Scheuermannʼs kyphosis (SK) is a rigid structural deformity of the thoracic spine defined radiographically as three or more contiguous vertebrae with at least 5° of wedging anteriorly. Prevalence of ...the disease is thought to be between 0.4% and 10%. The true cause of SK remains unclear; however, various theories include growth irregularities, mechanical factors, genetic factors, and/or poor bone quality as the causes. Patients with mild disease (less than 70°) generally have a favorable prognosis with good clinical outcomes. Most patients with SK are successfully treated nonsurgically with observation, anti-inflammatory medications, and physical therapy. Surgical intervention is indicated in patients with greater than 70° to 75° thoracic curves, greater than 25° to 30° thoracolumbar curves, intractable pain, neurologic deficit, cardiopulmonary compromise, or poor cosmesis. Because of advances in posterior spinal instrumentation, surgery can typically be performed through a posterior-only approach. When surgical treatment is planned, appropriate selection of the upper- and lower-instrumented vertebrae is important to achieve a well-balanced spine, preserve motion segments, and reduce the risk of junctional kyphosis.
Retrospective, propensity-matched observational study.
To assess the impact of cell saver homologous transfusion on perioperative medical complications in adult patients undergoing spinal deformity ...surgery.
Despite many endorsing its use, many analyses still refute the efficacy of CS on decreasing total perioperative allogenic RBC transfusions, cost efficiency, and its effect on perioperative complications.
Adult patients that underwent spinal deformity surgery at a single center between 2015-2021 were retrospectively reviewed. Patient-specific, operative, radiographic, and 30-day complications/readmission data were collected for further analysis. Two methods were utilized to test our hypothesis: 1) absolute threshold model: two cohorts created among patients who received ≥550 mL of CS intraoperatively and those who received less; 2) adjusted ratio model: two cohorts created dependent on the ratio of CS to EBL. Propensity-score matching (PSM) and various statistical tests were utilized to test the association between CS and perioperative medical complications.
278 patients were included in this analysis with a mean age of 61.3±15.7yrs and 67.6% being female. Using the first method, 73 patients received ≥550 mL of CS and 205 received less. PSM resulted in 28 pairs of patients. 39.3% of patients with ≥550 mL CS required readmission within 30 days compared to 3.57% patients in the <550 mL cohort (P=0.016) despite a nearly identical proportion of patients requiring intraoperative blood transfusions (P>0.9999). Using the second method, 155 patients had CS/EBL< 0.33 and 123 with CS/EBL ≥0.33. 5.16% and 21.9% among patients with CS/EBL<0.33 and CS/EBL≥0.33 respectively, were readmitted by the 30 day marker (P<0.0001).
Our findings indicate that greater CS volumes transfused are associated with higher rates of 30-day readmissions. Thus, surgeons should consider limiting CS volume intraoperatively to 550 mL and when greater volumes are required or preferred, ensuring that the ratio of CS:EBL remains under 0.33.
In Response to a Letter to the Editor Coury, Josephine R; Sardar, Zeeshan M
Spine (Philadelphia, Pa. 1976),
2022-May-15, 2022-05-15, 20220515, Letnik:
47, Številka:
10
Journal Article
Background. Spinal alignment can have a significant impact on a patient’s overall quality of life. Predicting the ideal sagittal spinal alignment of a specific individual is still a difficult task. ...The Multi-Ethnic Alignment Normative Study (MEANS) investigated skeletal alignment, including the spine and lower extremities, of the largest multi-ethnic cohort of asymptomatic adult volunteers. In this analysis, the authors aim to assess normative values of spinopelvic parameters and the regional cervical, thoracic, and lumbar spinal alignment in asymptomatic volunteers stratified by age and sex. Materials and Methods. Asymptomatic volunteers between ages 18 and 80 years were enrolled prospectively from centers in France, Japan, Singapore, Tunisia, and the United States. Volunteers included reported no significant neck or back pain (Visual Analog Scale ≤2), nor any known spinal disorder(s). All volunteers underwent a standing full-body or full-spine low-dose stereoradiograph. Results. MEANS consisted of 468 volunteers with a mean age of 40.4±14.8 years. Mean cervical lordosis from C2 to C7 was −0.4±12.7°. The T1-slope averaged 23.0±7.9° and showed strong correlation ( r =0.87) with the C7-slope mean of 19.8±8.6°. Thoracic kyphosis (TK) from T4 to T12 showed a mean of 37.4±10.9°. Average L1–S1 lumbar lordosis (LL) was −57.4±11.3°. The mean pelvic incidence (PI) measured 52.0±10.7° and pelvic tilt was 12.5±7.3°. Sacral slope averaged 39.5±8.2°. The average PI-LL was −5.4±10.7°. Approximately 60% of volunteers met the PI-LL criteria within ±10°, 8.3% were ≥10°, while 32.1% were ≤−10°. LL showed moderate correlation with PI ( r =0.53) and TK ( r =0.50), while there was no correlation between TK and PI. Multiple linear regression including PI, TK, and age resulted in the following equation LL=14.6+0.57 (PI)+0.57 (TK)−0.2 (age) ( r =0.75). Conclusions. LL did not change with increasing age in asymptomatic volunteers. However, TK did increase with age leading to an increase in T1-slope and a compensatory increase in cervical lordosis. TK did not correlate with PI and was an independent variable in the prediction of LL. Level of Evidence. Level II—prospective cohort study.
