The Effect of High-Normal Preoperative International Normalized Ratios on Outcomes and Complications After Anterior Cervical Spine Surgery.

Hematoma after anterior cervical spine surgery can result in neurologic and airway compromise. Current guidelines recommend an international normalized ratio (INR) <1.5 before elective spine surgery because of increased complications. The risk associated with an INR of 1.25 is not well studied. The purpose of this study was to determine the risk of complications associated with a preoperative INR >1.25 and ≤1.5 in patients undergoing elective anterior cervical spine surgery. The American College of Surgeons National Surgical Quality Improvement Program database was queried. Patients undergoing elective anterior cervical spine surgery from 2012 to 2016 who had an INR recorded within 24 hours of surgery were included. Outcomes of interest included postoperative hematoma requiring surgery, 30-day mortality, and 30-day readmissions and reoperations. A total of 2949 patients were included. The incidence of a postoperative hematoma that required surgical management was 0.2%, 0.6%, and 4.5% in the INR≤1, 11.25 and ≤1.5 before elective anterior cervical spine surgery is associated with significantly higher rates of postoperative hematoma formation as well as 30-day readmission and reoperation; there was a trend toward significance in mortality rate. [Orthopedics. 2024;47(1):e26-e32.].

The Impact of Smoking in Workers' Compensation Patients Receiving Spinal Cord Stimulation.

The objective of this study was to determine the impact of smoking on clinical outcomes in workers' compensation (WC) patients receiving spinal cord stimulation (SCS). One hundred and ninety-six patients from the Ohio Bureau of Workers' Compensation were identified who received SCS with implantation occurring between 2007-2012. Patients were divided into smokers (n = 120) and nonsmokers (n = 76). Population characteristics before and after implantation were analyzed between the two groups. A multivariate logistic regression was run to determine predictors of return to work (RTW) status. Our regression determined smoking (p = 0.006; odds ratio [OR] = 0.260) and body mass index (p = 0.036; OR = 0.905) to be negative predictors of RTW status. After implantation, smokers were less likely to RTW after 6 months and had higher pain scores after 6 and 12 months. Both smokers and nonsmokers had significance reductions in opioid use after SCS implantation. (Journal of Surgical Orthopaedic Advances 30(3):185-189, 2021).

Volar and Dorsal Blood Supply to the Lunate: A Cadaveric Study.

Although various studies have proposed vascular and mechanical factors, the etiology of Kienböck disease is unknown. Kienböck theorized that lunatomalacia resulted from traumatic disruption of blood supply and bony nutrition to the lunate. Extraosseous supply to the lunate, as far as volar or dorsal vessels are concerned, is still controversial. This study evaluated the extraosseous nutrient foramina from the dorsal and volar aspects of lunate specimens. A total of 913 specimens from the Hamann-Todd Osteological Collection in Cleveland, Ohio, were examined. The nutrient artery foramina on left and right lunate specimens were examined from dorsal and volar aspects. The number of nutrient artery foramen was tabulated. Age, sex, and race data were collected. Specimens were divided into groups according to the number of nutrient artery foramina, and the dorsal and volar foramina were compared. The average number of foramina on the dorsal aspect of the lunate (1.71) was greater than the volar aspect (1.64), except in specimens younger than 35 years. A greater number of specimens had 3 or more foramina on the dorsal side compared with the volar aspect. Based on this study, there was significant contribution of dorsal arterial vessels to the blood supply of lunate specimens older than 35 years, which contrasts with findings in earlier studies. The disruption of dorsal intercarpal and radiocarpal ligaments leading to the disruption of the dorsal arterial arches may contribute to vascular insufficiency of the lunate and should be evaluated further in the etiopathogenesis of Kienböck disease. [Orthopedics. 2021;44(2):e243-e247.].

Time to Surgery Affects Return to Work Rates for Workers' Compensation Patients With Single-Level Lumbar Disk Herniation.

