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1.
World Neurosurg ; 2020 Mar 11.
Artigo em Inglês | MEDLINE | ID: mdl-32171932

RESUMO

BACKGROUND: The operative microscope, a commonly used tool in neurosurgery, is critical in many supratentorial tumor cases. However, use of operating microscope for supratentorial tumor varies by surgeon. OBJECTIVES: To assess complication rates, readmissions, and costs associated with operative microscope use in supratentorial resections. METHODS: A retrospective analysis was conducted using a national administrative database to identify patients with glioma or brain metastases who underwent supratentorial resection between 2007 and 2016. Univariate and multivariate analyses were used to assess 30-day complications, readmissions and costs between patients who underwent resection with and without use of microscope. RESULTS: The cohort included 12058 glioma patients and 5433 metastasis patients. Rates of microscope use varied by state from 19.0% to 68.6%. Microscope use was associated with $5228.9 in additional costs of index hospitalization among glioma patients (p < 0.001), and $2824.0 among metastasis patients (p < 0.001). Rates of intraoperative cerebral edema were lower among the microscope cohort than among the non-microscope cohort (p < 0.027). Microscope use was associated with a slight reduction in 30-day rates of neurological complications (14.7% vs. 16.7%, p = 0.048), specifically in nonspecific cerebrovascular complications. There were no differences in rates of other complications, readmissions, or 30-day postoperative costs. CONCLUSIONS: Use of operative microscope for supratentorial resections varies by state and is associated with higher cost of surgery. Microscope use may be associated with lower rates of intraoperative cerebral edema and some cerebrovascular complications, but is not associated with significant differences in other complications, readmissions, or 30-day costs.

2.
Sci Rep ; 10(1): 4939, 2020 Mar 18.
Artigo em Inglês | MEDLINE | ID: mdl-32188895

RESUMO

Patient-reported outcome measures (PROMs) are commonly used to estimate disability of patients with spinal degenerative disease. Emerging technological advances present an opportunity to provide objective measurements of activity. In a prospective, observational study we utilized a low-cost consumer grade wearable accelerometer (LCA) to determine patient activity (steps per day) preoperatively (baseline) and up to one year (Y1) after cervical and lumbar spine surgery. We studied 30 patients (46.7% male; mean age 57 years; 70% Caucasian) with a baseline activity level of 5624 steps per day. The activity level decreased by 71% in the 1st postoperative week (p < 0.001) and remained 37% lower in the 2nd (p < 0.001) and 23% lower in the 4th week (p = 0.015). At no time point until Y1 did patients increase their activity level, compared to baseline. Activity was greater in patients with cervical, as compared to patients with lumbar spine disease. Age, sex, ethnic group, anesthesia risk score and fusion were variables associated with activity. There was no correlation between activity and PROMs, but a strong correlation with depression. Determining activity using LCAs provides real-time and longitudinal information about patient mobility and return of function. Recovery took place over the first eight postoperative weeks, with subtle improvement afterwards.

3.
Spine (Phila Pa 1976) ; 45(5): E288-E295, 2020 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-32045403

RESUMO

STUDY DESIGN: This was a retrospective study using national administrative data from the MarketScan database. OBJECTIVE: To investigate the complication rates, quality outcomes, and costs in a nationwide cohort of patients with movement disorders (MD) who undergo spinal deformity surgery. SUMMARY OF BACKGROUND DATA: Patients with MD often present with spinal deformities, but their tolerance for surgical intervention is unknown. METHODS: The MarketScan administrative claims database was queried to identify adult patients with MD who underwent spinal deformity surgery. A propensity-score match was conducted to create two uniform cohorts and mitigate interpopulation confounders. Perioperative complication rates, 90-day postoperative outcomes, and total costs were compared between patients with MD and controls. RESULTS: A total of 316 patients with MD (1.7%) were identified from the 18,970 undergoing spinal deformity surgery. The complication rate for MD patients was 44.6% and for the controls 35.6% (P = 0.009). The two most common perioperative complications were more likely to occur in MD patients, acute-posthemorrhagic anemia (26.9% vs. 20.8%, P < 0.05) and deficiency anemia (15.5% vs. 8.5%, P < 0.05). At 90 days, MD patients were more likely to be readmitted (17.4% vs. 13.2%, P < 0.05) and have a higher total cost ($94,672 vs. $85,190, P < 0.05). After propensity-score match, the overall complication rate remained higher in the MD group (44.6% vs. 37.6%, P < 0.05). 90-day readmissions and costs also remained significantly higher in the MD cohort. Multivariate modeling revealed MD was an independent predictor of postoperative complication and inpatient readmission. Subgroup analysis revealed that Parkinson disease was an independent predictor of inpatient readmission, reoperation, and increased length of stay. CONCLUSION: Patients with MD who undergo spinal deformity surgery may be at risk of higher rate of perioperative complications and 90-day readmissions compared with patients without these disorders. LEVEL OF EVIDENCE: 3.

