Faculty Bibliography

STUDY DESIGN:This was a retrospective cohort study. OBJECTIVE:The aim of this study was to compare the hospital charges and postoperative complications of minimally invasive surgery (MIS) and open approaches to sacroiliac joint (SIJ) fusion. SUMMARY OF BACKGROUND DATA:The data source utilized in this study is the Healthcare Cost and Utilization Project National Readmission Database (NRD) from 2016 and 2017. The NRD is a yearly nationally representative inpatient database from the Agency for Healthcare Research and Quality with information regarding patient demographics, diagnoses, procedures, and readmissions. MATERIALS AND METHODS:The 2016-2017 NRD was used to identify 2521 patients receiving SIJ fusion with open (n=1990) or MIS approaches (n=531) for diagnosed sacrum pain, sacroiliitis, sacral instability, or spondylosis after excluding for those who received prior SIJ fusion, those diagnosed with neoplasms or trauma of the pelvis or sacrum, and nonelective procedures. We then one-to-one propensity-matched the open (n=531) to the MIS approach (n=531) for age, sex, and Charlson Comorbidity Index. Statistical analysis was performed to compare total hospital charges, immediate surgical complications, nonelective readmission rate, and 30-, 90-, and 180-day postoperative complications between the 2 approaches. RESULTS:The mean total hospital charge was the only significant difference between 2 group. Open SIJ fusion had significantly higher charge compared with the MIS approach (open $101,061.90±$81,136.67; MIS $83,594.78±$49,086.00, P<0.0001). The open approach was associated with nonsignificant higher rates of novel lumbar pathology at 30-, 90-, and 180-day readmissions and revision surgeries at 30 and 180 days. MIS approach had higher rates nervous system complications at 30-, 90-, and 180-day readmission, as well as infection and urinary tract infection within 30 days, none being significant. Novel postprocedural pain was similar between the 2 groups at 90 and 180 days. CONCLUSIONS:The current study found that open SIJ fusion was associated with significantly higher hospital charges. Although no significant differences in postoperative complications were found, there were several notable trends specific to each surgical approach.

PURPOSE:This study evaluates the influence of patient frailty status on postoperative complications in those receiving single-level lumbar fusion surgery. METHODS:The nationwide readmission database was retrospectively queried between 2016 and 2017 for all patients receiving single-level lumbar fusion surgery. Readmissions were analyzed at 30, 90, and 180 days from primary discharge. Demographics, frailty status, and relevant complications were queried at index admission and all readmission intervals. Complications of interest included infection, urinary tract infection (UTI), posthemorrhagic anemia, inpatient length of stay (LOS), and adjusted all-payer costs. Nearest-neighbor propensity score matching for demographics was implemented to identify non-frail control patients with similar diagnoses and procedures. The analysis used nonparametric Mann-Whitney U testing and odds ratios. RESULTS:Comparing propensity-matched cohorts revealed significantly greater LOS and total all-payer inpatient costs in frail patients than non-frail patients with comparable demographics and comorbidities (p < 0.0001 for both). Furthermore, frail patients encountered higher rates of UTI (OR: 3.97, 95%CI: 3.21-4.95, p < 0.0001), infection (OR: 6.87, 95%CI: 4.55-10.86, p < 0.0001), and posthemorrhagic anemia (OR: 1.94, 95%CI: 1.71-2.19, p < 0.0001) immediately following surgery. Frail patients had significantly higher rates of 30-day (OR: 1.24, 95%CI: 1.02-1.51, p = 0.035), 90-day (OR: 1.38, 95%CI: 1.17-1.63, p < 0.001), and 180-day (OR: 1.55, 95%CI: 1.30-1.85, p < 0.0001) readmissions. Lastly, frail patients had higher rates of infection at 30-day (OR: 1.61, 95%CI: 1.05-2.46, p = 0.027) and 90-day (OR: 1.51, 95%CI: 1.07-2.16, p = 0.020) readmission intervals. CONCLUSIONS:Patient frailty status may serve as an important predictor of postoperative outcomes in patients receiving single-level lumbar fusion surgery.

