Postoperative fever discharge guidelines increase hospital charges associated with spine surgery.

BACKGROUND: Postoperative fever is a common sequel of spine surgery. In the presence of rigid nationally mandated clinical guidelines, fever management may consume more health care resources than is reasonably appropriate. OBJECTIVE: To study the relationship between postoperative fever, infection rate, and hospital charges in a cohort of spine surgery patients. METHODS: We retrospectively reviewed 578 spine surgery patients (lumbar microdiskectomy [LMD], anterior cervical decompression and fusion [ACDF], and lumbar decompression and fusion [LDF]). Differences in length of stay and hospital charges as well as risk factors and correlation with infection and readmission rates were studied. RESULTS: Postoperative fever occurred in 41.7% of all spine surgery patients and more often in LDF patients (77.2%). Type of surgery was the most important variable affecting the prevalence of postoperative fever. Significant differences in length of stay were elicited between patients with and without postoperative fever in the ACDF and LMD groups and in hospital cost in the LMD group. The average length of stay was 2.41 vs 4.47 (P < .01) in the LMD group, 1.67 vs 2.80 (P < .05) in the ACDF group, and 5.03 vs 5.65 (P > .05) in the LDF group. The average hospital charges were $16 261 vs $22 166 (P < .01) in the LMD group, $26 021 vs $29 125 (P > .05) in the ACDF group, and $53 627 vs $53 210 (P > .05) in the LDF group. Obesity, female sex, and ≥102°F postoperative temperature were the most significant predictors of infection. Delayed discharge referable to postoperative fever did not seem to influence the infection readmission rate. CONCLUSION: Postoperative fever in spine surgery patients is associated with a delay in patient discharge and increases in hospital charges. Postoperative fever discharge guidelines should be regularly and publicly subjected to appropriate cost-benefit analysis.

Comparison of outpatient and inpatient spine surgery patients with regards to obesity, comorbidities and readmission for infection.

Outpatient spine surgery is becoming popular because of its substantial economic advantages. We retrospectively studied 97 spine surgery outpatients and 578 inpatients who had proceeded through a common process of surgical venue selection. No differences (p > 0.05) were found in gender, race, obesity rate (46.9% versus [vs.] 42.9%), hypertension (9.7% vs. 8.8%), chronic obstructive pulmonary disease (11.8% vs. 13.5%), and history of stroke (1.9% vs. 2.5%). However, age was statistically different between inpatients (55 years) and outpatients (49 years) (p < 0.001). The prevalence of diabetes mellitus (19% vs. 10%), congestive heart disease (19.7% vs. 1.3%), coronary artery procedures (15.9% vs. 3.8%), and use of antidepressants (25.4% vs. 11.6%) was higher in the inpatient group (p < 0.05). There were more comorbidities in the inpatient cohort of each spine surgery type except for chronic obstructive pulmonary disease (COPD) and history of stroke in the outpatient cervical surgery group (p < 0.05). Among outpatients, only one patient (∼ 1%) had postoperative infection while among the inpatients, 16 patients had postoperative infections (2.8%) (p > 0.05). All seven patients readmitted due to infection were obese (body mass index ≥ 30). Obese patients in the inpatient cohort had higher chronic disease rates. Comorbidities are the main determinants of inpatient/outpatient selection. Postoperative infection was not a significant complication for appropriately selected patients for outpatient spine surgery. Despite increased hospital care and observation in the inpatient group, infection rates were not statistically different. Obesity seems to be a predictor of readmission with infection.

Prevalence of previously unknown elevation of glycosylated hemoglobin in spine surgery patients and impact on length of stay and total cost.

