Analysis of Postoperative Thoracolumbar Spine Infections in a Prospective Randomized Controlled Trial Using the Centers for Disease Control Surgical Site Infection Criteria.

INTRODUCTION: Wound infections following spinal surgery place a high toll on both the patient and the healthcare system. Although several large series studies have examined the incidence and distribution of spinal wound infection, the applicability of these studies varies greatly since nearly every study is either retrospective and/or lacks standard inclusion criteria for defining surgical site infection. To address this void, we present results from prospectively gathered thoracolumbar spine surgery data for which the Centers for Disease Control (CDC) criteria were stringently applied to define a surgical site infection (SSI). METHODS: A prospective randomized trial of 314 patients who underwent multilevel thoracolumbar spinal surgery with instrumentation followed by postoperative drain placement was completed (Takemoto et al., 2015). The trial consisted of two antibiotic arms: one for 24-hours, and the other for the duration of the drain; no differences were found between the arms. All infections meeting CDC criteria for SSI were included. RESULTS: A total of 40 infections met CDC criteria for SSI, for an overall incidence of 12.7%. Of these, 20 (50%) were culture-positive. The most common organism was Staphylococcus aureus (4 total: methicillin-sensitive=2; methicillin-resistant=2), followed by coagulase-negative Staphylococcus (3 cases), Propionibacterium acnes and Escherichia coli (2 cases each). Six infections grew multiple organisms, most commonly involving coagulase-negative staphylococcus and enterococcus. CONCLUSIONS: Our findings indicate that thoracolumbar SSI occurs at the higher end of the range cited in the literature (2-13%), which is largely based on retrospective data not subjected to the inclusivity of SSI as defined by the CDC. The three most common organisms in our analysis (S. aureus, P. acnes, E. coli) are consistent with previous reports. Staphylococcus aureus continues to be the most common causative organism and continued vigilance and searching for preventive measures need to be a high priority. This study provides Level I evidence.

Appropriateness of Twenty-four-Hour Antibiotic Prophylaxis After Spinal Surgery in Which a Drain Is Utilized: A Prospective Randomized Study.

BACKGROUND: Wound drains that are left in place for a prolonged period of time have a higher rate of bacterial contamination. Following spinal surgery, a drain is often left in place for a longer period of time if it maintains a high output. Given the major consequences of an infection following spinal surgery and the lack of data with regard to the use of antibiotics and drains, we performed a study of patients with a drain following spinal surgery to compare infection rates between those who were treated with antibiotics for twenty-four hours and those who received antibiotics for the duration for which the drain was in place. METHODS: We performed a prospective randomized trial of 314 patients who underwent multilevel thoracolumbar spinal surgery followed by use of a postoperative drain. The patients were randomized into two groups, one of which received perioperative antibiotics for twenty-four hours (twenty-four-hour group) and the other of which received antibiotics for the duration that the drain was in place (drain-duration group). Data collected included demographic characteristics, medical comorbidities, type of spinal surgery, and surgical site infection. RESULTS: Twenty-one (12.4%) of the 170 patients in the twenty-four-hour group and nineteen (13.2%) of the 144 in the drain-duration group developed a surgical site infection (p = 0.48). There were no significant differences between the twenty-four-hour and drain-duration groups with respect to demographic characteristics (except for the American Society of Anesthesiologists [ASA] classification), operative time, type of surgery, drain output, or length of hospital stay. CONCLUSIONS: Continuing perioperative administration of antibiotics for the entire duration that a drain is in place after spinal surgery did not decrease the rate of surgical site infections.

Cost analysis of anterior-posterior circumferential fusion and transforaminal lumbar interbody fusion.

