Article

Spinal Fusion in the United States Analysis of Trends From 1998 to 2008

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Abstract

Epidemiological study using national administrative data. To provide a complete analysis of national trends in spinal fusion from 1998 to 2008 and compare with trends in laminectomy, hip replacement, knee arthroplasty, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft. Previous studies have reported a rapid increase in volume of spinal fusions in the United States prior to 2001, but limited reports exist beyond this point, analyzing all spinal fusion procedures collectively. Data were obtained from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample for the years 1998 to 2008. Discharges were identified using International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes for the following procedures: spinal fusion, laminectomy, hip replacement, knee arthroplasty, percutaneous transluminal coronary angioplasty, and coronary artery bypass graft. Population-based utilization rates were calculated from the US census data. Between 1998 and 2008, the annual number of spinal fusion discharges increased 2.4-fold (137%) from 174,223 to 413,171 (P < 0.001). In contrast, during the same time period, laminectomy, hip replacement, knee arthroplasty, and percutaneous coronary angioplasty yielded relative increases of only 11.3%, 49.1%, 126.8%, and 38.8% in discharges, while coronary artery bypass graft experienced a decrease of 40.1%. Between 1998 and 2008, mean age for spinal fusion increased from 48.8 to 54.2 years (P < 0.001), in-hospital mortality rate decreased from 0.29% to 0.25% (P < 0.01), and mean total hospital charges associated with spinal fusion increased 3.3-fold (P < 0.001). The national bill for spinal fusion increased 7.9-fold (P < 0.001). Frequency, utilization, and hospital charges of spinal fusion have increased at a higher rate than other notable inpatient procedures, as seen in this study from 1998 to 2008. In addition, patient demographics and hospital characteristics changed significantly; in particular, whereas the average age for spinal fusion increased, the in-hospital mortality rate decreased.

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... Anterior cervical discectomy and fusion (ACDF) surgery has long been the customary surgical solution to radiculopathy, myelopathy, stenosis, and disc herniation/degenerative disc disease. [1,2] ACDF surgery is becoming more common as the annual number of operations skyrocketed from 540 in 2006 to 1565 in 2013, a staggering 190% increase in just 7 years. [3] As this procedure becomes more common, the average hospital bill of $34,000 may become a significant stressor to even more patients. ...
... [5] The incidence of revision surgery for TDR surgery is commonly lower than ACDF surgery. [2,6,10] However, complications do occur even after TDR surgery and may be related to cervical alignment. [11] The relationship between TDR and sagittal cervical spine alignment's biomechanics is not well understood. ...
... [4,10] In addition, the reoperation rates of TDR surgery are consistently lower than ACDF surgery. [2,6,10] However, the outcome for TDR surgery is not always good. One of the possible causes of this is alignment. ...
Article
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Introduction: The correlation between cervical alignment and clinical outcome of total disc replacement (TDR) surgery is arguable. We believe that this conflict exists because the parameters that influence the biomechanics of the cervical spine are not well understood, specifically the effect of TDR on different cervical alignments. Methods: A validated osseo-ligamentous model from C2-C7 was used in this study. The C2-C7 Cobb angle of the base model was modified to represent: lordotic (−10°), straight (0°), and kyphotic (+10°) cervical alignment. The TDR surgery was simulated at the C5-C6 segment. The range of motion (ROM), intradiscal pressure, annular stresses, and facet loads were computed for all the models. Results: The ROM results demonstrated kyphotic alignment after TDR surgery to be the most mobile when compared to intact base model (41% higher in flexion–extension, 51% higher in lateral bending, and 27% higher in axial rotation) followed by straight and lordotic alignment, respectively. The annular stresses for the kyphotic alignment when compared to intact base model were higher at the index level (33% higher in flexion–extension and 48% higher in lateral bending) compared to other alignments. The lordotic model demonstrated higher facet contact forces at the index level (75% higher in extension than kyphotic alignment, 51% higher in lateral bending than kyphotic alignment, and 78% higher in axial rotation than kyphotic alignment) when compared among the three alignment models. Conclusion: Preoperative cervical alignment should be an integral part of surgical planning for TDR surgery as different cervical alignments may significantly alter the postsurgical outcomes.
... More than 400,000 spinal fusion procedures are performed every year in the United States. 1 As the older population has increased, the utilization of spinal fusion for degenerative etiology has also significantly increased over the past decade. 1 Despite advancements in surgical techniques, approximately 10% to 40% of spine fusions fail, leading to failed back surgery ultimately requiring revision surgeries. ...
... More than 400,000 spinal fusion procedures are performed every year in the United States. 1 As the older population has increased, the utilization of spinal fusion for degenerative etiology has also significantly increased over the past decade. 1 Despite advancements in surgical techniques, approximately 10% to 40% of spine fusions fail, leading to failed back surgery ultimately requiring revision surgeries. 2 There remains a classically defined "difficult to fuse" patient population, that is, elderly patients (>65 years old), osteoporotic patients undergoing multilevel fusion, and patients with multiple prior fusion surgeries. ...
Article
Background: Direct current electrical stimulation may serve as a promising nonpharmacological adjunct promoting osteogenesis and fusion. The aim of this study was to evaluate the utility of electroactive spine instrumentation in the focal delivery of therapeutic electrical stimulation to enhance lumbar bone formation and interbody fusion. Methods: A finite element model of adult human lumbar spine (L4-L5) instrumented with single-level electroactive pedicle screws was simulated. Direct current electrical stimulation was routed through anodized electroactive pedicle screws to target regions of fusion. The electrical fields generated by electroactive pedicle screws were evaluated in various tissue compartments including isotropic tissue volumes, cortical, and trabecular bone. Electrical field distributions at various stimulation amplitudes (20-100 µA) and pedicle screw anodization patterns were analyzed in target regions of fusion (eg, intervertebral disc space, vertebral body, and pedicles). Results: Electrical stimulation with electroactive pedicle screws at various stimulation amplitudes and anodization patterns enabled modulation of spatial distribution and intensity of electric fields within the target regions of lumbar spine. Anodized screws (50%) vs unanodized screws (0%) induced high-amplitude electric fields within the intervertebral disc space and vertebral body but negligible electric fields in spinal canal. Direct current electrical stimulation via anodized screws induced electrical fields, at therapeutic threshold of >1 mV/cm, sufficient for osteoinduction within the target interbody region. Conclusions: Selective anodization of electroactive pedicle screws may enable focal delivery of therapeutic electrical stimulation in the target regions in human lumbar spine. This study warrants preclinical and clinical testing of integrated electroactive system in inducing target lumbar fusion in vivo. Clinical relevance: The findings of this study provide a foundation for clinically investigating electroactive intrumentation to enhance spine fusion.
... [3,4] However, a small percentage of patients contribute to the majority of these costs-roughly 10% of patients contribute to 63% of all US healthcare expenditures. [5,6] Given that lumbar spine surgeries may be among a hospital's most profitable services [7] and that the volume of spine surgery performed is increasingly annually, [8] identifying patients at risk of extended LOS and discharge to non-home destinations prior to surgery is a valuable opportunity to develop targeted pre-and peri-operative intervention, to improve quality and outcomes, and to decrease needless expense. ...
... Prior research has reported similar observations following spine surgery, [54] although other studies have reported no association between discharge disposition and hospital readmission risk. [52,55] Given the high costs of SNF and acute rehabilitation facilities, [4,56] coupled with the increase in spine surgery incidence, [8] understanding the cost-benefit analysis of utilizing medical facilities following discharge is particularly salient as healthcare expenditure continues to rise. [57] A 2014 Cochrane systematic review concluded that more evidence in the form of randomized control trials to assess the utility of rehabilitation following lumbar disc herniation is needed. ...
Article
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Background In the context of increased attention afforded to hospital efficiency and improved but safe patient throughput, decreasing unnecessary hospital length of stay (LOS) is imperative. Given that lumbar spine procedures may be among a hospital's most profitable services, identifying patients at risk of increased healthcare resource utilization prior to surgery is a valuable opportunity to develop targeted pre- and peri-operative intervention and quality improvement initiatives. The purpose of the present investigation was to examine patient factors that predict prolonged LOS as well as discharge disposition following elective, posterior, lumbar spine surgery. Methods We employed a retrospective cohort analysis on 779 consecutive patients treated with lumbar surgery without fusion. Our primary outcome measures were extended LOS (three or more midnights) and discharge disposition. Patient sociodemographic, procedural, and discharge characteristics were adjusted for in our analysis. Sociodemographic variables included Area of Deprivation Index (ADI), a comprehensive metric of socioeconomic status, utilizing income, education, employment, and housing quality based on patient zip code. Multivariable logistic regression and ordinal logistic regression analyses were performed to assess whether covariates were independently predictive of extended LOS and discharge disposition, respectively. Results 779 patients were studied, with a median age of 66 years (±15) and a median LOS of 1 midnight (range, 1-10 midnights). Patients in the most disadvantaged ADI quintile (adjusted odds ratio, aOR 2.48 95% CI 1.15-5.47), those who underwent a minimally-invasive or tubular retractor surgery (aOR 3.03 95% CI 1.02-8.56), those who had an intra-operative drain placed (aOR 4.46 95% CI 2.53-7.26), who had a cerebrospinal fluid leak (aOR 3.46 95% CI 1.55-7.58), who were discharged anywhere but home (aOR 17.11 95% CI 9.24-33.00), and those who were evaluated by physical therapy (aOR 7.23 95% CI 2.13-45.30) or OT (aOR 2.20 95% CI 1.13-4.22) had a significantly increased chance of an extended LOS. Preoperative opioid use was not associated with an increased LOS following surgery (aOR 1.12 95% CI 0.56-1.46). Extended LOS was not associated with post-discharge emergency department representation or unplanned readmission within 90 days following discharge (p=0.148). Patients who were older (aOR 1.99 95% CI 1.62-2.48), in higher quintiles on ADI (3rd quintile; aOR 1.90 95% CI 1.12-3.23, 4th quintile; aOR 1.79, 95% CI 1.05-3.05, 5th quintile; aOR 2.16 95% CI 1.26-3.75), who had a CSF leak (aOR 2.18 95% CI 1.22-3.86), or who had a longer procedure duration (aOR 1.38 95% CI 1.17-1.62) were more likely to require additional services or be sent to a subacute facility upon discharge. Conclusion Patient sociodemographics, along with procedural factors, and discharge disposition were all associated with an increased likelihood of prolonged LOS and resource intensive discharges following elective lumbar spine surgery. Several of these factors could be reliably identified pre-operatively and may be amenable to targeted preoperative intervention. Improving discharge disposition planning in the peri-operative period may allow for more efficient use of hospitalization and inpatient and post-acute resources.
... 4 In accordance with this epidemiological data, the frequency of spinal fusion has been increasing in some countries. 5 While bracing is an effective treatment in some cases, 6 progression to more severe AIS is often treated by posterior spinal fusion (PSF). 5,7 Bony fusion in PSF is usually achieved by dorsolateral decortication and application of autologous iliac crest bone graft (ICBG), 8,9 a technique for which the reported rate of pseudarthrosis is less than 5%. ...
... 5 While bracing is an effective treatment in some cases, 6 progression to more severe AIS is often treated by posterior spinal fusion (PSF). 5,7 Bony fusion in PSF is usually achieved by dorsolateral decortication and application of autologous iliac crest bone graft (ICBG), 8,9 a technique for which the reported rate of pseudarthrosis is less than 5%. 10,11 However, donor site morbidity is an issue of this technique and is reported to occur in 2% to 45% of all cases. ...
Article
Objective To evaluate radiological outcomes following the use of xenogeneic bone graft substitute (BGS) in patients undergoing multisegmental spinal fusion. Summery of Background Data Data exists for single level and short segment fusions, there presently is a paucity of data on fusion rate after bone augmentation with BGS in multisegmental posterior spinal fusion (PSF). The leading concern is pseudarthrosis, which often leads to a loss of correction after PSF. Therefore, the bone graft is an essential aspect of PSF. Methods We retrospectively analysed the radiological data of a consecutive cohort of patients who had been treated for adolescent idiopathic scoliosis (AIS) via multisegmental spinal fusion, in whom a bovine derived BGS had been used and had a complete dataset of 24 months follow-up. The Cobb angle of the main curve was measured pre-operatively and then at 6, 12 and 24 months post-operatively. Loosening of the screws was recorded at the same post-operative time points. Results After applying inclusion and exclusion criteria, 28 patients were included. We found no significant change of the cobb angle from the main curve as well as the cobb angle from the thoracic kyphosis during the 24 months of follow up. No patient showed a lack of bony fusion. There was 1 revision surgery, which was due to trauma. Conclusion In this cohort, all patients showed successful bone fusion during a 24-month follow-up. Additionally, there was no change in the Cobb angle during the 2-year post-operative period. Our data indicates that the use of bovine-derived BGS supports bone fusion after multisegmental posterior instrumented fusion of the spine.
... Elective spine surgery has increased in prevalence recently as advances in the field have allowed patients to improve significantly clinically and show marked reduction in pain and disability. 6 Despite the increased surgical volume and achievement of successful patient outcomes, spine surgery remains an invasive procedure with high risk of complications. Focusing on optimizing With cardiac disease being one of the most predominant comorbidities in the United States, spine surgery on these patients may present additional postoperative challenges. ...
