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Owoicho Adogwa, Isaac O. Karikari, Kevin R. Carr, Max Krucoff, Divya Ajay, Parastou Fatemi, Edgar L. Perez, Joseph S. Cheng, Carlos A. Bagley and Robert E. Isaacs

Object

A spinal epidural abscess (SEA) is a rare but severe infection requiring prompt recognition and management. The incidence of SEA has doubled in the past decade, owing to an aging population and to increased use of spinal instrumentation and vascular access. The optimal management of SEAs in patients 50 years of age and older remains a matter of considerable debate. In an older patient population with multiple comorbidities, whether intravenous antibiotics alone or in combination with surgery lead to superior outcomes remains unknown. The present study retrospectively analyzes cases of SEAs, in patients 50 years of age and older, treated at Duke University Medical Center over the past 15 years.

Methods

Eighty-two patients underwent treatment for a spinal epidural abscess between 1999 and 2013. There were 46 men and 36 women, whose overall mean age (± SD) was 65 ± 8.58 years (range 50–82 years). The mean duration of clinical follow-up was 41.38 ± 86.48 weeks. Thirty patients (37%) underwent surgery for removal of the abscess, whereas 52 (63%) were treated more conservatively, undergoing CT-guided aspiration or receiving antibiotics alone based on the results of blood cultures. The correlation between pretreatment variables and outcomes was evaluated in a multivariate regression analysis.

Results

Back pain and severe motor deficits were the most common presenting symptoms. Compared with baseline neurological status, the majority of patients (68%) reported being neurologically “better” or “unchanged.” Twelve patients (15%) had a good outcome (7 [23%] treated operatively vs 5 [10%] treated nonoperatively, p = 0.03), while clinical status in 41 patients (50%) remained unchanged (10 [33%] treated operatively vs 31 [60%] treated nonoperatively, p = 0.01). Overall, 20 patients (25%) died (9 [30%] treated operatively vs 11 [21%] treated nonoperatively, p = 0.43). In a multivariate logistic regression model, an increasing baseline level of pain, the presence of paraplegia or quadriplegia on initial presentation, and a dorsally located SEA were independently associated with poor outcomes.

Conclusions

The results of the study suggest that in patients 50 years of age and older, early surgical decompression combined with intravenous antimicrobial therapy was not associated with superior clinical outcomes when compared with intravenous antimicrobial therapy alone.

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Ankit I. Mehta, Owoicho Adogwa, Isaac O. Karikari, Paul Thompson, Terence Verla, Ulysses T. Null, Allan H. Friedman, Joseph S. Cheng, Carlos A. Bagley and Robert E. Isaacs

Object

Intradural extramedullary (IDEM) neoplasms are uncommon lesions that can pose a challenge for resection. Numerous factors affect the resectability and ultimately the outcome of these lesions. The authors report their 10-year institutional experience with the resection of IDEM neoplasms, focusing on the effect of location on surgical outcomes.

Methods

The authors performed a retrospective review of 96 consecutive patients who presented with a cervical and/or thoracic IDEM tumor that was resected between February 2000 and July 2009. All patients underwent MRI, and the axial location of the tumor was categorized as anterior, posterior, or lateral. Postoperative complications were assessed, as was neurological status at the patient's last follow-up clinic visit. Major complications assessed included CSF leakage requiring lumbar drainage, reexploration for epidural hematoma, and major postoperative neurological deficits.

Results

The mean ± SD age at presentation was 51.16 ± 17.87 years. Major surgical approach–related complications occurred in 15% of patients. Major non–approach related surgical complications occurred in 7.1% of patients, while minor complications occurred in 14.2% of patients. Postoperative neurological deficits occurred most commonly in the thoracic spine between T-1 and T-8. Based on axial spinal cord location, the surgery-related complications rates for all anterior tumors (n = 12) was 41.6%, whereas that for all lateral tumors (n = 69) was 4.4% and that for all posteriorly located tumors (n = 17) was 0%.

Conclusions

Spinal IDEM tumors that are anteriorly located in the upper thoracic spine were found to have the highest rate of surgery-related complications and postoperative neurological deficits. This finding may be associated with the unforgiving anatomy of the upper thoracic spine in which there is a higher cord-to-canal ratio and a tenuous vascular supply.

