Demographic and economic trends in vertebral fracture surgeries throughout the United States.

Background: Vertebral fractures, frequently resulting from high-impact trauma to the spine, are an increasingly relevant public health concern. Little is known about the long-term economic and demographic trends affecting patients undergoing surgery for such fractures. This study examines national economic and demographic trends in vertebral fracture surgery in the United States to improve value-based care and health care utilization. Methods: The National Inpatient Sample (NIS) was queried for patients who underwent surgical treatment of a vertebral fracture (ICD-9-CM-3.53) (excluding kyphoplasty and vertebroplasty) between 1993 and 2015. Demographic data included patient age, sex, income, insurance type, hospital size, and location. Economic data including aggregate charge, aggregate cost, hospital cost, and hospital charge were analyzed. Results: The number of vertebral fracture surgeries, excluding kyphoplasty and vertebroplasty, increased 461% from 3,331 in 1993 to 18,675 in 2014, while inpatient mortality increased from 1.9% to 2.5%.The mean age of patients undergoing vertebral fracture surgeries increased from 42 in 1993 to 53 in 2015. The aggregate cost of surgery increased from $189,164,625 in 2001 to $1,060,866,580 in 2014, a 461% increase. Conclusions: The significant increase in vertebral fracture surgeries between 1993 and 2014 may reflect an increased rate of fractures, more surgeons electing to treat fractures surgically, or a combination of both. The increasing rate of vertebral fracture surgery, coupled with increasing hospital costs and mortality, signifies that the treatment of vertebral fractures remains a challenging issue in healthcare. Further research is necessary to determine the underlying cause of both the increase in surgeries and the increasing mortality rate.

The language of all medical publications and spine publications from 1950 to 2020.

Background: Excellent research in all fields, including spine surgery, exists in many different regions and languages. This study seeks to determine the relative number of spine related peer-reviewed publications throughout the world based on language. Methods: Peer-reviewed publications from the eleven most prolific languages in regard to both the number of peer-reviewed spine publications indexed in PubMed and total peer-reviewed publications from 1950-2020 were identified in PubMed. Results: 29,711,547 peer-reviewed publications were analyzed for the languages of interest with 870,404 (3.0%) of those being spine related peer-reviewed publications. Between 1988 and 2019, non-English language peer-reviewed publications decreased annually for both all peer-reviewed publications and spine related peer-reviewed publications by 44% and 36%, respectively. All medical and spine specific peer reviewed publications in English compared to non-English publications have increased by 7.22 and 6.35 times since 1988, respectively. While the ratio of non-English to English spine related publications decreased in all eleven countries, the percentage of the number of spine specific publications written in Chinese (462%), Portuguese (378%), and Spanish (88%) have increased by the listed percentages. Conclusion: While the proportion of peer-reviewed publications in the field of spine surgery written in English have increased over the past several decades, there are many non-English language peer-reviewed publications each year, particularly in Chinese. Although the rapid increase in the proportion of English spine related publications is beneficial to English speaking physicians and researchers, further research is necessary to understand the impact on non-English speaking physicians and researchers.

The Rise and Fall of Bone Morphogenetic Protein 2 Throughout the United States.

STUDY DESIGN: Retrospective Database Study. OBJECTIVE: Investigate utilization of bone morphogenetic protein (BMP-2) between 2004 and 2014. SUMMARY OF BACKGROUND DATA: The utilization, particularly off-label utilization, of BMP-2 has been controversial and debated in the literature. Given the concerns regarding cancer and potential complications, the risk benefit profile of BMP must be weighed with each surgical case. The debate regarding the costs and potential side effects of BMP-2 compared with autologous iliac crest bone harvest has continued. METHODS: The National Inpatient Sample (NIS) database was queried for the use of BMP-2 (ICD-9-CM 84.52) between 2004 and 2014 across 44 states. The NIS database represents a 20% sample of discharges, weighted to provide national estimates. BMP-2 utilization rates in spine surgery fusion procedures were calculated as a fraction of the total number of thoracic, lumbar, and sacral spinal fusion surgeries performed each year. RESULTS: Between 2004 and 2014, BMP-2 was utilized in 927,275 spinal fusion surgeries. In 2004, BMP-2 was utilized in 28.3% of all cases (N=48,613). The relative use of BMP-2 in spine fusion surgeries peaked in 2008 at 47.0% (N=112,180). Since then, it has continued to steadily decline with an endpoint of 23.6% of cases in 2014 (N=60,863). CONCLUSIONS: Throughout the United States, the utilization of BMP-2 in thoracolumbar fusion surgeries increased from 28.3% to 47.0% between 2004 and 2008. However, from 2008 to 2014, the utilization of BMP-2 in thoracolumbar spine fusion surgeries decreased significantly from 47.0% to 23.4%. While this study provides information on the utilization of BMP-2 for the entire United States over an 11-year period, further research is needed to the determine the factors affecting these trends.

