Risk assessment of early therapeutic anticoagulation following cranial surgery: an institutional case series.

OBJECTIVE: Postoperative thrombotic complications represent a unique challenge in cranial neurosurgery as primary treatment involves therapeutic anticoagulation. The decision to initiate therapy and its timing is nuanced, as surgeons must balance the risk of catastrophic intracranial hemorrhage (ICH). With limited existing evidence to guide management, current practice patterns are subjective and inconsistent. The authors assessed their experience with early therapeutic anticoagulation (≤ 7 days postoperatively) initiation for thrombotic complications in neurosurgical patients undergoing cranial surgery to better understand the risks of catastrophic ICH. METHODS: Adult patients treated with early therapeutic anticoagulation following cranial surgery were considered. Anticoagulation indications were restricted to thrombotic or thromboembolic complications. Records were retrospectively reviewed for demographics, surgical details, and anticoagulation therapy start. The primary outcome was the incidence of catastrophic ICH, defined as ICH resulting in reoperation or death within 30 days of anticoagulation initiation. As a secondary outcome, post-anticoagulation cranial imaging was reviewed for new or worsening acute blood products. Fisher's exact and Wilcoxon rank-sum tests were used to compare cohorts. Cumulative outcome analyses were performed for primary and secondary outcomes according to anticoagulation start time. RESULTS: Seventy-one patients satisfied the inclusion criteria. Anticoagulation commenced on mean postoperative day (POD) 4.3 (SD 2.2). Catastrophic ICH was observed in 7 patients (9.9%) and was associated with earlier anticoagulation initiation (p = 0.02). Of patients with catastrophic ICH, 6 (85.7%) had intra-axial exploration during their index surgery. Patients with intra-axial exploration were more likely to experience a catastrophic ICH postoperatively compared to those with extra-axial exploration alone (OR 8.5, p = 0.04). Of the 58 patients with postoperative imaging, 15 (25.9%) experienced new or worsening blood products. Catastrophic ICH was 9 times more likely with anticoagulation initiation within 48 hours of surgery (OR 8.9, p = 0.01). The cumulative catastrophic ICH risk decreased with delay in initiation of anticoagulation, from 21.1% on POD 2 to 9.9% on POD 7. Concurrent antiplatelet medication was not associated with either outcome measure. CONCLUSIONS: The incidence of catastrophic ICH was significantly increased when anticoagulation was initiated within 48 hours of cranial surgery. Patients undergoing intra-axial exploration during their index surgery were at higher risk of a catastrophic ICH.

Clinical presentation and extent of resection impacts progression-free survival in spinal ependymomas.

PURPOSE: Primary treatment of spinal ependymomas involves surgical resection, however recurrence ranges between 50 and 70%. While the association of survival outcomes with lesion extent of resection (EOR) has been studied, existing analyses are limited by small samples and archaic data resulting in an inhomogeneous population. We investigated the relationship between EOR and survival outcomes, chiefly overall survival (OS) and progression-free survival (PFS), in a large contemporary cohort of spinal ependymoma patients. METHODS: Adult patients diagnosed with a spinal ependymoma from 2006 to 2021 were identified from an institutional registry. Patients undergoing primary surgical resection at our institution, ≥ 1 routine follow-up MRI, and pathologic diagnosis of ependymoma were included. Records were reviewed for demographic information, EOR, lesion characteristics, and pre-/post-operative neurologic symptoms. EOR was divided into 2 classifications: gross total resection (GTR) and subtotal resection (STR). Log-rank test was used to compare OS and PFS between patient groups. RESULTS: Sixty-nine patients satisfied inclusion criteria, with 79.7% benefitting from GTR. The population was 56.2% male with average age of 45.7 years, and median follow-up duration of 58 months. Cox multivariate model demonstrated significant improvement in PFS when a GTR was attained (p <.001). Independently ambulatory patients prior to surgery had superior PFS (p <.001) and OS (p =.05). In univariate analyses, patients with a syrinx had improved PFS (p =.03) and were more likely to benefit from GTR (p =.01). Alternatively, OS was not affected by EOR (p =.78). CONCLUSIONS: In this large, contemporary series of adult spinal ependymoma patients, we demonstrated improvements in PFS when GTR was achieved.

A comparison of successful versus failed nonoperative treatment approaches in patients with degenerative conditions of the lumbar spine.

