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ABSTRACT: BACKGROUND CONTEXT: Spine-related health-care expenditures accounted for $86 billion dollars in 2005, a 65% increase from 1997. However, when adjusting for inflation, surgeons have seen decreased reimbursement rates over the last decade. PURPOSE: To assess contribution of surgeon fees to overall procedure cost, we reviewed the charges and reimbursements for a noninstrumented lumbar laminectomy and compared the amounts reimbursed to the hospital and to the surgeon at a major academic institution. STUDY DESIGN/SETTING: Retrospective review of costs associated with lumbar laminectomies. PATIENT SAMPLE: Seventy-seven patients undergoing lumbar laminectomy for spinal stenosis throughout an 18-month period at a single academic medical center were included in this study. OUTCOME MEASURES: Cost and number of laminectomy levels. METHODS: The reimbursement schedule of six academic spine surgeons was collected over 18 months for performed noninstrumented lumbar laminectomy procedures. Bills and collections by the hospital and surgeon professional fees were comparatively analyzed and substratified by number of laminectomy levels and patient insurance status. Unpaired two-sample Student t test was used for analysis of significant differences. RESULTS: During an 18-month period, patients underwent a lumbar laminectomy involving on average three levels and stayed in the hospital on average 3.5 days. Complications were uncommon (13%). Average professional fee billing for the surgeon was $6,889±$2,882, and collection was $1,848±$1,433 (28% overall, 30% for private insurance, and 23% for Medicare/Medicaid insurance). Average hospital billing for the inpatient hospital stay minus professional fees from the surgeon was $14,766±$7,729, and average collection on such bills was $13,391±$7,256 (92% overall, 91% for private insurance, and 85% for Medicare/Medicaid insurance). CONCLUSION: Based on this analysis, the proportion of overall costs allocated to professional fees for a noninstrumented lumbar laminectomy is small, whereas those allocated to hospital costs are far greater. These findings suggest that the current focus on decreasing physician reimbursement as the principal cost saving strategy will lead to minimal reimbursement for surgeons without a substantial drop in the overall cost of procedures performed.
The spine journal: official journal of the North American Spine Society 04/2013; · 2.90 Impact Factor
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ABSTRACT: Object Unintended durotomies are a common complication of spine surgery and are often correlated with increased postoperative morbidity. Recently, ultrasonic bone curettes have been introduced in spine surgery as a possible alternative to the conventional high-speed drill, offering the potential for greater bone-cutting precision and less damage to surrounding soft tissues. To date, however, few studies have investigated the safety and efficacy of the ultrasonic bone curette in reducing the rates of incidental durotomy compared with the high-speed drill. Methods The authors retrospectively reviewed the records of 337 consecutive patients who underwent posterior cervical or thoracic decompression at a single institution between January 2009 and September 2011. Preoperative pathologies, the location and extent of spinal decompression, and the use of an ultrasonic bone curette versus the high-speed drill were noted. The rates of incidental durotomy, as well as hospital length of stay (LOS) and perioperative outcomes, were compared between patients who were treated using the ultrasonic bone curette and those treated using a high-speed drill. Results Among 88 patients who were treated using an ultrasonic bone curette and 249 who were treated using a high-speed drill, 5 (5.7%) and 9 (3.6%) patients had an unintentional durotomy, respectively. This finding was not statistically significant (p = 0.40). No patients in either cohort experienced statistically higher rates of perioperative complications, although patients treated using an ultrasonic bone curette tended to have a longer hospital LOS. This difference may be attributed to the fact that this series contained a statistically higher number of metastatic tumor cases (p < 0.0001) in the ultrasonic bone curette cohort, likely increasing the LOS for that patient population. In 13 patients, the dural defect was repaired intraoperatively. No patients who experienced an incidental durotomy had new-onset or permanent neurological deficits postoperatively. Conclusions The safety and efficacy of ultrasonic bone curettes in spine surgery has not been well established. This study shows that the ultrasonic bone curette has a similar safety profile compared with the high-speed drill, although both are capable of causing iatrogenic dural tears during spine surgery.
