Independent Association of Obesity and Nonroutine Discharge Disposition After Elective Anterior Cervical Discectomy and Fusion for Cervical Spondylotic Myelopathy

Factors Predisposing Patients to Nonhome Discharge After Surgery for Degenerative Cervical Myelopathy: A Retrospective Analysis

OBJECTIVE

The objective of this study is to evaluate factors associated with discharge to subacute care after surgery for degenerative cervical myelopathy.

DESIGN

This is a retrospective chart review of adults who underwent cervical spine surgery for degenerative cervical myelopathy between 2014 and 2020 ( N = 135).

RESULTS

Patients discharged to a subacute setting were older (68.1 ± 8.6 vs. 64.1 yrs ± 8.8, P = 0.01), more likely to be unmarried (55.8% vs. 33.7% married, P = 0.01), and more likely to have Medicare or Medicaid (83.7% vs. 65.9% private insurance, P = 0.03) than patients discharged home. A posterior surgical approach was associated with discharge to a subacute setting (62.8% vs. 43.5% anterior approach, P = 0.04). A total of 87.8% of patients discharged to a subacute setting required moderate or maximum assistance for bed mobility versus 26.6% of patients discharged home ( P < 0.0001). Compared with patients discharged home, patients discharged to a subacute setting ambulated a shorter distance in their first physical therapy evaluation after surgery (8.9 ± 35.8 vs. 53.7 ± 61.78 m in the home discharge group, P < 0.0001).

CONCLUSIONS

Analysis of these factors may guide discussions about patient expectations for postoperative discharge placement.

Racial/Ethnic Disparities Among Patients Undergoing Anterior Cervical Discectomy and Fusion or Posterior Cervical Decompression and Fusion for Cervical Spondylotic Myelopathy: A National Administrative Database Analysis

INTRODUCTION

The aim of this study was to investigate the impact of racial disparities on surgical outcomes for cervical spondylotic myelopathy (CSM).

METHODS

Adult patients undergoing anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) for CSM were identified from the 2016 to 019 National Inpatient Sample Database using the International Classification of Diseases codes. Patients were categorized based on approach (ACDF or PCDF) and race/ethnicity (White, Black, Hispanic). Patient demographics, comorbidities, operative characteristics, adverse events, and health care resource utilization were assessed. Multivariate logistic regression analyses were used to identify independent predictors of extended length of stay (LOS), nonroutine discharge (NRD), and exorbitant costs.

RESULTS

A total of 46,500 patients were identified, of which 36,015 (77.5%) were White, 7465 (16.0%) were Black, and 3020 (6.5%) were Hispanic. Black and Hispanic patients had a greater comorbidity burden compared to White patients (P = 0.001) and a greater incidence of any postoperative complication (P = 0.001). Healthcare resource utilization were greater in the PCDF cohort than the ACDF cohort and greater in Black and Hispanic patients compared to White patients (P < 0.001). Black and Hispanic patient race were significantly associated with extended hospital LOS ([Black] odds ratio [OR]: 2.24, P < 0.001; [Hispanic] OR: 1.64, P < 0.001) and NRD ([Black] OR: 2.33, P < 0.001; [Hispanic] OR: 1.49, P = 0.016). Among patients who underwent PCDF, Black race was independently associated with extended hospital LOS ([Black] OR: 1.77, P < 0.001; [Hispanic] OR: 1.47, P = 0.167) and NRD ([Black] OR: 1.82, P < 0.001; [Hispanic] OR: 1.38, P = 0.052).

CONCLUSIONS

Our study suggests that patient race may influence patient outcomes and healthcare resource utilization following ACDF or PCDF for CSM.

Indication as a predictor for outcomes in anterior cervical discectomy and fusion: The impact of myelopathy on disposition

BACKGROUND

While the indication for Anterior Cervical Discectomy and Fusion (ACDF) may influence the expected postoperative course, there is limited data comparing how length of stay (LOS) and disposition for patients with myelopathy differ from those with radiculopathy. This study aimed to compare LOS and discharge disposition, in patients undergoing ACDF for cervical radiculopathy versus those for myelopathy.

METHODS

A retrospective review of all adult ACDF cases between 2013 and 2019 was conducted analyzing sex, age, race, comorbidities, level of surgery, myelopathy measures when applicable, complications, dysphagia, hospital LOS, and discharge disposition.

RESULTS

A total of 157 patients were included in the study with 73 patients undergoing an ACDF for radiculopathy and 84 for myelopathy. Univariate analysis determined older age (p < 0.01), male sex (p = 0.03), presence of CKD (p < 0.01) or COPD (p = 0.01), surgery at C3/4 level (p = 0.01), and indication (p < 0.01) as predictors for a discharge to either acute rehabilitation or a skilled nursing facility rather than to home. Multivariate logistic regression demonstrated age and indication as the only independent predictors of disposition, with home disposition being more likely with decreased age (OR 0.92, 95 % CI 0.86-0.98) and radiculopathy as the diagnosis (OR 6.72, 95 % CI 1.22- 37.02).