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Owoicho Adogwa, Ricardo K. Carr, Katherine Kudyba, Isaac Karikari, Carlos A. Bagley, Ziya L. Gokaslan, Nicholas Theodore and Joseph S. Cheng

Object

Same-level recurrent lumbar stenosis, pseudarthrosis, and adjacent-segment disease (ASD) are potential complications that can occur after index lumbar spine surgery, leading to significant discomfort and radicular pain. While numerous studies have demonstrated excellent results following index lumbar spine surgery in elderly patients (age > 65 years), the effectiveness of revision lumbar surgery in this cohort remains unclear. The aim of this study was to assess the long-term effectiveness of revision lumbar decompression and fusion in the treatment of symptomatic pseudarthrosis, ASD, and same-level recurrent stenosis, using validated patient-reported outcomes.

Methods

After a review of the institutional database, 69 patients who had undergone revision neural decompression and instrumented fusion for ASD (28 patients), pseudarthrosis (17 patients), or same-level recurrent stenosis (24 patients) were included in this study. Baseline and 2-year scores on the visual analog scale for leg pain (VAS-LP), VAS for back pain (VAS-BP), Oswestry Disability Index (ODI), and Zung Self-Rating Depression Scale (SDS) as well as the time to narcotic independence, time to return to baseline activity level, health state utility (EQ-5D, the EuroQol-5D health survey), and physical and mental component summary scores of the 12-Item Short-Form Health Survey (SF-12 PCS and MCS) were assessed.

Results

Compared with the preoperative status, VAS-BP was significantly improved 2 years after surgery for ASD (mean ± standard deviation 9 ± 2 vs 4.01 ± 2.56, p = 0.001), pseudarthrosis (7.41 ± 1 vs 5.52 ± 3.08, p = 0.02), and same-level recurrent stenosis (7 ± 2.00 vs 5.00 ± 2.34, p = 0.003). The 2-year ODI was also significantly improved after surgery for ASD (29 ± 9 vs 23.10 ± 10.18, p = 0.001), pseudarthrosis (28.47 ± 5.85 vs 24.41 ± 7.75, p = 0.001), and same-level recurrent stenosis (30.83 ± 5.28 vs 26.29 ± 4.10, p = 0.003). The Zung SDS score and SF-12 MCS did not change appreciably after surgery in any of the cohorts, with an overall mean 2-year change of 1.01 ± 5.32 (p = 0.46) and 2.02 ± 9.25 (p = 0.22), respectively.

Conclusions

Data in this study suggest that revision lumbar decompression and extension of fusion for symptomatic pseudarthrosis, ASD, and same-level recurrent stenosis provides improvement in low-back pain, disability, and quality of life and should be considered a viable treatment option for elderly patients with persistent or recurrent back and radicular pain. Mental health symptoms may be more refractory to revision surgery.

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Owoicho Adogwa, Ryan Owens, Isaac Karikari, Vijay Agarwal, Oren N. Gottfried, Carlos A. Bagley, Robert E. Isaacs and Joseph S. Cheng

Object

Despite advances in technology and understanding in spinal physiology, reoperation for symptomatic adjacent-segment disease (ASD), same-level recurrent stenosis, and pseudarthrosis in elderly patients continues to occur. While revision lumbar surgery is effective, attention has turned to questions on the utility and value of the revision decompression and fusion procedure. To date, an analysis of the cost and health state gain associated with revision lumbar surgery in elderly patients with symptomatic pseudarthrosis, ASD, or same-level recurrent lumbar stenosis has yet to be performed. The aim of this study was to assess the long-term outcomes and cost-effectiveness of revision surgery in elderly patients with recurrent or persistent back and leg pain.

Methods

After reviewing their institutional database, the authors found 69 patients 65 years of age and older who had undergone revision decompression and instrumented fusion for back and leg pain associated with pseudarthrosis (17 patients), same-level recurrent stenosis (24 patients), or ASD (28 patients) and included them in this study. Total 2-year back-related medical resource utilization and health state values (quality-adjusted life years [QALYs], calculated from the EQ-5D, the EuroQol-5D health survey, with US valuation) were assessed. Two-year resource use was multiplied by unit costs based on Medicare national allowable payment amounts. The mean total 2-year cost per QALY gained after revision surgery was assessed.