Journal of neurosurgery. Spine 04/2013; · 1.61 Impact Factor
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ABSTRACT: Tumours of the spinal cord, although rare, are associated with high morbidity. Surgical resection remains the primary treatment for patients with this disease, and offers the best chance for cure. Such surgical procedures, however, carry substantial risks such as worsening of neurological deficit, paralysis and death. New therapeutic avenues for spinal cord tumours are needed, but genetic studies of the molecular mechanisms governing tumourigenesis in the spinal cord are limited by the scarcity of high-quality human tumour samples. Many spinal cord tumours have intracranial counterparts that have been extensively studied, but emerging data show that the tumours are genetically and biologically distinct. The differences between brain and spine tumours make extrapolation of data from one to the other difficult. In this Review, we describe the demographics, genetics and current treatment approaches for the most commonly encountered spinal cord tumours-namely, ependymomas, astrocytomas, haemangioblastomas and meningiomas. We highlight advances in understanding of the biological basis of these lesions, and explain how the latest progress in genetics and beyond are being translated to improve patient care.
Nature Reviews Neurology 03/2013; · 12.46 Impact Factor
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ABSTRACT: Object The rib head is an important landmark in the anterolateral approach to the thoracic spine. Resection of the rib head is typically the first step in gaining access to the underlying pedicle and ultimately the spinal canal. The goal of this work is to quantify the relationship of the rib head to the spinal canal and adjacent aorta at each thoracic level using CT-based morphometric measurements. Methods One hundred thoracic spine CT scans (obtained in 50 male and 50 female subjects) were evaluated in this study. The width and depth of each vertebra body were measured from T-1 to T-12. In addition, the distance of each rib head to the spinal canal was determined by drawing a line connecting the rib heads bilaterally and measuring the distance to this line from the most ventral aspect of the spinal canal. Finally, the distance of the left rib head to the thoracic aorta was measured at each thoracic level below the aortic arch. Results The vertebral body depth progressively increased in a rostral to caudal direction. The vertebral body width was at its minimum at T-4 and progressively increased to T-12. The rib head extended beyond the spinal canal maximally at T-1. This distance incrementally decreased toward the caudal levels, with the tip of the rib head lying approximately even with the ventral canal at T-11 and T-12. The distance between the aorta and the left rib head increased in a rostral to caudal direction as well. Conclusions The rib head is an important landmark in the anterolateral approach to the thoracic spine. At more cephalad levels, a larger portion of rib head requires resection to gain access to the spinal canal. At more caudad levels, there is a safer working distance between the rib head and aorta.
Journal of neurosurgery. Spine 03/2013; · 1.61 Impact Factor
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Patricia Zadnik,
Rachel Sarabia-Estrada,
Mari L Groves,
Camilo Molina,
Christopher Jackson,
Edward McCarthy, Ziya L Gokaslan,
Ali Bydon,
Jean-Paul Wolinsky,
Timothy F Witham,
Daniel M Sciubba
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ABSTRACT: Object Metastatic spine disease is prevalent in cancer victims; 10%-30% of the 1.2 million new patients diagnosed with cancer in the US exhibit spinal metastases. Unfortunately, treatments are limited for these patients, as disseminated disease is often refractory to chemotherapy and is difficult to treat with surgical intervention alone. New animal models that accurately recapitulate the human disease process are needed to study the behavior of metastases in real time. Methods In this study the authors report on a cell line that reliably generates bony metastases following intracardiac injection and can be tracked in real time using optical bioluminescence imaging. This line, RBC3, was derived from a metastatic breast adenocarcinoma lesion arising in the osseous spine of a rat following intracardiac injection of MDA-231 human breast cancer cells. Results Upon culture and reinjection of RBC3, a statistically significantly increased systemic burden of metastatic tumor was noted. The resultant spine lesions were osteolytic, as demonstrated by small animal CT scanning. Conclusions This cell line generates spinal metastases that can be tracked in real time and may serve as a useful tool in the study of metastatic disease in the spine.