Article
Background: The impact of an initially less invasive cardiac intervention on outcomes of future surgical spine procedures has been understudied; therefore, we sought to investigate the effect of coronary stents on postoperative outcomes in an elective spine fusion cohort. Methods: Elective spine fusion patients were isolated with International Classification of Diseases-Ninth Edition and current procedural terminology procedure codes in the PearlDiver database. Patients were stratified by number of coronary stents: (1) 1 to 2 stents (ST12); (2) 3 to 4 stents (ST34); (3) no stents. Mean comparison tests compared differences in demographics, diagnoses, comorbidities, and 30-day and 90-day complication outcomes. Logistic regression assessed the odds of complications associated with coronary stents, controlling for levels fused, age, sex, and comorbidities (odds ratio [95% confidence interval]). Statistical significance was P < 0.05. Results: A total of 726,061 elective spine fusion patients were isolated. Of those patients, 707,396 patients had no stent, 17,087 ST12, and 1578 ST34. At baseline (BL), ST12 patients had higher rates of morbid obesity, chronic kidney disease, congestive heart failure, chronic obstructive pulmonary disease, and diabetes mellitus compared with no stent and ST34 patients (all P < 0.001). Relative to no stent patients, ST12 patients had a longer length of stay and, at 30 days, significantly higher complication rates, including pneumonia, myocardial infarction (MI), sepsis, acute kidney injury, urinary tract infection (UTI), wound complications, transfusions, and 30-day readmissions (P < 0.05). Controlling for age, sex, comorbidities, and levels fused, ST12 was a significant predictor of MI within 30 days (OR 2.15 [95% CI 1.7-2.7], P < 0.001) and 90 days postoperatively (OR 1.87 [95% CI 1.6-2.2], P < 0.001). ST34 patients compared with no stent patients at 30 days presented with increased rates of complication, including pneumonia, MI, sepsis, UTI, wound complications, and 30-day readmissions. Regression analysis showed no significant differences in complications between ST12 vs ST34 at 30 days, but at 90 days, ST34 was associated with significantly increased rate and odds of death (1.1% vs 0.3%, P = 0.021; OR 1.94 [95% CI 1.13-3.13], P = 0.01). Conclusion: Cardiac stents failed to normalize risk profile of patients with coronary artery disease. Postoperatively at 90 days, elective spine fusion patients with 3 or more stents were significantly at risk of mortality compared with patients with fewer or no stents.
... Cervical or lumbar fusion is a good therapeutic option for a range of degenerative disorders that do not respond to conservative therapy, and spinal arthrodesis is an increasingly common orthopedic procedure (1). Autogenous iliac crest bone grafts (ICBGs) have conventionally been used for cervical or lumbar fusion, as this graft is widely accessible and possesses intrinsic osteoconductive, osteoinductive, and osteogenic qualities that promote osteoblastic proliferation and bone tissue development (2). ...
Article
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IntroductionThe clinical efficacy and safety of supercritical CO2-processed bone allografts prepared from living donors has yet to be confirmed in spinal surgery. Here we report our clinical and surgical experience of using supercritical CO2-processed bone allografts for lumbar and cervical fusion.Methods Sixteen patients underwent one or two level anterior cervical discectomy and fusion and 37 patients underwent anterior retroperitoneal route lumbar fusion using bone allografts processed using supercritical CO2 extraction combined with chemical viral inactivation. Fusion success was assessed radiographically in the immediate postoperative period and at one month, six months, one year, and three years postoperatively. Function and pain were assessed using visual analog scales, Odom's criteria, the neck disability index (NDI), and the Oswestry disability index (ODI).ResultsAt a mean of 43 and 47 months postoperatively, 95.3% and 90.5% of cervical and lumbar fusion patients had radiographic evidence of bone fusion, respectively. Over 80% of patients reported good to excellent outcomes according to Odom's criteria, the perception of pain significantly decreased, and the mean NDI and ODI scores significantly improved at the last follow-up compared with before the operations. There were no safety concerns. For the cervical group, the mean NDI score improved from 26.3 ± 6.01 preoperatively to 15.00 ± 8.03 and 17.60 ± 13.95 at immediate post-op (p = 0.02) and last follow-up visits (p = 0.037) respectively. For the lumbar cases, the mean ODI score improved from 28.31 ± 6.48 preoperatively to 14.68 ± 5.49 (p < 0.0001) and 12.54 ± 10.21 (p < 00001) at immediate post-op and last follow-up visits respectively.Conclusion Within the limitations of this study, the use of supercritical CO2-processed bone allografts resulted in satisfactory clinical outcomes and fusion rates with acceptable safety for both cervical and lumbar surgeries.
... For a long time, fusion was considered the gold standard following decompression surgery. In the USA, the annual incidence of lumbar fusion procedures rose by 262% from 1998 to 2015 [3]. Moreover, with the growing amount of lumbar fusion being performed, the related medical costs have soared from US$3.7 billion in 2004 to US$10.2 billion in 2015, an impressive 177% increase, resulting in a major socioeconomic burden [4]. ...
Article
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Background: Adjacent segment disease (ASD) is a common complication after lumbar fusion and is still traditionally treated by open surgery. In recent years, with the development of minimally invasive techniques, percutaneous endoscopic surgery(PES) has been used for the treatment of ASD after lumbar fusion due to its unique benefits. Nevertheless, it remains unclear about its significant clinical efficacy and advantages over conventional open surgery. Objectives: To evaluate the clinical efficacy and safety of PES in the treatment of ASD after lumbar fusion. Study design: A systematic review and meta-analysis studies about the role of PES in managing ASD after lumbar fusion. Methods: A systematic search review was conducted in PubMed, EMBASE, Cochrane Library, Web of Science, CNKI, VIP, WanFang, and SinoMed databases from the start of their construction to 15 November 2021. Eligible studies included references to clinical trials of PES for ASD after open lumbar fusion. Observations included pain relief, recovery of postoperative function, overall excellent rates, and indicators of the advantages of minimally invasive surgery compared to conventional surgery. Postoperative complications and recurrence rates were also recorded. Results: A total of 24 studies, including 20 single-arm studies and 4 clinical control studies, all involving 928 patients were included. A total of 694 patients were included in the single-arm analysis. The results of the single-arm meta-analysis showed that PES could significantly reduce low back and leg pain and improve the functional status of the lumbar spine in patients with ASD after open lumbar fusion compared to preoperatively, and had good clinical efficacy after surgery. A total of 234 patients were included in the four clinically controlled studies, and the results of the meta-analysis showed that PES could clearly reduce pain and improve lumbar function, with no significant difference in efficacy between PES and open surgery. However, PES has a lower surgical incision, less intraoperative bleeding, and shorter operative time and length of hospital stay compared to open surgery. Moreover, it has a lower rate of postoperative recurrence as well as complications and a longer duration of efficacy. Conclusions: On the basis of the available clinical literature and the results of this study, PES could achieve satisfactory clinical effects in ASD treatment after lumbar fusion. Compared with conventional open surgery, PES can not only obtain similar clinical results, but also had the advantages of less trauma and faster recovery. Nevertheless, a randomized controlled study is still needed to validate the findings of this study. Trial registration: Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42022298387.
... Severe pathological conditions of the spine, including deformity, trauma, degenerative disc disease, and spondylolisthesis, can be treated using the established orthopedic surgical technique called spinal fusion or spondylodesis [10,11]. Spinal fusion implants, which consist of specialized screws that are driven into the pedicles of the respective vertebrae, are used to achieve a fusion between two or more spine segments, thereby immobilizing the respective region and absorbing biomechanical forces. ...
Article
Despite the undeniable advantages of image-guided surgical assistance systems in terms of accuracy, such systems have not yet fully met surgeons' needs or expectations regarding usability, time efficiency, and their integration into the surgical workflow. On the other hand, perceptual studies have shown that presenting independent but causally correlated information via multimodal feedback involving different sensory modalities can improve task performance. This article investigates an alternative method for computer-assisted surgical navigation, introduces a novel sonification methodology for navigated pedicle screw placement, and discusses advanced solutions based on multisensory feedback. The proposed method comprises a novel sonification solution for alignment tasks in four degrees of freedom based on frequency modulation (FM) synthesis. We compared the resulting accuracy and execution time of the proposed sonification method with visual navigation, which is currently considered the state of the art. We conducted a phantom study in which 17 surgeons executed the pedicle screw placement task in the lumbar spine, guided by either the proposed sonification-based or the traditional visual navigation method. The results demonstrated that the proposed method is as accurate as the state of the art while decreasing the surgeon's need to focus on visual navigation displays instead of the natural focus on surgical tools and targeted anatomy during task execution.
... In the United States, the rate of spinal fixation and fusion procedures from 1998 to 2008 showed an increase of 137%, more than that of any other procedure involving implants. 19,20 This is also evident from the number of publications in the recent times. 21,22 Though it is difficult to get such a data from developing countries like India, unwarranted spinal fixations are definitely on the rise. ...
Article
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Introduction Microdiscectomy, as of now, is considered the gold standard for the treatment of herniated lumbar disc. It preserves motion at the spinal segment and does not alter the local spinal anatomy significantly, resulting in a “functional and mobile” spine. Development of increasingly better-quality implants has seen their indiscriminate use in cases without any demonstrable instability. We see an increasing number of patients of lumbar disc prolapse being treated by fixation and fusion procedures, without any clear indication or evidence supporting such practice. This adds to the operating time, blood loss, cost of surgery and leads to loss of motion at the spinal segment resulting in a “stiff and immobile spine.” Our 10-year experience of treating lumbar disc herniation by micro-discectomy makes a strong case for preserving the spinal motion segment wherever possible and to use fixation very judiciously only in cases of proven instability. Materials and Methods A total of 295 cases of lumbar disc prolapse operated by the first author from January 2013 to April 2022 were analyzed. All the patients had unilateral or bilateral radicular pain. Preoperatively instability was ruled out by dynamic X-rays. All the patients were operated in prone position on Wilson's frame. Microdiscectomy was done through the inter-laminar space. Patient outcomes and complications were analyzed. Results There was no mortality in our series. All the patients had significant relief of lower limb pain with improved visual analog scale scores postoperatively. The patients were followed up for 6 months. There were complications in 17 patients, all of which were treated successfully with a good outcome. None of the complications were attributable to failure of doing fixation. Conclusion Lumbar disc prolapse can be treated effectively by microdiscectomy. Fixation should be reserved for only those cases with demonstrable preoperative instability.
... An inter-and intra-rater variability study by Schwab et al. from the US was the third most cited article (= 172, 2012, in Spine) (Rajaee et al., 2012). This article has inter-rater reliability and inter-rater agreement for curve type and each modifier of the new adult spinal deformity (ASD) classification system. ...
Article
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Literature research requires an understanding of the similarities and differences between different types of journals. It has not yet been possible to use text-mining to demonstrate the differences between the topics of articles by presenting features of article keywords using forest plots. It is important for authors to make a quick assessment of the similarities and differences between research types when submitting an article for publication in a journal. Our study uses text mining and forest plotting techniques to extract article features and compare the similarities and differences between the two journals' research types. There were a total of 100 top-cited articles selected from Spine (Phila Pa 1976) and The Spine Journal: official journals of the North American Spine Society with impact factors of 3.19 and 3.22 respectively, as reported by Journal Citation Reports (JCR) for 2018. XLSTAT software was used to extract features from author-made keywords and medical subject headings (e.g., MeSH terms in PubMed). These 200 top-cited articles were analyzed and clustered by performing factor analysis and social network analysis (SNA). The study presented three types of results: (1) descriptive statistics, (2) classification analysis, and (3) inferential statistics. The chi-square test was used to examine the frequency of clusters and journals, and forest plots were used to analyze differences between journals in terms of research topics. It was observed that (1) the United States dominated publications, accounting for 54% of 200 articles; the MeSH term of surgery was simultaneously highlighted in both journals using a word cloud generator; (2) five-term clusters were identified, namely, (i) Pain & Prognosis, (ii) Statistics & Data, (iii) Spine & Surgery, (iv) physiopathology, and (v) physiology; (4) there were no differences in distribution counts among categories between journals (Chi Square = 1.64, df = 4, p = 0.82), but differences in category(factor) scores between journals were found(Q-statistic = 484.94, df = 4, p < 0.001). Using text mining and a forest plot, we are able to understand the relationships between the types of research in different journals. Readers can use this research as a reference for future journal submissions based on the study results.
... Spinal fusion has been utilized for treatment of a variety of disorders including congenital deformity, trauma, spondylolisthesis, and degenerative disease [9]. Its use has increased in the USA, driven by advances in fixation devices, bone grafting materials, and a growing elderly population. ...
Article
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Purpose of Review Recent literature has sought to understand differences in fusion failure, specifically considering how patient sex may play a role. Overall, there exists inconclusive data regarding any sex-based differences in bone healing. Recent Findings In vitro studies examining the roles of sex hormones, 5-LO, IGF-1, VEGF, osteoclasts, and OPCs seem to show sexually dimorphic actions. Additionally, donor characteristics and stem cell environment seem to also determine osteogenic potential. Building on this biomolecular basis, in vivo work investigates the aforementioned elements. Broadly, males tend to have a more robust healing compared to females. Taking these findings together, differences in sex hormones levels, their timing and action, and composition of the inflammatory milieu underlie variations in bone healing by sex. Summary Clinically, a robust understanding of bone healing mechanics can inform care of the transgender patient. Transgender patients undergoing hormone therapy present a clinically nuanced scenario for which limited long-term data exist. Such advances would help inform treatment for sports-related injury due to hormonal changes in biomechanics and treatment of transgender youth. While recent advances provide more clarity, conclusive answers remain elusive.
