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.

The obesity paradox and ventriculoperitoneal shunting in aneurysmal subarachnoid hemorrhage patients undergoing microsurgical clipping.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) can be devastating. Identifying predisposing factors is paramount in reducing aSAH-related mortality. Obesity's negative impact on health is well-established. However, the controversial "obesity paradox" in neurosurgery suggests that obesity may confer a survival advantage in SAH. We hypothesized that obesity would have a negative impact on outcomes following surgical clipping in aSAH. METHODS: A single-institution retrospective review was performed of aSAH patients undergoing surgical clipping from 2017 to 2021. Demographics and clinically relevant variables were collected. Obesity was defined as body mass index >30. Primary outcome was death or severe disability (mRS 4-6) at last follow-up. Secondary outcome was VPS placement. Multivariable Cox proportional-hazards model identified predictors of poor outcome. Kaplan-Meier curves identified survivorship differences between obese and non-obese patients. RESULTS: Poor outcome occurred in 11 of 52 total patients (21.2 %). There were no differences in demographics or distribution of Hunt Hess (HH), modified Fisher Grade (mFG), or external ventricular drain (EVD) placement between obese and non-obese patients. On univariate analysis, hypertension, older age, and non-obesity were predictive of poor outcome. On multivariable analysis, only obesity remained significant, suggesting a protective effect from poor outcome (HR 0.45 [0.21-0.95], p = 0.037). VPS placement occurred in 6 (11.5 %) patients for which obesity was not a significant predictor. CONCLUSIONS: Obesity may have a protective effect against poor outcome following surgical clipping in aSAH. Additionally, obesity does not appear to increase rate of EVD conversion to VPS. Thus, our study suggests that obesity should not preclude patients from open surgical intervention when clinically appropriate.

Repeat Flow Diversion for Retreatment of Incompletely Occluded Large Complex Symptomatic Cerebral Aneurysms: A Retrospective Case Series.

BACKGROUND AND OBJECTIVES: Data regarding radiographic occlusion rates after repeat flow diversion after initial placement of a flow diverter (FD) in large intracranial aneurysms are limited. We report clinical and angiographic outcomes on 7 patients who required retreatment with overlapping FDs after initial flow diversion for large intracranial aneurysms. METHODS: We performed a retrospective review of a prospectively maintained database of cerebrovascular procedures performed at our institution from 2017 to 2021. We identified patients who underwent retreatment with overlapping FDs for large (>10 mm) cerebral aneurysms after initial flow diversion. At last angiographic follow-up, occlusion grade was evaluated using the O'Kelly-Marotta (OKM) grading scale. RESULTS: Seven patients (median age 57 years) with cerebral aneurysms requiring retreatment were identified. The most common aneurysm location was the ophthalmic internal carotid artery (n = 3) and basilar trunk (n = 3). There were 4 fusiform and 3 saccular aneurysms. The median aneurysm width was 18 mm; the median neck size for saccular aneurysms was 7 mm; and the median dome-to-neck ratio was 2.8. The median time to retreatment was 9 months, usually due to symptomatic mass effect. After retreatment, the median clinical follow-up was 36 months, MRI/magnetic resonance angiography follow-up was 15 months, and digital subtraction angiography follow-up was 14 months. Aneurysm occlusion at last angiographic follow-up was graded as OKM A (total filling, n = 1), B (subtotal filling, n = 2), C (early neck remnant, n = 3), and D (no filling, n = 0). All patients with symptomatic improvement were OKM C, whereas patients with worsened symptom burden were OKM A or B. Two patients required further open surgical management for definitive management of the aneurysm remnant. CONCLUSION: Although most patients demonstrated a decrease in aneurysm remnant size, many had high-grade persistent filling (OKM grades A or B) in this subset of mostly large fusiform aneurysms. Larger studies with longer follow-up are warranted to optimize treatment strategies for atypical aneurysm remnants after repeat flow diversion.

Standardized Interview Scoring Methodology for Neurosurgical Residency Applicant Selection.

Interviews are critical to the neurosurgery resident application process. The COVID-19 pandemic forced residency interview activities are conducted virtually. To maintain a degree of control during a period of uncertainty, our department implemented a standardized survey for interviewers to evaluate the noncognitive attributes and program compatibility of applicants. Our objective was to assess the reliability and biases associated with our standardized interviewer survey implemented in neurosurgical residency interviews. A 5-question interviewer survey to assess applicant interview performance and program compatibility was implemented during the 2020 to 2021 interview season. After the application cycle, survey metrics were retrospectively reviewed. Multiple cohort analyses were performed by dividing interviewers into cohorts based on status (faculty or resident) and sex. Applicant scores were assessed within sex subgroups for each aforementioned interviewer cohort. Intraclass correlation coefficients (ICCs) were calculated to assess survey reliability. Fifteen interviewers (8 faculty and 7 residents) and 35 applicants were included. Female applicants (17%) and interviewers (20%) comprised the minority. There were no differences between resident and faculty reviewer scores; however, female reviewers gave higher overall scores than male reviewers ( P = .003). There was no difference in total scores between female and male applicants when evaluating all reviewers or subgroups of faculty, residents, females, or males. ICC analysis demonstrated good (ICC 0.75-0.90) or excellent (ICC > 0.90) reliability for all questions and overall score. The standardized interviewer survey was a feasible and reliable method for evaluating noncognitive attributes during neurosurgery residency interviews. There was no perceptible evidence of sex bias in our single-program experience.

A Biomechanical Assessment of Shaken Baby Syndrome: What About the Spine?

