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212. Pediatric Tethered Cord Associated Scoliosis: Incidence, Time Course, and Factors Associated with Progression of Spinal Deformity after Spinal Cord Untethering
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Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S–205S
211. Cost Analysis of Adolescent Idiopathic Scoliosis Correction Surgery in 125 Consecutive Cases Jonathan Kamerlink, MD1, Martin Quirno, MD1, Joshua Auerbach, MD2, Andrew H. Milby, BA3, Laura Dean, BA1, Joseph Dryer, MD1, Baron Lonner, MD1; 1NYU Hospital for Joint Diseases, New York, NY, USA; 2Washington University-St. Louis, St. Louis, MO, USA; 3The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
fused were identified as significant independent predictors of higher total cost. An accurate analysis of surgical and hospital cost, charge, and reimbursement for AIS is of paramount importance to ensure future equitable allocation of financial resources in this patient population and to provide opportunities for cost containment. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
BACKGROUND CONTEXT: Although achieving clinical success is the main goal in the surgical treatment of AIS, it is becoming increasingly important to do so in a cost-effective manner. PURPOSE: This study sets out to determine the costs, charges, and reimbursement associated with hospitalization for AIS correction surgery at one institution. STUDY DESIGN/SETTING: Retrospective hospital cost, charge, and reimbursement analysis PATIENT SAMPLE: 16,536 individual costs and charges including overall reimbursements on 125 consecutive patients who underwent surgical treatment for AIS by 3 different surgeons between 2006-2007 at a single institution. OUTCOME MEASURES: Patient’s costs, charges, and reimbursement as well as their demographic, surgical, and radiographic components. METHODS: We performed a retrospective review of 16,536 individual costs and charges including overall reimbursements on 125 consecutive patients who underwent surgical treatment for AIS by 3 different surgeons between 2006-2007 at a single institution. Pertinent demographic, surgical, and radiographic data were recorded for each patient. RESULTS: Mean age was 15.2 years with a mean BMI of 21.8. Females (88) outnumbered males (37) on a 2:1 ratio. The mean measured main thoracic curve was 50 , proximal curve 29 , and thoracolumbar curve 41 . Independently significant increases for total cost were found with number of pedicle screws placed, total levels fused ($1567), and the type of surgical approach ($9,600) (R2 50.35, p!0.03). Independently significant increases for reimbursement were found with the number of pedicle screws placed and the type of surgical approach ($9,431)(R2 50.12, p!0.02). The hospital was reimbursed 53% of total charges and 120% of total costs. Reimbursement correlated highest with charge (r5.45, p!0.001). Concerning rehospitalizations, the hospital was reimbursed 65% of charges and 93% of costs. Cost by Lenke curve type: Type 1 5 $29,955; Type 2:$31,414; Type 3:$31,975; Type 4: $60,754; Type 5:$32,652; Type 6:$33,416.
doi: 10.1016/j.spinee.2009.08.255
212. Pediatric Tethered Cord Associated Scoliosis: Incidence, Time Course, and Factors Associated with Progression of Spinal Deformity after Spinal Cord Untethering Matthew McGirt, MD1, Giannina Garces-Ambrossi, BASC1, Vivek Mehta, BASC1, Scott Parker, BASC1, Edward Ahn, MD1, Jon Weingart, MD1, Benjamin Carson, MD1, Amer Samdani, MD2, George Jallo, MD1; 1Johns Hopkins University, Baltimore, MD, USA; 2Shriner’s Hospital for Children, Philadelphia, PA, USA BACKGROUND CONTEXT: Tethered cord syndrome (TCS) is frequently associated with scoliosis in the pediatric population. Following spinal cord untethering, many patients continue to experience progression of spinal deformity. However, incidence, time course, and risk factors for scoliosis progression following tethered cord release remain unclear. PURPOSE: We set out to determine incidence, time course, and risk factors for scoliosis progression and whether tethered cord release alone would halt curve progression in pediatric TCS. STUDY DESIGN/SETTING: Retrospective review of a single institution experience. PATIENT SAMPLE: Twenty-seven consecutive pediatric cases of spinal cord untethering associated with scoliosis. OUTCOME MEASURES: Post-operative scoliosis status, Need for spinal stabilization via fusion. METHODS: We retrospectively reviewed 27 consecutive pediatric cases of spinal cord untethering associated with scoliosis. The incidence and factors associated with scoliosis progression (O10 degree increased Cobb angle) after untethering was evaluated via Kaplan-Meier method. RESULTS: Mean age was 8.9 years-old. All patients underwent cord untethering for lower extremity weakness or bowel and bladder changes. Mean 6 SD Cobb angle at presentation was 1 6 15 degree. Etiology of tethering included post-myelomeningocele repair in 14 (52%) patients, 4 (15%)fatty filium, 3 (11%) lipomeningocele, 3 (11%) occult spina bifida, and 2 (7%) diastematomyelia. Patients were followed for mean (6
Figure.
