The Outcomes of Patients With Neck Pain Following ACDF: A Comparison of Patients With Radiculopathy, Myelopathy, or Mixed Symptomatology.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The goal of the present study was to determine whether neck pain responds differently to anterior cervical discectomy and fusion (ACDF) between patients with cervical radiculopathy and/or cervical myelopathy. SUMMARY OF BACKGROUND DATA: Many patients who undergo ACDF because of radiculopathy/myelopathy also complain of neck pain. However, no studies have compared the response of significant neck pain to ACDF. METHODS: Patients undergoing one to three-level primary ACDF for radiculopathy and/or myelopathy with significant (Visual Analogue Scale [VAS] ≥ 3) neck pain and a minimum of 1-year follow-up were included. Based on preoperative symptoms patients were split into groups for analysis: radiculopathy (R group), myelopathy (M group), or both (MR group). Groups were compared for differences in Health Related Quality of Life outcomes: Physical Component Score-12, Mental Component Score (MCS)-12, Neck Disability Index, VAS neck, and VAS arm pain. RESULTS: Two hundred thirty-five patients met inclusion criteria. There were 117 patients in the R group, 53 in the M group, and 65 in the MR group. Preoperative VAS neck pain was found to be significantly higher in the R group versus M group (6.5 vs. 5.5; P = 0.046). Postoperatively, all cohorts experienced significant (P < 0.001) reduction in VAS neck pain, (ΔVAS neck; R group: -2.9, M: -2.5, MR: -2.5) with no significant differences between groups. However, myelopathic patients showed greater improvement in absolute MCS-12 scores (P = 0.011), RR (P = 0.006), and % minimum clinically important difference (P = 0.013) when compared with radiculopathy patients. This greater improvement remained following regression analysis (P = 0.025). CONCLUSION: Patients with substantial preoperative neck pain experienced significant reduction in their neck pain, disability, and physical function following ACDF, whether treated for radiculopathy or myelopathy. However, in this study, only myelopathy patients had significant improvements in their mental function as represented by MCS improvements. LEVEL OF EVIDENCE: 3.

Does an Uninstrumented Level Increase the Rate of Revision Surgery in a Multilevel Posterior Cervical Decompression and Fusion?

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The goal of this study is to determine if skipping a single level affects the revision rate for patients undergoing multilevel posterior cervical decompression and fusion (PCDF). SUMMARY OF BACKGROUND DATA: A multilevel PCDF is a common procedure for patients with cervical spondylotic myelopathy. With advanced pathology, it can be difficult to safely place screw instrumentation at every level increasing the risk of intraoperative and perioperative morbidity. It is unclear whether skipping a level during PCDF affects fusion and revision rates. PATIENTS AND METHODS: A cervical spine surgeries database at a single institution was used to identify patients who underwent ≥3 levels of PCDF. Inclusion criteria consisted of patients who had screws placed at every level or if they had a single level without screws bilaterally. Patients were excluded if the surgery was performed for tumor, trauma, or infection, and age below 18 years, or if there was <1 year of follow-up. RESULTS: A total of 157 patients met inclusion criteria, with 86 undergoing a PCDF with instrumentation at all levels and 71 that had a single uninstrumented level. Overall mean follow-up was 46.5±22.8 months. In patients with or without a skipped level, the revision rate was 25% and 26%, respectively (P<1.00). Univariate regression analysis demonstrated that proximal fixation level in the upper cervical region, having the fusion end at C7, prior surgery, and myelopathy were significant predictors of revision. Skipping a single level, however, was not predictive of revision. CONCLUSIONS: When performing a multilevel PCDF, there is no increase in the rate of revision surgery if a single level is uninstrumented. Conversely, other surgical factors, including the cranial and caudal levels, affect revision rates. In contrast to other reports, the C2 sagittal vertical axis did not affect reoperation rates. LEVEL OF EVIDENCE: Level IV.

Medicaid Reimbursement for Common Spine Procedures: Are Compensation Rates Consistent?

STUDY DESIGN: Health Services Research. OBJECTIVE: The purpose of this study is to determine the variability of Medicaid (MCD) reimbursement for patients who require spine procedures, and to assess how this compares to regional Medicare (MCR) reimbursement as a marker of access to spine surgery. SUMMARY OF BACKGROUND DATA: The current health care environment includes two major forms of government reimbursement: MCD and MCR, which are regulated and funded by the state and federal government, respectively. METHODS: MCD reimbursement rates from each state were obtained for eight spine procedures, utilizing online web searches: anterior cervical decompression and fusion, posterior cervical decompression and fusion, posterior lumbar decompression, single-level posterior lumbar fusion, posterior fusion for deformity (less than six levels; six to 12 levels; 13+ levels), and lumbar microdiscectomy. Discrepancy in reimbursement for these procedures on a state-to-state basis, as well as overall differences in MCD versus MCR reimbursement, was determined. Procedures were examined to identify whether certain surgical interventions have greater discrepancy in reimbursement. RESULTS: The average MCD reimbursement was 78.4% of that for MCR. However, there was significant variation between states (38.8%-140% of MCR for the combined eight procedures). On average, New York, New Jersey, Florida, and Rhode Island provided MCD reimbursements <50% of MCR reimbursements in the region. In total, 20 and 42 states provided <75% and 100% of MCR reimbursements, respectively. Based upon relative reimbursement, MCD appears to value microdiscectomy (84.1% of MCR; P = 0.10) over other elective spine procedures. Microdiscectomy also had the most interstate variation in MCD reimbursement: 39.0% to 207.0% of MCR. CONCLUSION: Large disparities were found between MCR and MCD when comparing identical procedures. Further research is necessary to fully understand the effect of these significant differences. However, it is likely that these discrepancies lead to suboptimal access to necessary spine care. LEVEL OF EVIDENCE: 4.