... S pinal fusion surgery, with the aim of obtaining a solid fusion between vertebrae, is now an established treatment for numerous lumbar spine disorders, including mechanical instability, degenerative disease, and deformity. Over the past century, the surgical strategy has evolved from autologous bone grafting to use of rigid pedicle screw systems and/or interbody fusion devices in combination with bone graft substitutes [1][2][3][4][5][6][7] . ...
Article
Full-text available
Background: Noninvasive assessment of osseous fusion after spinal fusion surgery is essential for timely diagnosis of patients with symptomatic pseudarthrosis and for evaluation of the performance of spinal fusion procedures. There is, however, no consensus on the definition and assessment of successful posterolateral fusion (PLF) of the lumbar spine. This systematic review aimed to (1) summarize the criteria used for imaging-based fusion assessment after instrumented PLF and (2) evaluate their diagnostic accuracy and reliability. Methods: First, a search of the literature was conducted in November 2018 to identify reproducible criteria for imaging-based fusion assessment after primary instrumented PLF between T10 and S1 in adult patients, and to determine their frequency of use. A second search in July 2021 was directed at primary studies on the diagnostic accuracy (with surgical exploration as the reference) and/or reliability (interobserver and intraobserver agreement) of these criteria. Article selection and data extraction were performed by at least 2 reviewers independently. The methodological quality of validation studies was assessed with the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies 2) and QAREL (Quality Appraisal of Reliability Studies). Results: Of the 187 articles included from the first search, 47% used a classification system and 63% used ≥1 descriptive criterion related to osseous bridging (104 articles), absence of motion (78 articles), and/or absence of static signs of nonunion (39 articles). A great variation in terminology, cutoff values, and assessed anatomical locations was observed. While the use of computed tomography (CT) increased over time, radiographs remained predominant. The second search yielded 11 articles with considerable variation in outcomes and quality concerns. Agreement between imaging-based assessment and surgical exploration with regard to demonstration of fusion ranged between 55% and 80%, while reliability ranged from poor to excellent. Conclusions: None of the available criteria for noninvasive assessment of fusion status after instrumented PLF were demonstrated to have both sufficient accuracy and reliability. Further elaboration and validation of a well-defined systematic CT-based assessment method that allows grading of the intertransverse and interfacet fusion mass at each side of each fusion level and includes signs of nonunion is recommended. Level of evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
... Spinal instrumentation with pedicle screws is an broadly established and increasingly used intervention in the surgical treatment of degenerative diseases, injuries, deformities or tumors of the spine. [1,2,3]. Hereby, the spinal segment is stabilized by driving screws into both pedicles of the respective vertebra and connect them with rods on either side that absorb most of the biomechanical forces. ...
Preprint
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There is an unmet clinical need for developing novel methods to complement and replace the current radiation-emitting imaging-based methods for the detection of loose pedicle screws as a complication after spinal fusion surgery which fail to identify a substantial amount of loose implants. In this work, we propose a new methodology and paradigm for the radiation-free, non-destructive, and easy-to-integrate detection of pedicle screw loosening based on vibroacoustic sensing. Furthermore, we propose a novel simulation technique for pedicle screw loosening, which is biomechanically validated. For the detection of a loose implant, we excite the vertebra of interest with a sine sweep vibration at the spinous process and attach a custom highly-sensitive piezo contact microphone to the screw head to capture the propagated vibration characteristics which are analyzed using a detection pipeline based on spectrogram features and a SE-ResNet-18. To validate the proposed approach, we conducted experiments using four human cadaveric lumbar spine specimens and evaluate our algorithm in a cross validation experiment. Our method reaches a sensitivity of 91.50 +- 6.58% and a specificity of 91.10 +- 2.27%. The proposed system shows great potentials for the development of alternative assessment methods for implant loosening based on vibroacoustic sensing.
... Aux USA, cette hausse est de 62,5% sur la période 1992-2003, tout particulièrement marquée pour les arthrodèses (230%) [478]. Sur la décennie suivante, cette hausse s'est poursuivie avec 137% d'augmentation entre 1998 et 2018 [362]. Pour les discectomies, le taux de réopération fluctue entre 9,2 et 10,2% [4], représentant 6,2% du total des opérations en France [182]. ...
Thesis
Les affections de la colonne sont la principale source de handicap mondiale. Leur impact sur les systèmes de santé et sociaux est monumental dans les pays occidentaux et sans doute négligé dans les pays en voie de développement. Bien que traditionnellement considéré comme non spécifique, il est possible dans certains cas de définir des sources anatomo-pathologiques responsables de la douleur des patients. Parmi elles, se trouve les fissures radiales de l’annulus fibrosus du disque intervertébral. Cette lésion structurelle à de nombreuses conséquences sur la biologie et la mécanique du disque intervertébral, pouvant conduire à une dégénérescence de la structure. Dans cette thèse nous nous intéressons aux déplacements et aux déformations du Nucleus Pulposus rendu plus importantes du fait de la brèche de l’annulus. McKenzie a émis l’hypothèse d’un nucleus mobile dans la fissure. Ces déformations / déplacements sont dépendants des forces imposées sur l’unité fonctionnelle par les mouvements physiologiques du rachis. Ainsi une flexion déplace / déforme le nucleus vers l’arrière, une extension vers l’avant et ainsi de suite. Afin de tester la pertinence de cette hypothèse, nous utilisons une approche quadruple, incluant :- Une revue systématique de la littérature avec une méta-analyse.- Une approche ex vivo, combinant IRM quantitative et analyse photomécanique.- Une approche in vivo d’analyse quantifié de mouvement.- Une approche in silico de modélisation par éléments finis.Nos résultats, quoique préliminaires, semblent confirmer cette hypothèse. Mais, nous sommes encore loin d’une validation ferme et définitive. D’autres recherches seront nécessaires pour finaliser cet objectif.
... For instance, the annual incidence in Norway increased by 54% between 1999 and 2013 to 119.9 per 100,000 people, of which 14.8% were reoperations (4). Spinal fusion surgery is also on the rise, evident from studies in the US and Europe (5)(6)(7)(8)(9)(10). The annual rate increased 4.33 times from 1998-2011 (11) and revision rates following primary spinal fusion surgery range from 8 to 45% (12). ...
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Spine surgery and spinal fusion surgery are rising. Revision rates following initial surgery are between 8 and 45%. Epidural fibrosis is a common response to spine surgery for most patients and increases complications in revision surgery. Previous research suggests using MESNA (Sodium 2-mercaptoethane sulfonate) in combination with mechanical blunt dissection safely reduces surgical complications. MESNA is a mucolytic agent which selectively cleaves disulphide bonds involved in the adherence and strength of fibrosis, meaning cutting instruments are not needed. The Chemically Assisted DISSection (CADISS®) System is an optimised non-cutting surgical device, consisting of a reconstitution cartridge for MESNA preparation, irrigated surgical instruments, and a footswitch to control MESNA release. This is the first study to investigate the use of the CADISS® System in revision spine surgery. Methods This was a prospective, open label, observational case study. We enrolled 21 patients for revision spine surgery with the CADISS® System at two Belgium sites. The primary assessment was the number of successful removals of epidural fibrosis without cutting. The amount of MESNA used, total dissection and procedure time were recorded. For secondary criterion, the surgeons assessed global satisfaction, facilitation of dissection, quickness of action, usability, bleeding reduction and visualisation of the cleavage plane using an 11-point Likert scale (0-10). Due to the exploratory nature, no formal statistical analysis was planned. We calculated the percentage and confidence interval of successful procedures, the medians and corresponding interquartile range of the Likert criterion, and the mean (±SD) of the amount of MESNA used, CADISS® dissection time and total procedure time. Results 24 fibrosis dissections were performed in 19 patients and 23 were successful (95.8%, CI: 78.9%; 99.9%). The mean amount of MESNA used, mean dissection time and procedure time were 16 ml (±4.94), 16.5 minutes (±16.1) and 86.3 minutes (±25.1), respectively. No dural tears were reported. The mean global satisfaction score was 9.0 (8.0–9.0). All other Likert criterion had scores of 8.0 or 9.0, excluding quickness of action, which scored 7.0 (6.0–9.0). Conclusions The CADISS® System in revision spine surgery has potential to effectively reduce dissection complications.
... 14 TXA has been proven effective during orthopedic surgeries, especially in arthroplasty procedures, but remains inconsistently used during spinal surgeries. 15 Therefore, we investigated TXA's effects on mitigating perioperative blood loss during corrective procedures for degenerative lumbar conditions, 16 one of the most frequent spinal conditions indicated for surgical intervention. Our goal was to determine whether TXA should be recommended for routine use in spinal surgeries to reduce blood loss volume, as well as transfusion requirements. ...
Article
Purpose: Spinal surgeries are often associated with a high incidence of perioperative blood loss, which poses several complications. Much current research focuses on the importance of antifibrinolytic drugs during spinal surgeries to reduce blood loss, which can also reduce the risk of the need for blood transfusions. We evaluated the effects of prophylactic, low-dose tranexamic acid (TXA) in spinal fusion surgeries on blood loss, blood transfusions, and associated complications. Materials and methods: TXA was administered to 90 patients at a constant infusion rate of 10 mg/kg for 20 minutes after anesthesia induction, followed by a maintenance dose of 1 mg/kg/h until the end of the operation. An additional 91 patients were included as controls. Results: There were no significant differences between the study groups in terms of intraoperative blood loss, which was 500 mL for both groups (p>0.999). Also, intraoperative blood transfusion requirements were similar between both groups (p=0.330). Mean blood transfusion amounts were 125±35 mL for patients in the TXA group and 85±25 mL in the control group. However, there was a significant reduction in postoperative blood transfusion (p=0.003) in the TXA group. Only three cases in the TXA group required blood transfusion, while 15 cases in the control group did. Conclusion: We confirmed that low dose TXA has no effect on intraoperative blood loss volume or blood transfusion requirements and that it can significantly reduce the need for postoperative blood transfusions.
... This technique has become more widely used owing to the expansion of the number of elderly people with spine disorders. 1 However,~10% of patients will experience fusion failure after surgery, and fusion failure remains a serious complication. 2 Applying osteoconductive biologic agents has been attempted to improve spinal fusion rates. ...
... In a retrospective study of a Korean nationwide database, Kim et al. [2] reported a 3.5-fold increase in fusion surgery for herniated intervertebral disk disease from 2003 to 2008. A review of the Healthcare Cost and Utilization Project Nationwide Inpatient Sample in the USA found that the annual number of spinal fusion discharges increased 2.4fold (from 174,223 to 413,171) [5]. ...
Article
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Study design Retrospective cohort study. Purpose The aim of our study was to determine the rates and indications of reoperations following primary lumbar fusion, as well as the independent risk factors for early and late reoperation. Methods We retrospectively reviewed patients who underwent lumbar fusion surgery between January 2017 and March 2020. All patients were followed up for more than 2 years. Characteristics, laboratory tests, primary diagnosis and surgery-related variables were compared among the early reoperation (< 3 months), the late reoperation (> 3 months) and the non-reoperation groups. Multivariable logistic regression analysis was used to identify independent risk factors for early and late reoperations. Results Of 821 patients included in our studies, 34 patients underwent early reoperation, and 36 patients underwent late reoperation. The cumulative reoperation rate was about 4.1% (95% CI 3.8–4.5%) at 3 months, 6.2% (95% CI 5.9–6.5%) at 1 year and 8.2% (95% CI 8.0–8.5%) at 3 years. Multivariable analysis indicated that osteoporosis (odds ratio [OR] 3.6, 95% CI 1.2–10.5, p = 0.02) and diabetes (OR 2.1, 95% CI 1.1–4.5, p = 0.04) were independently associated with early reoperation and multilevel fusion (OR 2.4, 95% CI 1.1–5.4, p = 0.03) was independently associated with late reoperation. Conclusions The most common reasons for early reoperation and late operation were surgical site infection and adjacent segment diseases, respectively. Osteoporosis and diabetes were independent risk factors for early reoperation, and multilevel fusion was independent risk factor for late reoperation. Surgeons should pay more attention to these patients, and future studies should consider the effects of follow-up periods on results.
... However, further studies are required to substantiate these claims since laminectomy remains one of the main surgical procedures for the treatment of LCS [1]. The annual average healthcare expenditure on laminectomy procedure in the USA has approximately doubled between 1998 and 2008 [9]. In 2016, Zaina et al. reviewed the effectiveness of various surgical procedures compared with non-surgical interventions in adults with symptomatic LCS and found inconclusive evidence supporting the superiority of surgical or medical approaches. ...
... In 2010, osteoporosis and osteopenia were identified in 10.3% and 43.9% of Americans over the age of 50, respectively [41]. These diseases of low BMD can lead to progression of ASD [23] and may be an explanation as to why the number of spinal fusion surgeries performed in the USA to correct such deformities continues to rise [6,31]. In addition, low BMD affects outcomes of fusion surgery. ...
Article
Full-text available
Study design Retrospective cohort. Background Over 44 million adults are estimated to have either osteoporosis or osteopenia. Adult spinal deformity (ASD) is estimated to affect between 32 and 68% of the elderly population. Objective Retrospective investigation comparing rates of postoperative complications following thoracolumbar scoliosis surgery in patients with normal bone mineral density (BMD) to those with osteopenia or osteoporosis in addition to analyzing the effects of pretreatment with anti-osteoporotic medications in patients with low BMD. Methods Using administrative database of Humana beneficiaries, ICD-9 and ICD-10 diagnosis codes were used to identify ASD patients undergoing multilevel thoracolumbar fusions between 2007 and 2017. Results The propensity matched population analyzed in this study contained 1044 patients equally represented by those with a history of osteopenia, osteoporosis, or normal BMD. Osteopenia and osteoporosis were associated with increased odds of revision surgery (OR 2.01 95% CI 1.36–2.96 and OR 1.57, 95% CI 1.05–2.35), respectively. Similarly, there was an almost twofold increased odds of proximal and distal junctional kyphosis in patients with osteopenia and osteoporosis (OR 1.95, 95% CI 1.40–2.74 and OR 1.88, 95% CI 1.34–2.64), respectively. A total of 258 (37.1%) patients with osteoporosis were pretreated with anti-osteoporotic medications and there was no statistically significant decrease in odds of proximal or distal junctional kyphosis or revision surgery in these patients. Conclusion Patients with ASD undergoing multilevel thoracolumbar fusion surgery have significantly higher rates of postoperative pseudarthrosis, proximal and distal junctional kyphosis, and revision surgery rates compared to patients with normal BMD.
