Evan O. Baird

National Trends in Outpatient Surgical Treatment of Degenerative Cervical Spine Disease

Study Design Retrospective population-based observational study. Objective To assess the growth of cervical spine surgery performed in an outpatient setting. Methods A retrospective study was conducted using the United States Healthcare Cost and Utilization Projects State Inpatient and Ambulatory Surgery Databases for California, New York, Florida, and Maryland from 2005 to 2009. Current Procedural Terminology, fourth revision (CPT-4) and International Classification of Diseases, ninth revision Clinical Modification (ICD-9-CM) codes were used to identify operations for degenerative cervical spine diseases in adults (age > 20 years). Disposition and complication rates were examined. Results There was an increase in cervical spine surgeries performed in an ambulatory setting during the study period. Anterior cervical diskectomy and fusion accounted for 68% of outpatient procedures; posterior decompression made up 21%. Younger patients predominantly underwent anterior fusion procedures, and patients in the eighth and ninth decades of life had more posterior decompressions. Charlson comorbidity index and complication rates were substantially lower for ambulatory cases when compared with inpatients. The majority (>99%) of patients were discharged home following ambulatory surgery. Conclusions Recently, the number of cervical spine surgeries has increased in general, and more of these procedures are being performed in an ambulatory setting. The majority (>99%) of patients are discharged home but the nature of analyzing administrative data limits accurate assessment of postoperative complications and thus patient safety. This increase in outpatient cervical spine surgery necessitates further discussion of its safety.

A meta-analysis of cervical foraminotomy: open versus minimally-invasive techniques

BACKGROUND CONTEXT The posterior cervical foraminotomy (PCF) may be performed using an open or minimally-invasive (MIS) approach using a tubular retractor. Although there are theoretical advantages such as less blood loss and shorter hospitalizations, there is no consensus in the literature regarding the best approach for treatment. PURPOSE To assess clinical outcomes of PCF treated with either an open or an MIS approach using a tubular retractor. STUDY DESIGN Systematic literature review and meta-analysis of English language studies for the treatment of cervical radiculopathy treated with foraminotomy. PATIENT SAMPLE Pooled patient results from Level I studies and Level IV retrospective studies. OUTCOME MEASURES Meta-analysis for clinical success as determined by Odom and Prolo criteria, and visual analog scale scores for arm and neck pain. METHODS A literature search of three databases was performed to identify investigations performed in the treatment of PCF with an open or MIS approach. The pooled results were performed by calculating the effect size based on the logit event rate. Studies were weighted by the inverse of the variance, which included both within and between-study errors. Confidence intervals (CIs) were reported at 95%. Heterogeneity was assessed using the Q statistic and I-squared, where I-squared is the estimate of the percentage of error due to between-study variation. RESULTS The initial literature search resulted in 195 articles, of which, 20 were determined as relevant on abstract review. An open foraminotomy approach was performed in six; similarly, an MIS approach was performed in three studies. The pooled clinical success rate was 92.7% (CI: 88.9, 95.3) for open foraminotomy and 94.9% (CI: 90.5, 97.4) for MIS foraminotomy, which was not statistically significant (p=.418). The open group demonstrated relative homogeneity with Q value of 7.6 and I(2) value of 34.3%; similarly, the MIS group demonstrated moderate study heterogeneity with Q value of 4.44 and I(2) value of 54.94%. CONCLUSIONS Patients with symptomatic cervical radiculopathy from foraminal stenosis can be effectively managed with either a traditional open or an MIS foraminotomy. There is no significant difference in the pooled outcomes between the two groups.

C5 nerve root palsy following decompression of the cervical spine: a systematic evaluation of the literature

C5 nerve root palsy is a rare and potentially debilitating complication of cervical spine surgery. Currently, however, there are no guidelines to help surgeons to prevent or treat this complication. We carried out a systematic review of the literature to identify the causes of this complication and options for its prevention and treatment. Searches of PubMed, Embase and Medline yielded 60 articles for inclusion, most of which addressed C5 palsy as a complication of surgery. Although many possible causes were given, most authors supported posterior migration of the spinal cord with tethering of the nerve root as being the most likely. Early detection and prevention of a C5 nerve root palsy using neurophysiological monitoring and variations in surgical technique show promise by allowing surgeons to minimise or prevent the incidence of C5 palsy. Conservative treatment is the current treatment of choice; most patients make a full recovery within two years.