CONCLUSIONS: Implants accounted for the highest percentage of total cost (29%) followed by ICU and inpatient room cost (22%), and OR (9.9%). The type of surgical approach, screws placed, and number of levels
Figure 1. Thirteen (48%) patients experienced scoliosis progression at a median of 29 months post-operatively.
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S–205S SD) of 6 (6 2) years. Thirteen (48%) patients experienced scoliosis progression at a median of 29 months post-operatively (Figure 1); 8 (29%) required fusion (Figure 2). At time of untethering, scoliosis !40 degree had 32% incidence of progression occurring at mean 54 months post-operatively, while scoliosis O40 degree had 88% incidence of progression occurring by only 24 months post-operatively (p50.0076, HR50.1682). Riser grade 0-2 patients were also more likely to experience scoliosis progression vs. Riser grade 3-5 (P50.04, HR53.44). While nearly all Riser grade 0-2 patients with curves O40 degree progressed (86%), no Riser grade 3-5 curves !40 degree progressed following spinal cord untethering (Figure 3). CONCLUSIONS: In our experience with pediatric TCS-associated scoliosis, the majority of patients with Cobb angle !40 degree experienced scoliosis stabilization after tethered cord release regardless of skeletal maturity. No skeletally mature patients progressed when untethered at Cobb angle !40 degree. During early stages of deformity progression, spinal cord untethering may be effective in halting progression of scoliosis in both skeletal mature and immature patients.
Figure 2. Eight (29%) patients required fusion as a result of scoliosis progression.
Figure 3. While nearly all Riser grade 0-2 patients with curves O40 degree progressed (86%), no Riser grade 3-5 curves !40 degree progressed following spinal cord untethering.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.256
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213. Intraoperative Judicious Fluid Management and Blood Conserving Techniques in Scoliosis Surgery Terry Amaral, MD1, Melanie Gambassi, PNP1, Vishal Sarwahi, MD1, Marina Moguilevtch, MD1, Adam Wollowick1; 1Montefiore Medical Center, Bronx, NY, USA BACKGROUND CONTEXT: With pedicle screw constructs, surgeons achieve improved correction with less motion segments fused, but with significant blood loss and increased transfusion requirements. Intraoperative overhydration has led to pulmonary compromise, coagulopathy, and increased blood loss. With fluid restriction and blood conserving techniques, periop blood transfusions and fluid overload morbidities will decrease. PURPOSE: Anesthesia fluid restriction techniques were compared to standard fluid techniques to determine if fluid restriction can lead to decreased blood transfusions and fluid overload morbidities in scoliosis surgery. STUDY DESIGN/SETTING: 75 patients indicated for scoliosis surgery were divided into control (standard fluid protocol) and experiemental (fluid restricted protocol). Both groups underwent blood conserving techniques (hypotensive anesthesia, cell saver, and transfusion triggers based on blood loss, serial hct, and cardio vascular parameters). ABG for the hct were performed at instrumentation and then once per ½ hour. Evaluated parameters include amount of intraoperative crystalloids, colloids, FFP, intraoperative transfusions, urine output, EBL, postoperative transfusions and FFP, and preop and postop hct. Evaluated fluid overload morbitites include time to extubation and postop pulmonary issues. PATIENT SAMPLE: 75 consecutive patients with adolecent idiopathic scoliosis were randomly divided into two groups with 35 patients in the standard fluid protocol group and 40 patients in the fluid restricted group. The age range is 10 to 18 years. Weight range is from 80lbs to 180lbs. OUTCOME MEASURES: Significant differences were determined for the demographics and the studied parameters which included the amount of intraoperative crystalloids, colloids, FFP, whether there were intraoperative transfusions, the urine output, EBL, postoperative transfusions and FFP, and preoperative and postoperative hct. Time to extubation and pulmonary issues were also reviewed. Fischer exact t-test and Chi square were used to determine p values. METHODS: Anesthesia and