Surgery for adult spinal deformity (ASD) poses substantial risks, including the development of symptomatic pseudarthrosis, which is twice as prevalent among patients with osteoporosis compared with ...those with normal bone mineral density (BMD). Limited data exist on the impact of teriparatide, an osteoanabolic compound, in limiting the rates of reoperation and pseudarthrosis after treatment of spinal deformity in patients with osteoporosis.
Osteoporotic patients on teriparatide (OP-T group) were compared with patients with osteopenia (OPE group) and those with normal BMD. OP-T patients were matched with OPE patients and patients with normal BMD at a 1:2:2 ratio. All patients had a minimum 2-year follow-up and underwent posterior spinal fusion (PSF) involving >7 instrumented levels. The primary outcome was the 2-year reoperation rate. Secondary outcomes included pseudarthrosis with or without implant failure, proximal junctional kyphosis (PJK), and changes in patient-reported outcomes (PROs). Clinical outcomes were analyzed using conditional logistic regression. Changes in PROs were analyzed using a mixed-effects model.
Five hundred and forty patients (52.6% normal BMD, 32.9% OPE, 14.4% OP-T) were included. In the unmatched cohort, 2-year reoperation rates (odds ratio OR = 0.45 95% confidence interval (CI): 0.20 to 0.91) and pseudarthrosis rates (OR = 0.25 95% CI: 0.08 to 0.61) were significantly lower in the OP-T group than the OPE group. Seventy-eight patients in the OP-T group were matched to 156 patients in the OPE group. Among these matched patients, at 2 years, 23.1% (36) in the OPE group versus 11.5% (9) in the OP-T group had a reoperation (OR = 0.45, p = 0.0188), 21.8% (34) versus 6.4% (5) had pseudarthrosis with or without implant failure (OR = 0.25, p = 0.0048), and 6.4% (10) versus 7.7% (6) had PJK (OR = 1.18, p = 0.7547), respectively. At 2 years postoperatively, PROs were better among OP-T patients than OPE patients. Subsequently, 78 patients in the OP-T group were matched to 156 patients in the normal BMD group. Among these matched patients, there was no significant difference in 2-year reoperation (OR = 0.85 95% CI: 0.37 to 1.98), pseudarthrosis (OR = 0.51 95% CI: 0.181 to 1.44), and PJK rates (OR = 0.77 95% CI: 0.28 to 2.06).
Osteoporotic patients on teriparatide demonstrated lower reoperation and symptomatic pseudarthrosis rates 2 years postoperatively compared with osteopenic patients. Moreover, patient-reported and clinical outcomes for osteoporotic patients on teriparatide were not different from those for patients with normal BMD.
Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
Understanding the scope of the volume and costs of lumbar fusions and discectomy procedures, as well as identifying significant trends within the Medicare system, may be beneficial in enhancing ...cost-efficiency and care delivery. However, there is a paucity of studies which analyze recent trends in lumbar fusion volume, utilization, and reimbursements.
This study seeks to define the costs of lumbar fusions and discectomy procedures and identify trends and variations in volume, utilization, and surgeon and hospital reimbursement rates in the Medicare system between 2012 and 2017.
Retrospective database study.
Medicare Part A and Part B claims submitted for lumbar spine procedures from 2012 to 2017, as documented in the Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use Files.
Procedure numbers and payments per episode.
This cross-sectional study tracked annual Medicare claims and payments to spine surgeons using publicly-available databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates (per 10,000 Medicare beneficiaries), and reimbursement rates, and to examine associations between county-specific and lumbar spine procedure utilization and reimbursements.
