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The Journal of the American Academy of... Jul 2022Out-of-pocket (OOP) costs for medical and surgical care can result in substantial financial burden for patients and families. Relatively little is known regarding OOP...
INTRODUCTION
Out-of-pocket (OOP) costs for medical and surgical care can result in substantial financial burden for patients and families. Relatively little is known regarding OOP costs for commercially insured patients receiving orthopaedic surgery. The aim of this study is to analyze the trends in OOP costs for common, elective orthopaedic surgeries performed in the hospital inpatient setting.
METHODS
This study used an employer-sponsored insurance claims database to analyze billing data of commercially insured patients who underwent elective orthopaedic surgery between 2014 and 2019. Patients who received single-level anterior cervical diskectomy and fusion (ACDF), single-level posterior lumbar fusion (PLF), total knee arthroplasty (TKA), and total hip arthroplasty (THA) were identified. OOP costs associated with the surgical episode were calculated as the sum of deductible payments, copayments, and coinsurance. Monetary data were adjusted to 2019 dollars. General linear regression, Wilcoxon-Mann-Whitney, and Kruskal-Wallis tests were used for analysis, as appropriate.
RESULTS
In total, 10,225 ACDF, 28,841 PLF, 70,815 THA, and 108,940 TKA patients were analyzed. Most patients in our study sample had preferred provider organization insurance plans (ACDF 70.3%, PLF 66.9%, THA 66.2%, and TKA 67.0%). The mean OOP costs for patients, by procedure, were as follows: ACDF $3,180 (SD = 2,495), PLF $3,166 (SD = 2,529), THA $2,884 (SD = 2,100), and TKA $2,733 (SD = 1,994). Total OOP costs increased significantly from 2014 to 2019 for all procedures (P < 0.0001). Among the insurance plans examined, patients with high-deductible health plans had the highest episodic OOP costs. The ratio of patient contribution (OOP costs) to total insurer contribution (payments from insurers to providers) was 0.07 for ACDF, 0.04 for PLF, 0.07 for THA, and 0.07 for TKA.
CONCLUSION
Among commercially insured patients who underwent elective spinal fusion and major lower extremity joint arthroplasty surgery, OOP costs increased from 2014 to 2019. The OOP costs for elective orthopaedic surgery represent a substantial and increasing financial burden for patients.
Topics: Arthroplasty, Replacement, Hip; Arthroplasty, Replacement, Knee; Diskectomy; Elective Surgical Procedures; Health Expenditures; Humans; Linear Models; Retrospective Studies; Spinal Fusion; Statistics, Nonparametric
PubMed: 35797680
DOI: 10.5435/JAAOS-D-22-00085 -
World Neurosurgery Jan 2021As an essential component of minimally invasive spine surgery, endoscopic spine surgery (ESS) has continuously evolved and has been accepted as a practical procedure by... (Review)
Review
As an essential component of minimally invasive spine surgery, endoscopic spine surgery (ESS) has continuously evolved and has been accepted as a practical procedure by the worldwide spine community. Especially for lumbar disc herniation (LDH), the percutaneous endoscopic or full-endoscopic discectomy technique has been scientifically proven through randomized controlled trials and meta-analyses to be a good alternative to open discectomy. The initial concept of endoscopic spine discectomy was concerned with indirect disc decompression using various instruments such as blind forceps, a nucleotome, laser, radiofrequency coblation, and some chemical agents. The main surgical field has been shifted from the intradiscal space to the epidural space. Precise and selective discectomy for extruded LDH in the epidural space under high-quality endoscopic visualization is now feasible. Furthermore, the medical applications of ESS is broadening to include spinal stenosis, segmental instability, infection, and even intradural lesions. In this review article, I describe the history of endoscopic spine discectomy and decompression techniques, as well as evolution of the paradigm. This history may help indicate the future of practical ESS.
