1
|
Trenchfield D, Lee Y, Lambrechts M, D'Antonio N, Heard J, Paulik J, Somers S, Rihn J, Kurd M, Kaye D, Canseco J, Hilibrand A, Vaccaro A, Kepler C, Schroeder G. Correction of Spinal Sagittal Alignment after Posterior Lumbar Decompression: Does Severity of Central Canal Stenosis Matter? Asian Spine J 2023; 17:1089-1097. [PMID: 38050360 PMCID: PMC10764140 DOI: 10.31616/asj.2023.0075] [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] [Received: 03/20/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 12/06/2023] Open
Abstract
STUDY DESIGN This study adopted a retrospective study design. PURPOSE Our study aimed to investigate the impact of central canal stenosis severity on surgical outcomes and lumbar sagittal correction after lumbar decompression. OVERVIEW OF LITERATURE Studies have evaluated sagittal correction in patients with central canal stenosis after lumbar decompression and the association of stenosis severity with worse preoperative sagittal alignment. However, none have evaluated the impact of spinal stenosis severity on sagittal correction. METHODS Patients undergoing posterior lumbar decompression (PLD) of ≤4 levels were divided into severe and non-severe central canal stenosis groups based on the Lee magnetic resonance imaging (MRI) grading system. Patients without preoperative MRI or inadequate visualization on radiographs were excluded. Surgical characteristics, clinical outcomes, and sagittal measurements were compared. Multivariate logistic regression was performed to determine the predictors of pelvic tilt (PT), sacral slope (SS), lumbar lordosis (LL), and pelvic incidence minus lumbar lordosis (PI-LL). RESULTS Of the 142 patients included, 39 had severe stenosis, and 103 had non-severe stenosis. The mean follow-up duration for the cohort was 4.72 months. Patients with severe stenosis were older, had higher comorbidity indices and levels decompressed, and longer lengths of stay and operative times (p <0.001). Although those with severe stenosis had lower lordosis, lower SS, and higher PI-LL mismatch preoperatively, no differences in Delta LL, SS, PT, or PI-LL were observed between the two groups (p >0.05). On multivariate regression, severe stenosis was a significant predictor of a lower preoperative LL (estimate=-5.243, p =0.045) and a higher preoperative PI-LL mismatch (estimate=6.192, p =0.039). No differences in surgical or clinical outcomes were observed (p >0.05). CONCLUSION Severe central lumbar stenosis was associated with greater spinopelvic mismatch preoperatively. Sagittal balance improved in both patients with severe and non-severe stenosis after PLD to a similar degree, with differences in sagittal parameters remaining after surgery. We also found no differences in postoperative outcomes associated with stenosis severity.
Collapse
Affiliation(s)
- Delano Trenchfield
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Yunsoo Lee
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark Lambrechts
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Nicholas D'Antonio
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jeremy Heard
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - John Paulik
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Sydney Somers
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jeffrey Rihn
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Mark Kurd
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - David Kaye
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose Canseco
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alan Hilibrand
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander Vaccaro
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher Kepler
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Gregory Schroeder
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| |
Collapse
|
2
|
Caprariu R, Oprea MD, Poenaru DV, Andrei D. Correlation between Preoperative MRI Parameters and Oswestry Disability Index in Patients with Lumbar Spinal Stenosis: A Retrospective Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2000. [PMID: 38004049 PMCID: PMC10672893 DOI: 10.3390/medicina59112000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 11/01/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023]
Abstract
Background and Objectives: Lumbar spinal stenosis (LSS) is a degenerative condition posing significant challenges in clinical management. Despite the use of radiological parameters and patient-reported outcome measures like the Oswestry Disability Index (ODI) for evaluation, there is limited understanding of their interrelationship. This study aimed to investigate the correlation between preoperative MRI parameters and ODI scores in patients with LSS undergoing surgical treatment. Materials and Methods: A retrospective analysis was conducted on 86 patients diagnosed with LSS over a 5-year period. Preoperative MRI measurements, including the cross-sectional area of the psoas muscle, lumbar canal stenosis, neural foramina area, and facet joint osteoarthritis, were assessed. ODI scores were collected preoperatively and at a 1-year follow-up. Statistical analyses were performed using IBM SPSS Statistics software (version 26). Results: Weak to moderate correlations were observed between certain MRI parameters and ODI scores. The initial ODI score had a weak positive correlation with the severity of lumbar canal stenosis according to Schizas criteria (rho = 0.327, p = 0.010) and a moderate negative correlation with the relative cross-sectional area of the psoas muscle (rho = -0.498, p = 0.000). At 1-year follow-up, the ODI had a weak negative correlation with the relative cross-sectional area of the psoas muscle (rho = -0.284, p = 0.026). Conclusions: While the severity of LSS showed a weak correlation with initial ODI, it was not a predictor of 1-year postoperative ODI. Furthermore, although the cross-sectional area of the thecal sac, the sagittal area of the neural foramen, and the grade of facet joint osteoarthritis influence the imagistic severity, none of them correlate with ODI. These findings underscore the need for a comprehensive model that integrates multiple imaging and clinical parameters for a holistic understanding of LSS and its functional outcomes.
Collapse
Affiliation(s)
- Radu Caprariu
- Department of Radiology and Medical Imaging, University of Medicine and Pharmacy “Victor Babes”, 300041 Timisoara, Romania;
| | - Manuel D. Oprea
- Department of Traumatology and Orthopedics, University of Medicine and Pharmacy “Victor Babes”, 300041 Timisoara, Romania;
| | - Dan V. Poenaru
- Department of Traumatology and Orthopedics, University of Medicine and Pharmacy “Victor Babes”, 300041 Timisoara, Romania;
| | - Diana Andrei
- Department of Balneology, Medical Rehabilitation and Rheumatology, University of Medicine and Pharmacy “Victor Babes”, 300041 Timisoara, Romania;
| |
Collapse
|
3
|
Lacroix M, Khalifé M, Ferrero E, Clément O, Nguyen C, Feydy A. Scoliosis. Semin Musculoskelet Radiol 2023; 27:529-544. [PMID: 37816361 DOI: 10.1055/s-0043-1772168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023]
Abstract
Scoliosis is a three-dimensional spinal deformity that can occur at any age. It may be idiopathic or secondary in children, idiopathic and degenerative in adults. Management of patients with scoliosis is multidisciplinary, involving rheumatologists, radiologists, orthopaedic surgeons, and prosthetists. Imaging plays a central role in diagnosis, including the search for secondary causes, follow-up, and preoperative work-up if surgery is required. Evaluating scoliosis involves obtaining frontal and lateral full-spine radiographs in the standing position, with analysis of coronal and sagittal alignment. For adolescent idiopathic scoliosis, imaging follow-up is often required, accomplished using low-dose stereoradiography such as EOS imaging. For adult degenerative scoliosis, the crucial characteristic is rotatory subluxation, also well detected on radiographs. Magnetic resonance imaging is usually more informative than computed tomography for visualizing associated canal and foraminal stenoses. Radiologists must also have a thorough understanding of postoperative features and complications of scoliosis surgery because aspects can be misleading.