A total of 772,532 lumbar spine procedures were performed in the Medicare population from 2012 to 2017, including 634,335 lumbar fusion surgeries and 138,197 primary lumbar discectomy and microdiscectomy single-level surgeries. There was a 26.0% increase in annual lumbar fusion procedure volume during the study period, with a compound annual growth rate (CAGR) of 4.7%. Lumbar discectomy/microdiscectomy experienced a 23.5% decrease in annual procedure volume (CAGR, −5.2%). Mean Medicare surgeon reimbursements for lumbar fusions nominally decreased by 3.7% from $767 in 2012 to $738 in 2017, equivalent to an inflation-adjusted decrease of 11.4% (CAGR, −0.7%). Mean Medicare payments for lumbar discectomy and microdiscectomy procedures nominally increased by 16.3% from $517 in 2012 to $601 in 2017, equivalent to an inflation-adjusted increase of 6.9% (CAGR, 3.1%).
This present study found the volume and utilization of lumbar fusions have increased since 2012, while lumbar discectomy and microdiscectomy volume and utilization have fallen. Medicare payments to hospitals and surgeons for lumbar fusions have either declined or not kept pace with inflation, and reimbursements for lumbar discectomy and microdiscectomy to hospitals have risen at a disproportionate rate compared to surgeon payments. These trends in Medicare payments, especially seen in decreasing allocation of reimbursements for surgeons, may be the effect of value-based cost reduction measures, especially for high-cost orthopedic and spine surgeries.
Expert consensus study.
This expert panel was created to establish best practice guidelines to identify and treat patients with poor bone health prior to elective spinal reconstruction.
Currently, no ...guidelines exist for the management of osteoporosis and osteopenia in patients undergoing spinal reconstructive surgery. Untreated osteoporosis in spine reconstruction surgery is associated with higher complications and worse outcomes.
A multidisciplinary panel with 18 experts was assembled including orthopedic and neurological surgeons, endocrinologists, and rheumatologists. Surveys and discussions regarding the current literature were held according to Delphi method until a final set of guidelines was created with over 70% consensus.
Panelists agreed that bone health should be considered in every patient prior to elective spinal reconstruction. All patients above 65 and those under 65 with particular risk factors (chronic glucocorticoid use, high fracture risk or previous fracture, limited mobility, and eight other key factors) should have a formal bone health evaluation prior to undergoing surgery. DXA scans of the hip are preferable due to their wide availability. Opportunistic CT Hounsfield Units of the vertebrae can be useful in identifying poor bone health. In the absence of contraindications, anabolic agents are considered first line therapy due to their bone building properties as compared with antiresorptive medications. Medications should be administered preoperatively for at least 2 months and postoperatively for minimum 8 months.
Based on the consensus of a multidisciplinary panel of experts, we propose best practice guidelines for assessment and treatment of poor bone health prior to elective spinal reconstructive surgery. Patients above age 65 and those with particular risk factors under 65 should undergo formal bone health evaluation. We also established guidelines on perioperative optimization, utility of various diagnostic modalities, and the optimal medical management of bone health in this population.Level of Evidence: 5.
Anterior cervical discectomy and fusion (ACDF) has been considered the gold standard for treating various cervical spine pathologies stemming from cervical degenerative disorders. While cervical ...artificial disc replacement has emerged as an alternative in select cases, ACDF still remains a commonly performed procedure.
This study seeks to define the costs of ACDF and identify trends and variations in ACDF volume, utilization, and surgeon and hospital reimbursement rates.
Retrospective analysis of patients undergoing ACDF
Medicare patients undergoing ACDF between 2012 and 2017
ACDF volume, utilization rates, and surgeon/hospital reimbursement rates
This study tracked annual Medicare claims and payments to ACDF surgeons using publicly-available databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates (per 10,000 Medicare beneficiaries), and reimbursement rates, and to examine associations between county-specific variables (ie, urban or rural, average household income, poverty rate, percent Medicare population, race/ethnicity demographics), and ACDF utilization and reimbursement rates.
A total of 264,673 ACDF surgeries were performed in the Medicare population from 2012 to 2017, with a 24.2% increase in annual procedure volume. Utilization also increased by 6.5% from 8.0 surgeries per 10,000 Medicare beneficiaries in 2012 to 8.5 in 2017. Hospital reimbursements for cervical spine fusion surgeries without complications or co-morbidities experienced nominal and inflation-adjusted increases of 9.5% and 0.7%, respectively, from $12,030.11 in 2012 to $13,167.64 in 2017. Surgeon reimbursements for single-level and multilevel ACDF each nominally decreased from $958.11 and $1,173.01, respectively, in 2012 to $950.34 and $1,138.41 in 2017 (a 0.8% and 2.9% decrease, respectively), but after adjusting for inflation, reimbursements per case fell by an average of 8.7% and 10.7%, respectively. In contrast, mean reimbursements per case for hospitals rose by 7.1% (1.5% inflation-adjusted decrease). A significant upward yearly trend in ambulatory surgical centers volume, resulted in a net increase of 184.5% between 2015 and 2017 (p<.001).
