Blaine Manning

Minimally invasive lumbar decompression—the surgical learning curve

BACKGROUND CONTEXT Minimally invasive spine surgery (MIS) procedures carry an inherently difficult learning curve based upon anecdotal evidence. Few studies have investigated the surgeons learning curve for MIS lumbar laminectomy or laminotomy with or without discectomy. PURPOSE To characterize the learning curve of a 1- or 2-level MIS lumbar decompression (LD) based on perioperative and postoperative parameters . STUDY DESIGN/SETTING Retrospective analysis of a prospectively maintained registry was used for this study. PATIENT SAMPLE There were 228 consecutive patients who underwent a primary 1- or 2-level MIS LD by a single surgeon for degenerative spinal pathology from 2009 to 2014. From 2005 to 2006, 50 patients underwent 1- or 2-level open LD consecutively. OUTCOME MEASURES Perioperative and postoperative outcomes (complications, visual analogue scale [VAS] scores, reoperations) were the outcome measures for this study. METHODS Patients were stratified into first and second groups as determined by the case number at which the procedural time reached a plateau. Demographics, comorbidity, pain scores, and surgical outcomes were compared between the first 50 patients and the subsequent 178 patients. The secondary analysis compared the surgical outcomes between the initial 50 MIS and 50 open LD patients. No funds were received in support of this work. RESULTS The initial cohort was older with a higher comorbidity burden (p<.05). However, body mass index, gender, smoking status, and ethnicity did not differ between cohorts. The initial cohort incurred a greater procedural time (p<.001) and longer length of hospitalization (p<.05) than the second cohort. Estimated blood loss (EBL), pain scores, complication rates, recurrent herniation rates, and reoperation rates were similar between groups. In the secondary analysis, the open LD patients demonstrated greater procedural time, higher EBL, and longer length of hospital stay than the MIS patients. However, the reoperation rate and 30-day readmission rate were not different between the MIS and open patients. CONCLUSIONS Continued surgical experience was associated with a reduced operative time, shorter length of hospitalization, and similar blood loss following an MIS LD. Independent of surgical experience, all patients demonstrated similar improvements in clinical outcomes. These findings appear to suggest that although surgical experience may improve perioperative parameters (operative time, length of hospitalization), an MIS LD may initially be performed safely without prior experience.

Spine Surgeon Selection Criteria: Factors Influencing Patient Choice.

Study Design. A prospective questionnaire. Objective. The aim of this study was to evaluate factors that patients consider when selecting a spine surgeon. Summary of Background Data. The rise in consumer-driven health insurance plans has increased the role of patients in provider selection. The purpose of this study is to identify factors that may influence a patients criteria for selecting a spine surgeon. Methods. Two hundred thirty-one patients who sought treatment by one spine surgeon completed an anonymous questionnaire consisting of 26 questions. Four questions regarded demographic information; 16 questions asked respondents to rate the importance of specific criteria regarding spine surgeon selection (scale 1–10, with 10 being the most important); and six questions were multiple-choice regarding patient preferences toward aspects of their surgeon (age, training background, etc.). Results. Patients rated board certification (9.26 ± 1.67), in-network provider status (8.10 ± 3.04), and friendliness/bedside manner (8.01 ± 2.35) highest among factors considered when selecting a spine surgeon. Most patients (92%) reported that 30 minutes or less should pass between check-in and seeing their surgeon during a clinic appointment. Regarding whether their spine surgeon underwent training as a neurosurgeon versus an orthopedic surgeon, 25% reported no preference, 52% preferred neurosurgical training, and 23% preferred orthopedic training. Conclusion. Our findings suggest that board certification and in-network health insurance plans may be most important in patients’ criteria for choosing a spine surgeon. Advertisements were rated least important by patients. Patients expressed varying preferences regarding ideal surgeon age, training background, proximity, medical student/resident involvement, and clinic appointment availability. The surgeon from whom patients sought treatment completed an orthopedic surgery residency; hence, it is notable that 52% of patients preferred a spine surgeon with a neurosurgical background. In the context of patients’ increasing role in health care decision-making and provider selection, understanding the factors that influence patients’ selection of a spine surgeon is important. Level of Evidence: 3

The utility of obtaining routine hematological laboratory values following an anterior cervical diskectomy and fusion.

