Kevin J. McGuire

The 2004 Marshall Urist Award: Delays until surgery after hip fracture increases mortality

The objective of this study was to analyze whether a delay in time from admission until surgical treatment increased the mortality rate for patients with a closed hip fracture. We used the day of the week of admission as an instrumental variable to pseudorandomize patients. We analyzed 18,209 Medicare recipients who were 65 years of age or older and had surgical treatment for a closed hip fracture. Patients for whom the delay between admission and surgery was 2 days or more had a 17% higher chance of dying by Day 30. Using instrumental variables analysis, we found a similar 15% increased risk of mortality in patients with delays until surgery of 2 or more days. Based on these results, we found that a delay of 2 or more days significantly increased the mortality rate. This suggests that delay to surgery independently affects mortality, therefore additional study on the effect of smaller delays on outcome is needed.

Relationship between preoperative expectations, satisfaction, and functional outcomes in patients undergoing lumbar and cervical spine surgery: A multicenter study

Study Design. Analysis of prospectively collected multicenter data. Objective. To explore the relationship between preoperative expectations and postoperative outcomes and satisfaction in lumbar and cervical spine surgery. Summary of Background Data. Back pain is one of the most common health problems, leading to the utilization of health care resources, work loss, and sick benefits. Patient expectations influence posttreatment outcomes, both surgical and nonsurgical. There is little research on the importance of preoperative expectations in spine surgery. Existing studies evaluate the technical aspects of interventions and functional outcomes but fail to take into account patient expectations. The authors hypothesized that expectations dramatically affect spine patient satisfaction independent of functional outcomes. Methods. Prospectively collected patient-entered data from patients undergoing lumbar and cervical spine surgery from 2 study centers collected using a Web-based patient health survey system were analyzed. The study included patients who underwent operative intervention (decompression with or without fusion) with at least a 3-month period of follow-up. Preoperative expectations were measured using the Musculoskeletal Outcomes Data Evaluation and Management Systems (MODEMS) expectation survey. Postoperative satisfaction and fulfillment of expectations were measured using the MODEMS satisfaction survey. Postoperative functional outcomes were measured using the Oswestry Disability Index and 36-item short form health survey. Ordinal logistic regression multivariate modeling was used to examine predictors of postoperative satisfaction. Linear regression multivariate modeling was used to examine predictors of functional outcomes. Results. Greater fulfillment of expectations led to higher postoperative satisfaction and was associated with better functional outcomes. Higher preoperative expectations led to decreased postsurgical satisfaction but were associated with improved functional outcomes. Higher postoperative satisfaction was associated with improved functional outcomes and vice versa. Type of surgery also influenced satisfaction and function, with cervical patients being less satisfied but having better functional outcomes than lumbar patients. Conclusion. This study showed that more than functional outcomes matter; preoperative expectations and fulfillment of expectations influence postoperative satisfaction in patients undergoing lumbar and cervical spine surgery. This underlines the importance of taking preoperative expectations into account to obtain an informed choice on the basis of the patients preferences.

The effect of high obesity on outcomes of treatment for lumbar spinal conditions: subgroup analysis of the spine patient outcomes research trial.