Collapse
Affiliation(s)
- Maxime Lacroix
- Department of Radiology, Hôpital Européen Georges-Pompidou, AP-HP Centre, Université Paris Cité, Paris, France
- Department of Musculoskeletal Radiology, Hôpital Cochin, AP-HP Centre, Université Paris Cité, Paris, France
| | - Marc Khalifé
- Department of Orthopaedic Surgery, Hôpital Européen Georges- Pompidou, AP-HP Centre, Université Paris Cité, Paris, France
| | - Emmanuelle Ferrero
- Department of Orthopaedic Surgery, Hôpital Européen Georges- Pompidou, AP-HP Centre, Université Paris Cité, Paris, France
| | - Olivier Clément
- Department of Radiology, Hôpital Européen Georges-Pompidou, AP-HP Centre, Université Paris Cité, Paris, France
| | - Christelle Nguyen
- Department of Physical and Rehabilitation Medicine, Hôpital Cochin, Université Paris Cité, Paris, France
| | - Antoine Feydy
- Department of Musculoskeletal Radiology, Hôpital Cochin, AP-HP Centre, Université Paris Cité, Paris, France
| |
Collapse
|
4
|
Lewandrowski KU, Yeung A, Lorio MP, Yang H, Ramírez León JF, Sánchez JAS, Fiorelli RKA, Lim KT, Moyano J, Dowling Á, Sea Aramayo JM, Park JY, Kim HS, Zeng J, Meng B, Gómez FA, Ramirez C, De Carvalho PST, Rodriguez Garcia M, Garcia A, Martínez EE, Gómez Silva IM, Valerio Pascua JE, Duchén Rodríguez LM, Meves R, Menezes CM, Carelli LE, Cristante AF, Amaral R, de Sa Carneiro G, Defino H, Yamamoto V, Kateb B. Personalized Interventional Surgery of the Lumbar Spine: A Perspective on Minimally Invasive and Neuroendoscopic Decompression for Spinal Stenosis. J Pers Med 2023; 13:jpm13050710. [PMID: 37240880 DOI: 10.3390/jpm13050710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/31/2023] [Accepted: 04/06/2023] [Indexed: 05/28/2023] Open
Abstract
Pain generator-based lumbar spinal decompression surgery is the backbone of modern spine care. In contrast to traditional image-based medical necessity criteria for spinal surgery, assessing the severity of neural element encroachment, instability, and deformity, staged management of common painful degenerative lumbar spine conditions is likely to be more durable and cost-effective. Targeting validated pain generators can be accomplished with simplified decompression procedures associated with lower perioperative complications and long-term revision rates. In this perspective article, the authors summarize the current concepts of successful management of spinal stenosis patients with modern transforaminal endoscopic and translaminar minimally invasive spinal surgery techniques. They represent the consensus statements of 14 international surgeon societies, who have worked in collaborative teams in an open peer-review model based on a systematic review of the existing literature and grading the strength of its clinical evidence. The authors found that personalized clinical care protocols for lumbar spinal stenosis rooted in validated pain generators can successfully treat most patients with sciatica-type back and leg pain including those who fail to meet traditional image-based medical necessity criteria for surgery since nearly half of the surgically treated pain generators are not shown on the preoperative MRI scan. Common pain generators in the lumbar spine include (a) an inflamed disc, (b) an inflamed nerve, (c) a hypervascular scar, (d) a hypertrophied superior articular process (SAP) and ligamentum flavum, (e) a tender capsule, (f) an impacting facet margin, (g) a superior foraminal facet osteophyte and cyst, (h) a superior foraminal ligament impingement, (i) a hidden shoulder osteophyte. The position of the key opinion authors of the perspective article is that further clinical research will continue to validate pain generator-based treatment protocols for lumbar spinal stenosis. The endoscopic technology platform enables spine surgeons to directly visualize pain generators, forming the basis for more simplified targeted surgical pain management therapies. Limitations of this care model are dictated by appropriate patient selection and mastering the learning curve of modern MIS procedures. Decompensated deformity and instability will likely continue to be treated with open corrective surgery. Vertically integrated outpatient spine care programs are the most suitable setting for executing such pain generator-focused programs.
Collapse
Affiliation(s)
- Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, Tucson, AZ 85712, USA
- Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá 111321, Colombia
- Department of Orthopedics at Hospital Universitário Gaffree Guinle Universidade Federal do Estado do Rio de Janeiro, R. Mariz e Barros, 775-Maracanã, Rio de Janeiro 20270-004, Brazil
- Brain Technology and Innovation Park, Pacific Palisades, CA 90272, USA
| | - Anthony Yeung
- Desert Institute for Spine Care, 1635 E Myrtle Ave Suite 400, Phoenix, AZ 85020, USA
- Department of Neurosurgery, University of New Mexico School of Medicine, 915 Camino de Salud NE Albuquerque, Albuquerque, NM 87106, USA
| | - Morgan P Lorio
- Advanced Orthopedics, 499 East Central Parkway, Altamonte Springs, FL 32701, USA
| | - Huilin Yang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou 215031, China
| | - Jorge Felipe Ramírez León
- Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá 111321, Colombia
- Minimally Invasive Spine Center Bogotá D.C. Colombia, Reina Sofía Clinic Bogotá D.C. Colombia, Bogotá 110141, Colombia
| | | | - Rossano Kepler Alvim Fiorelli
- Department of General and Specialized Surgery, Gaffrée e Guinle University Hospital, Federal University of the State of Rio de Janeiro (UNIRIO), Rio de Janeiro 20000-000, Brazil
| | - Kang Taek Lim
- Good Doctor Teun Teun Spine Hospital, Seoul 775 , Republic of Korea
| | - Jaime Moyano
- Torres Médicas Hospital Metropolitano, San Gabriel y Nicolás Arteta Torre Médica 3, Piso 5, Quito 170521, Ecuador
| | - Álvaro Dowling
- DWS Spine Clinic Center, CENTRO EL ALBA-Cam. El Alba 9500, Of. A402, Región Metropolitana, Las Condes 9550000, Chile
- Department of Orthopaedic Surgery, Faculdade de Medicina de Ribeirão Preto (FMRP) da Universidade de São Paulo (USP), Ribeirão Preto 14040-900, Brazil
| | | | - Jeong-Yoon Park
- Department of Neurosurgery, Spine and Spinal Cord Institute, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 731, Republic of Korea
| | - Hyeun-Sung Kim
- Department of Neurosurgery, Nanoori Hospital Gangnam Hospital, Seoul 731, Republic of Korea
| | - Jiancheng Zeng
- Department of Orthopaedic Surgery, West China Hospital Sichuan University, Chengdu 610041, China
| | - Bin Meng
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Soochow University, Suzhou 215005, China
| | | | - Carolina Ramirez
- Centro de Cirugía Mínima Invasiva-CECIMIN, Avenida Carrera 45 # 104-76, Bogotá 0819, Colombia
| | - Paulo Sérgio Teixeira De Carvalho
- Department of Neurosurgery, Pain and Spine Minimally Invasive Surgery Service at Gaffree Guinle University Hospital, Rio de Janeiro 20270-004, Brazil
| | - Manuel Rodriguez Garcia
- Spine Clinic, The American-Bitish Cowdray Medical Center I.A.P, Campus Santa Fe, Mexico City 05370, Mexico
| | - Alfonso Garcia
- Department of Orthopaedic Surgery, Espalda Saludable, Hospital Angeles Tijuana, Tijuana 22010, Mexico
| | - Eulalio Elizalde Martínez
- Department of Spine Surgery, Hospital de Ortopedia, UMAE "Dr. Victorio de la Fuente Narvaez", Ciudad de México 07760, Mexico
| | - Iliana Margarita Gómez Silva
- Department of Spine Surgery, Hospital Ángeles Universidad, Av Universidad 1080, Col Xoco, Del Benito Juárez, Ciudad de México 03339, Mexico
| | | | - Luis Miguel Duchén Rodríguez
- Center for Neurological Diseases, Bolivian Spine Association, Spine Chapter of Latin American Federation of Neurosurgery Societies, Public University of El Alto, La Paz 0201-0220, Bolivia
| | - Robert Meves
- Santa Casa Spine Center, São Paulo 09015-000, Brazil
| | - Cristiano M Menezes