Identifying an optimal composition of nonoperative therapies to trial in patients suffering from degenerative lumbar spine conditions prior to surgical management remains challenging. Contrasting successful versus failed nonoperative treatment approaches may provide clinicians with valuable insight. The purpose of this study was to compare the nonoperative therapy regimens in degenerative lumbar spine disorder patients successfully managed conservatively versus patients who failed primary treatment and opted for lumbar fusion surgery. Clinical records from patients diagnosed with lumbar stenosis or spondylolisthesis from 2007 to 2017 were gathered from a comprehensive insurance database. Patients were separated into two cohorts: patients managed successfully with nonoperative therapies and patients who failed conservative therapy and underwent lumbar fusion surgery. Nonoperative therapy utilization by the two cohortswere collected across a 2-year surveillance window. A total of 531,980 adult patients with lumbar stenosis or spondylolisthesis comprised the base population. There were 523,031 patients (98.3%) successfully treated with conservative management alone, while 8,949 patients (1.7%) ultimately failed nonoperative management and opted for lumbar fusion.Conservative therapy failure rates were especially high in patients with a smoking history (2.1%) and those utilizing lumbar epidural steroid injections (LESIs) (3.7%). A greater percentage of patients who failed conservative management utilized opioid medications (p < 0.0001), muscle relaxants (p < 0.0001), and LESIs (p < 0.0001). Patients who failed nonoperative management spent more than double than the successfully treated cohort (failed cohort: $1806.49 per patient; successful cohort: $768.50 per patient). In a multivariate logistic regression model, smoking, obesity and prolonged opioid use were independently associated with failure of nonoperative treatment.

Comparison of Postoperative Opioid Utilization in an ACDF Cohort: Narcotic Naive Patients Versus Preoperative Opioid Users.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To compare the postoperative opioid utilization rates and costs after anterior cervical discectomy and fusion (ACDF) procedures between groups of patients who were preoperative opioid users versus opioid naive. SUMMARY OF BACKGROUND DATA: Opioid medications are frequently prescribed after ACDF procedures. Given the current opioid epidemic, there is increased emphasis on early identification of patients at risk for prolonged postoperative opioid use. METHODS: Records from patients diagnosed with cervical stenosis who underwent a ≤3-level index ACDF surgery between 2007 and 2017 were collected from a large insurance database. International Classification of Diseases diagnosis/procedure codes, Current Procedural Terminology codes, and generic drug codes were used to search clinical records. Two cohorts were established: a group of patients who utilized opioids preoperatively and a group of patients who were opioid naive at the time of surgery. The 1-year utilization and costs of postoperative therapies were documented for each group. RESULTS: The preoperative opioid use cohort contained 4485 patients (61.6%), whereas the opioid-naive cohort included 2799 patients (38.4%). Postoperatively, 86.6% of the preoperative opioid use group continued to use opioids, whereas 59.0% of the opioid-naive group began using opioids. Patients who utilized opioids preoperatively were 4.48 times more likely (95% confidence interval, 3.99-5.02, P<0.001) to use opioids postoperatively and 4.30 times more likely (95% confidence interval, 3.10-5.94, P<0.001) to become opioid dependent compared with opioid-naive patients. In addition, after normalization, patients in the preoperative opioid use group utilized 3.7 times more opioid units/patient and billed for 5.3 times more dollars/patient than opioid-naive patients. CONCLUSIONS: In patients with cervical stenosis who undergo an ACDF procedure, the postoperative utilization and costs of opioids seem to be substantially higher in patients with preoperative opioid use compared with opioid-naive patients. Efforts should be made to avoid opioid use as a component of conservative management before surgery. LEVEL OF EVIDENCE: Level III.

An Assessment of Nonoperative Management Strategies in a Herniated Lumbar Disc Population: Successes Versus Failures.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare the utilization of conservative treatments in patients with lumbar intervertebral disc herniations who were successfully managed nonoperatively versus patients who failed conservative therapies and elected to undergo surgery (microdiscectomy). METHODS: Clinical records from adult patients with an initial herniated lumbar disc between 2007 and 2017 were selected from a large insurance database. Patients were divided into 2 cohorts: patients treated successfully with nonoperative therapies and patients that failed conservative management and opted for microdiscectomy surgery. Nonoperative treatments utilized by the 2 groups were collected over a 2-year surveillance window. "Utilization" was defined by cost billed to patients, prescriptions written, and number of units disbursed. RESULTS: A total of 277 941 patients with lumbar intervertebral disc herniations were included. Of these, 269 713 (97.0%) were successfully managed with nonoperative treatments, while 8228 (3.0%) failed maximal nonoperative therapy (MNT) and underwent a lumbar microdiscectomy. MNT failures occurred more frequently in males (3.7%), and patients with a history of lumbar epidural steroid injections (4.5%) or preoperative opioid use (3.6%). In a logistic multivariate regression analysis, male sex and utilization of opioids were independent predictors of conservative management failure. Furthermore, a cost analysis indicated that patients who failed nonoperative treatments billed for nearly double ($1718/patient) compared to patients who were successfully treated ($906/patient). CONCLUSION: Our results suggest that the majority of patients are successfully managed nonoperatively. However, in the subset of patients that fail conservative management, male sex and prior opioid use appear to be independent predictors of treatment failure.

