Faculty Bibliography

BACKGROUND CONTEXT: In the current value-based health care climate where spinal surgery is shifting to the ambulatory setting, factors influencing postoperative patient length of stay (LOS) have significance to both surgeons and hospital administrators. Underlying patient factors including the diagnosis of radiculopathy and myelopathy have not been investigated in this context. PURPOSE: Identify predictors extended LOS(E-LOS) between myelopathy(M), radiculopathy(R), and patients with both (MR). STUDY DESIGN/SETTING: Retrospective review of a single-center stereographic database. PATIENT SAMPLE: A total of 718 surgical cervical spine patients. OUTCOME MEASURES: Postoperative LOS, patient factors, preoperative HRQL, complications, predictors of E-LOS.
METHOD(S): Surgical cervical spine patients >=18yrs diagnosed with M or R primary diagnoses were isolated in the single-center Comprehensive Spine Quality Database (Quality). Patients were stratified by surgical approach: Anterior, Posterior or Combined. Top-quartile LOS values were labeled as extended. M and R patients were compared using chi-squared and independent samples t-tests, as appropriate. Univariate tests assessed differences in baseline patient-related and surgical data between M and R, and extended/non-extended LOS. Univariate/multivariate analyses were run to assess predictive factors of E-LOS in each diagnosis group. Regression with stepwise model selection was employed to explore factors potentially significant in predicting LOS.
RESULT(S): A total of 718 patients (54.5 years, 41.1%F, 29.1kg/m2). Mean CCI score: 1.11. Within the cohort, 177 patients (24.7%) had a diagnosis of myelopathy, 383 (53.3%) radiculopathy, and 22% with a diagnosis of myeloradiculopathy. Patients with M primary diagnosis were significantly older (62.2 vs 49.8yrs, p<0.001) and had a greater CCI score (1.64 vs 0.82, p<0.001) when compared to R patients. By approach: 76.7% anterior (57.6% of M, 90.6%R, 64.6%MR; p<0.001), 16.4% (35%M, 6%R, 20.9%MR; p<0.001) posterior, 6.5% (6.8%M, 3.4%R, 13.9%MR; p<0.001) combined. Average LOS: M(3.8days), R(1.5 days), MR(2.9 days) p<0.001. LOS for anterior approach in each diagnosis was as follows, M: 2.21, R: 1.21, MR: 1.69 days, p<0.001. Meanwhile, posterior approach LOS, M:6.06, R:2.91, MR:5.0, p<0.001; combined approach M: 5.17, R: 6.23, MR: 5.59, P=0.881. A total of 195 patients were categorized as E-LOS (Avg: 5.87 days), 87 M, 43 R, 65 MR. Major surgical approach of E-LOS for M (60.9%) and MR (44.6%) was posterior; whereas R E-LOS patients majorly underwent anterior procedures (53.5%). Generalized linear regression modeling found that the following combination of factors predicted E-LOS in R patients (R2=0.736, p=0.003):BMI, durotomy, CCI, anterior and combined approaches, and cardiac complications. An additional model discovered the predictors of E-LOS in M patients (R2= 0.312, p<0.001): age, hypertension, CCI, anterior and combined approaches, intraoperative complications, neuro complications, ileus, and return to OR in 90 days. Lastly, the model for E-LOS in MR patients consisted of (R2 = 0.267, p=0.001): age, durotomy, BL EQ5D, hypertension, posterior and combined approaches and postoperative complications, specifically neuro.
CONCLUSION(S): Independent of surgical approach, patients with a primary diagnosis of myelopathy, though older aged and higher comorbidity profile, had consistently longer overall postop LOS when compared to radiculopathy or myeloradiculopathy patients. The heightened risk in myelopathy patients for extended LOS should be considered when determining admission status for patients undergoing cervical spine surgery. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Distal junctional kyphosis (DJK) is a major concern following cervical deformity (CD) correction, leading to failed realignment and revision surgery. Undercorrection may be the major factor associated with DJK, however it is difficult to assess because the DJK erodes the correction and worsens traditional measures like cSVA. In-construct measures have been proposed that measure alignment within the fusion separate from the DJK and subjacent compensation. PURPOSE: To simulate cervical deformity corrections using surgical planning software to determine if undercorrection results in DJK. STUDY DESIGN/SETTING: Retrospective analysis of a prospective, multicenter CD database. PATIENT SAMPLE: A total of 69 CD patients. OUTCOME MEASURES: Radiographic measures: C2 plumblines, in-construct measures and DJK angle change.
