Raj J. Gala

Different Fusion Approaches for Single-level Lumbar Spondylolysis Have Similar Perioperative Outcomes

Study Design. Retrospective cohort study Objective. The aim of this study was to compare perioperative adverse events for patients with lumbar spondylolysis treated with transforaminal lumbar interbody fusion (TLIF), posterior spinal fusion (PSF), combined anterior and posterior fusion (AP fusion), or anterior lumbar interbody fusion (ALIF). Summary of Background Data. Previous cohort studies have shown similar long-term outcomes for different surgical approaches for this indication, but potential differences in 30-day perioperative adverse events have not been well characterized. Methods. The present study uses data extracted from the American College of Surgeons National Surgical Quality Improvement Database. Patients undergoing fusion with different approaches for lumbar spondylolysis were identified. Propensity score matching was utilized to account for potential differences in demographic and comorbidity factors. Comparisons among perioperative outcomes were then made among the propensity score-matched study groups. Results. Of 1077 cases of spondylolysis identified, 556 underwent TLIF, 327 underwent PSF, 108 underwent AP fusion, and 86 underwent ALIF. After propensity score matching, there were no differences in the rates of any of the 30-day individual adverse events studied and no differences in the aggregated groupings of any adverse event, serious adverse event, or minor adverse event. There was a significantly increased operative time in the AP fusion group, but there were no differences in hospital length of stay or readmission rates. Conclusion. Because perioperative adverse event rates were similar, even with a slightly longer operative time in the AP fusion group, these findings suggest that surgeon preference and long-term outcomes are better used to determine the recommendation of one surgical approach over another for single level fusions for lumbar spondylolysis. Level of Evidence. 3

Interspinous implants to treat spinal stenosis

Purpose of reviewLumbar spinal stenosis has historically been treated with open decompressive surgery which is associated with significant morbidity and may give rise to various complications. Interspinous spacers (ISS) have been developed as a less invasive strategy which may serve to avoid many of these risks. The two current spacers that are FDA approved and commercially available are the Coflex and Superion devices. The goal is to review these two implants, their indications, and patient selection.Recent findingsThe Coflex device has been shown to be analogous to decompression and fusion when treating moderate spinal stenosis. It provides dynamic stability after a decompression is performed, without the rigidity of pedicle-screw instrumentation. Recent results show improved outcomes in Coflex patients at 3xa0years of follow-up, as compared to decompression and fusion.The Superion implant is placed percutaneously in the interspinous space with minimal disruption of spinal anatomy. When compared to the X-Stop device (which is no longer available), the Superion implant shows improved outcomes at 3xa0years of follow-up.SummaryISS are lesser invasive options as compared to formal decompression and fusion for the treatment of lumbar spinal stenosis.

Incidence and Considerations of 90 day Readmissions following Posterior Lumbar Fusion

BACKGROUND CONTEXTnPosterior lumbar fusion (PLF) is a commonly performed procedure. The evolution of bundled payment plans is beginning to require physicians to more closely consider patient outcomes up to 90 days after an operation. Current quality metrics and other databases often consider only 30 postoperative days. The relatively new Healthcare Cost and Utilization Project Nationwide Readmissions Database (HCUP-NRD) tracks patient-linked hospital admissions data for up to one calendar year.nnnPURPOSEnTo identify readmission rates within 90 days of discharge following PLF and to put this in context of 30 day readmission and baseline readmission rates.nnnSTUDY DESIGNnRetrospective study of patients in the HCUP-NRD.nnnPATIENT SAMPLEnAny patient undergoing PLF performed in the first 9 months of 2013 were identified in the HCUP-NRD.nnnOUTCOME MEASURESnReadmission patterns up to a full calendar year after discharge.nnnMETHODSnPLFs performed in the first 9 months of 2013 were identified in the HCUP-NRD. Patient demographics and readmissions were tracked for 90 days after discharge. To estimate the average admission rate in an untreated population, the average daily admission rate in the last quarter of the year was calculated for a subset of PLF patients who had their operation in the first quarter of the year. This study was deemed exempt by the institutions Human Investigation Committee.nnnRESULTSnOf 26,727 PLFs, 1,580 patients (5.91%) were readmitted within 30 days of discharge and 2,603 patients (9.74%) were readmitted within 90 days of discharge. Of all readmissions within 90 days, 54.56% occurred in the first 30 days. However, if only counting readmissions above the baseline admission rate of a matched population from the 4th quarter of the year (0.08% of population/day), 89.78% of 90 day readmissions occurred within the first 30 days.nnnCONCLUSIONSnThe current study delineates readmission rates after PLF and puts this in the context of 30-day readmission rates and baseline readmission rates for those undergoing PLF. These results are important for patient counseling, planning, and preparing for potential bundled payments in spine surgery.

