Drivers of surgery for the degenerative hip, knee, and spine: a systematic review.

Surgical treatment for degenerative conditions of the hip, knee, and spine has an impact on overall healthcare spending. Surgical rates have increased dramatically and considerable regional variation has been observed. The reasons behind these increasing rates and variation across regions have not been well elucidated.We therefore identified demographic (D), social structure (SS), health belief (HB), personal (PR) and community resources (CR), and medical need (MN) factors that drive rates of hip, knee, and spine surgery.We conducted a systematic review to include all observational, population-based studies that compared surgical rates with potential drivers (D, SS, HB, PR, CR, MN). We searched PubMed combining key words focusing on (1) disease and procedure; (2) study methodology; and (3) explanatory models. Independent investigators selected potentially eligible studies from abstract review and abstracted methodological and outcome data. From an initial search of 256 articles, we found 37 to be potentially eligible (kappa 0.86) but only 28 met all our inclusion criteria.Age, nonminority, insurance coverage, and surgeon enthusiasm all increased surgical rates. Rates of arthroplasty were higher for females with higher education, income, obesity, rurality, willingness to consider surgery, and prevalence of disease, whereas spinal rates increased with male gender, lower income, and the availability of advanced imaging.Regional variation in these procedures exists because they are examples of preference-sensitive care. With strategies that may affect change in factors that are potentially modifiable by behavior or resources, extreme variation in rates may be reduced

Drivers of surgery for the degenerative hip, knee, and spine: a systematic review.

Surgical treatment for degenerative conditions of the hip, knee, and spine has an impact on overall healthcare spending. Surgical rates have increased dramatically and considerable regional variation has been observed. The reasons behind these increasing rates and variation across regions have not been well elucidated.We therefore identified demographic (D), social structure (SS), health belief (HB), personal (PR) and community resources (CR), and medical need (MN) factors that drive rates of hip, knee, and spine surgery.We conducted a systematic review to include all observational, population-based studies that compared surgical rates with potential drivers (D, SS, HB, PR, CR, MN). We searched PubMed combining key words focusing on (1) disease and procedure; (2) study methodology; and (3) explanatory models. Independent investigators selected potentially eligible studies from abstract review and abstracted methodological and outcome data. From an initial search of 256 articles, we found 37 to be potentially eligible (kappa 0.86) but only 28 met all our inclusion criteria.Age, nonminority, insurance coverage, and surgeon enthusiasm all increased surgical rates. Rates of arthroplasty were higher for females with higher education, income, obesity, rurality, willingness to consider surgery, and prevalence of disease, whereas spinal rates increased with male gender, lower income, and the availability of advanced imaging.Regional variation in these procedures exists because they are examples of preference-sensitive care. With strategies that may affect change in factors that are potentially modifiable by behavior or resources, extreme variation in rates may be reduced

Use of Lateral Access in the Treatment of the Revision Spine Patient

With the rate of spinal surgery increasing, we have seen a concomitant increase in the number of revision cases. It is, therefore, important to have a systematic approach to the management of these complicated patients with unique problems. A thorough understanding of the different pathologies affecting revision spine patients is critical to an effective treatment recommendation. Lateral access is a useful management approach since it can avoid the complications of operating through previous approaches. Furthermore, it possesses certain advantages for treatment in specific circumstances outlined in this paper. Long-term studies are needed to demonstrate the safety and efficacy of the lateral approach compared to the anterior and posterior approaches in the treatment of revision spine patients

Surgical techniques for spinopelvic reconstruction following total sacrectomy: a systematic review

PurposeTo identify all available reconstruction methods for a total sacrectomy. Secondarily, we aimed to evaluate outcomes based on different interventions.MethodsWe searched PubMed to identify sacral resections for tumors requiring internal fixation for stabilization. Demographic information, fixation techniques and postoperative outcomes were abstracted.ResultsTwenty-three publications (43 patients) met inclusion criteria from an initial search of 856 (κ 0.93). Mean age was 37 years and follow-up was 33 months. Fixation methods included a combination of spinopelvic fixation (SPF), posterior pelvic ring fixation (PPRF), and/or anterior spinal column fixation (ASCF). For the purposes of analysis, patients were segregated based on whether they received ASCF. Postoperative complications including wound/instrument infections, GI or vascular complications were reported at a higher rate in the non-ASCF group (1.63 complications/patient vs. 0.7 complications/patient). Instrument failure was seen in 5 (16.1 %) out of the 31 patients with reported outcomes. Specifically, 1 out of 8 patients (12.5 %) with ASCF compared with 4 out of 23 patients (17.4 %) without ASCF had hardware failure. At final follow-up, 35 of 39 patients were ambulating.ConclusionWhile surgical treatment of primary sacral tumors remains a challenge, there have been advances in reconstruction techniques following total sacrectomy. SPF has shifted from intrapelvic rod and hook constructs to pedicle and iliac screw-rod systems for improved rigidity. PPRF and ASCF have adapted for deficiencies in the posterior ring and anterior column. A trend toward a lower rate of hardware failure emerged in the group utilizing anterior spinal column support. Despite a more involved reconstruction with ASCF, surgical complications such as infection rates and blood loss were lower compared to the group without ASCF. While we cannot definitively say one system is superior to the other, based on the data gleaned from this systematic review, it is our opinion that incorporation of ASCF in reconstructing the spinopelvic junction may lead to improved outcomes. However, most importantly, we recommend that the treating surgeon operate on patients requiring a total sacrectomy based on his or her level of comfort, as these cases can be extremely challenging even among experts

