Cost savings analysis of intrawound vancomycin powder in posterior spinal surgery.

BACKGROUND CONTEXT: Recent studies have shown that prophylactic use of intrawound vancomycin in posterior instrumented spine surgery substantially decreases the incidence of wound infections requiring repeat surgery. Significant cost savings are thought to be associated with the use of vancomycin in this setting. PURPOSE: To elucidate cost savings associated with the use of intrawound vancomycin in posterior spinal surgeries using a budget-impact model. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Data from a cohort of 303 patients who underwent spinal surgery (instrumented and noninstrumented) over 2 years were analyzed; 96 of these patients received prophylactic intrawound vancomycin powder in addition to normal intravenous (IV) antibiotic prophylaxis, and 207 received just routine IV antibiotic prophylaxis. Patients requiring repeat surgical procedures for infection were identified, and the costs of these additional procedures were elucidated. OUTCOME MEASURE: Cost associated with the additional procedure to remediate infection in the absence of vancomycin prophylaxis. METHODS: We retrospectively reviewed the cost of return procedures for treatment of surgical site infection (SSI). The total reimbursement received by the health care facility was used to model the costs associated with repeat surgery, and this cost was compared with the cost of a single local application of vancomycin costing about $12. RESULTS: Of the 96 patients in the treatment group, the return-to-surgery rate for SSI was 0. In the group without vancomycin, seven patients required a total of 14 procedures. The mean cost per episode of surgery, based on the reimbursement, the health care facility received was $40,992 (range, $14,459-$114,763). A total of $573,897 was spent on 3% of the 207-patient cohort that did not receive intrawound vancomycin, whereas a total of $1,152 ($12×96 patients) was spent on the cohort treated with vancomycin. CONCLUSIONS: This study shows a reduction in SSIs requiring a return-to-surgery-with large cost savings-with use of intrawound vancomycin powder. In our study population, the cost savings totaled more than half a million dollars.

Success of junctional anterior cervical discectomy and fusion.

BACKGROUND CONTEXT: Junctional breakdown has long been a consideration for surgeons when performing an arthrodesis in the cervical spine. Numerous authors have reported symptomatic junctional disease after fusion with varying degrees of reoperation. To our knowledge, there are no large series recording the fusion rate using instrumentation as an adjuvant to bone grafting. PURPOSE: To determine the fusion rate when arthrodesis is performed in the setting of junctional stenosis using iliac crest autograft and instrumentation. STUDY DESIGN/SETTING: This is a retrospective review performed on patients at the senior author's institution. PATIENT SAMPLE: The patient population consisted of a consecutive series of patients undergoing an elective anterior-only cervical arthrodesis for junctional stenosis. OUTCOME MEASURES: The primary outcome is a physiologic measure from dynamic radiographs. Fusion was assessed by the absence of motion and radiolucent lines at the bone graft interface. METHODS: During the study period, a total of 56 consecutive patients underwent anterior treatment for junctional cervical stenosis. Forty-nine of these patients were treated with an anterior discectomy and instrumented arthrodesis using iliac crest autograft, and seven underwent a corpectomy. We retrospectively reviewed the patients' charts and radiographs to determine the fusion rate. RESULTS: A solid fusion was obtained in 81.6% of patients in the study group. In patients undergoing a single-level arthrodesis adjacent to a one-level fusion, the fusion rate was 95.2%. The fusion rate significantly dropped in patients with longer preexisting fusion segments. In patients with a two- or three-level fusions preoperatively, the union rate was 81.3% and 57.1%, respectively. CONCLUSIONS: Anterior cervical discectomy and arthrodesis yields a high fusion rate for cervical stenosis adjacent to a single-level fusion. A multilevel preexisting fusion segment leads to a significant decline in successfully achieving a solid adjacent fusion despite using iliac crest autograft and instrumentation.

Intraoperative somatosensory evoked potential monitoring during anterior cervical discectomy and fusion in nonmyelopathic patients--a review of 1,039 cases.

BACKGROUND CONTEXT: Intraoperative somatosensory evoked potential (SSEP) monitoring has been shown to reduce the incidence of new postoperative neurological deficits in scoliosis surgery. However, its usefulness during cervical spine surgery remains a subject of debate. PURPOSE: To determine the utility of intraoperative SSEP monitoring in a specific patient population (those with cervical radiculopathy in the absence of myelopathy) who underwent anterior cervical discectomy and fusion (ACDF) surgery. STUDY DESIGN: Retrospective review. PATIENT SAMPLE: A total of 1,039 nonmyelopathic patients who underwent single or multilevel ACDF surgery. The control group (462 patients) did not have intraoperative SSEP monitoring, whereas the monitored group (577 patients) had continuous intraoperative SSEP monitoring performed. OUTCOME MEASURE: A new postoperative neurological deficit. METHODS: SSEP tracings were reviewed for all 577 patients in the monitored group and all significant signal changes were noted. Medical records were reviewed for all 1,039 patients to determine if any new neurological deficits developed in the immediate postoperative period. RESULTS: None of the patients in the control group had any new postoperative neurological deficits. In the monitored group there were six instances of transient SSEP changes (1 due to suspected carotid artery compression; 5 thought to be due to transient hypotension) which resolved with the appropriate intraoperative intervention (repositioning of retractors; raising the arterial blood pressure). Upon waking up from anesthesia, one patient in the monitored group had a new neurological deficit (partial central cord syndrome) despite normal intraoperative SSEP signals. CONCLUSIONS: ACDF appears to be a safe surgical procedure with a low incidence of iatrogenic neurological injury. Transient SSEP signal changes, which improved with intraoperative interventions, were not associated with new postoperative neurological deficits. An intraoperative neurological deficit is possible despite normal SSEP signals.