4.
World Neurosurg ; 136: e671-e682, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31996335

RESUMO

BACKGROUND: Ventriculoperitoneal shunts are used to alleviate elevated intracranial pressure due to either hydrocephalus or idiopathic intracranial hypertension; however, shunt failure is a significant neurosurgical problem. Despite increases in intraoperative stereotactic navigation usage over the past decade, its effect on shunt survival remains unclear. METHODS: Shunt-naïve pediatric and adult patients receiving ventriculoperitoneal shunting between 2007 and 2015 were identified in a national administrative database. Multivariable logistic and Cox regressions were used to evaluate factors affecting stereotaxy usage and shunt survival. Matched cohorts were generated by propensity score balancing. RESULTS: Of 9677 patients identified, 932 received image-guided shunt placement. Total shunt failure rate was not associated with stereotaxy use (20.3% with stereotaxy vs. 19.4% without, P = 0.4602). In the matched setting, shunt survival was not extended by use of image guidance during placement (hazard ratio = 1.134, 95% confidence interval 0.923-1.393). Late shunt failures (defined as failures occurring at least 30 days after shunt placement) caused by infection occurred more frequently in the stereotaxy cohort (hazard ratio = 2.207, 95% confidence interval 1.115-4.366), whereas late shunt failures attributable to mechanical shunt failure were more common in the nonstereotaxy cohort (hazard ratio = 1.406, 95% confidence interval 1.002-1.973). CONCLUSIONS: Our findings suggest stereotaxy use during ventriculoperitoneal shunt placement does not affect shunt survival. Late shunt failures caused by infection occurred more frequently in the stereotaxy cohort, whereas late failures caused by mechanical shunt malfunction were more commonly encountered in the nonstereotaxy cohort.

5.
J Gen Intern Med ; 35(1): 291-297, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31720966

RESUMO

BACKGROUND: The morbidity and mortality associated with opioid and benzodiazepine co-prescription is a pressing national concern. Little is known about patterns of opioid and benzodiazepine use in patients with acute low back pain or lower extremity pain. OBJECTIVE: To characterize patterns of opioid and benzodiazepine prescribing among opioid-naïve, newly diagnosed low back pain (LBP) or lower extremity pain (LEP) patients and to investigate the relationship between benzodiazepine prescribing and long-term opioid use. DESIGN/SETTING: We performed a retrospective analysis of a commercial database containing claims for more than 75 million enrollees in the USA. PARTICIPANTS: Participants were adult patients newly diagnosed with LBP or LEP between 2008 and 2015 who did not have a red flag diagnosis, had not received an opioid prescription in the 6 months prior to diagnosis, and had 12 months of continuous enrollment after diagnosis. MAIN OUTCOMES AND MEASURES: Among patients receiving at least one opioid prescription within 12 months of diagnosis, we defined discrete patterns of benzodiazepine prescribing-continued use, new use, stopped use, and never use. We tested the association of these prescription patterns with long-term opioid use, defined as six or more fills within 12 months. RESULTS: We identified 2,497,653 opioid-naïve patients with newly diagnosed LBP or LEP. Between 2008 and 2015, 31.9% and 11.5% of these patients received opioid and benzodiazepine prescriptions, respectively, within 12 months of diagnosis. Rates of opioid prescription decreased from 34.8% in 2008 to 27.0% in 2015 (P < 0.001); however, prescribing of benzodiazepines only decreased from 11.6% in 2008 to 10.8% in 2015. Patients with continued or new benzodiazepine use consistently used more opioids than patients who never used or stopped using benzodiazepines during the study period (one-way ANOVA, P < 0.001). For patients with continued and new benzodiazepine use, the odds ratio of long-term opioid use compared with those never prescribed a benzodiazepine was 2.99 (95% CI, 2.89-3.08) and 2.68 (95% CI, 2.62-2.75), respectively. LIMITATIONS: This study used administrative claims analyses, which rely on accuracy and completeness of diagnostic, procedural, and prescription codes. CONCLUSION: Overall opioid prescribing for low back pain or lower extremity pain decreased substantially during the study period, indicating a shift in management within the medical community. Rates of benzodiazepine prescribing, however, remained at approximately 11%. Concurrent prescriptions of benzodiazepines and opioids after LBP or LEP diagnosis were associated with increased risk of long-term opioid use.

