Do Children With Medicaid Insurance Have Increased Revision Rates 5 Years After Posterior Spinal Fusions?

BACKGROUND: Socioeconomic disparities in musculoskeletal care are increasingly recognized, however, no studies to date have investigated the role of the insurance carrier on outcomes after posterior spinal fusion (PSF) with segmental spinal instrumentation for adolescent idiopathic scoliosis (AIS). METHODS: A US insurance dataset was queried using the PearlDiver Mariner software for all patients aged 10 to 18 undergoing PSF for a primary diagnosis of AIS between 2010 and 2020. Age, sex, geographic region, number of levels fused, and baseline medical comorbidities were queried. Complications occurring within 90 days of the index surgery were queried using the International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, 10th Revision (ICD-10) codes. Revision surgery was also queried up to 5 years after the index PSF. Categorical variables were compared using the Fisher χ 2 tests and continuous variables were compared using independent t tests. All-cause revision within 5 years was compared using the Kaplan-Meier analysis and a log-rank test. Significance was set at P -value <0.05. RESULTS: A total of 10,794 patients were identified with 9006 (83.4%) patients with private insurance and 1788 (16.6%) patients insured by Medicaid. The mean follow-up in the database was 5.36±3 years for patients with private insurance and 4.78±2.9 years for patients with Medicaid insurance ( P <0.001). Children with AIS and Medicaid insurance had a significantly higher prevalence of asthma, hypertension, and obesity. A larger percentage of children with Medicaid insurance (41.3%) underwent a ≥13-level PSF compared with privately insured children (34.5%) ( P <0.001). Medicaid patients did not experience higher odds of postoperative complications; in addition, revision surgeries occurred in 1.1% and 1.8% of patients with private insurance and Medicaid insurance, respectively at 5 years postoperatively ( P =0.223). CONCLUSION: Despite worse baseline comorbidities and longer fusion constructs, AIS patients insured with Medicaid did not have higher rates of complications or revisions at 5-year follow-up versus privately insured patients. LEVEL OF EVIDENCE: Level III-retrospective cohort study.

Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery.

BACKGROUND: Perioperative surgical site infection (SSI) after pediatric spine fusion is a recognized complication with rates between 0.5% and 1.6% in adolescent idiopathic scoliosis and up to 22% in "high risk" patients. Significant variation in the approach to infection prophylaxis has been well documented. The purpose of this initiative is to develop a consensus-based "Best Practice" Guideline (BPG), informed by both the available evidence in the literature and expert opinion, for high-risk pediatric patients undergoing spine fusion. For the purpose of this effort, high risk was defined as anything other than a primary fusion in a patient with idiopathic scoliosis without significant comorbidities. The ultimate goal of this initiative is to decrease the wide variability in SSI prevention strategies in this area, ultimately leading to improved patient outcomes and reduced health care costs. METHODS: An expert panel composed of 20 pediatric spine surgeons and 3 infectious disease specialists from North America, selected for their extensive experience in the field of pediatric spine surgery, was developed. Using the Delphi process and iterative rounds using a nominal group technique, participants in this panel were as follows: (1) surveyed for current practices; (2) presented with a detailed systematic review of the relevant literature; (3) given the opportunity to voice opinion collectively; and (4) asked to vote regarding preferences privately. Round 1 was conducted using an electronic survey. Initial results were compiled and discussed face-to-face. Round 2 was conducted using the Audience Response System, allowing participants to vote for (strongly support or support) or against inclusion of each intervention. Agreement >80% was considered consensus. Interventions without consensus were discussed and revised, if feasible. Repeat voting for consensus was performed. RESULTS: Consensus was reached to support 14 SSI prevention strategies and all participants agreed to implement the BPG in their practices. All agreed to participate in further studies assessing implementation and effectiveness of the BPG. The final consensus driven BPG for high-risk pediatric spine surgery patients includes: (1) patients should have a chlorhexidine skin wash the night before surgery; (2) patients should have preoperative urine cultures obtained; (3) patients should receive a preoperative Patient Education Sheet; (4) patients should have a preoperative nutritional assessment; (5) if removing hair, clipping is preferred to shaving; (6) patients should receive perioperative intravenous cefazolin; (7) patients should receive perioperative intravenous prophylaxis for gram-negative bacilli; (8) adherence to perioperative antimicrobial regimens should be monitored; (9) operating room access should be limited during scoliosis surgery (whenever practical); (10) UV lights need NOT be used in the operating room; (11) patients should have intraoperative wound irrigation; (12) vancomycin powder should be used in the bone graft and/or the surgical site; (13) impervious dressings are preferred postoperatively; (14) postoperative dressing changes should be minimized before discharge to the extent possible. CONCLUSIONS: In conclusion, we present a consensus-based BPG consisting of 14 recommendations for the prevention of SSIs after spine surgery in high-risk pediatric patients. This can serve as a tool to reduce the variability in practice in this area and help guide research priorities in the future. Pending such data, it is the unsubstantiated opinion of the authors of the current paper that adherence to recommendations in the BPG will not only decrease variability in practice but also result in fewer SSI in high-risk children undergoing spinal fusion. LEVEL OF EVIDENCE: Not applicable.