METHOD(S): A prospective database of operative CD patients was analyzed for severe DJK (kyphosis change>20degree in LIV to LIV-2) and traditional DJK (change>10degree). C2LIV-Tilt (angle of a line from the centroid of C2 to the centroid of the lower instrumented vertebra and a line along the posterior vertebral body wall of the LIV) was measured postoperatively and the correction was simulated in the preoperative X-ray to match the C2LIV-Tilt using planning software. Linear regression analysis using C2 pelvic angle (CPA) and Pelvic Tilt (PT) determined the simulated PT to match the virtual CPA. SVA measures were compared in patients with severe and traditional DJK and no DJK. Linear regression analysis was used to determine the C2-T4 and C2-T10 Tilts that correspond to DJK=10degree and cSVA=4cm.
RESULT(S): A total of 69 CD patients (mean age 61, 60% female) were included. Severe and traditional DJK occurred in 11 (16%) and 22 (32%) patients; 3 (4%) required DJK revision. Simulated corrections demonstrated that severe and traditional DJK pts had worse alignments compared to no DJK pts: cSVA (42.5 vs 33.0 vs 23.4mm, p<.001), C2-T3 SVA (74.5 vs 61.8 vs 41.4mm, p<.001), C2-LIV SVA (68.9 vs 57.3 vs 36.8mm, p<.001). Linear regression revealed a predictive relationship between in-construct measures (C2T4-Tilt and C2T10-Tilt) and cSVA and change in DJK (all R>.57, p<.001). cSVA=4cm corresponded to C2T4-Tilt of 10.4degree and C2T10-Tilt of 28.0degree. DJK change=10degree corresponded to C2T4-Tilt of 5.8degree and C2T10-Tilt of 20.1degree. Severe DJK pts had the worst postoperative alignment by all measures including cSVA, TSCL, CPA, C2LIV-Tilt, (all p<.001).
CONCLUSION(S): Simulated cervical deformity corrections demonstrated that severe DJK patients have insufficient corrections compared to patients without DJK. In-construct measures assess sagittal alignment within the fusion separate from DJK and subjacent compensation. They can be useful as intraoperative tools to gauge the adequacy of CD correction. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Severe cervical deformity (CD) can be a source of severe disability. Surgical correction of the deformity can markedly improve a patient's quality of life and functional status. However, high rates of complications have been reported, one of the most serious being distal junctional kyphosis (DJK). Although researchers have identified risk factors for DJK, no model has been proposed that predicts the magnitude of DJK. PURPOSE: To develop a model that can accurately predict the DJ angle following CD correction using radiographic measurements that can be obtained pre- and intraoperatively. STUDY DESIGN/SETTING: Retrospective review of a prospectively-collected CD database. PATIENT SAMPLE: A total of 131 preoperative patients with cervical deformity. OUTCOME MEASURES: DJK angle, reoperation for DJK METHODS: A prospective database of operative CD patients (C2-C7 Cobb>10degree, CL>10degree, cSVA>4cm or CBVA>25degree) with clinical and radiographic data at preoperative and any postoperative interval (3m, 6m, 1y, 2y). Patients with a history of fusion below L4 were excluded. DJK angle was defined as the Cobb from LIV to LIV-2, traditional DJK (tDJK) was a DJK angle change >10degree; a change >20degree was defined as severe DJK (sDJK) was a DJK angle change >20degree.Models were developed using a randomly selected 66.6% of patients. Pre- and intraoperative radiographic parameters significantly associated with DJK were identified and ranked in order of importance via a conditional variable importance table that used a nonreplacement sampling set of 4,000 conditional inference trees. Linear regression models were developed using the factors most strongly associated with postoperative DJK angle. The models were then validated in the remaining 33.3% of patients.