Journal of neurosurgery. Spine 12/2012; · 1.61 Impact Factor
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ABSTRACT: OBJECTIVE: Malignant osseous spinal neoplasms are aggressive tumors associated with poor outcomes despite aggressive multidisciplinary measures. While surgical resection has been shown to improve short-term local disease control, it remains debated whether surgical resection is associated with improved overall survival in patients with malignant primary osseous spinal neoplasms. The aim of this manuscript is to review survival data from a US cancer registry spanning 30 years to determine if surgical resection was independently associated with overall survival. METHODS: The SEER registry (1973-2003) was queried to identify cases of histologically confirmed primary spinal chordoma, chondrosarcoma, osteosarcoma, or Ewing's sarcoma of the mobile spine and pelvis. Patients with systemic metastasis were excluded. Age, gender, race, tumor location, and primary treatments were identified. Extent of local tumor invasion was classified as confined within periosteum versus extension beyond periosteum to surrounding tissues. The association of surgical resection with overall survival was assessed via Cox analysis adjusting for age, radiotherapy, and tumor invasiveness. RESULTS: 827 patients were identified with non-metastatic primary osseous spinal neoplasms (215 chordoma, 282 chondrosarcoma, 158 osteosarcoma, 172 Ewing's sarcoma). Overall, median survival was histology specific (chordoma, 96 months; Ewing's sarcoma, 90 months; chondrosarcoma, 88 months; osteosarcoma, 18 months). Adjusting for age, radiation therapy, and extent of local tumor invasion in patients with isolated (non-metastatic) spine tumors, surgical resection was independently associated with significantly improved survival for chordoma [hazard ratio (95 % confidence interval; 0.617 (0.25-0.98)], chondrosarcoma [HR (95 %CI); 0.153 (0.07-0.36)], osteosarcoma [HR (95 %CI); 0.382 (0.21-0.69)], and Ewing's sarcoma [HR (95 %CI); 0.494 (0.26-0.96)]. CONCLUSION: In our analysis of a 30-year US population-based cancer registry (SEER), patients undergoing surgical resection of primary spinal chordoma, chondrosarcoma, Ewing's sarcoma, or osteosarcoma demonstrated prolonged overall survival independent of patient age, extent of local invasion, or location. Surgical resection may play a role in prolonging survival in the multi-modality treatment of patients with these malignant primary osseous spinal neoplasms.
European Spine Journal 12/2012; · 1.97 Impact Factor
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ABSTRACT: Object Same-level recurrent lumbar stenosis, pseudarthrosis, and adjacent-segment disease (ASD) are potential complications that can occur after index lumbar spine surgery, leading to significant discomfort and radicular pain. While numerous studies have demonstrated excellent results following index lumbar spine surgery in elderly patients (age > 65 years), the effectiveness of revision lumbar surgery in this cohort remains unclear. The aim of this study was to assess the long-term effectiveness of revision lumbar decompression and fusion in the treatment of symptomatic pseudarthrosis, ASD, and same-level recurrent stenosis, using validated patient-reported outcomes. Methods After a review of the institutional database, 69 patients who had undergone revision neural decompression and instrumented fusion for ASD (28 patients), pseudarthrosis (17 patients), or same-level recurrent stenosis (24 patients) were included in this study. Baseline and 2-year scores on the visual analog scale for leg pain (VAS-LP), VAS for back pain (VAS-BP), Oswestry Disability Index (ODI), and Zung Self-Rating Depression Scale (SDS) as well as the time to narcotic independence, time to return to baseline activity level, health state utility (EQ-5D, the EuroQol-5D health survey), and physical and mental component summary scores of the 12-Item Short-Form Health Survey (SF-12 PCS and MCS) were assessed. Results Compared with the preoperative status, VAS-BP was significantly improved 2 years after surgery for ASD (mean ± standard deviation 9 ± 2 vs 4.01 ± 2.56, p = 0.001), pseudarthrosis (7.41 ± 1 vs 5.52 ± 3.08, p = 0.02), and same-level recurrent stenosis (7 ± 2.00 vs 5.00 ± 2.34, p = 0.003). The 2-year ODI was also significantly improved after surgery for ASD (29 ± 9 vs 23.10 ± 10.18, p = 0.001), pseudarthrosis (28.47 ± 5.85 vs 24.41 ± 7.75, p = 0.001), and same-level recurrent stenosis (30.83 ± 5.28 vs 26.29 ± 4.10, p = 0.003). The Zung SDS score and SF-12 MCS did not change appreciably after surgery in any of the cohorts, with an overall mean 2-year change of 1.01 ± 5.32 (p = 0.46) and 2.02 ± 9.25 (p = 0.22), respectively. Conclusions Data in this study suggest that revision lumbar decompression and extension of fusion for symptomatic pseudarthrosis, ASD, and same-level recurrent stenosis provides improvement in low-back pain, disability, and quality of life and should be considered a viable treatment option for elderly patients with persistent or recurrent back and radicular pain. Mental health symptoms may be more refractory to revision surgery.
