Lumbar Discectomy and Reoperation Among Workers' Compensation Cases in Florida and New York: Are Treatment Trends Similar to Other Payer Types?

OBJECTIVE: The aim of this study was to better understand current treatment trends and revision rates for lumbar disc herniation (LDH) in the workers' compensation (WC) population compared with other payer types. METHODS: This was a retrospective analysis of outpatient claims data from Florida and New York during 2014 to 2016. RESULTS: WC patients were less likely to undergo discectomy in Florida (15% vs 19%; P < 0.001) and New York (10% vs 15%; P < 0.001). The odds of WC patients undergoing revision discectomy were 1.5 times greater than patients covered by private payers or all other non-WC payers (P = 0.002). CONCLUSIONS: WC patients undergo discectomy significantly less often than non-WC counterparts, which may be related to a higher risk of reoperation. New evidence-based treatments, such as annular repair, may be critical to advancing care in this unique population.

Reduction of direct costs in high-risk lumbar discectomy patients during the 90-day post-operative period through annular closure.

PURPOSE: Despite being an extremely successful procedure, recurrent disc herniation is one of the most common post-discectomy complications in the lumbar spine and contributes significant health care and socioeconomic costs. Patients with large annular defects are at a high risk for reherniation, but an annular closure device (ACD) has been designed to reduce reherniation risk in this population and may, in turn, help control direct health care costs after discectomy. PATIENTS AND METHODS: This analysis examined the 90-day post-discectomy cost estimates among ACD-treated (n=272) and control (discectomy alone; n=278) patients in a randomized controlled trial (RCT). Direct medical costs were estimated based on 2017 Humana and Medicare claims. Index discectomies were assumed to occur in an outpatient (OP) setting, whereas repeat discectomies were assumed to be 60% in OP and 40% in inpatient (IP). A sensitivity analysis was performed on this assumption. The device cost was not included in the analysis in order to focus on costs in the 90-day post-operative period. RESULTS: Within 90 days of follow-up, post-operative complications occurred in 3.3% of the ACD patients and 8.6% of the control patients (P=0.01). The average 90-day cost to treat an ACD patient was $10,257 compared to $11,299 per control patient for a 80:20 distribution of Commercial:Medicare coverage ($1,042 difference). This difference varied from $687 with 100% Medicare to $1,132 with 100% Commercial coverage. Varying the IP vs OP distribution resulted in a cost difference range of $968 to $1,156 with the ACD. CONCLUSION: Augmenting discectomy with an ACD in high-risk patients with a large annular defect reduced reherniation and reoperation rates, which translated to a reduction of direct health care costs between $687 and $1,156 per patient during the 90-day post-operative period. Large annular defect patients are an easily identifiable high-risk population. Operative strategies that reduce complication risks in these patients, such as the ACD, could be advantageous from both patient care and economic perspectives.

The role of Osteocel Plus as a fusion substrate in minimally invasive instrumented transforaminal lumbar interbody fusion.

BACKGROUND: Instrumented lumbar fusion has become an accepted and effective surgical technique used to address a wide variety of conditions of the lumbar spine. Iliac crest autograft remains the gold standard with regards to bony fusion substrate. Unfortunately there are significant potential disadvantages associated with autograft harvest, including pain, infection, iatrogenic fracture and bleeding. Osteocel Plus (OC+) is an allograft cellular bone matrix containing mesenchymal stem cells (MSCs) and osteoprogenitor cells combined with DBM and cancellous bone. OC+ is designed to mimic the osteobiologic profile of human autograft bone, thereby eliminating the risks of autograft harvest. METHODS: A retrospective chart review was conducted to identify all patients who had undergone a MITLIF with OC+ for degenerative lumbar conditions. Patient demographics including age, sex, history of risk factors for nonunion including: osteoporosis documented on DEXA scanning, diabetes mellitus, smoking or steroid use were examined and recorded. Successful arthrodesis was judged based on post-operative X-ray imaging. RESULTS: 23 patients at 26 spinal levels underwent a MITLIF with OC+. Twenty-one patients (91.3%) and 24 levels (92.3%) went on to achieve radiographic evidence of solid bony arthrodesis by 12 months post-op. Six patients (26%) demonstrated clear evidence of early interbody bone growth within 6 months of surgery. CONCLUSION: OC+ results in robust and reproducible lumbar interbody fusion, in both young and older patients.

Acute tetraplegia and cardiac arrest following high cervical leptomeningeal metastasis of giant cell glioblastoma.