Open Versus Minimally Invasive Fixation Techniques for Thoracolumbar Trauma: A Meta-Analysis

Study Design Systematic literature review and meta-analysis of studies published in English. Objective This study evaluated differences in outcome variables between percutaneous and open pedicle screws for traumatic thoracolumbar fractures. Methods A systematic review of PubMed, Cochrane, and Embase was performed. The variables of interest included postoperative visual analog scale (VAS) pain score, kyphosis angle, and vertebral body height, as well as intraoperative blood loss and operative time. The results were pooled by calculating the effect size based on the standardized difference in means. The studies were weighted by the inverse of the variance, which included both within- and between-study error. Confidence intervals were reported at 95%. Heterogeneity was assessed using the Q statistic and I 2. Results After two-reviewer assessment, 38 studies were eliminated. Six studies were found to meet inclusion criteria and were included in the meta-analysis. The combined effect size was found to be in favor of percutaneous fixation for blood loss and operative time (p < 0.05); however, there were no differences in vertebral body height (VBH), kyphosis angle, or VAS scores between open and percutaneous fixation. All of the studies demonstrated relative homogeneity, with I 2 < 25. Conclusions Patients with thoracolumbar fractures can be effectively managed with percutaneous or open pedicle screw placement. There are no differences in VBH, kyphosis angle, or VAS between the two groups. Blood loss and operative time were decreased in the percutaneous group, which may represent a potential benefit, particularly in the polytraumatized patient. All variables in this study demonstrated near-perfect homogeneity, and the effect is likely close to the true effect.

The 5-year Cost-effectiveness of Anterior Cervical Discectomy and Fusion and Cervical Disc Replacement: A Markov Analysis

Study Design. A Markov state-transition model was developed to evaluate the cost-effectiveness of anterior cervical discectomy and fusion (ACDF) and cervical disc replacement (CDR) at 5 years. Objective. To determine the cost-effectiveness of ACDF and CDR at 5 years. Summary of Background Data. ACDF and CDR are surgical options for the treatment of an acute cervical disc herniation with associated myelopathy/radiculopathy. Cost-effectiveness analysis provides valuable information regarding which intervention will lead to a more efficient utilization of health care resources. Methods. Outcome and complication probabilities were obtained from existing literature. Physician costs were based on a fixed percentage of 140% of 2010 Medicare reimbursement. Hospital costs were determined from the Nationwide Inpatient Sample. Utilities were derived from responses to health state surveys (Short Form 36) at baseline and at 5 years from the treatment arms of the ProDisc-C trial. Incremental cost-effectiveness ratios were used to compare treatments. One-way sensitivity analyses were performed on all parameters within the model. Results. CDR generated a total 5-year cost of

A Meta-Analysis of the Clinical and Fusion Results following Treatment of Symptomatic Cervical Pseudarthrosis

102,274, whereas ACDF resulted in a 5-year cost of

Three-dimensional Intraoperative Imaging Modalities in Orthopaedic Surgery: A Narrative Review.

119,814. CDR resulted in a generation of 2.84 quality-adjusted life years, whereas ACDF resulted in 2.81. The incremental cost-effectiveness ratio was −

C5 Palsy After Cervical Spine Surgery: A Multicenter Retrospective Review of 59 Cases.

557,849 per quality-adjusted life year gained. CDR remained the dominant strategy below a cost of

Ambulatory Spine Surgery: A Survey Study

20,486. ACDF was found to be a cost-effective strategy below a cost of

Rare complications of cervical Spine surgery: Horner's syndrome

18,607. CDR was the dominant strategy when the utility value was above 0.713. CDR remained the dominant strategy assuming an annual complication rate less than 4.37%. Conclusion. ACDF and CDR were both shown to be cost-effective strategies at 5 years. CDR was found to be the dominant treatment strategy in our model. Further long-term studies evaluating the clinical and quality-of-life outcomes of these 2 treatments are needed to further validate the model. Level of Evidence: 5