BACKGROUND CONTEXT: Although lumbar interbody fusion has long been a common procedure in the practice of spine surgery, focus on the technological development has produced the relatively new procedure of transforaminal lumbar interbody fusion (TLIF). This procedure is often available to surgeons as an alternative to anterior-posterior circumferential fusion (AP fusion), and both procedures have been demonstrated to be clinically equivalent at up to 5 years after surgery. In the context of clinical equipoise, it is unknown which procedure is more economically advantageous. PURPOSE: To compare the hospital costs, charges, and payments received for surgical treatment with either AP fusion or TLIF. Future directions for health economic research with respect to spine surgery are also considered and discussed. STUDY DESIGN: This is an institutional review board-approved, single-institution retrospective chart review and cost analysis. PATIENT SAMPLE: Our study included patients undergoing either single-level AP fusion or single-level TLIF between 2006 and 2008. All patients were older than 18 years at the time of surgery; the decision of which procedure was performed was entirely at the discretion of the attending surgeon. OUTCOME MEASURES: Hospital costs, charges, and payments received for the treatment of each patient. METHODS: We performed a retrospective review of the medical and financial records of patients undergoing either AP fusion (n=179) or TLIF (n=90) on one operative level between 2006 and 2008. Medical records were evaluated for a history of spine surgery, operative time, estimated blood loss, and length of stay, whereas financial records were reviewed for the hospital costs, charges, and payments received as recorded by the hospital accounting data. Operative materials and service charges were also isolated and compared separately. This study was departmentally sponsored; there were no interest-associated biases for any of the authors involved. RESULTS: AP fusion patients had a longer operative time than TLIF patients, with a mean time of 246.5 versus 202.7 minutes (p<.01). Conversely, TLIF patients had a higher estimated blood loss during surgery (469.8 cm(3)) than AP fusion patients (311.2 cm(3)) (p<.01). The mean hospital cost for AP fusion was $25,165, whereas for TLIF was $23,390 (p=.04). The mean hospital charges and payments received for AP fusion were 1.07 (p=.05) and 1.35 (p<.01) times those received for TLIF, respectively. Therefore, mean hospital charges and payments received for TLIF were 0.93 and 0.76 times those received for AP fusion, respectively. CONCLUSIONS: Our study demonstrates that a single-level AP fusion results in longer operative time, lower blood loss during surgery, higher hospital costs, higher hospital charges, and greater payments received than a single-level TLIF. Although the decision on how best to treat a patient lies solely at the judgment of the attending surgeon, this comparative cost information may be pertinent in cases of clinical equivalence. This study also calls attention to various shortcomings that are found in present spine surgery cost-effectiveness research, as there is an ongoing need for increased standards of quality in the area of health economics research.

Comparative analysis of surgical approaches and osteotomies for the correction of sagittal plane spinal deformity in adults.

STUDY DESIGN: A retrospective review. OBJECTIVE: To compare the radiographical and clinical profiles between 2 surgical approaches for the correction of sagittal plane spinal deformity. SUMMARY OF BACKGROUND DATA: Sagittal plane decompensation is the radiographical parameter that carries the greatest impact on adverse outcomes. Surgical correction methods are heterogeneous, and opposing views pervade the spine community in consideration of the most effective approach and techniques to achieve correction. METHODS: A total of 33 cases with sagittal spinal deformity were assessed according to their surgical approach, posterior only versus combined anteroposterior group. Comparison was based on the demographic data, and radiographical parameters included pelvic tilt, pelvic incidence, sacral slope, lumbar lordosis, thoracic kyphosis, and sagittal vertical axis. RESULTS: Twenty two subjects were identified for the posterior-only and 11 subjects for the anteroposterior group. Average age was 58.7 years in the posterior-only and 55.7 years for the combined approach. Preoperative mean sagittal vertical axis was 186.6 and 147.7 mm, for the posterior-only and combined approaches, respectively (P = 0.1). Preoperative mean pelvic tilt was 34.2° for the posterior-only and 36.9° for the combined approach group (P = 0.5). A greater operative time for the combined approach was significant, 535 versus 333 minutes for the posterior-only approach (P < 0.001). In the posterior-only group, 8 of 22 patients and 7 of 11 patients in the combined-approach cohort experienced a postoperative complication (P = 0.16). The average follow-up was 41.8 and 47.7 months for the posterior-only and combined approaches, respectively (P = 0.4). CONCLUSION: A posterior-only or combined surgical approach had comparable radiographical outcomes. Higher morbidity was significant in regard to operative time in the combined-approach group. Deciding on the approach best suited for achieving correction in the sagittal plane likely resides on the surgeon's experience and expertise.

Cost-utility analysis modeling at 2-year follow-up for cervical disc arthroplasty versus anterior cervical discectomy and fusion: A single-center contribution to the randomized controlled trial.