The Impact of Insurance Status on the Development of Nonunion following Scaphoid Fracture

Purpose Certain factors have been associated with the development of scaphoid nonunion, including delayed diagnosis, smoking, inadequate initial management, proximal location, and carpal instability. We hypothesized that insurance status would also be a risk factor for the development of scaphoid nonunion. Methods A case‐control study was performed on patients who presented to a single surgeon at a tertiary referral center during 2006 to 2015. Cases were patients presenting with nonunions, controls, and patients with acute fractures. Patients were characterized as underinsured if they lacked any type of insurance or if they were on Medicaid. Results Patients (39 nonunions [cases] and 32 primary fractures [controls]) presenting with nonunions were more likely than controls to have had displaced fractures (72 vs. 41%) and fractures located at the proximal aspect of the scaphoid (18 vs. 0%), and to be underinsured (46 vs. 19%). Conclusion Patients presenting with nonunions were more likely to be underinsured than patients presenting with primary fractures. This finding suggests that underinsurance is a risk factor for the development of nonunion. Assuming delay between fracture and intervention is a known risk factor for the development of nonunion, and it is likely that the association between nonunion and underinsurance is mediated through this delay. Level of Evidence Prognostic, level III, case‐control study.

Outpatient elective posterior lumbar fusions appear to be safely considered for appropriately selected patients

BACKGROUND CONTEXTnThere has been growing interest in performing posterior lumbar fusions (PLFs) in the outpatient setting to optimize patient satisfaction and reduce cost. Although still done in only a small percentage of cases, this has been more possible because of advances in surgical techniques and anesthesia. However, data on the perioperative course of outpatient compared with inpatient PLF in a large sample size are scarce.nnnPURPOSEnThis study aimed to compare perioperative complications between outpatient and inpatient PLF in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.nnnSTUDY DESIGN/SETTINGnA retrospective cohort comparison study was carried out.nnnPATIENT SAMPLEnPatients undergoing PLF with or without interbody fusion from the 2005 to 2015 NSQIP database comprised the sample.nnnOUTCOME MEASURESnOutcome measures were postoperative complications within 30 days and readmission within 30 days.nnnMETHODSnPatients who underwent PLF with or without interbody fusion were identified in the 2005-2015 NSQIP database. Outpatient procedures were defined as cases that had hospital length of stay (LOS)=0 days, whereas inpatient procedures were defined as LOS=1-30 days. Patient characteristics, comorbidities, and procedural variables (inclusion of interbody fusion, instrumentation, and number of levels fused) were compared between the two cohorts. Propensity score-matched comparisons were then performed for postoperative complications and 30-day readmissions between the two groups.nnnRESULTSnThe current study included 360 outpatient and 36,610 inpatient PLF cases. After propensity matching to control potential confounding factors, statistical analysis revealed no significant difference in postoperative adverse events other than significantly lower blood transfusions in the outpatient group (2.78% vs. 10.83%, p<.001). Notably, the rate of readmissions was not different between the groups.nnnCONCLUSIONSnBased on the lack of differences in rates of most perioperative complications and 30-day readmissions between the outpatient and inpatient cohorts, it seems that outpatient PLF may be appropriately considered for select patients. However, extremely careful patient selection should be exercised.