Article
Background/context: Lumbar surgery is one of the interventions performed for patients with degenerative conditions. Purpose: This study aimed to investigate the effect of pain management education on pain intensity, anxiety, and disability after the lumbar surgery. Study design/setting: This randomized controlled trial was performed on seventy 30-65-year-old patients with lumbar canal stenosis and lumbar disc herniation from 2018 to 2019. Patient sample: Seventy participants were randomly divided into a control and an intervention group by a randomized block design. Participants in the intervention group received in-person pain management training twice a week for seven 60-90-minute sessions. Outcome measures: All participants in the two groups completed the study instruments (NRS, ODI, and PASS) before, immediately after, and three months after the study. Methods: Participants in the intervention group received in-person pain management training twice a week for seven 60-90-minute sessions. To analyze the treatment effects, repeated-measures multivariate analysis of variance (MANOVA) and effect sizes were used where appropriate and calculated by Partial ɳ2. Clinical outcome (MDC) for pain intensity and PASS was also reported. For participants lost to follow-up, we also used an "intention-to-treat" (ITT) approach. Results: The results of MANOVA indicated that there were significant differences between the two groups on ratings of pain intensity, anxiety, and disability. According to the MDC, the mean differences of pain intensity for the intervention group was also clinically improved. Meanwhile, the mean differences in pain anxiety between 3 different times in the two groups were not above the MDC (20.14), suggesting that the clinical improvements were not significant. The results were confirmed for all outcome measures; a statistically significant difference was found between the groups in ITT analyses (p<0.001). Conclusions: Physical and psychological pain management education was shown to be effective in decreasing pain intensity, anxiety, and disability. This strategy may be beneficial for such patients. Variables such as smoking behavior, past history of psychological disorders, and previous surgeries should be considered in future studies.
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Purpose: This study aims to investigate the necessity of cement-augmented pedicle screw fixation in single-segment isthmic spondylolisthesis with osteoporosis. Method: Fifty-nine cases were reviewed retrospectively. Thirty-three cases were in the polymethylmethacrylate-augmented pedicle screw (PMMA-PS) group, and the other 26 cases were in the conventional pedicle screw (CPS) group. Evaluation data included operation time, intraoperative blood loss, hospitalization cost, hospitalization days, rates of fusion, screw loosening, bone cement leakage, visual analog scores (VAS), Oswestry disability index (ODI), lumbar lordosis (LL), pelvic tilt (PT) and sacral slope (SS). Results: The operation time and blood loss in the CPS group decreased significantly compared to those in the PMMA-PS group (P < 0.05). The average hospitalization cost of the PMMA group was significantly higher than that of the CPS group (P < 0.05). There was no significant difference in the average hospital stay between the 2 groups (P > 0.05). The initial and last follow-up postoperative VAS and ODI improved significantly in the two groups (P < 0.05). There were no significant differences in VAS and ODI at each time point between the 2 groups (P > 0.05). The last postoperative spine-pelvic parameters were significantly improved compared with those preoperatively (P < 0.05). In the PMMA-PS group, the fusion rate was 100%. The fusion rate was 96.15% in the CPS group. No significant difference was found between the two groups for the fusion rate (P > 0.05). Nine patients in the PMMA-PS group had bone cement leakage (27.27%). There was no screw loosening in the PMMA-PS group. There were 2 cases of screw loosening in the CPS group. There were no significant differences in screw loosening, postoperative adjacent segment fractures, postoperative infection or postoperative revision between the 2 groups (P > 0.05). Conclusions: The use of PMMA-PS on a regular basis is not recommended for posterior lumbar interbody fusion for the treatment of single-segment isthmic spondylolisthesis with osteoporosis.
Article
Background Wound drainage's indwelling duration and general use are the centre of ongoing discussion. The aim of our prospective observational study was to evaluate the total drainage volume postoperatively and its course after lumbar interbody fusion surgeries to define an ideal point in time for drainage removal. Methods We included all patients who underwent monosegmental lumbar interbody fusion via transforaminal or posterior lumbar interbody fusion (TLIF/PLIF). After application of the exclusion criteria, 27 patients were included in our study. Drainage volume was measured three times a day and at the time of drain removal. Results The PLIF group reached higher total drainage volume (337.14 ml) than the TLIF group (215.5 ml) (p = 0.047. Drainage volume's plateau was reached after 33.0 h (±1.8 h) in the TLIF group and 25.3 h (±1.7 h) in the PLIF group following surgery. Conclusions Our study shows, that drainage volume did not increase significantly after the evening of the first postoperative day at latest. This was on average 33.0 h after surgery. Therefore, extraction of the drainage tube hereafter can be assumed to be safe.
Article
Full-text available
The present study examined the necessity of cement-augmented pedicle screw fixation in osteoporotic patients with single-segment isthmic spondylolisthesis.Fifty-nine cases were reviewed retrospectively. Thirty-three cases were in the polymethylmethacrylate-augmented pedicle screw (PMMA-PS) group, and the other 26 cases were in the conventional pedicle screw (CPS) group. Evaluation data included operation time, intraoperative blood loss, hospitalization cost, hospitalization days, rates of fusion, screw loosening, bone cement leakage, visual analogue scale (VAS) scores, Oswestry disability index (ODI), lumbar lordosis (LL), pelvic tilt (PT) and sacral slope (SS).The operation time and blood loss in the CPS group decreased significantly compared to those in the PMMA-PS group. The average hospitalization cost of the PMMA-PS group was significantly higher than that of the CPS group. There was no significant difference in the average hospital stay between the 2 groups. The initial and last follow-up postoperative VAS and ODI scores improved significantly in the two groups. There were no significant differences in VAS and ODI between the 2 groups at each time point. The last postoperative spine-pelvic parameters were significantly improved compared with those preoperatively. In the PMMA-PS group, the fusion rate was 100%. The fusion rate was 96.15% in the CPS group. No significant difference was found between the two groups for the fusion rate. Nine patients in the PMMA-PS group had bone cement leakage. There was no screw loosening in the PMMA-PS group. There were 2 cases of screw loosening in the CPS group. There were no significant differences in screw loosening, postoperative adjacent segment fractures, postoperative infection or postoperative revision between the 2 groups. The use of PMMA-PS on a regular basis is not recommended in posterior lumbar interbody fusion for the treatment of single-segment isthmic spondylolisthesis with osteoporosis.
Article
Spine fusion surgery is one of the most common orthopedic procedures, with over 400,000 performed annually to correct deformities and pain. However, complications occur in approximately one third of cases. While many of these complications may be related to poor bone quality, it is difficult to detect bone abnormalities prior to surgery. Areal BMD (aBMD) assessed by DXA may be artifactually high in patients with spine pathology, leading to missed diagnosis of deficits. In this study, we related preoperative imaging characteristics of both central and peripheral sites to direct measurements of bone quality in vertebral biopsies. We hypothesized that pre-operative imaging outcomes would relate to vertebral bone mineralization and collagen properties. Pre-operative assessments included DXA measurements of aBMD of the spine, hip, and forearm, central quantitative computed tomography (QCT) of volumetric BMD (vBMD) at the lumbar spine, and high resolution peripheral quantitative computed tomography (HRpQCT; Xtreme CT2) measurements of vBMD and microarchitecture at the distal radius and tibia. Bone samples were collected intraoperatively from the lumbar vertebrae and analyzed using Fourier-transform Infrared (FTIR) spectroscopy. Bone samples were obtained from 23 postmenopausal women (mean age 67 ± 7 years, BMI 28 ± 8 kg/m2). We found that patients with more mature bone by FTIR, measured as lower acid phosphate content and carbonate to phosphate ratio, and greater collagen maturity and mineral maturity/crystallinity (MMC), had greater cortical vBMD at the tibia and greater aBMD at the lumbar spine and one-third radius. Our data suggests that bone quality at peripheral sites may predict bone quality at the spine. As bone quality at the spine is challenging to assess prior to surgery, there is a great need for additional screening tools. Pre-operative peripheral bone imaging may provide important insight into vertebral bone quality and may foster identification of patients with bone quality deficits.
Article
Background Perioperative prophylactic antibiotic (PPA) use in spine surgery is known to reduce the rate of surgical site infections. In the past decade, several evidence-based guidelines have been published and surveillance systems to monitor the proper use of antimicrobials had been adapted by many institutes. Objective To report the trends of PPA prescription in lumbar fusion surgeries nationwide in the Republic of Korea. Methods This is a nationwide registry study. Using the population-based data from the Republic of Korea provided by the Korean Health Insurance Review and Assessment Service, data of all lumbar spinal fusion surgeries performed between 2010 and 2018 in adult patients (age ≥19 years) were reviewed. Results The most frequently used antibiotics were first-generation cephalosporins, which accounted for 38.2% of total PPA prescriptions and were prescribed in 58.96% of lumbar fusion surgeries. A gradual increase in prescription trends was observed. The second most frequently used PPAs were second-generation cephalosporins, which showed decrease in use from 2016. The frequency of vancomycin prescriptions gradually increased over the observation period and showed an almost four-fold increase in 2018 compared to 2010. First- and second-generation cephalosporins were prescribed less frequently to patients with renal disease. Conclusion The pattern of PPA use has changed remarkably over the observation period. Furthermore, specific differences in PPA prescriptions were observed among patients with certain co-morbidities.
Article
Background: Recent studies suggest that socioeconomic status (SES) influences outcomes after spinal fusion. The influence of SES on postoperative outcomes is increasingly relevant as rates of lumbar fusion rise. Objective: To determine the influence of SES variables including race, education, net worth, and homeownership on postoperative outcomes. Methods: Optum's deidentified Clinformatics Data Mart Database was used to conduct a retrospective review of SES variables for patients undergoing first-time, inpatient lumbar fusion from 2003 to 2021. Primary outcomes included hospital length of stay (LOS) and 30-day reoperation, readmission, and postoperative complication rates. Secondary outcomes included postoperative emergency room visits, discharge status, and total hospital charges. Results: In total, 217 204 patients were identified. On multivariate analysis, Asian, Black, and Hispanic races were associated with increased LOS (Coeff. [coefficient] 0.92, 95% CI 0.68-1.15; Coeff. 0.61, 95% CI 0.51-0.71; Coeff. 0.43, 95% CI 0.32-0.55). Less than 12th grade education (vs greater than a bachelor's degree) was associated with increased odds of reoperation (OR [odds ratio] 1.88, 95% CI 1.03-3.42). Decreased net worth was associated with increased odds of readmission (OR 1.32, 95% CI 1.25-1.40) and complication (OR 1.14, 95% CI 1.10-1.20). Renting a home (vs homeownership) was associated with increased LOS, readmissions, and total charges (Coeff. 0.30, 95% CI 0.17-0.43; OR 1.19, 95% CI 1.11-1.30; Coeff. 13 200, 95% CI 9000-17 000). Conclusion: Black race, less than 12th grade education, <$25K net worth, and lack of homeownership were associated with poorer postoperative outcomes and increased costs. Increasing perioperative support for patients with these sociodemographic risk factors may improve postoperative outcomes.
Chapter
Spinal surgical procedures such as fusion are common in the elderly population and may be associated with high rate of complications. A successful surgery can be life-changing by correcting debilitating deformities. In elderly patients, however, it can become particularly challenging given underlying impaired bone strength due to age- and menopause-related loss of bone mass and deterioration of bone microstructure. Poor bone quality is a risk factor for postoperative complications such as delayed healing, hardware loosening/failure, and adjacent compression deformities. Assessment of bone strength by standard of care techniques may also be affected by the spine disease itself. Bone density measurement of the spine by dual-energy X-ray absorptiometry (DXA) is often falsely elevated and therefore can be misleading due to underlying artifact by degenerative spine disease, osteophytes, and scoliosis. Newer methods of assessing bone quality preoperatively have been promising. Efforts to improve bone quality within a reasonable time frame and reduce risk of complications include perioperative use of antiresorptive or anabolic agents.
Chapter
Enhanced Recovery After Surgery (ERAS) protocols are multidisciplinary approaches to perioperative care, which aim to optimize surgical recovery by incorporating evidence-based approaches in the preoperative, intraoperative, and postoperative periods. As such, the goal of these strategies is to minimize stressors from various physiological and psychological sources. There is a compelling case for the implementation of ERAS into the routine management of spinal surgery, as many of these procedures are associated with long operative durations, considerable homeostatic stress, and significant postoperative pain which can lead to prolonged recovery, delayed mobilization, and increased opioid use. Elderly patients are a particularly vulnerable patient population in elective spinal surgery, as they tend to have more medical comorbidities and are also more sensitive to opioids. The purpose of this chapter is to summarize the components of ERAS protocols as they relate to spine surgery, and highlight advances in perioperative management such as the role of multimodal analgesia and minimally invasive techniques. A comprehensive literature review of published ERAS protocols and outcomes is provided.
