Evaluation of Factors Affecting Return to Work Following Carpal Tunnel Release: A Statewide Cohort Study of Workers' Compensation Subjects.

PURPOSE: Most randomized trials comparing open carpal tunnel release (OCTR) to endoscopic carpal tunnel release (ECTR) are not specific to a working population and focus mainly on how surgical technique has an impact on outcomes. This study's primary goal was to evaluate factors affecting days out of work (DOOW) following carpal tunnel release (CTR) in a working population and to evaluate for differences in medical costs, indemnity payments, disability ratings, and opioid use between OCTR and ECTR with the intent of determining whether one or the other surgical method was a determining factor. METHODS: Using the Ohio Bureau of Workers' Compensation claims database, individuals were identified who underwent unilateral isolated CTR between 1993 and 2018. We excluded those who were on total disability, who underwent additional surgery within 6 months of their index CTR, including contralateral or revision CTR, and those not working during the same month as their index CTR. Outcomes were evaluated at 6 months after surgery. Multivariable linear regression was performed to evaluate covariates associated with DOOW. RESULTS: Of the 4596 included participants, 569 (12.4%) and 4027 (87.6%) underwent ECTR and OCTR, respectively. Mean DOOW were 58.4 for participants undergoing OCTR and 56.6 for those undergoing ECTR. Carpal tunnel release technique was not predictive of DOOW. Net medical costs were 20.7% higher for those undergoing ECTR. Multivariable linear regression demonstrated the following significant predictors of higher DOOW: preoperative opioid use, legal representation, labor-intensive occupation, increasing lag time from injury to filing of a worker's compensation claim, and female sex. Being married, higher income community, and working in the public sector were associated with fewer DOOW. CONCLUSIONS: In a large statewide worker's compensation population, demographic, occupational, psychosocial, and litigatory factors have a significant impact on DOOW following CTR, whereas differences in surgical technique between ECTR and OCTR did not. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Donor cell engineering with GSK3 inhibitor-loaded nanoparticles enhances engraftment after in utero transplantation.

Host cell competition is a major barrier to engraftment after in utero hematopoietic cell transplantation (IUHCT). Here we describe a cell-engineering strategy using glycogen synthase kinase-3 (GSK3) inhibitor-loaded nanoparticles conjugated to the surface of donor hematopoietic cells to enhance their proliferation kinetics and ability to compete against their fetal host equivalents. With this approach, we achieved remarkable levels of stable, long-term hematopoietic engraftment for up to 24 weeks post-IUHCT. We also show that the salutary effects of the nanoparticle-released GSK3 inhibitor are specific to donor progenitor/stem cells and achieved by a pseudoautocrine mechanism. These results establish that IUHCT of hematopoietic cells decorated with GSK3 inhibitor-loaded nanoparticles can produce therapeutic levels of long-term engraftment and could therefore allow single-step prenatal treatment of congenital hematological disorders.

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).

In Utero Transplantation of Expanded Autologous Amniotic Fluid Stem Cells Results in Long-Term Hematopoietic Engraftment.

In utero transplantation (IUT) of hematopoietic stem cells (HSCs) has been proposed as a strategy for the prenatal treatment of congenital hematological diseases. However, levels of long-term hematopoietic engraftment achieved in experimental IUT to date are subtherapeutic, likely due to host fetal HSCs outcompeting their bone marrow (BM)-derived donor equivalents for space in the hematopoietic compartment. In the present study, we demonstrate that amniotic fluid stem cells (AFSCs; c-Kit+/Lin-) have hematopoietic characteristics and, thanks to their fetal origin, favorable proliferation kinetics in vitro and in vivo, which are maintained when the cells are expanded. IUT of autologous/congenic freshly isolated or cultured AFSCs resulted in stable multilineage hematopoietic engraftment, far higher to that achieved with BM-HSCs. Intravascular IUT of allogenic AFSCs was not successful as recently reported after intraperitoneal IUT. Herein, we demonstrated that this likely due to a failure of timely homing of donor cells to the host fetal thymus resulted in lack of tolerance induction and rejection. This study reveals that intravascular IUT leads to a remarkable hematopoietic engraftment of AFSCs in the setting of autologous/congenic IUT, and confirms the requirement for induction of central tolerance for allogenic IUT to be successful. Autologous, gene-engineered, and in vitro expanded AFSCs could be used as a stem cell/gene therapy platform for the in utero treatment of inherited disorders of hematopoiesis. Stem Cells 2019;37:1176-1188.