Journal of neurosurgery. Spine 12/2012; · 1.61 Impact Factor
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ABSTRACT: Management of patients undergoing neurosurgical spinal procedures requires balancing the competing risks of hemorrhage and thrombosis. Deep venous thrombosis (DVT) and pulmonary embolism (PE) may be significant complications following spinal surgery. The authors reviewed 30 studies regarding thromboembolic events following spinal surgery for various etiologies and analysed all the methods used to prevent thromboembolic events. Despite the low incidence of DVT (2.7%) and PE (2%), most spinal surgeons routinely treat patients with a non-invasive prophylactic method such as pneumatic sequential compression devices or compression stockings. Chemoprophylaxis is another effective method to prevent thromboembolic episodes. Inferior vena cava filters may be a safe and effective method to prevent thromboembolic episodes in this patient cohort when chemoprophylaxis and mechanical compression is contraindicated.
Journal of Clinical Neuroscience 10/2012; · 1.25 Impact Factor
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ABSTRACT: Object Hematogenous metastases to the sacrum can produce significant pain and lead to spinal instability. The object of this study was to evaluate the palliative benefit of surgery in patients with these metastases. Methods The authors retrospectively reviewed all cases involving patients undergoing surgery for metastatic disease to the sacrum at a single tertiary cancer center between 1993 and 2005. Results Twenty-five patients (21 men, 4 women) were identified as having undergone sacral surgery for hematogenous metastatic disease during the study period. Their median age was 57 years (range 25-71 years). The indications for surgery included palliation of pain (in 24 cases), need for diagnosis (in 1 case), and spinal instability (in 3 cases). The most common primary disease was renal cell carcinoma. Complications occurred in 10 patients (40%). The median overall survival was 11 months (95% CI 5.4-16.6 months). The median time from the initial diagnosis to the diagnosis of metastatic disease in the sacrum was 14 months (95% CI 0.0-29.3 months). The numerical pain scores (scale 0-10) were improved from a median of 8 preoperatively to a median of 3 postoperatively at 90 days, 6 months, and 1 year (p < 0.01). Postoperative modified Frankel grades improved in 8 cases, worsened in 3 (due to disease progression), and remained unchanged in 14 (p = 0.19). Among patients with renal cell carcinoma, the median overall survival was better in those in whom the sacrum was the sole site of metastatic disease than in those with multiple sites of metastatic disease (16 vs 9 months, respectively; p = 0.053). Conclusions Surgery is effective to palliate pain with acceptable morbidity in patients with metastatic disease to the sacrum. In the subgroup of patients with renal cell carcinoma, those with the sacrum as their solitary site of metastatic disease demonstrated improved survival.
Journal of neurosurgery. Spine 08/2012; 17(4):285-91. · 1.61 Impact Factor
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ABSTRACT: Investigation into the provider volume-outcomes association for patients undergoing spine surgery has been limited.
To examine the impact of surgeon and hospital volume on the outcomes after decompression with or without fusion for lumbar spinal stenosis.
Data from the Nationwide Inpatient Sample (2005-2008) were retrospectively extracted. Multivariate logistic regression analyses were performed to calculate the adjusted odds of in-hospital mortality and the development of a postoperative complication with increasing surgeon or hospital volume. Provider volume was evaluated continuously and categorically, divided by percentiles into quintiles. Very-low-volume surgeons performed < 15 procedures over 4 years. All analyses were adjusted for differences in patient age, sex, comorbidities, and primary payer, as well as hospital bed size, teaching status, and location (urban vs rural).