Article
OBJECTIVE Spinal deformity surgery is associated with significant blood loss, often requiring the transfusion of blood and/or blood products. For patients declining blood or blood products, even in the face of life-threatening blood loss, spinal deformity surgery has been associated with high rates of morbidity and mortality. For these reasons, patients for whom blood transfusion is not an option have historically been denied spinal deformity surgery. METHODS The authors retrospectively reviewed a prospectively collected data set. All patients declining blood transfusion who underwent spinal deformity surgery at a single institution between January 2002 and September 2021 were identified. Demographics collected included age, sex, diagnosis, details of any prior surgery, and medical comorbidities. Perioperative variables included levels decompressed and instrumented, estimated blood loss, blood conservation techniques used, length of surgery, length of hospital stay, and complications from surgery. Radiographic measurements included, where appropriate, sagittal vertical axis correction, Cobb angle correction, and regional angular correction. RESULTS Spinal deformity surgery was performed in 31 patients (18 male, 13 female) over 37 admissions. The median age at surgery was 41.2 years (range 10.9–70.1 years), and 64.5% had significant medical comorbidities. A median of 9 levels (range 5–16 levels) were instrumented per surgery, and the median estimated blood loss was 800 mL (range 200–3000 mL). Posterior column osteotomies were performed in all surgeries, and pedicle subtraction osteotomies in 6 cases. Multiple blood conservation techniques were used in all patients. Preoperative erythropoietin was administered prior to 23 surgeries, intraoperative cell salvage was used in all, acute normovolemic hemodilution was performed in 20, and perioperative administration of antifibrinolytic agents was performed in 28 surgeries. No allogenic blood transfusions were administered. Surgery was staged intentionally in 5 cases, and there was 1 unintended staging due to intraoperative blood loss from a vascular injury. There was 1 readmission for a pulmonary embolus. There were 2 minor postoperative complications. The median length of stay was 6 days (range 3–28 days). Deformity correction and the goals of surgery were achieved in all patients. Two patients underwent revision surgery during the follow-up period: one for pseudarthrosis and the other for proximal junctional kyphosis. CONCLUSIONS With proper preoperative planning and judicious use of blood conservation techniques, spinal deformity surgery may be performed safely in patients for whom blood transfusion is not an option. The same techniques can be applied widely to the general population in order to minimize blood loss and the need for allogeneic blood transfusion.
Article
Background: Two common approaches for open, one-level, posterior lumbar fusions include transforaminal lumbar interbody fusion (TLIF) and posterolateral fusion (PLF) alone without an interbody. Objective: To compare TLIF vs PLF alone in (1) discharge disposition, (2) return to work (RTW), and (3) patient-reported outcomes (PROs). Methods: A single-center, retrospective cohort study was undertaken between October 2010 and May 2021, all with a 1-year follow-up and excluding patients with isthmic spondylolisthesis. Minimum clinically important difference for each PRO was used, which included Numeric Rating Scale (NRS) and Oswestry Disability Index (ODI). Logistic/linear regression controlled for age, body mass index, disc height, flexion-extension movement, amount of movement on flexion-extension, and spondylolisthesis grade. Results: Of 850 patients undergoing open, 1-level, posterior lumbar fusion, 591 (69.5%) underwent a TLIF and 259 (30.5%) underwent a PLF alone. Patients undergoing TLIF were younger (59.0 ± 11.3 vs 63.3 ± 12.6, P < .001), had higher body mass index (31.3 ± 6.6 vs 30.2 ± 12.6, P = .019), and more often had private insurance (50.3% vs 39.0%, P < .001). Regarding discharge disposition, no significance was found in multivariate regression (odds ratio = 2.07, 95% CI = 0.39-10.82, P = .385) with similar RTW between TLIF and PLF alone (80.8% vs 80.4%, P = .645) (odds ratio = 1.15, 95% CI = 0.19-6.81, P = .873). Regarding PROs, patients undergoing a TLIF had higher preoperative (6.7 ± 2.3 vs 6.4 ± 2.5, P = .046) and 3-month NRS-back pain (3.4 ± 2.6 vs 2.9 ± 2.5, P = .036), with similar 12-month NRS-back pain. Regarding NRS-leg pain, no differences were observed preoperatively (P = .532) and at 3 months (P = .808). No other significant differences were observed in ODI. Conclusion: TLIF patients had slightly higher NRS-back pain at baseline and 3 months, but similar NRS-leg pain, despite the added risk of placing an interbody. No differences were seen in discharge disposition, RTW, and 12-month pain scores and ODI.
Article
Background: General anesthesia (GA) and spinal anesthesia (SA) have been adopted for lumbar spine surgery (LSS), but GA is used far more widely. We conducted a survey of spine surgeons to explore their attitudes and preferences regarding awake spine surgery under SA. Methods: A survey was emailed to 150 spine surgeons. Exposure and attitudes towards spine surgery under SA were elicited. A five-point Likert scale of agreement examined perceptions of SA, while attitudes towards SA were recorded by categorizing free text into themes. Results: Seventy-five surgeons completed the survey, 50 % response rate. Only 27 % said they perform LSS under SA. Most surgeons, 83 %, would recommend GA to a healthy patient undergoing lumbar laminectomy. Only 41 % believes SA to be as safe as GA, and only 30 % believes SA is associated with better postoperative pain control. The most common reasons why SA is not favored was lack of proven benefits over GA (65 %). When asked if a randomized trial finds SA to lead to less postoperative fatigue, 50 % said they would be more likely to offer SA, a significant increase from the baseline response of 27 % (p = 0.002). Conclusions: Our survey indicates that the low adoption of SA for LSS is due to lack of surgeons' belief in the benefits of SA over GA, and that a randomized patient-centered trial has the potential of changing surgeons' perspective and increasing adoption of SA for LSS.
Article
The objective of this study was to characterize recent trends in orthopedic device development across different subspecialty areas. Orthopedic 510(k) clearances, premarket approvals (PMAs; together, "authorizations"), and new market entrants from 2000 to 2019 were analyzed as markers of research and development activity. Data were extracted from the US Food and Drug Administration website and stratified into one of 9 "subspecialty" groups: spine, trauma, hip arthroplasty, knee arthroplasty, shoulder, hand/elbow, foot/ankle, cement/filler/graft, and other. Descriptive statistics were used to analyze the data. Growth rates were calculated from trailing 3-year averages. During the study period, there were 9906 orthopedic 510(k) clearances and 1409 PMAs, of which 61 were for original PMA submissions. The preponderance of 510(k) clearances were for devices used in spine (36%) and trauma (30%) surgery, followed by hip (11%) and knee (8%) arthroplasty. Annual 510(k) clearances for spine and trauma devices grew by 232% and 44%, respectively, whereas annual hip and knee arthroplasty clearances declined. Paralleling these findings, the influx of new manufacturers of orthopedic devices was greatest for the trauma surgery (438), spine surgery (383), and cement/filler/graft (181) markets. Spinal surgery and orthopedic trauma have become leading priorities in orthopedic product development during the past two decades. Meanwhile, hip and knee arthroplasty products have proportionally become a smaller category of new devices over time. These findings demonstrate changing priorities within orthopedic innovation. [Orthopedics. 20XX;XX(X):xx-xx.].
Chapter
Awake neurosurgery refers to neurosurgical procedures during which the patient is conscious during some time or the entire surgery. This chapter summarizes cumulative clinical experience and reviews available information on anesthesia techniques for awake neurosurgical procedures. We identified 118 publications that we consider valuable to orient the practitioner who wants to expand their knowledge of this subject. We describe the role and responsibility of the anesthesiologist in five types of awake procedures: craniotomy, depth electrode implant, carotid endarterectomy, laser ablation, and spine surgery. We catalog key aspects of the procedure work flow, selection of anesthetic agents particular to the procedure and monitoring modalities, and potential event management in each section. When appropriate, we review the anatomical and pathophysiological considerations relevant to an anesthesiologist involved in awake neurosurgical procedures. We describe the practice for patient preparation and review patients’ experiences of procedures.KeywordsAnesthesiaMonitoringAwake neurosurgeryAwake craniotomyCraniotomyIndicationsAnesthesia considerationsPatient selectionSedationAnalgesiaFunctional mappingDeep brain stimulationSpinal surgeryLaser interstitial thermal therapy
Article
Introduction: Morbidly obese patients are at increased risk for intraoperative and postoperative complications following spinal fusion. Preoperative weight loss can improve clinical outcomes. The present systematic literature review is aimed to evaluate the hypothesis that bariatric surgery before spinal fusion surgery is associated with higher rates of complications and revisions. Methods: Three databases were queried for literature pertaining to bariatric surgery prior to spinal fusion. A 2-author screening process was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Methodologic index for non-randomized studies criteria was used to objectively assess the methodologic quality of the studies reviewed. Retrospective cohort studies in which the patients underwent bariatric surgery were included. Results: Four retrospective cohort studies consisting of a total of 180,090 patients were included. Length of stay was significantly shorter for the bariatric surgery (BS) group patients than the control (C) groups patients (P = 0.009). There were no significant differences in 1-year mortality rate (P = 1.0), readmission rate (P = 0.86), overall postoperative complications (P = 0.83), and postoperative infections (P = 0.97) between the BS and C groups. Conclusions: There were no consistent differences in rates of postoperative complications, infections, hospital readmission, and mortality between obese patients with bariatric surgery prior to spinal fusion and control group patients. The present study does not support the hypothesis that bariatric surgery before spinal fusion contributes to a higher rate of postoperative complications in patients undergoing spinal fusion.
Article
Objective To determine the predictive value of modified frailty index (mFI) in evaluating sarcopenia and clinical outcomes in patients undergoing 1- or 2-level transforaminal lumbar interbody fusion (TLIF) Methods Patients who underwent a one- or two-level TLIF between 2012 and 2020 were retrospectively identified. Frailty was compared among groups using mFI, while sarcopenia was classified by psoas muscle cross-sectional area. Bivariate statistics compared demographics, comorbidities, and clinical outcomes. A linear regression model was developed using Charlson Comorbidity Index (CCI) or mFI scores as independent variables to determine potential predictors for improvement in one-year patient reported outcomes. Results Of 488 included patients, 60 were severely frail and 60 patients had sarcopenia, but sarcopenia was not associated with patient frailty (p=0.469). Severely frail patients had worse baseline ODI (p<0.001), MCS-12 (p=0.001), and PCS-12 (p<0.001), and worse improvement in ODI (p=0.037), PCS-12 (p<0.001), and VAS Back (p=0.007). mFI was an independent predictor of poorer improvement in VAS Back and ODI, while age + CCI additionally predicted poorer improvement in VAS Leg. Patients with higher mFI scores experienced longer length of stay, less frequent home discharge, and higher rates of complications, but similar readmission and reoperation rates. Conclusions Frailer patients experience poorer improvement in back pain, physical functioning, and disability after TLIF. mFI and the combination of age and CCI comparably predict patient reported outcomes but do not correlate to baseline sarcopenia. Frailty increased the risk of complications, length of hospital stay, and risk of non-home discharge.
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Background The removal of spinal implants was needed in revision surgery or in some cases whose fracture had healed or fusion had occured. The slip of polyaxial screw or mismatch of instruments would make this simple procedure intractable. Here we introduced a simple and practical method to address this clinical dilemma. Methods This is a retrospective study. The patients underwent new technique for retrieving the implants from July 2019 to July 2022 were labeled as group A, while the patients January 2017 to January 2020 were labeled as group B. Patients in each group were subdivided into revision surgery group and simple implants removal group according to the surgery fashion. In the new technique, the retrieved rod was cut off to a proper length which was matched with the size of tulip head, and was replaced into the tulip head. After tightened with nut, a monoaxial screw-rod “construct” was formed. Finally, a counter torque was applied to remove the “construct”. The operation duration, intraoperative blood loss, post-operative bacteria culture, hospital stay and costs were documented and analyzed. Results A total of 116 polyaxial screws with difficult removal of 78 patients (43 screws in group A, 73 screws in group B) were successfully retrieved by using this method. Significant differences were found in the mean operation duration, intraoperative blood loss when comparing the r group in group A and B, as well as the s group in group A and B (P < 0.05). There were no significant differences in hospital stay and costs between group A and B. Three patients were found positive bacteria culture of drainage tube/tape in group A (3/30), while 7 patients in group B (7/48). The most prevalent bacteria was Propionibacterium acnes. Conclusion This technique is practical and safe in for the poly-axial screw with difficult retrieval. Reduced operation duration and intraoperative bloods loss may potentially alleviate the hospitalization burden of patients. Positive cultivation results are common after implants removal surgery, but they rarely represent an organized infection. A positive culture with P. acnes or S. epidermidis should be interpreted with caution.
Article
Non-clinical mechanical performance testing is a critical aspect of intervertebral body fusion device (IBFD) development and regulatory evaluation. Recently, stakeholders have begun leveraging computational modeling and simulations such as finite element analysis (FEA) in addition to traditional bench testing. FEA offers advantages such as reduced experiment time, lower costs associated with elimination of bench testing (e.g. specimen manufacture and test execution), and elucidating quantities of interest that traditional testing cannot provide (e.g. stress and strain distributions). However, best practices for FEA of IBFDs are not well defined, and modeler decision making can significantly influence simulation setup and results. Therefore, the goal of this study was to determine the relative influence of modeling parameters when using FEA to assess non-clinical mechanical performance of IBFDs. FEA was used to conduct a series of IBFD static uniaxial compression simulations. Several parameters relating to implant geometry, loading/boundary conditions, and material properties were carefully controlled to assess their relative influence on two output variables (IBFD stiffness and yield load). Results were most influenced by device geometry, while the effects of boundary conditions and material properties were more significant within IBFDs of identical or similar geometries. These results will aid stakeholders in the development of standardized best practices for using FEA to assess non-clinical mechanical performance of IBFDs.