Topics: Diskectomy; Humans; Intervertebral Disc Degeneration; Intervertebral Disc Displacement; Minimally Invasive Surgical Procedures; Neuroendoscopy
PubMed: 32781148
DOI: 10.1016/j.wneu.2020.08.008 -
Journal of Visualized Experiments : JoVE Sep 2023With technical advancements, the full-endoscopic transforaminal approach for lumbar discectomy (ETALD) is gaining popularity. This technique utilizes various tools and...
With technical advancements, the full-endoscopic transforaminal approach for lumbar discectomy (ETALD) is gaining popularity. This technique utilizes various tools and instruments, including a dilator, a beveled working sleeve, and an endoscope with a 20-degree angle and 177 mm length, equipped with a 9.3-diameter oval shaft and a 5.6 mm diameter working channel. Additionally, the procedure involves using a Kerrison punch (5.5 mm), rongeur (3-4 mm), punch (5.4 mm), tip control radioablator applying a radiofrequency current of 4 MHz, fluid control irrigation and suction pump device, 5.5 mm oval burr with lateral protection, burr round, and the diamond round. During the surgery, it is essential to identify significant landmarks, including the caudal pedicle, ascending facet, annulus fibrosis, posterior longitudinal ligament, and the exiting nerve root. The steps of the technique are relatively easy to follow, especially when utilizing the appropriate instruments and having a good understanding of the anatomy. Research studies have demonstrated comparable outcomes to open microdiscectomy techniques. ETALD presents itself as a safe option for lumbar discectomy, as it minimizes tissue disruption, results in low postoperative surgical site pain, and allows for early mobilization.
Topics: Humans; Intervertebral Disc Displacement; Diskectomy, Percutaneous; Lumbar Vertebrae; Endoscopy; Diskectomy; Pain, Postoperative; Treatment Outcome; Retrospective Studies
PubMed: 37747222
DOI: 10.3791/65508 -
World Neurosurgery Jan 2021Transforaminal full endoscopic lumbar diskectomy (TELD) is a typical minimally invasive surgery, with the associated benefit of decreased possibility of anatomic... (Review)
Review
Transforaminal full endoscopic lumbar diskectomy (TELD) is a typical minimally invasive surgery, with the associated benefit of decreased possibility of anatomic structural injury, and is an effective alternative to open diskectomy. Among the various endoscopic spinal surgical techniques currently available, TELD is the most basic and traditional surgery that can be performed through the transforaminal route; it has been used for >30 years. Recently, with the advancements in surgical techniques, TELD has been successfully performed for patients with lumbar disk herniation of different types. However, beginner surgeons are unfamiliar with the anatomy of transforaminal endoscopic surgery and this surgery has a steep learning curve to date. If not well prepared, operators may experience complications that require reoperation in the early stages. These complications may include symptomatic incomplete decompression, exiting nerve root injury, dural tearing, and rarely, hematoma, infection, and visceral injury. Here, we propose several technical guidelines for TELD to increase the possibility of successful lumbar diskectomy and to reduce the incidence of complications. The first step is the accurate anatomic understanding of Kambin triangle and determining the appropriate endoscopic access angle, depending on the type of disk herniation. The second step is to determine a safe and easily accessible entry point and then landing and docking the working sleeve as close to the target as possible without causing exiting nerve root injury. The third step is complete decompression of the symptomatic nerve with free mobilization of the neural tissue. The final step involves performing foraminoplasty using an advanced technique to overcome the limitations associated with TELD in difficult cases.
Topics: Diskectomy; Diskectomy, Percutaneous; Humans; Intervertebral Disc Displacement; Lumbar Vertebrae; Minimally Invasive Surgical Procedures; Patient Positioning
PubMed: 32916343
DOI: 10.1016/j.wneu.2020.08.229 -
Clinical Spine Surgery Mar 2020Degenerative spondylolisthesis with or without spondylolysis, multiply recurrent disk herniation, and degenerative disk disease commonly presents as back and leg pain,... (Review)
Review
Degenerative spondylolisthesis with or without spondylolysis, multiply recurrent disk herniation, and degenerative disk disease commonly presents as back and leg pain, weakness and paresthesias. Surgical intervention, to include lumbar decompression with instrumented fusion with or without interbody fusion, is recommended to patients who are refractory to at least six weeks of nonoperative treatment, or patients with severe or progressive neurological deficits. This paper reviews the pre- and post-operative considerations, as well as the surgical technique, for a minimally invasive transforaminal lumbar interbody fusion for the above conditions.