Results

The mean (± standard deviation) time between the index surgery and revision surgery was 3.51 ± 3.63 years. A mean cumulative 2-year gain of 0.35 QALY was observed after revision surgery. The mean total 2-year cost of revision surgery was $28,256 ± $3000 (ASD: $28,829 ± $3812, pseudarthrosis: $28,069 ± $2508, same-level recurrent stenosis: $27,871 ± $2375). Revision decompression and extension of fusion was associated with a mean 2-year cost of $80,594 per QALY gained.

Conclusions

Revision decompression and fusion provided a significant gain in health state utility for elderly patients with symptomatic pseudarthrosis, same-level recurrent stenosis, or ASD, with a mean 2-year cost of $80,594 per QALY gained. When indicated, revision surgery for symptomatic ASD, same-level recurrent stenosis, and pseudarthrosis is a valuable treatment option for elderly patients experiencing persistent back and leg pain. Findings in this study provided a value measure of surgery that can be compared with future cost-per-QALY-gained studies of medical management or alternative surgical approaches.

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Owoicho Adogwa, Scott L. Parker, David N. Shau, Stephen K. Mendenhall, Clinton J. Devin, Joseph S. Cheng and Matthew J. McGirt

Object

Over the past decade, there has been a dramatic increase in the number of spinal fusions performed in the US and a corresponding increase in the incidence of adjacent-segment disease (ASD). Surgical management of symptomatic ASD consists of decompression of neural elements and extension of fusion. It has been shown to have favorable long-term outcomes, but the cost-effectiveness remains unclear. In this study, the authors set out to assess the cost-effectiveness of revision surgery in the treatment of ASD over a 2-year period.

Methods

Fifty patients undergoing neural decompression and extension of fusion construct for ASD-associated back and leg pain were included in the study. Two-year total back-related medical resource utilization, missed work, and health state values (quality-adjusted life years [QALYs], calculated from the EQ-5D with US valuation) were assessed. Two-year resource use was multiplied by unit costs based on Medicare national allowable payment amounts (direct cost), and patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Mean total 2-year cost per QALY gained after revision surgery was assessed.

Results

The mean (± SD) interval between prior fusion and revision surgery for ASD was 3.07 ± 2.02 years. A mean cumulative 2-year gain of 0.76 QALYs was observed after revision surgery. The mean total 2-year cost of extension of fusion constructs was $47,846 ± $32,712 (surgery cost: $24,063 ± $300; outpatient resource utilization cost: $4175 ± $3368; indirect cost: $19,607 ± $32,187). Revision decompression and extension of fusion was associated with a mean 2-year cost per QALY gained of $62,955.

Conclusions

In the authors' practice, revision decompression and extension of fusion provided a significant gain in health state utility for patients with symptomatic ASD, with a 2-year cost per QALY gained of $62,995. When indicated, revision surgery for ASD is a valuable treatment option for patients experiencing back and leg pain secondary to ASD. The findings provide a value measure of surgery that can be compared with future cost-per-QALY-gained studies of medical management or alternative surgical approaches.

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Owoicho Adogwa, Scott L. Parker, David N. Shau, Stephen K. Mendenhall, Oran Aaronson, Joseph S. Cheng, Clinton J. Devin and Matthew J. McGirt

Object

Despite advances in technology and understanding in spinal physiology, reoperation for symptomatic same-level recurrent stenosis continues to occur. Although revision lumbar surgery is effective, attention has turned to the question of the utility and value of revision decompression and fusion procedures. To date, an analysis of cost and heath state gain associated with revision lumbar surgery for recurrent same-level lumbar stenosis has yet to be described. The authors set out to assess the 2-year comprehensive cost of revision surgery and determine its value in the treatment of same-level recurrent stenosis.

Methods

Forty-two patients undergoing revision decompression and instrumented fusion for same-level recurrent stenosis–associated leg and back pain were included in this study. Two-year total back-related medical resource utilization, missed work, and health state values (quality-adjusted life years [QALYs], calculated from the EQ-5D with US valuation) were assessed. Two-year resource use was multiplied by unit costs based on Medicare national allowable payment amounts (direct cost), and patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). Mean total 2-year cost per QALY gained after revision surgery was assessed.