Article
Introduction A cascade of degenerative spine changes affects the structures including vertebral endplates and bodies of adjacent vertebrae that can be visualized on MRI imaging as Modic changes. The aim of the study was to assess the role of changes in the endplates and adjacent vertebral bodies in radiological results of monosegmental posterior lumbar interbody fusion (PLIF) in patients with degenerative lesions of the spine. Material and methods The design of the study was a monocenter retrospective comparative cohort study. The radiological results of PLIF performed in combination with transpedicular screw fixation for 122 patients with Modic changes in adjacent endplates and adjacent vertebral bodies were evaluated for interbody fusion, subsidence of interbody implants, segmental angle, interbody space height. The followup period was 1-2 years. Results Complete interbody fusion was seen in 94.4 % of Modic type 0 and in 77.3 % of Modic type II changes. Interbody cage subsidence occurred in 38.9 % Modic type I, 22.7 % in Modic type II, 9.1 % in Modic type III and in 11.3 % Modic type 0 changes. A significant decrease in the segmental angle was found in all types of Modic changes (p < 0.05) at 1-2 years with the greatest decrease noted in Modic type I (p = 0.000438). A significant decrease in the interbody space height was noted in all groups (p < 0.05) with the greatest decrease seen in Modic type I changes (p = 0.000438) and the minimum decrease noted in Modic type III changes (p = 0.000438). Discussion The role of the endplates and adjacent vertebral bodies in the results of surgical treatment was evident, and more research is needed to explore the sort of this relationship. Conclusions Modic changes in the endplates and adjacent red bone marrow showed a significant relationship with the radiological outcomes of monosegmental PLIF. The interbody fusion Tan grade I and Tan grade II was more common for Modic type 0 and less common for Modic type II changes. Subsidence of interbody implants was more common for Modic type I and less common for Modic type III changes (9.1%). Postoperative loss of interbody space height and segmental correction was common for Modic type I.
Article
Study design: Retrospective comparative cohort study using the National Surgical Quality Improvement Program. Objective: The aim of this study was to evaluate trends in the annual number of PSOs performed, describe the patient populations associated with each cohort, and compare outcomes between specialties.Summary of Background Data:Pedicle subtraction osteotomies (PSO) are complex and advanced spine deformity surgical procedures performed by neurosurgeons and orthopedic surgeons. Though both sets of surgeons can be equally qualified and credentialed to perform a PSO, it is possible that differences in training and exposure could translate into differences in patient management and outcomes. Methods: Patients that underwent lumbar PSO from 2005 to 2014 in the American College of Surgeons-National Surgical Quality Improvement Program registry were identified. Relevant demographic, preoperative comorbidity, and postoperative 30-day complications were queried and analyzed. The data was divided into 2 cohorts consisting of those patients who were treated by neurosurgeons versus orthopedic surgeons. Additional data from the Scoliosis Research Society Morbidity and Mortality database was queried and analyzed for comparison. Results: Demographic and comorbidity factors were similar between the neurosurgery and orthopedic surgery cohorts, except there were higher rates of hypertension among orthopedic surgeon-performed PSOs (65.66% vs. 48.67%, P=0.004). Except for 2012, in every year queried, orthopedic surgeons reported more PSOs than neurosurgeons. In patients who underwent lumbar fusion surgery, there was a higher rate of PSOs if the surgery was performed by an orthopedic surgeon (OR 1.7824, 95% CI: 1.4017-2.2665). The incidence of deep vein thrombosis after PSOs was higher for neurosurgery compared with orthopedic surgery (8.85% vs. 1.20%, P=0.004). However, besides deep vein thrombosis, there were no salient differences in surgical complication rates between neurosurgeon-performed PSOs and orthopedic surgeon-performed PSOs. Conclusions: The number of PSO procedures performed by neurosurgeons and orthopedic surgeons has increased annually. Differences in outcomes between neurosurgeons and orthopedic surgeons suggest an opportunity for wider assessment and alignment of adult spinal deformity surgery exposure and training across specialties.
Article
PurposeThe objective is to analyse peri-operative blood loss (BL) and hidden blood loss (HBL) rates in spinal deformity complex cases surgery, with a focus on the strategies to prevent major bleeding.Methods We retrospectively analysed surgical and anaesthesiologic data of patients who had been operated for adolescent idiopathic scoliosis (AIS) or adult spinal deformities (ASD) with a minimum of five levels fused. A statistical comparison among AIS, ASD without a pedicle subtraction osteotomy (PSO) (ASD-PSO( −)) and ASD with PSO (ASD-PSO( +)) procedures was performed with a view to identifying patient- and/or surgical-related factors affecting peri-operative BL and HBL.ResultsOne-hundred patients were included with a mean 9.9 ± 2.8 fused vertebrae and a mean 264.2 ± 68.3 minutes operative time (OT) (28.3 ± 9 min per level). The mean perioperative BL was 641.2 ± 313.8 ml (68.9 ± 39.5 ml per level) and the mean HBL was 556.6 ± 381.8 ml (60.6 ± 42.8 ml per level), with the latter accounting for 51.5% of the estimated blood loss (EBL). On multivariate regression analysis, a longer OT (p < 0.05; OR 3.38) and performing a PSO (p < 0.05; OR 3.37) were related to higher peri-operative BL, while older age (p < 0.05; OR 2.48) and higher BMI (p < 0.05; OR 2.15) were associated to a more significant post-operative HBL.Conclusion With the correct use of modern technologies and patient management, BL in major spinal deformity surgery can be dramatically reduced. Nevertheless, it should be kept in mind that 50% of patients estimated losses are hidden and not directly controllable. Knowing the per-level BL allows anticipating global losses and, possibly, the need of allogenic transfusions.
Article
OBJECTIVE Intervertebral devices are increasingly utilized for fusion in the lumbar spine, along with a variety of bone graft materials. These various grafting materials often have substantial cost burdens for the surgical procedure, although they are necessary to overcome the limitations in healing capacity for many traditional interbody devices. The use of bioactive interbody fusion devices, which have demonstrable stimulatory capacity for the surrounding osteoblasts and osteoprogenitor cells and allow for osseointegration, may reduce this heavy reliance on osteobiologics for achieving interbody fusion. The objective of this study was to evaluate the rate of successful interbody fusion with a bioactive lateral lumbar interbody titanium implant with limited volume and low-cost graft material. METHODS The authors conducted a retrospective study (May 2017 to October 2018) of consecutively performed lateral lumbar interbody fusions with a bioactive 3D-printed porous titanium interbody device. Each interbody device was filled with 2–3 cm ³ /cage of a commercially available ceramic bone extender (β-tricalcium phosphate-hydroxyapatite) and combined with posterior pedicle screw fixation. No other biological agents or grafts were utilized. Demographic, clinical, and radiographic variables were captured. Fusion success was the primary endpoint of the study, with graft subsidence, fixation failure, and patient-reported outcomes (Oswestry Disability Index [ODI] and visual analog scale [VAS]–back and –leg pain scores) collected as secondary endpoints. The authors utilized a CT-based fusion classification system that accounted for both intervertebral through-growth (bone bridging) and ingrowth (integration of bone at the endplate-implant interface). RESULTS In total, 136 lumbar levels were treated in 90 patients. The mean age was 69 years, and 63% of the included patients were female. Half (50.0%) had undergone previous spinal surgery, and a third (33.7%) had undergone prior lumbar fusion. A third (33.7%) were treated at multiple levels (mean levels per patient 1.51). One year after surgery, the mean improvements in patient-reported outcomes (vs preoperative scores) were −17.8 for ODI (p < 0.0001), −3.1 for VAS–back pain (p < 0.0001), and −2.9 for VAS–leg pain (p < 0.0001). Bone bridging and/or appositional integrity was achieved in 99.3% of patients, including 97.8% who had complete bone bridging. No fixation loosening or implant failure was observed at any segment. Low-grade graft subsidence (Marchi grade ≤ I) occurred in 3 levels (2.2%), and intraoperative endplate violation occurred twice (1.5%). High-grade subsidence was not found. No implant failure or revision surgery for pseudarthrosis/subsidence was necessary. CONCLUSIONS The use of bioactive titanium interbody devices with a large surface footprint appears to result in a very high rate of effective fusion, despite the use of a small volume of low-cost biological material. This potential change in the osteobiologics required to achieve high fusion rates may have a substantially beneficial impact on the economic burden inherent to spinal fusion.
Article
Study design: The present study design was that of a single center, retrospective cohort study to evaluate the influence of surgeon-specific factors on patient functional outcomes at 6 months following lumbar fusion. Retrospective review of a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis identified the present study population. Objective: This study seeks to evaluate surgeon-specific variable effects on patient-reported outcomes such as Oswestry Disability Index (ODI) and the effect of North American Spine Society (NASS) concordance on outcomes in the setting of variable surgeon characteristics. Summary of background data: Lumbar fusion is one of the fastest growing procedures performed in the United States. Although the impact of surgeon-specific factors on patient-reported outcomes has been contested, studies examining these effects are limited. Methods: This is a single center, retrospective cohort study analyzing a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis by 1 of 5 neurosurgery fellowship trained spine surgeons. The primary outcome was improvement of ODI at 6 months postoperative follow-up compared with preoperative ODI. Results: A total of 307 patients were identified for analysis. Overall, 62% of the study population achieved minimum clinically important difference (MCID) in ODI score at 6 months. Years in practice and volume of lumbar fusions were statistically significant independent predictors of MCID ODI on multivariable logistic regression (P=0.0340 and P=0.0343, respectively). Concordance with evidence-based criteria conferred a 3.16 (95% CI: 1.03, 9.65) times greater odds of achieving MCID. Conclusion: This study demonstrates that traditional surgeon-specific variables predicting surgical morbidity such as experience and procedural volume are also predictors of achieving MCID 6 months postoperatively from lumbar fusion. Independent of surgeon factors, however, adhering to evidence-based guidelines can lead to improved outcomes.
Article
Study design: Systematic Review. Objectives: To synthesize previous studies evaluating racial disparities in spine surgery. Methods: We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on racial disparities in spine surgery. Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses guidelines and protocol. The main outcome measures were the occurrence of racial disparities in postoperative outcomes, mortality, surgical management, readmissions, and length of stay. Results: A total of 1753 publications were assessed. Twenty-two articles met inclusion criteria. Seventeen studies compared Whites (Ws) and African Americans (AAs) groups; 14 studies reported adverse outcomes for AAs. When compared with Ws, AA patients had higher odds of postoperative complications including mortality, cerebrospinal fluid leak, nervous system complications, bleeding, infection, in-hospital complications, adverse discharge disposition, and delay in diagnosis. Further, AAs were found to have increased odds of readmission and longer length of stay. Finally, AAs were found to have higher odds of nonoperative treatment for spinal cord injury, were more likely to undergo posterior approach in the treatment of cervical spondylotic myelopathy, and were less likely to receive cervical disk arthroplasty compared with Ws for similar indications. Conclusions: This systematic review of spine literature found that when compared with W patients, AA patients had worse health outcomes. Further investigation of root causes of these racial disparities in spine surgery is warranted.
Article
Study design: Retrospective Comparative Study. Objective: The purpose of this study was to characterize trends in surgical approach for single-level lumbar fusion over the past decade. Summary of background data: The number of elective lumbar fusion cases performed is increasing annually. Several different surgical approaches exist for lumbar spinal fusion including novel anterior approaches developed in recent years. With ongoing innovation, trends in the utilization of common surgical approaches in recent years are unclear. Materials and methods: A retrospective cohort study was conducted using the PearlDiver database (Fort Wayne, IN). Patients undergoing single-level lumbar fusion between 2010 and 2019 were identified using Current Procedural Technology codes and divided into 4 mutually exclusive cohorts based on surgical approach: (1) anterior-only, (2) anterior approach with posterior instrumentation, (3) posterolateral, and (4) posterior-only interbody. Trend analyses of surgical approach utilization over the last decade were performed with the Cochran-Armitage test to evaluate the 2-tailed null hypothesis that utilization of each surgical approach for single-level lumbar fusion remained constant. Results: A total of 53,234 patients met inclusion criteria and were stratified into 4 cohorts: anterior-only (n=5104), anterior with posterior instrumentation (n=23,515), posterolateral (n=5525), and posterior-only interbody (n=19,090). Trend analysis revealed the utilization of a posterior-only interbody approach significantly decreased from 36.7% to 29.2% (P<0.001), whereas the utilization of a combined anterior and posterior approach significantly increased from 45.8% to 50.4% (P<0.001). The utilization of an anterior-only approach also significantly increased from 7.9% to 10.5% (P<0.001). Conclusions: Utilization of anterior-only and anterior with posterior instrumentation approaches for single-level lumbar fusion have been significantly increasing over the past decade while use of posterior-only interbody approach trended significantly downward. These data may be particularly useful for trainees and spine surgeons as new techniques and technology become available. Level of evidence: Level III-retrospective cohort study.
