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Paziuk T, Mazmudar AS, Issa TZ, Henry TW, Patel AA, Hilibrand AS, Schroeder GD, Kepler CK, Vaccaro AR, Rihn JA, Brodke DS, Bisson EF, Karamian BA. Does Operative Level Impact Dysphagia Severity After Anterior Cervical Discectomy and Fusion?: A Multicenter Prospective Analysis. Spine (Phila Pa 1976) 2024; 49:909-915. [PMID: 38369769 DOI: 10.1097/brs.0000000000004965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/29/2024] [Indexed: 02/20/2024]
Abstract
STUDY DESIGN Prospective multicenter cohort study. OBJECTIVE To explore the association between operative level and postoperative dysphagia after anterior cervical discectomy and fusion (ACDF). BACKGROUND Dysphagia is common after ACDF and has several risk factors, including soft tissue edema. The degree of prevertebral soft tissue edema varies based on the operative cervical level. However, the operative level has not been evaluated as a source of postoperative dysphagia. PATIENTS AND METHODS Adult patients undergoing elective ACDF were prospectively enrolled at 3 academic centers. Dysphagia was assessed using the Bazaz Questionnaire, Dysphagia Short Questionnaire, and Eating Assessment Tool-10 (EAT-10) preoperatively and at 2, 6, 12, and 24 weeks postoperatively. Patients were grouped based on the inclusion of specific surgical levels in the fusion construct. Multivariable regression analyses were performed to evaluate the independent effects of the number of surgical levels and the inclusion of each particular level on dysphagia symptoms. RESULTS A total of 130 patients were included. Overall, 24 (18.5%) patients had persistent postoperative dysphagia at 24 weeks and these patients were older, female, and less likely to drink alcohol. There was no difference in operative duration or dexamethasone administration. Patients with persistent dysphagia were significantly more likely to have C4-C5 included in the fusion construct (62.5% vs . 34.9%, P = 0.024) but there were no differences based on the inclusion of other levels. On multivariable regression, the inclusion of C3-C4 or C6-C7 was associated with more severe EAT-10 (β: 9.56, P = 0.016 and β: 8.15, P = 0.040) and Dysphagia Short Questionnaire (β: 4.44, P = 0.023 and (β: 4.27, P = 0.030) at 6 weeks. At 12 weeks, C3-C4 fusion was also independently associated with more severe dysphagia (EAT-10 β: 4.74, P = 0.024). CONCLUSION The location of prevertebral soft tissue swelling may impact the duration and severity of patient-reported dysphagia outcomes at up to 24 weeks postoperatively. In particular, the inclusion of C3-C4 and C4-C5 into the fusion may be associated with dysphagia severity.
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Affiliation(s)
- Taylor Paziuk
- Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University, Philadelphia, PA
| | - Aditya S Mazmudar
- Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University, Philadelphia, PA
| | - Tariq Z Issa
- Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University, Philadelphia, PA
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Tyler W Henry
- Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University, Philadelphia, PA
| | - Alpesh A Patel
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Alan S Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University, Philadelphia, PA
| | - Gregory D Schroeder
- Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University, Philadelphia, PA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University, Philadelphia, PA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University, Philadelphia, PA
| | - Jeffrey A Rihn
- Department of Orthopaedic Surgery, Rothman Institute and Thomas Jefferson University, Philadelphia, PA
| | - Darrel S Brodke
- Department of Orthopaedic Surgery, University Orthopaedic Center, University of Utah, Salt Lake City, UT
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT
| | - Brian A Karamian
- Department of Orthopaedic Surgery, University Orthopaedic Center, University of Utah, Salt Lake City, UT
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Mazmudar A, Paziuk T, Mangan J, Tran K, Oh S, Li S, Sherrod B, Bisson E, Brodke D, Kepler C, Schroeder G, Vaccaro A, Hilibrand A, Rihn JA. Evaluating the Effect of Gastroesophageal Reflux Disease on Postoperative Dysphagia Following Anterior Cervical Spine Surgery-A Prospective, Multicenter Study. Global Spine J 2024; 14:1595-1600. [PMID: 36625340 PMCID: PMC11394504 DOI: 10.1177/21925682231151645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVES The purpose of this study was to prospectively evaluate the impact of a preoperative diagnosis of gastroesophageal reflux disease on the incidence and severity of postoperative dysphagia in a multicenter population. METHODS After Institutional Review Board approval, written informed consent was obtained from all participating patients. Patients over 18 years of age who underwent an elective anterior cervical discectomy and fusion for a degenerative condition were prospectively enrolled at two academic centers from the years 2018 to 2020. Patients were separated into two groups: those with and without a preoperative diagnosis of GERD. Continuous variables were assessed using either an independent t-test or Mann Whitney U-test for parametric and non-parametric data. All categorical variables were compared using a chi-square test. RESULTS A total of 116 patients met study criteria and were subsequently enrolled. Overall rates of postoperative dysphagia increased to 47.3% (n = 53) at 2-weeks but eventually decreased towards the preoperative prevalence of 25.0% at the 24-week mark. Patients with preoperative diagnosis of GERD had lower dysphagia severity scores on a continuous variable analysis in both the DSQ and EAT-10 surveys at 2-week follow-up in addition to the Bazaz survey at 24-week follow-up. Our follow up at 24-weeks was 85.7%. CONCLUSIONS Our study shows that having a preoperative diagnosis of GERD has no significant effect on the incidence of dysphagia following ACDF. Nevertheless, having a preoperative diagnosis of GERD does seem to provide some protective effect on the severity of dysphagia that this patient population develops at multiple intervals over a 24-week postoperative period.
