Morphometric analysis of cervical neuroforaminal dimensions from C2-T1 using computed tomography of 1,000 patients.

BACKGROUND: Race and sex differences are not consistently reported in the literature. Fundamentally, anatomical differences of cervical neuroforaminal dimensions (CNFD) amongst these groups would be important to know. PURPOSE: To establish normative radiographic morphometric measurements of CNFD and uncover the influence of patient sex, race, and ethnicity while also considering anthropometric characteristics. STUDY DESIGN: Retrospective radiographic morphometric study. PATIENT SAMPLE: A total of 1,000 patients between 18 and 35 years of age who were free of spinal pathology. OUTCOME MEASURES: Foraminal height, axial width, and area of cervical neural foramen. METHODS: Cervical CTs were reviewed to measure CNFD, defined as follows: foraminal height, axial width, and area. Statistical analyses were performed to assess associations between CNFD, and patient height, weight, sex, race, and ethnicity. RESULTS: CNFD measurements followed a bimodal distribution pattern moving caudally from C2-T1. Irrespective of disc level, cervical CNFD were as follows: left and right widths of 6.6±1.5 and 6.6±1.5 mm, heights of 9.4±2.4 and 9.4±3.2 mm, and areas of 60.0±19.5 and 60.6±20.7 mm2. Left and right foraminal width were highest at C2-C3 and lowest at C3-C4. Left and right foraminal height were highest at C7-T1 and C6-C7, respectively and lowest at C3-C4. Left and right foraminal areas were highest at C2-C3 and lowest at C3-C4. Significant differences were observed for all CNFD measurements across disc levels. CNFD did not vary based on laterality. Significant CNFD differences were observed with respect to patient sex, race, and ethnicity. Male height and area were larger compared to females. In contrast, female foraminal width was larger compared to males. The Asian cohort demonstrated the largest foraminal widths. White and Hispanic patients demonstrated the largest foraminal heights and areas. Black patients demonstrated the smallest foraminal widths, heights, and areas. Patient height and weight were only weakly correlated with CNFD measurements across all levels from C2-T1. CONCLUSIONS: This study describes 36,000 normative measurements of 12,000 foramina from C2-T1. CNFD measurements vary based on disc level, but not laterality. Contrasting left- versus right-sided neuroforamina of the same level may aid in determining the presence of unilateral stenosis. Patient sex, race, and ethnicity are associated with CNFD, while patient anthropometric factors are weakly correlated with CNFD.

Gender, Racial, and Ethnic Differences in the Utilization of Cervical Disk Replacement for Cervical Radiculopathy.

INTRODUCTION: Cervical radiculopathy (CR) is commonly treated by spine surgeons, with surgical options including anterior cervical diskectomy and fusion (ACDF) and cervical disk replacement (CDR). CDR is a motion-sparing alternative to ACDF and was approved by the US FDA in 2007. CDR utilization has increased because evidence has emerged demonstrating its long-term efficacy. Despite CDR's efficacy, studies have suggested that socioeconomic factors may influence which patients undergo CDR versus ACDF. Our objective was to determine whether gender, racial, and ethnic disparities exist in the utilization of CDR versus ACDF for CR. METHODS: Patients age ≥18 years undergoing elective CDR or ACDF for CR between 2017 and 2020 were identified in the Vizient Clinical Database. Proportions of patients undergoing CDR and ACDF, as well as their comorbidities, complications, and outcomes, were compared by sex, race, and ethnicity. Bonferroni correction was done for multiple comparisons. RESULTS: A total of 7,384 patients, including 1,427 undergoing CDR and 5,957 undergoing ACDF, were reviewed. Black patients undergoing surgical treatment of CR were less likely to undergo CDR than ACDF, had a longer length of stay, and had higher readmission rates, while Hispanic patients had higher complication rates than non-Hispanic patients. DISCUSSION: Important racial and ethnic disparities exist in CR treatment. Interventions are necessary to ensure equal access to spine care by reducing barriers, such as underinsurance and implicit bias. LEVEL OF EVIDENCE: IV (Case Series).

Current Orthopaedic Residency Letters of Recommendation Are Not Biased by Gender of Applicant.

Letters of recommendation (LORs) are highly influential in the residency selection process. Differences in language and length of LORs by gender have been demonstrated for applicants applying to surgical residencies and fellowships. This had yet to be studied in orthopaedic surgery. Given the gender disparity in the field, we sought to investigate the impact of gender on orthopaedic residency applicant LORs. We hypothesized that differences in length and language would be present for women applicants as compared to men. METHODS: LORs for 2019 to 2020 applicants who applied to a single academic institution were selected for review. Female and male applicants were matched by medical school attended and United States Medical Licensing Examination Step 1 score. LORs were analyzed using both qualitative and quantitative analyses. Letters were evaluated for their word count, presence of language terms, and frequency of language terms. A similar subgroup language analysis was performed for standardized LORs (SLORs). RESULTS: Six hundred fifty-six applicants met the initial screening criteria-126 women and 530 men. After matching, 71 female applicants were paired with 111 male applicants. Word count was, on average, longer for female applicants. LORs for female applicants were more likely to contain language terms that characterized their ability, achievement, participation in athletics, awards received, fit, leadership, and personality traits. Of these terms, ability and participation in athletics were also found more frequently in LORs written for women. In addition, language characterizing technical skills was found more frequently in LORs of female applicants. Similar codes were found to be statistically significant in the SLOR subgroup analysis. CONCLUSION: This study highlights that current orthopaedic surgery residency LORs do not appear to be biased by applicant gender. LORs were longer for female applicants and described them more positively. Future female orthopaedic residency applicants should be assured that current female candidates are applying with at least similar if not greater subjective qualifications to their male counterparts based on the findings of this study.