6.
Neurosurgery ; 86(2): 272-280, 2020 Feb 01.
Artigo em Inglês | MEDLINE | ID: mdl-30937428

RESUMO

BACKGROUND: Idiopathic intracranial hypertension results in increased intracranial pressure leading to headache and visual loss. This disease frequently requires surgical intervention through lumboperitoneal (LP) or ventriculoperitoneal (VP) shunting. OBJECTIVE: To compare postoperative outcomes between LP and VP shunts, including failure and complication rates. METHODS: A retrospective analysis was conducted using a national administrative database (MarketScan) to identify idiopathic intracranial hypertension (IIH) patients who underwent LP or VP shunting from 2007 to 2014. Multivariate logistic and Cox regressions were performed to compare rates of shunt failure and time to shunt failure between LP and VP shunts while controlling for demographics and comorbidities. RESULTS: The analytic cohort included 1082 IIH patients, 347 of whom underwent LP shunt placement at index hospitalization and 735 of whom underwent VP shunt placement. Rates of shunt failure were similar among patients with LP and VP shunt (34.6% vs 31.7%; P = .382). Among patients who experienced shunt failure, the mean number of shunt failures was 2.1 ± 1.6 and was similar between LP and VP cohorts. Ninety-day readmission rates, complication rates, and costs did not differ significantly between LP and VP shunts. Patients who experienced more than two shunt failures tended to have an earlier time to first shunt failure (hazard ratio 1.41; 95% confidence interval 1.08-1.85; P = .013). CONCLUSION: These findings suggest that LP and VP shunts may have comparable rates of shunt failure and complication. Regardless of shunt type, earlier time to first shunt failure may be associated with multiple shunt failures.

7.
World Neurosurg ; 135: e548-e561, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31866457

RESUMO

BACKGROUND: Placement of Ommaya reservoirs for the administration of intrathecal chemotherapy may be complicated by comorbid thrombocytopenia among patients with hematologic or leptomeningeal disease. Aggregated data on risks of Ommaya placement among thrombocytopenic patients are lacking. This study assesses complications, revision rates, and costs associated with Ommaya placement among patients with thrombocytopenia in a large population sample. METHODS: Using a national administrative database, this retrospective study identifies a cohort of adult patients with cancer who underwent Ommaya placement between 2007 and 2016. Preoperative thrombocytopenia was defined as diagnosis of secondary thrombocytopenia, bleeding event, procedure to control bleeding, or platelet transfusion, within 30 days before index admission. Univariate and multivariate analyses were performed to assess costs, 30-day complications, readmissions, and revisions among patients with and without preoperative thrombocytopenia. RESULTS: The analytic cohort included 1652 patients, of whom 29.3% met criteria for preoperative thrombocytopenia. In-hospital mortality rates were 7.7% among patients thrombocytopenia with versus 1.2% among patients without thrombocytopenia (P < 0.001). Preoperative thrombocytopenia was associated with 14.5 times greater hazard of intracranial hemorrhage within 30 days following Ommaya placement, occurring in 25.6% versus 2.0% of patients with and without thrombocytopenia, respectively (P < 0.014). Revision rates did not differ significantly between patients with and without thrombocytopenia. Thrombocytopenia was associated with longer length of stay (7.4 vs. 13.9 days, P < 0.001) and additional $10,000 per patient in costs of index hospitalization (P < 0.001). CONCLUSIONS: This is the largest study to date documenting costs and complication rates of Ommaya placement in patients with and without thrombocytopenia.


Assuntos
Neoplasias/tratamento farmacológico , Trombocitopenia/complicações , Idoso , Antineoplásicos/administração & dosagem , Antineoplásicos/economia , Cateteres de Demora/economia , Custos e Análise de Custo , Sistemas de Liberação de Medicamentos/economia , Sistemas de Liberação de Medicamentos/instrumentação , Feminino , Humanos , Cobertura do Seguro , Seguro Saúde , Masculino , Neoplasias/economia , Estudos Retrospectivos , Trombocitopenia/economia , Resultado do Tratamento , Estados Unidos
8.
Robot Surg ; 6: 9-23, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31807602

RESUMO

Robot-assisted spine surgery has recently emerged as a viable tool to enable less invasive and higher precision surgery. The first-ever spine robot, the SpineAssist (Mazor Robotics Ltd., Caesarea, Israel), gained FDA approval in 2004. With its ability to provide real-time intraoperative navigation and rigid stereotaxy, robotic-assisted surgery has the potential to increase accuracy while decreasing radiation exposure, complication rates, operative time, and recovery time. Currently, robotic assistance is mainly restricted to spinal fusion and instrumentation procedures, but recent studies have demonstrated its use in increasingly complex procedures such as spinal tumor resections and ablations, vertebroplasties, and deformity correction. However, robots do require high initial costs and training, and thus, require justification for their incorporation into common practice. In this review, we discuss the history of spinal robots along as well as currently available systems. We then examine the literature to evaluate accuracy, operative time, complications, radiation exposure, and costs - comparing robotic-assisted to traditional fluoroscopy-assisted freehand approaches. Finally, we consider future applications for robots in spine surgery.