Marked Increase in Spinal Deformity Surgery Throughout the United States.

STUDY DESIGN: Retrospective cohort database study. OBJECTIVE: The aim of this study was to investigate trends in utilization and demographics in Spinal Deformity Surgery. SUMMARY OF BACKGROUND DATA: The aging population in the United States will likely result in increased incidence of adult degenerative scoliosis. With a national focus on resource utilization and value-based care, it is essential for surgeons, researchers, and health care policy makers to know utilization and demographic trends of spinal surgery with long fusion construct. METHODS: The National Inpatient Sample (NIS) database was queried for patients who underwent fusion or refusion of nine or more vertebrae (ICD-9-CM 81.64) between 2004 and 2015 across 44 states. Demographic and economic data include annual number of surgeries, incidence, patient age, sex, region, insurance type, charge, routine discharge, length of stay, and data. The NIS database represents a 20% sample of discharges from US hospitals, excluding rehabilitation and long-term acute care hospitals, which is weighted to provide national estimates. RESULT: In 2014, there were 14,615 fusions involving nine or more vertebrae across the United States. The number of fusions involving nine or more levels has increased 141% from 6072 in 2004. Long fusion constructs increased 460% from 2004 to 2014 among patients 65 to 84 years' old. The mean hospital cost associated with long fusion spine surgery was $69,546 per case in 2015. Between 2004 and 2014, the payer breakdown for individuals receiving spinal deformity surgery is as follows: 54.2% private insurance, 18% Medicare, and 21.2% Medicaid. CONCLUSION: The massive increase (141%) in utilization of long construct spine fusion was primarily driven by 460% rise in incidence of the surgery among those aged 65 to 84. Although the cause is unknown, it is possible that this rise was, at least in part, driven by the implementation of the affordable care act, improved surgical safety, and better knowledge of spinopelvic parameters.Level of Evidence: 3.

Comparison of medical comorbidities in Medicare patients treated by orthopaedic surgeons and neurosurgeons throughout the USA.

AIMS: Medical comorbidities are a critical factor in the decision-making process for operative management and risk-stratification. The Hierarchical Condition Categories (HCC) risk adjustment model is a powerful measure of illness severity for patients treated by surgeons. The HCC is utilized by Medicare to predict medical expenditure risk and to reimburse physicians accordingly. HCC weighs comorbidities differently to calculate risk. This study determines the prevalence of medical comorbidities and the average HCC score in Medicare patients being evaluated by neurosurgeons and orthopaedic surgeon, as well as a subset of academic spine surgeons within both specialities, in the USA. METHODS: The Medicare Provider Utilization and Payment Database, which is based on data from the Centers for Medicare and Medicaid Services' National Claims History Standard Analytic Files, was analyzed for this study. Every surgeon who submitted a valid Medicare Part B non-institutional claim during the 2013 calendar year was included in this study. This database was queried for medical comorbidities and HCC scores of each patient who had, at minimum, a single office visit with a surgeon. This data included 21,204 orthopaedic surgeons and 4,372 neurosurgeons across 54 states/territories in the USA. RESULTS: Orthopaedic surgeons evaluated patients with a mean HCC of 1.21, while neurosurgeons evaluated patients with a mean HCC of 1.34 (p < 0.05). The rates of specific comorbidities in patients seen by orthopaedic surgeons/neurosurgeons is as follows: Ischemic heart disease (35%/39%), diabetes (31%/33%), depression (23%/31%), chronic kidney disease (19%/23%), and heart failure (17%/19%). CONCLUSION: Nationally, comorbidity rate and HCC value for these Medicare patients are higher than national averages for the US population, with ischemic heart disease being six-times higher, diabetes two-times higher, depression three- to four-times higher, chronic kidney disease three-times higher, and heart failure nine-times higher among patients evaluated by orthopaedic surgeons and neurosurgeons.Cite this article: Bone Joint Open 2020;1-6:257-260.

Treatments Administered to the First 9152 Reported Cases of COVID-19: A Systematic Review.

