Abstract Background context Whereas the costs of primary surgery, revisions, and selected complications for adult spinal deformity (ASD) have been individually reported in the literature, the total ...costs over several years after surgery have not been assessed. The determinants of such costs are also not well understood in the literature. Purpose This study analyzes the total hospital costs and operating room (OR) costs of ASD surgery through extended follow-up. Study design/setting Single-center retrospective analysis of consecutive surgical patients. Patient sample Four hundred eighty-four consecutive patients undergoing surgical treatment for ASD from January 2005 through January 2011 with minimum three levels fused. Outcome measures Costs were collected from hospital administrative data on the total hospital costs incurred for the operation and any related readmissions, expressed in 2010 dollars and discounted at 3.5% per year. Detailed data on OR costs, including implants and biologics, were also collected. Methods We performed a series of paired t tests and Wilcoxon signed-rank tests for differences in total hospital costs over different follow-up periods. The goal of these tests was to identify a time period over which average costs plateau and remain relatively constant over time. Generalized linear model regression was used to estimate the effect of patient and surgical factors on hospital inpatient costs, with different models estimated for different follow-up periods. A similar regression analysis was performed separately for OR costs and all other hospital costs. Results Patients were predominantly women (n=415 or 86%) with an average age of 48 (18–82) years and an average follow-up of 4.8 (2–8) years. Total hospital costs averaged $120,394, with primary surgery averaging $103,143 and total readmission costs averaging $67,262 per patient with a readmission (n=130 or 27% of all patients). Operating room costs averaged $70,514 per patient, constituting the majority (59%) of total hospital costs. Average total hospital costs across all patients significantly increased (p<.01) after primary surgery, from $111,807 at 1-year follow-up to $126,323 at 4-year follow-up. Regression results also revealed physician preference as the largest determinant of OR costs, accounting for $14,780 of otherwise unexplained OR cost differences across patients, with no significant physician effects on all other non-OR costs (p<.05). Conclusions The incidence of readmissions increased the average cost of ASD surgery by more than 70%, illustrating the financial burden of revisions/reoperations; however, the cost burden resulting from readmissions appeared to taper off within 5 years after surgery. The estimated impact of physician preference on OR costs also highlights the variation in current practice and the opportunity for large cost reductions via a more standardized approach in the use of implants and biologics.
Abstract Background context Intraoperative imaging is essential in spinal surgery to both determine the correct level and place implants safely. Surgeons have a variety of options: C-arm fluoroscopy ...(C-arm), portable X-ray (XR) radiography, and portable cone-beam computed tomography (O-arm). Although these modalities have their respective advantages and disadvantages, direct comparison of radiation exposure to either the patient or the operating room (OR) staff has not been made. Purpose To determine the amount of radiation exposure to patients and OR staff during spine surgery with C-arm, XR, and O-arm. Study design An experimental model to assess radiation exposure to OR staff and phantom patient during spine surgery. Methods A plastic phantom was created to emulate patient volume and absorption scattering characteristics of a typical sized adult abdominal volume. Radiation exposure was measured with ion chamber dosimeters to determine entrance phantom and scatter exposures at common positions occupied by OR staff for C-arm, XR, and O-arm in typical image acquisition during spinal surgery. Results Single lateral (LAT)/posterior-anterior entrance patient radiation exposure for C-arm was on average 116/102 mR, single-exposure XR for LAT/anterior-posterior (AP) was 3,435/2,160 mR, and single-exposure O-arm for LAT/AP was 4,360/5,220 mR. O-arm surface exposure LAT/AP was equivalent to 38/41 C-arm and 1.5/2.4 XR exposures. The surgeon and surgeon assistant had higher levels of scatter radiation for C-arm, followed by O-arm and XR. For the LAT C-arm acquisition, a 7.7-fold increase in radiation exposure was measured on the X-ray tube side compared with the detector side. The anesthesiologist scatter radiation level for a single acquisition was highest for O-arm, followed by XR and C-arm. The radiologic technologist scatter radiation level was highest for XR, followed by O-arm and fluoroscopy. Overall radiation exposure to OR staff was less than 4.4 mR for a single acquisition in all modalities. Conclusions Assessment of radiation risk to the patient and OR staff should be part of the decision for utilization of any specific imaging modality during spinal surgery. This study provides the surgeon with information to better weigh the risks and benefits of each imaging modality.
Laminectomy with fusion (LF) and laminoplasty (LP) are common posterior decompression procedures used to treat multilevel degenerative cervical myelopathy (DCM). There is debate on their relative ...efficacy and safety for treatment of DCM. The goal of this study is to examine outcomes and costs of LF and LP procedures for DCM.
