Cost-effectiveness of lumbar discectomy and single-level fusion for spondylolisthesis: experience with the NeuroPoint-SD registry
OBJECT: There is significant practice variation and uncertainty as to the value of surgical treatments for lumbar spine disorders. The authors' aim was to establish a multicenter registry to assess the efficacy and costs of common lumbar spinal procedures by using prospectively collected outcomes. METHODS: An observational prospective cohort study was completed at 13 academic and community sites. Patients undergoing single-level fusion for spondylolisthesis or single-level lumbar discectomy were included. The 36-Item Short Form Health Survey (SF-36) and Oswestry Disability Index (ODI) data were obtained preoperatively and at 1, 3, 6, and 12 months postoperatively. Power analysis estimated a sample size of 160 patients: lumbar disc (125 patients) and lumbar listhesis (35 patients). The quality-adjusted life year (QALY) data were calculated using 6-dimension utility index scores. Direct costs and complication costs were estimated using Medicare reimbursement values from 2011, and indirect costs were estimated using the human capital approach with the 2011 US national wage index. Total costs equaled $14,980 for lumbar discectomy and $43,852 for surgery for lumbar spondylolisthesis. RESULTS: There were 198 patients enrolled over 1 year. The mean age was 46 years (49% female) for lumbar discectomy (n = 148) and 58.1 years (60% female) for lumbar spondylolisthesis (n = 50). Ten patients with disc herniation (6.8%) and 1 with listhesis (2%) required repeat operation at 1 year. The overall 1-year follow-up rate was 88%. At 30 days, both lumbar discectomy and single-level fusion procedures were associated with significant improvements in ODI, visual analog scale, and SF-36 scores (p = 0.0002), which persisted at the 1-year evaluation (p < 0.0001). By 1 year, more than 80% of patients in each cohort who were working preoperatively had returned to work. Lumbar discectomy was associated with a gain of 0.225 QALYs over the 1-year study period ($66,578/QALY gained). Lumbar spinal fusion for Grade I listhesis was associated with a gain of 0.195 QALYs over the 1-year study period ($224,420/QALY gained). CONCLUSIONS: This national spine registry demonstrated successful collection of high-quality outcomes data for spinal procedures in actual practice. These data are useful for demonstrating return to work and cost-effectiveness following surgical treatment of single-level lumbar disc herniation or spondylolisthesis. One-year cost per QALY was obtained, and this cost per QALY is expected to improve further by 2 years. This work sets the stage for real-world analysis of the value of health interventions.
The efficacy of lumbar discectomy and single-level fusion for spondylolisthesis: results from the NeuroPoint-SD registry
Object There is significant practice variation and considerable uncertainty among payers and other major stakeholders as to whether many surgical treatments are effective in actual US spine practice. The aim of this study was to establish a multicenter cooperative research group and demonstrate the feasibility of developing a registry to assess the efficacy of common lumbar spinal procedures using prospectively collected patient-reported outcome measures. Methods An observational prospective cohort study was conducted at 13 US academic and community sites. Unselected patients undergoing lumbar discectomy or single-level fusion for spondylolisthesis were included. Patients completed the 36-item Short-Form Survey Instrument (SF-36), Oswestry Disability Index (ODI), and visual analog scale (VAS) questionnaires preoperatively and at 1, 3, 6, and 12 months postoperatively. Power analysis estimated a sample size of 160 patients: 125 patients with lumbar disc herniation, and 35 with lumbar spondylolisthesis. All patient data were entered into a secure Internet-based data management platform. Results Of 249 patients screened, there were 198 enrolled over 1 year. The median age of the patients was 45.0 years (49% female) for lumbar discectomy (n = 148), and 58.0 years (58% female) for lumbar spondylolisthesis (n = 50). At 30 days, 12 complications (6.1% of study population) were identified. Ten patients (6.8%) with disc herniation and 1 (2%) with spondylolisthesis required reoperation. The overall follow-up rate for the collection of patient-reported outcome data over 1 year was 88.3%. At 30 days, both lumbar discectomy and single-level fusion procedures were associated with significant improvements in ODI, VAS, and SF-36 scores (p = 0.0002), which persisted over the 1-year follow-up period (p < 0.0001). By the 1-year follow-up evaluation, more than 80% of patients in each cohort who were working preoperatively had returned to work. Conclusions It is feasible to build a national spine registry for the collection of high-quality prospective data to demonstrate the effectiveness of spinal procedures in actual practice. Clinical trial registration no.: 01220921 (ClinicalTrials.gov).