- Universidade Federal de Minas Gerais (UFMG), Belo Horizonte 31270-901, Brazil
| | | | | | - Rodrigo Amaral
- Instituto de Patologia da Coluna (IPC), Faculdade de Medicina de Ribeirão Preto (FMRP) da Universidade de São Paulo (USP), São Paulo 14040-900, Brazil
| | | | - Helton Defino
- Hospital das Clínicas of Ribeirao Preto Medical School, Sao Paulo University, Ribeirão Preto 14040-900, Brazil
| | - Vicky Yamamoto
- Brain Technology and Innovation Park, Pacific Palisades, CA 90272, USA
- The USC Caruso Department of Otolaryngology-Head and Neck Surgery, USC Keck School of Medicine, Los Angeles, CA 90033, USA
- USC-Norris Comprehensive Cancer Center, Los Angeles, CA 90033, USA
- World Brain Mapping Foundation (WBMF), Pacific Palisades, CA 90272, USA
| | - Babak Kateb
- Brain Technology and Innovation Park, Pacific Palisades, CA 90272, USA
- World Brain Mapping Foundation (WBMF), Pacific Palisades, CA 90272, USA
- Society for Brain Mapping and Therapeutics (SBMT), Pacific Palisades, CA 90272, USA
- National Center for Nano Bio Electronic (NCNBE), Los Angeles, CA 90272, USA
| |
Collapse
|
5
|
Marie-Hardy L, Khalifé M, Upex P, Riouallon G, Wolff S. Pre- and postoperative MRI analysis of central decompression in MIS fusion with lumbar stenosis. Orthop Traumatol Surg Res 2023; 109:103222. [PMID: 35101598 DOI: 10.1016/j.otsr.2022.103222] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/04/2021] [Accepted: 06/21/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Mini-invasive approaches have grown substantially these last decades in spinal surgery, notably for lumbar decompressions and fusion, with advantages over open approaches in terms of morbidity reduction. However, to our knowledge, no study has measured on MRI the amount of central decompression obtained by MIS approach. The goal of this study was to precisely measure the decompression of central stenosis by unilateral MIS approaches. METHODS The files of 42 patients that had a MIS lumbar fusion with central decompression for central stenosis were reviewed. All patients had a pre- and postoperative MRI that allowed on T2 axial images to classify the central stenosis, according to Schizas' classification, and measure the dural sac cross-sectional area (DSCA) and the anteroposterior diameter (DAP). The statistical analysis was made with paired t-test. RESULTS Fifty-six levels were analyzed, mostly L4L5 (58%). The mean preoperative DSCA was 70.53mm2 and the mean postoperative DSCA was 172.2mm2. The mean preoperative DAP was 6.15mm and postoperative was 10.68mm. Preoperatively, the levels analyzed were rated B, C or D according to Schizas for 53 out of 56 levels and A1-4 for 51 out of 56 levels in postoperative. All the results were statistically significant (p<0.001). CONCLUSION Decompression, assessed by MRI, seems to be equivalent by MIS approach to open laminarthrectomy. MIS approaches have been studied clinically in these indications with very satisfying results. As a conclusion, MIS approaches seems to be a relevant and efficient option in the treatment of lumbar degenerative stenosis. LEVEL OF EVIDENCE IV, retrospective study.
Collapse
Affiliation(s)
- Laura Marie-Hardy
- Service d'orthopédie et traumatologie, université Paris Sorbonne, hôpital de la Pitié-Salpêtrière, 47, boulevard de l'Hôpital, 75013 Paris, France.
| | - Marc Khalifé
- Service de chirurgie orthopédique, groupe hospitalier Paris Saint-Joseph, Paris, France
| | - Peter Upex
- Service de chirurgie orthopédique, groupe hospitalier Paris Saint-Joseph, Paris, France
| | - Guillaume Riouallon
- Service de chirurgie orthopédique, groupe hospitalier Paris Saint-Joseph, Paris, France
| | - Stéphane Wolff
- Service de chirurgie orthopédique, groupe hospitalier Paris Saint-Joseph, Paris, France
| |
Collapse
|
6
|
Lewandrowski KU, Lorio MP. Determination of Work Related to Endoscopic Decompression of Lumbar Spinal Stenosis. J Pers Med 2023; 13:jpm13040614. [PMID: 37109000 PMCID: PMC10143172 DOI: 10.3390/jpm13040614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/19/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Background: Effective 1 January 2017, single-level endoscopic lumbar discectomy received a Category I Current Procedural Terminology (CPT®) code 62380. However, no work relative value units (wRVUs) are currently assigned to the procedure. A physician’s payment needs to be updated to commensurate with the work involved in the modern version of the lumbar endoscopic decompression procedure with and without the use of any implants to stabilize the spine. In the United States, the American Medical Association (AMA) and its Specialty Society Relative Value Scale Update Committee (RUC) proposes to the Centers for Medicare and Medicaid Services (CMS) what wRVUs to assign for any endoscopic lumbar surgery codes. Methods: The authors conducted an independent survey between May and June 2022 which reached 210 spine surgeons using the TypeForm survey platform. The survey link was sent to them via email and social media. Surgeons were asked to assess the endoscopic procedure’s technical and physical effort, risk, and overall intensity without focusing just on the time required to perform the surgery. Respondents were asked to compare the work involved in modern comprehensive endoscopic spine care with other commonly performed lumbar surgeries. For this purpose, respondents were provided with the verbatim descriptions of 12 other existing comparator CPT® codes and associated wRVUs of common spine surgeries, as well as a typical patient vignette describing an endoscopic lumbar decompression surgery scenario. Respondents were then asked to select the comparator CPT® code most reflective of the technical and physical effort, risk, intensity, and time spent on patient care during the pre-operative, peri- and intra-operative, and post-operative periods of a lumbar endoscopic surgery. Results: Of the 30 spine surgeons who completed the survey, 85.8%, 46.6%, and 14.3% valued the appropriate wRVU for the lumbar endoscopic decompression to be over 13, over 15, and over 20, respectively. Most surgeons (78.5%; <50th percentile) did not think they were adequately compensated. Regarding facility reimbursement, 77.3% of surgeons reported that their healthcare facility struggled to cover the cost with the received compensation. The majority (46.5%) said their facility received less than USD 2000, while another 10.7% reported less than USD 1500 and 17.9% reported less than USD 1000. The professional fee received by surgeons was <USD 1000 for 21.4%, <USD 2000 for 17.9%, and <USD 1500 for 10.7%, resulting in a fee less than USD 2000 for 50% of responding surgeons. Most responding surgeons (92.6%) recommended an endoscopic instrumentation carveout to pay for the added cost of the innovation. Discussion and Conclusions: The survey results indicate that most surgeons associate CPT® 62380 with the complexity and intensity of a laminectomy and interbody fusion preparation, considering the work in the epidural space using the contemporary outside-in and interlaminar technique and the work inside the interspace using the inside-out technique. Modern endoscopic spine surgery goes beyond the scope of a simple soft-tissue discectomy. The current iterations of the procedure must be considered to avoid undervaluing its complexity and intensity. Additional undervalued payment scenarios could be created if technological advances continue to replace traditional lumbar spinal fusion protocols with less burdensome, yet no less complex, endoscopic surgeries that necessitate a high surgeon effort in terms of time required to perform the operation and its intensity. These undervalued payment scenarios of physician practices, as well as the facility and malpractice expenses, should be further discussed to arrive at updated CPT® codes reflective of modern comprehensive endoscopic spine care.
