Validation of an electronic coding algorithm to identify the primary indication of orthopedic surgeries from administrative data

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.

Assessing the quality of shared decision making for elective orthopedic surgery across a large healthcare system: cross-sectional survey study

Background

Clinical guidelines recommend engaging patients in shared decision making for common orthopedic procedures; however, limited work has assessed what is occurring in practice. This study assessed the quality of shared decision making for elective hip and knee replacement and spine surgery at four network-affiliated hospitals.

Methods

A cross-sectional sample of 875 adult patients undergoing total hip or knee joint replacement (TJR) for osteoarthritis or spine surgery for lumbar herniated disc or lumbar spinal stenosis was selected. Patients were mailed a survey including measures of Shared Decision Making (SDMP scale) and Informed, Patient-Centered (IPC) decisions. We examined decision-making across sites, surgeons, and conditions, and whether the decision-making measures were associated with better health outcomes. Analyses were adjusted for clustering of patients within surgeons.

Results

Six hundred forty-six surveys (74% response rate) were returned with sufficient responses for analysis. Patients who had TJR reported lower SDMP scores than patients who had spine surgery (2.2 vs. 2.8; p < 0.001). Patients who had TJR were more likely to make IPC decisions (OA = 70%, Spine = 41%; p < 0.001). SDMP and IPC scores varied widely across surgeons, but the site was not predictive of SDMP scores or IPC decisions (all p > 0.09). Higher SDMP scores and IPC decisions were associated with larger improvements in global health outcomes for patients who had TJR, but not patients who had spine surgery.

Conclusions

Measures of shared decision making and decision quality varied among patients undergoing common elective orthopedic procedures. Routine measurement of shared decision making provides insight into areas of strength across these different orthopedic conditions as well as areas in need of improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04853-x.

Association between radicular low back pain and constipation: a retrospective cohort study using a real-world national database

INTRODUCTION

Previous observational studies have reported an association between lumbosacral radiculopathy (LSR), a form of low back pain (LBP) with nerve root involvement, and constipation. However, it is unclear whether this association is due to confounding variables such as comorbidities and medications.

OBJECTIVES

This study explores the possible association between LSR and constipation, with the hypothesis that adults with LSR have increased odds of developing constipation compared with those with nonradicular LBP.

METHODS

Adults aged 18 to 49 years with incident LSR and nonradicular LBP were identified from a national 70 million patient electronic health records network (TriNetX). Propensity score matching (PSM) was used to control for covariates and determine the odds ratio (OR) of constipation over a 1-year follow-up. Lumbar stenosis, cauda equina syndrome, and inflammatory bowel diseases were excluded.

RESULTS

After PSM, 503,062 patients were in each cohort. Before PSM, the likelihood of constipation was identical between cohorts (LSR 10.8% vs 10.9%; OR [confidence interval] = 0.99 [0.98-1.0], P = 0.251). This association was unchanged after PSM (LSR 10.8% vs 11.1%; OR [confidence interval] = 0.98 [0.97-0.99]; P = 0.003).

CONCLUSIONS

The study hypothesis can be refuted given that the OR approximated the null in a large propensity-matched sample. Patients with LSR have equivalent odds of constipation compared with those with nonradicular LBP, suggesting that LSR is not a direct cause of constipation. The similar risk of constipation between cohorts could be explained by factors common to LBP in general, such as pain severity, physical inactivity, and constipating medications.