Article
Study design: Pre-Clinical. Objective: Evaluate sex-dependent differences in the bone healing response to rhBMP-2 in a rat posterolateral spinal fusion model. Summary of background data: Minimal and conflicting data exist concerning potential sex-dependent differences in recombinant human bone morphogenetic protein-2 (rhBMP-2)-mediated bone regeneration in the context of spinal fusion. Methods: Forty-eight female and male Sprague-Dawley rats (N=24/group), underwent L4-L5 posterolateral fusion with bilateral placement of an absorbable collagen sponge, each loaded with 5 µg of BMP-2 (10 µg/animal). At 8 weeks post-operative, 10 specimens of each sex were tested in flexion-extension with quantification of range of motion (ROM) and stiffness. The remaining specimens were evaluated for new bone growth and successful fusion via radiography, blinded manual palpation and microcomputed tomography (microCT). Laboratory microCT quantified bone microarchitecture, and synchrotron microCT examined bone microstructure at the one micrometer level. Results: Manual palpation scores differed significantly between sexes, with mean fusion scores of 2.4±0.4 in females versus 3.1±0.6 in males, P<0.001. Biomechanical stiffness did not differ between sexes, but ROM was significantly greater and more variable for females versus males (3.7°±5.6° vs. 0.27°±0.15°, P<0.005, respectively). Laboratory microCT showed significantly smaller volumes of fusion masses in females versus males (262±87 mm3 vs. 732±238 mm3, respectively, P<0.001) but significantly higher bone volume fraction (0.27±0.08 vs. 0.12±0.05, respectively, P<0.001). Mean trabecular thickness was not different, but trabecular number was significantly greater in females (3.1±0.5 mm-1 vs. 1.5±0.4 mm-1, respectively, P<0.001). Synchrotron microCT showed fine bone structures developing in both sexes at the eight-week time point. Conclusions: This study demonstrates sex-dependent differences in bone regeneration induced by rhBMP-2. Further investigation is needed to uncover the extent of and mechanisms underlying these sex differences, particularly at different doses of rhBMP-2.
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Study design: Prospective Randomized Placebo Controlled Animal Trial. Objective: Determine the effect of daily subcutaneous abaloparatide injection on the intervertebral fusion rate in rabbits undergoing posterolateral fusion. Study of background data: Despite the wide utilization of spine fusion, pseudarthrosis remains prevalent and results in increased morbidity. Abaloparatide is a novel analog of parathyroid hormone-related peptide (1-34) and has shown efficacy in a rat posterolateral spine fusion model to increase fusion rates. The effect of abaloparatide on the fusion rate in a larger animal model remains unknown. Methods: 24 skeletally mature New Zealand White male rabbits underwent bilateral posterolateral spine fusion. Following surgery, the rabbits were randomized to receive either saline as control or abaloparatide subcutaneous injection daily. Specimens underwent manual assessment of fusion, radiographic analysis with both x-ray and high-resolution peripheral quantitative computed tomography, and biomechanical assessment. Results: Rabbits that received abaloparatide had a 100% (10/10) fusion rate compared to 45% (5/11) for controls (P<0.02) as assessed by manual palpation. Radiographic analysis determined an overall mean fusion score of 4.17±1.03 in the abaloparatide group versus 3.39±1.21 for controls (P<0.001). The abaloparatide group also had a greater volume of bone formed with a BV of 1209±543 mm3 compared to 551±152 mm3 (P<0.001) for controls. The abaloparatide group had significantly greater trabecular bone volume fraction and trabecular thickness and lower specific bone surface and connectivity density in the adjacent levels when compared to controls. Abaloparatide treatment did not impact trabecular number or separation. There were no differences in biomechanical testing in flexion, extension, or lateral bending (P>0.05) between groups. Conclusion: Abaloparatide significantly increased the fusion rate in a rabbit posterolateral fusion model as assessed by manual palpation. Additionally, there were marked increases in the radiographic evaluation of fusion.
Article
Lumbar fusion often remains the last treatment option for various acute and chronic spinal conditions, including infectious and degenerative diseases. Placement of a cage in the intervertebral space has become a routine clinical treatment for spinal fusion surgery to provide sufficient biomechanical stability, which is required to achieve bony ingrowth of the implant. Routinely used cages for clinical application are made of titanium (Ti) or polyetheretherketone (PEEK). Ti has been used since the 1980s; however, its shortcomings, such as impaired radiographical opacity and higher elastic modulus compared to bone, have led to the development of PEEK cages, which are associated with reduced stress shielding as well as no radiographical artefacts. Since PEEK is bioinert, its osteointegration capacity is limited, which in turn enhances fibrotic tissue formation and peri-implant infections. To address shortcomings of both of these biomaterials, interdisciplinary teams have developed biodegradable cages. Rooted in promising preclinical large animal studies, a hollow cylindrical cage (Hydrosorb™) made of 70:30 poly-l-lactide-co-d, l-lactide acid (PLDLLA) was clinically studied. However, reduced bony integration and unfavourable long-term clinical outcomes prohibited its routine clinical application. More recently, scaffold-guided bone regeneration (SGBR) with application of highly porous biodegradable constructs is emerging. Advancements in additive manufacturing technology now allow the cage designs that match requirements, such as stiffness of surrounding tissues, while providing long-term biomechanical stability. A favourable clinical outcome has been observed in the treatment of various bone defects, particularly for 3D-printed composite scaffolds made of medical-grade polycaprolactone (mPCL) in combination with a ceramic filler material. Therefore, advanced cage design made of mPCL and ceramic may also carry initial high spinal forces up to the time of bony fusion and subsequently resorb without clinical side effects. Furthermore, surface modification of implants is an effective approach to simultaneously reduce microbial infection and improve tissue integration. We present a design concept for a scaffold surface which result in osteoconductive and antimicrobial properties that have the potential to achieve higher rates of fusion and less clinical complications. In this review, we explore the preclinical and clinical studies which used bioresorbable cages. Furthermore, we critically discuss the need for a cutting-edge research program that includes comprehensive preclinical in vitro and in vivo studies to enable successful translation from bench to bedside. We develop such a conceptual framework by examining the state-of-the-art literature and posing the questions that will guide this field in the coming years.
Thesis
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THE OPTIMAL PATHWAY TO LUMBAR SPINAL FUSION Improving perioperative health and care with patients opting for lumbar spinal fusion surgery
Article
Study Design. This study describes recent United States trends and regional variations in the management of low back pain. Objectives. The authors investigated recent temporal trends and compared practices in different geographic regions. Summary of Background Data. Controversy exists concerning the appropriate medical and surgical management of patients with low back pain. Methods. National Hospital Discharge Survey data from 1979 through 1990 were analyzed. Case selection was based on previously developed algorithms intended to exclude nonmechanical causes of back pain. Results. Over the period of study, nonsurgical hospitalizations for low back pain decreased dramatically. In contrast, low back operation rates, particularly for fusion surgery, increased substantially. In recent years, surgery and hospitalization rates were highest in the South and lowest in the West. Conclusions. Rapidly increasing surgical rates and wide geographic variations suggest the need for a more consistent approach to back problems. [Key words: low back pain management, trends, regional variations, practice patterns] Spine 1994;19:1207-1213
Article
For several years, interest in clinical practice patterns has increased due to concerns about the costs and quality of health care. Our objectives were to examine recent trends and geographic variations in low back pain hospitalization. We analyzed data from a Washington State automated database for 1987-1992. Low back surgery rates in Washington changed little during the study years. In contrast, nonsurgical hospitalization rates fell from 15.5 to 5.1 per 10,000. The proportion of operations involving fusion decreased from 15.8% in 1987 to 11.7% in 1990, and then remained stable. During 1990, important county-to-county variations were observed in surgery rates, nonsurgical hospitalization rates, the proportion of operations involving fusion, and the percentage of surgical patients undergoing reoperation within 3 years. Wide county variations suggest that there may be overutilization or underutilization of low back pain treatments in some geographic areas. A more consistent approach to the management of back problems may benefit patients. (C) Lippincott-Raven Publishers.
Article
Despite increasing utilization of surgical spine fusions, a paucity of literature addressing perioperative complications after revision posterior spinal fusion (RPSF) versus primary posterior spine fusion (PPSF) of the thoracic and lumbar spine exists. To examine demographics of patients undergoing PPSF and RPSF of the thoracic and lumbar spine, assess the incidence of perioperative morbidity and mortality, and determine independent risk factors for in-hospital death. Analysis of nationally representative data collected for the National Inpatient Sample (NIS). All discharges included in the NIS with a procedure code for posterior thoracic and lumbar spine fusion from 1998 to 2006. In-hospital mortality and morbidity. Data collected for each year between 1998 and 2006 for the NIS were analyzed. Discharges with a procedure code for thoracic and lumbar spine fusion were included in the sample. The prevalence of patient- as well as health care-related demographics was evaluated by procedure type (primary vs. revision). Frequencies of procedure-related complications and in-hospital mortality were analyzed. Independent predictors for in-hospital mortality were determined. We identified 222,549 PPSF and 12,474 RPSF discharges between 1998 and 2006. Patients undergoing PPSF were significantly younger (51.23 years; confidence interval [CI]=51.16, 51.31) and had lower average comorbidity indices (0.40; CI=0.39, 0.41) than those undergoing RPSF (52.69 years; CI=52.43, 52.97) and (0.44; CI=0.43, 0.45), p<.0001. The incidence of procedure-related complications was 16.02% among RPSF compared with 13.44% in PPSF patients (p<.0001). In-hospital mortality rates after PPSF were approximately twice those of RPSF (0.28% vs. 0.15%, p=.006). Adjusted risk factors for increased in-hospital mortality included PPSF compared with RPSF, male gender, and increasing age. A number of comorbidities, complications, and specific surgical indications increased the risk for perioperative death. Despite being performed in generally younger and healthier patients and having lower perioperative morbidity, PPSF procedures are associated with increased mortality compared with RPSF procedures. The findings of this study can be used for risk stratification, accurate patient consultation, and hypothesis formation for future research.
Article
Population-based database analysis. To analyze trends in patient- and healthcare-system-related characteristics, utilization and outcomes associated with anterior cervical spine fusions. Anterior cervical decompression and spine fusion (ACDF) is one of the most commonly performed surgical procedures of the spine. However, few data analyzing trends in patient- and healthcare-system-related characteristics, utilization and outcomes exist. Data from 1990 to 2004 collected in the National Hospital Discharge Survey were accessed. ACDF procedures were identified. Five-year periods of interest (POI) were created for temporal analysis and changes in the prevalence and utilization of this procedure as well as in patient- and healthcare-system-related variables were examined. The changes in the occurrence of procedure-related complications were evaluated. An estimated total of 771,932 discharges after ACDF were identified. Temporally, an almost 8-fold increase in total prevalence was accompanied by a similar increase in utilization (23/100.000 civilians/POI to 157/100.000/civilians/POI). The highest increase in utilization was observed in those > or =65 years (28-fold). Average age increased from 47.2 years to 50.5 years over time. Length of hospital stay decreased from 5.17 days to 2.38 days. Overall procedure-related complication rates decreased from 4.6% to 3.03%. The prevalence of hypertension, diabetes mellitus, hypercholesterolemia, obesity, pulmonary, and coronary artery increased over time among patients undergoing ACDF. Despite limitations inherent to secondary analysis of large databases, we identified a number of significant changes in the utilization, demographics, and outcomes associated with ACDF, which can be used to assess the effect of changes in medical care, direct health care resources, and future research. The effect of the increased prevalence of comorbidities on medical practice remains to be evaluated. Further studies are necessary to evaluate causal relationships.
Article
We examined the rates of postoperative complications and mortality, as recorded in a hospital discharge registry for the State of Washington for the years 1986 through 1988, for patients who had had an operation on the lumbar spine. When patients who had had a malignant lesion, infection, or fracture are excluded, there were 18,122 hospitalizations for procedures on the lumbar spine, 84 per cent of which involved a herniated disc or spinal stenosis. The rates of morbidity and mortality during hospitalization, as well as the hospital charges, increased with the ages of the patients. The rate of complications was 18 per cent for patients who were seventy-five years or older. Nearly 7 per cent of patients who were seventy-five years old or more were discharged to nursing homes. Complications were most frequent among patients who had spinal stenosis, but multivariate analysis suggested that the complications associated with procedures for this condition were primarily related to the patient's age and the type of procedure. Complications, length of hospitalization, and charges were higher for patients who had had a spinal arthrodesis than for those who had not. Over-all, operations for conditions other than a herniated disc were associated with more complications and greater use of resources, particularly when arthrodesis was performed, than were operations for removal of a herniated disc. No data on symptoms or functional results were available.
Article
For several years, interest in clinical practice patterns has increased due to concerns about the costs and quality of health care. Our objectives were to examine recent trends and geographic variations in low back pain hospitalization. We analyzed data from a Washington State automated database for 1987-1992. Low back surgery rates in Washington changed little during the study years. In contrast, nonsurgical hospitalization rates fell from 15.5 to 5.1 per 10,000. The proportion of operations involving fusion decreased from 15.8% in 1987 to 11.7% in 1990, and then remained stable. During 1990, important county-to-county variations were observed in surgery rates, nonsurgical hospitalization rates, the proportion of operations involving fusion, and the percentage of surgical patients undergoing reoperation within 3 years. Wide county variations suggest that there may be overutilization or underutilization of low back pain treatments in some geographic areas. A more consistent approach to the management of back problems may benefit patients.
Article
Data from annual national surveys of hospitalizations were used to review trends. The trends in rates of hospitalizations with cervical and lumbar spine surgery were examined among persons > or = 25 years old. Preliminary analysis of national survey data indicated that during 1979 to 1990 the number of spine operations increased markedly. Data from the National Hospital Discharge Survey were used to calculate age-adjusted rates of hospitalizations. From 1979-81 to 1988-90, in each sex, the rate of hospitalizations with cervical spine surgery increased > 45%, with the rates for cervical fusion surgery increasing > 70%. The rate of hospitalizations with lumbar spine surgery increased > 33% in each sex, with the rate for lumbar fusion surgery increasing > 60% in each sex, the rate for lumbar disc surgery increasing 40% among males and 21% among females, and the rate for lumbar exploration/decompression surgery increasing > 65% in each sex. Between 1979 and 1990, rates of hospitalizations with cervical and lumbar spine surgery increased markedly among both sexes and for different categories of spine surgery.
