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Among patients with spondylolisthesis and lumbar spinal stenosis, laminectomy with fusion was associated with modestly greater improvement in physical health–related quality of life than laminectomy alone but not with significantly greater reduction in disability related to back pain. The increased use of the lumbar spinal fusion procedure in the United States, along with the wide variation in practice, is attracting interest from multiple stakeholders, including patients, physicians, payers, and policymakers. In a report published in 2014, spinal fusion (465,000 hospital-based procedures in 2011) accounted for the highest aggregate hospital costs ($12.8 billion in 2011) of any surgical procedure performed in U.S. hospitals. 1 The randomized, controlled Spine Patient Outcomes Research Trial (SPORT) showed that surgery was superior to nonoperative care for the management of lumbar degenerative spondylolisthesis. 2 In SPORT, most patients in the surgical group were treated by means . . .

Cervical radiculopathy is a common condition that usually results from compression and inflammation of the cervical nerve root or roots in the region of the neural foramen. It is frequently caused by cervical disc herniation and cervical spondylosis. The diagnosis can be established by history and physical examination, but care should be taken, as diagnoses can mimic or coexist with cervical radiculopathy, such as entrapment neuropathies. The pathophysiology, presentation, and clinical evaluation of cervical radiculopathy are discussed.

Abstract BACKGROUND: Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction. OBJECTIVE: To determine the feasibility of a randomized clinical trial comparing the clinical effectiveness and costs of ventral vs dorsal decompression with fusion surgery for treating CSM. METHODS: A nonrandomized, prospective, clinical pilot trial was conducted. Patients ages 40 to 85 years with degenerative CSM were enrolled at 7 sites over 2 years (2007-2009). Outcome assessments were obtained preoperatively and at 3 months, 6 months, and 1 year postoperatively. A hospital-based economic analysis used costs derived from hospital charges and Medicare cost-to-charge ratios. RESULTS: The pilot study enrolled 50 patients. Twenty-eight were treated with ventral fusion surgery and 22 with dorsal fusion surgery. The average age was 61.6 years. Baseline demographics and health-related quality of life (HR-QOL) scores were comparable between groups; however, dorsal surgery patients had significantly more severe myelopathy (P < .01). Comprehensive 1-year follow-up was obtained in 46 of 50 patients (92%). Greater HR-QOL improvement (Short-Form 36 Physical Component Summary) was observed after ventral surgery (P = .05). The complication rate (16.6% overall) was comparable between groups. Significant improvement in the modified Japanese Orthopedic Association scale score was observed in both groups (P < .01). Dorsal fusion surgery had significantly greater mean hospital costs ($29 465 vs $19 245; P < .01) and longer average length of hospital stay (4.0 vs 2.6 days; P < .01) compared with ventral fusion surgery. CONCLUSION: Surgery for treating CSM was followed by significant improvement in disease-specific symptoms and in HR-QOL. Greater improvement in HR-QOL was observed after ventral surgery. Dorsal fusion surgery was associated with longer length of hospital stay and higher hospital costs. The pilot study demonstrated feasibility for a larger randomized clinical trial.

Randomized trials have demonstrated the efficacy of craniectomy for the treatment of malignant cerebral edema following ischemic stroke. We sought to determine the prevalence and outcomes related to this by using a national database. Patient discharges with ischemic stroke as the primary diagnosis undergoing craniectomy were queried from the US Nationwide Inpatient Sample from 1999 to 2008. A subpopulation of patients was identified that underwent thrombolysis. Two primary end points were examined: in-hospital mortality and discharge to home/routine care. To facilitate interpretations, adjusted prevalence was calculated from the overall prevalence and two age-specific logistic regression models. The predictive margin was then generated using a multivariate logistic regression model to estimate the probability of in-hospital mortality after adjustment for admission type, admission source, length of stay, total hospital charges, chronic comorbidities, and medical complications. After excluding 71,996 patients with the diagnosis of intracranial hemorrhage and posterior intracranial circulation occlusion, we identified 4,248,955 adult hospitalizations with ischemic stroke as a primary diagnosis. The estimated rates of hospitalizations in craniectomy per 10,000 hospitalizations with ischemic stroke increased from 3.9 in 1999-2000 to 14.46 in 2007-2008 (p for linear trend<0.001). Patients 60+ years of age had in-hospital mortality of 44% while the 18-59 year old group was found to be 24% (p = 0.14). Outcomes were comparable if recombinant tissue plasminogen activator had been administered. Craniectomy is being increasingly performed for malignant cerebral edema following large territory cerebral ischemia. We suspect that the increase in the annual incidence of DC for malignant cerebral edema is directly related to the expanding collection of evidence in randomized trials that the operation is efficacious when performed in the correct patient population. In hospital mortality is high for all patients undergoing this procedure.