9.
Neuromodulation ; 2019 Dec 11.
Artigo em Inglês | MEDLINE | ID: mdl-31828896

RESUMO

INTRODUCTION: Randomized controlled trials (RCTs) have been critical in evaluating the safety and efficacy of functional neurosurgery interventions. Given this, we sought to systematically assess the quality of functional neurosurgery RCTs. METHODS: We used a database of neurosurgical RCTs (trials published from 1961 to 2016) to identify studies of functional neurosurgical procedures (N = 48). We extracted data on the design and quality of these RCTs and quantified the quality of trials using Jadad scores. We categorized RCTs based on the device approval status at the time of the trial and tested the association of device approval status with trial design and quality parameters. RESULTS: Of the 48 analyzed functional neurosurgery RCTs, the median trial size was 34.5 patients with a median age of 51. The most common indications were Parkinson's disease (N = 20), epilepsy (N = 10), obsessive-compulsive disorder (N = 4), and pain (N = 4). Most trials reported inclusion and exclusion criteria (95.8%), sample size per arm (97.9%), and baseline characteristics of the patients being studied (97.9%). However, reporting of allocation concealment (29.2%), randomization mode (66.7%), and power calculations (54.2%) were markedly less common. We observed that trial quality has improved over time (Spearman r, 0.49). We observed that trials studying devices with humanitarian device exemption (HDE) and experimental indications (EI) tended to be of higher quality than trials of FDA-approved devices (p = 0.011). A key distinguishing quality characteristic was the proportion of HDE and EI trials that were double-blinded, compared to trials of FDA-approved devices (HDE, 83.3%; EI, 69.2%; FDA-approved, 35.3%). Although more than one-third of functional neurosurgery RCTs reported funding from industry, no significant association was identified between funding source and trial quality or outcome. CONCLUSION: The quality of RCTs in functional neurosurgery has improved over time but reporting of specific metrics such as power calculations and allocation concealment requires further improvement. Device approval status but not funding source was associated with trial quality.

10.
Neurosurg Focus ; 47(5): E10, 2019 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-31675705

RESUMO

OBJECTIVE: Skull fractures are common after blunt pediatric head trauma. CSF leaks are a rare but serious complication of skull fractures; however, little evidence exists on the risk of developing a CSF leak following skull fracture in the pediatric population. In this epidemiological study, the authors investigated the risk factors of CSF leaks and their impact on pediatric skull fracture outcomes. METHODS: The authors queried the MarketScan database (2007-2015), identifying pediatric patients (age < 18 years) with a diagnosis of skull fracture and CSF leak. Skull fractures were disaggregated by location (base, vault, facial) and severity (open, closed, multiple, concomitant cerebral or vascular injury). Descriptive statistics and hypothesis testing were used to compare baseline characteristics, complications, quality metrics, and costs. RESULTS: The authors identified 13,861 pediatric patients admitted with a skull fracture, of whom 1.46% (n = 202) developed a CSF leak. Among patients with a skull fracture and a CSF leak, 118 (58.4%) presented with otorrhea and 84 (41.6%) presented with rhinorrhea. Patients who developed CSF leaks were older (10.4 years vs 8.7 years, p < 0.0001) and more commonly had skull base (n = 183) and multiple (n = 22) skull fractures (p < 0.05). These patients also more frequently underwent a neurosurgical intervention (24.8% vs 9.6%, p < 0.0001). Compared with the non-CSF leak population, patients with a CSF leak had longer average hospitalizations (9.6 days vs 3.7 days, p < 0.0001) and higher rates of neurological deficits (5.0% vs 0.7%, p < 0.0001; OR 7.0; 95% CI 3.6-13.6), meningitis (5.5% vs 0.3%, p < 0.0001; OR 22.4; 95% CI 11.2-44.9), nonroutine discharge (6.9% vs 2.5%, p < 0.0001; OR 2.9; 95% CI 1.7-5.0), and readmission (24.7% vs 8.5%, p < 0.0001; OR 3.4; 95% CI 2.5-4.7). Total costs at 90 days for patients with a CSF leak averaged $81,206, compared with $32,831 for patients without a CSF leak (p < 0.0001). CONCLUSIONS: The authors found that CSF leaks occurred in 1.46% of pediatric patients with skull fractures and that skull fractures were associated with significantly increased rates of neurosurgical intervention and risks of meningitis, hospital readmission, and neurological deficits at 90 days. Pediatric patients with skull fractures also experienced longer average hospitalizations and greater healthcare costs at presentation and at 90 days.

