Miguel A. Pelton

Georgetown University, Washington, Washington, D.C., United States

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Publications (24)49.83 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Emerging literature suggests superior clinical short and long-term outcomes of MIS (Minimally Invasive Surgery) TLIFs (Transforaminal Lumbar Interbody Fusion) versus open fusions. Few studies to date have analyzed the cost differences between the two techniques and their relationship to acute clinical outcomes. To determine the differences in hospitalization costs and payments for patients treated with primary single- level minimally invasive (MIS) versus open transforaminal lumbar interbody fusion (TLIF). The impact of clinical outcomes and their contribution to financial differences was explored as well. Study Design/Setting: This study was a non-randomized, non-blinded prospective review. Sixty-six consecutive patients undergoing a single-level TLIF (open/MIS) were analyzed (33 open, 33 MIS). Patients in either cohort (MIS/Open) were matched based on race, sex, age, smoking status, medical co-morbidities (Charleson Comorbidity index), payor and diagnosis. Every patient in the study had a diagnosis of either degenerative disc disease or spondylolisthesis and stenosis. Operative time (minutes), Length of stay (LOS, days), estimated blood loss (EBL,cc), anesthesia time (minutes),Visual Analog Scale (VAS) scores, and hospital cost/payment amount were assessed. The MIS and Open TLIF groups were compared based on clinical outcomes measures and hospital cost/payment data using SPSS version 20.0 (Chicago, IL)for statistical analysis. The two groups were compared using bivariate chi-squared analysis. Mann-Whitney tests were used for non-normal distributed data. Effect size estimate was calculated with Cohen's d statistic and the r statistic with a 95% confidence interval. Average surgical time was shorter for the MIS than the Open TLIF group (115.8 minutes versus 186 minutes respectively; p=0.001).Length of stay was also reduced for the MIS versus the Open group (2.3 days versus 2.9 days respectively; p=0.018). Average anesthesia time and EBL was also lower in the MIS group (p<0.001). VAS scores decreased for both groups, although these scores were significantly lower for the MIS group (p<0.001). Financial analysis demonstrated lower total hospital direct costs (blood, imaging, implant, lab, pharmacy, PT/OT/Speech, room and board)in the MIS versus the Open group ($19,512 v. $23,550, p <0.001). Implant costs were similar (p=0.686) in both groups although these accounted for about two-thirds of the hospital direct costs in the MIS cohort ($13,764) and half of these costs ($13,778) in the open group. Hospital payments were $6,248 higher for open TLIF patients compared to the MIS group (p=0.267). MIS TLIF technique demonstrated significant reductions of operative time, LOS, anesthesia time, VAS Scores and EBL compared to the open technique. This reduction in peri-operative parameters translated into lower total hospital costs over a 60 day peri-operative period. Although hospital reimbursements appear higher in the open group over the MIS group, shorter surgical times and length of stay days in the MIS technique provide opportunities for hospitals to reduce utilization of resources and to increase surgical case volume.
    The spine journal: official journal of the North American Spine Society 11/2013; 14(8). DOI:10.1016/j.spinee.2013.10.053 · 2.43 Impact Factor
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    ABSTRACT: The published literature has not characterized the surgeon's learning curve with the technically demanding technique of a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). To characterize based on intra- and perioperative parameters, the learning curve for one spine surgeon during his initial phases of performing an MIS TLIF. Retrospective analysis of a single institution and single surgeon experience with the unilateral MIS TLIF technique between July 2008 and April 2011. Sixty-five consecutive patients, with at least 1 year of follow-up, who underwent a unilateral, single-level, index MIS TLIF for the diagnosis of degenerative disk disease or lumbar spinal stenosis with grade I or II spondylolisthesis were analyzed based on data obtained from the medical records and postoperative imaging (computed tomography). Postoperative radiographic assessment of fusion at 1 year via computed tomography. Surgical parameters of surgical time (skin-skin, minutes), anesthesia time (induction-extubation, minutes), estimated blood loss (mL), intravenous fluids during surgery (mL), intraoperative complications (durotomy), and postoperative complications (pseudarthrosis, implant failure, malpositioned implants, graft-related complications) were also assessed. The senior author's first 100 consecutive MIS TLIFs were evaluated initially. Patients undergoing revision or multilevel surgery were excluded leaving a total of 65 consecutive primary MIS TLIFs. The first 33 patients were compared with the second 32 patients in terms of radiographic arthrodesis rates, surgical parameters, and intra-/postoperative complications. A two-tailed Student t test was used to assess for differences between the two cohorts where a p value of less than or equal to .05 denoting statistical significance. Pearson's correlation coefficient was used to determine any association between the date of surgery and surgical time. Average surgical time, estimated blood loss, intraoperative fluids, and duration of anesthesia was significantly longer in the first cohort (p<.05). There were no significant differences in intraoperative complications (two durotomies in both groups) or length of stay. There was no significant difference in postoperative complications at final follow-up based on computed tomography analysis (11 vs. 9, p=.649). In the first cohort, these complications included two cases of radiographic pseudarthrosis: one case of graft migration and one case of medial pedicle wall violation necessitating two revision surgeries. There were two cases of pseudarthrosis and one case of an early surgical site infection identified in the second group requiring three revision surgeries. Last, four cases of neuroforaminal bone growth were demonstrated, two in each cohort. Pearson's correlation coefficient demonstrated a negative correlation between the date of surgery and surgical time (r=-0.44; p<.001) estimated blood loss (r=-0.49; p<.001), duration of anesthesia (r=-0.41; p=.001), and intravenous fluids (r=-0.42; p=.001). The MIS TLIF is a technically difficult procedure to the practicing spine surgeon with regard to intra- and perioperative parameters of surgical time, estimated blood loss, intravenous fluid, and duration of anesthesia. Operative time and proficiency improved with understanding the minimally invasive technique. Further studies are warranted to delineate the methods to minimize the complications associated with the learning curve.
    The spine journal: official journal of the North American Spine Society 10/2013; 14(8). DOI:10.1016/j.spinee.2013.08.045 · 2.43 Impact Factor