Prognostic value of laboratory values in older patients with cervical spine fractures.

OBJECTIVES: To understand the prognostic value of laboratory markers at presentation on post-treatment survival of patients 50 and older following cervical spine fracture. PATIENTS AND METHODS: We obtained clinical data on patients 50 and older treated for cervical spine fracture in a single healthcare system (2006-2016). Our primary outcome consisted of 1-year mortality, with mortality within 3-months of presentation considered secondarily. Our primary predictors included serum glucose, serum creatinine, platelet-lymphocyte ratio (PLR) and neutrophil-lymphocyte ratio (NLR) at presentation. We used multivariable logistic regression to adjust for confounding from sociodemographic and clinical characteristics. Point estimates and 95 % confidence intervals (CI) from the final model were refined using Bayesian regression techniques. RESULTS: We included 1781 patients in this analysis, with an average age of 75.3 (SD 12.0). The mortality rate at 3-months was 12 % and 17 % at 1-year. In multivariable testing, neither elevated PLR or NLR were significant predictors of 1-year mortality. Elevated serum creatinine was associated with increased mortality at 1-year (OR 1.89; 95 % CI 1.30, 2.74), as was hyperglycemia (OR 1.50; 95 % CI 1.06, 2.13). Elevated serum creatinine remained influential (OR 1.64; 95 % CI 1.06, 2.54) on mortality at 3-months. CONCLUSIONS: This is the first study to evaluate laboratory values at presentation in conjunction with survival following cervical fractures. The results can be used to help forecast natural history and in expectation management. They may also help formulate treatment plans, especially when the need for surgical intervention is not clearly defined.

Do Medicare Accountable Care Organizations Reduce Disparities After Spinal Fracture?

BACKGROUND: National changes in health care disparities within the setting of trauma care have not been examined within Accountable Care Organizations (ACOs) or non-ACOs. We sought to examine the impact of ACOs on post-treatment outcomes (in-hospital mortality, 90-day complications, and readmissions), as well as surgical intervention among whites and nonwhites treated for spinal fractures. MATERIALS AND METHODS: We identified all beneficiaries treated for spinal fractures between 2009 and 2014 using national Medicare fee for service claims data. Claims were used to identify sociodemographic and clinical criteria, receipt of surgery and in-hospital mortality, 90-day complications, and readmissions. Multivariable logistic regression analysis accounting for all confounders was used to determine the effect of race/ethnicity on outcomes. Nonwhites were compared with whites treated in non-ACOs between 2009 and 2011 as the referent. RESULTS: We identified 245,704 patients who were treated for spinal fractures. Two percent of the cohort received care in an ACO, whereas 7% were nonwhite. We found that disparities in the use of surgical fixation for spinal fractures were present in non-ACOs over the period 2009-2014 but did not exist in the context of care provided through ACOs (odds ratio [OR] 0.75; 95% confidence interval [CI] 0.44, 1.28). A disparity in the development of complications existed for nonwhites in non-ACOs (OR 1.09; 95% CI 1.01, 1.17) that was not encountered among nonwhites receiving care in ACOs (OR 1.32; 95% CI 0.90, 1.95). An existing disparity in readmission rates for nonwhites in ACOs over 2009-2011 (OR 1.34; 95% CI 1.01, 1.80) was eliminated in the period 2012-2014 (OR 0.85; 95% CI 0.65, 1.09). CONCLUSIONS: Our work reinforces the idea that ACOs could improve health care disparities among nonwhites. There is also the potential that as ACOs become more familiar with care integration and streamlined delivery of services, further improvements in disparities could be realized.

Changes in healthcare delivery following spinal fracture in Medicare Accountable Care Organizations.

BACKGROUND CONTEXT: Accountable Care Organizations (ACOs) were designed to reduce healthcare costs while simultaneously improving quality. Given that the success of ACOs is predicated on controlling costs, concerns have been expressed that patients could be adversely affected through restricted access to surgery, including in the context of spine fracture care. PURPOSE: Evaluate the impact of Medicare ACO formation on the utilization of surgery and outcomes following spinal fractures. STUDY DESIGN: Retrospective review of Medicare claims (2009-2014). PATIENT SAMPLE: Patients treated for spinal fractures in an ACO or non-ACO. OUTCOME MEASURES: The utilization of surgery as treatment for spinal fractures, in-hospital mortality, 90-day complications, or hospital readmission within 90-days injury. METHODS: We used a pre-post study design to compare outcomes for patients treated in ACOs versus non-ACOs. Receipt of surgery for treatment of a spinal fracture was the primary outcome, with mortality, complications and readmissions treated secondarily. We used multivariable logistic regression adjusting for confounders to determine the association between environment of care (ACO vs. non-ACO) and the outcomes of interest. In all testing, beneficiaries treated in non-ACOs during 2009 to 2011 were used as the referent. RESULTS: During 2009 to 2011, 9% (n=10,866) of patients treated in non-ACOs received surgery, whereas a similar percentage (9%; n=210) underwent surgery in ACOs. This figure decreased to 8% (n=9,857) for individuals treated in non-ACOs over 2012 to 2014, although the surgical rate remained unchanged for those receiving care in an ACO (9%; n=227). There was no difference in the use of surgery among patients treated in ACOs (OR 0.96; 95% CI 0.79, 1.18) over 2012 to 2014. Similar increases in the odds of mortality were observed for both ACOs and non-ACOs during this period. A marginal, yet significant increase in complications was observed among ACOs, although there was no change in the odds of readmission. CONCLUSIONS: Our study found that the formation of ACOs did not result in alterations in the use of surgery for spinal fractures or substantive changes in outcomes. As ACOs continue to evolve, more emphasis should be placed on the incorporation of measures directly related to surgical and trauma care in the determinants of risk-based reimbursements.