Regional differences in prolonged non-operative therapy utilization prior to primary ACDF surgery.

There is a paucity of data characterizing regional variations in the utilization and costs of conservative management in patients suffering from cervical stenosis prior to anterior cervical discectomy and fusion (ACDF) surgery. An understating of these regional trends becomes critical as outcomes-based reimbursement strategies become standard. The objective of this investigation was to evaluate for regional differences in the utilization and overall costs of maximal non-operative therapy (MNT) prior to ACDF surgery. Medical records from patients with symptomatic cervical stenosis undergoing a ≤3-level index ACDF procedure between 2007 and 2016 were accessed from a large insurance database. Geographic regions (Midwest, Northeast, South, and West) reflected U.S. Census Bureau definitions. MNT utilization within 2-years prior to ACDF surgery was analyzed. An index ACDF surgery was performed in 15,825 patients. Patient regional breakdown was as follows: South (67.6% of patients), Midwest (21.8% of patients), West (8.9% of patients), Northeast (1.6% of patients). Regional variations were identified in the number of patients utilizing NSAIDs (p < 0.001), opioids (p < 0.001), muscle relaxants (p < 0.001), cervical epidural steroid injections (p = 0.001), physical therapy/occupational therapy treatments (p < 0.001), and chiropractor visits (p < 0.001). The West (64.5%) and South (63.5%) had the greatest proportion of patients utilizing narcotics. When normalized by the number of opioid using-patients however, the Northeast (691.4 pills/patient) and South (674.4 pills/patient) billed for the most opioid pills. The total direct cost associated with all MNT prior to index ACDF was $17,255,828. The Midwest ($1,277.72 per patient) and South ($1,047.86 per patient) had the greatest average dollars billed.

A comparison of prolonged nonoperative management strategies in cervical stenosis patients: Successes versus failures.

A paucity of evidence exists regarding the optimal composition of conservative therapies to best treat patients diagnosed with cervical stenosis prior to consideration of surgery. The purpose of this study was to compare the nonoperative therapy utilization strategies in cervical stenosis patients successfully managed with conservative treatments versus those that failed medical management and opted for an anterior cervical discectomy and fusion (ACDF) surgery. Medical records from adult patients with a diagnosis of cervical stenosis from 2007 to 2017 were collected retrospectively from a large insurance database. Patients were divided into two cohorts: patients treated successfully with nonoperative therapies and patients that failed conservative management and opted for ACDF surgery. Nonoperative therapies utilized by the two cohorts were collected over a 2-year surveillance window. A total of 90,037 adult patients with cervical stenosis comprised the base population. There were 83,384 patients (92.6%) successfully treated with nonoperative therapies alone, while 6,653 patients (7.4%) ultimately failed conservative management and received an ACDF. Failure rates of non-operative therapies were higher in smokers (11.2%), patients receiving cervical epidural steroid injections (11.2%), and male patients (8.1%). A greater percentage of patients who failed conservative management utilized opioid medications (p < 0.001), muscle relaxants (p < 0.001), and CESIs (p < 0.001). The costs of treating patients that failed conservative management was double the amount of the successfully treated group (failed cohort: $1,215.73 per patient; successful cohort: $659.58 per patient). A logistic regression analysis demonstrated that male patients, smokers, opioid utilization, and obesity were independent predictors of conservative treatment failure.

High-Grade Spondylolisthesis in Adults: Current Concepts in Evaluation and Management.

