Racial Disparities in Outcomes After Spine Surgery: A Systematic Review and Meta-Analysis.

OBJECTIVE: Racial disparities are a major issue in health care but the overall extent of the issue in spinal surgery outcomes is unclear. We conducted a systematic review/meta-analysis of disparities in outcomes among patients belonging to different racial groups who had undergone surgery for degenerative spine disease. METHODS: We searched Ovid MEDLINE, Scopus, Cochrane Review Database, and ClinicalTrials.gov from inception to January 20, 2021 for relevant articles assessing outcomes after spine surgery stratified by race. We included studies that compared outcomes after spine surgery for degenerative disease among different racial groups. RESULTS: We found 30 studies that met our inclusion criteria (28 articles and 2 published abstracts). We included data from 20 cohort studies in our meta-analysis (3,501,830 patients), which were assessed to have a high risk of observation/selection bias. Black patients had a 55% higher risk of dying after spine surgery compared with white patients (relative risk [RR], 1.55, 95% confidence interval [CI], 1.28-1.87; I2 = 70%). Similarly, black patients had a longer length of stay (mean difference, 0.93 days; 95% CI, 0.75-1.10; I2 = 73%), and higher risk of nonhome discharge (RR, 1.63; 95% CI, 1.47-1.81; I2 = 89%), and 30-day readmission (RR, 1.45; 95% CI, 1.03-2.04; I2 = 96%). No significant difference was noted in the pooled analyses for complication or reoperation rates. CONCLUSIONS: Black patients have a significantly higher risk of unfavorable outcomes after spine surgery compared with white patients. Further work in understanding the reasons for these disparities will help develop strategies to narrow the gap among the racial groups.

Construct Validity and Reliability of the Japanese Version of the Lumbar Stiffness Disability Index.

STUDY DESIGN: Outcome study to determine the construct validity and reliability of the Japanese version of the Lumbar Stiffness Disability Index. OBJECTIVE: The aim of this study was to evaluate the psychometric measurement properties of the Japanese version of the Lumbar Stiffness Disability Index (J-LSDI) following lumbar spinal surgery in order to assess its construct validity and reliability. SUMMARY OF BACKGROUND DATA: The LSDI was designed and validated as a tool to assess functional impacts of lumbar spine stiffness and diminished spinal flexibility. A Japanese version has been developed, but its construct validity and reliability have not been evaluated. METHODS: A Pearson correlation coefficient was calculated using flexion and extension range of motion, Oswestry Disability Index (ODI) and Tampa Scale for Kinesiophobia (TSK) as external standards to evaluate construct validity. An intraclass correlation coefficient (ICC) and a Bland-Altman analysis were used to evaluate test-retest reliability. RESULTS: A total of 244 patients following lumbar spinal surgery participated in the study. Fifty one of the 244 patients participated in the reliability study. The ICC of the J-LSDI for test-retest reliability was 0.89 (95% confidence interval, 0.79-0.93). There was no systematic error found in the results of the Bland-Altman analysis. One hundred ninety-three of the 244 patients participated in the validity study. There were significant correlations between the J-LSDI and trunk flexion range of motion (r = -0.66), extension (r = -0.51), ODI (r = 0.62), and TSK (r = 0.38). CONCLUSION: The construct validity and reliability of the Japanese version of the LSDI were confirmed. The J-LSDI can be used to evaluate lumbar stiffness and associated disability in Japanese patients following lumbar spinal surgery.Level of Evidence: 2.

Lower Satisfaction After Adult Spinal Deformity Surgery in Japan Than in the United States Despite Similar SRS-22 Pain and Function Scores: A Propensity-Score Matched Analysis.