BACKGROUND: Elevated levels of glycosylated hemoglobin (HbA1c) among spine surgery patients may have an impact on length of stay (LOS) and healthcare cost. MATERIALS AND METHODS: We retrospectively reviewed the charts of 556 spine surgery patients who underwent 1 of 3 types of surgery: lumbar microdiscectomy (LMD), anterior cervical decompression and fusion (ACDF), and lumbar decompression and fusion (LDF). Information was collected about their diabetes mellitus (DM) history and HbA1c levels. We used HbA1c 6.1% as the screening cutpoint. Percentages of nondiabetic patients, those with subclinical elevation of HbA1c and those with already known DM were calculated and statistical analysis was applied. RESULTS: After excluding the small group of well-controlled DM (n = 14), 72.4% of patients were nondiabetic, 14.3% were subclinical patients with previously unknown HbA1c elevation, and 13.3% were already known, confirmed DM patients. There were significant differences in the LDF group between the "No DM" and "Subclinical" groups (P < 0.05) in terms of cost and LOS (P < 0.05). Age and body mass index (BMI) were very significant predictors of total cost in spine surgery patients (P 0.05) in determining cost. CONCLUSIONS: There is a significant segment of spine surgery patients who were unaware of their elevated HbA1c status before their preoperative visit. These patients seem to utilize more healthcare resources, which is especially evident in the LDF group. We believe that HbA1c should be considered in the routine preoperative workup of spine surgery patients.

Causes and risk factors for postoperative fever in spine surgery patients.

Postoperative fever is a common dilemma faced by neurosurgeons. To study this problem, we prospectively collected patients who developed fever after spine surgery during the academic year 2007-2008 for whom the internist's consultation was requested. Eighty-five (85) patients were identified, of which 17 had an identifiable infectious cause for their febrile reaction (20%) - fever was attributed to urinary tract infection in 8 cases, pneumonia in 5 cases, wound infection in 3 cases (all lumbar), and cholecystitis in 1 case. The remaining 68 patients (80%) had no definitive diagnosis and fever was attributed to a peripheral venous line which, in this case, was replaced or discontinued. In 32 (37.6%) of the patients, the fever developed on postoperative day (POD) 2 or later. There was no statistically significant relationship between day of fever appearance and whether the fever was due to definite infection (P = 0.737). Comparing the basic group with another group of 456 spine surgery patients from 2006-2007 who might or might not have developed fever postoperatively using ANOVA, we found a significant difference in age (P = 0.011) and a very significant difference in hemoglobin level (P = 0.000) and HbA1c level (P = 0.000), but not in body mass index (BMI) (P = 0.289). Thus, most of the postoperative fever cases after spine surgery have no identifiable infectious focus and develop mainly in older patients with anemia and inadequately controlled HbA1c. A meticulous investigation of the source of fever including laboratory and radiological studies remains essential. Early mobilization is recommended for individuals undergoing lower spine surgery in order to decrease bacterial contamination from the gluteal cleavage.

Neurosarcoidosis--the great mimicker.

INTRODUCTION: Neurosarcoidosis is rare and difficult to diagnose especially in the absence of systemic involvement. CASE REPORT: A 22-year-old African-American man presented with inability to gaze laterally. He underwent magnetic resonance imaging (MRI) the day before that revealed "a 5-mm enhancing mass with surrounding edema in the pons anterior to the fourth ventricle most likely compatible with pontine glioma." CT angiography of the brain was negative. Two days later, the patient developed right facial droop. During craniotomy, a small lesion of rubbery consistency was identified at the mid-portion of the floor of the fourth ventricle. Frozen-section study came suggestive of lymphoma. Further pathological examination revealed sarcoidosis. The patient was discharged on prednisone, and he recovered quickly and completely. CONCLUSION: Neurosarcoidosis can mimic common neurosurgical entities. It is important to keep neurosarcoidosis in mind when making the diagnosis, which often requires biopsy.

Cauda equina syndrome-think of cancer.

Leptomeningeal carcinomatosis (LC) is a serious complication found in approximately 1% to 8% of patients with solid cancer and carries substantial rates of morbidity and mortality. Up to 48% of patients may present with LC before the presence of systemic cancer is known. We present the case of a patient who presented with symptoms of cauda equina syndrome and for whom subsequent investigations revealed intrathecal metastases and locally advanced lung cancer without respiratory symptoms or brain or bone metastases. The case emphasizes the need for thorough investigation in the presence of the triad: back pain, weakness in the lower extremities, and urinary urgency/incontinence. Cauda equina syndrome due to intrathecal metastases should always be considered. Spine MRI with contrast is the most informative investigative study for these patients, and myelography remains an important diagnostic method.

