Spine Surgeon Treatment Variability: The Impact on Costs

Cross-sectional analysis. Given the lack of strong evidence/guidelines on appropriate treatment for lumbar spine disease, substantial variability exists among surgical treatments utilized, which is associated with differences in costs to treat a given pathology. Our goal was to investigate the variability in costs among spine surgeons nationally for the same pathology in similar patients. Four hundred forty-five spine surgeons completed a survey of clinical and radiographic case scenarios on patients with recurrent lumbar disc herniation, low back pain, and spondylolisthesis. Those surveyed were asked to provide various details including their geographical location, specialty, and fellowship training. Treatment options included no surgery, anterior lumbar interbody fusion, posterolateral fusion, and transforaminal/posterior lumbar interbody fusion. Costs were estimated via Medicare national payment amounts. For recurrent lumbar disc herniation, no difference in costs existed for patients undergoing their first revision microdiscectomy. However, for patients undergoing another microdiscectomy, surgeons who operated 200 times/year ( 15 years ( < .001). For the treatment of low back pain, academic surgeons kept costs about 55% lower than private practice surgeons ( < .001). In the treatment of spondylolisthesis, there was significant treatment variability without significant differences in costs. Significant variability in surgical treatment paradigms exists for different pathologies. Understanding why variability in treatment selection exists in similar clinical contexts across practices is important to ensure the most cost-effective delivery of care among spine surgeons

A decade's experience in lumbar spine surgery in Belgium: sickness fund beneficiaries, 2000-2009.

PURPOSE: The purpose is to study rates, trends, geographic variations and outcome of lumbar spine surgery in the Belgian population during the last decade. METHODS: This is a retrospective cohort study using administrative data of the largest Belgian sickness fund from January 1, 2000 through December 31, 2009. Cases included lumbar laminectomy, combined discectomy and fusion, posterior interarticular fusion, anterior lumbar interbody fusion (ALIF), posterior lumbar interbody fusion (PLIF) and standard discectomy. The main outcome measures were age- and sex-adjusted rates of lumbar spine surgery, 1-year mortality, 1-year iterative surgery, no return to work (RTW) rate 1 year after surgery and length of hospital stay. Multivariate logistic regression analysis was used to determine the association between age, sex, geographic region, type of surgery, year of intervention and duration of pre-operative sick leave on outcome. RESULTS: Spine surgery rates rose 44 % from 2001 through 2009 and data for 2009 showed twofold variations in spine surgery rates among 10 Belgian provinces. Reported 1-year mortality varied from 0.6 to 2.5 % among surgical procedures performed in 2008. The overall 5-year reoperation rate was 12 %. RTW rates 1 year after standard discectomy, ALIF, PLIF and combined discectomy and fusion for the follow-up sample of 2008 were 14.4, 22.7, 26.1 and 30.6 %, respectively. The median length of hospital stay significantly decreased throughout the decade. Type of surgery and geographic region were significantly related to patient outcomes. CONCLUSIONS: Regional variations highlight professional uncertainty and controversy. The study results point to the need for peer comparisons and surgeon feedback.JOURNAL ARTICLEinfo:eu-repo/semantics/publishe

Surgical approach to cervical spondylotic myelopathy on the basis of radiological patterns of compression: prospective analysis of 129 cases

This is a prospective analysis of 129 patients operated for cervical spondylotic myelopathy (CSM). Paucity of prospective data on surgical management of CSM, especially multilevel CSM (MCM), makes surgical decision making difficult. The objectives of the study were (1) to identify radiological patterns of cord compression (POC), and (2) to propose a surgical protocol based on POC and determine its efficacy. Average follow-up period was 2.8 years. Following POCs were identified: POC I: one or two levels of anterior cord compression. POC II: one or two levels of anterior and posterior compression. POC III: three levels of anterior compression. POC III variant: similar to POC III, associated with significant medical morbidity. POC IV: three or more levels of anterior compression in a developmentally narrow canal or with multiple posterior compressions. POC IV variant: similar to POC IV with one or two levels, being more significant than the others. POC V: three or more levels of compression in a kyphotic spine. Anterior decompression and reconstruction was chosen for POC I, II and III. Posterior decompression was chosen in POC III variant because they had more incidences of preoperative morbidity, in spite of being radiologically similar to POC III. Posterior surgery was also performed for POC IV and IV variant. For POC IV variant a targeted anterior decompression was considered after posterior decompression. The difference in the mJOA score before and after surgery for patients in each POC group was statistically significant. Anterior surgery in MCM had better result (mJOA = 15.9) versus posterior surgery (mJOA = 14.96), the difference being statistically significant. No major graft-related complications occurred in multilevel groups. The better surgical outcome of anterior surgery in MCM may make a significant difference in surgical outcome in younger and fitter patients like those of POC III whose expectations out of surgery are more. Judicious choice of anterior or posterior approach should be made after individualizing each case

GRAMD4 mimics p53 and mediates the apoptotic function of p73 at mitochondria

p73, a member of the p53 family, shares high sequence homology with p53 and shows many p53-like properties: it binds to p53-DNA target sites, transactivates p53-responsive genes and induces cell cycle arrest and apoptosis. Apart from this transcription-dependent effect, less is known about the downstream mechanism(s) by which p73 controls cell fate at the mitochondria. We have previously identified GRAMD4 (alias KIAA0767 or Death-Inducing-Protein) as a novel p53-independent pro-apoptotic target of E2F1, which localizes to mitochondria. In this study, we found that p73-induced apoptosis is mediated by GRAMD4 expression and translocation to the mitochondria. We showed that this protein physically interacts with Bcl-2, promotes Bax mitochondrial relocalization and oligomerization, and is highly efficient in inducing mitochondrial membrane permeabilization with release of cytochrome c and Smac. Overexpression of p73α and p73β isoforms, but not p53, leads to direct GRAMD4 promoter transactivation. In addition, GRAMD4 induces changes in Bcl-2 and Bax protein levels. GRAMD4 transcription is activated in response to cisplatin (cDDP) in a manner dependent on endogenous p73. Using solid tumor xenografts, ectopic expression of GRAMD4 together with cDDP resulted in enhanced cancer killing. Our findings demonstrate that p73 is able to trigger apoptosis via the mitochondrial pathway by a new mechanism using pro-apoptotic GRAMD4 as mediator, and strongly support its p53-like function