Retrospective Cohort Study.
To clarify the association between preoperative albumin status and mortality and morbidity in lumbar spine surgery.
Hypoalbuminemia is a known marker of inflammation and ...is associated with frailty. Hypoalbuminemia is an identified risk factor for mortality following spine surgery for metastases, yet has not been well studied among spine surgical cohorts outside of metastatic cancer.
We identified patients with preoperative serum albumin lab values who underwent lumbar spine surgery at a US public university health system between 2014 and 2021. Demographic, comorbidity, and mortality data were collected along with pre- and postoperative Oswestry Disability Index (ODI) scores. Any cause readmission within one year of surgery was recorded. Hypoalbuminemia was defined as <3.5 g/dL in serum. We examined Kaplan-Meier survival plots based on serum albumin. Multivariable regression models were used to identify the association between preoperative hypoalbuminemia with mortality, readmission and ODI, while controlling for age, sex, race, ethnicity, procedure and Charlson Comorbidity Index.
Of 2,573 patients, 79 were identified as hypoalbuminemic. Hypoalbuminemic patients had significantly greater adjusted risk of mortality through 1 year (OR 10.2; 95% CI 3.1 - 33.5; P<0.001), and 7 years (HR 4.18; 95% CI 2.29 - 7.65; P<0.001). Hypoalbuminemic patients had ODI scores 13.5 points higher (95%CI 5.7 - 21.4; P<0.001) at baseline. Adjusted readmission rates were not different between groups through 1 year (OR 1.15; 0.5 - 2.62; P=0.75) or through full surveillance (HR 0.82; 95%CI 0.44 - 1.54; P=0.54).
Preoperative hypoalbuminemia was strongly associated with postoperative mortality. Hypoalbuminemic patients did not have demonstrably worse outcomes in their functional disability beyond 6 months. Within the first 6 months following surgery, the hypoalbuminemic group improved at a similar rate to the normoalbuminemic group despite having greater preoperative disability. However, causal inference is limited in this retrospective study.
•This study evaluates the prognostic value of VR-12 MCS on MIS-TLIF outcomes.•VR-12 MCS < 50 reported significantly inferior scores in all PROMs preoperatively.•MIS-TLIF patients with VR-12 MCS < 50 ...reported inferior postoperative outcomes.•VR-12 MCS < 50 reported greater rates of clinical improvement in mental health.•VR-12 MCS < 50 does not limit postoperative improvement in MIS-TLIF patients.
No study has examined the prognostic value of the Veterans RAND-12 (VR-12) Mental Component Score (MCS) on postoperative outcomes in minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) patients. This study examines the effect of preoperative VR-12 MCS on postoperative patient-reported outcome measures (PROMs) in MIS-TLIF patients. Patients were separated into 2 cohorts: VR-12 MCS < 50 and VR-12 MCS ≥ 50. PROMs of VR-12 MCS/Physical Component Score (PCS), Short Form-12 (SF-12) MCS/PCS, Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF), Patient Health Questionnaire-9 (PHQ-9), Visual Analog Scale (VAS) Back/Leg Pain (VAS-BP/LP), and Oswestry Disability Index (ODI) were collected.Of 329 patients, 151 were in the VR-12 MCS < 50 cohort. The VR-12 MCS < 50 cohort reported significantly inferior scores in all PROMs preoperatively, significantly inferior VR-12 MCS, SF-12 MCS, PROMIS-PF, PHQ-9, and ODI scores at 6-weeks postoperatively, and significantly inferior scores in all PROMs, except for VAS-BP at final follow-up. Magnitude of 6-week postoperative improvement was significantly greater in the VR-12 MCS < 50 cohort for VR-12 MCS, SF-12 MCS, and PHQ-9. Magnitude of final postoperative improvement was significantly greater in the VR-12 MCS < 50 cohort for VR-12 MCS, SF-12 MCS/PCS, and PHQ-9. MCID achievement rates were significantly greater in the VR-12 MCS < 50 cohort for VR-12 MCS, SF-12 MCS, and PHQ-9. MIS-TLIF patients with lesser preoperative VR-12 MCS reported inferior postoperative outcomes in mental health, physical function, pain, and disability. However, patients with inferior preoperative mental health reported greater rates of clinically meaningful improvement in mental health. Inferior preoperative mental health does not limit postoperative improvement in patients undergoing MIS-TLIF.
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.