The optimal timing of lumbar diskectomy in patients with lumbar disk herniation and radiculopathy has not been studied in the workers' compensation (WC) population. A total of 10,592 patients received lost-work compensation from the Ohio Bureau of Workers' Compensation for a lumbar disk herniation between 2005 and 2012. The primary outcome was whether subjects return to work (RTW). To determine the impact time to surgery had on RTW status, the authors performed a multivariate logistic regression analysis. They compared other secondary outcomes using chi-square and t tests. The authors identified 1287 WC patients with single-level disk herniation and radiculopathy. Average time from injury to surgery was 364 days (range, 2-2710 days). The WC patients with shorter duration of radiculopathy before diskectomy had higher RTW rates; fewer physical therapy, chiropractic, and psychotherapy sessions; and fewer postoperative diagnoses of psychological illnesses (P<.05). A multivariate logistic regression model showed that time to surgery was an independent, negative predictor of RTW (odds ratio [OR], 0.97 per month; P<.01). Legal representation (OR, 0.56; P<.01), psychological comorbidity (OR, 0.32; P=.01), and mean household income (OR, 1.01 per $1000; P<.01) also significantly affected RTW status. These results confirm that the duration of radiculopathy due to single-level lumbar disk herniation has a predictive value for the WC population undergoing diskectomy. Within 12 weeks of injury, post-diskectomy patients do reasonably well, with 70.0% of subjects returning to work. [Orthopedics. 2021;44(1):e43-e49.].

Symptomatic Epidural Hematoma after Elective Posterior Lumbar Decompression: Incidence, Timing, Risk Factors, and Associated Complications.

BACKGROUND: Symptomatic post-operative lumbar epidural hematoma (PLEH) is a complication of lumbar spine surgery that can cause permanent neurologic consequences through compression of the cauda equina and nerve roots. QUESTIONS/PURPOSES: We sought to investigate the incidence, timing, and risk factors for symptomatic epidural hematomas following posterior lumbar decompression, as well as to identify additional post-operative complications associated with symptomatic lumbar epidural hematomas. METHODS: Elective lumbar spine procedures were identified in the National Surgical Quality Improvement Program (NSQIP) database between 2012 and 2016. Analyzed predictors of reoperation or readmission within 30 days for symptomatic PLEH included demographics, comorbidities, pre-operative laboratory values, peri-operative characteristics, and post-operative complications. RESULTS: There were 75,878 cases included in the analysis. The incidence rate of symptomatic PLEH was 0.27% (n = 206), 54.4% (n = 112) of which occurred within 5 days of the procedure. Increased age, obesity (body mass index of 35 or higher), peri-operative transfusion, multilevel surgery (two or more levels), dural tear repair, and microscope use were independently associated with PLEH. Post-operative complications associated with PLEH included surgical site infection and urinary tract infection. CONCLUSIONS: Readmission or reoperation for symptomatic PLEH following elective lumbar spine surgery is rare and can occur many days or weeks after a procedure. There are modifiable risk factors for PLEH and associated additional post-operative complications that physicians should be suspicious of following posterior lumbar decompression.

The Effect of Diabetes Mellitus on Revision Discectomy after Single-level Lumbar Discectomy.

Diabetes currently affects over 25 million Americans, with the elderly carrying much of the disease burden. It's well known that diabetes increases the risk of surgical complications, but few studies have analyzed its effects on reoperation rates after single-level lumbar discectomy. Data was obtained using the commercially available Explorys software, which houses de-identified data for several healthcare systems. A database search was conducted to find all patients who'd undergone a lumbar discectomy. Scoliosis, spondylolisthesis, smoking history and obesity were excluded as possible confounding variables, after which 31,210 patients remained. Of them, 950 were found to have undergone a revision discectomy within 2 years. Those with diabetes were found to have a relative risk of 1.29 for revision discectomy compared to those who did not, 95% confidence interval (95% CI) 1.10-1.52, p < 0.002. These findings contribute to the importance of modifiable risk factor assessment preoperatively and their effects on surgical complications. (Journal of Surgical Orthopaedic Advances 29(3):159-161, 2020).

The Relationship Between Cigarette Smoking and the Prevalence, Frequency and Severity of Back Pain.