BACKGROUND: Patients with cervical disc herniations resulting in radiculopathy or myelopathy from single level disease have traditionally been treated with Anterior Cervical Discectomy and Fusion (ACDF), yet Cervical Disc Arthroplasty (CDA) is a new alternative. Expert suggestion of reduced adjacent segment degeneration is a promising future result of CDA. A cost-utility analysis of these procedures with long-term follow-up has not been previously reported. METHODS: We reviewed single institution prospective data from a randomized trial comparing single-level ACDF and CDA in cervical disc disease. Both Medicare reimbursement schedules and actual hospital cost data for peri-operative care were separately reviewed and analyzed to estimate the cost of treatment of each patient. QALYs were calculated at 1 and 2 years based on NDI and SF-36 outcome scores, and incremental cost effectiveness ratio (ICER) analysis was performed to determine relative cost-effectiveness. RESULTS: Patients of both groups showed improvement in NDI and SF-36 outcome scores. Medicare reimbursement rates to the hospital were $11,747 and $10,015 for ACDF and CDA, respectively; these figures rose to $16,162 and $13,171 when including physician and anesthesiologist reimbursement. The estimated actual cost to the hospital of ACDF averaged $16,108, while CDA averaged $16,004 (p = 0.97); when including estimated physicians fees, total hospital costs came to $19,811 and $18,440, respectively. The cost/QALY analyses therefore varied widely with these discrepancies in cost values. The ICERs of ACDF vs CDA with Medicare reimbursements were $18,593 (NDI) and $19,940 (SF-36), while ICERs based on actual total hospital cost were $13,710 (NDI) and $9,140 (SF-36). CONCLUSIONS: We confirm the efficacy of ACDF and CDA in the treatment of cervical disc disease, as our results suggest similar clinical outcomes at one and two year follow-up. The ICER suggests that the non-significant added benefit via ACDF comes at a reasonable cost, whether we use actual hospital costs or Medicare reimbursement values, though the actual ICER values vary widely depending upon the CUA modality used. Long term follow-up may illustrate a different profile for CDA due to reduced cost and greater long-term utility scores. It is crucial to note that financial modeling plays an important role in how economic treatment dominance is portrayed.

Retrospective cost analysis of cervical laminectomy and fusion versus cervical laminoplasty in the treatment of cervical spondylotic myelopathy.

BACKGROUND: Cervical laminoplasty (CLP) and posterior cervical laminectomy and fusion (CLF) are well-established surgical procedures used in the treatment of cervical spondylotic myelopathy (CSM). In situations of clinical equipoise, an influential factor in procedural decision making could be the economic effect of the chosen procedure. The object of this study is to compare and analyze the total hospital costs and charges pertaining to patients undergoing CLP or CLF for the treatment of CSM. METHODS: We performed a retrospective review of 81 consecutive patients from a single institution; 55 patients were treated with CLP and 26 with CLF. CLP was performed via the double-door allograft technique that does not require implants, whereas laminectomy fusion procedures included metallic instrumentation. We analyzed 10,682 individual costs (HC) and charges (HCh) for all patients, as obtained from hospital accounting data. The Current Procedural Terminology codes were used to estimate the physicians' fees as such fees are not accounted for via hospital billing records. Total cost (TC) therefore equaled the sum of the hospital cost and the estimated physicians' fees. RESULTS: The mean length of stay was 3.7 days for CLP and 5.9 days for CLF (P < .01). There were no significant differences between the groups with respect to age, gender, previous surgical history, and medical insurance. The TC mean was $17,734 for CLP and $37,413 for CLF (P < .01). Mean HCh for CLP was 42% of that for CLF, and therefore the mean charge for CLF was 238% of that for CLP (P < .01). Mean HC was $15,426 for CLP and $32,125 for CLF (P < .01); the main contributor was implant cost (mean $2582). CONCLUSIONS: Our study demonstrates that, in clinically similar populations, CLP results in reduced length of stay, TC, and hospital charges. In CSM cases requiring posterior decompression, we demonstrate CLP to be a less costly procedure. However, in the presence of neck pain, kyphotic deformity, or gross instability, this procedure may not be sufficient and posterior CLF may be required.