While ACDF volume and utilization has continued to increase since 2012, Medicare payments to hospitals and surgeons have struggled to keep up with inflation. Our study confirms that Medicare reimbursement per case continues to decrease at a disproportionate rate for surgeons, compared to hospitals. The increasing trend in procedures performed at ambulatory surgical centers shows promise for a future model of cost-efficient and value-based care.
Study Design. Multicenter Cohort. Objective. Assess normative values of sagittal spinal and lower extremity alignment in asymptomatic volunteers stratified by age and gender. Summary of Background ...Data. Our understanding of ideal sagittal alignment is still evolving. The Multiethnic Alignment Normative Study (MEANS) investigated skeletal alignment of the largest multiethnic cohort of asymptomatic adult volunteers. We aim to assess normative values of sagittal spinal and lower extremity alignment in asymptomatic volunteers stratified by age and gender. Materials and Methods. Asymptomatic volunteers between the ages of 18–80 years were enrolled prospectively and then analyzed retrospectively from six different centers. Volunteers included reported no significant neck or back pain, nor any known spinal disorder(s). All volunteers underwent a standing full-body or full-spine low-dose stereoradiograph. Results. MEANS consisted of 468 volunteers with a mean age of 40.4±14.8 years. Thoracic kyphosis (TK) from T4 to T12 showed a mean of 37.4±10.9°. The average L1–S1 lumbar lordosis (LL) was −57.4±11.3°. LL did not show significant differences across the five age groups. TK showed a significant difference based on age ( P <0.0001). Sagittal vertical axis increased across age groups from −14.2 mm in young adults to 17.0 mm in patients >64. Similar trend was seen for T1 pelvic angle with a mean of 5.0° in young adults and 13.7° in those older than age 64. Knee flexion increased across age groups without a significant change in odontoid-knee distance which is a surrogate for the center of the head aligned over the knees. Conclusions. In asymptomatic volunteers, sagittal alignment parameters showed a slow and steady change across age groups exemplified by an increase in TK. However, LL did not show a significant decrease across age groups. Volunteers used compensatory mechanisms such as slight pelvis retroversion, knee flexion, and neck extension to maintain an aligned sagittal posture with their head centered over their knees (odontoid-knee). Level of Evidence. 3
Purpose
This study aimed to evaluate whether adult spinal deformity patients undergoing revision for symptomatic pseudarthrosis have comparable two-year outcomes as patients who do not experience ...pseudarthrosis.
Methods
Patients whose indexed procedure was revision for pseudarthrosis (pseudo) were compared with patients who underwent a primary procedure and did not have pseudarthrosis by 2Y post-op (non-pseudo). Patients were propensity-matched (PSM) based on baseline (BL) sagittal alignment, specifically C7SVA and CrSVA-Hip. Key outcomes were 2Y PROs (SRS and ODI) and reoperation. All patients had a minimum follow-up period of two years.
Results
A total of 224 patients with min 2-year FU were included (pseudo = 42, non-pseudo = 182). Compared to non-pseudo, pseudo-patients were more often female (
P
= 0.0018) and had worse BL sagittal alignment, including T1PA (
P
= 0.02, C2-C7 SVA
P
= 0.0002, and CrSVA-Hip
P
= 0.004. After 37 PSM pairs were generated, there was no significant difference in demographics, BL and 2Y alignment, or operative/procedural variables. PSM pairs did not report any significantly different PROs at BL. Consistently, at 2Y, there were no significant differences in PROs, including SRS function 3.9(0.2) vs 3.7(0.2),
P
= 0.44, pain 4.0 (0.2) vs. 3.57 (0.2),
P
= 0.12, and ODI 25.7 (5.2) vs 27.7 (3.7),
P
= 0.76. There were no differences in 1Y (10.8% vs 10.8%,
P
> 0.99) and 2Y (13.2% vs 15.8%,
P
= 0.64) reoperation, PJK rate (2.6% vs 10.5%,
P
= 0.62), or implant failure (2.6% vs 10.5%,
P
= 0.37). Notably, only 2 patients (5.4%) had recurrent pseudarthrosis following revision. Kaplan–Meier curves indicated that patients undergoing intervention for pseudarthrosis had comparable overall reoperation-free survival (log-rank test,
χ
2 = 0.1975 and
P
= 0.66).
Conclusions
Patients undergoing revision for pseudarthrosis have comparable PROs and clinical outcomes as patients who never experienced pseudarthrosis. Recurrence of symptomatic pseudarthrosis was infrequent.