Study Design. Retrospective analysis of a prospectively maintained database. Objective. To characterize the utility of obtaining routine postoperative laboratory studies after an anterior cervical diskectomy and fusion (ACDF). Summary of Background Data. ACDF is typically associated with minimal blood loss and morbidity. However, at many institutions, postoperative laboratory studies are conducted routinely. This study aims to characterize the utility of these tests in the postoperative setting. Methods. A retrospective analysis of a prospectively maintained database of 332 patients who underwent an ACDF for degenerative cervical spine disease between 2007 and 2014 was performed. Patients with a concurrent corpectomy, posterior fusion, or revision procedure were excluded. Patient demographics, comorbidities, visual analogue scale scores, surgical and hospitalization parameters, complications, and transfusion volumes were assessed. The patients postoperative laboratory studies were compared with preoperative values. Statistical analysis was performed with independent sample T tests for continuous variables and &khgr;2 analysis for categorical data. An &agr; level of less than 0.05 denoted statistical significance. Results. A total of 332 patients were included with a mean age of 51.1 ± 11.7 years. The overall mean procedural time, estimated blood loss, and length of stay were 60.0 ± 30.1 minutes, 69.4 ± 36.2 mL, and 40.2 ± 20.3 hours, respectively. Overall, 98.1% of patients demonstrated radiographical arthrodesis at 1 year. After a 1- or 2-level ACDF, the postoperative hemoglobin, hematocrit, blood urea nitrogen, sodium, and calcium levels significantly decreased, whereas glucose and chloride levels increased when compared with the preoperative values (P < 0.05). In addition, the 1-level ACDF cohort was also associated with reduced postoperative potassium level (P < 0.05). However, none of the patients required intraoperative or postoperative blood product transfusion or demonstrated evidence of postoperative anemia. Two patients (0.89%) required postoperative potassium replacement based upon laboratory values alone without clinical symptomatology. There were no complications that were related to the patients hemodynamic status or fluid and electrolyte balance. Conclusion. In the majority of cases after an ACDF, no action was taken n the basis of the patients routine postoperative laboratory data. None of the patients required blood product transfusion, whereas only 0.89% (n = 2) required potassium replacement for laboratory anomalies without clinical symptomatology. These findings suggest that routine postoperative complete blood counts do not change postoperative management after an ACDF unless intraoperative bleeding is noted or the patient carries risk factors for postoperative hemorrhagic anemia. Level of Evidence: 3

Serial Mehta Cast Utilization in Infantile Idiopathic Scoliosis: Evaluation of Radiographic Predictors.

Background: Mehta cast utilization has gained a considerable momentum as a nonoperative treatment modality for the initial management of infantile idiopathic scoliosis (IIS). Despite its acceptance, there is paucity of data that characterize the radiographic parameters associated with Mehta casting and the factors correlated with a sustained curve correction. Methods: A retrospective review of IIS patients who underwent Mehta casting was performed with a mean 2-year follow-up. X-rays were evaluated at each visit for the Cobb angle, focal deformity, rib-vertebral angle difference, and height of concavity and convexity of the apical 3 vertebrae. Concave-to-convex height ratios were calculated and tracked for each patient. Radiographic parameters were compared from precasting to after final casting, and from final casting to most recent follow-up. Results: A total of 45 patients were identified, of whom 18 (40%) were male and 27 (60%) were female, with a mean age of 18.8±9.5 months at first casting and a mean follow-up of 37.7±19.7 months. Following final casting, the mean Cobb angle (25.6 vs. 52.7 degrees), focal deformity (17.4 vs. 30.5 degrees), rib-vertebral angle difference (18 vs. 32.3 degrees), and the concave-to-convex height ratios improved relative to precast parameters, respectively (P<0.001). At final follow-up, mean Cobb angle (16.2 vs. 25.6 degrees) and concave-to-convex height ratios progressively improved when compared with final cast measurements, respectively (P<0.001). Five (11%) patients did not demonstrate sustained curve correction at final follow-up, whereas 4 (9%) required growing-rod placement. Lastly, the regression analysis demonstrated improvements in the focal deformity (17.4 vs. 30.5) and the concave-to-convex height ratios of the +1 and −1 apical vertebrae from the precast to last cast periods (P<0.001). These findings were correlated with sustained Cobb angle correction from cast removal to the most recent follow-up. Conclusions: Radiographic parameters associated with control of progressive deformity for IIS include improvements in focal deformity and concave-to-convex height ratios for +1 and −1 apical vertebrae after final casting. Mehta casting is an effective treatment for symptomatic IIS and continues to provide IIS patients with significant curve correction. Level of Evidence: Level IV.