  • The Spine Journal 09/2013; 13(9):S42-S43. DOI:10.1016/j.spinee.2013.07.133 · 2.43 Impact Factor

  • The Spine Journal 09/2013; 13(9):S80. DOI:10.1016/j.spinee.2013.07.222 · 2.43 Impact Factor

  • The Spine Journal 09/2013; 13(9):S129-S130. DOI:10.1016/j.spinee.2013.07.335 · 2.43 Impact Factor
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    ABSTRACT: Recent reports of postoperative radiculitis, bone osteolysis, and symptomatic ectopic bone formation after recombinant human bone morphogenetic protein-2 (rhBMP-2) use in transforaminal lumbar interbody fusions (TLIFs) are a cause for concern. To determine the clinical and radiographic complications associated with BMP utilization in a minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) environment. Retrospective clinical case series at a single institution. Five hundred seventy-three consecutive patients undergoing an MIS-TLIF. Reoperation rates and total costs associated with complications of rhBMP-2 use and pseudarthrosis. A retrospective review of 610 consecutive patients undergoing an MIS-TLIF (2007-2010) by a single surgeon at our institution was performed (mean age 48.7 years, range 26-82 years). All patients underwent an MIS laminectomy with bilateral facetectomy, single TLIF cage, unilateral pedicle screw fixation, and 12 mg (large kit) or 4.2 mg (small kit) of rhBMP-2. The BMP-2 collagen-soaked sponge was placed anteriorly in the disc space, followed by local bone graft, and then the cage was filled only with local bone and no BMP-2. Patients were evaluated at 6 months and 1 year with computed tomography (CT) scan. Those demonstrating neuroforaminal bone growth, osteolysis/cage migration, or pseudarthrosis were reviewed, and cost data including direct cost/procedure for both index and revision surgeries were collected. Of the 573 patients, 10 (1.7%) underwent 15 additional procedures based on recalcitrant radiculopathy and CT evidence of neuroforaminal bone growth, vertebral body osteolysis, and/or cage migration. Thirty-nine patients (6.8%) underwent reoperation for clinically symptomatic pseudarthrosis. Bone overgrowth was associated with nerve impingement and radiculopathy in all 10 patients (small kit, n=9; large kit, n=1). Osteolysis and cage migration occurred in 2 (20%) of these same 10 patients. Average total costs were calculated per procedure ($19,224), and the costs for reoperation equaled $14,785 per encounter for neuroforaminal bone growth and $20,267 for pseudarthrosis. Symptomatic ectopic bone formation, vertebral osteolysis, and pseudarthrosis are recognized complications with the use of rhBMP-2 in MIS-TLIFs. Potential causes include improper dosage and a closed space that prevents the egress of the postoperative BMP-2 fluid collection. Management of these complications has a substantial cost for the patient and the surgeon and needs to be considered with the off-label use of rhBMP-2.
    The spine journal: official journal of the North American Spine Society 09/2013; 13(9):1118-25. DOI:10.1016/j.spinee.2013.07.028 · 2.43 Impact Factor

