arthritis (OA). METHODS: A study was performed on 133 patients that met strict criteria for UKA, but who underwent either medial UKA or TKA for isolated medial compartment OA based upon physician equipoise. The primary outcome-New Knee Society Score (KSS)-was assessed preoperatively and at 2 years postoperatively. A propensity score weighted regression was used to balance the groups on several key covariates, including age, gender, body mass index, and baseline KSS. RESULTS: After propensity weighting, there were no significant differences between UKA and TKA in overall baseline KSS or KSS after 2 years postoperatively. While TKA patients had demonstrated a significantly greater improvement in the symptoms KSS subscale, UKA patients had a significantly greater improvement in the function subscale. Expectations were significantly more likely to be met after UKA, but there were no differences in patient satisfaction. CONCLUSION: UKA and TKA are both highly successful options for treating patients with medial compartment OA, although functionality increased more, and expectations were more likely to be met, after UKA in this study. Given equivalent patient satisfaction after both TKA and UKA, surgeons should consider factors such as clinical experience, individual preference, cost of care, surgical risk, and recovery needs, when making treatment decisions regarding this clinical entity.

Assuntos

Artroplastia do Joelho/métodos , Osteoartrite do Joelho/cirurgia , Satisfação do Paciente , Idoso , Artroplastia do Joelho/efeitos adversos , Artroplastia do Joelho/psicologia , Índice de Massa Corporal , Feminino , Humanos , Articulação do Joelho/cirurgia , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Pontuação de Propensão , Estudos Retrospectivos , Índice de Gravidade de Doença , Cirurgiões , Resultado do Tratamento

RESUMO

STUDY DESIGN: This was a systematic review. OBJECTIVE: To review and synthesize information on subaxial lateral mass dimensions in order to determine the ideal starting point, trajectory, and size of a lateral mass screw. SUMMARY OF BACKGROUND DATA: The use of lateral mass instrumentation for posterior cervical decompression and fusion has become routine as these constructs have increased rigidity and fusion rates. METHODS: A systematic search of Medline and EMBASE was conducted. Studies that provided subaxial cervical lateral mass measurements, distance to the facet, vertebral artery and neuroforamen and facet angle made either directly (eg, cadaver specimen) or from patient imaging were considered for inclusion. Pooled estimates of mean dimensions were reported with corresponding 95% confidence intervals. Stratified analysis based on level, sex, imaging plane, source (cadaver or imaging), and measurement method was done. RESULTS: Of the 194 citations identified, 12 cadaver and 10 imaging studies were included. Pooled estimates for C3-C6 were generally consistent for lateral mass height (12.1 mm), width (12.0 mm), depth (10.8 mm), distance to the transverse foramen (11.8 mm), and distance to the nerve. C7 dimensions were most variable. Small sex-based differences in dimensions were noted for height (1.2 mm), width (1.3 mm), depth (0.43 mm), transverse foramen distance (0.9 mm), and nerve distance (0.3-0.8 mm). No firm conclusions regarding differences between measurements made on cadavers and those based on patient computed tomographic images are possible; findings were not consistent across dimensions. The overall strength of evidence is considered very low for all findings. CONCLUSIONS: Although estimates of height, width, and depth were generally consistent for C3-C6, C7 dimensions were variable. Small sex differences in dimensions may suggest that surgeons should use a slightly smaller screw in female patients. Firm conclusions regarding facet angulation, source of measurement, and method of measurement were not possible.

Assuntos

Vértebras Cervicais/patologia , Adolescente , Fenômenos Biomecânicos , Humanos , Articulação Zigapofisária/patologia

RESUMO

INTRODUCTION: Cervical myelopathy is a common indication for spine surgery. Modern medicine demands high quality, cost-effective treatment. Most cost analyses fail to account for complication costs from nonoperative treatment. The purpose is to compare the total health care costs for operative versus nonoperative treatment of cervical myelopathy. METHODS: The Center for Medicare and Medicaid Services Carrier File from 2005 to 2012 was reviewed using the PearlDiver database, representing a 5% sampling of Medicare billings which diagnosed patients with cervical myelopathy by International Classification of Diseases 9 code. Patients were separated into operative and nonoperative cohorts, and the total health care expenditures per patient normalized to 2012 dollars were collected. RESULTS: A total of 3209 patients were included, and 1755 (55.87%) underwent surgery. A 6-year cost analysis performed on 309 patients over the age of 65 from 2006 undergoing surgery resulted in a nonsignificant increase in total health care expenditures ($166,192 vs. $153,556; P=0.45). Operative treatment had a net decrease in total health care costs following the first year of surgery. CONCLUSIONS: There is no significant difference in the total health care expenditures for operative versus nonoperative treatment of cervical myelopathy after 3 years. It is critical to understand that nonoperative treatment of this progressive disease leads to a substantial increase in total health care expenditures with increased risk of falls, injury, and further morbidity.

Assuntos

Vértebras Cervicais/cirurgia , Atenção à Saúde/economia , Medicaid/economia , Medicare/economia , Doenças da Medula Espinal/economia , Doenças da Medula Espinal/cirurgia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Doenças da Medula Espinal/diagnóstico , Estados Unidos

RESUMO

Patients with spine-associated symptoms are transferred regularly to higher levels of care for operative intervention. It is unclear what factors lead to the transfer of patients with spine pathology to level I care facilities, and which transfers are indicated. All patients with isolated spinal pathology who were transferred from 2011 to 2015 were reviewed. Patients were divided into urgent transfers, defined as anyone who required operative intervention, and nonurgent transfers. Two hundred twenty-seven patients were transferred for isolated spinal pathology over 51 months; 109 (48.0%) patients required urgent intervention and 118 (52.0%) patients required nonurgent care. No significant differences were found between groups in terms of private insurance, age, sex, race, or Charlson comorbidity index. The urgent group was less likely to have a traumatic chief complaint (57.8% vs 78.0%, P = .001). More than half of all spine patients who were transferred to a tertiary care center required minimal intervention.