Displaced Femoral Neck Fractures in Workers' Compensation Patients Aged 45-65 Years: Is It Best to Fix the Fracture or Replace the Joint?

BACKGROUND: Optimal surgical management of displaced femoral neck fractures (dFNFs) in subjects 45-65 years old is unclear. We evaluated days out of work (dOOW), medical and indemnity costs, and secondary outcomes at 2 years between internal fixation (IF), hemiarthroplasty (HA), and total hip arthroplasty (THA) among workers' compensation (WC) subjects with isolated dFNFs aged 45-65. METHODS: We retrospectively identified 105 Ohio Bureau of WC subjects with isolated subcapital dFNFs aged 45-65 with 2 years of follow-up. In total, 37 (35.2%) underwent IF, 23 (21.9%) THA, and 45 (42.9%) HA from 1993 to 2017. Linear regression was used to determine if surgery type was predictive of dOOW postoperatively and to evaluate inflation-adjusted net medical and indemnity costs at 2 years. RESULTS: IF subjects were younger (52.9) than THA (58.5, P < .001) and HA (58.4, P < .001) subjects. Mean dOOW for THA subjects at 6 months, 1 year, and 2 years was 90.8, 114.6, and 136.6. This was significantly lower than IF (136.3, 182.0, 236.6) and HA (114.6, 153.3, 247.6) subjects at all time points. Medical costs were similar. Mean indemnity costs were 3.0 and 2.4 times higher among IF (P < .001) and HA (P = .007) groups compared to THA, respectively. Rates of postoperative permanent disability awards were 13.0%, 43.2%, and 35.6% for the THA, IF, and HA groups (P = .050). IF and HA subjects had a 24.3% and 11.1% revision rate. Overall, 77.8% and 100% of the IF and HA revisions were conversions to THA. CONCLUSION: WC subjects aged 45-65 with dFNFs treated with THA had fewer dOOW, lower indemnity costs, and less disability at 2 years. Longer follow-up will help determine the durability and long-term outcomes of these surgeries.

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 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).

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).

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).

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).

Smoking is Associated with Increased Blood Loss and Transfusion Use After Lumbar Spinal Surgery.

BACKGROUND: Little is known about the association between smoking and intraoperative blood loss and perioperative transfusion use in patients undergoing spinal surgery. However, we found that although many of the common complications and deleterious effects of smoking on surgical patients had been well documented, the aspect of blood loss seemingly had been overlooked despite data reported in nonorthopaedic sources to suggest a possible connection. QUESTIONS/PURPOSES: We asked: (1) Is smoking associated with increased estimated blood loss during surgery in patients undergoing lumbar spine surgery? (2) Is smoking associated with increased perioperative transfusion usage? METHODS: Between 2005 and 2009, 581 lumbar decompression procedures (with or without fusion) were performed at one academic spine center. Of those, 559 (96%) had sufficient chart documentation to categorize patients by smoking status, necessary intra- and postoperative data to allow analysis with respect to bleeding and transfusion-related endpoints, and who did not meet exclusion criteria. Exclusion criteria included: patients whose smoking status did not fit in our two categories, patients with underlying coagulopathy, patients receiving anticoagulants (including aspirin and platelet inhibitors), history of hepatic disease, history of platelet disorder or other blood dyscrasias, and patient or family history of any other known bleeding disorder. Smoking history in packs per day was obtained for all subjects. We defined someone as a smoker if the patient reported smoking up until the day of their surgical procedure; nonsmokers were patients who quit smoking at least 6 weeks before surgery or had no history of smoking. We used a binomial grouping for whether patients did or did not receive a transfusion perioperatively. Age, sex, number of levels of discectomies, number of levels decompressed, number of levels fused, and use of instrumentation were recorded. The same approaches were used for transfusions in all patients regardless of smoking history; decisions were made in consultation between the surgeon and the anesthesia team. Absolute indications for transfusion postoperatively were: a hemoglobin less than 7 g/dL, continued symptoms of dizziness, tachycardia, decreased exertional tolerance, or hypotension that failed to respond to fluid resuscitation. Multiple linear regression analyses correcting for the above variables were performed to determine associations with intraoperative blood loss, while logistic regression was used to analyze perioperative transfusion use. RESULTS: After controlling for potentially relevant confounding variables noted earlier, we found smokers had increased estimated blood loss compared with nonsmokers (mean, 328 mL more for each pack per day smoked; 95% CI, 249-407 mL; p < 0.001). We also found that again correcting for confounders, smokers had increased perioperative transfusion use compared with nonsmokers (odds ratio, 13.8; 95% CI, 4.59-42.52). CONCLUSIONS: Smoking is associated with increased estimated surgical blood loss and transfusion use in patients undergoing lumbar spine surgery. Patients who smoke should be counseled regarding these risks and on smoking cessation before undergoing lumbar surgery. LEVEL OF EVIDENCE: Level III, therapeutic study.