  • The Spine Journal 09/2013; 13(9):S2. DOI:10.1016/j.spinee.2013.07.034 · 2.43 Impact Factor

  • The Spine Journal 09/2013; 13(9):S132. DOI:10.1016/j.spinee.2013.07.341 · 2.43 Impact Factor

  • The Spine Journal 09/2013; 13(9):S65-S66. DOI:10.1016/j.spinee.2013.07.184 · 2.43 Impact Factor

  • The Spine Journal 09/2013; 13(9):S130-S131. DOI:10.1016/j.spinee.2013.07.337 · 2.43 Impact Factor

  • The Spine Journal 09/2013; 13(9):S84-S85. DOI:10.1016/j.spinee.2013.07.232 · 2.43 Impact Factor

  • 06/2013; 14(6):1-7. DOI:10.1097/01.CSS.0000430686.61633.cb
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    ABSTRACT: Study Design. Anonymous patient surveyObjective. Determine what patients believe surgeons should be paid to perform elective spine surgeries, and gauge awareness of actual Medicare reimbursement.Summary of Background Data. With increasing transparency, the public may become aware of physician reimbursements and may be a part of the debate regarding appropriate reimbursement. It is unknown what patient's perceive that spinal surgeons deserve to be, or are actually, paid to perform spinal procedures.Methods. 200 anonymous surveys were given to consecutive patients in an outpatient office setting by means of convenience sampling. Patients were asked how much they believe physicians are and should be reimbursed for typical spine procedures; and they were asked about their opinions of the actual reimbursement amount for these procedures. It was made explicit that the fee in question included only the surgeon's reimbursement and not that of the hospital. Data was tabulated, statistical comparisons were made and results were correlated with demographic informationResults. On average, respondents believed that surgeons should be paid $21,299 for performing a lumbar discectomy and estimated that Medicare actually pays $12,336 (actual average reimbursement $971). Similar disparities were seen for the other procedures.The vast majority of respondents believed that the average Medicare reimbursement for spine procedures was too low. For example, 92.2% of patients believed that $971 for a lumbar discectomy was "too low", 6.1% believed it was "about right," and only 1.6% believed that $971 was "too high".Conclusions. Patients believe that orthopaedic spine surgeons should be compensated over ten to twenty times more than current Medicare reimbursement rates. Patients overestimate the actual amount that Medicare reimburses by a factor of approximately 7 to 10. Less than 10% of patients think that the current Medicare payment is about right, and less than 2% think that surgeons are overpaid.
    Spine 03/2013; 12(9). DOI:10.1097/BRS.0b013e318291b752 · 2.30 Impact Factor
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    ABSTRACT: Study Design. Retrospective national database analysis.Objective. A national population-based database was analyzed to characterize cervical spine procedures performed at teaching and non-teaching hospitals with regards to patient demographics, clinical outcomes/complications, resource utilization and costs.Summary of Background Data. There are mixed reports in the literature regarding the quality and costs of healthcare provided by teaching hospitals in the United States. However, outcomes of cervical spine surgery based upon teaching-status remains largely unknown.Methods. Data from the Nationwide Inpatient Sample was obtained from 2002-2009. Patients undergoing elective anterior or posterior cervical fusion (ACF, PCF), or posterior cervical decompression (PCD; i.e. laminoforaminotomy, laminectomy, laminoplasty) for a diagnosis of cervical myelopathy and/or radiculopathy were identified and separated into two cohorts (teaching and non-teaching hospitals). Patient demographics, co-morbidities, complications, length of hospitalization, costs, and mortality were compared for both groups. Regression analysis was performed to assess independent predictors of mortality.Results. A total of 212,385 cervical procedures were identified from 2002-2009 in the United States, with 54.6% performed at teaching hospitals. More multilevel fusions and posterior approaches were performed in teaching hospitals (p<0.0005). Patients treated in teaching hospitals trended towards male gender, increased costs, and hospitalizations. Overall, procedure-related complications and in-hospital mortality were increased in teaching hospitals. Regression analysis revealed that significant predictors of mortality were age ≥ 65 (O.R. = 3.0) and multiple co-morbidities. Teaching status was not a significant predictor of mortality (p = 0.07).Conclusion. Patients treated in teaching hospitals for cervical spine surgery demonstrated longer hospitalizations, increased costs, and mortality over patients treated in non-teaching hospitals. Incidences of post-operative complications were identified as higher in teaching hospitals. Possible explanations for these findings are an increased complexity of procedures performed at teaching hospitals. Older age and presence of co-morbidities were more significant predictors of in-hospital mortality than teaching-status. Future studies should identify long-term complications and costs beyond an in-patient setting to assess if differences extend beyond the peri-operative period.
    Spine 02/2013; 38(13). DOI:10.1097/BRS.0b013e31828da26d · 2.30 Impact Factor
