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Mladen Djurasovic, Katlyn E. McGraw, Kelly Bratcher, Charles H. Crawford III, John R. Dimar II, Rolando M. Puno, Steven D. Glassman, R. Kirk Owens II and Leah Y. Carreon

OBJECTIVE

The goal of this study was to determine efficacy and cost-effectiveness of Cell Saver in 2- and 3-level lumbar decompression and fusion.

METHODS

Patients seen at a tertiary care spine center who were undergoing a posterior 2- or 3-level lumbar decompression and fusion were randomized to have Cell Saver used during their surgery (CS group, n = 48) or not used (No Cell Saver [NCS] group, n = 47). Data regarding preoperative and postoperative hemoglobin and hematocrit, estimated blood loss, volume of Cell Saver blood reinfused, number of units and volume of allogeneic blood transfused intraoperatively and postoperatively, complications, and costs were collected. Costs associated with Cell Saver use were calculated based on units of allogeneic blood transfusions averted.

RESULTS

Demographics and surgical parameters were similar in both groups. The mean estimated blood loss was similar in both groups: 612 ml in the CS group and 742 ml in the NCS group. There were 53 U of allogeneic blood transfused in 29 patients in the NCS group at a total blood product cost of $67,688; and 38 U of allogeneic blood transfused in 16 patients in the CS group at a total blood cost of $113,162, resulting in a cost of $3031 per allogeneic blood transfusion averted using Cell Saver.

CONCLUSIONS

Cell Saver use produced lower rates of allogeneic transfusion but was found to be more expensive than using only allogeneic blood for 2- and 3-level lumbar degenerative fusions. This increased cost may be reasonable to patients who perceive that the risks associated with allogeneic transfusions are unacceptable.

CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: randomized controlled trial; evidence: class III.

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Borys V. Gvozdyev, Leah Y. Carreon, Christopher M. Graves, Stephanie A. Riley, Katlyn E. McGraw, R. Joseph Head, John R. Dimar II and Steven D. Glassman

OBJECTIVE

Patient-reported outcomes (PROs) such as the Oswestry Disability Index (ODI) and EuroQol-5D (EQ-5D) are widely used to evaluate treatment outcomes following spine surgery for degenerative conditions. The goal of this study was to use the Charlson Comorbidity Index (CCMI) as a measure of general health status, for comparison with standard PROs.

METHODS

The authors examined serial CCMI scores, complications, and PROs in 371 patients treated surgically for degenerative lumbar spine conditions who were enrolled in the Quality and Outcomes Database from a single center. The cohort included 152 males (41%) with a mean age of 58.7 years. Patients with no, minor, or major complications were compared at baseline and at 1 year postoperatively.

RESULTS

Minor complications were observed in 177 patients (48%), and major complications in 34 (9%). There were no significant differences in preoperative ODI, EQ-5D, or CCMI among the 3 groups. At 1 year, there was a significantly greater deterioration in CCMI in the major complication group (1.03) compared with the minor (0.66) and no complication groups (0.44, p < 0.006), but no significant difference in ODI or EQ-5D.

CONCLUSIONS

Despite equivalent improvements in PROs, patients with major complications actually had greater deterioration in their general health status, as evidenced by worse CCMI scores. Because CCMI is predictive of medical and surgical risk, patients who sustained a major complication now carry a greater likelihood of adverse outcomes with future interventions, including subsequent spine surgery. Although PRO scores are a key metric, they fail to adequately reflect the potential long-term impact of major perioperative complications.

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Leah Y. Carreon, Mladen Djurasovic, John R. Dimar II, R. Kirk Owens II, Charles H. Crawford III, Rolando M. Puno, Kelly R. Bratcher, Katlyn E. McGraw and Steven D. Glassman

OBJECTIVE

Studies have shown that anxious or depressed patients may have poorer outcomes after lumbar fusion. These conclusions were drawn from questionnaires specifically designed to measure anxiety and depression. The objective of this study is to determine if responses to the EQ-5D anxiety/depression domain or the items used to calculate the 36-Item Short-Form Health Survey (SF-36) Mental Component Summary (MCS) can predict outcomes after lumbar fusion surgery.

METHODS

Patients enrolled in the National Neurosurgery Quality and Outcomes Database from a single center with 1-year follow-up were identified. The outcomes collected include the Oswestry Disability Index (ODI), EQ-5D, SF-36, and the back- and leg-pain numeric rating scales (range 0–10). Linear regression modeling was performed to predict the 1-year ODI scores using the EQ-5D anxiety/depression domain and the 14 items used to calculate SF-36 MCS.

RESULTS

Complete data were available for 312 (88%) of 353 eligible patients. The mean patient age was 58.5 years, 175 (56%) patients were women, and 52 patients were smokers. After controlling for other factors, the item in the SF-36 that asks “Have you felt downhearted and depressed?” is the strongest predictor of the 1-year ODI score (r2 = 0.191; p = 0.000) and 1-year EQ-5D score (r2 = 0.205; p = 0.000). Neither the EQ-5D anxiety/depression domain nor the diagnoses of anxiety or depression were predictors of 1-year outcomes.

CONCLUSIONS

Patient responses to SF-36 item “Have you felt downhearted and depressed?” account for 20% of the variability of the 1-year ODI and EQ-5D scores and can be used by clinicians to screen for anxiety or depression in patients prior to lumbar fusion surgery. Clinicians may offer psychological support to these patients preoperatively in order to improve treatment outcomes.