11.
Spine (Phila Pa 1976) ; 44(21): E1272-E1280, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31634303

RESUMO

STUDY DESIGN: Retrospective 1:1 propensity score-matched analysis on a national longitudinal database between 2007 and 2016. OBJECTIVE: The aim of this study was to compare complication rates, revision rates, and payment differences between navigated and conventional posterior lumbar fusion (PLF) procedures with instrumentation. SUMMARY OF BACKGROUND DATA: Stereotactic navigation techniques for spinal instrumentation have been widely demonstrated to improve screw placement accuracies and decrease perforation rates when compared to conventional fluoroscopic and free-hand techniques. However, the clinical utility of navigation for instrumented PLF remains controversial. METHODS: Patients who underwent elective laminectomy and instrumented PLF were stratified into "single level" and "3- to 6-level" cohorts. Navigation and conventional groups within each cohort were balanced using 1:1 propensity score matching, resulting in 1786 navigated and conventional patients in the single-level cohort and 2060 in the 3 to 6 level cohort. Outcomes were compared using bivariate analysis. RESULTS: For the single-level cohort, there were no significant differences in rates of complications, readmissions, revisions, and length of stay between the navigation and conventional groups. For the 3- to 6-level cohort, length of stay was significantly longer in the navigation group (P < 0.0001). Rates of readmissions were, however, greater for the conventional group (30-day: P = 0.0239; 90-day: P = 0.0449). Overall complications were also greater for the conventional group (P = 0.0338), whereas revision rate was not significantly different between the 2 groups. Total payments were significantly greater for the navigation group in both the single level and 3- to 6-level cohorts (P < 0.0001). CONCLUSION: Although use of navigation for 3- to 6-level instrumented PLF was associated with increased length of stay and payments, the concurrent decreased overall complication and readmission rates alluded to its potential clinical utility. However, for single-level instrumented PLF, no differences in outcomes were found between groups, suggesting that the value in navigation may lie in more complex procedures. LEVEL OF EVIDENCE: 3.


Assuntos
Vértebras Lombares/cirurgia , Fusão Vertebral/métodos , Adulto , Idoso , Estudos de Coortes , Bases de Dados Factuais , Procedimentos Cirúrgicos Eletivos , Feminino , Fluoroscopia , Humanos , Imagem Tridimensional/métodos , Laminectomia , Região Lombossacral/cirurgia , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Parafusos Pediculares , Pontuação de Propensão , Estudos Retrospectivos , Técnicas Estereotáxicas
12.
Spine (Phila Pa 1976) ; 44(21): E1281-E1288, 2019 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-31634304

RESUMO

STUDY DESIGN: A retrospective analysis of national longitudinal database. OBJECTIVE: The aim of this study was to examine the outcomes and cost-effectiveness of operating microscope utilization in anterior cervical corpectomy (ACC). SUMMARY OF BACKGROUND DATA: The operating microscope allows for superior visualization and facilitates ACC with less manipulation of tissue and improved decompression of neural elements. However, many groups report no difference in outcomes with increased cost associated with microscope utilization. METHODS: A longitudinal database (MarketScan) was utilized to identify patients undergoing ACC with or without microscope between 2007 and 2016. Propensity matching was performed to normalize differences between the two cohorts. Outcomes and costs were subsequently compared. RESULTS: A total of 11,590 patients were identified for the "macroscopic" group, while 4299 patients were identified for the "microscopic" group. For the propensity-matched analysis, 4298 patients in either cohort were successfully matched according to preoperative characteristics. Hospital length of stay was found to be significantly longer in the macroscopic group than the microscopic group (1.86 nights vs. 1.56 nights, P < 0.0001). Macroscopic ACC patients had an overall higher rate of readmissions [30-day: 4.2% vs. 3.2%, odds ratio (OR) = 0.76 (0.61-0.96), P = 0.0223; 90-day: 7.0% vs. 5.9%, OR = 0.82 (0.69-0.98), P = 0.0223]. Microscopic ACC patients had a higher rate of discharge to home [86.6% vs. 92.5%, OR = 1.91 (1.65-2.21), P < 0.0001] and lower rates of new referrals to pain management [1.0% vs. 0.4%, OR = 0.42 (0.23-0.74), P = 0.0018] compared with macroscopic ACC. Postoperative complication rate was not found to be significantly different between the groups. Finally, total initial admission charges were not significantly different between the macroscopic and microscopic groups ($30,175 vs. $29,827, P = 0.9880). CONCLUSION: The present study suggests that the use of the operating microscope for ACC is associated with decreased length of stay, readmissions, and new referrals to pain management, as well as higher rate of discharge to home. LEVEL OF EVIDENCE: 3.


