Terrence T. Kim

Cost-effectiveness analysis in minimally invasive spine surgery

OBJECT Medical care has been evolving with the increased influence of a value-based health care system. As a result, more emphasis is being placed on ensuring cost-effectiveness and utility in the services provided to patients. This study looks at this development in respect to minimally invasive spine surgery (MISS) costs. METHODS A literature review using PubMed, the Cost-Effectiveness Analysis (CEA) Registry, and the National Health Service Economic Evaluation Database (NHS EED) was performed. Papers were included in the study if they reported costs associated with minimally invasive spine surgery (MISS). If there was no mention of cost, CEA, cost-utility analysis (CUA), quality-adjusted life year (QALY), quality, or outcomes mentioned, then the article was excluded. RESULTS Fourteen studies reporting costs associated with MISS in 12,425 patients (3675 undergoing minimally invasive procedures and 8750 undergoing open procedures) were identified through PubMed, the CEA Registry, and NHS EED. The percent cost difference between minimally invasive and open approaches ranged from 2.54% to 33.68%-all indicating cost saving with a minimally invasive surgical approach. Average length of stay (LOS) for minimally invasive surgery ranged from 0.93 days to 5.1 days compared with 1.53 days to 12 days for an open approach. All studies reporting EBL reported lower volume loss in an MISS approach (range 10-392.5 ml) than in an open approach (range 55-535.5 ml). CONCLUSIONS There are currently an insufficient number of studies published reporting the costs of MISS. Of the studies published, none have followed a standardized method of reporting and analyzing cost data. Preliminary findings analyzing the 14 studies showed both cost saving and better outcomes in MISS compared with an open approach. However, more Level I CEA/CUA studies including cost/QALY evaluations with specifics of the techniques utilized need to be reported in a standardized manner to make more accurate conclusions on the cost effectiveness of minimally invasive spine surgery.

Robotics and the spine: a review of current and ongoing applications

OBJECT Robotics in the operating room has shown great use and versatility in multiple surgical fields. Robot-assisted spine surgery has gained significant favor over its relatively short existence, due to its intuitive promise of higher surgical accuracy and better outcomes with fewer complications. Here, the authors analyze the existing literature on this growing technology in the era of minimally invasive spine surgery. METHODS In an attempt to provide the most recent, up-to-date review of the current literature on robotic spine surgery, a search of the existing literature was conducted to obtain all relevant studies on robotics as it relates to its application in spine surgery and other interventions. RESULTS In all, 45 articles were included in the analysis. The authors discuss the current status of this technology and its potential in multiple arenas of spinal interventions, mainly spine surgery and spine biomechanics testing. CONCLUSIONS There are numerous potential advantages and limitations to robotic spine surgery, as suggested in published case reports and in retrospective and prospective studies. Randomized controlled trials are few in number and show conflicting results regarding accuracy. The present limitations may be surmountable with future technological improvements, greater surgeon experience, reduced cost, improved operating room dynamics, and more training of surgical team members. Given the promise of robotics for improvements in spine surgery and spine biomechanics testing, more studies are needed to further explore the applicability of this technology in the spinal operating room. Due to the significant cost of the robotic equipment, studies are needed to substantiate that the increased equipment costs will result in significant benefits that will justify the expense.

Minimally Invasive Spinal Surgery with Intraoperative Image-Guided Navigation

We present our perioperative minimally invasive spine surgery technique using intraoperative computed tomography image-guided navigation for the treatment of various lumbar spine pathologies. We present an illustrative case of a patient undergoing minimally invasive percutaneous posterior spinal fusion assisted by the O-arm system with navigation. We discuss the literature and the advantages of the technique over fluoroscopic imaging methods: lower occupational radiation exposure for operative room personnel, reduced need for postoperative imaging, and decreased revision rates. Most importantly, we demonstrate that use of intraoperative cone beam CT image-guided navigation has been reported to increase accuracy.