BACKGROUND: Information regarding the treatment of high-grade spondylolisthesis (HGS) in adults has been previously described; however, previous descriptions of the evaluation and surgical management of HGS do not represent more recent and now established approaches. The purpose of the current review is to discuss current concepts in the evaluation and management of patients with HGS. METHODS: Literature review. RESULTS: HGS is diagnosed in up to 11.3% of adults with spondylolisthesis and typically presents as nonspecific lower back pain. Regarding evaluation, a thorough history and physical examination should be performed, which may help predict the presence of HGS. Diagnostic imaging, and specifically the use of spino-pelvic parameters, are now commonly implicated in guiding treatment course and prognosis. When surgical intervention is indicated, surgical approaches include in situ fusion variations, reduction and partial reduction with fusion, and vertebrectomy. Although the majority of studies suggest improvements with these approaches, the literature is limited by a low level of evidence with regards to the superiority of one technique when compared with others. CONCLUSIONS: HGS is a unique cause of low back pain in adults that carries considerable morbidity, but rarely presents with neurologic symptoms. Although the definitions, classifications, and methods of diagnosis of this spinal deformity have been established and accepted, the ideal surgical management of this deformity remains highly debated. Fusion in situ techniques are often technically easier to perform and provide lower risk of neurologic complications, whereas reduction and fusion techniques offer greater restoration of global spino-pelvic balance. Preoperative spino-pelvic parameters may have utility in assisting in procedural selection; however, future, higher-quality and longer-term studies are warranted to determine the optimal surgical intervention among the widely available techniques currently used, and to better define the indications for these interventions.

Gender differences in use of prolonged non-operative therapies prior to index ACDF surgery.

Prior to anterior cervical discectomy and fusion (ACDF) surgery, patients suffering from cervical stenosis traditionally trial non-operative treatments for pain management. There is a paucity of data evaluating gender disparities in the prolonged utilization of conservative therapy prior to ACDF surgery. Therefore, the purpose of this study was to assess for gender-based differences in the utilization and cost of maximal non-operative therapy (MNT) for cervical stenosis prior to ACDF surgery. Medical records from patients with symptomatic cervical stenosis undergoing 1, 2, or 3-level index ACDF procedures between 2007 and 2016 were gathered from an insurance database consisting of 20.9 million covered lives. The utilization of MNTs within 5 years prior to index ACDF surgery was assessed. A total of 2254 patients (females: 53.1%) underwent an index ACDF surgery. There were a significantly greater percentage of female patients that utilized NSAIDs (p < 0.0001), opioids (p = 0.0019), muscle relaxants (p < 0.0001), cervical epidural steroid injections (p = 0.0428), and physical therapy/occupational therapy treatments (p < 0.0001). The total direct cost associated with all MNT prior to index ACDF was $4,833,384. On average, $2028.01 was spent per male patient while $2247.29 was spent per female patient. When normalized by number of pills billed per patient utilizing therapy, female patients utilized more NSAIDs (males: 591.8 pills, females: 669.3 pills), opioids (male: 1342.0 pills, female: 1650.1 pills), and muscle relaxants (males: 823.7 pills, females: 1211.1 pills). The results suggest that there may be gender differences in the utilization of non-operative therapies for symptomatic cervical stenosis prior to ACDF surgery.

Gender differences in the 3-month utilization of nonoperative therapies prior to primary lumbar microdiscectomy.

Patients with lumbar intervertebral disc herniation classically trial a brief course of conservative management prior to microdiscectomy surgery. Gender differences have previously been identified in the selection and symptomatic response to commonly-utilized nonoperative treatments. However, whether gender differences exist in the degree and cost of nonoperative therapy in this cohort remains unknown. Therefore, the purpose of this study was to assess for gender differences in the utilization and costs of nonoperative therapy in patients diagnosed with symptomatic lumbar intervertebral disc herniation 3-months prior to undergoing microdiscectomy. Medical records from adult patients diagnosed with a lumbar intervertebral disc herniation undergoing index microdiscectomy procedures from 2007 to 2017 were collected retrospectively from a large insurance database. The utilization of nonoperative therapy within 3-months after initial lumbar herniation diagnosis was determined. A total of 13,106 patients (55.4% Males) underwent index microdiscectomy. Male patients were more likely to fail conservative management and opt for surgery (Males: 2.9% vs. Females: 1.8%, p < 0.0001). A greater percentage of female patients utilized muscle relaxants (p = 0.0049), lumbar epidural steroid injections (p = 0.0007), and emergency department services (p = 0.001). The total direct cost of conservative treatment prior to microdiscectomy was $13,205,924, with males accountable for $7,457,023 (56.5%). When normalized by number of patients utilizing the respective therapy, males used fewer units of NSAIDs (males: 84.2 pills/patient; females: 97.3 pills/patient) and muscle relaxants (males: 77.5 pills/patient; females: 89.0 pills/patient). These results suggest that gender differences exist in the utilization of nonoperative therapies for the management of a lumbar intervertebral herniated disc prior to microdiscectomy surgery.

Adjunct Analgesia Reduces Pain and Opioid Consumption After Hip Arthroscopy: A Systematic Review of Randomized Controlled Trials.