A total of 48,971 admissions were examined. In-hospital mortality did not differ significantly with increasing provider volume. When examined continuously, greater surgeon volume was associated with a significantly lower adjusted odds of developing a complication (odds ratio, 0.72; 95% confidence interval, 0.65-0.78; P < .001). Patients who underwent surgery by very-low-volume surgeons (odds ratio, 1.38; 95% confidence interval, 1.19-1.60; P = .001), but not those treated by low-, medium-, or high-volume surgeons, had a significantly higher complication rate compared with those who underwent surgery by very high-volume surgeons. After adjustment for surgeon volume, hospital volume was not significantly associated with in-hospital mortality or complications.
In this nationwide study, patients treated by very-low-volume surgeons had a significantly higher complication rate compared with those treated by very high-volume surgeons.
Neurosurgery 06/2012; 70(6):1346-53; discussion 1353-4. · 2.79 Impact Factor
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ABSTRACT: Observational cross-sectional study.
Using data from the population-based cancer registries of the Surveillance, Epidemiology and End Results (SEER) program, we analyzed demographic features, tumor and treatment characteristics, as well as survival rates in patients with primary malignant astrocytomas of the spinal cord (PMASC).
PMASC is a rare neoplasm and is considered to carry the same dismal outcome as their cerebral counterparts. Our current knowledge is incomplete, and understanding the epidemiology, diagnosis, and optimal treatment still poses challenges.
The SEER data from 1973 to 2007 were reviewed for pathologically confirmed primary anaplastic astrocytomas (AA) and glioblastomas of the spinal cord (C72.0). We compared the clinical features and outcomes of the cohort in uni- and multivariate fashion. Survival was calculated and compared using Kaplan-Meier curves and log-rank analysis.
Our search criteria retrieved 135 patients diagnosed with PMASC. The median survival for PMASC was 13 months with 1-, 2-, and 5-year survival rates of 51.8%, 32.2%, and 18.7%. Patient diagnosed with AA had a median survival time of 17 months versus 10 months in patients diagnosed with glioblastomas. Adult patients observed markedly prolonged survival compared with the pediatric group, with a 16-month versus 9-month median survival, respectively. Multivariate analysis revealed age at diagnosis, pediatric and adult age groups, sex, tumor histology, and extent of resection as significant predictors of survival. Interestingly, outcomes did not significantly change throughout the last decades or by receiving radiotherapy.
Outcome for patients diagnosed with PMASC remains poor and presents an ongoing challenge for professionals in the field of neurospinal medicine and surgery. In our analyses of AA, adult patients, males, and patients undergoing radical resections were associated with increased survival. However, incidence of these lesions is low; hence, building strong collaborative, interdisciplinary, and multi-institutional study groups is necessary to define the optimal treatment of PMASC.
Spine 05/2012; 37(12):E727-35. · 2.08 Impact Factor
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ABSTRACT: Study background: Thoracolumbar fractures are among the most common type of traumatic spine fractures. The use of minimally invasive, percutaneous pedicle screw fixation for these fractures has been limited to case reports and small case series. The efficacy of this approach remains unclear.
Methods: The evaluation and management of a patient with traumatic T12 burst fracture is presented. In addition, a literature review of the Medline and PubMed databases was conducted.
Results: A total of 166 patients from 8 studies were identified. Average age was 46 years. Polytrauma was reported in 27% of patients. Average surgery time was 91 minutes, with an average blood loss of 95 milliliters. Reported complications were non-healing fracture in 3(2%), infection in 1(0.6%), mal-positioned screw in 1(0.6%), and hematoma in 1(0.6%) at a median follow-up time of 26 months. Pain improved by an average of 6 points after surgery according to visual analog score, and mean kyphosis correction in these studies was 8.5°.
Conclusions: This review demonstrates that minimally invasive, percutaneous pedicle screw fixation is a viable option for the management of traumatic thoracolumbar fractures in neurologically intact patients. Patients who are older and/or present with polytrauma may most benefit from this type of intervention.
Journal of Trauma & Treatment. 05/2012; 1(5).