Study Design. Spine Patient Outcomes Research Trial subgroup analysis. Objective. To evaluate the effect of high obesity on management of lumbar spinal stenosis, degenerative spondylolisthesis (DS), and intervertebral disc herniation (IDH). Summary of Background Data. Prior Spine Patient Outcomes Research Trial analyses compared nonobese and obese patients. This study compares nonobese patients (body mass index <30 kg/m2) with those with class I obesity (body mass index = 30–35 kg/m2) and class II/III high obesity (body mass index ≥35 kg/m2). Methods. For spinal stenosis, 250 of 634 nonobese patients, 104 of 167 obese patients, and 59 of 94 highly obese patients underwent surgery. For DS, 233 of 376 nonobese patients, 90 of 129 obese patients, and 66 of 96 highly obese patients underwent surgery. For IDH, 542 of 854 nonobese patients, 151 of 207 obese patients, and 94 of 129 highly obese patients underwent surgery. Outcomes included Short Form-36, Oswestry Disability Index, stenosis/sciatica bothersomeness index, low back pain bothersomeness index, operative events, complications, and reoperations. Operative and nonoperative outcomes were compared by change from baseline at each follow-up interval using a mixed effects longitudinal regression model. An as-treated analysis was performed because of crossover between surgical and nonoperative groups. Results. Highly obese patients had increased comorbidities. Baseline Short Form-36 physical function scores were lowest for highly obese patients. For spinal stenosis, surgical treatment effect and difference in operative events among groups were not significantly different. For DS, greatest treatment effect for the highly obese group was found in most primary outcome measures, and is attributable to the significantly poorer nonoperative outcomes. Operative times and wound infection rates were greatest for highly obese patients. For IDH, highly obese patients experienced less improvement postoperatively compared with obese and nonobese patients. However, nonoperative treatment for highly obese patients was even worse, resulting in greater treatment effect in almost all measures. Operative time was greatest for highly obese patients. Blood loss and length of stay was greater for both obese cohorts. Conclusion. Highly obese patients with DS experienced longer operative times and increased infection. Operative time was greatest for highly obese patients with IDH. DS and IDH saw greater surgical treatment effect for highly obese patients due to poor outcomes of nonsurgical management. Level of Evidence: 3

Outcomes for single-level lumbar fusion: the role of bone morphogenetic protein.

Study Design. Retrospective analysis of a population-based insurance claims data set. Objective. To determine the risk of repeat fusion and total costs associated with bone morphogenetic protein (BMP) use in single-level lumbar fusion for degenerative spinal disease. Summary of Background Data. The use of BMP has been proposed to reduce overall costs of spinal fusion through prevention of repeat fusion procedures. Although radiographic fusion rates associated with BMP use have been examined in clinical trials, few data exist regarding outcomes associated with BMP use in the general population. Methods. Using the MarketScan claims data set, 15,862 patients that underwent single-level lumbar fusion from 2003 to 2007 for degenerative disease were identified. Propensity scores were used to match 2372 patients who underwent fusion with BMP to patients who underwent fusion without BMP. Logistic regression models, Kaplan-Meier estimates, and Cox proportional hazards models were used to examine risk of repeat fusion, length of stay, and 30-day readmission by BMP use. Cost comparisons were evaluated with linear regression models using logarithmic transformed data. Results. At 1 year from surgery, BMP was associated with a 1.1% absolute decrease in the risk of repeat fusion (2.3% with BMP vs. 3.4% without BMP, P = 0.03) and an odds ratio for repeat fusion of 0.66 (95% confidence interval [CI] = 0.47–0.94) after multivariate adjustment. BMP was also associated with a decreased hazard ratio for long-term repeat fusion (adjusted hazards ratio = 0.74, 95% CI = 0.58–0.93). Cost analysis indicated that BMP was associated with initial increased costs for the surgical procedure (13.9% adjusted increase, 95% CI = 9.9%–17.9%) as well as total 1-year costs (10.1% adjusted increase, 95% CI = 6.2%–14.0%). Conclusion. At 1 year, BMP use was associated with a decreased risk of repeat fusion but also increased health care costs.

Survival after concurrent traumatic dislocation of the atlanto-occipital and atlanto-axial joints: a case report and review of the literature.