Factors Influencing Patient Selection of a Foot and Ankle Surgeon

An increasingly consumer-centric health insurance market has empowered patients to select the providers of their choice. There is a lack of studies investigating the rationale by which patients select a foot and ankle surgeon. In the present study, 824 consecutive new patients seeking treatment from 3 foot-ankle surgeons were consecutively administered an anonymous questionnaire prior to their first appointment. It included rating the importance of 15 factors regarding specialist selection on a 1 to 10 scale, with 10 designated “Very important” and 1 designated “Not important at all.” The remaining questions were multiple choice regarding patient perspectives on other surgeon aspects (appointment availability, waiting room times, clinic proximity, etc). Of 824 consecutive patients administered the survey, 305 (37%) responded. Patients rated board certification (9.24 ± 1.87) and on-site imaging availability (8.48 ± 2.37)—on a 1 to 10 scale, with 10 designated “Very important— as the 2 most important criteria in choosing a foot and ankle surgeon. Patients rated advertisements as least important. Among the patients, 91% responded that a maximum of 30 minutes should elapse between clinic check-in and seeing their physician; 61% responded that a maximum of 20 minutes should elapse between clinic check-in and seeing their physician. In the context of an increasingly consumer-driven paradigm of health care delivery and reimbursement, it is important to understand patients’ preferences in specialist selection. Levels of Evidence: Level III: Prospective questionnaire

Factors Influencing Patient Selection of an Orthopaedic Sports Medicine Physician

Background: The rise in consumer-centric health insurance plans has increased the importance of the patient in choosing a provider. There is a paucity of studies that examine how patients select an orthopaedic sports medicine physician. Purpose: To evaluate factors that patients consider when choosing an orthopaedic sports medicine physician. Study Design: Case series; Level of evidence, 4. Methods: A total of 1077 patients who sought treatment by 3 sports medicine physicians were administered an anonymous questionnaire. The questionnaire included 19 questions asking respondents to rate the importance of specific factors regarding the selection of orthopaedic sports medicine physicians on a scale of 1 (not important at all) to 10 (very important). The remaining 6 questions were multiple-choice and regarded the following criteria: preferred physician age, appointment availability, clinic waiting room times, travel distance, and medical student/resident involvement. Results: Of the 1077 consecutive patients administered the survey, 382 (35%) responded. Of these, 59% (n = 224) were male, and 41% (n = 158) were female. In ranking the 19 criteria in terms of importance, patients rated board certification (9.12 ± 1.88), being well known for a specific area of expertise (8.27 ± 2.39), and in-network provider status (8.13 ± 2.94) as the 3 most important factors in selecting an orthopaedic sports medicine physician. Radio, television, and Internet advertisements were rated the least important. Regarding physician age, 63% of patients would consider seeking a physician who is ≤65 years old. Approximately 78% of patients would consider seeking a different physician if no appointments were available within 4 weeks. Conclusion: The study results suggest that board certification, being well known for a specific area of expertise, and health insurance in-network providers may be the most important factors influencing patient selection of an orthopaedic sports medicine physician. Advertisements were least important to patients. Patient preferences varied regarding ideal physician age, clinic appointment availability, medical student/resident involvement, and travel distance in choosing an orthopaedic sports medicine physician. In the context of health care delivery and as reimbursement becomes increasingly consumer centered, understanding the process of provider selection is important.