Bilateral Pars Defects at the L4 Vertebra Result in Increased Degeneration When Compared With Those at L5: An Anatomic Study.

BACKGROUND: Cadaveric studies have examined disc degeneration at the L4-L5 and L5-S1 motion segments; however, we are not aware of another study that has examined the relationship between bilateral spondylolysis and its effect on degenerative disc disease at those levels. This may have been overlooked by researchers owing to the majority of spondylolysis occurring at the L5 vertebra. QUESTIONS/PURPOSES: Using osteologic specimens from a collection that included individuals who died in one city in the USA between 1893 and 1938, we asked: (1) do specimens with bilateral spondylolysis (bilateral pars defects) have increased levels of disc degeneration, at their respective motion segments, when compared with matched controls without spondylolysis, and (2) is the finding of a bilateral pars defect associated with more severe arthritis at L4-L5 than at L5-S1? METHODS: An observational study was performed on 665 skeletal lumbar spines from the Hamann-Todd Osteologic Collection at the Cleveland Museum of Natural History (Cleveland, OH, USA). The specimens included 534 males and 131 females ranging from 17 to 87 years old, with a nearly bell-shaped distribution of ages for males and a larger proportion of younger ages in the female specimens. Of those with spondylolysis, 81 had a defect at L5 and 14 had a defect at L4. The gross specimens were examined subjectively for evidence of arthrosis. At the time of examination, specific attention was not paid to the coexisting presence or absence of spondylolysis nor was the examiner blinded to the age of the specimens. Disc degeneration was measured by the classification of Eubanks et al., a modified version of the Kettler and Wilke classification. Linear regression was performed to derive a formula that would predict the amount of disc degeneration at L4-L5 and L5-S1 for the normal control population given a specimen's age, sex, and race. We then used this formula to evaluate the difference in disc degeneration at the corresponding level of the pars defect that is greater than the predicted amount for a control without spondylolysis. This allowed us to conclude that any significant differences found between the L4-L5 and L5-S1 cohorts were attributable to factors not simply inherent to their functional position in the spine of an individual without a bilateral pars defect. RESULTS: L4 spondylolysis and L5 spondylolysis showed greater amounts of degeneration compared with that of matched controls (L4 controls: mean = 1.52, SD = 0.74; L4 spondylolysis: mean = 3.21, SD = 0.87; p < 0.001; L5 controls: mean = 0.97, SD = 0.48; L5 spondylolysis: mean = 2.06, SD = 0.98; p < 0.001). When we controlled for the expected amount of degenerative disc disease at each level in controls, the observed degeneration was more severe at L4-L5 than at L5-S1 (p = 0.008, R-squared = 18.6). CONCLUSIONS: L4-L5 and L5-S1 bilateral spondylolysis groups had increased presence of degenerative disc disease compared with those without bilateral spondylolysis. For the same degree of spondylolysis, the observed amount of disc degeneration was greater at the L4-5 motion segment compared with L5-S1. CLINICAL RELEVANCE: Although not as common as the spondylolysis at L5-S1, we believe that our findings support that patients with L4-L5 spondylolysis can expect a greater degree of degenerative disc disease and increasing clinical symptoms. Multiple factors in the sacropelvic geometry of an individual, facet morphologic features at L4-L5, and the absence of the iliolumbar ligament at this level are possible contributing factors to the findings of this study.