Abstract. Purpose To report on the reduction of a double lumbar spine spondylolisthesis by use of Chiropractic BioPhysics(R) technique. Participant and Methods A 57 year-old male presented with ...severe chronic low back pains and sciatica. After playing hockey for 50 years, he was unable to continue and was forced to retire. Lumbar radiography showed an L3 retrolisthesis of -5.3 mm and an L4 anterolisthesis of 5.4 mm. Chiropractic BioPhysics technique including mirror image lumbar spine drop-table adjustments, corrective exercises and a unique pelvic extension traction was performed 50 times over 7-months. Results A radiograph after 3-months showed full reduction of the L3 retrolisthesis. A radiograph after 7-months showed full reduction of the L4 anterolisthesis. The patient reported full resolution of chronic back pains and was able to return to play hockey; a 1.75 year followup showed maintenance of the corrections and the patient remained injury-free while returning to play hockey. Conclusion A customized treatment program including Chiropractic BioPhysics lumbar spine traction, corrective exercises and drop-table spine manipulation resolved chronic back pains and fully reduced an L3 and L4 retro- and antero-listhesis, respectively. Further research may substantiate this treatment approach for reducing translational displacements in the lumbar spine. Routine upright radiography is required to diagnose spondylolisthesis.
Determine if herniation morphology based on the Michigan State University Classification is associated with differences in (1) patient-reported outcome measures (or (2) surgical outcomes after a ...microdiscectomy.
Adult patients undergoing single-level microdiscectomy between 2014 and 2021 were identified. Demographics and surgical characteristics were collected through a query search and manual chart review. The Michigan State University classification, which assesses disc herniation laterality (zone A was central, zone B/C was lateral) and degree of extrusion into the central canal (grade 1 was up to 50% of the distance to the intra-facet line, grade >1 was beyond this line), was identified on preoperative MRIs. patient-reported outcome measures were collected at preoperative, 3-month, and 1-year postoperative time points.
Of 233 patients, 84 had zone A versus 149 zone B/C herniations while 76 had grade 1 disc extrusion and 157 had >1 grade. There was no difference in surgical outcomes between groups (P > 0.05). Patients with extrusion grade >1 were found to have lower Physical Component Score at baseline. On bivariate and multivariable logistic regression analysis, extrusion grade >1 was a significant independent predictor of greater improvement in Physical Component Score at three months (estimate = 7.957; CI: 4.443–11.471, P < 0.001), but not at 1 year.
Although all patients were found to improve after microdiscectomy, patients with disc herniations extending further posteriorly reported lower preoperative physical function but experienced significantly greater improvement three months after surgery. However, improvement in Visual Analog Scale Leg and back, ODI, and MCS at three and twelve months was unrelated to laterality or depth of disc herniation.
Dural tears (DTs) are a frequent complication after lumbar spine surgery. We sought to determine the incidence of DTs and the related impact on health care expenditures after lumbar discectomies.
In ...this retrospective cohort study, all patients with first-time single-level lumbar discectomies at our institution who underwent minimally invasive surgery from 2015 to 2019 were reviewed. Age, sex, weight, height, body mass index, costs, revenues, length of stay, American Society of Anesthesiologists score, Charlson Comorbidity Index, and operative time (OT) were assessed. Exclusion criteria were age <18 years, previous spine surgery, multiple or traumatic disc herniations, and malignant and infectious diseases.
The follow-up time was at least 12 months postoperatively. Of 358 patients identified with lumbar discectomies, 230 met the inclusion criteria. Incidence of DTs was 3.5%. Mean costs (P < 0.001), economic loss (P < 0.01), and OT (P < 0.0001) were found to be significantly higher in the DT group compared with the control group of patients without a DT. The revenues were not statistically different between the 2 groups (P > 0.05). Further analysis of the control group by profit and loss revealed significantly higher body mass index (P < 0.05), length of stay (P < 0.0001), and OT (P < 0.0001) in the loss group.
DTs represent a significant socioeconomic burden in lumbar spine surgery and cause severe secondary complications. The impact of DTs on health care expenses is primarily based on significantly higher OT and a higher mean length of stay.
Racial disparities in spine surgery have been thoroughly documented in the inpatient (IP) setting. However, despite an increasing proportion of procedures being performed as same-day surgeries, ...whether similar differences have developed in the outpatient (OP) setting remains to be elucidated.
This study aimed to investigate racial differences in postoperative outcomes between Black and White patients following OP and IP lumbar and cervical spine surgery.
Retrospective cohort study.
Patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021.
Thirty-day rates of serious and minor adverse events, readmission, reoperation, non-home discharge, and mortality.