Patient Perspectives of Midlevel Providers in Orthopaedic Sports Medicine

Background: Midlevel providers (eg, nurse practitioners and physician assistants) have been integrated into orthopaedic systems of care in response to the increasing demand for musculoskeletal care. Few studies have examined patient perspectives toward midlevel providers in orthopaedic sports medicine. Purpose: To identify perspectives of orthopaedic sports medicine patients regarding midlevel providers, including optimal scope of practice, reimbursement equity with physicians, and importance of the physician’s midlevel provider to patients when initially selecting a physician. Study Design: Cross-sectional study; Level of evidence, 3. Methods: A total of 690 consecutive new patients of 3 orthopaedic sports medicine physicians were prospectively administered an anonymous questionnaire prior to their first visit. Content included patient perspectives regarding midlevel provider importance in physician selection, optimal scope of practice, and reimbursement equity with physicians. Results: Of the 690 consecutive patients who were administered the survey, 605 (87.7%) responded. Of these, 51.9% were men and 48.1% were women, with a mean age of 40.5 ± 15.7 years. More than half (51.2%) perceived no differences in training levels between physician assistants and nurse practitioners. A majority of patients (62.9%) reported that the physician’s midlevel provider is an important consideration when choosing a new orthopaedic sports medicine physician. Patients had specific preferences regarding which services should be physician provided. Patients also reported specific preferences regarding those services that could be midlevel provided. There lacked a consensus on reimbursement equity for midlevel practitioners and physicians, despite 71.7% of patients responding that the physician provides a higher-quality consultation. Conclusion: As health care becomes value driven and consumer-centric, understanding patient perspectives on midlevel providers will allow orthopaedic sports medicine physicians to optimize efficiency and patient satisfaction. Physicians may consider these data in clinical workforce planning, as patients preferred specific services to be physician or midlevel provided. It may be worthwhile to consider midlevel providers in marketing efforts, given that patients considered the credentials of the physician’s midlevel provider when initially selecting a new physician. Patients lacked consensus regarding reimbursement equity between physicians and midlevel providers, despite responding that the physician provides a higher-quality consultation. Our findings are important for understanding the midlevel workforce as it continues to grow in response to the increasing demand for orthopaedic sports care.

Arthroscopically Repaired Bucket-Handle Meniscus Tears: Patient Demographics, Postoperative Outcomes, and a Comparison of Success and Failure Cases

Objective To define patient demographics, preoperative, and intraoperative surgical variables associated with successful or failed repair of bucket-handle meniscal tears. Design All patients who underwent arthroscopic repair of a bucket-handle meniscus tear at a single institution between May 2011 and July 2016 with minimum 6-month follow-up were retrospectively identified. Patient demographic, preoperative (including imaging), and operative variables were collected and evaluated. A Kaplan-Meier curve was generated to demonstrate meniscus repair survivorship. Results In total, 75 patients (78 knees) with an average age of 26.53 ± 10.67 years met inclusion criteria. The average follow-up was 23.41 ± 16.43 months. Fifteen knees (19.2%) suffered re-tear of the repaired meniscus at an average 12.24 ± 9.50 months postoperatively. Survival analysis demonstrated 93.6% survival at 6 months, 84.6% survival at 1 year, 78.4% survival at 2 years, and 69.9% survival at 3 years. There was significant improvement from baseline to time of final follow-up in all patient-reported outcome (P < 0.05) except Marx score (P = 0.933) and SF-12 Mental Subscale (P = 0.807). The absence of other knee pathology (including ligament tear, contralateral compartment meniscal tear, or cartilage lesions) noted intraoperatively was the only variable significantly associated with repair failure (P = 0.024). Concurrent anterior cruciate ligament reconstruction (vs. no concurrent anterior cruciate ligament reconstruction) trended toward significance (P = 0.059) as a factor associated with successful repair. Conclusions With the exception of the absence of other knee pathology (including ligament tear, contralateral compartment meniscal tear, or cartilage lesions) noted intraoperatively, no other variables were significantly associated with re-tear. The results are relatively durable with 84.6% survival at 1 year. Surgeons should attempt meniscal repair when presented with a bucket-handle tear.