Dimensions of the Subaxial Lateral Mass: A Systematic Review of Anatomic (Morphometric) Measurement Studies.

STUDY DESIGN: This was a systematic review. OBJECTIVE: To review and synthesize information on subaxial lateral mass dimensions in order to determine the ideal starting point, trajectory, and size of a lateral mass screw. SUMMARY OF BACKGROUND DATA: The use of lateral mass instrumentation for posterior cervical decompression and fusion has become routine as these constructs have increased rigidity and fusion rates. METHODS: A systematic search of Medline and EMBASE was conducted. Studies that provided subaxial cervical lateral mass measurements, distance to the facet, vertebral artery and neuroforamen and facet angle made either directly (eg, cadaver specimen) or from patient imaging were considered for inclusion. Pooled estimates of mean dimensions were reported with corresponding 95% confidence intervals. Stratified analysis based on level, sex, imaging plane, source (cadaver or imaging), and measurement method was done. RESULTS: Of the 194 citations identified, 12 cadaver and 10 imaging studies were included. Pooled estimates for C3-C6 were generally consistent for lateral mass height (12.1 mm), width (12.0 mm), depth (10.8 mm), distance to the transverse foramen (11.8 mm), and distance to the nerve. C7 dimensions were most variable. Small sex-based differences in dimensions were noted for height (1.2 mm), width (1.3 mm), depth (0.43 mm), transverse foramen distance (0.9 mm), and nerve distance (0.3-0.8 mm). No firm conclusions regarding differences between measurements made on cadavers and those based on patient computed tomographic images are possible; findings were not consistent across dimensions. The overall strength of evidence is considered very low for all findings. CONCLUSIONS: Although estimates of height, width, and depth were generally consistent for C3-C6, C7 dimensions were variable. Small sex differences in dimensions may suggest that surgeons should use a slightly smaller screw in female patients. Firm conclusions regarding facet angulation, source of measurement, and method of measurement were not possible.

The Total Cost to the Health Care System in Medicare and Medicaid Patients for the Treatment of Cervical Myelopathy.

INTRODUCTION: Cervical myelopathy is a common indication for spine surgery. Modern medicine demands high quality, cost-effective treatment. Most cost analyses fail to account for complication costs from nonoperative treatment. The purpose is to compare the total health care costs for operative versus nonoperative treatment of cervical myelopathy. METHODS: The Center for Medicare and Medicaid Services Carrier File from 2005 to 2012 was reviewed using the PearlDiver database, representing a 5% sampling of Medicare billings which diagnosed patients with cervical myelopathy by International Classification of Diseases 9 code. Patients were separated into operative and nonoperative cohorts, and the total health care expenditures per patient normalized to 2012 dollars were collected. RESULTS: A total of 3209 patients were included, and 1755 (55.87%) underwent surgery. A 6-year cost analysis performed on 309 patients over the age of 65 from 2006 undergoing surgery resulted in a nonsignificant increase in total health care expenditures ($166,192 vs. $153,556; P=0.45). Operative treatment had a net decrease in total health care costs following the first year of surgery. CONCLUSIONS: There is no significant difference in the total health care expenditures for operative versus nonoperative treatment of cervical myelopathy after 3 years. It is critical to understand that nonoperative treatment of this progressive disease leads to a substantial increase in total health care expenditures with increased risk of falls, injury, and further morbidity.

Utilization of Time-driven Activity-based Costing to Determine the True Cost of a Single or 2-level Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: This is a prospective case series. OBJECTIVE: To determine the actual cost of performing 1- or 2-level anterior cervical discectomy and fusion (ACDF) using actual patient data and the time-driven activity-based cost methodology. SUMMARY OF BACKGROUND DATA: As health care shifts to use value-based reimbursement, it is imperative to determine the true cost of surgical procedures. Time-driven activity-based costing determines the cost of care by determining the actual resources used in each step of the care cycle. MATERIALS AND METHODS: In total, 30 patients who underwent a 1- or 2-level ACDF by 3 surgeons at a specialty hospital were prospectively enrolled. To build an accurate process map, a research assistant accompanied the patient to every step in the care cycle including the preoperative visit, the preadmission testing, the surgery, and the postoperative visits for the first 90 days. All resources utilized and the time spent with every member of the care team was recorded. RESULTS: In total, 27 patients were analyzed. Eleven patients underwent a single-level ACDF and 16 underwent a 2-level fusion. The total cost for the episode of care was $29,299±$5048. The overwhelming cost driver was the hospital disposable costs ($13,920±$6325) which includes every item used during the hospital stay. Intraoperative personnel costs including fees for the surgeon, resident/fellow, anesthesia, nursing, surgical technician, neuromonitoring, radiology technician and orderlies, accounted for the second largest cost at $6066±$1540. The total cost excluding hospital overhead and disposables was $9071±$1939. CONCLUSIONS: Reimbursement for a bundle of care surrounding a 1- or 2-level ACDF should be no less than $29,299 to cover the true costs of the care for the entire care cycle. However, this cost may not include the true cost of all capital expenditures, and therefore may underestimate the cost.