Can Internet information on vertebroplasty be a reliable means of patient self-education?

BACKGROUND: Studies of the quality and accuracy of health and medical information available on the Internet have shown that many sources provide inadequate information. However, to our knowledge, there are no published studies analyzing the quality of information available online regarding vertebroplasty. Because this has been a high-volume procedure with highly debated efficacy, it is critical that patients receive complete, accurate, and well-balanced information before deciding a treatment course. Additionally, few studies have evaluated the merit of academic site authorship or site certification on information quality, but some studies have used measurements of quality that are based primarily on subjective criteria or information accuracy rather than information completeness. QUESTIONS/PURPOSES: The purposes of our study were (1) to evaluate and analyze the information on vertebroplasty available to the general public through the Internet; (2) to see if sites sponsored by academic institutions offered a higher quality of information; and (3) to determine whether quality of information varied according to site approval by a certification body. METHODS: Three search engines were used to identify 105 web sites (35 per engine) offering information regarding vertebroplasty. Sites were evaluated for authorship/sponsorship, content, and references cited. Information quality was rated as "excellent," "high," "moderate," "low," or "unacceptable." Sites also were evaluated for contact information to set up an appointment. Data were analyzed as a complete set, then compared between authorship types, and finally evaluated by certification status. Academic sites were compared with other authorship groups and certified sites were compared with noncertified sites using Student's t-test. RESULTS: Appropriate indications were referenced in 74% of sites, whereas only 45% discussed a contraindication to the procedure. Benefits were expressed by 100% of sites, but risks were outlined in only 53% (p < 0.001). Ninety-nine percent of sites provided step-by-step descriptions of the procedure, and 44% of sites also included images. Alternative treatments were mentioned by 51% of sites. Twenty-seven percent of sites referenced peer-reviewed literature, 41% offered experiential or noncited data based on American populations, and 7% offered analogous data from international populations. Thirty percent of sites provided contact information for patient appointment scheduling. Seven percent of sites were classified as excellent quality, 6% as high quality, 11% as moderate quality, 19% as poor quality, and 57% as unacceptable. Sixteen percent of sites were sponsored by academic institutions, 62% by private groups, 8% by biomedical device companies, and 14% were sponsored otherwise. Academic sites reported fewer risks of the procedure than private sites or other sites (p = 0.05 and p = 0.04), but reported more risks than industry sites (p = 0.007). Academic sites were more likely than sites classified as other to offer contact information for patient appointment scheduling (p = 0.004). Nine percent of sites evaluated were Health on the Net Foundation (HONCode) certified. No association with improved information quality was observed in these sites relative to noncertified sites (all p > 0.05). CONCLUSIONS: Internet information regarding vertebroplasty is not only inadequate for proper patient education, but also potentially misleading as sites are more likely to present benefits of the procedure than risks. Although academic sites might be expected to offer higher-quality information than private, industry, or other sites, our data would suggest that they do not. HONCode certification cannot be used reliably as a means of qualifying website information quality. Academic sites should be expected to set a high standard and alter their Internet presence with adequate information distribution. Certification bodies also should alter their standards to necessitate provision of complete information in addition to emphasizing accurate information. Treating physicians may want to counsel their patients regarding the limitations of information present on the Internet and the pitfalls of current certification systems. LEVEL OF EVIDENCE: Level IV, economic and decision analyses. See the Instructions for Authors for a complete description of levels of evidence.

Femoral head asymmetry and coxa magna: anatomic study.

BACKGROUND: Coxa magna, the asymmetrical circumferential enlargement of the femoral head, is an important sequela of pediatric disorders such as Legg-Calvé-Perthes disease. Definitions vary because of lack of controls and a scarcity of research on the distribution of the femoral head asymmetry. This study aims at defining the normal distribution of asymmetry between the left and the right femoral head and neck in the population and how demographics affect these properties. The study also looked at the distribution of side dominance (left or right). METHODS: This study measured 230 paired femurs from individuals (20 to 40 y old) distributed for sex and ethnicity. The height and weight of the individuals were also recorded. The femoral head diameter and minimal femoral neck diameter in the anteroposterior view were measured on each paired femurs. The absolute and percent differences were determined to define asymmetry. RESULTS: Most of the population fell within 3% of asymmetry for the femoral head and 4% for the femoral neck. The maximum head percent asymmetry was 7.4%. Absolute difference in millimeters to percent asymmetry showed a ratio of 2:1 for the femoral head and 3:1 for the femoral neck. African Americans showed greater femoral head symmetry and a bias toward left-sided femoral head and neck enlargement when compared with their white counterparts. CONCLUSIONS: There was a high degree of symmetry between the left and right femoral heads and necks, which supports definitions found in the literature that define coxa magna above 10%. This study defines asymmetry in the femoral head in the normal population, which will help to define a quantitative definition of coxa magna.

