Vadim Goz

Cost-effectiveness analysis: comparing single-level cervical disc replacement and single-level anterior cervical discectomy and fusion: clinical article.

OBJECTnIn recent years, there has been increased interest in the use of cervical disc replacement (CDR) as an alternative to anterior cervical discectomy and fusion (ACDF). While ACDF is a proven intervention for patients with myelopathy or radiculopathy, it does have inherent limitations. Cervical disc replacement was designed to preserve motion, avoid the limitations of fusion, and theoretically allow for a quicker return to activity. A number of recently published systematic reviews and randomized controlled trials have demonstrated positive clinical results for CDR, but no studies have revealed which of the 2 treatment strategies is more cost-effective. The purpose of this study was to evaluate the cost-effectiveness of CDR and ACDF by using the power of decision analysis. Additionally, the authors aimed to identify the most critical factors affecting procedural cost and effectiveness and to define thresholds for durability and function to focus and guide future research.nnnMETHODSnThe authors created a surgical decision model for the treatment of single-level cervical disc disease with associated radiculopathy. The literature was reviewed to identify possible outcomes and their likelihood following CDR and ACDF. Health state utility factors were determined from the literature and assigned to each possible outcome, and procedural effectiveness was expressed in units of quality-adjusted life years (QALYs). Using ICD-9 procedure codes and data from the Nationwide Inpatient Sample, the authors calculated the median cost of hospitalization by multiplying hospital charges by the hospital-specific cost-to-charge ratio. Gross physician costs were determined from the mean Medicare reimbursement for each current procedural terminology (CPT) code. Uncertainty as regards both cost and effectiveness numbers was assessed using sensitivity analysis.nnnRESULTSnIn the reference case, the model assumed a 20-year duration for the CDR prosthesis. Cervical disc replacement led to higher average QALYs gained at a lower cost to society if both strategies survived for 20 years (

Perioperative complications and mortality after spinal fusions: analysis of trends and risk factors.

3042/QALY for CDR vs

Kyphoplasty and vertebroplasty: trends in use in ambulatory and inpatient settings

8760/QALY for ACDF). Sensitivity analysis revealed that CDR needed to survive at least 9.75 years to be considered a more cost-effective strategy than ACDF. Cervical disc replacement becomes an acceptable societal strategy as the prosthesis survival time approaches 11 years and the

Health state utility of patients with single-level cervical degenerative disc disease: comparison of anterior cervical discectomy and fusion with cervical disc arthroplasty.

50,000/QALY gained willingness-to-pay threshold is crossed. Sensitivity analysis also indicated that CDR must provide a utility state of at least 0.796 to be cost-effective.nnnCONCLUSIONSnBoth CDR and ACDF were shown to be cost-effective procedures in the reference case. Results of the sensitivity analysis indicated that CDR must remain functional for at least 14 years to establish greater cost-effectiveness than ACDF. Since the current literature has yet to demonstrate with certainty the actual durability and long-term functionality of CDR, future long-term studies are required to validate the present analysis.

Arytenoid Dislocation as a Cause of Prolonged Hoarseness after Cervical Discectomy and Fusion

Study Design. Retrospective review. Objective. To analyze the trends in complications and mortality after spinal fusions. Summary of Background Data. Utilization of spinal fusions has been increasing during the past decade. It is essential to evaluate surgical outcomes to better identify patients who benefit most from surgical intervention. Integration of empiric evidence from large administrative databases into clinical decision making is instrumental in providing higher-quality, evidence-based, patient-centered care. Methods. This study used Nationwide Inpatient Sample data from 2001 through 2010. Patients who underwent spinal fusions were identified using the CCS (Clinical Classifications Software) and ICD-9 (International Classification of Diseases, 9th Revision) codes. Data on patient comorbidities, primary diagnosis, and postoperative complications were obtained via ICD-9 diagnosis codes and via CCS categories. National estimates were calculated using weights provided as part of the database. Time trend analysis for average length of stay, total charges, mortality, and comorbidity burden was performed. Univariate and multivariate models were constructed to identify predictors of mortality and postoperative complications. Results. An estimated 3,552,873 spinal fusions were performed in the United States between 2001 and 2010. The national bill for spinal fusions increased from

Comparative analysis of patients with cauda equina syndrome versus an unaffected population undergoing spinal surgery.

10 billion to

Cervical Disc Arthroplasty versus Anterior Cervical Discectomy and Fusion; Utilization and Perioperative Outcomes

46.8 billion. Today, patients are older and have a greater comorbidity burden than 10 years ago. Mortality remained relatively constant at 0.46%, 1.2%, and 0.14% for cervical, thoracic, and lumbar fusions, respectively. Morbidity rates showed an increasing trend at all levels. Multivariate analysis of 19 procedures and patient-related risk factors and 9 perioperative complications identified 85 statistically significant (P< 0.01) interactions. Conclusion. The data on perioperative risks and risk factors for postoperative complications of spinal fusions presented in this study is pivotal to appropriate surgical patient selection and well-informed risk-benefit evaluation of surgical intervention. Level of Evidence: N/A

Perioperative Complications and Mortality After Spinal Fusions: Analysis of Trends and Risk Factors