surgical records were reviewed from the patient charts to determined if there was a significant decrease in transfusion rate and fluid overload morbidities between fluid restriction and standard fluid protocols. RESULTS: Average age 14.5 years (p50.220), average weight was 130.2lbs (p50.250), Males:females were similar (p50.288). Average levels fused was 11.9 (p50.468). Preop hct were similar (p50.09). Cell saver in control is 650 cc and experimental is 280 cc (p50.030). Cyrstalloids given 5232 cc and 4200 cc restricted (p50.005). Colloids given 486 cc control and 395 cc restricted (p50.030). Urine output for control is 1231 cc and restricted 1209 cc (p50.89). EBL for control was1879 cc and for restricted was 876 cc with p50.008. Transfusions for control was 30 of 35 patients transfused while restricted had 15 of 40 (p50.00001). When transfusion was necessary, more units were need for control averaging 2.3 to 1.0 (p50.00001). Postop hct were similar with 29 for control and 28 for restricted (p50.1). In the control group 4 patients remained intubated postop and 2 patients developed pneumonia postop. Restricted patients were all extubated and did not developed pneumonia. CONCLUSIONS: Fluid restriction and blood conserving methods in anesthesia has decreased perioperative blood transfusions and fluid overload morbidities . FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.257
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S–205S
211. Cost Analysis of Adolescent Idiopathic Scoliosis Correction Surgery in 125 Consecutive Cases Jonathan Kamerlink, MD1, Martin Quirno, MD1, Joshua Auerbach, MD2, Andrew H. Milby, BA3, Laura Dean, BA1, Joseph Dryer, MD1, Baron Lonner, MD1; 1NYU Hospital for Joint Diseases, New York, NY, USA; 2Washington University-St. Louis, St. Louis, MO, USA; 3The University of Pennsylvania School of Medicine, Philadelphia, PA, USA
fused were identified as significant independent predictors of higher total cost. An accurate analysis of surgical and hospital cost, charge, and reimbursement for AIS is of paramount importance to ensure future equitable allocation of financial resources in this patient population and to provide opportunities for cost containment. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs.
BACKGROUND CONTEXT: Although achieving clinical success is the main goal in the surgical treatment of AIS, it is becoming increasingly important to do so in a cost-effective manner. PURPOSE: This study sets out to determine the costs, charges, and reimbursement associated with hospitalization for AIS correction surgery at one institution. STUDY DESIGN/SETTING: Retrospective hospital cost, charge, and reimbursement analysis PATIENT SAMPLE: 16,536 individual costs and charges including overall reimbursements on 125 consecutive patients who underwent surgical treatment for AIS by 3 different surgeons between 2006-2007 at a single institution. OUTCOME MEASURES: Patient’s costs, charges, and reimbursement as well as their demographic, surgical, and radiographic components. METHODS: We performed a retrospective review of 16,536 individual costs and charges including overall reimbursements on 125 consecutive patients who underwent surgical treatment for AIS by 3 different surgeons between 2006-2007 at a single institution. Pertinent demographic, surgical, and radiographic data were recorded for each patient. RESULTS: Mean age was 15.2 years with a mean BMI of 21.8. Females (88) outnumbered males (37) on a 2:1 ratio. The mean measured main thoracic curve was 50 , proximal curve 29 , and thoracolumbar curve 41 . Independently significant increases for total cost were found with number of pedicle screws placed, total levels fused ($1567), and the type of surgical approach ($9,600) (R2 50.35, p!0.03). Independently significant increases for reimbursement were found with the number of pedicle screws placed and the type of surgical approach ($9,431)(R2 50.12, p!0.02). The hospital was reimbursed 53% of total charges and 120% of total costs. Reimbursement correlated highest with charge (r5.45, p!0.001). Concerning rehospitalizations, the hospital was reimbursed 65% of charges and 93% of costs. Cost by Lenke curve type: Type 1 5 $29,955; Type 2:$31,414; Type 3:$31,975; Type 4: $60,754; Type 5:$32,652; Type 6:$33,416.