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Affiliation(s)
- Aditya Mazmudar
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute and Thomas Jefferson University, Philadelphia, PA, USA
| | - Taylor Paziuk
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute and Thomas Jefferson University, Philadelphia, PA, USA
| | - John Mangan
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute and Thomas Jefferson University, Philadelphia, PA, USA
| | - Khoa Tran
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute and Thomas Jefferson University, Philadelphia, PA, USA
| | - Samuel Oh
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute and Thomas Jefferson University, Philadelphia, PA, USA
| | - Sandy Li
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute and Thomas Jefferson University, Philadelphia, PA, USA
| | - Brandon Sherrod
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Erica Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Darrel Brodke
- Department of Orthopaedic Surgery, University Orthopaedic Center, University of Utah, Salt Lake City, UT, USA
| | - Christopher Kepler
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute and Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory Schroeder
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute and Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander Vaccaro
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute and Thomas Jefferson University, Philadelphia, PA, USA
| | - Alan Hilibrand
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute and Thomas Jefferson University, Philadelphia, PA, USA
| | - Jeffrey A Rihn
- Department of Orthopaedic Surgery, Rothman Orthopaedic Institute and Thomas Jefferson University, Philadelphia, PA, USA
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Desai A, Butke J, Herring EZ, Labak CM, Mauria R, Mahajan UV, Ronald A, Gerges C, Sajatovic M, Kasliwal MK. Indication as a predictor for outcomes in anterior cervical discectomy and fusion: The impact of myelopathy on disposition. Clin Neurol Neurosurg 2024; 236:108092. [PMID: 38134756 DOI: 10.1016/j.clineuro.2023.108092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 12/12/2023] [Accepted: 12/17/2023] [Indexed: 12/24/2023]
Abstract
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.
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Affiliation(s)
- Ansh Desai
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Jeffrey Butke
- Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Eric Z Herring
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Collin M Labak
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Rohit Mauria
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Uma V Mahajan
- Department of Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States
| | - Andrew Ronald
- Department of Orthopedic Surgery, Boston University, Boston, MA, United States
| | - Christina Gerges
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR, United States
| | - Martha Sajatovic
- Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center & Case Western Reserve University School of Medicine, Cleveland, OH, United States
| | - Manish K Kasliwal
- Case Western Reserve University School of Medicine, Cleveland, OH, United States; Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH, United States.
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Droeghaag R, Schuermans VNE, Hermans SMM, Smeets AYJM, Caelers IJMH, Hiligsmann M, Evers S, van Hemert WLW, van Santbrink H. Methodology of economic evaluations in spine surgery: a systematic review and qualitative assessment. BMJ Open 2023; 13:e067871. [PMID: 36958779 PMCID: PMC10040072 DOI: 10.1136/bmjopen-2022-067871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
OBJECTIVES The present study is a systematic review conducted as part of a methodological approach to develop evidence-based recommendations for economic evaluations in spine surgery. The aim of this systematic review is to evaluate the methodology and quality of currently available clinical cost-effectiveness studies in spine surgery. STUDY DESIGN Systematic literature review. DATA SOURCES PubMed, Web of Science, Embase, Cochrane, Cumulative Index to Nursing and Allied Health Literature, EconLit and The National Institute for Health Research Economic Evaluation Database were searched through 8 December 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Studies were included if they met all of the following eligibility criteria: (1) spine surgery, (2) the study cost-effectiveness and (3) clinical study. Model-based studies were excluded. DATA EXTRACTION AND SYNTHESIS The following data items were extracted and evaluated: pathology, number of participants, intervention(s), year, country, study design, time horizon, comparator(s), utility measurement, effectivity measurement, costs measured, perspective, main result and study quality. RESULTS 130 economic evaluations were included. Seventy-four of these studies were retrospective studies. The majority of the studies had a time horizon shorter than 2 years. Utility measures varied between the EuroQol 5 dimensions and variations of the Short-Form Health Survey. Effect measures varied widely between Visual Analogue Scale for pain, Neck Disability Index, Oswestry Disability Index, reoperation rates and adverse events. All studies included direct costs from a healthcare perspective. Indirect costs were included in 47 studies. Total Consensus Health Economic Criteria scores ranged from 2 to 18, with a mean score of 12.0 over all 130 studies. CONCLUSIONS The comparability of economic evaluations in spine surgery is extremely low due to different study designs, follow-up duration and outcome measurements such as utility, effectiveness and costs. This illustrates the need for uniformity in conducting and reporting economic evaluations in spine surgery.