»:Lumbar disc herniation is one of the most common spinal pathologies, often occurring at the L4-L5 and L5-S1 levels. The highest incidence has been reported in patients between the fourth and sixth decades of life. »:The severity of symptoms is influenced by the patient's risk factors, the location, and the extent and type of disc herniation. »:Lumbar disc herniation can be effectively treated with multiple treatment protocols. In most cases, first-line treatment includes oral analgesic medication, activity modification, and physical therapy. When nonoperative treatments do not provide adequate relief, patients may elect to undergo a fluoroscopically guided contrast-enhanced epidural steroid injection. A subgroup of patients whose condition is refractory to any type of nonoperative modalities will proceed to surgery, most commonly an open or minimally invasive discectomy. »:The treatment algorithm for symptomatic lumbar disc herniation often is a stepwise approach: failure of initial nonoperative measures leads to more aggressive treatment when symptoms mandate and, as such, necessitates the use of a multidisciplinary team approach. The core team should consist of an interventional physiatrist, an orthopaedic surgeon, a physician assistant, and a physical therapist. Additional team members may include nurses, radiologists, neurologists, anesthesiologists, spine fellows, psychologists, and case managers. »:This review article describes a case scenario that uses a multidisciplinary team approach for the treatment of an acute L4-L5 disc herniation in a 31-year-old patient without any major comorbidities.

STUDY DESIGN/METHODS:Retrospective database study. OBJECTIVE:To assess the intra- and postoperative complications of cervical laminoplasty and to evaluate the effect of intraoperative neuromonitoring use on postoperative limb paralysis incidence. SUMMARY OF BACKGROUND DATA/BACKGROUND:Cervical laminoplasty is a known procedure for the management of cervical spondylotic myelopathy (CSM). METHODS:This was a retrospective study of 532 patients with CSM who underwent cervical laminoplasty between 2007 and the first quarter of 2016 using the Humana subset of the PearlDiver Database. The database was queried using the relevant International Classification of Diseases (ICD-9 and ICD-10) codes for CSM and Current Procedural Terminology (CPT) codes for cervical laminoplasty. The intra- and postoperative incidence of surgical and medical complications and reoperations was then determined and was compared with a propensity score-matched cohort of patients who had posterior laminectomy and fusion (490 patients in each group), using multivariate logistic regression analysis. RESULTS:Laminoplasty was associated with a lower incidence of dysphagia (odds ratio [OR] = 0.37, 95% confidence interval [CI] = 0.16-0.79; P = 0.014), 30-day readmission (OR = 0.51, 95% CI = 0.35-0.75; P < 0.001), urinary tract infection (OR = 0.58, 95% CI = 0.37-0.93; P = 0.023), and incision and drainage, exploration or evacuation (OR = 0.28, 95% CI = 0.08-0.79; P = 0.026). The use of intraoperative neuromonitoring was associated with a non-significant lower incidence of limb paralysis within 1 and 3 months postoperatively (OR = 0.52 and 0.51, 95% CI = 0.23-1.19 and 0.23-1.11; P = 0.119 and 0.091, respectively). CONCLUSION/CONCLUSIONS:Compared with posterior laminectomy and fusion, laminoplasty had lower rates of dysphagia, urinary tract infection, and 30-day readmission. The use of intraoperative neuromonitoring was associated with a lower risk of postoperative limb paralysis, but it did not achieve statistical significance. LEVEL OF EVIDENCE/METHODS:4.