doi: 10.1016/j.spinee.2009.08.255
212. Pediatric Tethered Cord Associated Scoliosis: Incidence, Time Course, and Factors Associated with Progression of Spinal Deformity after Spinal Cord Untethering Matthew McGirt, MD1, Giannina Garces-Ambrossi, BASC1, Vivek Mehta, BASC1, Scott Parker, BASC1, Edward Ahn, MD1, Jon Weingart, MD1, Benjamin Carson, MD1, Amer Samdani, MD2, George Jallo, MD1; 1Johns Hopkins University, Baltimore, MD, USA; 2Shriner’s Hospital for Children, Philadelphia, PA, USA BACKGROUND CONTEXT: Tethered cord syndrome (TCS) is frequently associated with scoliosis in the pediatric population. Following spinal cord untethering, many patients continue to experience progression of spinal deformity. However, incidence, time course, and risk factors for scoliosis progression following tethered cord release remain unclear. PURPOSE: We set out to determine incidence, time course, and risk factors for scoliosis progression and whether tethered cord release alone would halt curve progression in pediatric TCS. STUDY DESIGN/SETTING: Retrospective review of a single institution experience. PATIENT SAMPLE: Twenty-seven consecutive pediatric cases of spinal cord untethering associated with scoliosis. OUTCOME MEASURES: Post-operative scoliosis status, Need for spinal stabilization via fusion. METHODS: We retrospectively reviewed 27 consecutive pediatric cases of spinal cord untethering associated with scoliosis. The incidence and factors associated with scoliosis progression (O10 degree increased Cobb angle) after untethering was evaluated via Kaplan-Meier method. RESULTS: Mean age was 8.9 years-old. All patients underwent cord untethering for lower extremity weakness or bowel and bladder changes. Mean 6 SD Cobb angle at presentation was 1 6 15 degree. Etiology of tethering included post-myelomeningocele repair in 14 (52%) patients, 4 (15%)fatty filium, 3 (11%) lipomeningocele, 3 (11%) occult spina bifida, and 2 (7%) diastematomyelia. Patients were followed for mean (6
Figure.
CONCLUSIONS: Implants accounted for the highest percentage of total cost (29%) followed by ICU and inpatient room cost (22%), and OR (9.9%). The type of surgical approach, screws placed, and number of levels
Figure 1. Thirteen (48%) patients experienced scoliosis progression at a median of 29 months post-operatively.
Proceedings of the NASS 24th Annual Meeting / The Spine Journal 9 (2009) 1S–205S SD) of 6 (6 2) years. Thirteen (48%) patients experienced scoliosis progression at a median of 29 months post-operatively (Figure 1); 8 (29%) required fusion (Figure 2). At time of untethering, scoliosis !40 degree had 32% incidence of progression occurring at mean 54 months post-operatively, while scoliosis O40 degree had 88% incidence of progression occurring by only 24 months post-operatively (p50.0076, HR50.1682). Riser grade 0-2 patients were also more likely to experience scoliosis progression vs. Riser grade 3-5 (P50.04, HR53.44). While nearly all Riser grade 0-2 patients with curves O40 degree progressed (86%), no Riser grade 3-5 curves !40 degree progressed following spinal cord untethering (Figure 3). CONCLUSIONS: In our experience with pediatric TCS-associated scoliosis, the majority of patients with Cobb angle !40 degree experienced scoliosis stabilization after tethered cord release regardless of skeletal maturity. No skeletally mature patients progressed when untethered at Cobb angle !40 degree. During early stages of deformity progression, spinal cord untethering may be effective in halting progression of scoliosis in both skeletal mature and immature patients.