Assuntos

Serviços Médicos de Emergência , Transferência de Pacientes/tendências , Traumatismos da Coluna Vertebral , Centros de Atenção Terciária , Adulto , Idoso , Feminino , Humanos , Masculino , Auditoria Médica , Pessoa de Meia-Idade , Transferência de Pacientes/estatística & dados numéricos , Estudos Retrospectivos , Traumatismos da Coluna Vertebral/cirurgia

RESUMO

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study investigates the association between spinal cord injuries (SCI) and post-injury mortality. SUMMARY OF BACKGROUND DATA: SCIs) are severe conditions treated in the acute trauma setting. Owing to neurological deficits, unstable spinal columns, and associated injuries, these patients often have complex inpatient hospitalizations with significant morbidity and mortality. It is assumed that a high rate of postinjury mortality would follow such severe injuries; however, the effect of SCI and its treatment on predictors of longevity remain largely unknown. METHODS: Patients seen at a regional referral center for SCI were reviewed from a prospectively maintained database. Four hundred and twenty-six patients with SCI and varying degrees of injury between 2004 and 2009 were collected. Injury characteristics, including injury severity score, level of SCI, and type of SCI were retrieved. To determine independent predictors of 5-year mortality, a logistic regression using patient and injury characteristics at the time of presentation was performed. RESULTS: Average age was 47.4 years (range: 14-95), and 74.5% (318/426) were male. Half of the cohort sustained low-energy mechanisms of injury (220/426; 52.4%). The 30-day, 90-day, 1-year, 2-year, and 5-year mortality rates in the SCI cohort were 6.6% (28/426), 9.2% (39/426), 12.0% (51/426), 15.0% (64/426), and 17.8%, respectively (76/426). Logistic regression demonstrated that increasing age (B = 1.06, P < 0.001), increasing ICU length-of-stay (B = 1.06; P = 0.002), decreased motor score at presentation (B = 0.98; P = 0.004), and lack of surgical intervention (B = 0.38; P < 0.001) were independent predictors of mortality at 5 years. CONCLUSION: There is substantial mortality associated with SCI. A significant proportion of the mortalities occurred acutely after injury. Mortality was associated with neurological deficit and severity of injury, as well as with preinjury patient characteristics. To combat this high rate of death, efforts are needed to address the concomitant disease processes associated with neurological deficits. LEVEL OF EVIDENCE: 3.

Assuntos

Escala de Gravidade do Ferimento , Doenças do Sistema Nervoso/diagnóstico , Doenças do Sistema Nervoso/mortalidade , Traumatismos da Medula Espinal/diagnóstico , Traumatismos da Medula Espinal/mortalidade , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Mortalidade/tendências , Doenças do Sistema Nervoso/terapia , Estudos Prospectivos , Estudos Retrospectivos , Traumatismos da Medula Espinal/terapia , Adulto Jovem

RESUMO

STUDY DESIGN: A retrospective, matched cohort study. OBJECTIVES: This study aims to investigate the association between surgical site infection (SSI) and mortality and ascertain any factors that predict mortality in those diagnosed with SSI. SUMMARY OF BACKGROUND DATA: Despite significant efforts toward mitigation, SSI, including deep infection, remains a common complication following spine surgery, Considerable morbidity may be associated with infection, including hospital readmission, revision surgery, and delayed rehabilitation. However, it is not known whether this increase in morbidity is associated with increased mortality. METHODS: Patients from a single center requiring reoperation for SSI following elective spine surgery between 2005 and 2013 were identified in a retrospective fashion. These patients were then matched one-to-three with patients undergoing elective spine surgery without SSI. Patients were matched for age, gender, body mass index (BMI), Charlson comorbidity index, year of surgery, spine region, and approach. The Social Security Death Index was utilized to identify deceased patients and their time of death. Univariate statistics were then utilized to compare mortality rates between the two groups. In addition, the SSI cohort was evaluated for predictors of mortality following SSI. RESULTS: One-hundred ninety-five patients developed SSI at a mean of 27.4 (range: 1-467) days from the index surgery. Ninety-day, 1-year, 2-year, and 5-year mortality rates were 1.54% versus 1.03% (P = 0.70), 4.62% versus 1.2% (P = 0.006), 7.73% versus 2.25% (P = 0.001), and 15.45% versus 3.43% (P = 0.0002) for SSI versus control patients, respectively. Predictors of 2-year mortality in the SSI cohort were increased age (P = 0.02) and increased Charlson Comorbidity Index (P < 0.001). Region and approach of surgery, days to infection, and reason for elective surgery did not influence mortality. CONCLUSION: SSI results in significant morbidity in the postoperative period, with the risk of reoperation, prolonged hospitalization, and need for other invasive procedures. In addition, this study provides evidence that SSI is associated with an increased mortality following elective spine surgery. LEVEL OF EVIDENCE: 4.

Assuntos

Coluna Vertebral/cirurgia , Infecção da Ferida Cirúrgica/mortalidade , Fatores Etários , Idoso , Estudos de Casos e Controles , Comorbidade , Procedimentos Cirúrgicos Eletivos/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Readmissão do Paciente , Reoperação , Estudos Retrospectivos , Infecção da Ferida Cirúrgica/cirurgia , Estados Unidos/epidemiologia