Alok D. Sharan

Similarities and differences in the treatment of spine trauma between surgical specialties and location of practice.

Study Design. Questionnaires administered to practicing orthopedic and neurosurgical spine surgeons from various regions of the United States and abroad. Objectives. To determine similarities and differences in the treatment of spinal trauma. Summary of Background Data. Spinal trauma is generally referred to subspecialists of orthopedic or neurosurgical training. Prior studies have suggested that there is significant variability in the management of such injuries. Methods. Questionnaires based on eight clinical scenarios of commonly encountered cervical, thoracic, and lumbar injuries were administered to 35 experienced spinal surgeons. Surgeons completed profile information and answered approximately one dozen questions for each case. Data were analyzed with SPSS software to determine the levels of agreement and characteristics ofrespondents that might account for a lack of agreement on particular aspects of management. Results. Of the 35 surgeons completing the questionnaire, 63% were orthopedists, 37% were neurosurgeons, and 80% had been in practice for more than 5 years. Considerable agreement was found in the majority of clinical decisions, including whether or not to operate and the timing of surgery. Of the differences noted, neurosurgeons were more likely to obtain a MRI, and orthopedists were more likely to use autograft as a sole graft material. Physicians from abroad were, in general, more likely to operate and to use an anterior approach during surgery than physicians from the northeastern United States. Conclusions. More commonalities were identified in the management of spinal trauma than previously reported. When found, variability in opinion was related to professional and regional differences. Spine 2004;29:685–696

Alterations in T2 relaxation magnetic resonance imaging of the ovine intervertebral disc due to nonenzymatic glycation.

Study Design. An in vitro study using ovine intervertebral discs to correlate the effects of increasing advanced glycation end-products (AGEs) with disc hydration evaluated by magnetic resonance imaging (MRI). Objective. To determine the relationship between the level of AGEs and tissue water content in intervertebral discs using T2 relaxation MRI. Summary of Background Data. AGEs result from nonenzymatic glycation, and AGEs have been shown to accumulate in the intervertebral disc tissue with aging and degeneration. AGEs can alter biochemical properties, including the hydrophobicity of the extracellular matrix. Because one of the degenerative signs of the intervertebral disc (IVD) is reduced hydration, we hypothesized that increased levels of tissue AGEs contribute to disc hydration. T2 relaxation MRI has been shown to be sensitive to the hydration status of the disc and may be valuable in detecting the changes in the IVD mediated by the increase of AGEs. Methods. Thirty-eight IVDs were obtained from 4 ovine spines, and the annulus fibrosis (AF) and nucleus pulposus (NP) tissues were isolated from these discs. The tissues were incubated in either a ribosylation or control solution for up to 8 days to induce the formation of AGEs. T2 relaxation times were obtained from these tissues after ribosylation. These tissues were subsequently analyzed for hydration, proteoglycan, collagen, and AGEs content. Results. In vitro ribosylation led to the increased accumulation of AGEs and reduced water content in both the AF and NP in a dose-dependent manner, but did not affect the proteoglycan and collagen composition. When analyzed by MRI, ribosylation significantly altered the mean T2 relaxation times in the NP (P = 0.001), but not in the AF (P = 0.912). Furthermore, the mean T2 values in the NP significantly decreased with increasing periods of incubation time (P < 0.001). Conclusion. This study demonstrates that levels of AGEs in the IVD may affect the tissue water content. Moreover, these ribosylation-mediated changes in tissue hydration were detectable using T2 relaxation MRI. T2 relaxation MRI may provide a noninvasive tool to measure in vivo changes in disc hydration that are negatively correlated with the accumulation of AGEs.

Internet resources for spine surgeons.

To classify web sites on common spinal disorders as to their utility for the spine surgeon and patient. Five common spinal disorders were used to generate lists of relevant sites. These sites were categorized as to their relevance for patients and surgeons, their sponsoring organization, and their comprehensiveness. A total of 56,249 web sites were found using the five key words on five search engines. Using the And operator, a total of 227 web sites were generated. The majority of sites were patient oriented. Physician- or organization-sponsored sites were the most common. Ten sites were found to have comprehensive information for both patients and spine surgeons. Many web sites exist that discuss disorders of the spine. Currently there is not any one web site that contains comprehensive information for both the spine surgeon and patient.

Managing the Delivery of Health Care: What Can Health Care Learn From the Business Community?

The passage of the Patient Protection and Affordable Care Act in March 2010 has resulted in dramatic changes to the delivery of health care in the United States toward a value-based system. While this is a significant change from the previous model, it presents an opportunity for high-quality health care providers to improve patient outcomes while also increasing revenue. However, those that lack a clear strategy to effectively implement change and communicate the increased value to the patients likely will suffer, regardless of how successful or prestigious they seem today.

Intramedullary Nailing in a Tibial Shaft Fracture With Distal Articular Extension

Newer-generation intramedullary nails that allow placement of distal locking screws near the end of the nail have helped extend the indications for nailing in different types of tibial fractures.

Value-based Insurance Design

The increasing awareness of the scarcity of health care resources is forcing the health care industry to improve quality while lowering the cost. One method by which employers and insurance companies are attempting to do this is with value-based insurance design. In these plans, patients pay a lower amount for certain services that are considered high value and a higher amount for services that are considered low value.

Understanding Time-driven Activity-based Costing

Transitioning to a value-based health care system will require providers to increasingly scrutinize their outcomes and costs. Although there has been a great deal of effort to understand outcomes, cost accounting in health care has been a greater challenge. Currently the cost accounting methods used by hospitals and providers are based off a fee-for-service system. As resources become increasingly scarce and the health care system attempts to understand which services provide the greatest value, it will be critically important to understand the true costs of delivering a service. An understanding of the true costs of a particular service will help providers make smarter decisions on how to allocate and utilize resources as well as determine which activities are nonvalue added. Achieving value will require providers to have a greater focus on accurate outcome data as well as better methods of cost accounting.

The Service-Profit Chain in Spine Surgery.

Medicine has always been a service industry (as opposed to a manufacturing industry), as there is a shift from volume to value in health care, this point is becoming increasingly important. The delivery of good care extends beyond the technical aspects of performing a complex operation or prescribing the right type of medicine. Intuitively physicians have always understood the value of the physician-patient relationship, and its correlation to a good outcome. As patients are increasingly being forced to spend a greater portion of their personal income on health care through high-deductible plans and larger co-pays, physicians have to differentiate themselves through the delivery of great service beyond the delivery of superior health outcomes. Understanding the service-profit chain can help physicians succeed in the transition to a value-based health care system.

Understanding Business Models in Health Care.

The increasing focus on the costs of care is forcing health care organizations to critically look at their basic set of processes and activities, to determine what type of value they can deliver. A business model describes the resources, processes, and cost assumptions that an organization makes that will lead to the delivery of a unique value proposition to a customer. As health care organizations are beginning to transform their structure in preparation for a value-based delivery system, understanding business model theory can help in the redesign process.

Understanding Competition in Spine Care.

The changing landscape from volume to value represents a natural transformation in the health care industry. Increasingly provider groups are finding themselves responding to unfamiliar market forces. Whether explicit or implicit, competition is playing a larger role for the sustainability of providers. For spine care providers who are attempting to navigate the transition from volume to value, understanding the forces that shape competition in health care can help achieve success.