The purpose of this study was to examine the relationship between smoking and back pain in a cross-sectional analysis. Using the Osteoarthritis Initiative database, a multi-center, longitudinal, observational cohort study with 4796 participants, we examined the prevalence of back pain and of limitations in activity due to back pain, as well as the frequency and severity of back pain in participants who were current smokers compared to those who had never smoked. Data was evaluated using binary and ordinal logistic regression analyses. An increase in prevalence, frequency and severity of back pain was strongly associated with smoking. This demonstrates a relationship between smoking and back pain; however, further studies are needed to evaluate causation. (Journal of Surgical Orthopaedic Advances 29(3):165-168, 2020).

Effect of Nicotine Dependence and Smoking on Revision Diskectomy After Single-Level Lumbar Diskectomy.

Removal of a herniated disk that is causing neural compression is among the most common indications for spinal surgery. Previous population database studies of risk factors for reoperation after this procedure analyzed small to medium numbers of patients. To date, no study has concurrently assessed the effect of modifiable risk factors, such as smoking and nicotine dependence, with a large number of patients. Data were obtained with commercially available software that houses de-identified data for several major US health care systems. A database search was conducted to find all patients who had undergone lumbar diskectomy. Obesity, scoliosis, spondylolisthesis, and depression were excluded as possible confounding variables. The remaining patients were divided into smoking and nonsmoking groups. Those who had undergone revision lumbar diskectomy within 2 years were counted. Pearson's chi-square statistical test was used to determine significance at P<.05. Of the 50 million patient records in the software platform, 53,360 patients were identified who had undergone single-level lumbar diskectomy. Of these, 26,980 fulfilled the inclusion criteria. A total of 890 of those patients had undergone revision lumbar diskectomy within 2 years of their original procedure. Those who smoked were found to have a relative risk of 2.47 compared with nonsmokers (95% confidence interval, 2.17-2.82; P<.0001). Nicotine dependence and smoking had a significant effect on the rate of reoperation. These findings support the importance of preoperative assessment of modifiable risk factors and their effects on surgical complications. [Orthopedics. 2020;43(5):e438-e441.].

The Effect of Obesity on Revision Discectomy After Singlelevel Lumbar Discectomy.

The prevalence of obesity has been rising, creating a major public health concern. While several studies have shown obesity to increase the risk of surgical complications, few have analyzed its effects on reoperation, specifically after singlelevel lumbar discectomy. Data was obtained using the commercially available Explorys software that houses deidentified data for several major healthcare systems. A database search was used to find all patients who had undergone a lumbar discectomy. Scoliosis, spondylolisthesis, smoking history and depression were excluded as possible confounding variables, after which 25,960 patients remained. Of them, 690 were found to have undergone a revision discectomy within 2 years. Those who were obese were found to have a relative risk of 1.64 for revision discectomy compared to those who were nonobese, 95% confidence interval (95%CI) 1.322.03, p 0.0001. These findings contribute to the importance of modifiable risk factor assessment preoperatively and their effects on surgical complications. (Journal of Surgical Orthopaedic Advances 29(1):1012, 2020).

Shorter Time to Surgery Is Associated With Better Outcomes for Spondylolisthesis in the Workers' Compensation Population.

This study sought to determine the impact of time to surgery on clinical outcomes in patients with spondylolisthesis in the workers' compensation (WC) population. There is conflicting evidence regarding the effect of time to surgery on patients with spondylolisthesis. Patients receiving WC are known to have worse outcomes following spine surgery compared with the general population. A total of 791 patients from the Ohio Bureau of Workers' Compensation were identified who underwent lumbar fusion for spondylolisthesis between 1993 and 2013. The patients were divided into those who had surgery within 2 years of injury date and after 2 years. Confounding factors were corrected for in a multivariate logistic regression to determine predictors of return to work (RTW) status. Multivariate logistic regression determined that longer time to surgery (P=.003; odds ratio, 0.89 per year), age at index fusion (P=.003; odds ratio, 0.98 per year), and use of physical therapy before fusion (P=.008; odds ratio, 0.54) were negative predictors of RTW status. Patients who had surgery within 2 years were more likely to RTW and have fewer days absent from work, lower medical costs, and fewer sessions of psychotherapy, physical therapy, and chiropractor care. The authors demonstrated that for WC patients with spondylolisthesis, longer time to surgery was a negative predictor of RTW status. Patients who had surgery within 2 years of injury date were significantly more likely to RTW compared with after 2 years. [Orthopedics. 2020;43(3):154-160.].