Topics: Diskectomy; Humans; Lumbar Vertebrae; Minimally Invasive Surgical Procedures; Patient Positioning; Postoperative Complications; Spinal Fusion
PubMed: 31625956
DOI: 10.1097/BSD.0000000000000902 -
Journal of Visualized Experiments : JoVE Jan 2024Thoracic disc herniations are a degenerative pathology of the thoracic spine wherein a portion of nucleus pulposis herniates into the epidural space, potentially causing... (Review)
Review
Thoracic disc herniations are a degenerative pathology of the thoracic spine wherein a portion of nucleus pulposis herniates into the epidural space, potentially causing spinal cord or nerve root compression. Traditional surgical treatment for patients with thoracic disc herniations requires relatively invasive anterior or posterolateral approaches that involve extensive muscular dissection and removal of bone in order to access and remove the disc herniation without causing undue compression of the spinal cord. Full endoscopic thoracic discectomy is a minimally invasive technique which allows for the resection of thoracic disc herniations through a small (1 cm) incision, minimizing collateral tissue trauma and obviating the need for the extensive muscle dissection and bony removal required for traditional surgical approaches. In this article, we describe in detail the operative technique for full endoscopic thoracic discectomy and discuss the pearls and pitfalls of the technique. We also provide a review of the outcomes and complications as seen in the literature.
Topics: Humans; Intervertebral Disc Displacement; Diskectomy; Endoscopy; Lumbar Vertebrae; Spinal Cord; Treatment Outcome
PubMed: 38284530
DOI: 10.3791/65951 -
The Journal of the American Academy of... Sep 2020Outcomes after anterior cervical diskectomy and fusion (ACDF) and cervical total disk arthroplasty (TDA) are satisfactory, but related morbidity and revision surgery... (Comparative Study)
Comparative Study
Comparing Predictors of Complications After Anterior Cervical Diskectomy and Fusion, Total Disk Arthroplasty, and Combined Anterior Cervical Diskectomy and Fusion-Total Disk Arthroplasty With a Minimum 2-Year Follow-Up.
INTRODUCTION
Outcomes after anterior cervical diskectomy and fusion (ACDF) and cervical total disk arthroplasty (TDA) are satisfactory, but related morbidity and revision surgery rates are notable. This study sought to determine complication variations among ACDF, TDA, and combined ACDF-TDA as well as predictors of postoperative complications.
METHODS
Patients undergoing 1- to 2-level ACDF and/or TDA with at least a 2-year follow-up from 2009 to 2011 were identified from the Statewide Planning and Research Cooperative System database. Patient demographics, hospital-related parameters, mortality, and postoperative outcomes were compared, and their predictors were identified using multivariate logistic regression.
RESULTS
A total of 16,510 and 449 individuals underwent ACDF and cervical TDA, respectively, and 201 underwent ACDF-TDA. ACDF-TDA patients had the highest rates of cardiac complications and pulmonary embolism (PE) (P ≤ 0.006), whereas TDA patients had higher individual surgical and device/implant/internal fixation complications (P ≤ 0.025). ACDF-TDA patients experienced the lowest rate of revisions. Cervical TDA increased the odds of any surgical complications (OR = 2.5, P = 0.002), overall complications (OR = 1.57, P = 0.034), and revisions (OR = 2.29, P < 0.001). Deyo index predicted any medical/surgical complications (OR = 1.43 and 1.19, respectively). Female sex was associated with increased odds of readmission (OR 1.30, P < 0.001) but was protective against medical complications (OR = 0.81, P = 0.013).
