STUDY DESIGN.Prospective observational cohort study.
OBJECTIVE.To determine if postoperative cervical sagittal balance is an independent predictor of health-related quality of life outcome after ...surgery for cervical spondylotic myelopathy.
SUMMARY OF BACKGROUND DATA.Both ventral and dorsal fusion procedures for CSM are effective at reducing the symptoms of myelopathy. The importance of cervical sagittal balance in predicting overall health-related quality of life outcome after ventral versus dorsal surgery for CSM has not been previously explored.
METHODS.A prospective, nonrandomized cohort of 49 patients undergoing dorsal and ventral fusion surgery for CSM was examined. Preoperative and postoperative C2–C7 sagittal vertical axis was measured on standing lateral cervical spine radiographs. Outcome was assessed with 2 disease-specific measures—the modified Japanese Orthopedic Association scale and the Oswestry Neck Disability Index and 2 generalized outcome measures—the Short-Form 36 physical component summary (SF-36 PCS) and Euro-QOL-5D. Assessments were performed preoperatively, and at 3 months, 6 months, and 1 year postoperatively. Statistical analyses were performed using SAS version 9.3 (SAS Institute).
RESULTS.Most patients experienced improvement in all outcome measures regardless of approach. Both preoperative and postoperative C2–C7 sagittal vertical axis measurements were independent predictors of clinically significant improvement in SF-36 PCS scores (P = 0.03 and P = 0.02). The majority of patients with C2–C7 sagittal vertical axis values greater than 40 mm did not improve from an overall health-related quality of life perspective (SF-36 PCS) despite improvement in myelopathy. The postoperative sagittal balance value was inversely correlated with a clinically significant improvement of SF-36 PCS scores in patients undergoing dorsal surgery but not ventral surgery (P = 0.03 vs. P = 0.93).
CONCLUSION.Preoperative and postoperative sagittal balance measurements independently predict clinical outcomes after surgery for CSM.Level of Evidence2
Abstract
BACKGROUND
Identifying which factors influence treatment costs of transsphenoidal surgery for removal of sellar lesions can be complex.
OBJECTIVE
To identify which patient-level factors are ...associated with higher costs and evaluate the relationship between expenditures and short-term patient-reported outcomes.
METHODS
We used an institutional database tool to review prospectively collected data on patients (≥10 yr old) undergoing transsphenoidal sellar surgery. Hospital costs, demographic data, disease-specific variables, hospital-related measures, and patient-reported outcomes (Euro-QOL 5D EQ-5D responses) were collected for all patients.
RESULTS
One hundred seventeen patients met the inclusion criteria. A multivariable logistic regression model for hospital costs showed a significant association between higher costs and adrenocorticotropic hormone-secreting tumors (odds ratio OR 86.34, 95% confidence interval CI 3.43-2176.42), larger tumor size (OR 1.13, 95% CI 1.01-1.28), and in-hospital complications (OR 14.98, 95% CI 2.21-101.68). The largest contributor to hospital costs in our cohort was facility cost (75%), followed by pharmacy (13%) and supply (7%) costs. Most patients (65.8%) had stable or improved EQ-5D responses at 1-mo follow-up. Stability or improvement in EQ-5D was more likely in patients with lower preoperative EQ-5D scores (P < .015) and with higher postoperative EQ-5D scores (P < .001) on univariate analysis.
CONCLUSION
Most patients undergoing transsphenoidal surgery for sellar tumors experience stable or improved postoperative quality of life, even shortly after surgery. Factors associated with increased costs of surgery included larger tumor size and in-hospital complications. Using these data, further study can be directed at determining which interventions may improve the value of transsphenoidal surgery.
Abstract
BACKGROUND
Examining the costs of single- and multilevel anterior cervical discectomy and fusion (ACDF) is important for the identification of cost drivers and potentially reducing patient ...costs. A novel tool at our institution provides direct costs for the identification of potential drivers.
OBJECTIVE
To assess perioperative healthcare costs for patients undergoing an ACDF.
METHODS
Patients who underwent an elective ACDF between July 2011 and January 2017 were identified retrospectively. Factors adding to total cost were placed into subcategories to identify the most significant contributors, and potential drivers of total cost were evaluated using a multivariable linear regression model.
