Effect of Surgical Setting on Hospital-Reported Outcomes for Elective Lumbar Spinal Procedures: Tertiary Versus Community Hospitals.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: As hospital compensation becomes increasingly dependent on pay-for-performance and bundled payment compensation models, hospitals seek to reduce costs and increase quality. To our knowledge, no reported data compare these measures between hospital settings for elective lumbar procedures. The study compares hospital-reported outcomes and costs for elective lumbar procedures performed at a tertiary hospital (TH) versus community hospitals (CH) within a single health care system. METHODS: Retrospective review of a physician-maintained, prospectively collected database consisting of 1 TH and 4 CH for 3 common lumbar surgeries from 2015 to 2016. Patients undergoing primary elective microdiscectomy for disc herniation, laminectomy for spinal stenosis, and laminectomy with fusion for degenerative spondylolisthesis were included. Patients were excluded for traumatic, infectious, or malignant pathology. Comparing hospital settings, outcomes included length of stay (LOS), rates of 30-day readmissions, potentially preventable complications (PPC), and discharge to rehabilitation facility, and hospital costs. RESULTS: A total of 892 patients (n = 217 microdiscectomies, n = 302 laminectomies, and n = 373 laminectomy fusions) were included. The TH served a younger patient population with fewer comorbid conditions and a higher proportion of African Americans. The TH performed more decompressions (P < .001) per level fused; the CH performed more interbody fusions (P = .007). Cost of performing microdiscectomy (P < .001) and laminectomy (P = .014) was significantly higher at the TH, but there was no significant difference for laminectomy with fusion. In a multivariable stepwise linear regression analysis, the TH was significantly more expensive for single-level microdiscectomy (P < .001) and laminectomy with single-level fusion (P < .001), but trended toward significance for laminectomy without fusion (P = .052). No difference existed for PPC or readmissions rate. Patients undergoing laminectomy without fusion were discharged to a facility more often at the TH (P = .019). CONCLUSIONS: We provide hospital-reported outcomes between a TH and CH. Significant differences in patient characteristics and surgical practices exist between surgical settings. Despite minimal differences in hospital-reported outcomes, the TH was significantly more expensive.

Assuring optimal physiologic craniocervical alignment and avoidance of swallowing-related complications after occipitocervical fusion by preoperative halo vest placement.

STUDY DESIGN: A retrospective review. OBJECTIVE: To assess the utility of preoperative halo immobilization in the avoidance of swallowing complications-associated occipitocervical fixation. SUMMARY OF BACKGROUND DATA: The craniocervical region is commonly affected by a number of pathologic processes. Fixation of the upper cervical spine to the occiput provides an excellent means of treating these conditions. Occipitocervical fixation, however, is associated with a number of potential complications. One under-reported postoperative complication is the swallowing difficulty that some patients experience. Another is the overall patient dissatisfaction with postoperative head position. One means that the authors have used to avoid these complications is the use of preoperative halo vest fixation. METHODS: In this article, we report our experience with preoperative halo vest immobilization for occipitocervical fusion in 12 consecutive patients over a 5-month period and its effect on postoperative complications. We also report our experience with the index case of this series in which the patient required operative revision because of severe postoperative dysphagia and stridor after an occipitocervical fusion. RESULTS: All patients achieved satisfactory postoperative head position using the preoperative halo immobilization technique. One patient experienced transient dysphagia, which did not require intervention. No patients experienced any complications related to the placement of the halo vest itself. CONCLUSIONS: Preoperative halo immobilization allows patients, who are going to have their head permanently fixed in a particular position, to determine if they are able to tolerate the new head position. This allows the surgeon to adjust the head position before permanently locking the patient in the position, if necessary. We, therefore, advocate the use of preoperative halo immobilization as a means of assuring physiologic craniocervical neutrality and the avoidance of the resultant complications.

Surgical management of spinal metastases: analysis of prognostic factors during a 10-year experience.

OBJECT: Refinement of surgical techniques, especially anterior approaches, for the management of spinal metastases has improved patient outcomes, despite the fact that a complete analysis of the prognostic factors that would inform patient selection has not been undertaken. The authors sought to identify such prognostic factors for neurological outcome and life expectancy in patients with spinal metastases. METHODS: The authors used Kaplan-Meier techniques, log-rank comparisons, and a multivariate model stratified by tumor type to identify prognostic factors for duration of ability to walk and survival in patients who underwent surgical treatment for spinal metastases during a decade when all current treatment options were available. Preoperatively, 53 (87%) of the 61 patients in the study population suffered neurological symptoms (for example, weakness) and 52 (85%) were ambulatory. Postoperatively, 59 (97%) were ambulatory. Most patients who survived 6 months (81%) remained ambulatory, as did 66% of those alive at 1.6 years. The median postoperative survival was 10 months. The risk factors for loss of ambulation were preoperative loss of ambulatory ability, recurrent or persistent disease after primary radiotherapy of the operative site, a procedure other than corpectomy, and tumor type other than breast cancer. Prognostic factors for reduced survival were surgical intervention extending over two or more spinal segments, recurrent or persistent disease after primary radiotherapy involving the operative site, diagnosis other than breast cancer, and a cervical spinal procedure. CONCLUSIONS: The results of this analysis allowed the authors to create a simple prognostic factor scoring system that can be applied to individual patients. The positive experience derived from this study supports an expanded role for the surgical treatment of metastatic spinal disease.