Figure 2. Eight (29%) patients required fusion as a result of scoliosis progression.
Figure 3. While nearly all Riser grade 0-2 patients with curves O40 degree progressed (86%), no Riser grade 3-5 curves !40 degree progressed following spinal cord untethering.
FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.256
113S
213. Intraoperative Judicious Fluid Management and Blood Conserving Techniques in Scoliosis Surgery Terry Amaral, MD1, Melanie Gambassi, PNP1, Vishal Sarwahi, MD1, Marina Moguilevtch, MD1, Adam Wollowick1; 1Montefiore Medical Center, Bronx, NY, USA BACKGROUND CONTEXT: With pedicle screw constructs, surgeons achieve improved correction with less motion segments fused, but with significant blood loss and increased transfusion requirements. Intraoperative overhydration has led to pulmonary compromise, coagulopathy, and increased blood loss. With fluid restriction and blood conserving techniques, periop blood transfusions and fluid overload morbidities will decrease. PURPOSE: Anesthesia fluid restriction techniques were compared to standard fluid techniques to determine if fluid restriction can lead to decreased blood transfusions and fluid overload morbidities in scoliosis surgery. STUDY DESIGN/SETTING: 75 patients indicated for scoliosis surgery were divided into control (standard fluid protocol) and experiemental (fluid restricted protocol). Both groups underwent blood conserving techniques (hypotensive anesthesia, cell saver, and transfusion triggers based on blood loss, serial hct, and cardio vascular parameters). ABG for the hct were performed at instrumentation and then once per ½ hour. Evaluated parameters include amount of intraoperative crystalloids, colloids, FFP, intraoperative transfusions, urine output, EBL, postoperative transfusions and FFP, and preop and postop hct. Evaluated fluid overload morbitites include time to extubation and postop pulmonary issues. PATIENT SAMPLE: 75 consecutive patients with adolecent idiopathic scoliosis were randomly divided into two groups with 35 patients in the standard fluid protocol group and 40 patients in the fluid restricted group. The age range is 10 to 18 years. Weight range is from 80lbs to 180lbs. OUTCOME MEASURES: Significant differences were determined for the demographics and the studied parameters which included the amount of intraoperative crystalloids, colloids, FFP, whether there were intraoperative transfusions, the urine output, EBL, postoperative transfusions and FFP, and preoperative and postoperative hct. Time to extubation and pulmonary issues were also reviewed. Fischer exact t-test and Chi square were used to determine p values. METHODS: Anesthesia and surgical records were reviewed from the patient charts to determined if there was a significant decrease in transfusion rate and fluid overload morbidities between fluid restriction and standard fluid protocols. RESULTS: Average age 14.5 years (p50.220), average weight was 130.2lbs (p50.250), Males:females were similar (p50.288). Average levels fused was 11.9 (p50.468). Preop hct were similar (p50.09). Cell saver in control is 650 cc and experimental is 280 cc (p50.030). Cyrstalloids given 5232 cc and 4200 cc restricted (p50.005). Colloids given 486 cc control and 395 cc restricted (p50.030). Urine output for control is 1231 cc and restricted 1209 cc (p50.89). EBL for control was1879 cc and for restricted was 876 cc with p50.008. Transfusions for control was 30 of 35 patients transfused while restricted had 15 of 40 (p50.00001). When transfusion was necessary, more units were need for control averaging 2.3 to 1.0 (p50.00001). Postop hct were similar with 29 for control and 28 for restricted (p50.1). In the control group 4 patients remained intubated postop and 2 patients developed pneumonia postop. Restricted patients were all extubated and did not developed pneumonia. CONCLUSIONS: Fluid restriction and blood conserving methods in anesthesia has decreased perioperative blood transfusions and fluid overload morbidities . FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2009.08.257