RESULT(S): A total of 131 patients were included (60 +/-10y, 62% female). Mean follow-up was 14+/-8 months. The most common LIV was T2 (20.6%) with an LIV below T2 in 44%. The mean postoperative DJK angle was 14.6degree +/-14degree. 35% of patients developed DJK (11% sDJK). Five patients underwent a subsequent revision surgery due to DJK. The model development subset included 84 patients and did not differ significantly from the validation subset in terms of radiographic or clinical parameters. The variables identified as being most significant were: Intraoperative change of CL (DELTACL) and C2-LIV Tilt (DELTAC2-LIV), and preoperative DJK angle (DJK-Apre). The initial model including DELTACL and DELTAC2-LIV accounted for 19.6% of the variability in postoperative DJKA (r=.470, p<0.001). The following model, which included preoperative DJKA, accounted for 37.0% of the variability (R=.609, p<0.001).DJKA = 9.365 + (.123* DELTACL) - (0.315* DELTAC2-LIV) - (0.504*DJKApre) This equation was then validated in the remaining 47 patients. It shows that as you improve alignment by increasing CL and decreasing the C2-LIV tilt, the DJK angle increases. Predicted and actual postoperative DJKA values were highly correlated (R=0.871, R2= 0.759, p<0.001). The model RMSE was 0.97. The model had better specificity for sDJK vs tDJK (94% vs 57%), accuracy (85% vs 61%), and NPV (89% vs 72%). But worse sensitivity (17% vs 67%) and PPV (29% vs 50%).
CONCLUSION(S): DJK is a serious, but fairly common complication following correction of CD and can lead to pain and disability necessitating revision surgery. Through the use of pre- and intraoperative measurements, surgeons can reliably predict the magnitude of DJK following correction. In order of importance, the variables that increased the DJK angle were, preoperative DJK angle, the magnitude of the correction within the construct and the change in CL. The models developed in this study, which reliably predict postoperative DJK angle and severe DJK, can be easily applied in a clinical setting when planning postoperative alignment for CD correction. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Often patients with cervical deformity (CD) require extensive fusions that extend into the thoracic spine. However, factors that influence the treatment approach and level selection are poorly understood. PURPOSE: To examine if there are significant differences between patients with CD who have a lowest instrumented vertebrae (LIV) to the upper thoracic (UT) vs the midthoracic (MT) spine. STUDY DESIGN/SETTING: Comparative cohort study. PATIENT SAMPLE: Prospective adult cervical deformity database. OUTCOME MEASURES: NDI, mJOA, SWAL-QOL.
METHOD(S): A prospective CD database was analyzed for the following inclusion criteria: LIV between C7-T5 and a UIV of C2, and 1 yr min follow-up (f/u). Patient demographics, operative details, radiographic parameters and clinical outcomes were compared between those with a LIV from C7-T2 (UT) vs T3-T5 (MT). X2 and independent samples T-Tests were performed for statistical analysis RESULTS: A total of 64 patients met inclusion criteria for the study and 46 were included in the analysis (avg. age 62, 58% female, avg 1yr f/u) with 22 in UT vs 24 in the MT groups. No differences were seen in age or revision case prevalence, EBL, operative time or surgical approach (anterior, posterior, combined) types between groups. MT patients had a higher pre-op cSVA, TS-CL, Max Kyphosis and T9PA and were treated with a larger number of PSOs (p<0.01). There was a larger correction in Cervical Lordosis (CL) seen in the MT group (29 vs 17, p=0.04) and larger changes in T4-T12 (9.6 vs 0.0, p<0.01). No differences were seen in DJK (p=0.22) or rates of revision surgery (5% vs 21%, p=0.19,

BACKGROUND CONTEXT: Choosing the surgical approach and osteotomy type is challenging when surgically treating cervical deformity. Preoperative assessment of flexibility and final alignment would be useful for surgeons treating this complex problem. Currently extension lateral XR are inconstantly taken for the management of cervical deformity for planning purposes. PURPOSE: Investigate the relationship of surgical procedure choice and the pre-operative flexibility of the cervical spine. Determine if extension lateral XR (ELXR) can also predict the final postoperative alignment. STUDY DESIGN/SETTING: Retrospective review of prospective, consecutively enrolled multicenter cervical deformity database PATIENT SAMPLE: A total of 106 cervical deformity patients OUTCOME MEASURES: Surgical treatment, radiographic alignment parameters (SS, T1S-CL, cSVA, C2 slope, T1 slope) METHODS: A prospective database of operative cervical deformity patients was analyzed. Inclusion was cervical kyphosis>10degree, cervical scoliosis>10degree, C2-C7 SVA>4cm or chin-brow vertical angle>25degree. Patients were excluded if they did not have neutral and ELXR or did not have deformity limited to the cervical or cervicothoracic spine. The ELXR was compared to preoperative neutral lateral, and 3 mo alignment XR and type of surgical osteotomy based upon the Ames Classification. Statistical analysis included t-test and chi-squared.
