The incidence and cost of devices explanted during single-level anterior diskectomy/fusions

Anterior Cervical Interbody Fusion Using a Polyetheretherketone (PEEK) Cage Device and Local Autograft Bone

In a population of patients with high rates of tobacco use, diabetes mellitus, obesity, and other factors that negatively affect fusion rates, local autograft may be a good choice for efficacy and cost savings.

Operative costs, reasons for operative waste, and vendor credit replacement in spinal surgery

BACKGROUND

In 2012, Epstein et al. documented that educating spinal surgeons reduced the cost of operative waste (explanted devices: placed but removed prior to closure) occurring during anterior cervical diskectomy/fusion from 20% to 5.8%.[5] This prompted the development of a two-pronged spine surgeon-education program (2012-2014) aimed at decreasing operative costs for waste, and reducing the nine reasons for operative waste.

METHODS

The spine surgeon-education program involved posting the data for operative costs of waste and the nine reasons for operative waste over the neurosurgery/orthopedic scrub sinks every quarter. These data were compared for 2012 (latter 10 months), 2013 (12 months), and 2014 (first 9 months) (e.g. data were normalized). Savings from a 2013 Vendor Credit Replacement program were also calculated.

RESULTS

From 2012 to 2013 and 2014, spinal operative costs for waste were, respectively reduced by 64.7% and 61% for orthopedics, and 49.4% and 45.2% for neurosurgery. Although reduced by the program, the major reason for operative waste for all 3 years remained surgeon-related factors (e.g. 159.6, to 67, and 96, respectively). Alternatively, the eight other reasons for operative waste were reduced from 68.4 (2012) to 12 (2013) and finally to zero by 2014. Additionally, the Vendor Replacement program for 2013 netted $78,564.

CONCLUSIONS

The spine surgeon-education program reduced the costs/reasons for operative waste for 2012 to lower levels by 2013 and 2014. Although the major cost/reasons for operative waste were attributed to surgeon-related factors, these declined while the other eight reasons for operative waste were reduced to zero by 2014.

A review article on the benefits of early mobilization following spinal surgery and other medical/surgical procedures

Background:

The impact of early mobilization on perioperative comorbidities and length of stay (LOS) has shown benefits in other medical/surgical subspecialties. However, few spinal series have specifically focused on the “pros” of early mobilization for spinal surgery, other than in acute spinal cord injury. Here we reviewed how early mobilization and other adjunctive measures reduced morbidity and LOS in both medical and/or surgical series, and focused on how their treatment strategies could be applied to spinal patients.

Methods:

We reviewed studies citing protocols for early mobilization of hospitalized patients (day of surgery, first postoperative day/other) in various subspecialties, and correlated these with patients’ perioperative morbidity and LOS. As anticipated, multiple comorbid factors (e.g. hypertension, high cholesterol, diabetes, hypothyroidism, obesity/elevated body mass index hypothyroidism, osteoporosis, chronic obstructive pulmonary disease, coronary artery disease and other factors) contribute to the risks and complications of immobilization for any medical/surgical patient, including those undergoing spinal procedures. Some studies additionally offered useful suggestions specific for spinal patients, including prehabilitation (e.g. rehabilitation that starts prior to surgery), preoperative and postoperative high protein supplements/drinks, better preoperative pain control, and early tracheostomy, while others cited more generalized recommendations.

Results:

In many studies, early mobilization protocols reduced the rate of complications/morbidity (e.g. respiratory decompensation/pneumonias, deep venous thrombosis/pulmonary embolism, urinary tract infections, sepsis or infection), along with the average LOS.

Conclusions:

A review of multiple medical/surgical protocols promoting early mobilization of hospitalized patients including those undergoing spinal surgery reduced morbidity and LOS.

Is "mini-invasive" technique for iliac crest harvesting an alternative to cervical cage implant? An overview of a large personal experience

Background:

Autograft bone provides an excellent substrate for multilevel arthrodesis after anterior discectomy and is inexpensive. However, the use of tricortical bone could increase the discomfort for the patient.