CONCLUSIONS

Myelopathic patients, as compared to those with radiculopathy at presentation, had significantly longer LOS, increased dysphagia, and were more often discharged to a facility. Understanding these two distinct populations as separate entities will streamline the pre and post-surgical care as the current DRG codes and ICD 10 PCS do not differentiate the expected post-operative course in patients undergoing ACDF for myelopathy versus radiculopathy.

Morbid Obesity Increases Length of Surgery in Elective Anterior Cervical Discectomy and Fusion Procedures but Not Readmission or Reoperation Rates: A Cohort Study

BACKGROUND

As the obesity epidemic grows, the number of morbidly obese patients undergoing anterior cervical discectomy and fusion (ACDF) continues to increase. Despite the association of obesity with perioperative complications in anterior cervical surgery, the impact of morbid obesity on ACDF complications remains controversial, and studies examining morbidly obese cohorts are limited.

METHODS

A single-institution, retrospective analysis of patients undergoing ACDF from September 2010 to February 2022 was performed. Demographic, intraoperative, and postoperative data were collected via review of the electronic medical record. Patients were categorized as nonobese (body mass index [BMI] <30), obese (BMI 30-39.9), or morbidly obese (BMI ≥40). Associations of BMI class with discharge disposition, length of surgery, and length of stay were assessed using multivariable logistic regression, multivariable linear regression, and negative binomial regression, respectively.

RESULTS

The study included 670 patients undergoing single-level or multilevel ACDF: 413 (61.6%) nonobese, 226 (33.7%) obese, and 31 (4.6%) morbidly obese patients. BMI class was associated with prior history of deep venous thrombosis (P < 0.01), pulmonary thromboembolism (P < 0.05), and diabetes mellitus (P < 0.001). In bivariate analysis, there was no significant association between BMI class and reoperation or readmission rates at 30, 60, or 365 days postoperatively. In multivariable analysis, greater BMI class was associated with increased length of surgery (P = 0.03), but not length of stay or discharge disposition.

CONCLUSIONS

For patients undergoing ACDF, greater BMI class was associated with increased length of surgery, but not reoperation rate, readmission rate, length of stay, or discharge disposition.

Prognostic Factors Impacting Surgical Outcomes in Patients With Cervical Spondylotic Myelopathy

The purpose of surgical decompression in patients who have CSM is to stop the progression of symptoms and hopefully improve function. It is critical to understand prognostic factors that affect the outcome. Factors intrinsic to the patient that can adversely affect outcomes include diabetes, older age, tobacco use, the presence of mental health disease, and obesity. MRI imaging findings of T2 hyperintensity and clinical duration and severity of symptoms is also associated with poorer outcomes. Patients should be counseled regarding the efficacy of decompressive procedures for CSM and given realistic expectations based on their unique biophysical profiles.

Characteristics of Patients Selected for Surgical Treatment of Spinal Meningioma

BACKGROUND

Spinal meningiomas are benign extra-axial tumors that can present with neurological deficits. Treatment partly depends on the degree of disability as there is no agreed-upon patient selection algorithm at present. We aimed to elucidate general patient selection patterns in patients undergoing surgery for spinal meningioma.

METHODS

Data for patients with spinal tumors admitted between 2016 and 2019 were extracted from the U.S. Nationwide Inpatient Sample. We identified patients with a primary diagnosis of spinal meningioma (using International Classification of Disease, 10^th revision codes) and divided them into surgical and nonsurgical treatment groups. Patient characteristics were evaluated for intergroup differences.

RESULTS

Of 6395 patients with spinal meningioma, 5845 (91.4%) underwent surgery. Advanced age, nonwhite race, obesity, diabetes mellitus, chronic renal failure, and anticoagulant/antiplatelet use were less prevalent in the surgical group (all P < 0.001). The only positive predictor of surgical treatment was elective admission status (odds ratio, 3.166; P < 0.001); negative predictors were low income, Medicaid insurance, anxiety, obesity, and plegia. Patients with bowel-bladder dysfunction, plegia, or radiculopathy were less likely to undergo surgical treatment. The surgery group was less likely to experience certain complications (deep vein thrombosis, P < 0.001; pulmonary embolism, P = 0.002). Increased total hospital charges were associated with nonwhite race, diabetes, depression, obesity, myelopathy, plegia, and surgery.

CONCLUSIONS

Patients treated surgically had a decreased incidence of complications, comorbidities, and Medicaid payer status. A pattern of increased utilization of health care resources and spending was also observed in the surgery group. The results indicate a potentially underserved population of patients with spinal meningioma.