30-day Mortality Following Surgery for Spinal Epidural Abscess: Incidence, Risk Factors, Predictive Algorithm, and Associated Complications.

STUDY DESIGN: Retrospective case-control study. OBJECTIVE: To determine incidence and timing of mortality following surgery for spinal epidural abscess (SEA), identify risk factors for mortality, and identify complications associated with mortality. SUMMARY OF BACKGROUND DATA: SEA is a serious condition with potentially devastating sequelae. There is a paucity of literature characterizing mortality following surgery for SEA. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was used. Patients with a diagnosis of SEA were included. A Cox proportional hazards model identified independent risk factors for 30-day mortality. A predictive model for mortality was created. Multivariate models identified postoperative complications associated with mortality. RESULTS: There were 1094 patients included, with 40 cases of mortality (3.7%), the majority of which occurred within 2 weeks postoperatively (70%). Independent risk factors for 30-day mortality were age>60 years (hazard ratio [HR]: 2.147, P = 0.027), diabetes (HR: 2.242, P = 0.015), respiratory comorbidities (HR: 2.416, P = 0.037), renal comorbidities (HR: 2.556, P = 0.022), disseminated cancer (HR: 5.219, P = 0.001), and preoperative thrombocytopenia (HR: 3.276, P = 0.001). A predictive algorithm predicts a 0.3% mortality for zero risk factors up to 37.5% for 4 or more risk factors. A ROC area under curve (AUC) was 0.761, signifying a fair predictor (95% CI: 0.683-0.839, P < 0.001). Cardiac arrest (adjusted odds ratio [aOR]: 72.240, 95% confidence interval [CI]: 27.8-187.721, P < 0.001), septic shock (aOR: 15.382, 95% CI: 7.604-31.115, P < 0.001), and pneumonia (aOR: 2.84, 95% CI: 1.109-7.275, P = 0.03) were independently associated with mortality. CONCLUSION: The 30-day mortality rate following surgery for SEA was 3.7%. Of the mortalities that occurred within 30 days of surgery, the majority occurred within 2 weeks. Independent risk factors for mortality included older age, diabetes, hypertension, respiratory comorbidities, renal comorbidities, metastatic cancer, and thrombocytopenia. Risk for mortality ranged from 0.3% to 37.5% based on number of risk factors. Septic shock, cardiac arrest, and pneumonia were associated with mortality. LEVEL OF EVIDENCE: 3.

Multilevel Lumbar Fusion Is a Risk Factor for Lower Return to Work Rates Among Workers' Compensation Subjects With Degenerative Disc Disease.

Discogenic fusion is associated with variable outcomes, especially if multiple levels are fused. This study sought to determine the impact of fused levels on return to work (RTW) status in a workers' compensation (WC) setting. Nine hundred thirty-seven subjects were selected for study. The primary outcome was the ability to RTW within 2 years following fusion and to sustain this level for greater than 6 months. Many secondary outcomes were collected. A multivariate logistic regression model was used to determine the impact of multilevel fusion on RTW status. Of the multilevel fusion group, 21.7% met the RTW criteria versus 28.1% of the single-level fusion group (p < .028). Multilevel fusion was a negative predictor of RTW status (p < .041; OR 0.71). Additional negative predictors included prolonged time out of work, male gender, chronic opioid analgesia, and legal representation. Multilevel fusion led to poor clinical outcomes while overall RTW rates were low, which suggests a limited role of discogenic fusion within the WC setting. (Journal of Surgical Orthopaedic Advances 27(3):209-218, 2018).

The Effect of Age on the Benefits of Early Decompression for Cervical Spondylotic Myelopathy.