Sports Medicine Physician Selection Criteria: Factors Influencing Patient Choice

Objectives: The rise in consumer-driven health insurance plans has increased the role of the patient in provider selection. The purpose of the present study is to identify factors that may influence a patient’s criteria for selecting his or her sports medicine physician. Methods: A total of 1077 patients who sought treatment by three sports medicine physicians were administered an anonymous questionnaire. Of these, 382 patients (35%) completed the survey. Response rates for each survey question ranged between 98% and 100%. The first part of the questionnaire consisted of 3 questions regarding demographic information. The second portion of the questionnaire consisted of 25 questions regarding provider selection. Of these, 19 questions asked respondents to rate the importance of specific criteria for the purposes of sports medicine physician selection on a scale of 1 to 10, with 10 being the most important. The remaining 6 questions were multiple-choice questions regarding the following criteria: the importance of physician age, appointment availability, clinic waiting room times, travel distance, and medical student/resident involvement. Results: Of the 382 respondents, 59% (n=224) were male and 41% (158) female. Regarding age, 29% (112) of respondents were under 35 years, 63% (234) between age 35 and 65 years, and 8% (35) were over 65 years. The majority of patients (89%) reported that 30 minutes or less should pass between check-in and seeing their physician during a clinic appointment. Most patients expressed no preference regarding resident (71%) or medical student (68%) involvement in their care. Regarding physician age, 63% of patients would consider seeking a physician who is younger than 65 years. Approximately 78% of patients would consider seeking a different physician if no appointments were available within 4 weeks. The ranking of the 19 criteria in terms of importance to patients are listed in Table 1. Patients rated board certification (9.12 ± 1.88), being “well-known” for a specific area of expertise (8.27 ± 2.39), and in-network provider status (8.13 ± 2.94) as the three most important factors in selecting a sports medicine physician. Radio, television, and internet advertisement were rated by patients as the least important factors in sports medicine physician selection. Conclusion: Our findings suggest that board certification, being “well-known” for a specific area of expertise, and in-network health insurance plans may be the most important factors influencing patients’ criteria for sports medicine physician selection. Radio, television, and internet advertisements were the least important criteria considered by patients. Patients expressed varying preferences regarding the ideal physician age, medical student/resident involvement, and clinic appointment availability when choosing a sports medicine physician. In the context of the increasing role of patients in health decision-making and provider selection, understanding the factors that influence patients’ selection of a sports medicine physician is important. Table 1. Ranking of Nineteen Sports Medicine Physician Selection Criteria According to the Results of the Anonymous Questionnaire Completed by Patients† Rank Score Sports Medicine Physician Selection Criterion 1 9.12 ± 1.88 Board-certified 2 8.27 ± 2.39 “Well-known” for specific area of expertise 3 8.13 ± 2.94 Within insurance network 4 8.10 ± 2.28 Friendliness and bedside manner 5 7.75 ± 2.58 On-site imaging equipment available 6 7.36 ± 2.40 Appearance/Atmosphere of clinic facilities 7 6.89 ± 3.10 Recommendation by family member or friend 8 6.23 ± 3.20 Location of medical school, residency, and fellowship 9 6.02 ± 3.08 Actively involved in media research 10 5.98 ± 3.19 Positive online review (e.g. healthgrades.com, yelp.com, ratemd.com, etc) 11 5.95 ± 3.00 Receiving additional information (e.g. pamphlets, internet resources) 12 5.83 ± 3.16 Negative online review (e.g. healthgrades.com, yelp.com, ratemd.com, etc) 13 5.61 ± 3.37 Referral from primary care doctor or other physician 14 4.75 ± 3.22 Affiliation with professional sports team 15 4.48 ± 3.17 On-site physical therapy facilities available 16 4.36 ± 2.86 Size of the practice group 17 2.29 ± 2.23 Radio advertisement 18 2.28 ± 2.25 Internet advertisement 19 2.17 ± 2.09 TV advertisement † Patient responses were recorded with range of values between 1= Not important at all to 10= Very important; Represented by Mean ± Standard Deviation(n).

Paper #12: Radiographic Parameters Correlating With Success of Mehta Cast Utilization in Infantile Idiopathic Scoliosis

Methods: A retrospective review of IIS patients who underwent Mehta casting was performed with a mean 2-year follow up. X-rays were evaluated at each visit for the Cobb angle, focal deformity, ribvertebral angle difference (RVAD), and height of concavity and convexity of the apical 3 vertebrae. Concave-to-convex height ratios were calculated and tracked for each patient. Radiographic parameters were compared from pre-casting to after final casting, and from final casting to most recent follow up.