BACKGROUND: Patients who undergo hip arthroscopy inevitably experience pain postoperatively; however, the efficacy and safety of adjunct analgesia to prevent or reduce pain are not well-understood. PURPOSE: To perform a comprehensive qualitative synthesis of available randomized controlled trials evaluating the effect of adjunct analgesia on postoperative (1) pain, (2) opioid use, and (3) length of stay (LOS) in patients undergoing hip arthroscopy. STUDY DESIGN: Systematic review. METHODS: PubMed, OVID/MEDLINE, and Cochrane Controlled Register of Trials were queried for studies pertaining to analgesia interventions for patients undergoing hip arthroscopy. Two authors independently assessed article bias and eligibility. Data pertaining to changes in pain scores, additional analgesia requirements, length of hospital stay, and complications were extracted and qualitatively reported. Network meta-analyses were constructed to depict mean pain, opioid use, and LOS among the 3 analgesia categories (blocks, local infiltration analgesia, and celecoxib). RESULTS: Fourteen level 1 studies were included; 12 (85.7%) reported pain reductions in the immediate and perioperative period after hip arthroscopy. Of the 7 studies that assessed an intervention (2 celecoxib, 1 fascia iliaca block, 1 lumbar plexus block, 1 femoral nerve block, 1 intra-articular bupivacaine, 1 extracapsular bupivacaine) versus placebo, more than half reported that patients who received an intervention consumed significantly fewer opioids postoperatively than patients who received placebo (lowest P value = .0006). Of the same 7 studies, 2 reported significantly shortened LOS with interventions, while 4 reported no statistically significant difference in LOS and 1 did not report LOS as an outcome. CONCLUSION: The majority of studies concerning adjunct analgesia for patients undergoing hip arthroscopy suggest benefits in pain reduction early in the postoperative period. There is mild evidence that adjunct analgesia reduces postoperative opioid use and currently inconclusive evidence that it reduces length of hospital stay. Furthermore, it appears that local infiltration analgesia may provide the greatest benefits in reductions in pain and opioid consumption. We recommend the use of adjunct analgesia in appropriately selected patients undergoing hip arthroscopy without contraindication who are at a high risk of severe postoperative pain.

Regional Variation in Nonoperative Therapy Utilization for Symptomatic Lumbar Stenosis and Spondylolisthesis: A 2-Year Costs Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To characterize regional variations in maximal nonoperative therapy (MNT) costs in patients suffering from lumbar stenosis or spondylolisthesis. METHODS: Medical records from patients with symptomatic lumbar stenosis or spondylolisthesis undergoing primary ≤3-level lumbar decompression and fusion procedures from 2007 to 2016 were gathered from a large insurance database. Geographic regions (Midwest, Northeast, South, and West) reflected the US Census Bureau definitions. Records were searchable by International Classification of Diseases diagnosis/procedure codes, Current Procedural Terminology codes, and insurance-specific generic drug codes. Utilization of MNT, defined as cost billed, prescriptions written, and number of units disbursed, within 2-years prior to index surgery was assessed. RESULTS: A total of 27 877 patients underwent 1-, 2-, or 3-level lumbar decompression and fusion surgery. Regional breakdown of the study cohort was as follows: South 62.3%, Midwest 25.2%, West 10.4%, Northeast 2.1%. Regional variations in the number of patients using nonsteroidal anti-inflammatory drugs (NSAIDs) (P < .0001), opioids (P < .0001), muscle relaxants (P < .0001), and lumbar steroid injections (P < .0001) were detected. A significant difference was identified in the regional MNT failure rates (P < .0001). The total cost associated with MNT prior to index surgery was $48 411 125 ($1736.60/patient), with the Midwest ($1943.83/patient) responsible for the greatest average spending. Despite comprising 62.3% of the cohort, the South was accountable for 67.5% of NSAID prescriptions, 64.6% of opioid prescriptions, and 71.2% of muscle relaxant prescriptions. CONCLUSIONS: Regional differences exist in the costs of MNT in patients with lumbar stenosis and spondylolisthesis prior to surgery. Future studies should focus on identifying patients likely to fail prolonged nonoperative management.

