Lumbar spine arthrodesis. A comparison of hospital costs between 1986 and 1993.

The purpose of this project was to evaluate the hospital costs of one- and two-level spinal arthrodesis and to determine areas where costs may be effectively reduced. The hospital bills of 40 patients (20 each in 1986 and 1993) who had undergone single-level and double-level lumbar arthrodesis were reviewed. Each patients's bill was examined and the specific charge items were assigned to one of seven "service centers." To effectively compare costs in the two different years, dollar values on 1986 bills were converted to inflation-adjusted 1993 amounts (the consumer price index over this interval was about 35%). The hospital cost (mean) for single- and double-level spinal arthrodesis increased from $7,457 (1986) to $19,712 (1993). In inflation-adjusted 1993 dollars the actual increase was 97%. All but two service centers demonstrated increased costs. The most dramatically increased in price was implant cost ($300 in 1986 vs $2,967 in 1993, a 638% increase with inflation adjustment). When adjusted for inflation, surgeons' fees actually decreased by 18% at our institution ($7,503 in 1986 vs $8,338 in 1993). The other service center that showed a decrease was the hospital room (-15%). The anesthesia charge, recovery-room fee, operating-room charge, and the "other" charges increased between 36% and 288%. As a percentage of the total hospital bill, implant cost accounted for approximately 4% of the 1986 charges, whereas in 1993 it accounted for more than 15% of the total bill. None of the other service centers showed such a drastic increase. Increasingly sophisticated technology has dramatically raised hospital charges. Strategies to reduce the overall cost of spinal surgery should concentrate on controlling the cost of spinal implants.

A correlation of cervical magnetic resonance imaging and discography/computed tomographic discograms.

STUDY DESIGN: The morphology of sagittal T2-weighted magnetic resonance imaging (MRI) of the cervical spine was correlated with provocative discography and subsequent computed tomography (CT) discograms in 52 patients with discogenic pain. OBJECTIVES: The authors determined if the morphology of cervical spine discs, as seen on MRI, correlates with discography/CT discograms in patients with discogenic pathology. SUMMARY OF BACKGROUND DATA: Several studies have demonstrated a correlation between MRI and discography in the lumbar spine. No studies have attempted to show if this relationship exists in the cervical spine region. METHODS: The morphology of cervical T2-weighted MRI was characterized with regard to the disc nuclear signal and posterior anulus status. Provocative discography was evaluated with regard to positive or negative responses. Computed tomography was performed after discography on each patient. RESULTS: There was no correlation between pain response or morphology as seen on either discography or CT discography. A significant correlation was found between abnormality as seen on MRI and pain response on discography but the false-positive and false-negative rates were high. CONCLUSION: Our results suggest that several MRI patterns correlate well with positive or negative cervical discography responses while several other patterns are equivocal. Magnetic resonance imaging is a useful adjunct to cervical discography but there are some MRI patterns that cannot be considered pathologic, and discography is required to diagnose discogenic pain syndrome.

Clinical use of a syndesmosis screw in stage IV pronation-external rotation ankle fractures.

The purpose of this study was to determine if biomechanical data obtained in studies on cadavers correlates with clinical results in the surgical treatment of stage IV pronation-external rotation (PER-IV) ankle fractures. We surgically treated 20 patients who sustained isolated PER-IV ankle injuries and followed 18 of the patients for an average of 2.5 years. Radiographs were evaluated using previously established methods, and clinical outcome was based on the criteria of Cedell. Eleven patients sustained a PER-IV injury with a medial malleolus fracture; 2 required a syndesmosis screw due to poor medial fixation. Good or excellent results were obtained in 90% of the patients in this group; the poor outcome of 1 patient was due to the development of reflex sympathetic dystrophy. Seven patients had a PER-IV injury with a deltoid ligament tear; because of widening of the syndesmosis, 1 patient required an early operation (within 1 week), and 2 patients required late operations (after 1 month). None of these patients should have required a syndesmosis screw based on biomechanical studies. Good or excellent results were obtained in 71% of the patients in this group. We conclude that the biomechanical data concerning placement of a syndesmosis screw in PER-IV ankle fractures does not correlate with in vivo outcome when a deltoid ligament injury occurs. A screw that stabilizes the distal tibiofibular syndesmosis should probably be placed in patients who sustain PER-IV injuries with deltoid ligament ruptures regardless of the level of the fibula fracture.