PURPOSE:This study aimed to evaluate facet joint parameters and osteoarthritis grades, and segmental angular and translational motions among different grades of L5/S1 intervertebral disc (IVD) degeneration. METHODS:This retrospective study analysed kinematic magnetic resonance imaging (kMRI) images of the lumbar spine of 214 patients with low back pain. Degenerations of the L5/S1 IVDs and facet joints osteoarthritis were assessed using the Pfirrmann and Pathria grading scales, respectively. Facet joint parameters included facet joint angle and facet joint space width. Angular and translation segmental motions were measured using MRI Analyzer software. RESULTS:The mean age of the studied patients was 44.1 ± 13.9 years. Patients with L5/S1 disc degeneration were associated with higher odds of facet joint osteoarthritis (odds ratio = 2.28, 95% confidence interval = 1.23-4.23, P = 0.008). There was a positive correlation between L5/S1 disc degeneration grade and the facet joint grade (r = 0.365, P > 0.001). Grade IV facet joint osteoarthritis did not appear in grades I or II disc degeneration (P > 0.001). The average facet joint width decreased significantly with increasing Pfirrmann grading (P = 0.017). The difference in facet joint angle between groups was not statistically significant (P = 0.532). The differences in the angular and translational motions were not statistically significant (P = 0.530, and 0.510, respectively). CONCLUSION:A positive correlation exists between L5/S1 disc degeneration and facet joint osteoarthritis grades. The facet joint space width decreases significantly with increasing grade of disc degeneration.

BACKGROUND CONTEXT:Posterior cervical foraminotomy (PCF) is a relatively safe procedure for the treatment of cervical radiculopathy. Though most often performed as an inpatient procedure, there is an increasing number of patients treated in an outpatient setting. PURPOSE:This study aimed to compare the perioperative complication rates associated with inpatient and outpatient single-level PCF. STUDY DESIGN/SETTING:Retrospective database study. PATIENT SAMPLE:Patients with cervical radiculopathy who underwent inpatient or outpatient single-level PCF between 2007 to the first quarter of 2016. OUTCOME MEASURES:Charlson Comorbidity Index (CCI) was used as a broad measure of comorbidity. Surgical complications included cervical nerve root injury, dural tear, wound complications, infection, dysphagia, cervicalgia, and revision surgery. Medical complications included pulmonary embolism and lower limb deep vein thrombosis, acute myocardial infarction, acute respiratory failure, pneumonia, sepsis, and urinary complications. METHODS:This study was a retrospective review of patients who received single-level PCF from 2007 to the first quarter of 2016 as either outpatients or inpatients using the Humana subset of the PearlDiver Patient Record Database. The incidence of perioperative medical and surgical complications was queried using relevant International Classification of Diseases (ICD-9-CM and ICD-10-CM) and Current Procedural Terminology codes. Multivariate logistic regression analysis, adjusted for age, gender, and CCI, was performed to calculate odds ratios (ORs) of complications among inpatients relative to outpatients treated with PCF. Propensity score matching was done, and comparisons were made for postoperative complications. RESULTS:Throughout the time period, 1,469 and 1,192 patients received inpatient and outpatient single-level PCF, respectively. The mean CCIs±standard deviation of inpatient and outpatient groups undergoing PCF were 2.83±3.11 and 1.46±2.21, respectively (p<.001). After propensity score matching, patients who received PCF in an inpatient setting showed significantly higher rates of wound complications (OR=1.53, 95% confidence interval [CI]=1.04-2.23; p=.029), infection (OR=1.91, CI=1.15-3.15; p=.012), acute respiratory failure (OR=2.50, CI=1.23-5.08; p=.011), and urinary tract infections and incontinence (OR=2.11, CI=1.32-3.38; p=.002). CONCLUSIONS:Outpatient single-level PCF was associated with a lower rate of perioperative medical and surgical complications. The PCF in the outpatient setting can potentially be a safe procedure for the treatment of cervical radiculopathy with appropriate patient selection.