DISCUSSION
Combined ACDF-TDA procedures were not associated with increases in 2-year individual or overall complications, readmissions, or revisions.
LEVEL OF EVIDENCE
Level 3-Therapeutic study.
Topics: Adult; Cervical Vertebrae; Cohort Studies; Diskectomy; Female; Follow-Up Studies; Heart Diseases; Humans; Male; Middle Aged; Negative Results; Patient Readmission; Postoperative Complications; Prosthesis Failure; Pulmonary Embolism; Reoperation; Spinal Fusion; Time Factors; Total Disc Replacement
PubMed: 31860582
DOI: 10.5435/JAAOS-D-19-00666 -
Spine May 2023Retrospective analysis on prospectively collected data.
STUDY DESIGN
Retrospective analysis on prospectively collected data.
OBJECTIVE
The purposes of this study were to (1) assess disparities in relative utilization of outpatient cervical spine surgery between White and Black patients from 2010 to 2019 and (2) to measure how these racial differences have evolved over time.
SUMMARY OF BACKGROUND DATA
Although outpatient spine surgery has become increasingly popularized over the last decade, it remains unknown how racial disparities in surgical utilization have translated to the outpatient setting and whether restrictive patterns of access to outpatient cervical spine procedures may exist.
METHODS
A retrospective cohort study from 2010 to 2019 was conducted using the National Surgical Quality Improvement Program database. Relative utilization of outpatient (same-day discharge) for anterior cervical discectomy and fusion (OP-ACDF) and cervical disk replacement (OP-CDR) were assessed and trended over time between races. Multivariable regressions were subsequently utilized to adjust for baseline patient factors and comorbidities.
RESULTS
Overall, Black patients were significantly less likely to undergo OP-ACDF or OP-CDR surgery when compared with White patients ( P <0.03 for both OP-ACDF and OP-CDR). From 2010 to 2019, a persisting disparity over time was found in outpatient utilization for both ACDF and CDR ( e.g. White vs. Black OP-ACDF: 6.0% vs. 3.1% in 2010 compared with 16.7% vs. 8.5% in 2019). These results held in all adjusted analyses.
CONCLUSIONS
To our knowledge, this is the first study reporting racial disparities in outpatient spine surgery and demonstrates an emerging disparity in outpatient cervical spine utilization among Black patients. These restrictive patterns of access to same-day outpatient hospital and surgery centers may contribute to broader disparities in the overall utilization of major spine procedures that have been previously reported. Renewed interventions are needed to both understand and address these emerging inequalities in outpatient care before they become more firmly established within our orthopedic and neurosurgery spine delivery systems.
Topics: Humans; Retrospective Studies; Outpatients; Diskectomy; Cervical Vertebrae; Patient Discharge; Spinal Fusion
PubMed: 36730624
DOI: 10.1097/BRS.0000000000004544 -
The Spine Journal : Official Journal of... Jan 2023Biportal endoscopic discectomy has been frequently performed in recent years and has shown acceptable clinical outcomes. However, evidence regarding its efficacy and... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND CONTEXT
Biportal endoscopic discectomy has been frequently performed in recent years and has shown acceptable clinical outcomes. However, evidence regarding its efficacy and safety remains limited.
PURPOSE
This study aimed to compare the clinical efficacy and safety of biportal endoscopic with that of open microscopic discectomy in patients with single-level herniated lumbar discs.
STUDY DESIGN
Prospective, randomized, multicenter, open-label, assessor-blind, non-inferiority controlled trial.
PATIENT SAMPLE
Sixty-four participants suffering from low back and leg pain with a single-level herniated lumbar disc and required discectomy.