Racial Differences in Perioperative Opioid Utilization in Lumbar Decompression and Fusion Surgery for Symptomatic Lumbar Stenosis or Spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To assess for racial differences in opioid utilization prior to and after lumbar fusion surgery for patients with lumbar stenosis or spondylolisthesis. METHODS: Clinical records from patients with lumbar stenosis or spondylolisthesis undergoing primary <3-level lumbar fusion from 2007 to 2016 were gathered from a comprehensive insurance database. Records were queried by International Classification of Diseases diagnosis/procedure codes and insurance-specific generic drug codes. Opioid use 6 months prior, through 2 years after surgery was assessed. Multivariate regression analysis was employed to investigate independent predictors of opioid use following lumbar fusion. RESULTS: A total of 13 257 patients underwent <3-level posterior lumbar fusion. The cohort racial distribution was as follows: 80.9% white, 7.0% black, 1.0% Hispanic, 0.2% Asian, 0.2% North American Native, 0.8% "Other," and 9.8% "Unknown." Overall, 57.8% patients utilized opioid medications prior to index surgery. When normalized by the number opiate users, all racial cohort saw a reduction in pills disbursed and dollars billed following surgery. Preoperatively, Hispanics had the largest average pills dispensed (222.8 pills/patient) and highest average amount billed ($74.67/patient) for opioid medications. The black cohort had the greatest proportion of patients utilizing preoperative opioids (61.8%), postoperative opioids (87.1%), and long-term opioid utilization (72.7%), defined as use >1 year after index operation. Multivariate logistic regression analysis indicated Asian patients (OR 0.422, 95% CI 0.191-0.991) were less likely to use opioids following lumbar fusion. CONCLUSIONS: Racial differences exist in perioperative opioid utilization for patients undergoing lumbar fusion surgery for spinal stenosis or spondylolisthesis. Future studies are needed corroborate our findings.

Total Health Care Expenditure in Patients With a Herniated Lumbar Disk That Ultimately Require Surgery: A 3- and 6-month Cost Comparison of Maximum Nonoperative Treatment.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: To compare the cost of maximum nonoperative therapy (MNT) in patients diagnosed with a herniated lumbar disk undergoing primary (1-3 mo) versus prolonged (4-6 mo) conservative management before microdiscectomy. SUMMARY OF BACKGROUND DATA: Patients diagnosed with a herniated lumbar disk often attempt a 3-month trial of conservative management before microdiscectomy. A paucity of data exists characterizing the cost of a subsequent round of nonoperative therapies in patients who fail their initial trial, rather than undergo surgery. METHODS: Clinical records from patients diagnosed with a herniated lumbar disk undergoing index microdiscectomy surgery from 2007 to 2017 were gathered from a large insurance database. Records were searchable by International Classification of Diseases diagnosis/procedure codes, Current Procedural Terminology codes, and generic drug codes. Two cohorts were established: patients undergoing primary (1-3 mo) versus prolonged (4-6 mo) courses of conservative management. Nonoperative therapy utilization was documented from initial herniation diagnosis to microdiscectomy surgery. "Utilization" encompassed cost billed to patients, prescriptions written, and quantity of units dispensed. RESULTS: The 3-month MNT cohort included 4587 patients and the 6-month MNT cohort contained 1506 patients. A greater percentage of 6-month cohort patients utilized opioids (P=0.0052), muscle relaxants (P=0.0061), and lumbar steroid injections (P<0.0001). When considering the average amount spent on conservative management, 6-month patients ($1824/patient) spent 1.55 times more than 3-month patients ($1178/patient). The 6-month:3-month average spending ratio was <2.0 for all of the nonoperative therapies except nonsteroidal anti-inflammatory drugs (2.66) and epidural steroid injections (2.25). When normalized by the number of opioid users, the number of opioid medications dispensed was proportionally less in 3-month patients compared with 6-month patients, with a 6-month:3-month ratio of 1.52. CONCLUSIONS: The costs associated with a subsequent course of nonoperative therapies for symptomatic lumbar disk herniation seem to be slightly less than that of the primary trial. Assuming a minimal clinical benefit after the initial trial of nonsurgical therapies, the incremental cost-effectiveness ratio of a subsequent trial versus surgery may be unfavorable. Future studies identifying patients likely to benefit from surgery earlier in the treatment course is required. LEVEL OF EVIDENCE: Level III.