Descriptive Analysis of Associated Factors for Urgent Versus Nonurgent Inpatient Spine Transfers to a Tertiary Care Hospital.

Patients with spine-associated symptoms are transferred regularly to higher levels of care for operative intervention. It is unclear what factors lead to the transfer of patients with spine pathology to level I care facilities, and which transfers are indicated. All patients with isolated spinal pathology who were transferred from 2011 to 2015 were reviewed. Patients were divided into urgent transfers, defined as anyone who required operative intervention, and nonurgent transfers. Two hundred twenty-seven patients were transferred for isolated spinal pathology over 51 months; 109 (48.0%) patients required urgent intervention and 118 (52.0%) patients required nonurgent care. No significant differences were found between groups in terms of private insurance, age, sex, race, or Charlson comorbidity index. The urgent group was less likely to have a traumatic chief complaint (57.8% vs 78.0%, P = .001). More than half of all spine patients who were transferred to a tertiary care center required minimal intervention.

Preinjury Patient Characteristics and Postinjury Neurological Status Are Associated With Mortality Following Spinal Cord Injury.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: This study investigates the association between spinal cord injuries (SCI) and post-injury mortality. SUMMARY OF BACKGROUND DATA: SCIs) are severe conditions treated in the acute trauma setting. Owing to neurological deficits, unstable spinal columns, and associated injuries, these patients often have complex inpatient hospitalizations with significant morbidity and mortality. It is assumed that a high rate of postinjury mortality would follow such severe injuries; however, the effect of SCI and its treatment on predictors of longevity remain largely unknown. METHODS: Patients seen at a regional referral center for SCI were reviewed from a prospectively maintained database. Four hundred and twenty-six patients with SCI and varying degrees of injury between 2004 and 2009 were collected. Injury characteristics, including injury severity score, level of SCI, and type of SCI were retrieved. To determine independent predictors of 5-year mortality, a logistic regression using patient and injury characteristics at the time of presentation was performed. RESULTS: Average age was 47.4 years (range: 14-95), and 74.5% (318/426) were male. Half of the cohort sustained low-energy mechanisms of injury (220/426; 52.4%). The 30-day, 90-day, 1-year, 2-year, and 5-year mortality rates in the SCI cohort were 6.6% (28/426), 9.2% (39/426), 12.0% (51/426), 15.0% (64/426), and 17.8%, respectively (76/426). Logistic regression demonstrated that increasing age (B = 1.06, P < 0.001), increasing ICU length-of-stay (B = 1.06; P = 0.002), decreased motor score at presentation (B = 0.98; P = 0.004), and lack of surgical intervention (B = 0.38; P < 0.001) were independent predictors of mortality at 5 years. CONCLUSION: There is substantial mortality associated with SCI. A significant proportion of the mortalities occurred acutely after injury. Mortality was associated with neurological deficit and severity of injury, as well as with preinjury patient characteristics. To combat this high rate of death, efforts are needed to address the concomitant disease processes associated with neurological deficits. LEVEL OF EVIDENCE: 3.

Health Education Specialist Practice Analysis 2015 (HESPA 2015): Process and Outcomes.

The Health Education Specialist Practice Analysis 2015 (HESPA 2015) was conducted to update and validate the Areas of Responsibilities, Competencies, and Sub-competencies for Entry- and Advanced-Level Health Education Specialists. Two data collection instruments were developed-one was focused on Sub-competencies and the other on knowledge items related to the practice of health education. Instruments were administered to health education specialists (N = 3,152) using online survey methods. A total of 2,508 survey participants used 4-point ordinal scales to rank Sub-competencies by frequency of use and importance. The other 644 participants used the same 4-point frequency scale to rank related knowledge items. Composite scores for Sub-competencies were calculated and subgroup comparisons were conducted that resulted in the validation of 7 Areas of Responsibilities, 36 Competencies, and 258 Sub-competencies. Of the Sub-competencies, 141 were identified as Entry-level, 76 Advanced 1-level, and 41 Advanced 2-level. In addition, 131 knowledge items were verified. The HESPA 2015 findings are compared with the results of the Health Education Job Analysis 2010 and will be useful to those involved in professional preparation, continuing education, and employment of health education specialists.