Impact of Cirrhosis on Morbidity and Mortality After Spinal Fusion.

Study designRetrospective large database study.ObjectiveTo determine the impact of cirrhosis on perioperative outcomes and resource utilization in elective spinal fusion surgery.MethodsElective spinal fusion hospitalizations in patients with and without cirrhosis were identified using ICD-9-CM codes between the years of 2009 and 2011 using the Nationwide Inpatient Sample database. Main outcome measures were in-hospital neurologic, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, wound-related complications, and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients with and without cirrhosis undergoing spinal fusion.ResultsA total of 1 214 694 patients underwent elective spinal fusions from 2009 to 2011. Oh these, 6739 were cirrhotic. Cirrhosis was a significant independent predictor for respiratory (odds ratio [OR] = 1.43, confidence interval [CI] 1.29-1.58; P < .001), gastrointestinal (OR = 1.72, CI 1.48-2.00; P < .001), urinary and renal (OR = 1.90, CI 1.70-2.12; P < 0.001), wound (OR = 1.36, CI 1.17-1.58; P < 0.001), and overall inpatient postoperative complications (OR = 1.43, CI 1.33-1.53; P < .001). Cirrhosis was also independently associated with significantly greater inpatient mortality (OR = 2.32, CI 1.72-3.14; P < .001). Cirrhotic patients also had significantly longer lengths of stay (5.35 vs 3.35 days; P < .001) and inpatient costs ($36 738 vs$29 068; P < .001).ConclusionsCirrhosis is associated with increased risk of perioperative complications, mortality and greater resource utilization. Cirrhotic patients undergoing spinal fusion surgeries should be counseled on these increased risks. Current strategies for perioperative management of cirrhotic patients undergoing spinal fusion surgery need improvement

Impact of Cirrhosis on Morbidity and Mortality After Spinal Fusion.

Study designRetrospective large database study.ObjectiveTo determine the impact of cirrhosis on perioperative outcomes and resource utilization in elective spinal fusion surgery.MethodsElective spinal fusion hospitalizations in patients with and without cirrhosis were identified using ICD-9-CM codes between the years of 2009 and 2011 using the Nationwide Inpatient Sample database. Main outcome measures were in-hospital neurologic, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, wound-related complications, and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients with and without cirrhosis undergoing spinal fusion.ResultsA total of 1 214 694 patients underwent elective spinal fusions from 2009 to 2011. Oh these, 6739 were cirrhotic. Cirrhosis was a significant independent predictor for respiratory (odds ratio [OR] = 1.43, confidence interval [CI] 1.29-1.58; P < .001), gastrointestinal (OR = 1.72, CI 1.48-2.00; P < .001), urinary and renal (OR = 1.90, CI 1.70-2.12; P < 0.001), wound (OR = 1.36, CI 1.17-1.58; P < 0.001), and overall inpatient postoperative complications (OR = 1.43, CI 1.33-1.53; P < .001). Cirrhosis was also independently associated with significantly greater inpatient mortality (OR = 2.32, CI 1.72-3.14; P < .001). Cirrhotic patients also had significantly longer lengths of stay (5.35 vs 3.35 days; P < .001) and inpatient costs ($36 738 vs$29 068; P < .001).ConclusionsCirrhosis is associated with increased risk of perioperative complications, mortality and greater resource utilization. Cirrhotic patients undergoing spinal fusion surgeries should be counseled on these increased risks. Current strategies for perioperative management of cirrhotic patients undergoing spinal fusion surgery need improvement

Outcomes and Complications After Spinal Fusion in Patients With Obstructive Sleep Apnea.