A retrospective review of patients who underwent IP or OP microdiscectomy, laminectomy, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR) between 2017 and 2021 was conducted using the National Surgical Quality Improvement Program (NSQIP) database. Disparities between Black and White patients in (1) adverse event rates, (2) readmission rates, (3) reoperation rates, (4) non-home discharge rates, (5) mortality rates, (6) operative times, and (7) hospital LOS between Black and White patients were measured and compared between IP and OP surgical settings. Multivariable logistic regression analyses were used to adjust for potential effects of baseline demographic and clinical differences.
Of 81,696 total surgeries, 49,351 (60.4%) were performed as IP and 32,345 (39.6%) were performed as OP procedures. White patients accounted for a greater proportion of IP (88.2% vs. 11.8%) and OP (92.7% vs. 7.3%) procedures than Black patients. Following IP surgery, Black patients experienced greater odds of serious (OR 1.214, 95% CI 1.077–1.370, p=.002) and minor adverse events (OR 1.377, 95% CI 1.113–1.705, p=.003), readmission (OR 1.284, 95% CI 1.130–1.459, p<.001), reoperation (OR 1.194, 95% CI 1.013–1.407, p=.035), and non-home discharge (OR 2.304, 95% CI 2.101–2.528, p<.001) after baseline adjustment. Disparities were less prominent in the OP setting, as Black patients exhibited greater odds of readmission (OR 1.341, 95% CI 1.036–1.735, p=0.026) but were no more likely than White patients to experience adverse events, reoperation, individual complications, non-home discharge, or death (p>.050 for all).
Racial inequality in postoperative complications following spine surgery is evident, however disparities in complication rates are relatively less following OP compared to IP procedures. Further work may be beneficial in elucidating the causes of these differences to better understand and mitigate overall racial disparities within the inpatient setting. These decreased differences may also provide promising indication that progress towards reducing inequality is possible as spine care transitions to the OP setting.
Osteoporosis is a prevalent but underdiagnosed condition. As compared to dual-energy X-ray absorptiometry (DXA) measures, we aimed to develop a deep convolutional neural network (DCNN) model to ...classify osteopenia and osteoporosis with the use of lumbar spine X-ray images. Herein, we developed the DCNN models based on the training dataset, which comprising 1616 lumbar spine X-ray images from 808 postmenopausal women (aged 50 to 92 years). DXA-derived bone mineral density (BMD) measures were used as the reference standard. We categorized patients into three groups according to DXA BMD T-score: normal (T ≥ −1.0), osteopenia (−2.5 < T < −1.0), and osteoporosis (T ≤ −2.5). T-scores were calculated by using the BMD dataset of young Chinese female aged 20–40 years as a reference. A 3-class DCNN model was trained to classify normal BMD, osteoporosis, and osteopenia. Model performance was tested in a validation dataset (204 images from 102 patients) and two test datasets (396 images from 198 patients and 348 images from 147 patients respectively). Model performance was assessed by the receiver operating characteristic (ROC) curve analysis. The results showed that in the test dataset 1, the model diagnosing osteoporosis achieved an AUC of 0.767 (95% confidence interval CI: 0.701–0.824) with sensitivity of 73.7% (95% CI: 62.3–83.1), the model diagnosing osteopenia achieved an AUC of 0.787 (95% CI: 0.723–0.842) with sensitivity of 81.8% (95% CI: 67.3–91.8); In the test dataset 2, the model diagnosing osteoporosis yielded an AUC of 0.726 (95% CI: 0.646–0.796) with sensitivity of 68.4% (95% CI: 54.8–80.1), the model diagnosing osteopenia yielded an AUC of 0.810 (95% CI, 0.737–0.870) with sensitivity of 85.3% (95% CI, 68.9–95.0). Accordingly, a deep learning diagnostic network may have the potential in screening osteoporosis and osteopenia based on lumbar spine radiographs. However, further studies are necessary to verify and improve the diagnostic performance of DCNN models.
We developed deep convolutional neural network (DCNN) models to classify osteopenia and osteoporosis with the use of lumbar spine X-ray images, as compared to dual energy X-ray absorptiometry (DXA) measures. Display omitted
•We trained a 3-class DCNN model to classify osteoporosis and osteopenia in postmenopausal women.•DCNN model for osteoporosis achieved an AUC of 0.767 and 0.726 in two test datasets.•DCNN model for osteopenia achieved an AUC of 0.787 and 0.810 in two test datasets.•DCNN has potential in classifying osteoporosis with the use of lumbar X-ray images.
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