6% Require Revision Lumbar Discectomy
How many people have to go through a revision lumbar discectomy?
No one has answered that question on a national basis—until now.
Researchers from Ohio State University under the direction of Safdar N. Khan, M.D., the University of New South Wales, Midwest Orthopaedics at Rush University and Hospital for Special Surgery joined forces on work entitled, “What is the Rate of Revision Discectomies After Primary Discectomy on a National Scale?” published in the August 28, 2917 edition of Clinical Orthopaedics and Related Research.
The authors wrote, “The Medicare 5% National Sample Administrative Database (SAF5) and a large national database from Humana Inc (HORTHO) were used to catalog the number of patients undergoing a lumbar discectomy. Both of these databases have been cited in numerous peer-reviewed publications during the previous 5 years and routinely are audited by PearlDiver Inc. We identified patients using relevant ICD-9 codes and Current Procedural Terminology (CPT) codes, including ICD-9 72210 (lumbar disc displacement) for disc herniation. We used appropriate CPT codes to identify patients who had a lumbar discectomy. We analyzed patients undergoing additional surgery including those who had repeat discectomy (CPT-63042: laminotomy, re-exploration single interspace, lumbar) and patients who had additional more-extensive decompressive procedures with or without fusion after their primary procedure.”
“Revision surgery rates were calculated for patients 65 years and older and those younger than 65 years and for each database (Humana Inc and Medicare). Patients from the two databases also were analyzed based on four distinct geographic regions in the United States where their surgery occurred. There were a total of 7,520 patients who underwent a lumbar discectomy for an intervertebral disc displacement with at least 5 years of follow-up in the HORTHO and SAF5 databases. We used cumulative incidence of revision surgery to estimate the survivorship of these patients.
Frank Phillips, M.D. is a co-author, as well as professor, and director of the Division of Spine Surgery at Rush. He told OTW, “Lumbar discectomy is the most frequently performed spine surgery. Recurrent herniation and additional surgery is one of the most frequent complications of the procedure. Smaller studies have reported varied rates of recurrent herniation as well as the risk of requiring future spine surgery. Both of these outcomes are of intense interest to patients in terms of their need for further future treatment as well as to payers in defining the value of discectomy surgery.”
“Past studies have involved small patient samples. The current study leverages ‘big data’ to look at the outcomes of discectomy in an extremely large cohort of patients, likely reflective of the experience in real world practice across the United States.”
“Around 6% of patients that underwent discectomy surgery had revision surgery by 7 years. Survival analysis showed survival rates greater than 93% for a primary discectomy up to 7 years after the surgery. The survivorship was lower for patients younger than 65 years (93% versus 95% [p = 0.02]).”
Safdar N. Khan, M.D., a lead author on this study and associate professor and chief, Division of Spine Surgery, Department of Orthopaedic Surgery at Wexner Medical Center at The Ohio State University told OTW, “This study defines the rate of repeat discectomy surgery that will better allow surgeons to counsel their patients. Fortunately at seven years after index surgery, very few patients have required further surgery.”
New Knee Society Score vs. WOMAC
Not content to leave questions unanswered about the New Knee Society Score (NKSS), researchers from India delved into this topic in order to measure it longitudinally. Their work, “What is the Responsiveness and Respondent Burden of the New Knee Society Score?” was published in the September 2017 edition of Clinical Orthopaedics and Related Research.
The authors wrote, “During an 8-month period, 165 patients underwent TKA [total knee arthroplasty] by the same surgeon at our institution, of whom 148 (90%) completed this study; the others were excluded because of distance to travel or loss to follow-up at the specified time. The NKSS, WOMAC [Western Ontario & McMaster Universities Osteoarthritis Index], and SF-12 [Short Form Health Survey] were completed by each patient 1 day before surgery and at 3 and 12 months postoperatively. At the same times, the original KSS (OKSS) which is designed as an observer’s assessment, was completed by the same orthopaedic fellow for all patients…”
Rajesh Maniar, M.Ch. Orth., orthopedic surgeon at Lilavati Hospital and Research Centre in Mumbai and co-author told OTW, “The New Knee Society Score (NKSS) has been validated by a task force, but there is no literature report on its responsiveness and respondent burden in a large, longitudinal cohort of patients. We as independent non-developers, undertook to do this and compare it with other established scores in 148 patients, all operated by a single surgeon, using the same implant and uniform procedure and followed longitudinally over more than one year. We did several statistical analyses for each parameter. Responsiveness was assessed in terms of effect size, standardized response mean and ceiling and floor effects. Respondent burden was assessed through time to completion and ease of completion. Convergent validity was assessed by determining Pearson’s correlation coefficient.”
“Our results showed that the NKSS was most responsive, followed by the original KSS, WOMAC and SF-12. The NKSS also showed no ceiling effect, indicating adequate potential for recording future improvement. We confirmed that the NKSS can be used interchangeably with the WOMAC scale; it also showed reliable convergent validity with the SF-12 and OKSS [Original Knee Society Score]. However, it did pose a greater respondent burden, for which its short-form version needs to be evaluated.”
Ream-and-Run Works
When it comes to ream-and-run, how do clinical outcomes relate to radiographs?
What does medialization of the humeral head mean for outcomes?
New work entitled, “Clinical and Radiographic Outcomes of the Ream-and-Run Procedure for Primary Glenohumeral Arthritis,” is featured in the August 2, 2017 edition of The Journal of Bone and Joint Surgery.
Jeremy S. Somerson, M.D. orthopedic surgeon with the department of Orthopaedic Surgery and Rehabilitation at the University of Texas in Galveston and co-author told OTW, “Prior studies have shown good outcomes with the ream-and-run surgery, but there has been little study of postoperative radiographic changes. Our primary interest in this data set was the ability to measure radiographic postoperative changes and correlate them with clinical outcomes.”
“The study used a novel measurement technique to determine the position of the humeral head relative to the scapula. This allowed us to determine the amount of medialization of the humeral head over time.”
The authors wrote, “Two-year clinical outcomes were available for 101 patients (95% were male). Comparable radiographs at postoperative baseline and follow-up evaluations were available for 50 shoulders…”
Dr. Somerson commented to OTW, “Similar to prior reports, the ream-and-run surgery resulted in improvements in function and comfort at a minimum of two-years postoperatively. Some patients were noted to experience greater than 5mm of medialization over this two-year period. However, patients who showed large amounts of medialization did not have worse clinical outcomes at two years.”
“This study gives us additional data to help counsel patients who are considering the ream-and-run surgery. Although medialization did not have a negative impact on short-term results, we will need longer-term data to determine the practical implications of these findings. For carefully selected patients, the ream-and-run is an option that avoids the risk of prosthetic glenoid loosening with good short-term and mid-term clinical outcomes.”