STUDY DESIGN: A multicenter retrospective case series. OBJECTIVE: The purpose of this study was to compare the clinical outcomes of a surgical treatment for adult spinal deformity (ASD) in the United States (US) with those in Japan (JP) in a matched cohort. SUMMARY OF BACKGROUND DATA: Surgical outcomes of thoracic-lumbar-sacral (TLS) spinal fusions in adult spinal deformity ASD patients who live in Asian countries are poorly understood. METHODS: A total of 300 surgically treated ASDs of age more than 50 years with the lowest instrumented vertebra at the pelvis and a minimum follow-up of 2 years (2y) were consecutively included. Patients were propensity-score matched for age, sex, levels fused, and 2y postop sagittal spinal alignment. Demographic, surgical, and radiographic parameters were compared between the US and JP groups. RESULTS: A total of 186 patients were matched by propensity score and were almost identical within these parameters: age (US vs. JP: 66 ±â€Š8 vs. 65 ±â€Š7 yr), sex (females: 90% vs. 89%), levels fused (10 ±â€Š3 vs. 10 ±â€Š2), 2y C7 sagittal vertical axis (C7SVA) (5 ±â€Š5 vs. 5 ±â€Š4 cm), 2y Pelvic incidence minus lumbar lordosis (9 ±â€Š15° vs. 9 ±â€Š15°), and 2y pelvic tilt (PT) (25 ±â€Š10° vs. 24 ±â€Š10°). Oswestry Disability Index (ODI) scores and Scoliosis Research Society patient questionnaire ((SRS-22) function and pain scores were similar at 2y between the US and JP groups (ODI: 27 ±â€Š19% vs. 28 ±â€Š14%, P = 0.72; SRS-22 function: 3.6 ±â€Š0.9 vs. 3.6 ±â€Š0.7, P = 0.54; SRS-22 pain: 3.6 ±â€Š1.0 vs. 3.8 ±â€Š0.8, P = 0.11). However, significantly lower satisfaction was observed in JP than in the US (SRS-22 satisfaction: 4.3 ±â€Š0.9 vs. 4.0 ±â€Š0.8, P < 0.01). CONCLUSION: Surgical treatment for ASD was similarly effective in patients in the US and in JP. However, satisfaction scores were lower in JP compared with the US. Differences in lifestyle and cultural expectations may impact patient satisfaction following ASD surgery. LEVEL OF EVIDENCE: 3.

Is C1 lateral mass screw placement safe for the Chinese, Indians, and Malays? An analysis of 180 computed tomography scans.

INTRODUCTION: C1 lateral mass (C1LM) screw is a common procedure in spine surgery. However, related studies are lacking in Asia. We aim to determine the safety of C1LM screw for the Chinese, Indians, and Malays. METHODS: Three-dimensional computed tomographies of 180 subjects (60 from each ethnic) were analyzed. The length and angulations of C1LM screw and the location of internal carotid artery (ICA) in relation to C1LM were assessed and classified according to the classification by Murakami et al. The incidence of ponticulus posticus (PP) was determined and the differences among the population of these three ethnics were recorded. RESULTS: The average base length was 8.5 ± 1.4 mm. The lengths within the lateral mass were between 14.7 ± 1.6 mm and 21.7 ± 2.3 mm. The prevalence of PP was 8.3%. 55.3% (199) of ICA were located in zone 0, 38.3% (138) in zone 1-1, 6.4% (23) in zone 1-2, and none in zone 1-3 and zone 2. The average angulation from the entry point to the ICA was 8.5° ± 6.4° laterally. The mean distance of ICA from C1 anterior cortex was 3.7 ± 1.7 mm (range: 0.6∼11.3). There was no difference in distribution of ICA in zone 1 among the three population (Chinese-47%, Indians-61%, and Malays-53%; p > 0.05). CONCLUSIONS: No ICA is located medial to the entry point of C1LM screw. If bicortical purchase of C1LM screw is needed, screw protrusion of less than 3 mm or medially angulated is safe for ICA. The incidence of PP is 8.3% with higher prevalence among the Indian population.

The effect of race on outcomes of surgical or nonsurgical treatment of patients in the Spine Patient Outcomes Research Trial (SPORT).

STUDY DESIGN: Retrospective review of the data collected prospectively through the Spine Patient Outcomes Research Trial (SPORT). OBJECTIVE: To determine the effect that race or ethnicity had on outcomes after spine surgery in the 3 arms of SPORT. SUMMARY OF BACKGROUND DATA: There is a dearth of research regarding the effect of race or ethnicity on outcome after treatment of spinal disorders. METHODS: All participants from the 3 arms of the SPORT were evaluated in an as-treated analysis, with patients categorized as white, black, or other. Baseline and operative characteristics of the groups were compared using the χ test and analysis of variance. Differences in the changes between baseline and 1-, 2-, 3-, and 4-year time points in the operative and nonoperative treatments were evaluated with a mixed effects longitudinal regression model, and differences between racial groups were compared with a multiple degrees of freedom Wald test. RESULTS: A total of 2427 patients (85% white, 8% black, and 7% other) were included. Surgery was performed on 67% of white patients, 54% of blacks, and 68% of others. Whites and others were significantly more likely to undergo surgery than blacks (67% and 68% vs. 54%, P = 0.003). Complications and the risk of additional surgeries were not significantly different between racial groups. Regardless of race, all patients improved more with surgical management than with nonoperative treatment for all outcome measures at all time points. The average 4-year area-under-the-curve results revealed surgical and nonoperative treatment resulted in statistically significant improvement in whites relative to blacks for SF-36 bodily pain (P < 0.001), physical function (P < 0.001), and Oswestry Disability Index (P < 0.001). No significant differences were noted in treatment effect for primary outcome measures or self-rated progress across racial groups. CONCLUSION: These results illustrate important differences between racial groups in terms of response to spine care. Although there were quantitative differences between groups, these findings are not necessarily indications of health care disparities.