Cervical myelopathy is the most common cause of acquired spinal cord dysfunction in people aged >55 years. Advanced age and duration of symptoms have been implicated in the literature as negative prognostic indicators for postoperative functional improvement, but very few studies have evaluated the interaction of these factors. We retrospectively reviewed 125 patients who underwent surgery for cervical myelopathy. Patients were stratified according to age greater or less than 65 years and duration of symptoms of greater or less than 12 and 24 months. Functional outcomes were assessed using the Nurick score. Simple regression and multiple regression analyses were done, controlling for sex, preoperative Nurick score, surgical approach, smoking status, diabetes status, prior surgery, number of levels fused, ethanol use, and signal change on preoperative magnetic resonance imaging. The average change in Nurick score in all patients was 1.36, with a significant difference between patients with symptoms for <24 months and those with symptoms for >24 months (1.54 vs 0.98, P = .03). Multiple regression analysis revealed that older patients had a significant difference at 24 months (1.69 vs 1.25, P = .01), whereas younger patients showed slightly lower improvement overall and a change in Nurick score at both thresholds that was statistically nonsignificant.

Cervicothoracic Pedicle Morphometry: Using an Osteological Collection to Characterize Trends in Pedicle Size.

Pedicle screws are a common treatment option for spinal instability. Despite their popularity, pedicle screws carry the risk of transpedicular violation with subsequent neural and vascular damage. This study measured the pedicle dimensions of 500 dry specimens in an osteological collection. The data provide the orthopedic spine surgeon with an accurate measure of pedicle morphometry in light of previously limited and contradictory results. The study demonstrates that pedicle height at the cervicothoracic junction tends to increase with body height, particularly for females. Additionally, T1 pedicle width is smaller for females than males and, for males, tends to decrease with increasing body weight. These results are valuable to the spine surgeon because they suggest that taller patients may afford a larger margin for error in the vertical plane. However, they also demonstrate that heavier patients do not have wider pedicles and thus cannot be assumed to tolerate or require larger-diameter screws. (Journal of Surgical Orthopaedic Advances 27(1):33-38, 2018).

Lumbar Discography Is Associated With Poor Return to Work Status Following Lumbar Fusion Surgery in a Workers' Compensation Setting.

Lumbar discography (LD) is used to guide surgical decision making in patients with degenerative disc disease (DDD). Its safety and diagnostic accuracy are under contention. This study evaluates LD's efficacy within the workers' compensation (WC) population. Multivariate logistic regression analysis was used to determine the impact that undergoing LD before lumbar fusion for DDD had on return to work (RTW) rates among 1407 WC subjects. Discography was negatively associated with RTW status (p = .042; OR 0.76); 22.2% (142/641) of LD subjects met the RTW criteria, compared with 29.6% (227/766) of controls. Additional preoperative risk factors included psychological comorbidity (p < .001; OR 0.34), age greater than 50 (p < .005; OR 0.64), male gender (p < .037; OR 0.75), chronic opioid use (p < .001; OR 0.53), legal representation (p < .034; OR 0.72), and fusion technique (p < .043). LD subjects used postoperative narcotics for an average of 123 additional days (p < .001). This raises concerns regarding the utility of discography in the WC population. (Journal of Surgical Orthopaedic Advances 27(1):25-32, 2018).

The Association Between Body Mass Index and the Prevalence, Severity, and Frequency of Low Back Pain: Data From the Osteoarthritis Initiative.

STUDY DESIGN: Cross-sectional study. OBJECTIVE: To determine whether there is an association between body mass index (BMI) and the prevalence, severity, and frequency of low back pain and identify other potential patient risk factors for the development of low back pain. SUMMARY OF BACKGROUND DATA: Many studies have implicated that a high BMI is a risk factor for low back pain. However, few studies have examined the association between increased BMI and the prevalence, severity, and frequency of low back pain. METHODS: Data from the Osteoarthritis Initiative, a multicenter, prospective study of knee osteoarthritis, were used to conduct this study, which included 4796 patients. BMI was categorized according to the World Health Organization classification and the prevalence, severity, and frequency of low back pain were assessed. Logistic regression was performed to identify additional patient risk factors associated with low back pain. RESULTS: The prevalence of low back pain was found to be significantly higher in patients with an elevated BMI compared to those with normal or underweight BMI and demonstrated a stepwise increase with each BMI category. Approximately 47.4% of patients with normal or underweight BMI complained of low back pain compared with 72.8% of morbidly obese patients (P < 0.0001). No association was seen between BMI and the frequency or severity of low back pain episodes. Osteoarthritis of the back and depression were patient variables found to be associated with all three measures (prevalence, severity, and frequency) of low back pain. CONCLUSION: Elevated BMI is strongly associated with an increased prevalence of low back pain. Depression and osteoarthritis of the back are associated with the prevalence, severity, and frequency of low back pain. LEVEL OF EVIDENCE: 3.