PURPOSE:To evaluate the reliability and validity of the multi-positional magnetic resonance imaging in measuring occipitocervical parameters using the standard cervical dynamic radiographs as a reference. METHODS:Patients were included if they underwent both dynamic radiograph and cervical multi-positional MRI within a 2-week interval from January 2013 to December 2016. Twelve occipitocervical parameters were measured on both image modalities in all positions (neutral, flexion and extension): Posterior Atlanto-Dental Interval, Anterior Atlanto-Dental Interval (AADI), Dens-to-McRae distance, Dens-to-McGregor distance, Occipito-atlantal Cobb angle (C01 angle), Occipito-axis Cobb angle (C02 Cobb angle), Atlas-axis Cobb angle (C12 angle), Redlund-Johnell, Modified Ranawat, Clivus canal angle, Occiput inclination, and Occiput cervical distance. Pearson correlation and linear regression analysis were used to evaluate the correlation of both modalities for each parameter. A p value of < 0.05 was considered statistically significant. RESULTS:Cervical images of 70 patients were measured and analyzed. There was a significant positive correlation between dynamic X-ray and multi-positional MRI for all parameters (p < 0.05) except AADI. Dens-to-McGregor distance and Redlund-Johnell parameter demonstrated a very strong correlation in the neutral position (r = 0.72, r = 0.79 respectively) and moderate to very strong correlation(r > 0.4) for Modified Ranawat, Clivus canal angle, C02 Cobb angle and C02 distance in all neck position. The intra-class correlation (ICC) of intra- and inter-observer showed good to excellent reliability, and ICCs were 0.67-0.98. CONCLUSIONS:Multi-positional MRI can be a reliable imaging option for diagnosis of occipitocervical instability or basilar invagination compared to standard dynamic radiographs.

STUDY DESIGN/METHODS:Retrospective review of insurance database. PURPOSE/OBJECTIVE:To investigate national trends, complications, and costs after cervical disc replacement (CDR) using an administrative insurance database representative of the United States population. OVERVIEW OF LITERATURE/BACKGROUND:As CDR continues to be used to treat patients with cervical stenosis, it is important to gain a better understanding of its use on a national level, potential complications, and cost. This information will allow for optimal patient counseling, risk stratification, and healthcare cost assessments. Several prior studies have investigated complications associated with CDR, but they have been limited by small sample size, single institution experiences, limited follow-up, and potential conflicts of interest. METHODS:Patients who underwent single or multilevel CDR between 2007 and 2015 were identified using an insurance database. We collected data on annual trends, reimbursement costs, patient demographic information, hospital information, and information on complications from the time of operation to 1 year postoperative. RESULTS:Total of 293 patients underwent either single or multilevel CDR. The number of procedures increased nonlinearly over time at an average of 17% per year, with a greater increase seen in the outpatient setting. Less than 3.7% of patients had new onset pain within 1 year after CDR. Within 1 year, 12.3% of patients reported a mechanical and/or bone-related complication. There were no patients who indicated a new nerve injury within 6 months of follow-up. Less than 3.7% of patients presented with dysphagia or dysphonia within 6 months, infection within 3 months, or a revision or reoperation within 1 year. Average reimbursement for single-level inpatient versus outpatient CDR was US $33,696.28 and US $34,675.12, respectively (p=0.29). CONCLUSIONS:This study demonstrated that the use of CDR continued to increase. The most common complication was mechanical and/or bone-related, and cost analysis demonstrated no significant difference between inpatient and outpatient CDR.

The purpose of this study was to assess trends in the use of perioperative single and continuous peripheral nerve blocks (PNBs) and their associations with emergency department (ED) visits after arthroscopic rotator cuff repair (RCR) surgery. The authors used a large database from a private insurer to identify patients who received perioperative PNBs for arthroscopic RCR surgeries from 2007 to 2015. They analyzed patient demographics as well as trends in perioperative PNB use. They also assessed rates of single shot vs continuous PNB use and compared rates of postoperative ED visits according to PNB type. The rate of perioperative PNB for arthroscopic RCR was higher than previously reported (65.9%) and increased over time (52.8% in 2007 to 64.6% in 2015; P=.029). Single shot PNBs were more common than continuous, catheter-mediated PNBs (60.0% vs 6.6%; P<.001), although the use of continuous blocks increased at a greater rate during the study period. Patients who received a perioperative continuous PNB were significantly more likely to visit an ED within 7 days of their surgery than those who received a single shot PNB or no PNB (6.71% vs 4.78% vs 4.74%; P<.02). The rates of ED visits within each group did not change significantly over time. Continuous PNBs are increasingly common for patients undergoing arthroscopic RCR surgery but are associated with increased rates of postoperative ED visits. Studies are needed to identify the reasons for this increased rate of ED visits and strategies to decrease ED use. [Orthopedics. 2020; 43(2): 127-131.].