The emergence of SARS-CoV-2/2019 novel coronavirus (COVID-19) has created a global pandemic with no approved treatments or vaccines. Many treatments have already been administered to COVID-19 patients but have not been systematically evaluated. We performed a systematic literature review to identify all treatments reported to be administered to COVID-19 patients and to assess time to clinically meaningful response for treatments with sufficient data. We searched PubMed, BioRxiv, MedRxiv, and ChinaXiv for articles reporting treatments for COVID-19 patients published between 1 December 2019 and 27 March 2020. Data were analyzed descriptively. Of the 2706 articles identified, 155 studies met the inclusion criteria, comprising 9152 patients. The cohort was 45.4% female and 98.3% hospitalized, and mean (SD) age was 44.4 years (SD 21.0). The most frequently administered drug classes were antivirals, antibiotics, and corticosteroids, and of the 115 reported drugs, the most frequently administered was combination lopinavir/ritonavir, which was associated with a time to clinically meaningful response (complete symptom resolution or hospital discharge) of 11.7 (1.09) days. There were insufficient data to compare across treatments. Many treatments have been administered to the first 9152 reported cases of COVID-19. These data serve as the basis for an open-source registry of all reported treatments given to COVID-19 patients at www.CDCN.org/CORONA . Further work is needed to prioritize drugs for investigation in well-controlled clinical trials and treatment protocols.

Change in rates of primary atlantoaxial spinal fusion surgeries in the United States (1993-2015).

OBJECTIVE: The objective of this study was to investigate revision burden and associated demographic and economic data for atlantoaxial (AA) fusion procedures in the US. METHODS: Patient data from the National Inpatient Sample (NIS) database for primary AA fusion were obtained from 1993 to 2015, and for revision AA fusion from 2006 to 2014 using ICD-9 procedure codes. Data from 2006 to 2014 were used in comparisons between primary and revision surgeries. National procedure rates, hospital costs/charges, length of stay (LOS), routine discharge, and mortality rates were investigated. RESULTS: Between 1993 and 2014, 52,011 patients underwent primary AA fusion. Over this period, there was a 111% increase in annual number of primary surgeries performed. An estimated 1372 patients underwent revision AA fusion between 2006 and 2014, and over this time period there was a 6% decrease in the number of revisions performed annually. The 65-84 year-old age group increased as a proportion of primary AA fusions in the US from 35.9% of all AA fusions in 1997 to 44.2% in 2015, an increase of 23%. The mean hospital cost for primary AA surgery increased 32% between 2006 and 2015, while the mean cost for revision AA surgery increased by 35% between 2006 and 2014. Between 2006 and 2014, the mean hospital charge for primary AA surgery increased by 67%; the mean charge for revision surgery over that same period increased by 57%. Between 2006 and 2014, the mean age for primary AA fusions was 60 years, while the mean age for revision AA fusions was 52 years. The mean LOS for both procedures decreased over the study period, with primary AA fusion decreasing by 31% and revision AA fusion decreasing by 24%. Revision burden decreased by 21% between 2006 and 2014 (mean 4.9%, range 3.2%-6.4%). The inpatient mortality rate for primary AA surgery decreased from 5.3% in 1993 to 2.2% in 2014. CONCLUSIONS: The number of primary AA fusions between 2006 and 2014 increased 22%, while the number of revision procedures has decreased 6% over the same period. The revision burden decreased by 21%. The inpatient mortality rate decreased 62% (1993-2014) to 2.2%. The increased primary fusion rate, decreased revision burden, and decreased inpatient mortality determined in this study may suggest an improvement in the safety and success of primary AA fusion.

Clonal immortalized human glial cell lines support varying levels of JC virus infection due to differences in cellular gene expression.

JC virus (JCV) is a ubiquitous human polyomavirus that causes the demyelinating disease Progressive Multifocal Leukoencephalopathy (PML). JCV replicates in limited cell types in culture, predominantly in human glial cells. Following introduction of a replication defective SV40 mutant that expressed large T protein into a heterogeneous culture of human fetal brain cells, multiple phenotypes became immortalized (SVG cells). A subset of SVG cells could support JCV replication. In the current study, clonal cell lines were selected from the original SVG cell culture. The 5F4 clone showed low levels of viral growth. The 10B1 clone was highly permissive for JCV DNA replication and gene expression and supported persistent and stable JCV infection over months in culture. Microarray analysis revealed that viral infection did not significantly change gene expression in these cells. More resistant 5F4 cells expressed high levels of transcription factors known to inhibit JCV transcription. Interestingly, 5F4 cells expressed high levels of RNA of markers of radial glia and 10B1 cells had high expression of markers of immature glial cells and activation of transcription regulators important for stem/progenitor cell self-renewal. These SVG-derived clonal cell lines provide a biologically relevant model to investigate cell type differences in JCV host range and pathogenesis, as well as neural development. Several transcription regulators were identified which may be targets for therapeutic modulation of expression to abrogate JCV replication in PML patients. Additionally, these clonal cell lines can provide a consistent culture platform for testing therapies against JCV infection of the central nervous system.