Reduction in Narcotic Use After Lumbar Decompression and Fusion in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The purpose of this study is to assess change in opioid use before and after lumbar decompression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis. METHODS: A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. Opioid use 6 months preoperatively through 2 years postoperatively was assessed. RESULTS: The study included 13 257 patients that underwent 1-, 2-, or 3-level posterior lumbar instrumented fusion. Overall, 57.8% of patients used opioids preoperatively. Throughout the 6-month preoperative period, 2 368 008 opioid pills were billed for (51.6 opioid pills/opioid user/month). When compared with preoperative opioid use, patients billed fewer opioid medications in the 2-year period postoperatively: 33.6 pills/patient/month (8 851 616 total pills). In a multivariate logistic regression analysis, obesity (odds ratio [OR] 1.10, 95% CI 1.004-1.212), preoperative narcotic use (OR 3.43, 95% CI 3.179-3.708), length of hospital stay (OR 1.02, 95% CI 1.010-1.021), and receiving treatment in the South (OR 1.18, 95% CI 1.074-1.287) or West (OR 1.26, 95% CI 1.095-1.452) were independently associated with prolonged postoperative (>1 year) opioid use. Additionally, males (OR 0.87, 95% CI 0.808-0.945) were less likely to use long-term opioid therapy. CONCLUSIONS: This study demonstrates that reduction in opioid use was observed postoperatively in comparison with preoperative values in patients with symptomatic lumbar stenosis or spondylolisthesis that underwent lumbar decompression with fusion. Further prospective studies that are more methodologically stringent are needed to corroborate our findings.

Sex Differences in Opioid Use in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis Undergoing Lumbar Decompression and Fusion.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: To investigate sex differences in opioid use after lumbar decompression and fusion surgery for patients with symptomatic lumbar stenosis or spondylolisthesis. SUMMARY OF BACKGROUND DATA: Recent studies have demonstrated higher prevalence of chronic pain states and greater pain sensitivity among women compared with men. Furthermore, differences in responsivity to pharmacological and non-pharmacological treatments have been observed. Whether sex differences in perioperative opioid use exists in patients undergoing lumbar fusion for symptomatic stenosis or spondylolisthesis remains unknown. METHODS: An insurance database, including private/commercially insured and Medicare Advantage beneficiaries, was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1,2, or 3-level index lumbar decompression and fusion procedures between 2007 and 2016. Records were searchable by International Classification of diseases diagnosis and procedure codes, and generic drug codes specific to Humana. Opioid use 6-months prior to through 2-years after index surgery was assessed. The primary outcome was sex differences in opioid use after index lumbar surgery. The secondary outcome was independent predictors of prolonged opioid use after lumbar fusion. RESULTS: Of the 13,257 participants (females: 7871, 59.8%), 58.4% of women used opioids compared with 56.9% of men prior to index surgery. At 1-year after surgery, continuous opioid use was observed in 67.1% of women compared with 64.2% of men (P < 0.001). Within 2-years postoperatively, opioid use was observed in 83.1% of women versus 82.5% men. In a multivariate logistic regression analysis, female sex (odds ration [OR] 1.14, 95% confidence interval [CI]: 1.058-1.237), obesity (OR 1.10, 95% CI: 1.004-1.212), and preoperative narcotic use (OR 3.43, 95% CI: 3.179-3.708) was independently associated with prolonged (>1 yr) opioid use after index surgery. CONCLUSION: We observed a higher prevalence of chronic opioid use among women following lumbar fusion surgery. Female sex was independently associated with prolonged opioid use after index surgery. LEVEL OF EVIDENCE: 3.

Regional Differences in the Cost and Utilization of Nonoperative Management Within 3 Months Prior to Lumbar Microdiscectomy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this investigation was to evaluate the regional variations in the use of nonoperative therapies in patients diagnosed with a lumbar intervertebral disc herniation 3 months prior to undergoing microdiscectomy surgery. SUMMARY OF BACKGROUND DATA: Regional variations in the management of chronic pain conditions have been previously identified. Patients suffering from a lumbar intervertebral disc herniation are typically treated with a brief course of conservative management prior to attempting microdiscectomy surgery. Whether regional differences exist in the utilization or costs of maximum nonoperative therapy (MNT) remains unknown. METHODS: Medical records from patients diagnosed with a lumbar intervertebral disc herniation undergoing 1, 2, or 3-level index microdiscectomy operations between 2007 and 2017 were gathered from the HORTHO insurance database consisting of private/commercially insured and Medicare Advantage beneficiaries. Patient regional designation was divided into Midwest, Northeast, South, and West territories and was derived from the insurance claim location. The utilization of MNT within 3 months after initial lumbar herniation diagnosis in adult patients was analyzed. RESULTS: Our population consisted of 13,106 patients who underwent primary index microdiscectomy surgery. Significant regional variation was identified in the nonoperative therapy failure rate (P<0.0001), with the highest proportion of Midwest patients failing (2.7%). There were statistical differences in the regional distribution of patients utilizing NSAIDs (P<0.0001), muscle relaxants (P <0.0001), lumbar epidural steroid injections (P <0.0001), physical therapy and occupational therapy sessions (P <0.0001), chiropractor treatments (P <0.0001), and emergency department services (P = 0.0049). The total direct cost associated with all MNT prior to microdiscectomy was $13,205,924, with 59.6% from the South, 31.1% from the Midwest, 8.3% from the West, and 1.1% from the Northeast. CONCLUSION: These findings indicate that regional differences exist in the utilization and costs of MNT of a lumbar intervertebral herniated disc prior to microdiscectomy surgery. LEVEL OF EVIDENCE: 3.

