Lumbar Spine Surgery and What We Lost in the Era of the Coronavirus Pandemic: A Survey of the Lumbar Spine Research Society

Socioeconomic disparities in lumbar fusion rates were exacerbated during the COVID-19 pandemic

Background

The COVID-19 pandemic disrupted healthcare access and utilization throughout the US, with variable impact on patients of different socioeconomic status (SES) and race. We characterize pre-pandemic and pandemic demographic and SES trends of lumbar fusion patients in the US.

Methods

Adults undergoing first-time lumbar fusion 1/1/2004-3/31/2021 were assessed in Clinformatics® Data Mart for patient age, geographical location, gender, race, education level, net worth, and Charlson Comorbidity Index (CCI). Multivariable regression models were used to evaluate the significance of trends over time, with a focus on pandemic trends 2020-2021 versus previous trends 2004-2019.

Results

The total 217,204 patients underwent lumbar fusions, 1/1/2004-3/31/2021. The numbers and per capita rates of lumbar fusions increased 2004-2019 and decreased in 2020 (first year of COVID-19 pandemic), with large variation in geographic distribution. There was overall a significant decrease in proportion of White patients undergoing lumbar fusion over time (OR=0.997, p<.001), though they were more likely to undergo surgery during the pandemic (OR=1.016, p<.001). From 2004-2021, patients were more likely to be educated beyond high school. Additionally, patients in the highest (>$500k) and lowest (<$25k) net worth categories had significantly more fusions over time (p<.001). During the pandemic (2020-2021), patients in higher net worth groups were more likely to undergo lumbar fusions ($150k-249k & $250k-499k: p<.001) whereas patients in the lowest net worth group had decreased rate of surgeries (p<.001). Lastly, patients' CCI increased significantly from 2004 to 2021 (coefficient=0.124, p<.001), and this trend held true during the pandemic (coefficient=0.179, p<.001).

Conclusions

To the best of our knowledge, our work represents the most comprehensive and recent characterization of SES variables in lumbar fusion rates. Unsurprisingly, lumbar fusions decreased overall with the onset of the COVID-19 pandemic. Importantly, disparities in fusion patients across patient race and wealth widened during the pandemic, reversing years of progress, a lesson we can learn for future public health emergencies.

Changes in frailty among patients hospitalized for spine pathologies during the COVID-19 pandemic in Germany-a nationwide observational study

PURPOSE

In spine care, frailty is associated with poor outcomes. The aim of this study was to describe changes in frailty in spine care during the coronavirus disease 2019 (COVID-19) pandemic and their relation to surgical management and outcomes.

METHODS

Patients hospitalized for spine pathologies between January 1, 2019, and May 17, 2022, within a nationwide network of 76 hospitals in Germany were retrospectively included. Patient frailty, types of surgery, and in-hospital mortality rates were compared between pandemic and pre-pandemic periods.

RESULTS

Of the 223,418 included patients with spine pathologies, 151,766 were admitted during the pandemic and 71,652 during corresponding pre-pandemic periods in 2019. During the pandemic, the proportion of high-frailty patients increased from a range of 5.1-6.1% to 6.5-8.8% (p < 0.01), while the proportion of low frailty patients decreased from a range of 70.5-71.4% to 65.5-70.1% (p < 0.01). In most phases of the pandemic, the Elixhauser comorbidity index (ECI) showed larger increases among high compared to low frailty patients (by 0.2-1.8 vs. 0.2-0.8 [p < 0.01]). Changes in rates of spine surgery were associated with frailty, most clearly in rates of spine fusion, showing consistent increases among low frailty patients (by 2.2-2.5%) versus decreases (by 0.3-0.8%) among high-frailty patients (p < 0.02). Changes in rates of in-hospital mortality were not associated with frailty.

CONCLUSIONS

During the COVID-19 pandemic, the proportion of high-frailty patients increased among those hospitalized for spine pathologies in Germany. Low frailty was associated with a rise in rates of spine surgery and high frailty with comparably larger increases in rates of comorbidities.