Article
This study describes recent United States trends and regional variations in the management of low back pain. The authors investigated recent temporal trends and compared practices in different geographic regions. Controversy exists concerning the appropriate medical and surgical management of patients with low back pain. National Hospital Discharge Survey data from 1979 through 1990 were analyzed. Case selection was based on previously developed algorithms intended to exclude nonmechanical causes of back pain. Over the period of study, nonsurgical hospitalizations for low back pain decreased dramatically. In contrast, low back operation rates, particularly for fusion surgery, increased substantially. In recent years, surgery and hospitalization rates were highest in the South and lowest in the West. Rapidly increasing surgical rates and wide geographic variations suggest the need for a more consistent approach to back problems.
Article
Although high geographic variation in back surgery rates within the United States have been documented, international comparisons have not been published. The authors compared rates of back surgery in eleven developed countries to determine if back surgery rates are higher: 1) in the United States than in other developed countries, 2) in countries with more neurologic and orthopaedic surgeons per capita, and 3) in countries with higher rates of other surgical procedures. Data on back surgery rates and physician supply were obtained from health agencies within these eleven countries. Country-specific rates of other surgical procedures were available from published sources. The rate of back surgery in the United States was at least 40% higher than in any other country and was more than five times those in England and Scotland. Back surgery rates increased almost linearly with the per capita supply of orthopaedic and neurosurgeons in the country. Countries with high back surgery rates also had high rates of other discretionary procedures such as tonsillectomy and hysterectomy. These findings illustrate the potentially large impact of health system differences on rates of back surgery. Better outcome studies, however, are needed to determine whether Americans are being subjected to excessive surgery or if those in other developed countries are suffering because back surgery is underutilized.
Article
To study temporal trends and geographic variations in the use of surgery for spinal stenosis, estimate short-term morbidity and mortality of the procedure, and examine the likelihood of repeat back surgery after surgical repair. Cohort study based on Medicare claims. Hospital care. All Medicare beneficiaries 65 years of age or older who received a lumbar spine operation for spinal stenosis in 1985 or 1989 were followed through 1991 (10,260 patients from the 1985 cohort and 18,655 from the 1989 cohort). Two outcomes were measured: (1) rates of operation for spinal stenosis by state and (2) on an individual level, operative complications (cardiopulmonary, vascular, or infectious), postoperative mortality, and time between first operation and any subsequent reoperation. Rates of surgery for spinal stenosis increased eightfold from 1979 to 1992 for patients aged 65 and older and varied almost fivefold among US states. Mortality and operative complications increased with age and comorbidity. Complications were more likely for men and for individuals receiving spinal fusions. The 1989 cohort experienced a slightly higher probability of reoperation than the 1985 cohort for the first 3 years of follow-up. A rapid increase in surgery rates for spinal stenosis was identified over a 14-year period. The wide geographic variations and substantial complication rate from this elective surgical procedure (partly related to patient age) suggest a need for more information on the relative efficacy of surgical and nonsurgical treatments for this condition. The risks and benefits of particular surgical procedures for specific clinical and demographic subgroups as well as individual patient preferences regarding surgical risks and possible outcomes should also be evaluated further. These issues are likely to become increasingly important with the aging of the US population.
Article
Population-based variations in rates of operations for the treatment of lumbar disc herniation and spinal stenosis are well known. This variability may occur in part because of differences in the threshold at which physicians recommend an operation, reflecting uncertainty about the optimum use of an operative procedure. To the best of our knowledge, no previous reports have indicated whether differences in population-based rates of operative treatment are associated with patient outcomes. The Maine Lumbar Spine Study is an ongoing prospective study of 655 patients who had a herniated lumbar disc or spinal stenosis. The patients were enrolled by their physicians, who provided baseline demographic and treatment-related data. The patients completed baseline and follow-up questionnaires that focused on symptoms, function, satisfaction, and quality of life. Small-area variation analysis was used to develop three distinct so-called spine service areas in Maine. The outcomes (usually at four years; minimum, two years) were compared among these areas, in which a total of 250 patients had been managed operatively and had answered questionnaires. Population-based rates of operative treatment derived from statewide data that had been collected over five years in the state of Maine ranged from 38 percent below to 72 percent above the average rate in the state (a greater than fourfold difference). The outcomes for the patients who had been managed by surgeons in the lowest-rate area were superior to those for the patients in the two higher-rate areas. Seventy-nine percent (fifty-seven) of seventy-two patients in the lowest-rate area had marked or complete relief of pain in the lower extremity compared with 60 percent (eighteen) of thirty patients in the highest-rate area. The improvements in the Roland disability score (p < or = 0.01), quality of life (p < or = 0.01), and satisfaction (p < or = 0.05) were significantly greater among the patients in the lowest-rate area. The patients in the higher-rate areas generally had less severe symptoms and findings at baseline than those in the lowest-rate area did. Higher population-based rates of elective spinal operations may be associated with inferior outcomes. This variability is possibly related to differences in physicians' preferences with regard to recommending an operation and in their criteria for the selection of patients. Physicians cannot assume that their outcomes will be the same as those of others, and therefore they need to evaluate their own results.
Article
A national hospitalization database was used to determine rates and trends in the treatment of cervical disc disease. To examine the temporal and geographic variations in hospitalizations and surgical procedures for cervical disc disease. Studies of spinal surgery during the 1980s showed significant increases in the rates for all procedures, particularly those involving fusion. The management of cervical disc disease continues to be controversial. Data from the National Hospital Discharge Survey from 1990 through 1999 were analyzed. Records were selected and categorized according to an algorithm of International Classification of Diseases (ICD-9) procedure and diagnosis codes. During the study period, the rate of hospitalization for surgical and nonsurgical treatment of cervical disc disease did not increase significantly. There was, however, a statistically significant increase in the proportion of hospitalizations for the surgical treatment of cervical disc disease that included a fusion procedure. There also was significant geographic variation in the rate of fusion procedures, with the South having the highest rate. Although the rate of surgery for cervical disc disease did not increase significantly during the 1990s, the rate of fusion procedures did rise significantly.
Article
Critical analysis of the results reported in published literature. The purpose of this study was to evaluate whether various technical advancements have affected the outcome of lumbar spinal fusion for degenerative disease by critically analyzing the available literature from the past two decades. To improve fusion rate and clinical outcome, various surgical options for lumbar spinal fusion for degenerative disc disorders have been introduced over the past 20 years. However, an important fundamental question still remains: What has been the impact of these new techniques and innovations on surgical results? A comprehensive computer search of the English literature from 1979 to 2000 concerning lumbar/lumbosacral spinal fusion was performed using the keywords degenerative, lumbar, and fusion. Numerous deficiencies were noted in the reviewed literature. Nearly half of the studies failed to specify methodologic design, and documentation of brace use, graft source, fusion location, and fusion rate was missing in 38, 10, 2, and 4 of the 84 articles reviewed, respectively. From the data gathered, a noticeable trend toward the increasing use of internal fixation was noted, accounting for 23% of fusions in the 1980s versus 41% in the 1990s. Despite this trend, an improvement in overall fusion rate or clinical outcome could not be demonstrated. Numerous technologic advancements in lumbar spine fusion have been made over the past 20 years. Future advances in care are dependent on review of reported results. The numerous deficiencies detected in the analyzed literature herald the necessity for a uniform system of outcomes reporting containing a core of critical demographic, perioperative, and postsurgical information. Although a shift toward a greater use of technology was noted in the published literature, the clinical benefit of this trend remains unclear.
Article
Retrospective cohort study using national sample administrative data. To determine if lumbar fusion rates increased in the 1990s and to compare lumbar fusion rates with those of other major musculoskeletal procedures. Previous studies found that lumbar fusion rates rose more rapidly during the 1980s than did other types of lumbar surgery. We used the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1988 through 2001 to examine trends. U.S. Census data were used for calculating age and sex-adjusted population-based rates. We excluded patients with vertebral fractures, cancer, or infection. In 2001, over 122,000 lumbar fusions were performed nationwide for degenerative conditions. This represented a 220% increase from 1990 in fusions per 100,000. The increase accelerated after 1996, when fusion cages were approved. From 1996 to 2001, the number of lumbar fusions increased 113%, compared with 13 to 15% for hip replacement and knee arthroplasty. Rates of lumbar fusion rose most rapidly among patients aged 60 and above. The proportion of lumbar operations involving a fusion increased for all diagnoses. Lumbar fusion rates rose even more rapidly in the 90s than in the 80s. The most rapid increases followed the approval of new surgical implants and were much greater than increases in other major orthopedic procedures. The most rapid increases in fusion rates were among adults aged 60 and above. These increases were not associated with reports of clarified indications or improved efficacy, suggesting a need for better data on the efficacy of various fusion techniques for various indications.
Article
We compared children who were hospitalized for the management of idiopathic scoliosis (IS) and neuromuscular scoliosis (NMS) via analysis of the 2000 Healthcare Cost and Utilization Project Kid Inpatient Database. Children with NMS had longer lengths of stay (9.2 vs. 6.1 days, P < 0.001), higher total charges (66,953 US dollars vs. 47,463 US dollars, P < 0.001), more diagnoses (6.3 vs. 2.5, P < 0.001), and more total procedures (4.2 vs. 3.0, P < 0.001) than did children with IS. Children with NMS more frequently developed pneumonia (3.5% vs. 0.7%, P < 0.001), respiratory failure (24.1% vs. 9.2%, P < 0.001), urinary tract infections (5.3% vs. 0.7%, P < 0.001), and surgical wound infections (1.3% vs. 0.3%, P < 0.001). Overall, 1570 children with NMS underwent spinal surgery, totaling to 105 US dollars million in hospital charges and 14,444 hospital days. We conclude that children with NMS experience significantly more complicated and costly hospitalizations than do children with IS. These results may add information on preoperative care, surgical decision-making, discussions of informed consent, and the provision of anticipatory guidance for children and their caregivers.
Article
Several reports suggest that spine surgery has experienced rapid growth in the past decade. Limited data exist, however, documenting the increase in spinal fusion. The objective of this work was to quantify and characterize the contemporary practice of spinal fusion in the United States. Clinical data were obtained from the Nationwide Inpatient Sample for the years from 1993 to 2003. All patients with International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes indicating cervical fusion, thoracolumbar fusion, lumbar or unspecified fusion were identified (n = 471,990). Primary ICD-9-CM diagnosis codes were used to determine the rationale for surgical fusion. Population-based utilization rates overall and for each procedure were calculated from United States census data. Rank order of spinal fusion compared with other inpatient procedures from the Nationwide Inpatient Sample was reported for the years 1997 to 2003. Overall utilization increased during the time period for cervical, thoracolumbar, and lumbar fusions by 89, 31, and 134%, respectively. Patients aged 40 to 59 years experienced the rapid rise in utilization for cervical fusions (60-110 per 100,000) and lumbar fusions (35-84 per 100,000). For patients 60 years and older, utilization also increased for cervical (30-67 per 100,000), thoracolumbar (4-9 per 100,000), and lumbar (42-108 per 100,000). Spinal fusion rose from the 41st most common inpatient procedure in 1997 to the 19th in 2003. Cervical, thoracolumbar, and lumbar spinal fusion have experienced a rapid increase in utilization in isolation and compared with other surgical procedures in contemporary practice. These changes are most pronounced for patients over 40 years of age, and degenerative disc disease seems to account for much of this increase.
Article
Cervical spine injury, with or without spinal cord injury, is an important cause of morbidity and mortality in the United States. While substantial regional variation has been shown in per capita rates of elective cervical spine surgery, similar data regarding arthrodesis rates for traumatic cervical injury have not been reported, to our knowledge. We assessed the rates of cervical spinal arthrodesis for patients who had a cervical spine injury with or without an associated spinal cord injury. The data for the present study came from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample from 1998 to 2002. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients with a cervical vertebral fracture or dislocation with or without an associated spinal cord injury. Hospitals were grouped according to their teaching status, location (urban or rural), and volume of cervical spine injury patients. The rates of spinal arthrodesis and halo/tong placement were compared for patients within each diagnostic category. Twenty-eight thousand, five hundred and eighteen patients with a cervical spine injury were analyzed. Spinal arthrodesis was performed for 16.5% of patients who had a cervical fracture without an associated spinal cord injury, for 50.4% of patients who had a cervical spine fracture with an associated spinal cord injury, and for 44.1% of patients who had a cervical dislocation. With the numbers available, the rates of arthrodesis for patients who had a fracture without a spinal cord injury and for patients who had a cervical dislocation were not significantly different between high and low-volume centers, although the rate for patients who had a cervical fracture with a spinal cord injury was significantly higher at high-volume hospitals. The rates of arthrodesis did not vary significantly between urban teaching and nonteaching hospitals, with the numbers available, for patients in any of the three diagnostic categories. Individual hospitals had a threefold to fivefold variation in the arthrodesis rate for patients with a cervical spine injury, depending on the diagnostic category. The present study demonstrated substantial differences in the rate of arthrodesis for patients with cervical spine trauma, depending on the diagnostic category. The variations in the rates of arthrodesis within diagnostic categories appear to be lower than the previously reported variation in the rates of elective cervical spine procedures.
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