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Objective: Determine patient and injury characteristics predictive of vascular injury (VAI) in blunt cervical spine (BCS) trauma to identify high-risk patients and propose an alternative screening protocol., Methods: Patients presenting between 2014 and 2018 with BCS injury and cervical spine CT imaging were included. Demographics and injury characteristics of BCS injuries were collected. Univariate and multivariate analyses to determine risk factors for VAI were performed. Once factors associated with greater odds of VAI were identified, this information was used to create an alternative protocol for indicating CTA in patients who sustained BCS injury., Results: A total of 475 patients were included. CTA of the neck was performed in 55.5% patients. In patients who received CTA, 18.2% had a contraindication to receiving anti-platelet therapy, and 25% were already receiving anti-coagulation therapy as an outpatient medication. VAI was found in 13.2% patients. In patients with VAI, 48.5% were already receiving anti-coagulation as outpatient medication. Acute kidney injury was found in 10.5% patients who had received CTA. Factors associated with greater odds of having VAI included transverse foramen involvement(p = 0.0001), subluxation/displacement/dislocation of fracture(p = 0.03), high energy mechanism(p = 0.02), SLIC score > 4(p = 0.04), and concomitant lumbar spine injury(p = 0.03). Using Modified Hawkeye Protocol, 40.2% of patients were indicated to receive a CTA, and 17 VAI were identified. Compared to Denver Criteria, CTAs were performed in 73 less patients(p = 0.04)., Conclusions: Updated protocols utilizing evidence-based clinical parameters to predict chance of VAI may avoid unnecessary advanced imaging and contrast load to patients in the setting of BCS trauma., (Copyright © 2021. Published by Elsevier B.V.)

Study Design: Retrospective, observational study., Objective: To examine the costs associated with nonoperative management (diagnosis and treatment) of cervical radiculopathy in the year prior to anterior cervical discectomy and fusion (ACDF)., Summary of Background Data: While the costs of operative treatment have been previously described, less is known about nonoperative management costs of cervical radiculopathy leading up to surgery., Methods: The Humana claims dataset (2007-2015) was queried to identify adult patients with cervical radiculopathy that underwent ACDF. Outcome endpoint was assessment of cumulative and per-capita costs for nonoperative diagnostic (x-rays, computed tomographic [CT], magnetic resonance imaging [MRI], electromyogram/nerve conduction studies [EMG/NCS]) and treatment modalities (injections, physical therapy [PT], braces, medications, chiropractic services) in the year preceding surgical intervention., Results: Overall 12,514 patients (52% female) with cervical radiculopathy underwent ACDF. Cumulative costs and per-capita costs for nonoperative management, during the year prior to ACDF was $14.3 million and $1143, respectively. All patients underwent at least one diagnostic test (MRI: 86.7%; x-ray: 57.5%; CT: 35.2%) while 73.3% patients received a nonoperative treatment. Diagnostic testing comprised of over 62% of total nonoperative costs ($8.9 million) with MRI constituting the highest total relative spend ($5.3 million; per-capita: $489) followed by CT ($2.6 million; per-capita: $606), x-rays ($0.54 million; per-capita: $76), and EMG/NCS ($0.39 million; per-capita: $467). Conservative treatments comprised of 37.7% of the total nonoperative costs ($5.4 million) with injections costs constituting the highest relative spend ($3.01 million; per-capita: $988) followed by PT ($1.13 million; per-capita: $510) and medications (narcotics: $0.51 million, per-capita $101; gabapentin: $0.21 million, per-capita $93; NSAIDs: 0.107 million, per-capita $47), bracing ($0.25 million; per-capita: $193), and chiropractic services ($0.137 million; per-capita: $193)., Conclusion: The study quantifies the cumulative and per-capital costs incurred 1-year prior to ACDF in patients with cervical radiculopathy for nonoperative diagnostic and treatment modalities. Approximately two-thirds of the costs associated with cervical radiculopathy are from diagnostic modalities. As institutions begin entering into bundled payments for cervical spine disease, understanding condition specific costs is a critical first step., Level of Evidence: 3.

Study Design: Retrospective, observational study., Objective: To examine the influence of patient, hospital, and procedural characteristics on hospital costs and length hospital of stay (LOS)., Summary of Background Data: Successful bundled payment agreements require management of financial risk. Participating institutions must understand potential cost input before entering into these episodes-of-care payment contracts. Elective anterior cervical discectomy and fusion (ACDF) has become a popular target for early bundles given its frequency and predictability., Methods: A national discharge database was queried to identify adult patients undergoing elective ACDF. Using generalized linear models, the impact of each patient, hospital, and procedures characteristic on hospitalization costs and the LOS was estimated., Results: In 2011, 134,088 patients underwent ACDF in the United States. Of these 31.6% had no comorbidities, whereas 18.7% had three or more. The most common conditions included hypertension (44.4%), renal disease (15.9%), and depression (14.7%). Mean hospital costs after ACDF was $18,622 and mean hospital LOS was 1.7 days. With incremental comorbidities, both hospital costs and LOS increased. Both marginal costs and LOS rose with inpatient death (+$17,181, +2.0 days), patients with recent weight loss (+$8351, +1.24 days), metastatic cancer (+$6129 +0.80 days), electrolyte disturbances (+$4175 +0.8 days), pulmonary-circulatory disorders (+$4065, +0.6 days), and coagulopathies (+$3467, +0.58 days). Costs and LOS were highest with the following procedures: addition of a posterior fusion/instrumentation ($+11,189, +0.9 days), revision anterior surgery (+$3465, +0.3 days), and fusion of more than three levels (+$3251, +0.2 days). Patients treated in the West had the highest costs (+$9300, +0.3 days). All P values were less than 0.05., Conclusion: Hospital costs and LOS after ACDF rise with increasing patient comorbidities. Stakeholders entering into bundled payments should be aware of that certain patient, hospital, and procedure characteristics will consume greater resources., Level of Evidence: 3.