Vertebral coccidioidomycosis: presentation and multidisciplinary management.

BACKGROUND: Vertebral involvement is a severe complication of infection caused by Coccidioides species. METHODS: We conducted a retrospective review of patients diagnosed with vertebral coccidioidomycosis at an academic medical center between 1996 and 2009. RESULTS: We identified 39 cases of vertebral coccidioidomycosis. Thirty-four patients (79%) were male, and 23 patients (61%) were black. Black patients were overrepresented in comparison with all other patients by a 50-fold odds ratio (95% confidence interval, 26-95). Only 8 patients (20%) were immunocompromised, including 7 who had received systemic steroids. The number of infected vertebrae ranged from 1 to 24; 8 patients (21%) had epidural involvement. All patients received a triazole as part of medical therapy, and 20 patients also received amphotericin B, typically early in the course. Twenty-six patients (67%) required surgery, 18 of whom also required hardware placement. The most common indication for surgery was pain, but 7 patients had neurologic compromise. No patients developed recurrent or refractory infection at the site of surgical debridement, but 6 patients experienced disease relapse after stopping antifungal therapy. CONCLUSION: Vertebral infection caused by Coccidioides species requires a multispecialty approach that always includes medical therapy and frequently requires surgical intervention for debridement or stabilization. A favorable outcome can usually be achieved, but discontinuation of medical therapy is associated with a high risk of relapse, which can occur years later.

Outcomes after spine surgery among racial/ethnic minorities: a meta-analysis of the literature.

BACKGROUND CONTEXT: Prior research has identified disparities in access to care, resource utilization, and outcomes in members of racial and ethnic minorities. However, the role that race/ethnicity may play in influencing outcomes after spine surgery has not been previously studied. PURPOSE: To characterize the effect of race and ethnicity on outcome after spine surgery. STUDY DESIGN: Systematic literature review and meta-analysis. PATIENT SAMPLE: Of 11 investigations selected in the initial analysis, four reported results in a fashion that enabled their inclusion in the meta-analysis. These four studies included a total of 128,635 patients. OUTCOME MEASURES: "Favorable" or "unfavorable" postsurgical outcomes were determined based on parameters described in each included investigation. METHODS: A systematic literature review was performed to identify all studies documenting outcomes, complications, or mortality after spine surgical procedures. Eligible studies had to include raw data that enabled separate analysis of white and nonwhite patients. Outcome was categorized as "favorable" or "unfavorable" based on scales included in each investigation. The Q-statistic was used to determine heterogeneity, and a meta-analysis was performed to assess the relative risk for unfavorable outcome among nonwhite patients after spine surgery. RESULTS: Eleven studies met initial selection criteria but only four were eligible for inclusion in the meta-analysis. The meta-analysis included 128,635 patients among whom 12,194 (9.5%) had unfavorable outcomes. Among white patients, 9.4% sustained an unfavorable outcome as compared with 10.4% of nonwhites. CONCLUSIONS: In light of the small number of studies able to be included in the meta-analysis, no firm conclusions can be drawn regarding the effect of race/ethnicity on outcome after spinal surgery. There is a pressing need for more robust research regarding spine surgical outcomes among different racial and ethnic minority groups.

An anatomical study in a Chinese population of the position of the rib head for placing anterior vertebral body screws.

The instrumentation of anterior vertebral body screws has become an important approach for the treatment of unstable fractures or curvature of the spine, but little attention has been paid to the starting point of placing the screws and the variability of the rib head position. We analysed the variability of rib head position in a Chinese population in terms of the spinal canal and vertebral body using computed tomography (CT). Images from transverse CT scans of the T4-T12 vertebral bodies of 30 normal individuals were 3-D reconstructed and analysed for measurement of parameters which included: 1) distance between the left (or right) anterior border of the rib head and the posterior (or anterior) margin of the vertebral body [L(R)ARHP(A)VB]; 2) left (or right) transverse dimension [L(R)TD]; 3) left (or right) posterior (or anterior) safe angle [L(R)P(A)SA]; and 4) distance between the inferior border of the left (or right) rib head and the superior (or inferior) end-plate in the sagittal plane [I L(R)RHS(I)EP]. The ARHPVB, PSA, and IRHIEP gradually decrease, but ARHAVB, TD, ASA, and IRHSEP gradually increase, from T4 to T12, indicating that the position of the rib head changes from a more anterior position to a more posterior position and from a more superior position to a more inferior position, as the number of the vertebra increases. Our study has provided a comprehensive reference guide for accurate and safe instrumentation of vertebral body screws in treating related spine diseases.