Assuntos
Custos e Análise de Custo , Descompressão Cirúrgica , Idoso , Estudos de Coortes , Bases de Dados Factuais , Feminino , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Alta do Paciente , Complicações Pós-Operatórias/etiologia , Estudos Retrospectivos , Resultado do Tratamento
13.
Clin Spine Surg ; 2019 Oct 10.
Artigo em Inglês | MEDLINE | ID: mdl-31609798

RESUMO

BACKGROUND: Although the incidence of spinal fusions has increased significantly in the United States over the last quarter century, national trends of anterior lumbar interbody fusion (ALIF) utilization are not known. PURPOSE: The objective of this study was to characterize trends, clinical characteristics, risk factors associated with, and outcomes of ALIF in the United States. STUDY DESIGN: This was an epidemiological study using national administrative data from the MarketScan database. METHODS: Using a large administrative database, we identified adults who underwent ALIF in the United States from 2007 to 2014. The incidence of ALIF was studied longitudinally over time and across geographic regions in the United States. Data related to postoperative complications, length of stay, readmission, and cost were collected. RESULTS: We identified 49,945 patients that underwent ALIF in the United States between 2007 and 2014. The total number of ALIF procedures increased from 3650 in 2007 to 6151 in 2014, accounting for an average increase of 24.07% annually. The Southern United States performed the highest number of ALIFs. The most common conditions treated were degenerative disc disease and spondylolisthesis. Over one third of patients (34.6%) underwent multilevel fusion. The most common complications were iron deficiency anemia, urinary tract infections, and pulmonary complications. Hospital and physician pay increased significantly during the study period. CONCLUSIONS: For the first time in our knowledge, we identified national trends in ALIF utilization, outcomes, and cost using a large administrative database. Our study reaffirms prior work that has demonstrated low rates of complications, mortality, and readmission following ALIF. LEVEL OF EVIDENCE: Level III.

14.
J Neurosurg Spine ; : 1-8, 2019 Sep 13.
Artigo em Inglês | MEDLINE | ID: mdl-31518975

RESUMO

OBJECTIVE: Objective functional measures such as the 6-minute walking test (6WT) are increasingly applied to evaluate patients with degenerative diseases of the lumbar spine before and after (surgical) treatment. However, the traditional 6WT is cumbersome to apply, as it requires specialized in-hospital infrastructure and personnel. The authors set out to compare 6-minute walking distance (6WD) measurements obtained with a newly developed smartphone application (app) and those obtained with the gold-standard distance wheel (DW). METHODS: The authors developed a free iOS- and Android-based smartphone app that allows patients to measure the 6WD in their home environment using global positioning system (GPS) coordinates. In a laboratory setting, the authors obtained 6WD measurements over a range of smartphone models, testing environments, and walking patterns and speeds. The main outcome was the relative measurement error (rME; in percent of 6WD), with |rME| < 7.5% defined as reliable. The intraclass correlation coefficient (ICC) for agreement between app- and DW-based 6WD was calculated. RESULTS: Measurements (n = 406) were reliable with all smartphone types in neighborhood, nature, and city environments (without high buildings), as well as with unspecified, straight, continuous, and stop-and-go walking patterns (ICC = 0.97, 95% CI 0.97-0.98, p < 0.001). Measurements were unreliable indoors, in city areas with high buildings, and for predominantly rectangular walking courses. Walking speed had an influence on the ME, with worse accuracy (2% higher rME) for every kilometer per hour slower walking pace (95% CI 1.4%-2.5%, p < 0.001). Mathematical adjustment of the app-based 6WD for velocity-dependent error mitigated the rME (p < 0.011), attenuated velocity dependence (p = 0.362), and had a positive effect on accuracy (ICC = 0.98, 95% CI 0.98-0.99, p < 0.001). CONCLUSIONS: The new, free, spine-specific 6WT smartphone app measures the 6WD conveniently by using GPS coordinates, empowering patients to independently determine their functional status before and after (surgical) treatment. Measurements of 6WD obtained for the target population under the recommended circumstances are highly reliable.