Background: Risk factors for complication after single-level anterior cervical discectomy and fusion remain poorly defined. The purpose of this study was to identify the incidence and risk factors for complication from a large, prospectively collected database, with a separate emphasis on the safety of outpatient procedures., Methods: The American College of Surgeons National Surgical Quality Improvement Program prospectively collects thirty-day morbidity and mortality data from more than 480 hospitals around the United States. We retrospectively queried this database to identify cases of single-level elective anterior cervical discectomy and fusion. Univariate and multivariate analyses were used to identify risk factors for complication, and a propensity score model was used to create matched inpatient and outpatient cohorts., Results: Of 2914 cases identified, 597 (20.5%) received outpatient treatment and 2317 (79.5%) received inpatient treatment. The overall incidence of any systemic morbidity was 3.2%. There were five mortalities (0.2%), four in the inpatient cohort and one in the outpatient cohort. Patient age over sixty-five years, body mass index of >30 kg/m 2 , American Society of Anesthesiologists class of 3 or 4, current dialysis, current corticosteroid use, recent sepsis, and operative times longer than 120 minutes were each independent risk factors for complication in the multivariate analysis. After propensity score matching to control for comorbidities, there were no significant differences in complication rates between inpatients and outpatients, and outpatient treatment was not a risk factor for complication in the multivariate analysis., Conclusions: Single-level elective anterior cervical discectomy and fusion had low complication rates, with no additional risk seen with outpatient as compared with inpatient procedures. It seems reasonable to consider inpatient admission for any patient with the risk factors identified here, particularly difficult airways. This information may be useful to surgeons performing informed consents for medical optimization and for selecting patients most appropriate for outpatient treatment., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Background Context: Limited or no data exist evaluating risk factors associated with prolonged opioid use following cervical arthrodesis.Purpose: The objectives of this study were to assess trends in postoperative narcotic use among preoperative opioid users (OUs) versus non-opioid users (NOUs) and to identify factors associated with postoperative narcotic use at 1 year following cervical arthrodesis.Study Design/setting: This is a retrospective observational study.Patient Sample: The patient sample included 17,391 patients (OU: 52.4%) registered in the Humana Inc claims dataset who underwent anterior cervical fusion (ACF) or posterior cervical fusion (PCF) between 2007 and 2015.Outcome Measures: Prolonged opioid usage was defined as narcotic prescription filling at 1 year following cervical arthrodesis.Methods: Based on preoperative opioid use, patients were identified as an OU (history of narcotic prescription filled within 3 months before surgery) or a NOU (no preoperative prescription). Rates of opioid use were evaluated preoperatively for OU and trended for 1 year postoperatively for both OU and NOU. Multivariable regression techniques investigated factors associated with the use of narcotics at 1 year following ACF and PCF. Based on the model findings, a web-based interactive app was developed to estimate 1-year postoperative risk of using narcotics following cervical arthrodesis (http://neuro-risk.com/opiod-use/ or https://www.neurosurgerycost.com/opioid/opioid_use).Results: Overall, 87.4% of the patients (n=15,204) underwent ACF, whereas 12.6% (n=2187) underwent PCF. At 1 month following surgery, 47.7% of NOUs and 82% of OUs had a filled opioid prescription. Rates of prescription opioids declined significantly to 7.8% in NOUs versus 50.5% in OUs at 3 months, but plateaued at the 6- to 12-month postoperative period (NOU: 5.7%-6.7%, OU: 44.9%-46.9%). At 1 year, significantly higher narcotic prescription filling rates were observed in OUs compared with NOUs (45.3% vs. 6.3%, p<.001). Preoperative opioid use was a significant driver of 1-year narcotic use following ACF (odds ratio [OR]: 7.02, p<.001) and PCF (OR: 6.98, p<.001), along with younger age (≤50 years), history of drug dependence, and lower back pain.Conclusions: Over 50% of the patients used opioids before cervical arthrodesis. Postoperative opioid use fell dramatically during the first 3 months in NOU, but nearly half of the preoperative OUs will remain on narcotics at 1 year postoperatively. Our findings serve as a baseline in identifying patients at risk of chronic use and encourage discontinuation of opioids before cervical spine surgery. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Limited or no data exist evaluating risk-factors associated with prolonged opioid use following cervical arthrodesis. PURPOSE To assess trends in postoperative narcotic use amongst preoperative opioid users (OU) versus nonopioid users (NOU), and identify factors associated with postoperative narcotic use at one year following cervical arthrodesis. STUDY DESIGN/SETTING Retrospective, observational cohort study with longitudinal follow-up. PATIENT SAMPLE A total of 17,391 patients (OU: 52.4%) registered in the Humana Inc. claims dataset that underwent anterior (ACF) or posterior cervical fusions (PCF) between 2007 and 2015. OUTCOME MEASURES Prolonged opioid usage defined as narcotic prescription filling at one year following cervical arthrodesis. METHODS Based on preoperative opioid use, patients were identified as an OU (history of narcotic prescription filled within 3-months before surgery) or a NOU (no preoperative prescription). Rates of opioid use were evaluated preoperatively for OU, and trended for 1-year postoperatively for both OU and NOU. Multivariable regression techniques investigated factors associated with the use of narcotics at one year following ACF and PCF. Based on the model findings, a web-based interactive app was developed to estimate 1-year postoperative risk of using narcotics following cervical arthrodesis: https://www.neurosurgerycost.com/opioid/opioid%5fuse RESULTS Overall, 87.4% patients (n=15,204) underwent ACF while 12.6% (n=2,187) underwent PCF. At one month following surgery, 47.7% NOU and 82% OUs had a filled opioid prescription. At three months, rates of prescription opioids declined significantly to 7.8% in NOUs versus 50.5% in OUs, while plateauing at 6-12 month postoperative period (NOU:5.7-6.7%; OU:44.9-46.9%). At one year, significantly higher narcotic prescription filling rates were observed in OUs compared to NOUs (45.3% vs. 6.3%;p<.001). Preoperative opioid use was a significant driver of 1-year narcotic use following ACF (OR:7.02;p<.001) and PCF (OR:6.98;p<.001) along with younger age (<=50 years), history of drug dependence and lower back pain. CONCLUSIONS Over 50% patients used opioids prior to cervical arthrodesis. Postoperative opioid-use fell dramatically during the first three months in NOU, but nearly half of the preop opioid users will remain on narcotics at one year postop. Our findings serve as a baseline in identifying patients at risk for chronic use and encourage discontinuation of opioids prior to cervical spinal surgery FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective, observational.Objective: The aim of this study was to define the impact of preoperative chronic opioid therapy (COT) on outcomes following cervical spine fusions.Summary Of Background Data: Opioid therapy is a commonly practiced method to control acute postoperative pain. However, concerns exist relating to use of prescription opioids, including inherent risk of abuse, tolerance, and inferior outcomes following major surgery.Methods: A commercial dataset was queried from 2007 to 2015 for patients undergoing primary cervical spine arthrodesis [ICD-9 codes 81.01-81.03]. Primary outcome measures were 1-year and 2-year reoperation rates, emergency department (ED) visits, adverse events, and prolonged postoperative opioid use. Secondary outcomes included short-term outcomes including 90-day complications (cardiac, renal, neurologic, infectious, etc.). COT was defined as a history of opioid prescription filling within 3 months before surgery and was the primary exposure variable of interest. Generalized linear models investigated the association of preoperative COT on primary/secondary endpoints following risk-adjustment.Results: Overall, 20,730 patients (51.3% female; 85.9% >50 years) underwent primary cervical spine arthrodesis. Of these, 10,539 (n = 50.8%) met criteria for COT. Postoperatively, 75.3% and 29.8% remained on opioids at 3 months and 1 year. Multivariable models identified an association between COT and an increased risk of 90-day ED visit [odds ratio (OR): 1.25; P < 0.001] and wound complications (OR: 1.24; P = 0.036). At 1 year, COT was strongly associated with reoperations (OR: 1.17; P = 0.043), ED visits (OR: 1.31; P < 0.001), and adverse events including wound complications (OR: 1.32; P < 0.001), infections (OR: 1.34; P = 0.042), constipation (OR: 1.11; P = 0.032), neurological complications (OR: 1.44; P = 0.01), acute renal failure (OR: 1.24; P = 0.004), and venous thromboembolism (OR: 1.20; P = 0.008). At 2 years, COT remained a significant risk factor for additional long-term negative outcomes such as reoperations, including adjacent segment disc disease (OR: 1.21; P = 0.005), ED visits (OR: 1.32; P < 0.001), and other adverse events. Preoperative COT was associated with prolonged postoperative narcotic use at 3 months (OR: 1.30; P < 0.001), 1 year (OR: 5.17; P < 0.001), and at 2 years (OR: 5.75; P < 0.001) after cervical arthrodesis.Conclusion: Preoperative COT is a modifiable risk factor that is strongly associated with prolonged postoperative opioid use. In addition, COT was associated with inferior short-term and long-term outcomes after cervical spine fusion.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]