Giant cell glioblastoma multiforme (gcGBM) is an unusual subtype of high-grade glioma (grade IV, World Health Organization classification). We report a patient with a rare acute tetraplegia, followed by lethal cardiac arrest, who had undergone a prior resection of a supratentorial gcGBM. Neuroradiological workup revealed a large, high cervical compressive leptomeningeal mass consistent with a drop metastasis. Due to the possibility of a rapid clinical deterioration in patients with high cervical cord compression, the diagnosis of drop metastasis to the spine should be considered in patients with a previous history of supratentorial GBM who present with acute diffuse motor weakness.

Pathologic cervical burst fracture presenting with airway compromise.

Mechanical airway compromise following cervical spine injury or fracture is a rare but known entity. It most commonly is the result of the development of a retropharyngeal hematoma or prevertebral soft tissue edema that obstructs the airway, leading to respiratory distress and emergent need for airway management and possible surgical intervention. We present a novel case of airway compromise following a C3 burst fracture without associated retropharyngeal hematoma or prevertebral soft tissue edema. Surgical management is discussed, and a review of relevant literature is provided. Pathological cervical spine fracture must be included in the differential diagnosis of a patient presenting with acute airway obstruction of unknown etiology.

Wrong-sided surgery.

OBJECT: Perhaps the single greatest error that a surgeon hopes to avoid is operating at the wrong site. In this report, the authors describe the incidence and possible determinants of incorrect-site surgery (ICSS) among neurosurgeons. METHODS: The authors asked neurosurgeons to complete an anonymous survey. These surgeons were asked to report the number of craniotomies and lumbar and cervical discectomies performed during the previous year, as well as whether ICSS had occurred. They were also asked detailed questions regarding the potential determinants of ICSS. RESULTS: There was a 75% response rate and a 68% survey completion rate. Participating neurosurgeons performed 4695 lumbar and 2649 cervical discectomies, as well as 10,203 craniotomies. Based on this self-reporting, the incidence of wrong-level lumbar surgery was estimated to be 4.5 occurrences per 10,000 operations. The ICSSs per 10,000 cervical discectomies and craniotomies were 6.8 and 2.2, respectively. Neurosurgeons recognized fatigue, unusual time pressure, and emergent operations as factors contributing to ICSS. For spine surgery, in particular, unusual patient anatomy and a failure to verify the operative site by radiography were also commonly reported contributors. CONCLUSIONS: Neurosurgical ICSSs do occur, but are rare events. Although there are significant limitations to the survey-based methodology, the data suggest that the prevention of such errors will require neurosurgeons to recognize risk factors and increase the use of intraoperative imaging.

A novel technique for the intraoperative monitoring of detrusor activity in intradural lesions of the cauda equina. Technical note.

BACKGROUND: Intradural pathology in the region of the cauda equina is uncommon and generally comes to attention secondary to pain or neurologic deficit. A number of surgeons choose to excise these lesions under EMG monitoring of the nerve roots supplying the lower extremity muscles, anal sphincter, and detrusor muscle. In this article, the authors describe a detrusor muscle monitoring technique that has been found to be simple, reliable, and cost-effective in the management of intradural pathology of the cauda equina. METHODS: Fourteen consecutive patients with tumors of the cauda equina who underwent surgical management performed using the standard Foley catheter monitoring technique were included in this study and their outcomes analyzed. RESULTS: In 86% of patients, a gross total resection was achieved. Subtotal resections were performed in 2 patients because of involvement of critical nerve roots. In all cases, the nerve roots supplying the detrusor muscle were successfully identified using this technique. No patient suffered a clinically apparent decline in bladder function during the postoperative period. CONCLUSION: The standard Foley catheter detrusor monitoring technique is a simple, reliable, and cost-effective method to identify and prevent injury to the sacral nerve roots innervating the urinary bladder during intradural exploration of the cauda equina.

Mechanisms of morbid hearing loss associated with tumors of the endolymphatic sac in von Hippel-Lindau disease.

CONTEXT: Endolymphatic sac tumors (ELSTs) are associated with von Hippel-Lindau disease and cause irreversible sensorineural hearing loss (SNHL) and vestibulopathy. The underlying mechanisms of audiovestibular morbidity remain unclear and optimal timing of treatment is not known. OBJECTIVE: To define the mechanisms underlying audiovestibular pathophysiology associated with ELSTs. DESIGN, SETTING, AND PATIENTS: Prospective and serial evaluation of patients with von Hippel-Lindau disease and ELSTs at the National Institutes of Health between May 1990 and December 2006. MAIN OUTCOME MEASURES: Clinical findings and audiologic data were correlated with serial magnetic resonance imaging and computed tomography imaging studies to determine mechanisms underlying audiovestibular dysfunction. RESULTS: Thirty-five patients with von Hippel-Lindau disease and ELSTs in 38 ears (3 bilateral ELSTs) were identified. Tumor invasion of the otic capsule was associated with larger tumors (P = .01) and occurred in 7 ears (18%) causing SNHL (100%). No evidence of otic capsule invasion was present in the remaining 31 ears (82%). SNHL developed in 27 of these 31 ears (87%) either suddenly (14 ears; 52%) or gradually (13 ears; 48%) and 4 ears had normal hearing. Intralabyrinthine hemorrhage was found in 11 of 14 ears with sudden SNHL (79%; P < .001) but occurred in none of the 17 ears with gradual SNHL or normal hearing. Tumor size was not related to SNHL (P = .23) or vestibulopathy (P = .83). CONCLUSIONS: ELST-associated SNHL and vestibulopathy may occur suddenly due to tumor-associated intralabyrinthine hemorrhage, or insidiously, consistent with endolymphatic hydrops. Both of these pathophysiologic mechanisms occur with small tumors that are not associated with otic capsule invasion.