Methods:

We reviewed cases of cervical disc diseases operated on by a single neurosurgeon (AS), within the period June 2000-December 2011. A total of 221 patients were considered for the present study; 109 female, 112 male, averaging 49 years of age. Only patients who could be followed up for at least one year were included in the present study. The grafts obtained with the technique described are bi- (and not tri-) cortical, and always of sufficient size in order to fit two spaces if necessary.

Results:

The technique is not associated with long-term significant donor site pain except for a striking minority of patients, it shortens the hospital stay, it offers comparable results to the published surgical series in which cage and/or modern implants are used.

Conclusions:

Autograft bone can be reasonably considered as one of the possible alternatives to be used in the surgical management of cervical disk disease.

Iliac crest autograft versus alternative constructs for anterior cervical spine surgery: Pros, cons, and costs

Background:

Grafting choices available for performing anterior cervical diskectomy/fusion (ACDF) procedures have become a major concern for spinal surgeons, and their institutions. The “gold standard”, iliac crest autograft, may still be the best and least expensive grafting option; it deserves to be reassessed along with the pros, cons, and costs for alternative grafts/spacers.

Methods:

Although single or multilevel ACDF have utilized iliac crest autograft for decades, the implant industry now offers multiple alternative grafting and spacer devices; (allografts, cages, polyether-etherketone (PEEK) amongst others). While most studies have focused on fusion rates and clinical outcomes following ACDF, few have analyzed the “value-added” of these various constructs (e.g. safety/efficacy, risks/complications, costs).

Results:

The majority of studies document 95%-100% fusion rates when iliac crest autograft is utilized to perform single level ACDF (X-ray or CT confirmed at 6-12 postoperative months). Although many allograft studies similarly quote 90%-100% fusion rates (X-ray alone confirmed at 6-12 postoperative months), a recent “post hoc analysis of data from a prospective multicenter trial” (Riew KD et. al., CSRS Abstract Dec. 2011; unpublished) revealed a much higher delayed fusion rate using allografts at one year 55.7%, 2 years 87%, and four years 92%.

Conclusion:

Iliac crest autograft utilized for single or multilevel ACDF is associated with the highest fusion, lowest complication rates, and significantly lower costs compared with allograft, cages, PEEK, or other grafts. As spinal surgeons and institutions become more cost conscious, we will have to account for the “value added” of these increasingly expensive graft constructs.

Reducing the cost and frequency of explantations associated with single-level anterior diskectomy and fusion at a single institution through education

STUDY DESIGN

We prospectively evaluated the costs/frequency of explanted instrumentation (devices implanted but removed prior to closure) for all single-level anterior diskectomy (1-ADF) procedures performed in 2010 at a single institution before and after surgeon education.

OBJECTIVE

To determine whether surgeon education would reduce the costs/frequency of explantation for 1-ADF.

SUMMARY OF BACKGROUND DATA

In 2009, we reported that the cost of explanted devices was 9.2% of the cost of implanted devices.

METHODS

The costs/frequencies of explantation for 1-ADF performed in 2010 at the same institution by the same surgeons were analyzed before and after surgeon education. From January through April, surgeons were unaware of concerns regarding explantation. At the end of April 2010, spinal surgeons were educated about explantation costs/frequency at 2 meetings. Explantation costs/frequencies for the first 4 months of 2010 were compared with those for the last 8 months as well as with the results from 2009.

RESULTS

Prior to surgeon education, instrumentation was explanted in 45.5% of the cases, whereas after education explantation occurred in 16% of the cases. The explantation rate (the number of explanted devices as a percentage of implanted devices) was lower after education for screws (12.5% vs. 7.7%), plates (9.4% vs. 0%), and allograft spacers (7.1% vs. 2.9%), and lower than for rates from 2009. In 2010, the overall cost of explanted devices as a percentage of implanted devices was also lower after surgeon education (5.8%) than before surgeon education in 2010 (20.0%) or 2009 (9.2%).

CONCLUSION

The frequency and cost of explanted instrumentation used to perform 1-ADF were reduced through surgeon education.