BACKGROUND: Shaken baby syndrome occurs following inertial loading of the pediatric head, resulting in retinal hemorrhaging, subdural hematoma, and encephalopathy. However, the anatomically vulnerable cervical spine receives little attention. Automotive safety literature is replete with biomechanical data involving forward-facing pediatric surrogates in frontal collisions, an environment analogous to shaking. Publicly available data involving child occupants were utilized to study pediatric neck and head injury potential. We hypothesized that inertial loading provides a greater risk of injury to the cervical spine than to the head. METHODS: Full-scale automotive crash tests (n = 131) and deceleration sled tests (n = 32) utilizing forward-facing 3-year-old surrogates with head accelerometers and cervical force sensors were analyzed. One hundred sixty-seven full-scale vehicle and 33 sled test runs were assessed in the context of published injury assessment reference values (IARVs) for closed head injury (head injury criterion 15 [HIC15]) and cervical tensile strength in the 3-year-old model. RESULTS: One hundred sixty-one (96%) child surrogates in full-scale crash tests exceeded the cervical peak tension IARV, while only 37 (22%) surpassed the HIC15 IARV. Similarly, in sled testing runs, 27 (82%) pediatric surrogates exceeded cervical tension IARVs, while 1 (3%) surpassed the HIC15 IARV. In both full-scale and sled tests, all surrogates surpassing the HIC15 IARV also exceeded the cervical tension IARV. Positive linear correlations were observed between HIC15 and cervical tensile forces in both full-scale vehicle (R2 = 0.15) and sled testing runs (R2 = 0.54). CONCLUSIONS: These data support the hypothesis that inertial loading of the head provides a greater injury risk to the cervical spine than to closed-head injury.

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.

Extent of resection and survival outcomes in World Health Organization grade II meningiomas.

PURPOSE: WHO grade II meningiomas behave aggressively, with recurrence rates as high as 60%. Although complete resection in low-grade meningiomas is associated with a relatively low recurrence rate, the impact of complete resection for WHO grade II meningiomas is less clear. We studied the association of extent of resection with overall and progression-free survivals in patients with WHO grade II meningiomas. METHODS: A retrospective database review was performed to identify all patients who underwent surgical resection for intracranial WHO grade II meningiomas at our institution between 1995 and 2019. Kaplan-Meier analysis was used to compare overall and progression-free survivals between patients who underwent gross total resection (GTR) and those who underwent subtotal resection (STR). Multivariable Cox proportional-hazards analysis was used to identify independent predictors of tumor recurrence and mortality. RESULTS: Of 214 patients who underwent surgical resection for WHO grade II meningiomas (median follow-up 53.4 months), 158 had GTR and 56 had STR. In Kaplan-Meier analysis, patients who underwent GTR had significantly longer progression-free (p = 0.002) and overall (p = 0.006) survivals than those who underwent STR. In multivariable Cox proportional-hazards analysis, GTR independently predicted prolonged progression-free (HR 0.57, p = 0.038) and overall (HR 0.44, p = 0.017) survivals when controlling for age, tumor location, and adjuvant radiation. CONCLUSIONS: Extent of resection independently predicts progression-free and overall survivals in patients with WHO grade II meningiomas. In an era of increasing support for adjuvant treatment modalities in the management of meningiomas, our data support maximal safe resection as the primary goal in treatment of these patients.

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.

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.

Heart dose and coronary artery calcification in patients receiving thoracic irradiation for lung cancer.

BACKGROUND: Thoracic irradiation (TIR) is associated with an increased risk of coronary artery disease (CAD) and coronary-related death. Lung cancer patients receive considerable doses of TIR, making them a high-risk population that may benefit from post-therapy surveillance. Coronary artery calcium (CAC) is a known biomarker of CAD development and may serve as a useful indicator of disease progression in this population. We hypothesized greater CAC progression in lung cancer patients subjected to higher whole heart radiation doses. METHODS: CAC progression (pre- and >2 years post-TIR) from chest CT scans of lung cancer patients were evaluated. A 2:1 matched control population was established controlling for age, gender, race, and CT scan interval. Vessel-specific CAC presence, progression, and extension in pre- and post-interval CT studies was evaluated by two blinded reviewers using the ordinal method. Dosimetric treatment files were restored and contours of the whole heart and proximal left anterior descending artery (LAD) were created within existing plans to compute radiation doses (Pinnacle Treatment Planning Software). Binary logistic regression analysis identified factors predictive for CAC development. Multiple logistic regression analysis with hierarchal method was used to assess covariates. RESULTS: Thirty-five patients and 65 controls (50% female) were evaluated; mean age 57 years, mean follow-up post-radiation 4.9±2.2 years. Average mean and maximum left anterior descending coronary artery (LAD) radiation doses were 19.9 Gy (95% CI, 14.1-25.7) and 30.7 Gy (95% CI, 23.8-37.5), respectively; 91.6% inter-observer variability. There was greater incidence of coronary calcification in irradiated patients (48.6% vs. 24.6%; P=0.01). In interval CT scans, a greater proportion of radiated patients demonstrated new coronary calcification (P=0.007) and extension within the LAD (P=0.003). Radiation exposure was the only independent predictor of new calcification (OR 3.1; 95% CI: 1.09-9.2). CONCLUSIONS: We identified both an increase in the development and progression of CAC in lung cancer patients receiving TIR. Future studies utilizing alternative cancer populations and larger sample sizes are necessary to further correlate radiographic and dosimetric observations to cardiovascular events.

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.

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.

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.

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.