Collapse
Affiliation(s)
- Kai-Uwe Lewandrowski
- Center for Advanced Spine Care of Southern Arizona, Tucson, AZ 85712, USA
- Department of Orthopaedics, Fundación Universitaria Sanitas, Bogotá 111321, Colombia
- Department of Orthopedics at Hospital Universitário Gaffrée e Guinle, Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro 20270-004, Brazil
- Correspondence: ; Tel.: +1-520-204-1495
| | | |
Collapse
|
7
|
Yang J, Xiong Y, Hu Y, Huang M, Zhang L, Pu X, Li Q. The reliability, correlation with clinical symptoms and surgical outcomes of dural sac cross-sectional area, nerve root sedimentation sign and morphological grade for lumbar spinal stenosis. BMC Musculoskelet Disord 2023; 24:225. [PMID: 36964515 PMCID: PMC10039594 DOI: 10.1186/s12891-023-06353-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 03/21/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND No study had directly compared the reliability, correlation with clinical symptoms, and surgical outcomes of dural sac cross-sectional area (DCSA), nerve root sedimentation sign (SedSign), and morphological grade for lumbar spinal stenosis (LSS). METHODS From January 2017 to December 2020, 202 patients with LSS were retrospectively analyzed. The narrowest segments were assessed via T2-weighted cross-sectional images using DCSA, morphological grade, and SedSign by two independent observers. Three classifications' reliabilities were evaluated. Correlations between three classifications and between each of the classifications and symptoms or surgical outcomes 12 months postoperatively were evaluated. RESULTS There were 144 males and 58 females; 23, 52, and 127 patients had the narrowest segment in L2-3, L3-4, and L4-5, respectively. The intra-observer reliability of DCSA ranged from 0.91 to 0.93, and the inter-observer reliability was 0.90. The intra-observer reliability of SedSign ranged from 0.83 to 0.85, and the inter-observer reliability was 0.75. The intra-observer reliability of morphological grade ranged from 0.72 to 0.78, and the inter-observer reliability was 0.61. Each of these classifications was correlated with the other two (P < 0.01). For preoperative symptoms, DCSA was correlated with leg pain (LP) (r = - 0.14), Oswestry Disability Index (ODI) (r = - 0.17), and claudication (r = - 0.19). Morphological grade was correlated with LP (r = 0.19) and claudication (r = 0.27). SedSign was correlated with ODI (r = 0.23). For postoperative outcomes, morphological grade was correlated with LP (r = - 0.14), and SedSign was correlated with ODI (r = 0.17). CONCLUSIONS Substantial to almost perfect intra and inter-observer reliabilities for the three classifications were found; however, these classifications had either weak correlations with symptoms and surgical outcomes or none at all. Based on our findings, using one of them without conducting other tests for LSS will have limited or uncertain value in surgical decision-making or evaluating the prognostic value.
Collapse
Affiliation(s)
- Jin Yang
- Department of Orthopedic Surgery, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, Sichuan, 646000, China
| | - Yiling Xiong
- Department of Radiology, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, Sichuan, 646000, China
| | - Yuexuan Hu
- Department of Clinical Skills Center, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, Sichuan, 646000, China
| | - Mei Huang
- Department of Clinical Skills Center, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, Sichuan, 646000, China
| | - Li Zhang
- Department of Clinical Skills Center, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, Sichuan, 646000, China
| | - Xia Pu
- Department of Clinical Skills Center, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, Sichuan, 646000, China
| | - Qiuhan Li
- Department of Clinical Skills Center, Affiliated Hospital of Southwest Medical University, 25 Taiping Road, Luzhou, Sichuan, 646000, China.
| |
Collapse
|
8
|
Aaen J, Banitalebi H, Austevoll IM, Hellum C, Storheim K, Myklebust TÅ, Anvar M, Weber C, Solberg T, Grundnes O, Brisby H, Indrekvam K, Hermansen E. The association between preoperative MRI findings and clinical improvement in patients included in the NORDSTEN spinal stenosis trial. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:2777-2785. [PMID: 35930062 DOI: 10.1007/s00586-022-07317-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 05/24/2022] [Accepted: 07/04/2022] [Indexed: 06/15/2023]
Abstract
PURPOSE To investigate potential associations between preoperative MRI findings and patient reported outcome measures (PROMs) after surgery for lumbar spinal stenosis (LSS). METHODS The NORDSTEN trial included 437 patients. We investigated the association between preoperative MRI findings such as morphological grade of stenosis (Schizas grade), quantitative grade of stenosis (dural sac cross-sectional area), disc degeneration (Pfirrmann score), facet joint tropism and fatty infiltration of the multifidus muscle, and improvement in patient reported outcome measures (PROMs) 2 years after surgery. We dichotomized each radiological parameter into a moderate or severe category. PROMs i.e., Oswestry Disability Index (ODI), Zurich Claudication Questionnaire (ZCQ) and Numeric rating scale (NRS) for back and leg pain were collected before surgery and at 2 year follow-up. In the primary analysis, we investigated the association between MRI findings and ODI score (dichotomized to ≥ 30% improvement or not). In the secondary analysis, we investigated the association between MRI findings and the mean improvement on the ODI-, ZCQ- and NRS scores. We used multivariable regression models adjusted for patients' gender, age, smoking status and BMI. RESULTS The primary analysis showed that severe disc degeneration (Pfirrmann score 4-5) was significantly associated with less chance of achieving a 30% improvement on the ODI score (OR 0.54, 95% CI 0.34, 0.88). In the secondary analysis, we detected no clinical relevant associations. CONCLUSION Severe disc degeneration preoperatively suggest lesser chance of achieving 30% improvement in ODI score after surgery for LSS. Other preoperative MRI findings were not associated with patient reported outcome.
Collapse
Affiliation(s)
- Jørn Aaen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway.
- Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Hasan Banitalebi
- Department of Diagnostic Imaging, Akershus University Hospital, Lørenskog, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Ivar Magne Austevoll
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Christian Hellum
- Division of Orthopedic Surgery, Oslo University Hospital Ullevaal, Oslo, Norway
| | - Kjersti Storheim
- Communication and Research Unit for Musculoskeletal Health (FORMI), Oslo University Hospital, Oslo, Norway
| | - Tor Åge Myklebust
- Department of Research and Innovation, Møre and Romsdal Hospital Trust, Ålesund, Norway
| | | | - Clemens Weber
- Department of Neurosurgery, Stavanger University Hospital, Stavanger, Norway
- Dept. of Quality and Health Technology, University of Stavanger, Stavanger, Norway
| | - Tore Solberg
- Department of Neurosurgery and the Norwegian Registry for Spine Surgery (NORspine), University Hospital of Northern Norway, Tromsø, Norway
- Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Oliver Grundnes
- Department of Orthopedics, Akershus University Hospital, Lørenskog, Norway
| | - Helena Brisby
- Dept of Orthopaedics, Sahlgrenska University Hospital, Gothenburg, Sweden
- Dept. of Orthopaedics, Institute for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kari Indrekvam
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Erland Hermansen
- Department of Orthopedic Surgery, Ålesund Hospital, Møre and Romsdal Hospital Trust, Ålesund, Norway
- Kysthospitalet in Hagevik. Orthopedic Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| |
Collapse
|
9
|
Marchand AA, Houle M, O'Shaughnessy J, Châtillon CÉ, Descarreaux M. Physical Predictors of Favorable Postoperative Outcomes in Patients Undergoing Laminectomy or Laminotomy for Central Lumbar Spinal Stenosis: Secondary Analysis of a Randomized Controlled Trial. Front Neurol 2022; 13:848665. [PMID: 35493839 PMCID: PMC9051316 DOI: 10.3389/fneur.2022.848665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/15/2022] [Indexed: 11/25/2022] Open
Abstract
Study Design Secondary analysis of a randomized controlled trial. Objective To identify preoperative physical variables associated with favorable postoperative outcome in individuals undergoing laminectomy or laminotomy for degenerative central lumbar spinal stenosis. Summary of Background Data Clinical or condition specific variables have most commonly been studied as predictors of postoperative outcome in lumbar spinal stenosis. If associated to favorable postoperative outcome, modifiable physical variables would inform prehabilitation interventions for patients with degenerative central lumbar spinal stenosis. Methods Patients awaiting surgery for central lumbar spinal stenosis were recruited to participate in a randomized controlled trial. Following baseline data collection of demographics, clinical portrait and physical testing, participants were randomized to either 6-week active prehabilitation program or hospital standard care. Complete baseline and postoperative data were obtained from 58 participants which were included in the present analysis. Favorable postoperative outcome was determined based on two outcome measures. Favorable outcome was defined as a decrease of ≥30% on the Numerical Rating Scale for leg pain intensity and a decrease of ≥30% on the Oswestry Disability Index for low back disability. Baseline physical variables were used to conduct binary logistic regression. Results Sixty percent of participants were determined as having a favorable postoperative outcome. None of the included physical variables were found to be predictors of a favorable postoperative outcome based on leg pain intensity and low back pain-associated disability [trunk flexors muscle strength (OR = 0.73; 95%CI (0.02–27.12)] lumbar extensors muscle endurance [OR= 1.09; 95%CI (0.95–1.24)] total ambulation time [OR = 1.00 95%CI (0.99–1.01)] lumbar active range of motion in extension [OR = 1.08; 95%CI (0.95–1.23)] and knee extensors muscle strength [OR=1.02; 95%CI (0.98–1.06)]. Conclusion Results show that none of the investigated variables, all related to low back and lower limbs physical capacity, were predictors of postoperative recovery. Further testing in larger cohort is needed to assess the full potential of physical outcome measures as predictors of postoperative recovery.
Collapse
Affiliation(s)
- Andrée-Anne Marchand
- Department of Chiropractic, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
- *Correspondence: Andrée-Anne Marchand
| | - Mariève Houle
- Department of Anatomy, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Julie O'Shaughnessy
- Department of Chiropractic, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| | - Claude-Édouard Châtillon
- Department of Neurosurgery, Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, QC, Canada
- Division of Neurosurgery, Faculty of Medicine, University of Montreal, Trois-Rivières, QC, Canada
| | - Martin Descarreaux
- Department of Human Kinetics, Université du Québec à Trois-Rivières, Trois-Rivières, QC, Canada
| |
Collapse
|
10
|
Wang H, Liu C, Meng Z, Zhou W, Chen T, Zhang K, Wu A. Real-world study for identifying the predictive factors of surgical intervention and the value of magnetic resonance imaging in patients with low back pain. Quant Imaging Med Surg 2022; 12:1830-1843. [PMID: 35284262 PMCID: PMC8899926 DOI: 10.21037/qims-21-584] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 11/04/2021] [Indexed: 09/18/2023]
Abstract
BACKGROUND Low back pain (LBP) is a prevalent disease and can be disabling. Currently, many patients with LBP with or without radiculopathy commonly undergo magnetic resonance imaging (MRI) for diagnosis and therapeutic assessment, yet the final intervention is mainly centered around nonoperative treatment. This study's aim was to identify the predictive factors of surgical treatment and the value of MRI in patients with LBP with or without radiculopathy. METHODS The study included a training cohort that consisted of 461 patients with MRI from January 2014 to December 2018. Demographic characteristics and MRI findings were collected from our medical records. We developed and validated 2 nomograms to predict the possibility of receiving surgical treatment in LBP patients, based on multivariable logistic regression analysis. The performance of the 2 nomograms was assessed in terms of their calibration, discrimination, and clinical usefulness. An independent validation cohort containing 163 patients was comparatively analyzed. RESULTS The baseline model incorporated 6 clinicopathological variables, while the MRI model consisted of 9 variables including several MRI findings. Internal validation revealed the good performance of the 2 nomograms in discrimination and calibration, with a concordance index (C-index) of 0.799 (95% CI: 0.743-0.855) for the baseline model and 0.834 (95% CI: 0.783-0.884) for the MRI model, which showed that the addition of MRI findings to the nomogram failed to achieve better prognostic value (Z statistic =-1.509; P=0.131). Application of the 2 models in the validation cohort also showed good discrimination (baseline model: C-index 0.75, 95% CI: 0.671-0.829; MRI model: C-index 0.777, 95% CI: 0.696-0.857) and calibration. No significant predictive benefit was found in the MRI model in the validation cohort (Z statistic =-0.588; P=0.557). CONCLUSIONS This study showed that clinical demographic characteristics provide good prognostic value to determine whether LBP patients with or without radiculopathy require surgical treatment. The addition of MRI findings yielded no significantly incremental prognostic value.
Collapse
Affiliation(s)
- Hui Wang
- Department of Orthopedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopedics, Wenzhou, China
| | - Chang Liu
- Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Camperdown, Sydney, Australia
| | - Zhou Meng
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD, USA
| | - Wenxian Zhou
- Department of Orthopedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopedics, Wenzhou, China
| | - Tao Chen
- Department of Orthopedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopedics, Wenzhou, China
| | - Kai Zhang
- Department of Orthopedics, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Orthopedic Implants, Shanghai, China
| | - Aimin Wu
- Department of Orthopedics, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Zhejiang Provincial Key Laboratory of Orthopedics, Wenzhou, China
| |
Collapse
|
11
|
McIlroy S, Walsh E, Sothinathan C, Stovold E, Norwitz D, Norton S, Weinman J, Bearne L. Pre-operative prognostic factors for walking capacity after surgery for lumbar spinal stenosis: a systematic review. Age Ageing 2021; 50:1529-1545. [PMID: 34304266 DOI: 10.1093/ageing/afab150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Lumbar spinal stenosis (LSS) reduces walking and quality of life. It is the main indication for spinal surgery in older people yet 40% report walking disability post-operatively. Identifying the prognostic factors of post-operative walking capacity could aid clinical decision-making, guide rehabilitation and optimise health outcomes. OBJECTIVE To synthesise the evidence for pre-operative mutable and immutable prognostic factors for post-operative walking in adults with LSS. DESIGN Systematic review with narrative synthesis. METHODS Electronic databases (CENTRAL, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, OpenGrey) were searched for observational studies, evaluating factors associated with walking after surgery in adults receiving surgery for LSS from database inception to January 2020. Two reviewers independently evaluated studies for eligibility, extracted data and assessed risk of bias (Quality in Prognosis Studies). The Grading of Recommendations Assessment, Development and Evaluation method was used to determine level of evidence for each factor. RESULTS 5526 studies were screened for eligibility. Thirty-four studies (20 cohorts, 9,973 participants, 26 high, 2 moderate, 6 low risk of bias) were included. Forty variables (12 mutable) were identified. There was moderate quality of evidence that pre-operative walking capacity was positively associated with post-operative walking capacity. The presence of spondylolisthesis and the severity of stenosis were not associated with post-operative walking capacity. All other factors investigated had low/very low level of evidence. CONCLUSION Greater pre-operative walking is associated with greater post-operative walking capacity but not spondylolisthesis or severity of stenosis. Few studies have investigated mutable prognostic factors that could be potentially targeted to optimise surgical outcomes.