A prospective evaluation of the role for intraoperative x-ray in lumbar discectomy. Predictors of incorrect level exposure.

BACKGROUND: Lumbar discectomy is among the most frequently performed procedures by spine surgeons. Among the potential difficulties encountered during this procedure, incorrect spinal level surgery remains a significant concern for surgeons and patients. Multiple groups have advocated the use of intraoperative x-ray to reduce the incidence of incorrect level surgery; however, this technique has not been prospectively evaluated. METHODS: In an effort to determine the incidence of incorrect level exposure during lumbar discectomy and to define patient characteristics predictive of wrong level exposure, we examined 100 consecutive patients who underwent lumbar discectomy by a single surgeon. After exposure, the surgeon was asked to identify the level exposed, which was confirmed by intraoperative x-ray. Several patient characteristics were then examined by logistical regression to identify features predictive of a mismatch between level of exposure and level of pathology. RESULTS: The study population was composed of 48 men and 52 women who were aged 18 to 83 years. Patient weights ranged from 105 to 410 lb. There were 51 patients who had pathology at the L5-S1 level; 44 patients, L4-L5; 3 patients, L3-L4; and 1 patient, L2-L3. Four patients had transitional vertebrae. The intended level was initially exposed in 85% of cases. Age and level of pathology (P < .05) were identified as factors predictive of a mismatch between intraoperative level of exposure and preoperative level of pathology. CONCLUSIONS: Pathology above L5-S1 and patient age have been shown to reliably predict incorrect level exposure. Based upon the findings of this study, the routine use of intraoperative x-ray to confirm the level of exposure should be considered in all cases of lumbar discectomy.

Multiple metachronous brain metastases from primary ureteral carcinoma.

Transitional cell carcinoma (TCC) of the ureter is an uncommon urologic malignancy, with approximately 150 cases diagnosed annually. Metastatic brain disease from ureteral TCC is exceedingly rare. To our knowledge, our case report represents only the second report of brain metastasis from ureteral TCC and the only reported patient to undergo resection of their TCC brain metastasis.

Long-term natural history of hemangioblastomas in patients with von Hippel-Lindau disease: implications for treatment.

OBJECT: In the course of their lives most patients with von Hippel-Lindau (VHL) disease require treatment for several symptom-producing hemangioblastomas of the cerebellum, brainstem, or spinal cord. However, many tumors never produce symptoms and do not require treatment. Detection at an early stage of lesions that will later produce symptoms and ultimately require treatment would allow for earlier excision of hemangioblastomas of the spinal cord, brainstem, or cerebellum, and may identify cerebellar hemangioblastomas that can be treated with radiosurgery at a stage before treatment is contraindicated because of tumor size or the presence of an associated cyst. METHODS: To identify features predictive of symptom development that might allow for earlier treatment of smaller, presymptomatic hemangioblastomas in patients with VHL disease, the authors reviewed and analyzed the serial clinical and imaging findings in all patients with VHL disease who were followed up at the National Institutes of Health for more than 10 years. Features predictive of symptom formation were determined by recursive partition and regression analyses. Nineteen patients (10 men and nine women; mean age 32.6 +/- 11.6 years) harboring a total of 143 hemangioblastomas were identified (mean follow-up duration 12.4 +/- 1.4 years). Hemangioblastomas were located in the cerebellum (68 hemangioblastomas, 48% of patients), brainstem (17 hemangioblastomas, 12% of patients), and spinal cord (58 hemangioblastomas, 40% of patients). Despite measurable growth in almost all hemangioblastomas (138 lesions, 97% of patients), only 58 (41% of patients) became symptomatic. Hemangioblastomas grew in a stuttering pattern. (mean growth period 13 +/- 15 months, mean quiescent period 25 +/- 19 months). Twenty-six (45%) of the hemangioblastomas that eventually produced symptoms were not among the tumors that were apparent on the initial MR imaging study. Depending on location, the hemangioblastoma size and/or tumor and cyst growth rates predicted symptom development and the need for treatment (p < 0.05). Cerebellar hemangioblastomas growing faster than 112 mm3/ month or larger than 69 mm3 with associated tumor and cyst growth rates greater than 14 mm3/month became symptomatic (100% sensitivity, 72% specificity). Brainstem hemangioblastomas larger than 245 mm3 with growth rates greater than 0.1 mm3/month became symptomatic (75% sensitivity, 89% specificity). Spinal hemangioblastomas larger than 22 mm3 became symptomatic (79% sensitivity, 94% specificity). CONCLUSIONS: Because hemangioblastomas exhibit a stuttering growth pattern, frequently remain asymptomatic, and do not require treatment for long intervals, unqualified radiographic progression is not an indication for treatment. Basing the decision to intervene in individual tumors solely on radiographic progression would have resulted in approximately four additional procedures per patient during the 10-year study period. Threshold values are presented for tumor size and/or tumor and cyst growth rates that can be used to predict symptom formation and future need for treatment.