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    ABSTRACT: Study Design. Retrospective analysis of a population-based database. Objective. To investigate national epidemiological trends of cervical spine surgical procedures from 2002-2009. Summary of Background Data. Anterior cervical fusion (ACF), posterior cervical fusion (PCF), and posterior cervical decompression (PCD) are procedures routinely performed for cervical degenerative pathology. Studies regarding epidemiological trends of these procedures is currently lacking in the literature. Methods. Data from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project was obtained for each year between 2002 and 2009. Patients undergoing ACF, PCF, and PCD for the diagnosis of cervical radiculopathy and myelopathy were identified. Demographics, costs, and mortality were assessed in the surgical subgroups. A P value of 0.001 was used to denote significance. Results. An estimated 1,323,979 cervical spine surgical procedures were performed between 2002 and 2009. There was a significant upward trend in the mean age of patients undergoing cervical spine surgery during this time period. ACF and PCF cohorts demonstrated statistically significant increases in comorbidities and costs from 2002-2009. The PCF group had the greatest mortality, comorbidities, costs, and longest hospitalizations compared with ACF and PCF cohorts across all time periods. Conclusion. Our study demonstrates that cervical spine surgical procedures have increased between 2002 and 2009 (P = 0.001). The primary increase in volume is due to the increasing number of ACFs. Despite older patients with more comorbidities undergoing ACF and PCF procedures, mortality has not changed. However, this time period. We hypothesize that these increased costs are due to an increased comorbidity burden in patients undergoing ACF or PCF. Results of this study can be used to set benchmarks for future epidemiological investigations in cervical spine surgery.
    Spine 02/2013; 38(14). DOI:10.1097/BRS.0b013e31828be75d · 2.30 Impact Factor
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    ABSTRACT: Study Design. Retrospective database analysis.Objective. A nationwide population-based database was analyzed to identify the incidence, risk factors, and mortalities associated with venous thromboembolism (VTE) after cervical spine surgery.Summary of Background Data. Pulmonary embolism (PE) and deep vein thrombosis (DVT) are potential complications that may occur after orthopaedic procedures. Incidences of these complications are not well characterized after cervical spine surgery.Methods. Data from the Nationwide Inpatient Sample database was obtained from 2002-2009. Patients undergoing anterior cervical fusion (ACF), posterior cervical fusion (PCF), and posterior cervical decompression (PCD; i.e. lamino-foraminotomy, laminectomy, laminoplasty) for the diagnosis of cervical myelopathy and/or radiculopathy were identified. Incidences of PE and DVT were calculated. Co-morbidities were calculated using the modified Charlson Co-morbidity Index (CCI). Mortality associated with these complications was assessed in the 3 surgical subgroups. Statistical analysis was performed to assess significant differences between groups. Logistic regression was used to identify independent predictors of VTE. A p-value of <0.0005 was used to denote significance.Results. There were 273,396 cervical procedures recorded in the NIS database from 2002-2009. PCF-treated patients had statistically the highest incidences of DVT and PE, while the lowest PE and DVT rates were found in ACF-treated patients (p<0.0005). All patients with thromboembolic events had significantly increased rates of mortality, hospitalization, and costs compared to patients without VTE across all procedural groups. Logistic regression analysis demonstrated statistically significant predictors of VTE to be male gender, pulmonary circulation disorders, fluid/electrolyte disorders, and teaching-hospital status.Conclusions. Thromboembolic events are potential complications of cervical spine surgery. The highest rates of VTE were identified in those patients undergoing PCF. Regardless of approach, DVT and PEs resulted in increased mortality rates and hospitalization. We recommend a thorough pre-operative assessment to identify patients at risk for VTE and treat accordingly to decrease the incidence of these thromboembolic events.
    Spine 01/2013; 13(9). DOI:10.1097/BRS.0b013e3182897839 · 2.30 Impact Factor
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    ABSTRACT: Study Design. Retrospective database analysis.Objective. A population-based database was analyzed to identify the incidence, risk factors, and mortality associated with thromboembolic events after lumbar spine surgery.Summary of Background Data. Pulmonary embolism (PE) and deep vein thrombosis (DVT) are potential complications that may occur after orthopaedic procedures. The incidence of these complications is not well characterized after lumbar spine surgery.Methods. Data from the Nationwide Inpatient Sample was obtained from 2002-2009. Patients undergoing lumbar decompression (LD), or lumbar fusion (LF) for degenerative etiologies were identified. Acute PE and DVT incidences and mortality rates were calculated. Co-morbidities were calculated using a modified Charlson Co-morbidity Index (CCI). Statistical analysis was performed using Student T-test for discrete variables and χ-test for categorical data. Logistic regression was used to identify independent predictors of thromboembolic events. A p-value of <0.0005 was used to denote statistical significance.Results. A total 578,457 LDs and LFs were identified from 2002-2009. DVT incidences were 2.4 and 4.3 per 1,000 cases in the LD and LF groups, respectively. PE incidences were 1.0 and 2.6 per 1,000 cases in the LD and LF groups, respectively. LF patients with thromboembolic events were younger, had fewer co-morbidities, and incurred greater costs than LD patients. Statistically significant predictors of DVT were pulmonary circulation disorders, coagulopathy, fluid/electrolyte disorders, anemia, obesity, teaching hospital status, and larger hospitals. Predictors for the development of a PE were pulmonary circulation disorders, fluid/electrolyte disorders, anemia, African-American ethnicity and teaching hospitals status.Conclusion. Patients undergoing LD or LF are at inherent risk of thromboembolic events. DVT and PE are more common after LF procedures. Pre-operative pulmonary circulation disorders, fluid/electrolyte disorders, deficiency anemia, and teaching hospital status were significant risk factors for both DVT and PE. Preventive measures in patients at risk may decrease the incidence of thromboembolic events.
    Spine 01/2013; 38(13). DOI:10.1097/BRS.0b013e318286b7c0 · 2.30 Impact Factor
  • Steven J. Fineberg · Matthew Oglesby · Miguel Pelton · Kern Singh ·