Collapse
Affiliation(s)
- Suzanne McIlroy
- Physiotherapy Department, King’s College Hospital NHS Foundation Trust, London, UK
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Edward Walsh
- Physiotherapy Department, King’s College Hospital NHS Foundation Trust, London, UK
| | | | - Elizabeth Stovold
- Population Health Research Institute, St George's University of London, London, UK
| | - Daniel Norwitz
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sam Norton
- Health Psychology, King’s College London, London, UK
| | - John Weinman
- Institute of Pharmaceutical Science, King’s College London, London, UK
| | - Lindsay Bearne
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| |
Collapse
|
12
|
Myllykangas H, Ristolainen L, Hurri H, Lohikoski J, Kautiainen H, Puisto V, Österman H, Manninen M. Obese people benefit from lumbar spinal stenosis surgery as much as people of normal weight. J Orthop Surg Res 2021; 16:550. [PMID: 34488826 PMCID: PMC8422720 DOI: 10.1186/s13018-021-02692-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 08/24/2021] [Indexed: 12/04/2022] Open
Abstract
Background Lumbar spinal stenosis (LSS) is a common degenerative condition of the spine that causes back pain radiating to the lower extremity. Surgical treatment is indicated to treat progressive radical symptoms. Obesity has been associated with inferior results in the domains of quality of life (QoL) following an LSS operation, but the research findings have been limited. This paper aims to identify whether obesity affects QoL due to back pain among patients who underwent an operation for LSS. Methods This study is based on a series of patients operated on for LSS between 2012 and 2018. Operated patients who returned for follow-up forms within the first or second years were included. A total of 359 patients were selected, 163 males (45%) and 196 females (55%). The mean age was 68.9 years. The EuroQol five-dimension scale (EQ-5D) questionnaire was chosen to measure QoL and the Oswestry Disability Index (ODI) for functional disability. Results QoL, as measured by EQ-5D, was preoperatively lower in those patients with a BMI ≥ 30. One year after the operation, all groups had a similar trend of improved QoL. At the second year, the results in all groups levelled off even though there was no statistical difference in clinical outcomes (p = 0.92). The ODI was preoperatively statistically higher in patients with a BMI ≥ 30 (p < 0.001). Two years after the surgery, all groups had improved ODI scores, but there was no statistical difference in ODI between the BMI groups (p = 0.54). Conclusion Surgical intervention for debilitating or longstanding symptoms of LSS should be considered as a treatment option for suitable patients in spite of an elevated BMI.
Collapse
Affiliation(s)
- Henni Myllykangas
- Orton Orthopaedic Hospital, Tenholantie 10, 00280, Helsinki, Finland.
| | | | - Heikki Hurri
- Orton Orthopaedic Hospital, Tenholantie 10, 00280, Helsinki, Finland
| | - Jouni Lohikoski
- Orton Orthopaedic Hospital, Tenholantie 10, 00280, Helsinki, Finland
| | | | - Ville Puisto
- Orton Orthopaedic Hospital, Tenholantie 10, 00280, Helsinki, Finland
| | - Heikki Österman
- Orton Orthopaedic Hospital, Tenholantie 10, 00280, Helsinki, Finland
| | - Mikko Manninen
- Orton Orthopaedic Hospital, Tenholantie 10, 00280, Helsinki, Finland
| |
Collapse
|
13
|
Lorio D, Twetten M, Golish SR, Lorio MP. Determination of Work Relative Value Units for Management of Lumbar Spinal Stenosis by Open Decompression and Interlaminar Stabilization. Int J Spine Surg 2021; 15:1-11. [PMID: 33900951 DOI: 10.14444/8026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Effective January 1, 2017, open surgical decompression and interlaminar stabilization (ILS) received a Category I Current Procedural Terminology (CPT®) code 22867. The current work relative value units (wRVUs) assigned to the procedure of 13.5 are not reflective of the amount of work involved. During the survey process, CPT® 22867 was erroneously assessed with a percutaneous "sister" code (CPT® 22869), which is performed with no decompression (but within the same new "family") and primarily by nonsurgeons. However, similar CPT® code descriptors assigned to each of these new codes undermined their procedural differences during the survey process and generated confusion among physician survey responders, the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC), and ultimately the Centers for Medicare and Medicaid Services (CMS) regarding the value of ILS. The resulting physician payment determination for the ILS procedure has had severe deleterious effects on this procedure being offered to lumbar spinal stenosis (LSS) patients. Our independent society-driven survey presents new data that assess the accuracy of the assigned wRVUs for CPT® 22867. METHODS An independent survey was driven by the International Society for the Advancement of Spine Surgery (ISASS) in November 2018 and sent to 58 US surgeons with experience performing open decompression with ILS (CPT® 22867) and without financial conflicts of interest as analogous to RUC survey financial disclosure requests. Respondents were asked to compare CPT® 22867 with a list of 10 other comparator CPT® codes reflective of common spine surgeries. The survey presented each comparator CPT® code with its code descriptor and corresponding wRVUs alongside the code descriptor for CPT® 22867. A patient vignette was also provided that describes a typical clinical scenario for the surveyed procedure. Respondents were then asked to indicate which comparator CPT® code on the reference list is most similar to the survey code descriptor and typical patient/service vignette provided, as well as specify estimated wRVUs for CPT® 22867 relative to their selected comparator CPT® code. The surgeons' responses were analyzed to determine comparator CPT® codes and estimated wRVUs. RESULTS Among the 28 surgeons who responded to the survey, both open decompression codes (57.1%) and fusion codes (42.9%) were chosen as most similar to the typical patient/service for CPT® 22867. Furthermore, the laminectomy procedure (CPT® 63047) was chosen as the surveyed surgeons' model response for a reference procedure in terms of similar work intensity and time for CPT® 22867. After calculating the difference between the selected comparator codes and estimated wRVUs, nearly all respondents had a positive calculated difference, indicating that surgeons selected wRVUs lower than they deemed appropriate as a result of the listed CPT® codes they were required to use. In the spirit of the Rasch analysis, the regression analysis estimated wRVUs for CPT® 22867 that are greater than its assigned wRVUs (13.5) and its most comparable procedure (CPT® 63047; reference wRVUs: 15.37). DISCUSSION AND CONCLUSIONS The survey results indicate that the wRVUs assigned to CPT® 22867 are significantly undervalued at 13.50 and have directly resulted in the underreimbursement for surgeons performing the ILS procedure. This misvaluation of the code has created a supply-and-demand anomaly in which the rate of ILS procedures has flatlined despite increasing rates of fusion procedures and an increasing older population. This anomaly is a cause of concern for policy makers and the health care community for the future of safeguarding patient welfare and procedural innovation. Therefore, understanding the clinical economic impact and appropriately addressing potential misvalued codes, such as the ILS procedure, are critical to protecting the future of patient care.