Scoliosis surgery in the elderly: Complications, readmissions, reoperations and mortality

The operative management of scoliosis in the elderly remains controversial. The authors of this study sought to evaluate outcomes in elderly patients with scoliosis undergoing deformity correction. Patient data was obtained from a 5% sample of the Medicare Provided Analysis and Review database (MEDPAR). Patients over 65years of age with scoliosis undergoing corrective surgery were identified between the years 2005 to 2011. A total of 453 patients were analyzed: 262 (57%) between ages 66 to 74years, and 191 (42%) over the age of 75years. Female predominance (78%) was observed in this sample. Pre-diagnosis follow-up averaged 118months. Post-surgery follow-up averaged 33months. Patients between 66 and 74years old were mostly discharged home, while patients over the age of 75years were discharged to skilled nursing facilities (SNFs) (38.55% versus 34.04%, p value=0.0011). Readmission rates were lower in patients between 66 and 74years old when compared to patients over the age of 75years (9.92% versus 17.28%, p value=0.0217). Complication rates 30-days after discharge were less in patients between 66 and 74years, compared to those over 75years (21% versus 26.6%, respectively), but this was not statistically significant. These findings suggest varying outcomes following scoliosis surgery in the elderly, but interpretation of these results is weakened by the inherent limitations of database utilization. Future prospective studies are needed to understand risk factors and other confounding variables, such as discharge disposition, that may influence outcomes.

Resection of spinal column tumors utilizing image-guided navigation: a multicenter analysis.

OBJECTIVE The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions. METHODS This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance. RESULTS The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14-87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62-865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5-7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1-36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden. CONCLUSIONS O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.

Economics of image guidance and navigation in spine surgery

Background: Image-guidance and navigation in spinal surgery is becoming more widely utilized. Several studies have shown the use of this technology to increase accuracy of pedicle screw placement, decrease the rates of revision surgery, and minimize radiation exposure. In this paper, the authors analyze the economics of image-guided surgery (IGS) and navigation in spine surgery. Methods: A literature review was performed using PubMed, the CEA Registry, and the National Health Service Economic Evaluation Database. Each article was screened for inclusion and exclusion criteria, including costs, reoperation, readmission rates, operating room time, and length of stay. Results: Thirteen studies were included in the analysis. Six studies were identified to meet the inclusion criteria for reporting costs and seven met the criteria for analysis of efficacy. Average costs ranged from

Introduction: Intraoperative spinal imaging and navigation

17,650 to

Erratum to: Surgical management of primary spinal hemangiopericytomas: an institutional case series and review of the literature

39,643. Pedicle screw misplacement rates using IGS ranged from 1.20% to 15.07% while reoperation rates ranged from 0% to 7.42%. Conclusion: There is currently an insufficient amount of studies reporting on the economics of spinal navigation to accurately conclude on its cost-effectiveness in clinical practice. Although a few of these studies showed less costs associated with intraoperative imaging, none were able to establish a statistically significant difference. Preliminary findings drawn from this study indicate a possible cost-effectiveness advantage with IGS, but more comprehensive data on costs need to be reported in order to validate its utilization.

Outcomes and National Trends for the Surgical Treatment of Lumbar Spine Trauma

Image-guided surgery (IGS) has been evolving since the early 1990s and is now used on a daily basis in the operating theater for spine surgery at many institutions. In the last 5 years, spinal IGS has greatly benefitted from important enhancements including portable intraoperative CT (iCT) coupled with high-speed computerized stereotactic navigation systems and optical-based camera tracking technology.

The role of sacral slope in lumbosacral fusion: a biomechanical study.

Purpose Hemangiopericytoma (HPC) is a rare tumor of the central nervous system. Primary spinal occurrence of this tumor is extremely uncommon and cases involving the intramedullary spinal cord are even more rare. The purpose of this study was to explore the clinical features, surgical strategies, outcome and pathology in a consecutive series of patients treated at a single institution.