RESULT(S): A total of 106 from 164 patients met the inclusion criteria. Mean age of 60 yo, with 58% females. Of the study population, 43.4% of patients had prior cervical surgery. The evaluation of ELXR in patients who received grade 1-2 osteotomies (as compared to those who received grade 5,6 or 7), shows they have statistically lower T1S (23.06 vs 35.46; p=.021), lower T1S-CL (20.90 vs 36.29; p=.033), lower cSVA (24.66 vs 48.35; p<.001) and lower C2Slope (18.69 vs 37.46; p=.008). Subsequent analysis revealed the anterior approach chosen over the post approach when, in extension, patients achieved more normal radiographic alignment T1S (21.17 vs 31.59; p=.018), lower cSVA (11.18 vs 36.44; p<.001), lower T1S-CL (13.68 vs 28.13; p=.014) and lower C2 slope (8.49 vs 28.28; p<.001). Patients were more likely to have a post approach when they had larger than normativeT1S-CL>17 in the ELXR (46.77% vs 36.36%; p=.033). Overall, while surgery created a significant change in all radiographic parameters; the 3 month lateral XR and baseline ELXR were statistically similar for T1S-CL (26.04 vs 24.83; p=.542) and C2Slope (23.27 vs 22.87; p=.839).
CONCLUSION(S): Preoperative ELXR had a significant association with surgical approach and grade of osteotomy. The ELXR was statistically similar to the post-operative 3-month lateral XR and should be used to predict final cervical alignment. Obtaining ELXR is a critical alignment tool, and should be obtained as a part of the preoperative surgical plan. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The Patient-Reported Outcomes Measurement Information System (PROMIS) is a comprehensive self-report measurement tool with patient functions, symptoms, behaviors, and mental health outcomes. Little work has been done correlating PROMIS physical health domain metrics with established adult spinal deformity (ASD) classifications such as SRS-Schwab. PURPOSE: To correlate sagittal alignment components via the SRS-Schwab classification system with established PROMIS domains in a cohort of ASD patients. STUDY DESIGN/SETTING: Retrospective review of a single-center stereoradiographic database. PATIENT SAMPLE: A total of 41 ASD patients with complete baseline radiographic and PROMIS data. OUTCOME MEASURES: PROMIS physical health domain metrics (Pain Intensity [PI], Physical Function [PF], Pain Interference [Interference]), SRS-Schwab modifiers (SVA, PI-LL, PT) METHODS: Surgical ASD patients (SVA>=5cm, PT>=25degree or TK >=60degree) >=18 years old with available baseline (BL) radiographic and PROMIS data were isolated in the single-center comprehensive Spine Quality Database (Quality). Patients were classified according to SRS-Schwab deformity modifiers(0,+,++) for SVA, PI-LL and PT. Descriptives and univariate analyses compared population-weighted PROMIS scores for PI, PF and Interference across ASD deformity modifiers. Conditional Tree Analysis (CTA) with logistic regression sampling established cut-off points for PROMIS scores predicting severe malalignment (++) at BL compared to mild or moderate (0,+).
RESULT(S): A total of 41 patients (58.95 yrs,75.6%F,29.1kg/m2) met inclusion criteria. BL SRS modifiers were as follows: SVA 51.2%, 2.4%, 46.3% (0,+,++); PI-LL 27.3%, 12.1%, 60.6%(0,+,++); PT 18.2%, 36.4%, 45.5% (0,+,++). Mean cohort PI score was 94.2+/-6.0, mean PF score 8.95+/-10.1, mean Inter score 57.84+/-5.46. PF and Interference differed significantly across low and high SVA groups, with low SVA having significantly higher PF (13.50 vs 3.68,p<0.001) and lower Inter (59.62 vs 56.30, p=0.05). PI did not differ across SVA groups (p>0.05). Low PI-LL pts had significantly higher PF than pts with ++PI-LL (19.3 vs 4.15,p=0.001) and trended lower PI and Inter without significance. No significant differences in PI, PF or Inter were found across PT groups (all p>0.05). CTA found a PI score>98 or PF score <6 were independent predictors of Severe (++) SVA as opposed to Mild/Moderate SVA. For example, a PF score<6 increased odds of ++SVA by at least 2.7x compared to 0/+SVA. Similarly, significant thresholds for PI (>98) and PF (<8) scores were found for ++PI-LL, but not ++PT (p>0.05). Pain Interference did not predict SRS metrics to a significant degree (all p>0.05).