OUTCOME MEASURES
Outcomes were assessed with the use of patient-reported outcome measures (PROMs), visual analog scale (VAS) pain score for surgical site, low back and lower extremity, Oswestry Disability Index (ODI) for lumbar disabilities, European Quality of Life-5 Dimensions value for quality of life, and painDETECT for neuropathic pain. Surgery-related outcomes such as hospital stay, operation time, and opioid usage were collected. Adverse events occurring during the follow-up period were also noted.
METHODS
All participants were randomly assigned in a 1:1 ratio to undergo biportal endoscopic (biportal group) or microscopic discectomy (microscopy group). The primary outcome was the difference in ODI scores at 12-months post surgically based on a modified intention-to-treat strategy, with a non-inferiority margin of 12.8 points. The secondary outcomes included PROMs, surgery-related outcomes, and adverse events.
RESULTS
The ODI score at the 12-month follow-up was 11.97 in the microscopy group and 13.89 in the biportal group (mean difference, 1.92; 95% confidence interval [CI], -3.50 to 7.34), showing the non-inferiority of biportal group. The results for the secondary outcomes were similar to those for the primary outcome. Creatinine phosphokinase ratios were low in the biportal group. Early surgical site pain was slightly lower in the biportal group (mean difference of VAS pain score at 48-hr, -0.98; 95% CI, -1.77 to -0.19). Adverse events including reoperation showed no significant difference between the groups.
CONCLUSION
Biportal endoscopic discectomy was non-inferior to microscopic discectomy over a 12 month period. Biportal endoscopic discectomy is suggested to be a relatively safe and effective surgical technique with the slight advantage of reduced muscle damage. However, the clinical implications of surgical site pain should be carefully considered.
Topics: Humans; Intervertebral Disc Displacement; Quality of Life; Prospective Studies; Lumbar Vertebrae; Diskectomy; Endoscopy; Treatment Outcome; Pain; Retrospective Studies; Diskectomy, Percutaneous
PubMed: 36155241
DOI: 10.1016/j.spinee.2022.09.003 -
Spine Jul 2022A retrospective study.
STUDY DESIGN
A retrospective study.
OBJECTIVE
This study sought to characterize the incidence and timing of postoperative emergency department (ED) visits after common outpatient spinal surgeries performed at ambulatory surgery centers (ASCs) and at hospital outpatient departments (HOPDs).
SUMMARY OF BACKGROUND DATA
Outpatient spine surgery has markedly grown in popularity over the past decade. The incidence of ED visits after outpatient spine surgery is not well established.
METHODS
This study was a retrospective analysis of a large commercial claims insurance database of patients 65 years old and below. Patients who underwent single-level anterior cervical discectomy and fusion, laminectomy, and microdiscectomy were identified. Incidence, timing, and diagnoses associated with ED visits within the postoperative global period (90 d) after surgery were assessed.
RESULTS
In total, 202,202 patients received outpatient spine surgery (19.1% in ASC vs. 80.9% in HOPD). Collectively, there were 22,198 ED visits during the 90-day postoperative period. Approximately 9.0% of patients had at least 1 ED visit, and the incidence varied by procedure: anterior cervical discectomy and fusion 9.9%, laminectomy 9.5%, and microdiscectomy 8.5% ( P <0.0001). After adjusting for age, sex, and comorbidity index, the odds of at least 1 ED visit were higher among patients who received surgery at HOPD versus ASC for all 3 procedures. The majority (56.1%) ED visits occurred during the first month postoperatively; 30.8% (n=6841) occurred within the first week postoperatively, and 10.7% (n=2370) occurred on the same day as the surgery. Postoperative pain was the most common reason for ED visits.
CONCLUSIONS
Among commercially insured patients who received outpatient spine surgery, the incidence of ED visits during the 90-day postoperative period was ~9%. Our results indicate opportunities for improved postoperative care planning after outpatient spinal surgery.
Topics: Aged; Ambulatory Surgical Procedures; Diskectomy; Emergency Service, Hospital; Humans; Outpatients; Postoperative Complications; Retrospective Studies
PubMed: 35797547
DOI: 10.1097/BRS.0000000000004368