Results

The mean (± SD) interval between prior and revision surgery was 4.16 ± 4.64 years. Bone morphogenetic protein was used in 7 cases of revision arthrodesis (16.7%). A mean cumulative 2-year gain of 0.84 QALY was observed after revision surgery. The mean total 2-year cost of revision fusion was $49,431 ± $7583 (surgery cost $21,060 ± $4459; outpatient resource utilization cost $9748 ± $5292; indirect cost $18,623 ± $9098). Revision decompression and extension of fusion was associated with a mean 2-year cost per QALY gained of $58,846.

Conclusions

In the authors' practice, revision decompression and fusion provided a significant gain in health state utility for patients with symptomatic same-level recurrent stenosis, with a 2-year cost per QALY gained of $58,846. When indicated, revision surgery for same-level recurrent stenosis is a valuable treatment option for patients experiencing back and leg pain secondary to this disease. The authors' findings provide a value measure of surgery that can be compared with the results of future cost-per-QALY-gained studies of medical management or alternative surgical approaches.

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Scott L. Parker, Stephen K. Mendenhall, David Shau, Owoicho Adogwa, Joseph S. Cheng, William N. Anderson, Clinton J. Devin and Matthew J. McGirt

Object

Spinal surgical outcome studies rely on patient-reported outcome (PRO) measurements to assess treatment effect. A shortcoming of these questionnaires is that the extent of improvement in their numerical scores lack a direct clinical meaning. As a result, the concept of minimum clinical important difference (MCID) has been used to measure the critical threshold needed to achieve clinically relevant treatment effectiveness. As utilization of spinal fusion has increased over the past decade, so has the incidence of adjacent-segment degeneration following index lumbar fusion, which commonly requires revision laminectomy and extension of fusion. The MCID remains uninvestigated for any PROs in the setting of revision lumbar surgery for adjacent-segment disease (ASD).

Methods

In 50 consecutive patients undergoing revision surgery for ASD-associated back and leg pain, PRO measures of back and leg pain on a visual analog scale (BP-VAS and LP-VAS, respectively), Oswestry Disability Index (ODI), 12-Item Short Form Health Survey Physical and Mental Component Summaries (SF-12 PCS and MCS, respectively), and EuroQol-5D health survey (EQ-5D) were assessed preoperatively and 2 years postoperatively. The following 4 well-established anchor-based MCID calculation methods were used to calculate MCID: average change; minimum detectable change (MDC); change difference; and receiver operating characteristic curve (ROC) analysis for the following 2 separate anchors: health transition item (HTI) of the SF-36 and satisfaction index.

Results

All patients were available for 2-year PRO assessment. Two years after surgery, a statistically significant improvement was observed for all PROs (mean changes: BP-VAS score [4.80 ± 3.25], LP-VAS score [3.28 ± 3.25], ODI [10.24 ± 13.49], SF-12 PCS [8.69 ± 12.55] and MCS [8.49 ± 11.45] scores, and EQ-5D [0.38 ± 0.45]; all p < 0.001). The 4 MCID calculation methods generated a range of MCID values for each of the PROs (BP-VAS score, 2.3–6.5; LP-VAS score, 1.7–4.3; ODI, 6.8–16.9; SF-12 PCS, 6.1–12.6; SF-12 MCS, 2.4–10.8; and EQ-5D, 0.27–0.54). The area under the ROC curve was consistently greater for the HTI anchor than the satisfaction anchor, suggesting this as a more accurate anchor for MCID.

Conclusions

Adjacent-segment disease revision surgery–specific MCID is highly variable based on calculation technique. The MDC approach with HTI anchor appears to be most appropriate for calculation of MCID after revision lumbar fusion for ASD because it provided a threshold above the 95% CI of the unimproved cohort (greater than the measurement error), was closest to the mean change score reported by improved and satisfied patients, and was not significantly affected by choice of anchor. Based on this method, MCID following ASD revision lumbar surgery is 3.8 points for BP-VAS score, 2.4 points for LP-VAS score, 6.8 points for ODI, 8.8 points for SF-12 PCS, 9.3 points for SF-12 MCS, and 0.35 quality-adjusted life-years for EQ-5D.