Posterior occipitoatlantal hypermobility in Down syndrome: an analysis of 199 patients.

We endeavored to determine the prevalence of occipitoatlantal hypermobility in individuals with Down syndrome, to establish objective radiographic criteria for this entity, and to correlate this with neurologic abnormality. In a retrospective analysis, upper cervical spine radiographs of 210 patients with Down syndrome were compared with those of 102 normal individuals. Radiographs were evaluated using the Powers ratio. Patients identified with radiographic evidence of posterior occipitoatlantal hypermobility were then examined clinically and compared with a matched group of patients with Down syndrome and normal Powers ratios. Of the patients with Down syndrome, 8.5% had a Powers ratio of < 0.55, which was indicative of posterior occipitoatlantal hypermobility (POAH). Furthermore, 66% of those with an abnormal Powers ratio had positive neurologic findings upon physical exam, a finding that was statistically significant when compared to a matched group of patients with Down syndrome and normal Powers ratio.

Intraoperative arterial occlusion in total joint arthroplasty.

Major arterial occlusion during surgery is an uncommon complication. The authors report on two patients who developed intraoperative arterial occlusion during total joint arthroplasty. Both of the patients were smokers and had significant peripheral vascular disease.

Ipsilateral fractures of the femoral neck and shaft.

The management of ipsilateral fractures of the femoral neck and shaft has proved to be a challenge to the orthopaedist. Most major institutions have treatment protocols that emphasize early rigid stabilization of the femoral-neck fracture to minimize the incidence of avascular necrosis of the femoral head. Since 1985, the authors' protocol has been to reduce and stabilize the femoral-neck fracture anatomically, followed by treatment of the femoral-shaft fracture. In 1990, we began treating this segmental fracture pattern with reconstruction nails. This study reviews the cases of 11 patients treated at the Medical College of Georgia Hospital from November 1985 to March 1992. Nine of the 11 underwent surgery within 12 hours of injury; 4 of these patients were treated with reconstruction nails. The mean follow-up was 2 years. Seven of the 11 had a good functional outcome, whereas 4 had a fair outcome. The results indicate that patients with ipsilateral fractures of the femoral neck and shaft can obtain good results when early (< 12 hours) rigid anatomic stabilization of the femoral neck is performed. The authors recommend utilizing a reconstruction nail for stabilizing this dual fracture whenever possible.

The evolution of an acute care hospital unit to a DRG-exempt rehabilitation unit. A preliminary communication.

The Health Care Financing Administration's decision to adopt a prospective based payment system has caused many institutions to implement new policies and practices. A recent area of interest for many hospitals has been the creation of diagnosis-related group (DRG) exempt units to maximize reimbursement practices. We analyzed changes which occurred when an eight bed acute care stroke unit (SU) was converted to a DRG exempt eight bed rehabilitation unit (RU). The time period involved was 1 1/2 months before and 1 1/2 months after the transition occurred. Analysis of data from the pre- and posttransition periods revealed that: (1) length of stay increased significantly from 11.7 to 15.3 days (P less than 0.001); (2) functional independence measure (FIM) score improvement was significantly greater (P less than 0.05) for RU patients (0.84/day) than for SU patients (0.39/day); (3) disposition to home v other facilities increased significantly from 50 to 81% (P less than 0.05); (4) the overall occupancy increased from 94 to 100% and all beds were filled with rehabilitation patients; (5) the proportion of patients with Medicare as their primary insurer was comparable before (64%) and after (67%) unit conversion; (6) gross income from rehabilitation patients increased by 43%. Indirect savings via reduction of acute hospital length of stay for Medicare patients increased total income from operation of this unit. We conclude that patients on the RU stayed longer, had greater daily improvements in functional status, and were more likely to be discharged to home. This appears to be due to a more efficient use of rehabilitation beds and a concomitant overall improvement in reimbursement to the hospital.(ABSTRACT TRUNCATED AT 250 WORDS)