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Asdrubal Falavigna, Orlando Righesso and Alisson Roberto Teles

Object

The purpose of this study was to present straightforward preoperative methods to define the need for manubriotomy in the anterior surgical approach to the cervicothoracic junction.

Methods

Preoperative MR imaging and CT scanning studies were performed in all patients. The CT images with sagittal reconstructions including the manubrium were done to apply the so-called surgeons' view line. This line is parallel to the inferior plateau of the superior healthy vertebrae or the vertebrae above the herniated intervertebral disc, and the decision concerning the need for manubriotomy depends on the correlation between this line and the manubrium.

Results

Preoperative planning of the need for manubriotomy was correct in all cases. Manubriotomy was never performed in C-7 corpectomy or C7–T1 discectomy cases; nevertheless, manubriotomy was needed in half of the cases when the T-1 corpectomy was the lowest level to be resected (8 cases), and in 4 cases the lowest level to be approached was T-2. The mean surgical time, bleeding volume, postoperative pain intensity, and length of hospital stay were less in the cervicotomy than in the manubriotomy group.

Conclusions

By using the surgeons' view line and its correlation with the manubrium, the need for manubriotomy can be predicted without compromising decompression and reconstruction. The statistical differences observed in the surgical variables between the manubriotomy and cervicotomy cases justified the use of preoperative evaluation of the need for manubriotomy as an aid to surgical planning and to give the patient and family realistic expectations about the surgery.

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Asdrubal Falavigna, Orlando Righesso, Vincent C. Traynelis, Alisson Roberto Teles and Pedro Guarise da Silva

Object

Deep wound infections are one of the most common and serious complications of spinal surgery. The impact of such infections on long-term outcomes is not well understood. The purpose of this study was to evaluate the functional status and satisfaction in patients who suffered a deep wound infection after undergoing lumbar arthrodesis for symptomatic degenerative disc disease.

Methods

The authors conducted a prospective study in 13 patients with a clinical and radiological diagnosis of symptomatic degenerative lumbar stenosis and instability; after undergoing decompression and instrumentation-augmented arthrodesis, the patients suffered a deep wound infection (infection group). A 3:1 (39-patient) matched cohort was selected for comparison (control group). All surgeries were performed during the same period and by a single surgeon. The postoperative infections were all treated in a similar manner and the instrumentation was not removed. Both groups were followed up and assessed with validated outcome instruments: Numerical Rating Scale of pain, Oswestry Disability Index, 36-Item Short Form Health Survey, Beck Depression Inventory, and Hospital Anxiety and Depression Scale. Patient satisfaction was also determined.

Results

The median follow-up duration was 22 months (range 6–108 months). The mean patient age was 62 ± 10 years, and 59.6% of the patients were female. There was no significant difference between the groups in pain, functional disability, quality of life, or depression and anxiety. However, 53.8% of the patients with infection were not satisfied with the procedure at the final evaluation, compared with 15.4% of the patients without a deep wound infection (p = 0.003).

Conclusions

Patients with successfully treated postoperative deep wound infections do not have a difference in functional outcome compared with patients who underwent an identical operation but did not suffer a complicating infection. Patients who suffered an infection were more likely to be unsatisfied with the procedure than patients who did not.

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Asdrubal Falavigna, Nicolas Scheverin, Orlando Righesso, Alisson R. Teles, Maria Carolina Gullo, Joseph S. Cheng and K. Daniel Riew

OBJECT

Lumbar discectomy is one of the most common surgical spine procedures. In order to understand the value of this surgical care, it is important to understand the costs to the health care system and patient for good results. The objective of this study was to evaluate for the first time the cost-effectiveness of spine surgery in Latin America for lumbar discectomy in terms of cost per quality-adjusted life year (QALY) gained for patients in Brazil.

METHODS

The authors performed a prospective cohort study involving 143 consecutive patients who underwent open discectomy for lumbar disc herniation (LDH). Patient-reported outcomes were assessed utilizing the SF-6D, which is derived from a 12-month variation of the SF-36. Direct medical costs included medical reimbursement, costs of hospital care, and overall resource consumption. Disability losses were considered indirect costs. A 4-year horizon with 3% discounting was applied to health-utilities estimates. Sensitivity analysis was performed by varying utility gain by 20%. The costs were expressed in Reais (R$) and US dollars ($), applying an exchange rate of 2.4:1 (the rate at the time of manuscript preparation).

RESULTS

The direct and indirect costs of open lumbar discectomy were estimated at an average of R$3426.72 ($1427.80) and R$2027.67 ($844.86), respectively. The mean total cost of treatment was estimated at R$5454.40 ($2272.66) (SD R$2709.17 [$1128.82]). The SF-6D utility gain was 0.044 (95% CI 0.03197–0.05923, p = 0.017) at 12 months. The 4-year discounted QALY gain was 0.176928. The estimated cost-utility ratio was R$30,828.35 ($12,845.14) per QALY gained. The sensitivity analysis showed a range of R$25,690.29 ($10,714.28) to R$38,535.44 ($16,056.43) per QALY gained.

CONCLUSIONS

The use of open lumbar discectomy to treat LDH is associated with a significant improvement in patient outcomes as measured by the SF-6D. Open lumbar discectomy performed in the Brazilian supplementary health care system provides a cost-utility ratio of R$30,828.35 ($12,845.14) per QALY. The value of acceptable cost-effectiveness will vary by country and region.