The Effect of the Coronavirus Disease 2019 (COVID-19) Pandemic on Elective Cervical Spine Surgery Utilization and Complications in the United States: A Nationwide Temporal Trends Analysis

OBJECTIVES

As a result of the coronavirus disease 2019 (COVID-19) pandemic, elective surgeries nationwide were suspended. The objective was to compare temporal trends in patient demographics, case volumes, and postoperative complications of patients undergoing elective cervical spine surgery from pre-COVID-19 (2019-2020 Q1) to post-COVID-19 (2020 Q2-Q4).

METHODS

The 2019 to 2020 American College of Surgeon's National Surgery Quality Improvement Program database was queried for common elective cervical spine surgeries. Patients pre-COVID-19 (2019-2020 Q1) were compared with those undergoing surgery during post-COVID-19 (2020 Q2-Q4) protocols. Procedural use, patient demographics, and complications were compared. Linear regression was used to evaluate case volume changes over time. P values less than 0.05 were significant.

RESULTS

In total, 31,013 patients underwent elective cervical spine surgery in 2019 (N = 16,316) and 2020 (N = 14,697); an overall 10% decline. Compared with the calendar year 2019 through 2020 Q1 mean, elective surgery volume decreased by 21.6% in 2020 Q2 and never returned to prepandemic baseline. The percentage decline in case volume from 2019 to 2020 Q1 to 2020 Q2 was greatest for anterior cervical discectomy and fusion (23.3%), followed by cervical decompression (23.4%), posterior cervical fusion (15.0%), and cervical disc arthroplasty and vertebral corpectomy (13.7%). Patients undergoing surgery in 2020 Q2-Q4 had overall greater comorbidity burden (American Society of Anesthesiologists grade 3 and 4) (P < 0.001). From 2019-2020 Q1 versus 2020 Q2-Q4, there was a significant increase in total complication (5.5% vs. 6.8%, P < 0.001), reoperation (1.9% vs. 2.2%, P = 0.048), and mortality (0.25% vs. 0.37%, P = 0.049) rates.

CONCLUSIONS

Elective surgery declined drastically during the second quarter of 2020. Patients undergoing surgery during the pandemic had an overall greater comorbidity burden, resulting in increased total complication and mortality rates over the study period.

Effects of the COVID-19 Pandemic on Spinal Fusion Procedures for Spinal Infections in a Nationwide Hospital Network in Germany

BACKGROUND

 The full impact of the COVID-19 pandemic on surgical spine care is difficult to assess due to a lack in nationwide evidence from more recent phases of the pandemic. We aimed to describe changes in in-hospital processes associated with spinal fusion procedures in the treatment of spinal infections (SI) during different phases of the pandemic.

METHODS

 In this retrospective observational study, we examined the in-hospital prevalence and outcomes of spinal fusion procedures for SI (along with patient characteristics, rates of transfer to intensive care units, and mortality rates) during the first four waves of the pandemic compared with the corresponding prepandemic periods in 2019. We used administrative data from a nationwide network of 76 hospitals managing 7% of all in-hospital cases in Germany.

RESULTS

 We observed no significant change in the prevalence of SI fusion procedures during the pandemic, neither in total numbers (349 vs. 373) nor for each wave separately. On a patient level, we found no differences in age, sex, and the prevalence of paresis, and no relevant differences in associated comorbidities. The rate of mechanical ventilation did not change during any of the examined pandemic waves: it ranged between 9.5 and 18.6% during the pandemic and 3.1 and 16.0% during the corresponding prepandemic control periods. The rate of transfer to intensive care changed only during wave 4 (from 70.4 to 54.8%; p = 0.046) but not in any other pandemic phases. We observed no changes in in-hospital mortality rates (range: 2.9-9.7% vs. 6.2-11.3%) or in duration of hospital stay (range: 26.2-30.8 days vs. 20.8-29.2 days).