Subacute transverse myelitis with Lyme profile dissociation.

INTRODUCTION: Transverse myelitis is a very rare neurologic syndrome with an incidence per year of 1-5 per million population. We are presenting an interesting case of subacute transverse myelitis with its MRI (magnetic resonance imaging) and CSF (cerebrospinal fluid) findings. CASE: A 46-year-old African-American woman presented with decreased sensation in the lower extremities which started three weeks ago when she had a 36-hour episode of sore throat. She reported numbness up to the level just below the breasts. Lyme disease antibodies total IgG (immunoglobulin G) and IgM (immunoglobulin M) in the blood was positive. Antinuclear antibody profile was within normal limits. MRI of the cervical spine showed swelling in the lower cervical cord with contrast enhancement. Cerebrospinal fluid was clear with negative Borrelia Burgdorferi IgG and IgM. Herpes simplex, mycoplasma, coxiella, anaplasma, cryptococcus and hepatitis B were all negative. No oligoclonal bands were detected. Quick improvement ensued after she was given IV Ceftriaxone for 7 days. The patient was discharged on the 8(th) day in stable condition. She continued on doxycycline for 21 days. CONCLUSIONS: Transverse myelitis should be included in the differential diagnosis of any patient presenting with acute or subacute myelopathy in association with localized contrast enhancement in the spinal cord especially if flu-like prodromal symptoms were reported. Lyme disease serology is indicated in patients with neurological symptoms keeping in mind that dissociation in Lyme antibody titers between the blood and the CSF is possible.

Prevalence of opioid dependence in spine surgery patients and correlation with length of stay.

OBJECTIVE: We addressed the prevalence of opioid dependence (OD) in spine surgery patients and its correlation with length of stay (LOS) as the most important determinant of hospital cost. METHODS: The study took place at Georgia Neurosurgical Institute and the Medical Center of Central Georgia between March 2006 and January 2007. A prospective convenience sample of 150 spine surgery patients (48 lumbar diskectomy, 60 cervical decompression and fusion, and 42 lumbar decompression and fusion [LDF]) was assembled. Patients were interviewed before surgery using a questionnaire designed in accordance with the World Health Organization and DSM-IV-TR criteria for the diagnosis of OD. The prevalence of OD was calculated based on questionnaire results. Pain intensity was quantified during admission using a 0-to-10 pain scale. We used pain intensity multiplied by duration of pain in months (WR index) as a new parameter. Lengths of stay were collected following patients' discharge from hospital. Pearson correlation and regression analysis were performed using SPSS software. RESULTS: Thirty (20.00 percent) patients were opioid dependent. The prevalence was highest among LDF patients (23.81 percent), females (22.78 percent), and, to a lesser degree, Caucasians (20.87 percent). There was no correlation between OD and age (r = 0.08, p > 0.1) or between OD and LOS (r = 0.09, p > 0.1). This study proved a very significant positive correlation between OD and pain intensity (r = 0.24, p < 0.01) and between OD and the WR index (r = 0.30, p < 0.01). On the other hand, there was a significant positive correlation between LOS and age (r = 0.42, p < 0.01), between LOS and the number of previous spine surgeries (r = 0.28, p < 0.01), and between LOS and duration of pain (r = 0.18, p < 0.05). Regression analysis showed that age, ethnicity, and type of surgery were the main determinants of LOS. CONCLUSIONS: Chronic pain and prolonged use of opioids raise the prevalence of OD in spine surgery patients to 20 percent. The lack of effect of OD on LOS after surgical intervention means that efforts to decrease LOS by trying to satisfy patients' craving for opioids will not be fruitful. Older, African-American LDF patients with a lengthy history of pain and multiple spine surgeries in the past are the most likely to stay longer in hospital.