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ABSTRACT: En bloc resection of primary sacral tumors has a demonstrated survival benefit. Total and high sacral amputations are traditionally performed by using a staged anterior and subsequent posterior approach. However, we have found that en bloc resection and biomechanical reconstruction of the spinal column is possible from a posterior-only approach in many cases.
To assess our series of posterior-only sacrectomies, emphasizing postoperative complications and overall surgical and oncologic outcome.
Sixty-nine consecutive patients underwent sacral resections for tumor at our institution between 2004 and 2009. Medical records of all patients were reviewed, and patients were excluded if they had an intentional intralesional resection, hemipelvectomy, or a previous operation. The records of the resulting 36 consecutive patients who underwent primary posterior-only en bloc sacral resections were retrospectively reviewed.
Of the posterior-only patients, all underwent midline posterior approaches for en bloc sacral resection. Sacral amputation was defined by the by sacral root preservation: total (2 cases), high (8 cases), middle (9 cases), low (12 cases), and distal (5 cases). Chordoma was the most common tumor type (30 cases), and surgical margins were marginal in 34 cases and contaminated in 2. Overall, there were 13 complications, including 9 wound infections/revisions. The extent of sacrectomy, and thus the extent of roots sacrificed, correlated with functional outcome.
It may be possible to perform a posterior-only approach to en bloc sacral resections/reconstructions in patients with tumors that do not extend beyond the lumbosacral junction or invade the bowel requiring bowel resection and diversion.
Neurosurgery 05/2012; 71(2):357-64; discussion 364. · 2.79 Impact Factor
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ABSTRACT: The management of spinal column tumors continues to be a challenge for clinicians. The mechanisms of tumor recurrence after surgical intervention as well as resistance to radiation and chemotherapy continue to be elucidated. Furthermore, the pathophysiology of metastatic spread remains an area of active investigation. There is a growing body of evidence pointing to the existence of a subset of tumor cells with high tumorigenic potential in many spine cancers that exhibit characteristics similar to those of stem cells. The ability to self-renew and differentiate into multiple lineages is the hallmark of stem cells, and tumor cells that exhibit these characteristics have been described as cancer stem cells (CSCs). The mechanisms that allow nonmalignant stem cells to promote normal developmental programming by way of enhanced proliferation, promotion of angiogenesis, and increased motility may be used by CSCs to fuel carcinogenesis. The purpose of this review is to discuss what is known about the role of CSCs in tumors of the osseous spine. First, this article reviews the fundamental concepts critical to understanding the role of CSCs with respect to chemoresistance, radioresistance, and metastatic disease. This discussion is followed by a review of what is known about the role of CSCs in the most common primary tumors of the osseous spine.
Neurosurgery 03/2012; 71(1):117-25. · 2.79 Impact Factor
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ABSTRACT: Advocates of minimally invasive discectomy (MID) have promoted this operation as an alternative to open discectomy (OD), arguing that there may be less injury to the paraspinal muscles, decreased postoperative pain, and a faster recovery time. However, a recently published large randomized controlled trial (RCT) comparing these approaches reported inferior relief of leg pain in patients undergoing MID. The authors conducted a meta-analysis to evaluate complications and improvement in leg pain in patients with radiculopathy enrolled in RCTs comparing OD to MID.
The authors performed a literature search using Medline and EMBASE of studies indexed between January 1990 and January 2011. Predetermined RCT eligibility included the usage of tubular retractors during MID, a minimum follow-up duration of 1 year, and quantification of pain with the visual analog scale (VAS). Trials that only evaluated patients with recurrent disc herniation were excluded. Data on operative parameters, complications, and VAS scores of leg pain were extracted by 2 investigators. A meta-analysis was performed assuming random effects to determine the difference in mean change for continuous outcomes and the risk ratio for binary outcomes.