CONCLUSION(S): Inferior PROMIS scores of pain intensity and physical function predicted increasingly severe SRS sagittal modifiers at baseline, specifically severe sagittal vertical axis and lumbopelvic mismatch. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: The opioid crisis in the US is currently catastrophic. A large number of patients use opioids preoperatively. PURPOSE: The goal of this study is to look at a group of patients who were on opioids prior to adult spinal deformity surgery, and compare outcomes in those who ceased and those who continued opioid use post operatively. We also aim to identify factors associated with postoperative opioid cessation. STUDY DESIGN/SETTING: Retrospective review of a prospective multicenter database of ASD patients. PATIENT SAMPLE: A total of 296 surgical ASD patients who were using opioids (daily or weekly) prior to surgical intervention. OUTCOME MEASURES: Post-operative opioid cessation or decreased use, HRQOL (SF-36, ODI, back pain, leg pain), and patient satisfaction.
METHOD(S): A multicenter prospective database of surgical ASD patients was reviewed. Opioid use was measured using the SRS-22r Q11. We included all surgical ASD patients who using opioids pre-operatively (daily or weekly) and completed 2-year follow up. Patients were divided based on 2-year opioid use: decreased/ceased vs continued. Groups were compared in regards to demographics, radiographic parameters, HRQL, invasiveness of surgery, complications, re-operations, and satisfaction.
RESULT(S): Our database had a total of 1,281 surgical patients, out of which 760 were eligible for 2-year follow up. Of those eligible, 578 (76.05%) completed their 2-year follow up. A total of 547 of these patients answered SRS22R-Q11 at baseline at 2-years (with the remainder choosing to not answer this question). There were 296 (54.11%) of 547 ASD patients undergoing surgery reported using opioids preoperatively. Of those, 171 (57.8%) had decreased or ceased opioids 2 years after surgical intervention. Those who decreased/ceased had a higher proportion of females (83.83% vs 72.00%, p=0.014). There was no other statistically significant difference in demographics (BMI, co-morbidities, age, prior spine surgery, smoking) or radiographic parameters (PI-LL, SVA, PT). Those who decreased/ceased opioids had higher baseline SF-36 M

BACKGROUND CONTEXT: The Adult Spinal Deformity Frailty Index (ASD-FI), a validated modality for quantifying frailty, stratifies patients into categories not frail (NF), frail (F) and severely frail (SF). However, the cost of treating each frailty state is unknown. PURPOSE: Investigate the cost utility of treating not frail versus frail or severely frail ASD patients. STUDY DESIGN/SETTING: Retrospective review of a prospective single center adult spinal deformity database. PATIENT SAMPLE: A total of 79 operative and non operative ASD patients >=18 years old, with baseline and 2Y ASD-FI and Oswestry Disability Index (ODI) scores. OUTCOME MEASURES: ODI, SF-6D, Cost per quality adjusted life years (QALY), Incremental Cost Effectiveness, Ratio (ICER).
METHOD(S): Inclusion criteria was surgical ASD (scoliosis>=20degree, SVA>=5cm, PT>=25degree, or thoracic kyphosis >=60degree) patients >18 years with available frailty and ODI data at BL and 2-years post op. Independent T-Tests assessed baseline radiographic differences in PT, PI-LL, and Schwab SVA modifier status between NF vs. F/SF patients. Utility data was calculated using the ODI converted to the SF-6D using published conversion methods. QALYs utilized a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs were calculated using the PearlDiver database. After accounting for complications, LOS, revisions, and death, cost per QALY at 2Y and life expectancy were calculated for NF, and F/SF patients. ICER was compared between non op and operative NF and F/SF patients at 2Y and life expectancy.
