Preferences of Spine Surgeons With Regard to Management of Intraoperative Durotomy: A Survey of Current Management.

STUDY DESIGN: This was a cross-sectional study. OBJECTIVE: The objective of this study was to determine spine surgeons' preferences for the intraoperative and postoperative management of intraoperative durotomy (IDT) in decompression and spinal fusion surgeries. SUMMARY OF BACKGROUND DATA: Management guidelines for IDT remain elusive. Traditionally, management consists of intraoperative suturing and postoperative bed rest. However, preferences of North American spine surgeons may vary, particularly according to type of surgery. MATERIALS AND METHODS: Spine surgeons of AO Spine North America (AOSNA) were surveyed online anonymously to determine which techniques they preferred to manage IDT in decompression and fusion. Differences in preferences according to surgery type were compared using the Fisher exact test. A series of linear regressions were conducted to identify demographic predictors of spine surgeons' preferences. RESULTS: Of 217 respondents, most were male (95%), orthopedic surgeons (70%), practiced at an academic center (50%), were in practice 0-19 years (71%) and operated on 100-300 patients per year (70%). The majority of surgeons applied sutures (93%-96%) and sealant (82%-84%). Surgeons also used grafts (26%-27%), drains (18%), other techniques (4%-5%), blood patch (2%-3%), or no intraoperative management (1%-2%). Postoperatively, most surgeons recommended bed rest (74%-75%). Antibiotics (22%), immediate mobilization (18%-20%), reoperation (14%-16%), other techniques (6%), or no postoperative management (5%) were also preferred. Management preferences did not vary significantly between decompression and fusion surgeries (all P-values>0.05). Specialty, practice facility, years in practice, and patients per year were identified as independent predictors of IDT management preferences (P<0.05). CONCLUSIONS: Although North American spine surgeons preferred to manage IDT with sutures augmented by sealant followed by bed rest after surgery, less common techniques were also preferred during the intraoperative and postoperative periods. Notably, intraoperative and postoperative IDT management preferences did not change in accordance to the type of surgery being conducted. LEVEL OF EVIDENCE: Level V.

Variation in Costs of Spinal Implants in United States Academic Medical Centers.

STUDY DESIGN: Retrospective study of benchmarking database. OBJECTIVE: To evaluate the variability in direct costs of spinal implants across various academic medical centers, determining variability between and within specific manufacturers, and to measure the relationship between purchasing volume and price. SUMMARY OF BACKGROUND DATA: Spinal implants are a significant component of the cost of surgery. There is an absence of transparency of how much various medical centers in the United States pay for implants because of the use of nondisclosure agreements as part of price negotiations. Transparency of information on costs and awareness of costs by physicians will be useful in managing costs in a value-based health care economy. METHODS: Purchasing records of 45 academic medical centers over a 12-month period were examined. Purchasing volume and unit pricing for pedicle screws (PS), anterior cervical plates (ACP), and transforaminal lumbar interbody fusion (TLIF) cages were collected for 6 manufacturers. Overall variation in implant costs across centers and for each manufacturer was determined as was the relationship between purchasing volume and unit price. RESULTS: We found variation in implant costs between medical centers, and between manufacturers for PS, ACP and TLIF similar to joint replacement implants. Regression analysis showed that for each 10-fold increase in purchasing volume, the unit price decreased by $126 for PS, $242 for ACP, and $789 for TLIF. CONCLUSION: There was variation in implant costs between medical centers and manufacturers of implants, with a small negative relationship between purchasing volume and cost. Transparency in cost negotiation, surgeon awareness of costs and alignment between surgeon and hospital goals may help decrease the cost of spinal implants, and the cost of care for patients undergoing instrumented fusions.