A 2-Year Cost Analysis of Maximum Nonoperative Treatments in Patients With Symptomatic Lumbar Stenosis or Spondylolisthesis That Ultimately Required Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The purpose of this study is to characterize the utilization and costs of maximal nonoperative therapies (MNTs) within 2 years prior to spinal fusion surgery in patients with symptomatic lumbar stenosis or spondylolisthesis. METHODS: A large insurance database was queried for patients with symptomatic lumbar stenosis or spondylolisthesis undergoing index 1-, 2-, or 3-level lumbar decompression and fusion procedures between 2007 and 2016. This database consists of 20.9 million covered lives and includes private/commercially insured and Medicare Advantage beneficiaries. The utilization of MNTs within 2 years prior to index surgery was assessed by cost billed to the patient, prescriptions written, and number of units billed. RESULTS: A total of 27 877 out of 3 423 114 (0.8%) eligible patients underwent posterior lumbar instrumented fusion. Patient MNT utilization was as follows: 11 383 (40.8%) used nonsteroidal anti-inflammatory drugs (NSAIDs), 19 770 (70.9%) used opioids, 12 414 (44.5%) used muscle relaxants, 14 422 (51.7%) received lumbar epidural steroid injection (LESI), 11 156 (40.0%) attended physical therapy/occupational therapy, 4005 (14.4%) presented to the emergency department, and 4042 (14.5%) received chiropractor treatments. The total direct cost associated with all MNTs prior to index spinal fusion was $28 241 320 ($1013.07 per/patient). LESI comprised the largest portion of the total cost of MNT ($15 296 941, 54.2%), followed by opioids ($3 702 463, 13.1%) and NSAIDs ($3 058 335, 10.8%). CONCLUSIONS: Opioids are the most frequently prescribed and most used therapy in the preoperative period. Assuming minimal improvement in pain and functional disability after maximum nonoperative therapies, the incremental cost effectiveness ratio for MNT could be highly unfavorable.

Retraction: Limited post-operative dexamethasone use does not affect lumbar fusion: a single institutional experience.

[This retracts the article DOI: 10.21037/jss.2018.05.20.].

A Two-Year Cost Analysis of Maximum Nonoperative Treatments in Patients with Cervical Stenosis that Ultimately Required Surgery.

OBJECTIVE: The aim of this study is to characterize the use and associated costs of maximal nonoperative therapy (MNT) received within 2-years before anterior cervical discectomy and fusion (ACDF) surgery in patients with symptomatic cervical stenosis. METHODS: An insurance database, including private/commercially insured and Medicare Advantage beneficiaries, was queried for patients undergoing 1-level, 2-level, or 3-level ACDF procedures between 2007 and 2016. Research records were searchable by International Classification of Diseases diagnosis and procedure, Current Procedural Terminology, and generic drug codes. The use of MNTs within 2 years before index ACDF surgery was assessed by cost billed to patients, prescriptions written, and number of units billed. RESULTS: Of 220,902 (7.16%) eligible patients, 15,825 underwent index surgery. Patient breakdown of the use of MNT modalities was as follows: 5731 (36.2%) used nonsteroidal antiinflammatory drugs; 9827 (62.1%) used opioids; 7383 (46.7%) used muscle relaxants; 3609 (22.8%) received cervical epidural steroid injection; 5504 (34.8%) attended physical therapy/occupational therapy; 1663 (10.5%) received chiropractor treatments; and 200 (1.3%) presented to the emergency department. During the 2-year preoperative period, there were 51,675 prescriptions for diagnostic cervical imaging. The total direct cost associated with all MNTs before ACDF was $16,056,556. Cervical spine imaging comprised the largest portion of the total MNT cost ($8,677,110; 54.0%), followed by cervical epidural steroid injection ($3,315,913; 20.7%) and opioids ($2,228,221; 13.9%). Opiates were the most frequently prescribed therapy (71,602 prescriptions). DISCUSSION: Opioids are the most frequently prescribed and most used therapy in the preoperative period for cervical stenosis. Further studies and improved guidelines are necessary to determine which patients may benefit from ACDF earlier in the course of nonoperative therapies.