Six trials comprising 837 patients (of whom 388 were randomized to MID and 449 were randomized to OD) were included. The mean operative time was 49 minutes during MID and 44 minutes during OD; this difference was not statistically significant. Incidental durotomies occurred significantly more frequently during MID (5.67% compared with 2.90% for OD; RR 2.05, 95% CI 1.05-3.98). Intraoperative complications (incidental durotomies and nerve root injuries) were also significantly more common in patients undergoing MID (RR 2.01, 95% CI 1.07-3.77). The mean preoperative VAS score for leg pain was 6.9 in patients randomized to MID and 7.2 in those randomized to OD. With long-term follow-up (1-2 years postoperatively), the mean VAS score improved to 1.6 in both the MID and OD cohorts. There was no significant difference in relief of leg pain between the 2 approaches with either short-term follow-up (2-3 months postoperatively, 0.81 points on the VAS, 95% CI -4.71 to 6.32) or long-term follow-up (2.64 on the VAS, 95% CI -2.15 to 7.43). Reoperation for recurrent herniation was more common in patients randomized to the MID group (8.50% compared with 5.35% in patients randomized to the OD group), but this difference was not statistically significant (RR 1.56, 95% CI 0.92-2.66). Total complications did not differ significantly between the operations (RR 1.50, 95% CI 0.97-2.33).
The current evidence suggests that both OD and MID lead to a substantial and equivalent long-term improvement in leg pain. Adequate decompression, regardless of the operative approach used, may be the primary determinant of pain relief-the major complaint of many patients with radiculopathy. Incidental durotomies occurred significantly more frequently during MID, but total complications did not differ between the techniques.
Journal of neurosurgery. Spine 03/2012; 16(5):452-62. · 1.61 Impact Factor
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ABSTRACT: Despite widespread belief that patients admitted to teaching hospitals in July-the beginning of the academic year-have inferior outcomes, there has been little evidence to support the existence of the July phenomenon. Moreover, the impact of July admission on the outcomes after surgery for spinal metastases has not been investigated.
Data from the Nationwide Inpatient Sample (2005-2008) were retrospectively extracted. Patients who underwent surgery for metastatic spinal disease and were admitted to a teaching hospital were included. Multivariate logistic regression was conducted to calculate the odds of in-hospital death, the occurrence of an intraoperative complication, and the development of a postoperative complication depending on whether admission was in July or between August and June. All analyses were adjusted for differences in patient age, sex, comorbidities, primary tumor histology, visceral metastases, myelopathy, insurance status, hospital volume, and admission type.
A total of 2920 admissions were evaluated. In-hospital mortality was higher in July compared with between August and June-7.5% versus 4.2%. The adjusted odds of in-hospital death were significantly higher for patients admitted in July (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.13-2.91; P = .01). Patients admitted in July were significantly more likely to develop an intraoperative complication (OR, 2.11; 95% CI, 1.41-3.17; P < .001), but not a postoperative complication (OR, 1.08; 95% CI, 0.81-1.45; P = .60).
In this nationwide study based on an administrative database, patients undergoing surgery for metastatic spinal disease at teaching hospitals in July had higher rates of in-hospital mortality and intraoperative complications.
Cancer 03/2012; 118(5):1429-38. · 4.77 Impact Factor
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ABSTRACT: Disparities based on insurance status in the American health care system are well established. However, to the authors' knowledge, this is the first study to evaluate variables that may explain differences based on payer type in the outcomes after surgery for spinal metastases.
Data from the Nationwide Inpatient Sample (2005-2008) were retrospectively extracted. Patients ages 18 to 64 years who underwent surgery for spinal metastases were included. Multivariate logistic regression was performed to calculate the adjusted odds of in-hospital death and the development of a complication for Medicaid recipients and for those without insurance compared with privately insured patients. All analyses were adjusted for differences in patient age, gender, primary tumor histology, socioeconomic status, hospital bed size, and hospital teaching status.
A total of 2157 hospital admissions were evaluated. The adjusted odds of in-hospital death were significantly higher for Medicaid recipients (crude rate: 6.5%; odds ratio [OR], 1.79; 95% confidence interval [95% CI], 1.11-2.88 [P = .02]) and uninsured patients (crude rate: 7.7%; OR, 2.15; 95% CI, 1.04-4.46 [P = .04]) compared with privately insured patients (crude rate: 3.8%). Complication rates were also significantly higher for Medicaid recipients (OR, 1.34; 95% CI, 1.04-1.72 [P = .02]). However, after also adjusting for acuity of presentation, the odds of in-hospital death were not significantly different for Medicaid (OR, 1.38; 95% CI, 0.86-2.21 [P = .18]) or uninsured patients (OR, 1.86; 95% CI, 0.90-3.83 [P = .09]); in addition, complication rates did not appear to differ significantly.