15.
World Neurosurg ; 132: 421-428.e1, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31398524

RESUMO

BACKGROUND: Grade II spondylolisthesis remains a complex surgical pathology for which there is no consensus regarding optimal surgical strategies. Surgical strategies vary regarding extent of reduction, use of instrumentation/interbody support, and anterior versus posterior approaches with or without decompression. Here we provide the first report on the efficacy of robotic spinal surgery systems in support of the treatment of grade II spondylolisthesis. METHODS: Using 2 illustrative cases, we provide a technical report describing how robotic spinal surgery platform can be used to treatment grade II spondylolisthesis with a novel instrumentation strategy. RESULTS: We describe how the "reverse Bohlman" technique to achieve a large anterior fusion construct spanning the pathological level and buttressed by the adjacent level above, coupled with a novel, high-fidelity posterior fixation scheme with transdiscal S1-L5 and S2 alar iliac (S2AI) screws placed in a minimally invasive fashion with robot guidance allows for the best chance of fusion in situ. CONCLUSIONS: The reverse Bohlman technique coupled with transdiscal S1-L5 and S2AI screw fixation accomplishes the surgical goals of creating a solid fusion construct, avoiding neurologic injury with aggressive reduction, and halting the progression of anterolisthesis. The use of robot guidance allows for efficient placement of these difficult screw trajectories in a minimally invasive fashion.


Assuntos
Parafusos Ósseos , Procedimentos Neurocirúrgicos/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Coluna Vertebral/cirurgia , Espondilolistese/cirurgia , Idoso , Feminino , Humanos , Fixadores Internos , Dor Lombar/etiologia , Dor Lombar/cirurgia , Vértebras Lombares/cirurgia , Masculino , Pessoa de Meia-Idade , Sacro/cirurgia , Fusão Vertebral/instrumentação , Fusão Vertebral/métodos , Espondilolistese/diagnóstico por imagem , Resultado do Tratamento
16.
World Neurosurg ; 131: e579-e585, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31404690

RESUMO

BACKGROUND: Spinal arteriovenous malformations (AVM) are an abnormal interconnection of vasculature in the spine than can lead to significant neurologic deficit if left untreated. OBJECTIVE: The objective of this study was to characterize how patients with spinal AVM initially presented, what treatment options were used, and their overall outcomes on a national scale. METHODS: The MarketScan database was queried to identify adult patients diagnosed with a spinal AVM from 2007 to 2015. Trends in management, postoperative complication rates, and costs were determined. RESULTS: In total, 976 patients were identified with having a diagnosis of a spinal AVM. Patients were more commonly treated with an open incision than an embolization (40.1% vs. 15.4%). The overall complication rate was 33.61%. Spinal AVM admissions have been stable over the past decade, and mean cost of hospitalization has risen from of $48,700 in 2007 to $71,292 in 2015. Patients who underwent open surgery had a greater complication rate than those treated with embolization (31.15% vs. 18.25%, P < 0.005); however, this may be strongly influenced by complexity of spinal AVM pathology and not treatment modality. CONCLUSIONS: Costs of spinal AVM management continue to rise, even when treatment modalities have reduced length of stay significantly. Open surgery may lead to more postoperative complications and a greater length of stay than endovascular approaches. Further studies should look to identify the efficacy of endovascular approaches for spinal cord AVMs, particularly in complex spinal AVM traditionally treated with open surgery and to isolate factors leading to the elevated hospitalization costs.


Assuntos
Malformações Arteriovenosas/terapia , Embolização Terapêutica/métodos , Procedimentos Neurocirúrgicos/métodos , Complicações Pós-Operatórias/epidemiologia , Medula Espinal/irrigação sanguínea , Adulto , Idoso , Malformações Arteriovenosas/economia , Malformações Arteriovenosas/epidemiologia , Embolização Terapêutica/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/economia , Complicações Pós-Operatórias/economia , Estados Unidos/epidemiologia
17.
World Neurosurg ; 131: e468-e473, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31404695

RESUMO

BACKGROUND: The landmark Patchell trial established surgical decompression followed by adjuvant radiotherapy as standard-of-care for patients with spinal cord compression caused by metastatic cancer. However, little comparative evidence exists with regard to the choice of specific surgical approaches for these patients. We sought to conduct a comparative analysis of outcomes of surgical options for spinal metastatic disease. METHODS: This was an epidemiologic study using national administrative data from the MarketScan database. We queried the MarketScan database (2007-2016), identifying patients with a diagnosis of spinal metastasis treated with surgical decompression (N = 1054). We used descriptive statistics and hypothesis testing to compare baseline characteristics, complications, quality metrics, and costs. RESULTS: We identified patients with spinal metastases undergoing laminectomy (N = 760), corpectomy (N = 193), or both combined procedures (laminectomy and corpectomy, N = 101). No significant differences in baseline demographics, follow-up time, or primary tumor histology were observed. We found a greater 30-day postoperative complication rate among patients undergoing corpectomy (P < 0.0001), driven by increased rate of postoperative anemia and pulmonary complications. Length of stay and 30-day readmission rates did not vary between surgical approaches. Total index hospitalization and 30-day payments were greatest among patients undergoing combined procedures and lowest for patients undergoing laminectomy alone. CONCLUSIONS: Our findings highlight distinct complication profiles and quality outcomes associated with selection of surgical approach for patients with spinal metastases. These findings must be interpreted with a clear understanding of the limitations.


