Islam Elboghdady

Cost analysis of incidental durotomy in spine surgery.

Study Design. Retrospective database analysis. Objective. To characterize the consequences of an incidental durotomy with regard to perioperative complications and total hospital costs. Summary of Background Data. There is a paucity of data regarding how an incidental durotomy and its associated complications may relate to total hospital costs. Methods. The Nationwide Inpatient Sample database was queried from 2008 to 2011. Patients who underwent cervical or lumbar decompression and/or fusion procedures were identified, stratified by approach, and separated into cohorts based on a documented intraoperative incidental durotomy. Patient demographics, comorbidities (Charlson Comorbidity Index), length of hospital stay, perioperative outcomes, and costs were assessed. Analysis of covariance and multivariate linear regression were used to assess the adjusted mean costs of hospitalization as a function of durotomy. Results. The incidental durotomy rate in cervical and lumbar spine surgery is 0.4% and 2.9%, respectively. Patients with an incidental durotomy incurred a longer hospitalization and a greater incidence of perioperative complications including hematoma and neurological injury (P < 0.001). Regression analysis demonstrated that a cervical durotomy and its postoperative sequelae contributed an additional adjusted

Mesenchymal stem cell allograft as a fusion adjunct in one- and two-level anterior cervical discectomy and fusion: a matched cohort analysis

7638 (95% confidence interval, 6489–8787; P < 0.001) to the total hospital costs. Similarly, lumbar durotomy contributed an additional adjusted

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

2412 (95% confidence interval, 1920–2902; P < 0.001) to the total hospital costs. The approach-specific procedural groups demonstrated similar discrepancies in the mean total hospital costs as a function of durotomy. Conclusion. This analysis of the Nationwide Inpatient Sample database demonstrates that incidental durotomies increase hospital resource utilization and costs. In addition, it seems that a cervical durotomy and its associated complications carry a greater financial burden than a lumbar durotomy. Further studies are warranted to investigate the long-term financial implications of incidental durotomies in spine surgery and to reduce the costs associated with this complication. Level of Evidence: 3

Postoperative Narcotic Consumption in Workmanʼs Compensation Patients Following a Minimally Invasive Transforaminal Lumbar Interbody Fusion

BACKGROUND CONTEXT Live mesenchymal stem cell (MSC) allograft-containing allogeneic bone grafts have recently gained popularity and currently account for greater than 17% of all bone grafts and bone graft substitutes used in spinal surgery. Although the claim of cellular bone matrices containing osteogenic cells with osteoinductive properties is attractive, little is known about their clinical success when used in anterior cervical discectomy and fusion (ACDF). PURPOSE The objective of this study was to report on the radiographic fusion rates in one- and two-level instrumented ACDF using an MSC. STUDY DESIGN/SETTING This was a retrospective review of prospectively matched cohort of patients with radiologic assessment of fusion as the primary end point. PATIENT SAMPLE Two matched cohorts of adult patients who underwent ACDF with MSC or standard allograft were included. OUTCOMES MEASURES The outcome measures included radiographic and clinical evidence of healing at 1 year. METHODS A consecutive series of 57 patients who underwent a one- or two-level instrumented ACDF procedure between 2010 and 2012 were retrospectively analyzed. All fusion constructs comprised an interbody allograft, an anterior plate, and Osteocel (NuVasive, San Diego, CA, USA). These patients were matched to a control group of 57 patients. RESULTS Of the 57 cases in both cohorts, 29 (50.9%) were single-level, and 28 (49.1%) were two-level instrumented ACDFs. There were no significant differences in patient age (p=.71), gender, comorbidity burden (Charlson Comorbidity Index [CCI]: 1.95; 2.42, p=.71) or body mass index (p=.79). At the 1-year follow-up, 50 of 57 (87.7%) patients in the Osteocel cohort demonstrated a solid fusion compared with 54 of 57 (94.7%) in the control group (p=.19). Seven (12.3%) patients in the Osteocel cohort were reported as having a failed fusion at 1 year. CONCLUSIONS This is the first non-industry sponsored study to analyze a matched cohort assessing the 1-year arthrodesis rates associated with a nonstructural MSC allograft in one- and two-level ACDF procedures. Although not statistically significant, patients treated with MSC allografts demonstrated lower fusion rates compared with a matched non-MSC cohort.

Minimally invasive transforaminal lumbar interbody fusion for lumbar spondylolisthesis

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

Preoperative narcotic utilization: accuracy of patient self-reporting and its association with postoperative narcotic consumption.

Study Design. Retrospective cohort analysis of a prospective registry. Objective. To assess the differences in perioperative narcotic consumption between Workmans compensation (WC) and non-Workmans compensation (non-WC) patients after a single-level minimally invasive transforaminal lumbar interbody fusion. Summary of Background Data. There is concern regarding the potential overutilization of opioid pain medication in WC patients. However, the impact of WC status on perioperative narcotic consumption after lumbar spine procedures has not been previously reported. Methods. A cohort of patients who underwent primary 1-level minimally invasive transforaminal lumbar interbody fusion procedures for degenerative spinal pathology between 2007 and 2013 was retrospectively analyzed using a prospectively collected registry. First, preoperative and perioperative characteristics were compared between WC and non-WC patients. Second, mean oral morphine equivalent was compared between WC and non-WC patients with adjustment for any preoperative or perioperative differences between cohorts. Results. A total of 136 single-level, primary minimally invasive-transforaminal lumbar interbody fusion procedures were included in the analysis, of which 46 (33.8%) were WC patients. WC patients were younger (47.8 ± 11.2 vs. 57.9 ± 10.4 yr; P < 0.001) and had a lower comorbidity burden (Charlson Comorbidity Index: 1.85 ± 1.30 vs. 3.42 ± 2.07; P < 0.001) than non-WC patients. The distribution of ethnicity differed between WC and non-WC patients (P = 0.002). WC patients incurred longer procedural times (135.2 ± 52.2 vs. 118.9 ± 33.7 min; P < 0.05). However, the estimated blood loss, length of hospital stay, and day of discharge were no different between WC and non-WC patients. Mean oral morphine equivalent consumption did not differ between WC and non-WC patients after adjustment for differences in age, ethnicity, Charlson Comorbidity Index, and procedural time between cohorts. Conclusion. Despite concerns for greater opioid use in the WC population, this analysis demonstrated similar total narcotic consumption between WC and non-WC patients during the immediate postoperative period. Long-term studies are warranted to assess whether this similarity in regard to perioperative narcotic consumption persists beyond the immediate postoperative period. Level of Evidence: 3

The Impact of Worker's Compensation Claims on Outcomes and Costs Following an Anterior Cervical Discectomy and Fusion.

A 59-year-old woman with a history of persistent low back pain presents to the clinic with intermittent claudication and worsening right leg pain. The patient denies any bladder or bowel symptoms. On physical examination, there is bilateral lower extremity weakness specifically in the right extensor hallucis longus. The patient also demonstrates decreased sensation to light touch over the dorsum of the foot. Diagnostic magnetic resonance imaging (MRI) demonstrates an L5-S1 spondylolisthesis with spinal stenosis. Given the persistent neurological symptoms and evidence of spinal instability the patients is scheduled to undergo a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).