Collapse
Affiliation(s)
- Delaine Lorio
- University of Edinburgh Business School, Edinburgh, Scotland
| | - Matthew Twetten
- International Society for the Advancement of Spine Surgery, Wheaton, Illinois
| | | | | |
Collapse
|
14
|
Effects of age and sex on the distribution and symmetry of lumbar spinal and neural foraminal stenosis: a natural language processing analysis of 43,255 lumbar MRI reports. Neuroradiology 2021; 63:959-966. [PMID: 33594502 PMCID: PMC8128837 DOI: 10.1007/s00234-021-02670-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/03/2021] [Indexed: 01/07/2023]
Abstract
Purpose The purpose of this study is to investigate relationship of patient age and sex to patterns of degenerative spinal stenosis on lumbar MRI (LMRI), rated as moderate or greater by a spine radiologist, using natural language processing (NLP) tools. Methods In this retrospective, IRB-approved study, LMRI reports acquired from 2007 to 2017 at a single institution were parsed with a rules-based natural language processing (NLP) algorithm for free-text descriptors of spinal canal stenosis (SCS) and neural foraminal stenosis (NFS) at each of six spinal levels (T12-S1) and categorized according to a 6-point grading scale. Demographic differences in the anatomic distribution of moderate (grade 3) or greater SCS and NFS were calculated by sex, and age and within-group differences for NFS symmetry (left vs. right) were calculated as odds ratios. Results Forty-three thousand two hundred fifty-five LMRI reports (34,947 unique patients, mean age = 54.7; sex = 54.9% women) interpreted by 152 radiologists were studied. Prevalence of significant SCS and NFS increased caudally from T12-L1 to L4-5 though less at L5-S1. NFS was asymmetrically more prevalent on the left at L2-L3 and L5-S1 (p < 0.001). SCS and NFS were more prevalent in men and SCS increased with age at all levels, but the effect size of age was largest at T12-L3. Younger patients (< 50 years) had relatively higher NFS prevalence at L5-S1. Conclusion NLP can identify patterns of lumbar spine degeneration through analysis of a large corpus of radiologist interpretations. Demographic differences in stenosis prevalence shed light on the natural history and pathogenesis of LSDD.
Collapse
|
15
|
Hofmann UK, Keller RL, von Bernstorff M, Walter C, Mittag F. Predictability of the effects of epidural injection in lumbar spinal stenosis by assessment of lumbar MRI scans. J Back Musculoskelet Rehabil 2020; 33:613-621. [PMID: 31743983 DOI: 10.3233/bmr-181249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Numerous classification systems have been proposed to interpret lumbar MRI scans. The clinical impact of the measured parameters remains unclear. To evaluate the clinical significance of imaging results in patients with multisegmental degenerative pathologies, treating specialists can perform image-guided local injections to target defined areas such as the epidural space. OBJECTIVE The aim of this retrospective study was to evaluate the correlation between lumbar spinal stenosis measurements obtained by MRI and improvement obtained through local epidural injection. METHODS In this retrospective study various measurement and classification systems for lumbar spinal stenosis were applied to MRI scans of 100 patients with this pathological condition. The reported effect of epidural bupivacaine/triamcinolone injections at the site was recorded in these patients and a comparative analysis performed. RESULTS MRI features assessed in this study did not show any relevant correlation with reported pain relief after epidural injection in patients with chronic lumbar stenosis, with the exception of posterior disc height with a weak Kendall's tau of -0.187 (p= 0.009). CONCLUSIONS Although MRI is crucial for evaluating lumbar spinal stenosis, it cannot replace but is rather complementary to a good patient history and clinical examination or the results of local diagnostic injections.
Collapse
Affiliation(s)
- Ulf Krister Hofmann
- Department of Orthopaedic Surgery, University Hospital of Tübingen, D-72076 Tübingen, Germany
| | - Ramona Luise Keller
- Department of Orthopaedic Surgery, University Hospital of Tübingen, D-72076 Tübingen, Germany.,Faculty of Medicine, Julius-Maximilians University of Würzburg, D-97080 Würzburg, Germany
| | - Maximilian von Bernstorff
- Department of Orthopaedic Surgery, University Hospital of Tübingen, D-72076 Tübingen, Germany.,Faculty of Medicine, Eberhard-Karls University of Tübingen, D-72076 Tübingen, Germany
| | - Christian Walter
- Department of Orthopaedic Surgery, University Hospital of Tübingen, D-72076 Tübingen, Germany
| | - Falk Mittag
- Department of Orthopaedic Surgery, University Hospital of Tübingen, D-72076 Tübingen, Germany
| |
Collapse
|
16
|
Patients With Persistent Low Back Pain and Nerve Root Involvement: To Operate, or Not to Operate, That Is the Question. Spine (Phila Pa 1976) 2020; 45:483-490. [PMID: 31658235 DOI: 10.1097/brs.0000000000003304] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE The aims of this study were to evaluate the outcome of surgical and nonsurgical treatment for patients with lumbar herniated disc (LHD) or lumbar spinal stenosis (LSS) after 2 years and to identify predictors for nonsuccess. SUMMARY OF BACKGROUND DATA Studies regarding the clinician's ability to identify patients with a poor prognosis are not in concurrence and further studies are warranted. METHODS This study included 390 patients with LHD or LSS referred for surgical evaluation after unsuccessful conservative treatment. Nonsuccess was defined as a Roland-Morris Disability score above 4 (0-23) or a Numeric Rating Scale back and leg pain score above 20 (0-60). Uni- and multivariate logistic regression analyses were used to investigate potential predictive factors including sociodemographic characteristics, history findings, levels of pain and disability, and magnetic resonance imaging findings. RESULTS Rates of nonsuccess at 2 years were approximately 30% in surgically treated patients with LHD, approximately about 60% in patients with LSS for disability, and 30% and 40%, respectively for pain. For the main outcome variable, disability, in the final multiple logistic regression model, nonsuccess after surgery was associated with male sex (odds ratio [OR] 2.04, 95% confidence interval [CI]: 1.02-4.11, P = 0.04), low level of education (OR 2.60, 95% CI: 1.28-5.29, P = 0.01), high pain intensity (OR 3.06, 95% CI: 1.51-6.21, P < 0.01), and widespread pain (OR 3.59, 95% CI: 1.36-9.46, P = 0.01). CONCLUSION The results indicate that the prognosis for patients referred for surgery with persistent LHD or LSS and unsuccessful conservative treatment is substantially better when surgery is performed as opposed to not performed. The predictive value of the variables male sex, low level of education, high pain intensity, and widespread pain location found in our study are partly in accordance with results of previous studies. Thus, our results warrant further investigation until firm conclusions can be made. LEVEL OF EVIDENCE 3.