RESULTS
A total of 465 patients (mean, age 53 ± 12 yr, 54% male) met the inclusion criteria for this study. The distribution of total cost was broken down into supplies/implants (39%), facility utilization (37%), physician fees (14%), pharmacy (7%), imaging (2%), and laboratory studies (1%). A multivariable linear regression analysis showed that total cost was significantly affected by the number of levels operated on, operating room time, and length of stay. Costs also showed a narrow distribution with few outliers and did not vary significantly over time.
CONCLUSION
These results suggest that facility utilization and supplies/implants are the predominant cost contributors, accounting for 76% of the total cost of ACDF procedures. Efforts at lowering costs within these categories should make the most impact on providing more cost-effective care.
Dysphagia is a regular occurrence after cervical spine surgery, and the development of dysphagia postoperatively is associated with worsened quality of life for patients. Despite the frequency and ...negative implications of this adverse outcome, there is no clear consensus for defining dysphagia within the spinal literature. Numerous patient-reported outcomes questionnaires are currently used to elucidate the presence and severity of postoperative dysphagia, several of which are not validated instruments. This variability in reporting creates difficulty when trying to determine the prevalence of dysphagia and any potential mitigating factors. In the current review, the authors discuss the causes of postoperative dysphagia after cervical spine surgery, metrics for evaluating postoperative dysphagia, risk factors for the development of this adverse outcome, and strategies for preventing its development. Readers will be able to use this information to improve patient outcomes after cervical spine surgery.
Degenerative spine disease with low back pain affects ∼80% of the U.S. population, and spinal stenosis and degenerative spondylolisthesis affect ∼20% of the population. Nonoperative and operative ...interventions have both been studied extensively to better our understanding of how these strategies enable us to improve outcomes in patients with degenerative lumbar spondylolisthesis. This review aims to compare nonoperative and operative strategies and describe the use of incremental cost-effectiveness ratios to assess treatment options in this patient population.
Study Design.
Multicenter prospective study.
Objective.
Our aim was to evaluate the incidence and predictors of postoperative dysphagia in patients undergoing anterior cervical discectomy and fusion ...(ACDF).
Summary of Background Data.
Dysphagia is a common complication after ACDF that can have significant effect on patients’ quality of life, but the frequency of occurrence and potential risk factors are not known.
Methods.
A multicenter prospective study was undertaken at three academic sites to evaluate patients undergoing ACDF between September 2018 and September 2020. Included patients were aged 18 to 80 years and were undergoing primary or revision ACDF for a degenerative condition. Dysphagia was assessed using the validated Eating Assessment Tool (EAT-10) questionnaire, with dysphagia defined as EAT-10 ≥ 3.
Results.
A total of 170 patients (53.5% female; mean age at surgery 55.0 yr) were included. At preoperative baseline, 23 patients (13.5%) had dysphagia. Rates of dysphagia increased to 45.3% at 2 weeks postoperatively but gradually decreased to 15.3% at 24weeks. On univariate analysis, patients with dysphagia at 2weeks had longer operations (113.1 ± 58.4
vs.
89.0 ± 39.8 minutes,
P
=
0.003) and higher baseline dysphagia rates (18.2%
vs.
6.2%,
P
=
0.018) and were more likely to be female (66.2%
vs.
45.7%,
P
=
0.009). Patients with prolonged dysphagia had more levels fused (2.1 ± 1.0
vs.
1.7 ± 0.7,
P
=
0.020), longer operations (131.8 ± 63.1
vs.
89.3 ± 44.3 min-minutes,
P
<
0.001), and higher baseline dysphagia rates (32%
vs.
7.1%,
P
<
0.001) and were more likely to be smokers (24%
vs.
8%,
P
=
0.021). On multivariate analysis to determine associations with prolonged dysphagia, only smoking status (OR 6.2, 95% CI 1.57–24.5,
P
=
0.009) and baseline dysphagia (OR 5.1, 95% CI 1.47–17.6,
P
=
0.01) remained significant.
Conclusion.
Dysphagia is common immediately after ACDF, but rates of prolonged dysphagia are similar to preoperative baseline rates. We identified dysphagia rates over time and several patient factors associated with development of short- and long-term postoperative dysphagia.