This nationwide study suggests that disparities based on insurance status for patients undergoing surgery for spinal metastases may be attributable to a higher acuity of presentation. Cancer 2012. © 2012 American Cancer Society.
Cancer 01/2012; 118(19):4833-41. · 4.77 Impact Factor
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ABSTRACT: Recombinant human bone morphogenetic proteins (rhBMPs) are FDA-approved for specific spinal fusion procedures, but their use is contraindicated in spine tumor resection beds because of an unclear interaction between tumor tissue and such growth factors. Interestingly, a number of studies have suggested that BMPs may slow the growth of adenocarcinomas in vitro, and these lesions represent the majority of bony spine tumors. In this study, the authors hypothesized that rhBMP-2 placed in an intraosseous spine tumor in the rat could suppress tumor and delay the onset of paresis in such animals.
Twenty-six female nude athymic rats were randomized into an experimental group (Group 1) or a positive control group (Group 2). Group 1 (tumor + 15 μg rhBMP-2 sponge, 13 rats) underwent transperitoneal exposure and implantation of breast adenocarcinoma (CRL-1666) into the L-6 spine segment, followed by the implantation of a bovine collagen sponge impregnated with 15 μg of rhBMP-2. Group 2 (tumor + 0.9% NaCl sponge, 13 rats) underwent transperitoneal exposure and tumor implantation in the lumbar spine but no local treatment with rhBMP-2. An additional 8 animals were randomized into 2 negative control groups (Groups 3 and 4). Group 3 (15 μg rhBMP-2 sponge, 4 rats) and Group 4 (0.9% NaCl sponge, 4 rats) underwent transperitoneal exposure of the lumbar spine along with the implantation of rhBMP-2- and saline-impregnated bovine collagen sponges, respectively. Neither of the negative control groups was implanted with tumor. The Basso-Beattie-Bresnahan (BBB) scale was used to monitor daily motor function regression and the time to paresis (BBB score ≤ 7).
In comparison with the positive control animals (Group 2), the experimental animals (Group 1) had statistically significant longer mean (25.8 ± 12.2 vs 13 ± 1.4 days, p ≤ 0.001) and median (20 vs 13 days) times to paresis. In addition, the median survival time was significantly longer in the experimental animals (20 vs 13.5 days, p ≤ 0.0001). Histopathological analysis demonstrated bone growth and tumor inhibition in the experimental animals, whereas bone destruction and cord compression were observed in the positive control animals. Neither of the negative control groups (Groups 3 and 4) demonstrated any evidence of neurological deterioration, morbidity, or cord compromise on either gross or histological analysis.
This study shows that the local administration of rhBMP-2 (15 μg, 10 μl of 1.5-mg/ml solution) in a rat spine tumor model of breast cancer not only fails to stimulate local tumor growth, but also decreases local tumor growth and delays the onset of paresis in rats. This preclinical experiment is the first to show that the local placement of rhBMP-2 in a spine tumor bed may slow tumor progression and delay associated neurological decline.
Journal of neurosurgery. Spine 01/2012; 16(4):365-72. · 1.61 Impact Factor
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World Neurosurgery 01/2012; · 0.68 Impact Factor
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ABSTRACT: The bony spine is overall the third most common site for distant cancer metastasis, with the cervical spine involved in approximately 8 to 20% of metastatic spine disease cases. Diagnosis and management of metastatic spine disease requires disease categorization into the compartment involved, pathology of the lesion, and anatomic region involved. The diagnostic approach should commence with careful physical examination, and the workup should include plain radiographs, magnetic resonance imaging, computed tomography, and bone scintigraphy. Management ranges from palliative nonoperative to aggressive surgical treatment. Optimal management requires proper patient selection to individualize the most appropriate treatment modality.
Orthopedic Clinics of North America 01/2012; 43(1):75-87, viii-ix. · 1.25 Impact Factor