CONCLUSIONS

 The main finding of our study is that within this nationwide network of spine care centers in Germany, the delivery of surgical treatment of SI by means of spinal fusion procedures was maintained throughout the first four waves of the pandemic. Furthermore, there were no relevant changes in patient demographics, in-hospital processes, and mortality rates.

Association between chiropractic spinal manipulation and lumbar discectomy in adults with lumbar disc herniation and radiculopathy: retrospective cohort study using United States' data

OBJECTIVES

Chiropractic spinal manipulative therapy (CSMT) and lumbar discectomy are both used for lumbar disc herniation (LDH) and lumbosacral radiculopathy (LSR); however, limited research has examined the relationship between these therapies. We hypothesised that adults receiving CSMT for newly diagnosed LDH or LSR would have reduced odds of lumbar discectomy over 1-year and 2-year follow-up compared with those receiving other care.

DESIGN

Retrospective cohort study.

SETTING

101 million patient US health records network (TriNetX), queried on 24 October 2022, yielding data from 2012 query.

PARTICIPANTS

Adults age 18-49 with newly diagnosed LDH/LSR (first date of diagnosis) were included. Exclusions were prior lumbar surgery, absolute indications for surgery, trauma, spondylolisthesis and scoliosis. Propensity score matching controlled for variables associated with the likelihood of discectomy (eg, demographics, medications).

INTERVENTIONS

Patients were divided into cohorts according to receipt of CSMT.

PRIMARY AND SECONDARY OUTCOME MEASURES

ORs for lumbar discectomy; calculated by dividing odds in the CSMT cohort by odds in the cohort receiving other care.

RESULTS

After matching, there were 5785 patients per cohort (mean age 36.9±8.2). The ORs (95% CI) for discectomy were significantly reduced in the CSMT cohort compared with the cohort receiving other care over 1-year (0.69 (0.52 to 0.90), p=0.006) and 2-year follow-up (0.77 (0.60 to 0.99), p=0.040). E-value sensitivity analysis estimated the strength in terms of risk ratio an unmeasured confounding variable would need to account for study results, yielding point estimates for each follow-up (1 year: 2.26; 2 years: 1.92), which no variables in the literature reached.

CONCLUSIONS

Our findings suggest receiving CSMT compared with other care for newly diagnosed LDH/LSR is associated with significantly reduced odds of discectomy over 2-year follow-up. Given socioeconomic variables were unavailable and an observational design precludes inferring causality, the efficacy of CSMT for LDH/LSR should be examined via randomised controlled trial to eliminate residual confounding.

Impact on neurosurgical management in a Level 1 trauma center post COVID-19 shelter-in-place restrictions

The stringent restrictions from shelter-in-place (SIP) policies placed on hospital operations during the COVID-19 pandemic led to a sharp decrease in planned surgical procedures. This study quantifies the surgical rebound experienced across a neurosurgical service post SIP restrictions in order to guide future hospital programs with resource management. We conducted a retrospective review of all neurosurgical procedures at a public Level 1 trauma center between February 15th to August 30th for the years spanning 2018-2020. We categorized patient procedures into four comparative one-month periods: pre-SIP; SIP; post-SIP; and late recovery. Patient procedures were designated as either cranial; spinal; and other; as well as Elective or Add-on (Urgent/Emergent). Categorical variables were analyzed using χ2 tests and Fisher's exact tests. A total of 347 cases were reviewed across the four comparative periods and three years studied; with 174 and 152 spinal and cranial procedures; respectively. There was a proportional increase; relative to historical controls; in total spinal procedures (p-value < 0.001) and elective spinal procedures (p-value < 0.001) in the 2020 SIP to Post-SIP. The doubling of elective spinal cases in the Post-SIP period returned to historical baseline levels in three months after SIP restrictions were lifted. Total cranial procedures were proportionally increased during the SIP period relative to historical controls (p-value = 0.005). We provide a census on the post-pandemic neurosurgical operative demands at a major public Level 1 trauma hospital, which can potentially be applied for resource allocations in other disaster scenarios.