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Affiliation(s)
- Ruud Droeghaag
- Orthopedic Surgery, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Valérie N E Schuermans
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Neurosurgery, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
- Neurosurgery, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Sem M M Hermans
- Orthopedic Surgery, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
| | - Anouk Y J M Smeets
- Neurosurgery, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
- Neurosurgery, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Inge J M H Caelers
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Neurosurgery, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Mickaël Hiligsmann
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Health Services Research, Maastricht University, Maastricht, The Netherlands
| | - Silvia Evers
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Health Services Research, Maastricht University, Maastricht, The Netherlands
- Centre of Economic Evaluation & Machine Learning, Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | | | - Henk van Santbrink
- Caphri School of Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
- Neurosurgery, Zuyderland Medical Centre Heerlen, Heerlen, The Netherlands
- Neurosurgery, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
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Muacevic A, Adler JR, Ihionkhan E, Vingan R, Khan MF, Azmi H, Karimi R, Roth PA. Assessment of Spine Patient Preferences for the Location of Surgery Between a Hospital and an Ambulatory Surgical Center in the Time of COVID-19: An Analysis of Patient Surveys. Cureus 2022; 14:e31655. [PMID: 36545174 PMCID: PMC9760451 DOI: 10.7759/cureus.31655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction There has been a recent increase in the number of spinal procedures that can be performed in ambulatory surgical centers (ASCs). Studies have found that patients who undergo procedures at ASCs tend to have lower complication rates following procedures, including lower infection rates. Furthermore, ASCs offer significantly lower costs of procedures to patients and health insurance companies as compared to the costs of procedures performed in a hospital. Despite precautions and screening in place by ASCs, patients may be hesitant to undergo procedures outside of the hospital. Conversely, the ongoing COVID-19 pandemic has created hesitancy for many to go to the hospital for care due to the presence of COVID patients. Objective To assess patient preferences in the location of elective spine procedures between ASCs and hospitals, the authors conducted a survey of spine surgery candidates in a single practice. Methods A survey measuring patient age, vaccination status, fear of contracting COVID-19, and preference of surgery location was given to spinal surgery candidates at a single practice between fall 2021 and winter 2022. Statistical differences between the means of response groups were measured by a two-sample Z-score test. Results A total of 58 surveys were completed by patients. No difference in preference was observed by age. A difference was observed between genders, with 66% of females preferring ASCs to 40% of males (α=0.03). Patients with a fear of contracting COVID-19 preferred to have their procedure performed in an ASC. No difference was observed in location due to vaccination status, but unvaccinated patients had a significantly lower fear of contracting COVID-19 (α=0.02). Conclusion The differences in patient preferences have no clear cause, highlighting the need for better patient education in regard to the risks and benefits of each location of surgery. The fear of contracting COVID-19 on the day of surgery appears to be more ideological than rational for unvaccinated patients, who had less fear of contracting COVID-19 than vaccinated patients, despite being more likely to contract COVID-19 than vaccinated patients.
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Frailty as a Superior Predictor of Dysphagia and Surgically Placed Feeding Tube Requirement After Anterior Cervical Discectomy and Fusion Relative to Age. Dysphagia 2022; 38:837-846. [PMID: 35945302 DOI: 10.1007/s00455-022-10505-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/25/2022] [Indexed: 11/03/2022]
Abstract
Frailty is a measure of physiological reserve that has been demonstrated to be a discriminative predictor of worse outcomes across multiple surgical subspecialties. Anterior cervical discectomy and fusion (ACDF) is one of the most common neurosurgical procedures in the United States and has a high incidence of postoperative dysphagia. To determine the association between frailty and dysphagia after ACDF and compare the predictive value of frailty and age. 155,300 patients with cervical stenosis (CS) who received ACDF were selected from the 2016-2019 National Inpatient Sample (NIS) utilizing International Classification of Disease, tenth edition (ICD-10) codes. The 11-point modified frailty index (mFI-11) was used to stratify patients based on frailty: mFI-11 = 0 was robust, mFI-11 = 1 was prefrail, mFI-11 = 2 was frail, and mFI-11 = 3 + was characterized as severely frail. Demographics, complications, and outcomes were compared between frailty groups. A total of 155,300 patients undergoing ACDF for CS were identified, 33,475 (21.6%) of whom were frail. Dysphagia occurred in 11,065 (7.1%) of all patients, and its incidence was significantly higher for frail patients (OR 1.569, p < 0.001). Frailty was a risk factor for postoperative complications (OR 1.681, p < 0.001). Increasing frailty and undergoing multilevel ACDF were significant independent predictors of negative postoperative outcomes, including dysphagia, surgically placed feeding tube (SPFT), prolonged LOS, non-home discharge, inpatient death, and increased total charges (p < 0.001 for all). Increasing mFI-11 score has better prognostic value than patient age in predicting postoperative dysphagia and SPFT after ACDF.
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