This is a retrospective review of adult patients (<18) at a single center who underwent elective LP and LF of at least 3 levels from C3-C7. Outcome measures included operative characteristics, inpatient mobility status, length of stay, complications, revision surgery, VAS neck pain scores, and changes in radiographic alignment. Oral opioid analgesic needs and hospital cost comparison were also assessed.
LP cohort (n=76) and LF cohort (n=59) reported no difference in neck pain at baseline, 1, 6, 12, and 24 months postoperatively (p>.05). Patients were successfully weaned off opioids at similar rates (LF: 88%, LP: 86%). Fixed and variable costs respectively with LF cases hospital were higher, 15.7% and 25.7% compared to LP cases (p=.03 and p<.001). LF has a longer length of stay (4.2 vs. 3.1 days, p=.001). Wound-related complications were 5 times more likely after LF (13.6% vs. 5.9%, RR: 5.15) and C5 palsy rates were similar across the groups (LF: 11.9% LP: 5.6% RR: 1.8). Ground-level falls requiring an emergency department visit were more likely after LF (11.9% vs. 2.6%, p=.04).
When treating multilevel DCM, LP has similar rates of new or increasing axial neck pain compared to LF. LF was associated with greater hospital costs, length of stay, and complications compared to LP. LP may in fact be a less morbid and more cost-effective alternative to LF for patients without cervical deformity.
Abstract Background context Atlantooccipital dislocation (AOD) results in profound patient morbidity and mortality and is difficult to accurately diagnose using current evaluation techniques. Purpose ...To evaluate the utility of computed tomography (CT) images in the diagnosis of AOD and compare the revised occipital condyle–C1 interval (CCI) and the condylar sum to the current radiographic criteria used to detect AOD. Study design Retrospective review to evaluate the sensitivity, specificity, and the interobserver reliability of eight radiographic criteria as applied to CT imaging. Patient sample Ten cases of clinical AOD and 10 cases of non-AOD cervical injury. Outcome measures Measured values: revised CCI, Wholey basion-dens interval (BDI), and Harris basion-axis interval (BAI). Calculated values: Sun interspinous ratio, Powers ratio, and condylar sum. Assessment of Lee X-line and atlantooccipital joint asymmetry. Methods A board certified neuroradiologist, two orthopedic spine surgeons, and two medical students reviewed the CT images for each patient in the series and applied the aforementioned criteria. Results Average sensitivity between all reviewers for CCI, condylar sum, and atlantooccipital asymmetry was highest at 1.0, 1.0, and 0.96, respectively. Basion-dens interval, X-line, Sun ratio, BAI, and Powers ratio had sensitivities of 0.72, 0.54, 0.32, 0.26, and 0.26, respectively. Revised CCI and condylar sum had significantly better sensitivity than any other test (vs. BDI, p=.014, all others, p<.001) except atlantooccipital asymmetry (p>.99). Specificity for all measurements was 0.78 or greater, except X-line at 0.38. Interobserver reliabilities were the greatest for CCI, condylar sum, atlantooccipital asymmetry, and BDI. Conclusions The revised CCI (>2.5 mm abnormal) and condylar sum (≥5 mm abnormal) are highly sensitive and reliable radiographic criteria for the detection of AOD when applied to CT imaging.
Abstract Background context The Morel-Lavallée lesion occurs from a compression and shear force that usually separates the skin and subcutaneous tissue from the underlying muscular fascia. A dead ...space is created that becomes filled with blood, liquefied fat, and lymphatic fluid from the shearing of vasculature and lymphatics. If not treated appropriately, these lesions can become infected, cause tissue necrosis, or form chronic seromas. Purpose To review appropriate identification and treatment of Morel-Lavallée lesions in spinopelvic dissociation patients. Study design Uncontrolled case series. Methods Retrospective review of medical records. No funding was received in support of this study. The authors report no conflicts of interest. Results We present four cases of patients with traumatic spinopelvic dissociation. All had concomitant lumbosacral Morel-Lavallée lesions. All four trauma patients suffered traumatic spinopelvic dissociation with concomitant lumbosacral Morel-Lavallée lesions. Appropriate treatment included irrigation and debridement, drainage, antibiotics, and vacuum-assisted wound closure. Conclusions Our series reflects an association of Morel-Lavallée lesion in spinopelvic dissociation trauma patients. Possibly, the rotatory injury that occurs at the spinopelvic junction creates a shear force to form the Morel-Lavallée lesion. When presented with a spinopelvic dissociation patient, one should be prepared to treat a Morel-Lavallée lesion.