Insurance status, geography, race, and ethnicity as predictors of anterior cervical spine surgery rates and in-hospital mortality: an examination of United States trends from 1992 to 2005.

STUDY DESIGN: Retrospective cross-sectional study. OBJECTIVE: To determine the role of race, insurance status, and geographic location on US anterior cervical spine surgery rates and in-hospital mortality between 1992 and 2005. SUMMARY OF BACKGROUND DATA: Previous investigation indicates that anterior cervical spine surgery has been increasingly used in the management of degenerative cervical spine disease throughout the 1990s. Significant predictors of health outcomes, including race, ethnicity, geography, and insurance coverage have yet to be investigated in detail for these procedures. METHODS: Cases of anterior cervical spine surgery were identified from the Nationwide Inpatient Sample. The US population counts were taken from the Current Population Survey. Multivariate regression models were employed to describe national rates of anterior cervical spine surgery and model the odds of death among admissions for anterior cervical spine surgery. All models incorporated adjustment for hospital sample clustering, age, and comorbidity status. RESULTS: Based on an analysis of a total 100,286,482 hospital discharge records, an estimated 965,600 anterior cervical spine procedures were performed between 1992 and 2005 in the United States. During this period, rates of surgery increased by 289%. Though adjusted rates of surgery were lowest among minority populations, disparities decreased with time. The mean age of patients, as well as the average preoperative comorbidity status, increased with time. The odds of mortality did not significantly increase between 1992 and 2005. Odds of in-hospital death were greatest in among black patients (P < 0.001) and lowest in Southern states (P < 0.001) and patients with private insurance (P < 0.001). CONCLUSION: With the recent rise of anterior cervical spine procedures in the United States, substantial variation in the delivery of surgical care exists along a number of demographic factors. A detailed investigation of variation in surgical decision-making algorithms among spine specialists, as well as a determination of differences among patient populations in attitudes toward surgery, may help elucidate the trends observed in this study.

Differences in the work-up and treatment of conditions associated with low back pain by patient gender and ethnic background.

STUDY DESIGN: Retrospective review comparing physician workup of degenerative lumbosacral pathologies between different genders and ethnic groups. OBJECTIVES: To investigate whether patient ethnicity and gender influence the workup and treatment of degenerative spinal pathologies. SUMMARY OF BACKGROUND DATA: Data from numerous studies suggest that patient gender and ethnicity play a role in medical decision-making, with white males receiving more frequent interventions than women and minorities. METHODS: Patients enrolled for an "initial visit" in the National Spine Network database with lumbosacral level degenerative diagnosis were reviewed. Variables included patient gender, ethnicity, age, duration of symptoms, patient-graded severity of symptoms, radicular symptom pattern, and work status. RESULTS: We identified 5690 patients with degenerative lumbosacral pathologies. Although females were more likely than males to have imaging tests ordered, male (18.5%) patients were significantly more likely to have surgery recommended than female (16.3%) patients (P < 0.031). Nonwhite females were 52% less likely to have surgery offered at initial visit, as compared to white males (P < 0.005). More imaging tests were ordered or reviewed among whites (76.6%) than among any other ethnic group (P = 0.162). White (18.3%) and Asian (22.5%) patients were significantly more likely to have surgery recommended or prescribed than black (11.1%) and Hispanic (14.5) patients (P < 0.0001). CONCLUSIONS: This study suggests that ethnicity and gender affect the workup and surgical management of degenerative spinal disorders. However, it should be noted that there are a number of confounding factors not identified in the database, including managed care and insurance status and cultural differences, which may affect both test ordering and treatment recommendations. Further study of bias in clinical decision-making is indicated to assure equal delivery of quality care.

Prevalence of spondyloarthropathies and HLA-B27 in the native population of Chukotka, Russia.

OBJECTIVE: We sought to determine the prevalence and nature of spondyloarthropathies (SPA) and the prevalence of HLA-B27 in the native selected circumpolar population of Chukotka, Russia. METHODS: We conducted a cross sectional study that included medical examinations and interviews of 355 of 498 (71.3%) native residents of 2 Eastern Chukotka settlements, Enmelen and Nunligran. RESULTS: Among them were 268 Chukchas, 7 Eskimos, and 80 subjects of mixed race. There were 9 subjects (2.5%) with SPA, 3 of 7 Chukchas had ankylosing spondylitis (AS) (1.1%), 2 reactive arthritis (ReA), 2 with undifferentiated SPA. Among the mixed race persons one Chukcha-Eskimo had AS, one Eskimo-Russian had psoriatic arthritis (PsA). We found a high percentage of HLA-B27 antigen in the population, 34% in Chukcha natives and 25% in mixed race. CONCLUSION: Our data complement other studies of circumpolar populations and reinforce the reported high prevalences of SPA and HLA-B27 among those populations.