Peter D. Angevine

National and Regional Rates and Variation of Cervical Discectomy With and Without Anterior Fusion, 1990-1999

Study Design. A national hospitalization database was used to determine rates and trends in the treatment of cervical disc disease. Objective. To examine the temporal and geographic variations in hospitalizations and surgical procedures for cervical disc disease. Summary of Background Data. Studies of spinal surgery during the 1980s showed significant increases in the rates for all procedures, particularly those involving fusion. The management of cervical disc disease continues to be controversial. Methods. Data from the National Hospital Discharge Survey from 1990 through 1999 were analyzed. Records were selected and categorized according to an algorithm of International Classification of Diseases (ICD-9) procedure and diagnosis codes. Results. During the study period, the rate of hospitalization for surgical and nonsurgical treatment of cervical disc disease did not increase significantly. There was, however, a statistically significant increase in the proportion of hospitalizations for the surgical treatment of cervical disc disease that included a fusion procedure. There also was significant geographic variation in the rate of fusion procedures, with the South having the highest rate. Conclusions. Although the rate of surgery for cervical disc disease did not increase significantly during the 1990s, the rate of fusion procedures did rise significantly.

Cost-effectiveness of Single-level Anterior Cervical Discectomy and Fusion for Cervical Spondylosis

Study Design. Cost-effectiveness analysis with retrospective cost analysis and literature review. Objective. To determine the relative cost-effectiveness of anterior cervical discectomy and fusion (ACDF) with autograft, allograft, and allograft with plating for single-level anterior cervical spondylosis. Summary of Background Data. There are several accepted methods of surgically treating single-level cervical spondylosis anteriorly. No study has clearly demonstrated the superiority of one method over the alternatives. The techniques may differ in their operative risks and resource use, perioperative complications, short-term outcome, and long-term outcome and complications. Formal cost-effectiveness analysis (CEA) provides a structure for analyzing many variables and comparing different treatment outcomes. Sensitivity analysis is used to test the robustness of the model and to determine variables that have significant effects on the results. Future areas of research and refinements of the CEA model can be developed from these findings. Methods. A retrospective review of hospital charges was performed for 78 patients who underwent single-level ACDF with allograft alone or ACDF with allograft and plating (ACDFP). The charges were converted to estimated costs for fiscal year 2000 using the ratio of costs to charges method. A CEA model was developed consisting of a decision-analysis model for the first year postsurgery and a Markov model for the next 4 years after surgery. Probabilities and outcome utilities were estimated from the literature. Outcome was measured in quality-adjusted life years (QALYs), and incremental CEA was performed. Several variables were tested in one-way sensitivity analysis. Results. Compared with ACDF with autograft, ACDF with allograft offered an improvement in quality of life at a cost of

Deep hypothermic circulatory arrest for complex cerebral aneurysms: lessons learned.

496 per QALY. ACDFP provided additional gains in quality of life compared with ACDF with allograft at a cost of

Anterior lumbar interbody fusion for treatment of failed back surgery syndrome: an outcome analysis.

32,560 per QALY in the base case analysis. In sensitivity analysis, these estimates varied between

OPERATIVE MANAGEMENT OF SPINAL HEMANGIOBLASTOMA

417 and

Health economic studies: an introduction to cost-benefit, cost-effectiveness, and cost-utility analyses.

741 per QALY and between

Randomized Controlled Trials of the Treatment of Lumbar Disk Herniation: 1983-2007

19,090 per QALY and domination of ACDFP by ACDF with allograft, respectively. The results were most sensitive to assumptions regarding differences in the length of the postoperative recovery period. Conclusions. ACDF with allograft offers a benefit relative to ACDF with autograft at a cost of

RADIOGRAPHIC MEASUREMENT TECHNIQUES

496 per QALY. ACDFP has a benefit relative to ACDF with allograft at an approximate cost of

Background to understanding value-based surgical spine care.

32,560 per QALY. CEA provides a method for comparing the benefits and risks of these three procedures. Further research needs to be performed regarding these procedures, particularly examining the postoperative recovery period.

DEEP HYPOTHERMIC CIRCULATORY ARREST FOR COMPLEX CEREBRAL ANEURYSMS

OBJECTIVEDeep hypothermic circulatory arrest is a useful adjunct for treating complex aneurysms. Decreased cerebral metabolism and resultant ischemic tolerance create an environment suitable for devascularizing high-risk lesions. However, the advent of modern imaging modalities, innovative cerebral revascularization strategies, and the emergence of endovascular stenting and coiling limit the number of aneurysms requiring this surgical intervention. We present 66 patients with intracranial aneurysms who underwent surgical clipping under deep hypothermic arrest and attempt to identify patients well-suited for this procedure. METHODSThis study was conducted during a 15-year period and examined patients with aneurysms of the anterior and posterior cerebral circulation. Demographics, aneurysm characteristics, and surgical factors were evaluated as predictors of functional outcome. RESULTSPatient age and the duration of cardiac arrest were independent predictors of early clinical outcome (P < 0.05). Our experience suggests that the ideal patient is younger than 60 years old and harbors few medical comorbidities. Individuals with large aneurysms of the anterior communicating artery, internal carotid artery bifurcation, posterior inferior cerebellar artery, midbasilar, or vertebral arteries and with an absence of thrombosis and calcium may be most likely to experience favorable outcomes. Circulatory arrest should not exceed 30 minutes. Postoperative computed tomographic scanning and timely anesthetic emergence allow for early detection of hemorrhage. Complete dissection of the aneurysm before bypass and avoiding extreme hypothermia yield a low incidence of life-threatening postoperative hematomas. CONCLUSIONHypothermic circulatory arrest is a useful technique for neuroprotection during the clipping of complex cerebral aneurysms. This procedure, however, has several associated risks. Patient factors, pathoanatomic characteristics, and surgical parameters may be used to guide patient selection.