Histomorphometric assessment of thoracoscopically assisted anterior release in a porcine model: safety and completeness of disc discectomy with surgeon learning curve.

STUDY DESIGN: A retrospective study using histomorphometric analysis to quantify the percentage of discectomy following thoracoscopic anterior release and fusion in a porcine model. OBJECTIVE: To investigate the safety and completeness of disc and endplate removal with respect to the learning curve of the surgeon in a porcine thoracoscopic anterior fusion model. SUMMARY OF BACKGROUND DATA: The thoracoscopic approach has been used to perform an anterior release and fusion before an open posterior instrumentation, however, there is concern that the technique may not provide sufficient visualization or exposure to perform safely and completely. METHODS: A total of 32 pigs (160 discs) were assigned to 2 groups (early experience, n = 16; late experience, n = 16), and underwent 5 level thoracoscopic anterior release followed by anterior instrumentation and fusion from T5 to T10. At 4 months after surgery, the spines were harvested, and each discectomy disc was histomorphometrically analyzed to determine the percentage of disc excision and amount of endplate removal. RESULTS: There were no significant differences in the percent disc excision between the early (67% +/- 11%) and late groups (69% +/- 10%). Greater than 50% of the disc was excised in 151 of 160 discectomies (94%). Both superior and inferior endplates were resected in 92 of 160 disc levels (57%). The amount of endplate removal had improved over time in both early and late groups (P < 0.0001). The histologic examination revealed no evidence for posterior longitudinal ligament disruption or spinal canal encroachment in any disc. CONCLUSIONS: Video-assisted thoracoscopic discectomy is safe and allows for a significant amount of disc material excision. This study did not demonstrate a learning curve with respect to the amount of disc material excised, but a learning curve was seen for endplate excision.

Analysis of patient and parent assessment of deformity in idiopathic scoliosis using the Walter Reed Visual Assessment Scale.

OBJECTIVES: This study evaluates the Walter Reed Visual Assessment Scale (WRVAS) compared with clinical parameters and written descriptions of the deformity from idiopathic scoliosis patients and their parents. SUMMARY OF BACKGROUND DATA: The WRVAS demonstrates seven visible aspects of spinal deformity in an analogue scale. Higher scores reflect worsening deformity. MATERIALS AND METHODS: The WRVAS was administered to 182 idiopathic scoliosis patients at four centers in conjunction with open-ended questions about patients' and their parents' perceptions of their spinal deformity. The open-ended responses were categorized as either "deformity noted" or "no deformity noted." RESULTS: WRVAS scores strongly correlate with curve magnitude (P = 0.01) and clearly differentiates curves of 30 degrees or more from lesser curves. Among treatment groups, patients with surgery recommended had significantly higher scores than that of other patients. The instrument differentiated those noting no deformity from those noting a deformity. The correlation between patients' and parents' scores was high (Spearman's rho = 0.8). When a deformity was noted, parents gave higher scores than did their children for rib prominence, shoulder level, scapular rotation, and the total score, but not for the other dimensions. CONCLUSIONS: Increasing scores of the WRVAS are strongly correlated with curve magnitude lending construct validity to this type of assessment tool. Patients with "surgery recommended" report more visible deformity on the scale than observed, braced, and postoperative patients, supporting the hypothesis that surgery improves the perceived appearance. Parents perceive more deformity of the ribs and shoulders more than did the patients, but other aspects of the deformity are identified equally. WRVAS scores correlate significantly with curve magnitude and treatment. Parents and patients have similar scores, but with parents perceiving more deformity of the ribs and shoulders than patients.