wide Inpatient Dataset (2011-2014).
PATIEN T SAMPLE: Patients who underwent one of the four lumbar
spine surgical procedures under study.
OUTCOME MEASURES: The development of a complication or
hospital readmission within 90 days of the surgical procedure.
METHODS: For each specific procedure, individual surgeon volume
was separately plotted against the number of complications and readmissions in a spline analysis that adjusted for all co-variates. Spline
cut points were used to create a categorical variable of procedure
volume for each individual procedure. Multivariable logistic regression analysis was then separately performed using the categorical
volume-outcome metric for each individual procedure and for the
outcomes of 90-day complications and 90-day readmissions.
RESULTS: In all, 187,185 spine surgical procedures met our inclusion
criteria, performed by 5,514 different surgeons at 178 hospitals. Spline
analysis determined that the procedure volume cut-point was 25 for
decompressions, 40 for discectomy, 43 for interbody fusion and 35 for
posterolateral fusions. For surgeons who failed to meet the volume
metric, there was a 78% increase in the odds of complications following decompressions, a 61% increase in the odds of complications
following discectomy, a 17% increase in the odds of complications
following lumbar interbody fusions and a 54% increase in the odds
of complications following posterolateral fusions. Findings were
similar for readmission measures as well.
CONCLUSIONS: The results of this work allow us to identify meaningful volume-based benchmarks for the performance of common
lumbar spine surgical procedures including decompression, discectomy and fusion-based procedures. Based on our determinations,
readily achievable goals would include roughly four discectomy and
lumbar interbody fusion procedures per month, three posterolateral
lumbar fusions per month and at least one decompression surgery
every other week.
Outstanding Paper: Runner Up
A minimum of 5-year follow-up after lumbar
transforaminal epidural steroid injections in patients with
lumbar radicular pain due to intervertebral disc herniation
David J. Kennedy, MD, Patricia Zheng, MD, Matthew Smuck, MD,
Zachary L. McCormick, MD, Lisa Huynh, MD, Byron J. Schneider, MD
BACKGROUND CONTEXT: Patients with lumbosacral radiculopathy from an intervertebral disc herniation are frequently treated by
transforaminal epidural steroid injections (TFESIs). The long-term
outcomes of these patients are poorly described.
PURPOSE: To determine the long-term outcomes for a homogenous
group of patients with acute unilateral lumbar radicular pain due to
single-level herniated nucleus after lumbar epidural steroid injec-
tion at ≥ 5 years.
PATIEN T SAMPLE: Subjects enrolled into a previous reported multi-institutional randomized controlled trial, ≥ 18 years old with single
leg radicular pain rating ≥4/10 for less than 6 months’ duration, with
radiographic imaging demonstrating an anatomically congruent
single-level herniated nucleus pulposus.
OUTCOME MEASURES: Presence of recurrent or persistent pain,
pain within last week, current opioid use for radicular symptoms,
additional spine injections for radicular pain, progression to surgery,
and unemployment due to pain as determined by independent
phone interview at least 5 years after enrollment due to the initial
METHODS: All patients initially underwent a single-level lumbar
TFESI due to failure of conservative care, but could elect to pursue
surgical intervention or repeat injections through shared decision-making with the treating physician when and if pain control was
deemed inadequate. After ≥ 5 years, an independent assessor
contacted the subjects by phone and performed a standardized
interview to determine outcomes. Fisher’s exact test was used to
compare outcomes for those who pursued versus those who did
not pursue surgery.
RESULTS: During the recruitment period (December 2008-Decem-
ber 2012), 78 subjects were enrolled. At 5 years, 39 (50%) of the 78
subjects were reachable for independent phone follow-up. Of these,
30 [76.9%, 95% CI ( 61.7-87.4%)] had a history of recurrent pain since
the initial TFESI. However, only 9 [ 23.1%, 95% CI ( 12. 7-38.3%)] had
current pain, while 3 [ 7.7%, 95% CI ( 2. 7-20.3%)] were currently taking
opioid medications. Nine [ 23.1%, 95% CI ( 12. 7-38.3%)] had received
additional TFESIs, and 19 [ 48.7%, 95% CI ( 33. 9-63.8%)] had received
surgery. Only 3 [ 7.7%, 95% CI ( 2. 7-20.3%)] were unemployed due
to related pain at time of follow-up. When comparing the group
that had surgery vs those who did not, there were no differences in
the rates of recurrent pain ( 16, 84.2% vs 14 (70.0%, p=0.81), current
pain ( 6, 31.6% vs 3, 15.0%, p=0.47), opioid use ( 2, 10.5% vs 1, 5.0%;
p= 1.00), rate of additional injections ( 6, 31.6% vs 3, 15.0%, p=0.47),
or unemployment status ( 2, 10.5% vs 1, 5.0%; p= 1.00).
CONCLUSIONS: Despite a high success rate at 6 months, the majority
of subjects experienced a recurrence of symptoms at some time during
the subsequent 5 years. Fortunately, few reported current symptoms and
a small minority required additional injections, surgery or opioid pain
medications. Lumbar disc herniation is a disease that can be effectively
treated in the short-term by TFESI or surgery, but long-term recurrence
rates are high regardless of treatment received.
Please see these papers in full in the January 2018 issue of The
Spine Journal at: www.thespinejournalonline.com.