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.].

Resource Utilization following Anterior Versus Posterior Cervical Decompression and Fusion for Acute Central Cord Syndrome.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study is to compare the impact of anterior cervical decompression and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for the treatment of acute traumatic central cord syndrome (CCS) on hospital episodes of care in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination. SUMMARY OF BACKGROUND DATA: Acute traumatic CCS is the most common form of spinal cord injury in the United States. CCS is commonly treated with surgical decompression and fusion. Hospital resource utilization based on surgical approach remains unclear. METHODS: Patients undergoing ACDF and PCDF for acute traumatic CCS were identified using the 2019 Medicare Provider Analysis and Review Limited Data Set and Centers for Medicare and Medicaid Services 2019 Impact File. Multivariate models for hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. Subanalysis of accommodation and revenue center cost drivers was performed. RESULTS: There were 1474 cases that met inclusion criteria: 673 ACDF (45.7%) and 801 PCDF (54.3%). ACDF was independently associated with a decreased cost of $9802 (P<0.001) and a 59.2% decreased risk of discharge to nonhome destinations (adjusted odds ratio: 0.408, P<0.001). The difference in length of stay was not statistically significant. On subanalysis of cost drivers, ACDF was associated with decreased charges ($55,736, P<0.001) compared with PCDF, the largest drivers being the intensive care unit ($15,873, 28% of total charges, P<0.001) and medical/surgical supply charges ($19,651, 35% of total charges, P<0.001). CONCLUSIONS: For treatment of acute traumatic CCS, ACDF was associated with almost $10,000 less expensive cost of care and a 60% decreased risk of discharge to nonhome destination compared with PCDF. The largest cost drivers appear to be ICU and medical/surgical-related. These findings may inform value-based decisions regarding the treatment of acute traumatic CCS. However, injury and patient clinical factors should always be prioritized in surgical decision-making, and increased granularity in reimbursement policies is needed to prevent financial disincentives in the treatment of patients with CCS better addressed with posterior approach-surgery.

Elective Single-Level Primary Anterior Cervical Decompression and Fusion for Degenerative Spondylotic Cervical Myelopathy is Associated With Decreased Resource Utilization Versus Posterior Cervical Decompression and Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare elective single-level anterior cervical discectomy and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for degenerative cervical myelopathy (DCM) in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination in Medicare patients. A sub-analysis of potential cost drivers was also performed. BACKGROUND: In the era of value-based medicine, there is substantial interest in reducing the cost of care. Both ACDF and PCDF are used to treat DCM but carry different morbidity and risk profiles that can impact hospital resource utilization. However, this has not been assessed on a national level. METHODS: Patients undergoing single-level elective ACDF and PCDF surgery were identified using the 2019 Medicare Provider Analysis and Review (MedPAR) Limited Data Set (LDS) and Centers for Medicare and Medicaid Services (CMS) 2019 Impact File. Multivariate models of hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. A univariate sub-analysis of 9 revenue centers was performed. RESULTS: In all, 3942 patients met the inclusion criteria. The mean cost of elective single-level cervical fusion for myelopathy was $18,084±10,783, and the mean length of stay was 2.45±2.95 d. On multivariate analysis, ACDF was independently associated with decreased cost of $5,814 (P<0.001), shorter length of stay by 1.1 days (P<0.001), and decreased risk of nonhome discharge destination by 58% (adjusted odds ratio: 0.422, P<0.001).On sub-analysis of 9 revenue centers, medical/surgical supply ($10,497, 44%), operating room charges ($5401, 23%), and accommodations ($3999, 17%) were the largest drivers of charge differences. CONCLUSIONS: Single-level elective primary ACDF for DCM was independently associated with decreased cost, decreased hospital length of stay, and a lower rate of nonhome discharge compared with PCDF. Medical and surgical supply, operating room, and accommodation differences between ACDF and PCDF are potential areas for intervention. Increased granularity in reimbursement structures is warranted to prevent the creation of disincentives to the treatment of patients with DCM with pathology that is better addressed with PCDF. LEVEL OF EVIDENCE: Level-III Retrospective Cohort Study.