Preoperative Opioid Use is a Predictor of Poor Return to Work in Workers' Compensation Patients After Lumbar Diskectomy.

STUDY DESIGN: A retrospective cohort. OBJECTIVE: The aim of this study was to determine the impact of preoperative opioid use in workers' compensation (WC) patients undergoing lumbar diskectomy (LD). SUMMARY OF BACKGROUND DATA: The prevalence of back pain among opioid users approached 60%. Long-term opioid dependence in spine surgery patients is roughly 20%. Despite pervasive use, there is no evidence to support long-term opioid analgesic use for back pain. METHODS: Ten thousand five hundred ninety-two patients received compensation from the Ohio Bureau of Workers' Compensation for a lumbar disc herniation between 2005 and 2012. Patients with spine comorbidities, smoking history, or multilevel surgery were excluded. Preoperatively, 566 patients had no opioid use, 126 had short-term opioid use (STO), 315 had moderate opioid use (MTO), and 279 had long-term opioid use (LTO). The primary outcome was whether subjects returned to work (RTW). RESULTS: Seven hundred twelve (55.4%) patients met our RTW criteria. There was a significant difference in RTW rates among the no opioid (64.1%), MTO (52.7%), and LTO (36.9%) populations. Multivariate logistic regression analysis found several covariates to be independent negative predictors of RTW status: preoperative opioid use [P < 0.01; odds ratio (OR) = 0.54], time to surgery (P < 0.01; OR = 0.98 per month), legal representation (P < 0.01; OR = 0.57), and psychiatric comorbidity (P = 0.02; OR = 0.36). Patients in the LTO group had higher medical costs (P < 0.01), rates of psychiatric comorbidity (P < 0.01), incidence of failed back surgery syndrome (FBSS) (P < 0.01), and postoperative opioid use (P < 0.01) compared with the STO and no opioid groups. CONCLUSION: Preoperative opioid use was determined to be a negative predictor of RTW rates after LD in WC patients. In addition, long-term preoperative opioid use was associated with higher medical costs, psychiatric illness, FBSS, and postoperative opioid use. Even a short or moderate course of preoperative opioids was associated with worse outcomes compared with no use. For WC patients undergoing LD, judicious use of preoperative opioid analgesics may improve clinical outcomes and reduce the opioid burden. LEVEL OF EVIDENCE: 3.

Preoperative Opioid Use: A Risk Factor for Poor Return to Work Status After Single-level Cervical Fusion for Radiculopathy in a Workers' Compensation Setting.

STUDY DESIGN: Retrospective comparative case-control study. OBJECTIVES: The objectives of this study are: (1) How preoperative opioid use impacts RTW status after single-level cervical fusion for radiculopathy? and (2) What are other postsurgical outcomes affected by preoperative opioid use? SUMMARY OF BACKGROUND DATA: Opioid use has increased significantly in the past decade. The use of opioids has a drastic impact on workers' compensation population, an at-risk cohort for poorer surgical and functional outcomes than the general population. METHODS AND MATERIALS: Data was retrospectively collected from Ohio Bureau of Workers' Compensation between 1993 and 2011. The study population included patients who underwent single-level cervical fusion for radiculopathy as identified by current procedural terminology codes and International Classification of Diseases-9 codes. On the basis of opioid use before surgery, two groups were constructed (opioids vs. non-opioids). Using a multivariate logistic regression model, the effect of preoperative opioid use on return to work (RTW) status after fusion was analyzed and compared between the groups. RESULTS: In the regression model, preoperative opioid use was a negative predictor of RTW status within 3-year follow-up after surgery. Opioid patients were less likely to have stable RTW status [odds ratio (OR), 0.50; 95% confidence interval (CI), 0.38-0.65; P=0.05] and were less likely to RTW within the first year after surgery (OR, 0.50; 95% CI, 0.37-0.66; P=0.05) compared with controls. Stable RTW was achieved in 43.3% of the opioids group and 66.6% of control group (P=0.05). RTW rate within the first year after fusion was 32.5% of opioids group and 57% of control group (P<0.05).Reoperation and permanent disability rates after surgery were higher in the opioid group compared with the control group (P<0.05). CONCLUSIONS: In a workers' compensation, patients with work-related injury who underwent single-level cervical fusion for radiculopathy and received opioids before surgery had worse RTW status, a higher reoperation rate, and higher rate of awarded permanent disability after surgery.