BACKGROUND CONTEXTnVertebral compression fractures (VCFs) are a substantial health concern. Kyphoplasty (KP) and vertebroplasty (VP) are vertebral augmentation procedures (VAPs) used to treat VCFs.nnnPURPOSEnTo compare VP and KP patient demographics and evaluate inpatient and outpatient utilization trends.nnnSTUDY DESIGNnRetrospective analysis of patient demographics, and inpatient and outpatient utilization trends, from California, New York, and Florida inpatient and ambulatory discharge databases.nnnMETHODSnHospitalizations for VP and KP were identified from California, New York, and Florida inpatient and ambulatory discharge databases from 2005 to 2008. International Classification of Diseases, Ninth Revision diagnosis codes for pathologic, dorsal, and lumbar fracture of vertebrae were cross-referenced with ICD-9 procedure codes and Current Procedural Terminology codes to select the population. Patients younger than 40 years or those who underwent both procedures were excluded.nnnRESULTSnThe final population contained 61,851 VAPs (35,805 KPs and 26,046 VPs). Kyphoplasty showed increased inpatient and outpatient utilization. Vertebroplasty utilization remained at a low level of 6/100,000 capita. Kyphoplasty patients had more comorbidities than VP patients. In Florida in 2008, radiologists performed most VPs (52.3%) and orthopedists performed the most KPs (35.45%). Postoperative complication rates were significantly different; 0.79% of KPs had cardiac complications versus 0.57% of VPs (p=.0073). Respiratory complications occurred in 0.83% of KPs and 0.49% of VPs (p<.0001).nnnCONCLUSIONSnVertebral augmentation procedures have seen a continued increase in use from 2004 to 2008. Use of KP significantly outpaces the use of VP. Reasons for the increasing utilization of KP likely include financial incentives, the specialty performing KP, perceived safety, and effectiveness of vertebral height restoration. Conflicting evidence regarding which procedure is safer warrants further evaluation.

Antifibrinolytics Reduce Blood Loss in Adult Spinal Deformity Surgery: A Prospective Randomized Controlled Trial

OBJECTnCost-effectiveness analysis (CEA) of medical interventions has become increasingly relevant to the discussion of optimization of care. The use of utility scales in CEA permits a quantitative assessment of effectiveness of a given intervention. There are no published utility values for degenerative disc disease (DDD) of the cervical spine, anterior cervical discectomy and fusion (ACDF), or cervical disc replacement (CDR). The purpose of this study was to define health utility values for those health states.nnnMETHODSnThe 36-Item Short Form Health Survey data from the ProDisc-C investigational device exemption study were obtained for single-level DDD at baseline and 24 months postoperatively after ACDF or CDR procedures. Patients in the original study were randomized to either ACDF or CDR. Utilizing a commercially available Short Form-6 dimensions program, utility scores were calculated for each health state using a set of parametric preference weights obtained from a sample of the general population using the recognized valuation technique of standard gamble.nnnRESULTSnThe baseline health state utility (HSU) value for a patient with single-level DDD was 0.54 in both the ACDF and CDR groups. Postoperative changes in HSU values were seen in both intervention groups at 24 months. Cervical disc replacement had a HSU value of 0.72. Anterior cervical discectomy and fusion was found to have a postoperative utility state of 0.71. No statistically significant difference was found in the HSU for ACDF and CDR at 24 months of follow-up.nnnCONCLUSIONSnThis study represents the first calculated HSU value for a patient with single-level cervical DDD. Additionally, 2 common treatment interventions for this disease state were assessed. Both treatments were found to have significant impact on the HSU values. These values are integral to future CEA of ACDF and CDR.

Thursday, September 27, 2018 3:35 PM–5:05 PM Section on Motion Technology Abstract Presentations

Study Design Case series of two arytenoid dislocations after anterior cervical discectomy. Objective To recognize arytenoid dislocation as a possible cause of prolonged hoarseness in patients after anterior cervical discectomies. Summary of Background Data Prolonged hoarseness is a common postoperative complication after anterior cervical spine surgery. The etiology of prolonged postoperative hoarseness is usually related to a paresis of the recurrent laryngeal nerve. However, other causes of postoperative hoarseness may be overlooked in this clinical scenario. Other possible etiologies include pharyngeal and laryngeal trauma, hematoma and edema, injury of the superior laryngeal nerve, as well as arytenoid cartilage dislocation. Arytenoid dislocation is often misdiagnosed as vocal fold paresis due to recurrent or laryngeal nerve injury. Methods We report two cases of arytenoid dislocation and review the literature on this pathology. Results Two patients treated with anterior cervical discectomy and fusion experienced prolonged postoperative hoarseness. Arytenoid dislocation was confirmed by flexible fiber-optic laryngoscopy in both cases. The dislocations experienced spontaneous reduction at 6 weeks and 3 months postsurgery. Conclusions Arytenoid dislocation must be considered in the differential diagnosis of prolonged postoperative hoarseness and evaluated for using direct laryngoscopy, computed tomography, or a laryngeal electromyography. Upon diagnosis, treatment must be considered immediately. Slight dislocations can reduce spontaneously without surgical intervention; however, operative intervention may be required at times.