Posterior subtemporal transtentorial approach to intraparenchymal lesions of the anteromedial region of the superior cerebellum.

OBJECT: To overcome the limitations associated with surgical approaches that have been described for accessing intraparenchymal lesions of the anteromedial region of the superior cerebellum, the authors used a posterior subtemporal transtentorial approach to remove tumors in this region. In this paper they describe the surgical technique that they used as well as the operative findings and clinical outcomes observed in patients who underwent resection of tumors in the anteromedial superior cerebellum. METHODS: The consecutive patients with anteromedial superior cerebellar tumors who underwent resection performed using the posterior subtemporal transtentorial approach at the National Institutes of Health were included in this study. Clinical, neuroimaging, and operative results were analyzed. Three patients (two men and one woman) with anteromedial superior cerebellar tumors (two hemangioblastomas and one pilocytic astrocytoma) underwent resection via this approach. All the tumors were larger than 3 cm in diameter (range 3.1-3.5 cm). This approach provided excellent surgical access and permitted complete tumor resection in each case. The patients remained neurologically unchanged compared with preoperative baseline findings at the last follow-up examination (conducted at 4, 18, and 42 months postoperatively). One patient displayed a mild transient confusion immediately after surgery, but it resolved within 6 days. CONCLUSIONS: The posterior subtemporal transtentorial approach provides excellent access to the anteromedial superior cerebellar region. This approach permits resection of large lesions in this location, while avoiding many of the limitations associated with other approaches to this site.

Edema is a precursor to central nervous system peritumoral cyst formation.

Despite the common occurrence and frequent clinical effects of peritumoral cysts in the central nervous system (CNS), the mechanism underlying their development and evolution is not understood. Because they commonly produce peritumoral cysts and because serial magnetic resonance imaging (MRI) is obtained in von Hippel-Lindau disease patients, hemangioblastomas provide an opportunity to examine the pathophysiology of CNS peritumoral cyst formation. Serial MRI was correlated with the clinical findings in 16 von Hippel-Lindau disease patients with 22 CNS hemangioblastomas (11 spinal cord; 11 cerebellar) that were associated with the appearance and evolution of peritumoral cysts. Hemangioblastoma-associated cyst wall histomorphological analysis was performed on postmortem tissues from three von Hippel-Lindau disease patients (not in the clinical series). Comparative proteomic profiling was performed on peritumoral cyst fluid and serum. Vascular endothelial growth factor levels were determined in peritumoral cysts. MRI clearly showed peritumoral edema that developed and slowly and progressively evolved into enlarging hemangioblastoma-associated cysts in all tumors (mean follow-up, 130 +/- 38 months; mean +/- standard deviation). Postcontrast MRI demonstrated convective leakage of gadolinium into cysts. Mean time required for edema to evolve into a cyst was 36 +/- 23 months (range, 8-72 months). Thirteen (59%) hemangioblastoma-cysts became symptomatic (mean time to symptom formation after cyst development, 35 +/- 32 months; range, 3-102 months) and required resection. Protein profiles of cyst fluid and serum were similar. Mean cyst fluid vascular endothelial growth factor concentration was 1.5 ng/ml (range, 0-5.4 ng/ml). Histology of the cyst walls was consistent with reactive gliosis. CNS peritumoral cyst formation is initiated by increased tumor vascular permeability, increased interstitial pressure in the tumor, and plasma extravasation with convective distribution into the surrounding tissue. When the delivery of plasma from the tumor exceeds the capacity of the surrounding tissue to absorb the extravasated fluid, edema (with its associated increased interstitial pressure) and subsequent cyst formation occur.