Assuntos
Descompressão Cirúrgica/métodos , Laminectomia/métodos , Compressão da Medula Espinal/cirurgia , Neoplasias da Coluna Vertebral/cirurgia , Adulto , Descompressão Cirúrgica/economia , Feminino , Custos de Cuidados de Saúde , Humanos , Laminectomia/economia , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Complicações Pós-Operatórias/epidemiologia , Compressão da Medula Espinal/etiologia , Neoplasias da Coluna Vertebral/complicações , Neoplasias da Coluna Vertebral/secundário
18.
Clin Spine Surg ; 32(8): E372-E379, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31180992

RESUMO

BACKGROUND: Outpatient cervical artificial disk replacement (ADR) is a promising candidate for cost reduction. Several studies have demonstrated low overall complications and minimal readmission in anterior cervical procedures. OBJECTIVE: The objective of this study was to compare clinical outcomes and cost associated between inpatient and ambulatory setting ADR. MATERIALS AND METHODS: Outcomes and cost were retrospectively analyzed for patients undergoing elective ADR in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases. RESULTS: A total of 1789 index ADR procedures were identified in the inpatient database (State Inpatient Databases) compared with 370 procedures in the ambulatory cohort (State Ambulatory Surgery and Services Databases). Ambulatory patients presented to the emergency department 19 times (5.14%) within 30 days of the index procedure compared with 4.2% of inpatients. Four unique patients underwent readmission within 30 days in the ambulatory ADR cohort (1% total) compared with 2.2% in the inpatient ADR group. No ambulatory ADR patients underwent a reoperation within 30 days. Of the inpatient ADR group, 6 unique patients underwent reoperation within 30 days (0.34%, Charlson Comorbidity Index zero=0.28%, Charlson Comorbidity Index>0=0.6%). There was no significant difference in emergency department visit rate, inpatient readmission rate, or reoperation rates within 30 days of the index procedure between outpatient or inpatient ADR. Outpatient ADR is noninferior to inpatient ADR in all clinical outcomes. The direct cost was significantly lower in the outpatient ADR group ($11,059 vs. 17,033; P<0.001). The 90-day cumulative charges were significantly lower in the outpatient ADR group (mean $46,404.03 vs. $80,055; P<0.0001). CONCLUSIONS: ADR can be performed in an ambulatory setting with comparable morbidity, readmission rates, and lower costs, to inpatient ADR.

19.
JAMA Netw Open ; 2(5): e193676, 2019 05 03.
Artigo em Inglês | MEDLINE | ID: mdl-31074820

RESUMO

Importance: Low back pain (LBP) with or without lower extremity pain (LEP) is one of the most common reasons for seeking medical care. Previous studies investigating costs in this population targeted patients receiving surgery. Little is known about health care utilization among patients who do not undergo surgery. Objectives: To assess use of health care resources for LBP and LEP management and analyze associated costs. Design, Setting, and Participants: This cohort study used a retrospective analysis of a commercial database containing inpatient and outpatient data for more than 75 million individuals. Participants were US adults who were newly diagnosed with LBP or LEP between 2008 and 2015, did not have a red-flag diagnosis, and were opiate naive prior to diagnosis. Dates of analysis were October 6, 2018, to March 7, 2019. Exposures: Newly diagnosed LBP or LEP. Main Outcomes and Measures: The primary outcome was total cost of care within the first 6 and 12 months following diagnosis, stratified by whether patients received spinal surgery. An assessment was performed to determine whether patients who did not undergo surgery received care in accordance with proposed guidelines for conservative LBP and LEP management. Costs resulting from use of different health care services were estimated. Results: A total of 2 498 013 adult patients with a new LBP or LEP diagnosis (median [interquartile range] age, 47 [36-58] years; 1 373 076 [55.0%] female) were identified. More than half (55.7%) received no intervention. Only 1.2% of patients received surgery, but they accounted for 29.3% of total 12-month costs ($784 million). Total costs of care among the 98.8% of patients who did not receive surgery were $1.8 billion. Patients who did not undergo surgery frequently received care that was inconsistent with clinical guidelines for LBP and LEP: 32.3% of these patients received imaging within 30 days of diagnosis and 35.3% received imaging without a trial of physical therapy. Conclusions and Relevance: The findings suggest that surgery is rare among patients with newly diagnosed LBP and LEP but remains a significant driver of spending. Early imaging in patients who do not undergo surgery was also a major driver of increased health care expenditures. Avoidable costs among patients with typically self-limited conditions result in considerable economic burden to the US health care system.

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