Increasingly studies have identified socioeconomic factors adversely affecting healthcare outcomes for a multitude of diseases. To date, however, there has not been a study correlating socioeconomic details from nationwide databases on the prevalence of advanced coronary artery disease. We seek to identify whether socioeconomic factors contribute to advanced coronary artery disease prevalence in the United States. State specific prevalence data was queried form the United States Nationwide Inpatient Sample for 2009. Patients undergoing percutaneous coronary angioplasty and coronary artery bypass graft were identified as principal procedures. Non-cardiac related procedures, lung lobectomy and hip replacement (partial and total) were identified and used as control groups. Information regarding prevalence was then merged with data from the Behavioral Risk Factor Surveillance System, the largest, on-going telephone health survey system tracking health conditions and risk behaviors in the United States. Pearson's correlation coefficient was calculated for individual socioeconomic variables including employment status, level of education, and household income. Household income and education level were inversely correlated with the prevalence of percutaneous coronary angioplasty (-0.717; -0.787) and coronary artery bypass graft surgery (-0.541; -0.618). This phenomenon was not seen in the non-cardiac procedure control groups. In multiple linear regression analysis, socioeconomic factors were significant predictors of coronary artery bypass graft and percutaneous transluminal coronary angioplasty (p<0.001 and p=0.005, respectively). Socioeconomic status is related to the prevalence of advanced coronary artery disease as measured by the prevalence of percutaneous coronary angioplasty and coronary artery bypass graft surgery.

Cerebral edema develops in response to and as a result of a variety of neurologic insults such as ischemic stroke, traumatic brain injury, and tumor. It deforms brain tissue, resulting in localized mass effect and increase in intracranial pressure (ICP) that are associated with a high rate of morbidity and mortality. When administered in bolus form, hyperosmolar agents such as mannitol and hypertonic saline have been shown to reduce total brain water content and decrease ICP, and are currently the mainstays of pharmacological treatment. However, surprisingly, little is known about the increasingly common clinical practice of inducing a state of sustained hypernatremia. Herein, we review the available studies employing sustained hyperosmolar therapy to induce hypernatremia for the prevention and/or treatment of cerebral edema. Insufficient evidence exists to recommend pharmacologic induction of hypernatremia as a treatment for cerebral edema. The strategy of vigilant avoidance of hyponatremia is currently a safer, potentially more efficacious paradigm.

Background Iatrogenic injury to the vertebral artery during posterior cervical fusion is a rare and potentially disastrous complication. Differentiating arterial from brisk venous bleeding would be ideal to assist in the intra-operative management. Definitive angiography is typically not feasible during most routine spine surgery. Case description We describe the case of a patient undergoing an occipitocervical fusion, where brisk bleeding was encountered during dissection of the CB lateral mass. While the dissection was thought to be superficial to critical structures, the nature of the hemorrhage could not be definitely determined by visual inspection by two senior surgeons. The hemorrhage did not readily cease with standard maneuvers such as, the application of various hemostatic agents. Simultaneous blood gas analysis was performed on samples obtained from the patient’s radial artery and from the hemorrhage in the operative bed. Comparative analysis concluded that the bleeding encountered in the surgical field was venous in nature. Conclusion Blood gas analysis can be a useful adjunct in determining the nature of hemorrhage from vascular structures in spine surgery when visual inspection is indeterminate.

Herniated intervertebral discs can result in pain and neurological compromise. Treatment for this condition is categorized as surgical or non-surgical. We sought to identify trends in inpatient surgical management of herniated intervertebral discs using a national database. Patient discharges identified with a principal procedure relating to laminectomy for excision of herniated intervertebral disc were selected from the Nationwide Inpatient Sample (Healthcare Cost and Utilization Project - Agency for Healthcare Research and Quality, Rockville, MD), under the auspices of a data user agreement. These surgical patients did not undergo instrumented fusion. To account for the Nationwide Inpatient Sample weighting schema, design-adjusted analyses were used. The estimates of standard errors were calculated using SUDAAN software (Research Triangle International, NC, USA). This software is based on the International Classification of Diseases, 9(th) Revision, Clinical Modification (ICD-9-CM); a uniform and standardized coding system. Using International Classification of Disease 9(th) Revision clinical modifier (ICD-9 CM) procedure code 80.51, we were able to identify disc excision, in part or whole, by laminotomy or hemilaminectomy. The incidence of laminectomy for the excision of herniated intervertebral disc has decreased dramatically from 1993 where 266,152 cases were reported [CI = 22,342]. In 2007, only 123,398 cases were identified [CI = 12,438]. The average length of stay in 1993 was 4 days [CI = 0.17], and in 2007 it decreased to just 2 days [CI = 0.17]. Both these comparisons were significantly different at P < 0.001. The average inflation adjusted (2007 buying power) charge of the procedure in 1993 was 14,790.87 USD [CI = 916.85]. This value rose in 2007 to 24,639 USD [CI = 1,485.51]. This difference was significant at P < 0.001. National estimates indicate that the incidence of inpatient laminectomy for the excision of herniated intervertebral disc has decreased significantly. This trend is multifactorial and is likely related to developments in outcomes research, the growing popularity of alternative procedures (intervertebral instrumented fusion), and transition to an ambulatory setting of surgical care.