Study Design. A case report of a patient who survived a traumatic disassociation of both atlanto-occipital and atlantoaxial joints. Objective. To describe a rare case of concurrent atlanto-occipital and atlantoaxial dislocation with a review of the related literature regarding occipitocervical dislocation. Summary of Background Data. Cases of isolated atlanto-occipital or atlantoaxial dislocation have typically resulted in death or devastating neurologic deficit. Survival after the simultaneous dislocation at both joints is extremely rare. Methods. The initial evaluation, subsequent management, and surgical treatment of a 25-year-old male who sustained a concurrent dislocation of the atlantoaxial and atlanto-occipital joints from a motor vehicle collision are reported and the related literature is discussed. Results. The patient was transferred to our hospital after initial stabilization according to Emergency Medical Service criteria and management based on the Advanced Trauma Life Support protocol. A complete (ASIA A) spinal cord injury was diagnosed on admission. Radiographic evaluation revealed dislocations of the atlanto-occipital and atlantoaxial joints. Subsequently, the patient underwent surgical stabilization with instrumented posterior fusion from the occiput to C5. Intraoperatively, traumatic pseudomeningocele was diagnosed and repaired with pericranial autograft. The vital function parameters currently remain stable, but the patient is ventilator-dependent and did not regain motor or sensory function. Conclusion. The rapid response time of emergency medical services and stabilization according to the Advanced Trauma Life Support protocol now lead to the survival of patients with significant deficit from occipitocervical injuries. A high index of suspicion is required to appropriately manage a patient with this devastating injury in order to maximize the chance for survival.

Torticollis in children: can dynamic computed tomography help determine severity and treatment.

For children with torticollis, dynamic computed tomography scanning (DCTS) is the imaging modality of choice in diagnosing atlantoaxial rotatory subluxation (AARS). At present, there is no grouping system based on DCTS to determine severity and direct treatment. Fifty children with torticollis underwent DCTS in the workup for AARS. The relative rotation of C1 versus C2 was compared for left and right rotation views. Each DCTS was classified: stage 0, torticollis but normal DCTS; stage 1, limitation of motion (<15° difference between C1 and C2, but C1 crosses midline of C2); and stage 2, fixed (C1 does not cross midline of C2). Duration of symptoms and treatment were compared. There were 27 girls and 23 boys with a mean age of 8.2 years. There were 8 stage 0, 30 stage 1, and 12 stage 2 DCTS. Average onset of symptoms to diagnosis was 6.7 days for stage 0, 8.6 days for stage 1, and 20 days for stage 2. A significant trend was found between increasing intensity of treatment and stage. Using this grouping system, the authors found that patients with a higher stage had an increase in the mean duration of symptoms and intensity of treatment.

Intraoperative waste in spine surgery: incidence, cost, and effectiveness of an educational program.

Study Design. Prospective observational study. Objective. This study aims to quantify the incidence of intraoperative waste in spine surgery and to examine the efficacy of an educational program directed at surgeons to induce a reduction in the intraoperative waste. Summary of background data. Spine procedures are associated with high costs. Implants are a main contributor of these costs. Intraoperative waste further exacerbates the high cost of surgery. Methods. Data were collected during a 25-month period from one academic medical center (15-month observational period, 10-month post–awareness program). The total number of spine procedures and the incidence of intraoperative waste were recorded prospectively. Other variables recorded included the type of product wasted, cost associated with the product or implant wasted, and reason for the waste. Results. Intraoperative waste occurred in 20.2% of the procedures prior to the educational program and in 10.3% of the procedures after the implementation of the program (P < 0.0001). Monthly costs associated with surgical waste were, on average,

Validation of an administrative coding algorithm for classifying surgical indication and operative features of spine surgery.

17680 prior to the awareness intervention and

Geographic variation in the surgical treatment of degenerative cervical disc disease: American Board of Orthopedic Surgery Quality Improvement Initiative; part II candidates.

5876 afterwards (P = 0.0006). Prior to the intervention, surgical waste represented 4.3% of total operative spine budget. After the awareness program this proportion decrease to an average of 1.2% (P = 0.003). Conclusion. Intraoperative waste in spine surgery exacerbates the already costly procedures. Extrapolation of this data to the national level leads to an annual estimate of

Mortality in elderly patients with hyperostotic disease of the cervical spine after fracture: an age- and sex-matched study

126,722,000 attributable to intraoperative spine waste. A simple educational program proved to be and continues to be effective in making surgeons aware of the import of their choices and the costs related to surgical waste.