Risk Factors for Undergoing Surgical Intervention for Vertebral Compression Fractures: An Analysis of 703,499 Patients.

BACKGROUND: Vertebral compression fractures (VCFs) are typically treated nonoperatively but can be treated with either kyphoplasty or vertebroplasty when indicated. The decision to treat patients with/without surgical intervention is dependent on the severity of deformity and patient risk profile. The aims of this study were to: 1) compare baseline patient demographics, 2) identify risk factors of patients undergoing operative vs. nonoperative management, and 3) identify patient-specific risk factors associated with postoperative readmissions. METHODS: This retrospective database study used patient information from January 1st, 2010, to October 31st, 2021. Cohorts were identified by patients diagnosed with VCFs through International Classification of Disease, Ninth Revision (ICD-9), ICD-10 codes, identifying those undergoing kyphoplasty/vertebroplasty via Current Procedural Terminology codes. The 2 research domains utilized in this investigation were baseline demographic profiles of patients who underwent kyphoplasty or vertebroplasty for treatment of VCFs, and those who underwent nonoperative management served as the control cohort. RESULTS: Of the 703,499 patients diagnosed with VCFs, 76,126 patients (10.8%) underwent kyphoplasty or vertebroplasty within 90 days of diagnosis of a VCF. Univariate analysis demonstrated female sex was associated with increased risk of undergoing surgical management for VCF (P < 0.0001). Several comorbidities were significantly associated with increased rates of readmission including hypertension, tobacco use, coronary artery disease, and chronic obstructive pulmonary disease (P < 0.0001 for all). CONCLUSIONS: This study highlights specific comorbidities that are significantly associated with higher rates of kyphoplasty or vertebroplasty for the treatment of thoracolumbar wedge compression fractures and increased risk for 90-day postoperative hospital readmission.

Risk Factors for Readmission Following Surgical Decompression for Spinal Epidural Abscesses: An Analysis of 4595 Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The study aimed to (1) compare baseline demographics of patients undergoing surgery for SEA who were/were not readmitted; (2) identify risk factors for 90-day readmissions; and (3) quantify 90-day episode-of-care health care costs. BACKGROUND: Spinal epidural abscess (SEA), while rare, occurring ~2.5-5.1/10,000 admissions, may lead to permanent neurologic deficits and mortality. Definitive treatment often involves surgical intervention via decompression. METHODS: A search of the PearlDiver database from 2010 to 2021 for patients undergoing decompression for SEA identified 4595 patients. Cohorts were identified through the International Classification of Disease, Ninth Revision (ICD-9), ICD-10, and Current Procedural Terminology codes. Baseline demographics of patients who were/were not readmitted within 90 days following decompression were aggregated/compared, identifying factors associated with readmission. Using Bonferroni correction, a P-value<0.001 was considered statistically significant. RESULTS: Readmission within 90 days of surgical decompression occurred in 36.1% (1659/4595) of patients. While age/gender were not associated with readmission rate, alcohol use disorder, arrhythmia, chronic kidney disease, ischemic heart disease, and obesity were associated with readmission. Readmission risk factors included fluid/electrolyte abnormalities, obesity, paralysis, tobacco use, and pathologic weight loss (P<0.0001). Mean same-day total costs ($17,920 vs. $8204, P<0.001) and mean 90-day costs ($46,050 vs. $15,200, P<0.001) were significantly higher in the readmission group. CONCLUSION: A substantial proportion of patients (36.1%) are readmitted within 90 days following surgical decompression for SEA. The top 5 risk factors in descending order are fluid/electrolyte abnormalities, pathologic weight loss, tobacco use, pre-existing paralysis, and obesity. This study highlights areas for perioperative medical optimization that may reduce health care utilization.