    12/2012; 13(12):1-7. DOI:10.1097/01.CSS.0000423195.25125.e2
  • Miguel A. Pelton · Kern Singh ·

    The Spine Journal 09/2012; 12(9):S46. DOI:10.1016/j.spinee.2012.08.135 · 2.43 Impact Factor
  • Krzysztof Siemionow · Miguel A Pelton · Jonathan A Hoskins · Kern Singh ·
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    ABSTRACT: Study Design. Single center retrospective study.Objective. To identify predictors of length of stay (LOS) days in patients undergoing 1 level minimally invasive (MIS) transforaminal interbody fusions (TLIF).Summary of Background Data. Recent studies suggest intra-operative fluid administration; colloid and crystalloid administration amongst other intra-operative variables may prolong length of stay days and increase complications. Therefore, an understanding of which pre-operative, intra-operative and immediate post-operative parameters best predict immediate length of stay days will help risk-stratify patients and guide decision making.Methods. We retrospectively reviewed 104 patients undergoing a MIS TLIF at one institution between 2008 and 2010. Two groups were selected based on the time of discharge. Group I consisted of patients discharged within 24 hours after surgery and Group II consisted of patients discharged more than 24 hours after surgery. Multiple regression analysis was performed to determine which pre-operative, intra-operative and post-operative variables were independent predictors of length of stay days.Results. Seventy- eight patients (75%) with a LOS greater than 24 hours had significantly higher estimated blood loss, received more crystalloids, had higher total fluids, longer surgical time, lower end of case temperature, lower hemoglobin during hospitalization, and a lower pre-op narcotic use. Multiple regression analysis showed that significant predictors of increased length of stay were: post-operative creatinine, VAS score, intra-operative colloids, fluids input at end of surgical case, crystalloid to colloid ratio, fluid balance, oxycontin use, mean percentage of FiO2, and pre-operative hemoglobin.Conclusions. Patients undergoing 1 level MIS TLIF for degenerative conditions can overall expect a short LOS post-operatively. Multiple preoperative, intraoperative and immediate post-operative factors can prolong the length of stay in this group. This information should help the surgical team in optimizing their intra-operative patient management.
    Spine 05/2012; 37(24). DOI:10.1097/BRS.0b013e31825c6688 · 2.30 Impact Factor

Publication Stats

104 Citations
49.83 Total Impact Points


  • 2013
    • Georgetown University
      Washington, Washington, D.C., United States
  • 2012-2013
    • Rush University Medical Center
      • Department of Orthopaedic Surgery
      Chicago, Illinois, United States
    • Chicago Orthopaedics & Sports Medicine
      Chicago, Illinois, United States