The Timing of Surgery Affects Return to Work Rates in Patients With Degenerative Lumbar Stenosis in a Workers' Compensation Setting.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: The objective of this study is to determine how time to surgery affects outcomes for degenerative lumbar stenosis (DLS) in a workers' compensation (WC) setting. SUMMARY OF BACKGROUND DATA: WC subjects are known to be a clinically distinct population with variable outcomes following lumbar surgery. No study has examined the effect of time to surgery in this clinically distinct population. MATERIALS AND METHODS: A total of 227 Ohio WC subjects were identified who underwent primary decompression for DLS between 1993 and 2013. We allocated patients into 2 groups: those that received operative decompression before and after 1 year of symptom onset. Our primary outcome was, if patients were able to make a stable return to work (RTW). The authors classified subjects as RTW if they returned within 2 years after surgery and remained working for >6 months. RESULTS: The early cohort had a significantly higher RTW rate [50% (25/50) vs. 30% (53/117); P=0.01]. A logistic regression was performed to identify independent variables that predicted RTW status. Our regression model showed that time to surgery remained a significant negative predictor of RTW status (P=0.04; odds ratio, 0.48; 95% confidence interval, 0.23-0.91). Patients within the early surgery cohort cost on average, $37,332 less in total medical costs than those who opted for surgery after 1 year (P=0.01). Furthermore, total medical costs accrued over 3 years after index surgery was on average, $13,299 less when patients received their operation within 1 year after symptom onset (P=0.01). CONCLUSIONS: Overall, time to surgery had a significant impact on clinical outcomes in WC subjects receiving lumbar decompression for DLS. Patients who received their operation within 1 year had a higher RTW rate, lower medical costs, and lower costs accrued over 3 years after index surgery. The results presented can perhaps be used to guide surgical decision-making and provide predictive value for the WC population.

Treatment of Recurrent Lumbar Disc Herniation With or Without Fusion in Workers' Compensation Subjects.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine outcomes after reoperation discectomy with or without fusion surgery for recurrent lumbar disc herniation (RLDH) in the workers' compensation (WC) population. SUMMARY OF BACKGROUND DATA: RLDH is estimated to occur in 7% to 24% of patients after discectomy. There are two main surgical options after reherniation: a revision discectomy (RD), or an RD combined with fusion (RDF). METHODS: A total of 10,592 patients received lost-work compensation from the Ohio Bureau of Workers' Compensation for a lumbar disc herniation between 2005 and 2012. Patients with lumbar spine comorbidities, a smoking history, or multilevel surgery were excluded. One hundred two patients had RD alone for RLDH and 196 had RDF procedures. The primary outcome was whether subjects returned to work (RTW). RESULTS: A total of 298 WC patients met our study criteria, including 230 (77.2%) men and 68 (22.8%) women with an average age of 39.4 years (range 19-66). The RDF group had lower rates of RTW than the RD group (27.0% vs 40.2%; P = 0.03). Multivariate regression analysis showed that reoperation with discectomy and fusion (P = 0.04; odds ratio [OR] = 0.56), psychiatric illness (P < 0.01; OR = 0.19), and opioid analgesic use within 1 month of reoperation (P < 0.01; OR = 0.44) were independent negative predictors of RTW. RDF patients were supplied with opioids for 252.3 days longer (P < 0.01) and incurred $34,914 (31.8%) higher medical costs (P < 0.01) than the RD alone group. CONCLUSION: We analyzed outcomes after operative management of RLDH in the WC population. WC patients receiving RDF had lower RTW rates, higher costs, and a longer duration of postoperative opioid use than those receiving RD alone. This information allows for informed patient management decisions and suggests that fusion should be reserved for patients with clear indications for its use. We are unable to conclude what treatment method is best, but rather we provide a baseline for future studies. LEVEL OF EVIDENCE: 3.