Collapse
|
17
|
Bentov I, Kaplan SJ, Pham TN, Reed MJ. Frailty assessment: from clinical to radiological tools. Br J Anaesth 2019; 123:37-50. [PMID: 31056240 DOI: 10.1016/j.bja.2019.03.034] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 02/05/2019] [Accepted: 03/05/2019] [Indexed: 12/21/2022] Open
Abstract
Frailty is a syndrome of cumulative decline across multiple physiological systems, which predisposes vulnerable adults to adverse events. Assessing vulnerable patients can potentially lead to interventions that improve surgical outcomes. Anaesthesiologists who care for older patients can identify frailty to improve preoperative risk stratification and subsequent perioperative planning. Numerous clinical tools to diagnose frailty exist, but none has emerged as the standard tool to be used in clinical practice. Radiological modalities, such as computed tomography and ultrasonography, are widely performed before surgery, and are therefore available to be used opportunistically to objectively evaluate surrogate markers of frailty. This review presents the importance of frailty assessment by anaesthesiologists; lists common clinical tools that have been applied; and proposes that utilising radiological imaging as an objective surrogate measure of frailty is a novel, expanding approach for which anaesthesiologists can significantly contribute to broad implementation.
Collapse
Affiliation(s)
- Itay Bentov
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA.
| | - Stephen J Kaplan
- Section of General, Thoracic, and Vascular Surgery, Department of Surgery, Virginia Mason Medical Center, Seattle, WA, USA
| | - Tam N Pham
- Division of Trauma, Burn, and Critical Care Surgery, Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - May J Reed
- Division of Gerontology and Geriatric Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
| |
Collapse
|
18
|
Dural sac cross-sectional area and morphological grade show significant associations with patient-rated outcome of surgery for lumbar central spinal stenosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2552-2564. [PMID: 28856447 DOI: 10.1007/s00586-017-5280-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Revised: 07/27/2017] [Accepted: 08/19/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE Lumbar central spinal stenosis (LSS) is one of the most common reasons for spine surgery in the elderly patient. Magnetic resonance imaging (MRI) represents the gold standard for the assessment of LSS and can be used to obtain quantitative measures of the dural sac cross-sectional area (DCSA) or qualitative measures (morphological grades A-D) of the rootlet/cerebrospinal fluid ratio. This study investigated the intercorrelation between these two MRI evaluation methods and explored their respective relationships with the patient baseline clinical status and outcome 12 months after surgery. METHODS This was a retrospective analysis of prospectively collected data from 157 patients (88 male, 69 female; age 72 ± 7 years) who were undergoing first-time surgery for LSS. Patients with foraminal or isolated lateral stenosis were excluded. The Core Outcome Measures Index (COMI) was completed before and 12 months after surgery. Preoperative T2 axial MRIs were blinded and independently evaluated for DCSA and morphological grade. Spearman rank correlation coefficients described the relationship between the two MRI measures of stenosis severity and between each of these and the COMI baseline and change-scores (pre to 12 months' postop). Multiple logistic regression analysis (controlling for baseline COMI, age, gender, number of operated levels, health insurance status) was used to analyse the influence of stenosis severity on the achievement of the minimum clinically important change (MCIC) score for COMI and on global treatment outcome (GTO). RESULTS There was a correlation of ρ = -0.69 (p < 0.001) between DCSA and morphological grade. There was no significant correlation between COMI baseline scores and either DCSA or morphological grades (p > 0.85). However, logistic regression revealed significant (p < 0.05) associations between stenosis ratings and 12-month outcome, whereby patients with more severe stenosis (as measured using either of the methods) benefited more from the surgery. Patients with a DCSA <75 mm2 or morphological grade D had a 4-13-fold greater odds of achieving the MCIC for COMI or a "good" GTO, compared with patients in the least severe categories of stenosis. CONCLUSIONS Postoperative outcome was clearly related to the degree of preoperative radiological LSS. The two MRI methods appeared to deliver similar information, as given by the relatively strong correlation between them and their comparable performance in relation to baseline and 12-month outcomes. However, the qualitative morphological grading can be performed in an instant, without measurement tools, and does not deliver less clinically useful information than the more complex and time-consuming measures; as such, it may represent the preferred method in the clinical routine for assessing the extent of radiological stenosis and the likelihood of a positive outcome after decompression.
Collapse
|
19
|
Surgical versus nonsurgical treatment of lumbar degenerative kyphosis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2017; 26:2153-2159. [PMID: 28247076 DOI: 10.1007/s00586-017-5008-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 02/04/2017] [Accepted: 02/13/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Surgery is widely performed for lumbar degenerative kyphosis (LDK), but its effectiveness as compared with nonsurgical treatment has not been demonstrated. METHODS In this prospective study, surgical candidates with LDK were enrolled at three spine centres. Two treatment options were performed either surgery using a pedicle subtraction osteotomy or nonsurgical care. Outcomes were measured using a Visual analogue scale (VAS) of back pain as a primary endpoint, the Oswestry disability index (ODI), the 36-item short-form health survey (SF-36), sagittal vertical axis (SVA) and treatment-related complications. RESULTS Of the 126 LDK patients treated during the reference period, 97 patients were enrolled (47 in the surgical group and 50 in the nonsurgical group). Surgical group produced statistically reduced VAS of back pain and better functional outcomes than nonsurgical group since 12 months after treatment, but the rate of serious complications was higher after surgery. Interestingly, both surgical and nonsurgical groups had improved outcomes in terms of pain intensity and function at the 2-year follow-up period. CONCLUSIONS Surgery might be a preferred treatment option for LDK, but great caution is needed. And conservative treatment could be the considerable treatment option for LDK who is unwilling or has poor medical condition to operate.
Collapse
|
20
|
Is There an Association Between Radiological Severity of Lumbar Spinal Stenosis and Disability, Pain, or Surgical Outcome?: A Multicenter Observational Study. Spine (Phila Pa 1976) 2016; 41:E78-83. [PMID: 26352747 DOI: 10.1097/brs.0000000000001166] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Observational multicenter study. OBJECTIVE To evaluate if the severity of lumbar spinal stenosis (LSS) on magnetic resonance imaging (MRI) correlates with preoperative disability, pain, or surgical outcomes. SUMMARY OF BACKGROUND DATA Surgeons use the morphological appearance of LSS on MRI for clinical decision making. However, the associations between radiological severity of LSS and disability, pain, or surgical outcomes remain unclear. METHODS Evaluation of severity of LSS on preoperative MRI according to the Schizas morphological classification. Patient and treatment data were retrieved from the Norwegian Registry for Spine Surgery. Preopertaive outcome measures were Oswestry disability index (ODI) and numeric rating scale (NRS) scores for back and leg pain. Postopertive outcome measures were ODI and NRS scores for back and leg pain at 1 year, changes in ODI and NRS scores after treatment, duration of surgery, length of hospital stay, and perioperative complications. RESULTS Of 202 patients included, 7 were found to have mild stenosis, 38 had moderate stenosis, 108 had severe stenosis, and 49 had extreme stenosis. The radiological severity of LSS was not linked to preoperative ODI (P = 0.089), NRS back pain (P = 0.273), or NRS leg pain (P = 0.282) scores. There were no differences in ODI (P = 0.933), NRS back pain (P = 0.652), or NRS leg pain (P = 0.912) scores after 1 year. The radiological severity of stenosis was not associated with change in ODI (P = 0.494), NRS back pain (P = 0.235), NRS leg pain (P = 0.790), duration of surgery (P = 0.661), length of hospital stay (P = 0.739), or perioperative complication rates (P = 0.467). CONCLUSION Among patients who underwent decompressive surgery for LSS, radiological severity of stenosis was not associated with preoperative disability and pain, or clinical outcomes 1 year after surgery. In this patient group, the radiological severity of LSS has no clear clinical correlation and should therefore not be overemphasized in clinical decision making. LEVEL OF EVIDENCE 2.
Collapse
|