Level of Evidence:
3
IMPORTANCE: Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction worldwide. It remains unknown whether a ventral or dorsal surgical approach provides the best results. ...OBJECTIVE: To determine whether a ventral surgical approach compared with a dorsal surgical approach for treatment of cervical spondylotic myelopathy improves patient-reported physical functioning at 1 year. DESIGN, SETTING, AND PARTICIPANTS: Randomized clinical trial of patients aged 45 to 80 years with multilevel cervical spondylotic myelopathy enrolled at 15 large North American hospitals from April 1, 2014, to March 30, 2018; final follow-up was April 15, 2020. INTERVENTIONS: Patients were randomized to undergo ventral surgery (n = 63) or dorsal surgery (n = 100). Ventral surgery involved anterior cervical disk removal and instrumented fusion. Dorsal surgery involved laminectomy with instrumented fusion or open-door laminoplasty. Type of dorsal surgery (fusion or laminoplasty) was at surgeon’s discretion. MAIN OUTCOMES AND MEASURES: The primary outcome was 1-year change in the Short Form 36 physical component summary (SF-36 PCS) score (range, 0 worst to 100 best; minimum clinically important difference = 5). Secondary outcomes included 1-year change in modified Japanese Orthopaedic Association scale score, complications, work status, sagittal vertical axis, health resource utilization, and 1- and 2-year changes in the Neck Disability Index and the EuroQol 5 Dimensions score. RESULTS: Among 163 patients who were randomized (mean age, 62 years; 80 49% women), 155 (95%) completed the trial at 1 year (80% at 2 years). All patients had surgery, but 5 patients did not receive their allocated surgery (ventral: n = 1; dorsal: n = 4). One-year SF-36 PCS mean improvement was not significantly different between ventral surgery (5.9 points) and dorsal surgery (6.2 points) (estimated mean difference, 0.3; 95% CI, −2.6 to 3.1; P = .86). Of 7 prespecified secondary outcomes, 6 showed no significant difference. Rates of complications in the ventral and dorsal surgery groups, respectively, were 48% vs 24% (difference, 24%; 95% CI, 8.7%-38.5%; P = .002) and included dysphagia (41% vs 0%), new neurological deficit (2% vs 9%), reoperations (6% vs 4%), and readmissions within 30 days (0% vs 7%). CONCLUSIONS AND RELEVANCE: Among patients with cervical spondylotic myelopathy undergoing cervical spinal surgery, a ventral surgical approach did not significantly improve patient-reported physical functioning at 1 year compared with outcomes after a dorsal surgical approach. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02076113
OBJECTIVE Patient-reported outcomes (PROs) play a pivotal role in defining the value of surgical interventions for spinal disease. The concept of minimum clinically important difference (MCID) is ...considered the new standard for determining the effectiveness of a given treatment and describing patient satisfaction in response to that treatment. The purpose of this study was to determine the MCID associated with surgical treatment for degenerative lumbar spondylolisthesis. METHODS The authors queried the Quality Outcomes Database registry from July 2014 through December 2015 for patients who underwent posterior lumbar surgery for grade I degenerative spondylolisthesis. Recorded PROs included scores on the Oswestry Disability Index (ODI), EQ-5D, and numeric rating scale (NRS) for leg pain (NRS-LP) and back pain (NRS-BP). Anchor-based (using the North American Spine Society satisfaction scale) and distribution-based (half a standard deviation, small Cohen's effect size, standard error of measurement, and minimum detectable change MDC) methods were used to calculate the MCID for each PRO. RESULTS A total of 441 patients (80 who underwent laminectomies alone and 361 who underwent fusion procedures) from 11 participating sites were included in the analysis. The changes in functional outcome scores between baseline and the 1-year postoperative evaluation were as follows: 23.5 ± 17.4 points for ODI, 0.24 ± 0.23 for EQ-5D, 4.1 ± 3.5 for NRS-LP, and 3.7 ± 3.2 for NRS-BP. The different calculation methods generated a range of MCID values for each PRO: 3.3-26.5 points for ODI, 0.04-0.3 points for EQ-5D, 0.6-4.5 points for NRS-LP, and 0.5-4.2 points for NRS-BP. The MDC approach appeared to be the most appropriate for calculating MCID because it provided a threshold greater than the measurement error and was closest to the average change difference between the satisfied and not-satisfied patients. On subgroup analysis, the MCID thresholds for laminectomy-alone patients were comparable to those for the patients who underwent arthrodesis as well as for the entire cohort. CONCLUSIONS The MCID for PROs was highly variable depending on the calculation technique. The MDC seems to be a statistically and clinically sound method for defining the appropriate MCID value for patients with grade I degenerative lumbar spondylolisthesis. Based on this method, the MCID values are 14.3 points for ODI, 0.2 points for EQ-5D, 1.7 points for NRS-LP, and 1.6 points for NRS-BP.
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