Study designRetrospective database study.ObjectiveTo investigate the impact obstructive sleep apnea (OSA) has on perioperative complications, inpatient mortality, and costs in patients undergoing spinal fusions.MethodsHospitalizations for spinal fusion surgery between the years 2009 and 2011 were identified using the Nationwide Inpatient Sample and grouped into patients with and without OSA. Patient demographic data, comorbidities, hospital characteristics, hospitalization outcomes, and costs were extracted and compared. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients undergoing spinal fusion with and without OSA.ResultsA total of 107 451 (7.7%) OSA patients who underwent spinal fusions were identified from 2009 to 2011. Compared with patients without OSA, OSA patients were significantly older, more likely to be male, and have significantly greater comorbidity burden. Multivariable regression analysis demonstrated that OSA had a significant independent association with slightly increased respiratory (odds ratio [OR] = 1.13, confidence interval [CI] = 1.09-1.16; P < .001), urinary and renal (OR = 1.11, CI = 1.07-1.16; P < .001) or overall inpatient complications (OR = 1.05, CI = 1.02-1.05; P < .001). OSA was also independently associated with significantly lower inpatient mortality (OR = 0.39, CI = 0.33-0.45; P < .001).ConclusionsWhile OSA confers greater comorbidity burden and is associated with slightly higher inpatient complication rates following spinal fusions, diagnosed OSA was not an independent predictor of inpatient mortality. A cautious interpretation of this finding is that on a national level, the current methods of preoperative medical optimization and inpatient management of OSA are satisfactory

Does Addition of Tobramycin Powder Reduce Infection Rates After Spine Surgery?

Study designRetrospective chart review.ObjectivesTo evaluate the efficacy of tobramycin and vancomycin powder in reducing surgical site infections in posterior lumbar instrumented fusion.MethodsA multicenter, electronic database search was conducted for all patients who underwent posterior instrumented lumbar fusions.ResultsThe addition of vancomycin powder decreased postoperative infections from an incidence of 5.7% down to a rate of 2.0%. This difference was statistically significant (P = .018). The addition of tobramycin powder to the wound in addition to vancomycin further decreased the infection rate down to 1.8%. The postoperative infection rate was statistically significant (P = .041) when compared with the no-powder group. However, the difference was not statistically significant (P = 1.00) when compared with vancomycin alone. There was also a trend toward gram-negative organisms with the addition of more antibiotic powder. In the control group, for example, the organisms cultured were 66% methicillin-sensitive Staphylococcus aureus and 33% gram-negative organisms. In the vancomycin group, 30% of the organisms cultured were Staphylococcus aureus and 60% gram-negative organisms. In the vancomycin and tobramycin powder group, 100% of the organisms cultured were gram-negative.ConclusionsThere is a reduction in surgical site infections with addition of antibiotic powder to the wound prior to closure. However, the reduction in the infection rate was not as great with the addition of tobramycin powder to vancomycin alone and there was a noticeable change in the spectrum of organism cultured with this addition. Clinicians should consider the risk-to-benefit ratio in each case when deciding to use antibiotic powder

The Utility of Flexion-Extension Radiographs in Degenerative Cervical Spondylolisthesis.

Study designRetrospective radiologic analysis.ObjectiveThe aim was to investigate if lateral flexion-extension radiographs identify additional cases of degenerative cervical spondylolisthesis (DCS) that would be missed by obtaining solely neutral upright radiographs, and determine the reliability of magnetic resonance imaging (MRI) in diagnosis.Summary of background dataDCS and instability can be a cause of neck pain, radiculopathy, and even myelopathy. Standard anteroposterior and lateral radiographs and MRI of the cervical spine will identify most cervical spine pathology, but spondylolisthesis and instability are dynamic issues. Standard imaging may also miss DCS in some cases.MethodsWe compared the number of patients who demonstrated cervical spondylolisthesis on lateral neutral and flexion-extension radiographs in addition to MRI. We used established criteria to define instability as ≥2 mm of listhesis on neutral imaging, and ≥1 mm of motion between flexion-extension radiographs.ResultsA total of 111 patients (555 cervical levels) were analyzed. In all, 41 patients (36.9%) demonstrated cervical spondylolisthesis on neutral and/or flexion-extension radiographs. Of the 77 levels of spondylolisthesis, 17 (22.1%) were missed on neutral radiographs ( P ,0.05). Twenty levels (26.0%) were missed when flexion-extension radiographs were used alone ( P =0.02). Twenty-nine levels (37.7%) of DCS identified on radiograph were missed by MRI ( P =0.004).ConclusionsLateral flexion-extension views can be useful in the diagnosis of DCS. These views provide value by identifying a significant cohort of patients that would be undiagnosed based on neutral radiographs alone. Moreover, MRI missed 38% of DCS cases identified by radiographs. Therefore, lateral radiographs can be a useful adjunct to neutral radiographs and MRI when instability is suspected or if these imaging modalities are unable to identify the source of a patient's neck or arm pain