Extracranial carotid plaque length and parent vessel diameter significantly affect baseline ipsilateral intracranial blood flow
BACKGROUND: : The degree of carotid artery stenosis has traditionally been used as a marker of hemodynamic compromise and increased stroke risk. However, the hemodynamic effect of carotid atherosclerotic plaque length on cerebral blood flow has not previously been studied. OBJECTIVE: : To determine whether carotid plaque length, in addition to degree of stenosis, significantly affects carotid blood flow in patients with >65% carotid stenosis. METHODS: : Consecutively treated surgical patients with unilateral >65% carotid stenosis at a single institution were analyzed. Quantitative measurements of plaque length, internal carotid artery (ICA) vessel diameter, and degree of stenosis were made from magnetic resonance angiography images. Quantitative phase-contrast magnetic resonance angiography flow maps were generated to estimate ICA flow compromise by calculating a ratio of the ipsilateral/contralateral ICA flow rates. RESULTS: : Of 38 eligible patients, 23 had full anatomic and ICA flow data sets available for analysis. Univariate regression analysis demonstrated that longer carotid plaques and increasing percentage carotid stenosis were associated with a significant decline in ipsilateral ICA flow (P = .008 and P = .02, respectively). A multivariate regression identified both plaque length and vessel diameter as independent predictors of ICA flow (P = .001 and P = .002, respectively). CONCLUSION: : Carotid plaque length and vessel diameter appear to be significant variables, in addition to degree of stenosis, in predicting ipsilateral carotid blood flow compromise in patients undergoing carotid revascularization
Cervical corpectomy and strut grafting
Cervical corpectomy and strut grafting is a deceptively simple procedure that has been performed for many years for a variety of cervical spine disorders (infection, neoplastic disease, and trauma) but most commonly for cervical spondylosis. The procedure requires attention to detail to ensure adequate decompression of the neural structures and avoiding injury to the soft tissues of the neck and the vertebral artery in the transverse foramina. The following description of the technique is one we have successfully used for cervical corpectomy and strut grafting. We also discuss patient selection criteria, avoidance of common complications, and postoperative management
Perfusion and diffusion tensor imaging in a patient with locked-in syndrome after neurosurgical vascular bypass and endovascular embolization of a basilar artery aneurysm: case report [Case Report]
OBJECTIVE AND IMPORTANCE/OBJECTIVE:Locked-in syndrome is a state of preserved consciousness in the setting of quadriplegia, anarthria, and usually also includes lateral gaze palsy. It is most commonly associated with upper brainstem infarction variably sparing the third cranial nerve nucleus. There are likely many etiologies that contribute to this clinical syndrome. These are incompletely understood, and the syndrome remains a rare but devastating complication that can occur after neurosurgical and neurovascular interventions. Advanced magnetic resonance imaging techniques such as perfusion and diffusion tensor imaging may help to elucidate the mechanism behind locked-in syndrome. To the authors' knowledge, there are no reports in the literature of perfusion and diffusion tensor findings in patients with this syndrome. A postprocedural case of locked-in syndrome is described with abnormalities on perfusion and diffusion tensor imaging in the absence of any changes in conventional magnetic resonance imaging. CLINICAL PRESENTATION/METHODS:A 57-year-old man who presented with acute onset headache, ataxia, and other nonspecific symptoms was found on imaging to have a giant fusiform basilar artery aneurysm. INTERVENTION/METHODS:A saphenous vein graft bypass between the proximal right external carotid artery and P2 segment of the right posterior cerebral artery followed immediately by endovascular embolization of the aneurysm sac and distal left vertebral artery was performed. CONCLUSION/CONCLUSIONS:Postprocedural angiography demonstrated patency of the bypass graft, and diffusion weighted imaging showed no evidence for acute brainstem infarction. Nevertheless, despite technically successful procedures and the absence of abnormalities on conventional magnetic resonance imaging, the patient developed quadriplegia and anarthria and remained in a locked-in state until he expired. Abnormalities were, however, seen on both perfusion and diffusion tensor imaging, where hypoperfusion, increased mean diffusivity, and decreased fractional anisotropy were observed in the ventral brainstem. The findings suggested a disruption of pontine white matter tracts. Advanced imaging techniques may allow us to image important microstructural changes that were previously not discernable and assist in the evaluation of patients with complex neurological sequelae such as locked-in syndrome.
Prolonged intrathecal baclofen withdrawal syndrome. Case report and discussion of current therapeutic management [Case Report]
The authors describe a patient who experienced a prolonged course of intrathecal baclofen withdrawal syndrome after removal of an implantable baclofen pump for treatment of pump infection and meningitis. The current literature outlines management options for the acute management of this syndrome. In this report the authors discuss the long-term presentation of this syndrome and suggest a treatment strategy for management of the syndrome. A 37-year-old man who presented with a baclofen pump infection and meningitis experienced acute onset of intrathecal baclofen withdrawal syndrome 12 hours after the pump had been surgically removed. The patient's symptoms evolved into a severe, treatment-refractory withdrawal syndrome lasting longer than 1 month. Oral baclofen replacement with adjunctive administration of parenteral gamma-aminobutyric acid agonists only served to stabilize the patient's critical condition throughout his hospital course. Replacement of the baclofen pump and restoration of intrathecal delivery of the medication was necessary to trigger the patient's dramatic recovery and complete reversal of the withdrawal syndrome within approximately 48 hours. These findings indicate that a more direct method of treating infected baclofen pumps than immediate surgical removal is necessary to prevent the onset of intrathecal baclofen withdrawal syndrome. Various options for preventing the onset of the syndrome while simultaneously treating the infection are discussed