RESULT(S): Seventy-nine ASD patients met inclusion criteria. Descriptive statistics for the cohort were: age 51.0+/-6.8, 76% women, BMI 26.7+/-6.8, 54% osteotomy, 54% decompression, and 11.6+/-4.2 average levels fused. At BL, there were 48 NF, 26 F, and 4 SF pts. The average BL frailty for NF pts was 0.13+/-0.08, 0.39+/-0.06 for F, and 0.59+/-0.08 for SF pts. There were no differences in PT, PI-LL, or severe SVA Schwab modifier grades between NF or F/SF pts (all p>0.05). At 2-year follow up, there was no difference in the average cost of ASD surgery, $91,068.98 for NF patients and $90,888.53 for F/SF pts (p>0.05). The cost per QALY was higher for NF pts at 2 years vs F/SF pts ($464,239.62 vs. $321,107.89, p<0.05). If the utility gained was sustained to life expectancy, the cost per QALY was $70,796.43 for NF and $48,968.88 for F/SF (p<0.05). When compared to non op ASD pts, the ICER was $447,943.96 vs. $313,211.01 for NF and F/SF at 2 years, and $68,311.35 vs. $47,764.61 for NF and F/SF at life expectancy.
CONCLUSION(S): Frail and severely frail patients had lower cost per QALY compared to not frail patients at 3 years and life expectancy. In addition, when compared to a non operative cohort of ASD patients, frail and severely frail patients had lower ICER values. While these results support operative correction of frail and severely frail patients, it is important to note that these patients are often at worse baseline disability, which is closely related to frailty scores, and have more opportunity to improve postoperatively. In addition, there may be a threshold of frailty that is not operable due to the risk of severe complications that is not captured by this analysis. While future research should investigate economic outcomes at extended follow-up times, these findings support the cost effectiveness of ASD surgery at all frailty states. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: As the opioid crisis has gained national attention, there has been an increasing effort to decrease opioid usage. Simultaneously, patient satisfaction is a crucial metric in the American health care system, and has been closely linked to effective pain management in surgical patients. PURPOSE: Examine rates of pain medication prescription and concurrent patient satisfaction in spine surgery patients. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: A total of 1,729 patients undergoing any spine surgery. OUTCOME MEASURES: Rates of non-opioid pain medication prescriptions during hospitalization as part of a multimodal analgesia regimen, morphine milligram equivalents (MME) of opioids used during hospitalization, Press Ganey Satisfaction Survey data.
METHOD(S): Patients >=18yo undergoing spine surgery between 6/25/2017-6/30/2018 at a single institution by spine surgeons performing >=20 surgeries/quarter and who had medication data during hospitalization available included. Additional data collected included physician and procedure type. All data analyzed by quarter. Chi-squared test to compare percentages and ANOVA to compare means across quarters. Multivariate regression used to compare procedure-specific trends, controlling for age, revision and level of pain. Significance set at p<0.05.
RESULT(S): A total of 1,759 patients were included, 427 in Quarter 1 (Q1), 439 in Q2, 453 in Q3 and 440 in Q4. Mean total MME per patient hospitalization was 574.46, no significant difference between quarters (p=0.116). Mean MME/day per patient decreased between quarters (p=0.048), with highest mean 91.84 in Q2 and lowest 77.50 in Q4. From Q1 to Q4, three physicians had decreased mean MME/day (75.47->50.92, p=0.023; 115.70->46.05, p=0.013; 92.89->69.53, p=0.42, respectively) and two physicians had decreased total MME (815.88->243.15, p=0.004; 706.79->451.72, p=0.014, respectively). MME/day decreased (74.78->52.37, p=0.046) for discectomy cases. Controlling for age, revision and level of pain, total MME decreased for discectomies (p=0.006). Among all procedures, acetaminophen, NSAID and steroid prescription rates increased (9.13%->17.05%, p=0.001; 6.32%->9.77%, p=0.048; 9.13%->17.05%, p=0.001, respectively). This was also the case in fusion patients specifically (9.09%->17.99%, p=0.002; 2.77%->5.76%, p=0.024; 9.09%->17.99%, p=0.002, respectively). NSAID prescription in laminectomy patients also increased (3.23%->4.89%, p=0.041). Concurrently, benzodiazepine and GABA analog prescriptions decreased among all procedures (19.20%->10.68%, p<0.001; 9.84%->4.77%, p=0.025, respectively). Benzodiazepine prescriptions in fusion patients also decreased (24.51%->12.23%, p<0.001). No significant differences between quarters for mean pain ratings (p=0.521). Also no differences between quarters for responses to questions from Press Ganey Satisfaction Survey regarding how often staff talk about pain (p=0.164), whether staff talk about pain treatment (p=0.595) or recommending the hospital (p=0.096). This was also the case for top box ratings for the same questions (p=0.381, 0.837, 0.610, respectively). No significant differences between quarters for responses in all other patient satisfaction questions (range p=0.359-0.988) or their top box ratings (range p=0.359-0.988).
CONCLUSION(S): Over the studied time period, opioid use decreased and nonopioid prescriptions increased during hospitalization, while satisfaction scores remained unchanged. These findings indicate an increasing effort in reducing opioid use amongst providers, and suggest the ability to do so without impacting overall satisfaction rates. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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BACKGROUND CONTEXT: Numerous advances have been made in the field of spine fusion, such as minimally invasive (MIS) or robotic assisted spine surgery. However, it is unknown how these advances have impacted the cost of care. PURPOSE: Compare the economic outcomes of lumbar spine fusion between open, MIS and robotic assisted surgery patients. STUDY DESIGN/SETTING: Retrospective review of a single center spine surgery database. PATIENT SAMPLE: A total of 360 propensity matched patients. OUTCOME MEASURES: Costs, EuroQol-5D (EQ5D), Cost per quality adjusted life years (QALY).
METHOD(S): Inclusion criteria: surgical patients >18 years undergoing lumbar fusion surgery. Patients were categorized into 3 groups based on procedure type: open, MIS or robotic. Open patients undergoing poster spinal fusion were considered as the control group. MIS patients included those undergoing transforaminal or lateral lumbar interbody fusion with percutaneous screws. Robotic patients were those undergoing robot assisted fusion. Propensity score matching was performed between all groups for the number of levels fused. Costs were calculated using the PearlDiver database, which reflects both private insurance and Medicare reimbursement claims for ICD-9 codes. For robot cases, costs were reflective of operational fees and initial purchase cost. Complications and comorbidities (CC) and major complications and comorbidities (MCC) were assessed according to CMS.gov manual definitions. QALYs and cost per QALY were calculated using a 3% discount rate to account for residual decline to life expectancy (78.7 years). Costs per QALY were calculated for both 1 year and life expectancy, assuming no loss of benefit.
RESULT(S): A total of 360 propensity matched patients (120 open, 120 MIS, 120 robot) met inclusion. Descriptive statistics for the cohort were: age 58.8+/-13.5, 50% women, BMI 29.4+/-6.3, op time 294.4+/-119.0, LOS 4.56+/-3.31 days, EBL 515.9+/-670.0 cc, and 2.3+/-2.2 average levels fused. Rates of postop complications were significantly higher in robotic cases versus open and MIS (43% vs. 21% and 22% for open and MIS, p<0.05). However, revision rates were comparable between all groups (3% open, 3% MIS, 5% robotic, p>0.05). After factoring in complications, revisions, and purchasing and operating fees, the costs of robotic cases was significantly higher than both open and MIS surgery ($60,047.01 vs. $42,538.98 open and $41,471.21 MIS). In a sub analysis of 42 patients with BL and 1Y EQ5D data, the cost per QALY at 1Y for open, MIS, and robot assisted cases was $296,624.48, $115,911.69, and $592,734.30. If utility gained was sustained to life expectancy, the cost per QALY was $14,905.75, $5,824.71, $29,785.64 for open, MIS, and robot assisted cases.
CONCLUSION(S): Numerous advances have been made in the field of spine surgery, however, there has been limited discussion of the effect these advances have on economic outcomes. When matched for levels fused, robot assisted surgery patients had significantly higher rates of complications and 30% higher costs of surgery compared to minimally invasive and open spine surgery patients. While 1 year economic outcomes weren't optimal for robotic surgery cases, the projected costs per quality adjusted life years at life expectancy were well below established acceptable thresholds. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
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