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Open Access Publications from the University of California

Scholarly Works (11 results)

  • Article
  • Peer Reviewed
UC Irvine Previously Published Works (2011)
Although magnetic resonance imaging (MRI) is frequently used to assess the lumbar spine, there are few reports in the medical literature that have evaluated using MRI immediately following spinal surgery. Furthermore, descriptions of the subdural changes after lumbar spine surgery are also infrequent. In this paper, we present two cases with subdural change seen on MRI immediately after lumbar surgery. Both the patients had mild symptoms that resolved spontaneously, and the follow-up MRI scans showed resolution of the subdural changes. Subdural changes should be considered as one of the possible causes of unexpected symptoms in patients following lumbar spinal surgery.
    Cover page: MRI Changes of the Spinal Subdural Space after Lumbar Spine Surgeries: Report of Two Cases
    • Article
    • Peer Reviewed
    UC Irvine Previously Published Works (2016)

    Study design

    A retrospective, propensity score, multivariate analysis of the National Trauma Data Bank (NTDB) between 2008 and 2011.

    Objective

    The aim of this study was to determine the relationship between insurance status and rates of surgery for acute spinal fractures with and without spinal cord injury (SCI).

    Summary of background data

    The decision for surgery in patients with spinal fractures is often based on fracture pattern and stability, associated SCI, and the presence of ligamentous and other associated injuries. It is poorly understood how nonclinical factors, such as insurance status, influence the decision for surgical intervention in patients sustaining spinal trauma.

    Methods

    Using NTDB admission years 2008 to 2011, we included patients 18 to 64 years old who sustained a fracture of the cervical or thoracolumbar spine. Patients were excluded if they sustained polytrauma (Injury Severity Score ≥27) or a major injury (Abbreviated Injury Scale severity ≥3) to the head, thorax, or abdomen. Our main outcome measure was surgical versus nonsurgical treatment for spinal injury; our main predictor was insurance status. Hierarchical multivariate regression analysis and propensity scores were used to determine the relationship between insurance status and surgical treatment, controlling for other factors. We calculated adjusted odds ratios (ORs) for rates of surgery.

    Results

    Our propensity score multivariate analysis demonstrated significantly higher rates of surgery in patients with SCI (OR = 11.76, P < 0.001), insurance (OR = 1.27, P < 0.001), white (OR = 1.21, P = 0.018) versus black race, blunt trauma (OR = 5.63, P < 0.001), shock (OR = 1.62, P < 0.001), higher Glasgow Coma Scale (GCS) score (OR = 1.02, P = 0.002), transfer from lower acuity hospital (OR = 1.51, P < 0.001), and treatment at teaching hospitals (OR = 1.49, P < 0.001). Multivariable subgroup analysis of SCI patients similarly revealed higher surgical rates for insured patients (OR = 1.46, P < 0.001) than those without insurance.

    Conclusion

    Patients with traumatic spine fractures were more likely to receive surgery if they were insured, regardless of the presence of SCI.
      Cover page: The Influence of Insurance Status on the Surgical Treatment of Acute Spinal Fractures
      • Article
      • Peer Reviewed
      ICTS Publications (2012)

      Surgical treatment for degenerative conditions of the hip, knee, and spine has an impact on overall healthcare spending. Surgical rates have increased dramatically and considerable regional variation has been observed. The reasons behind these increasing rates and variation across regions have not been well elucidated.

      We therefore identified demographic (D), social structure (SS), health belief (HB), personal (PR) and community resources (CR), and medical need (MN) factors that drive rates of hip, knee, and spine surgery.

      We conducted a systematic review to include all observational, population-based studies that compared surgical rates with potential drivers (D, SS, HB, PR, CR, MN). We searched PubMed combining key words focusing on (1) disease and procedure; (2) study methodology; and (3) explanatory models. Independent investigators selected potentially eligible studies from abstract review and abstracted methodological and outcome data. From an initial search of 256 articles, we found 37 to be potentially eligible (kappa 0.86) but only 28 met all our inclusion criteria.

      Age, nonminority, insurance coverage, and surgeon enthusiasm all increased surgical rates. Rates of arthroplasty were higher for females with higher education, income, obesity, rurality, willingness to consider surgery, and prevalence of disease, whereas spinal rates increased with male gender, lower income, and the availability of advanced imaging.

      Regional variation in these procedures exists because they are examples of preference-sensitive care. With strategies that may affect change in factors that are potentially modifiable by behavior or resources, extreme variation in rates may be reduced.

        Cover page: Drivers of surgery for the degenerative hip, knee, and spine: a systematic review.
        • Article
        • Peer Reviewed
        UC Irvine Previously Published Works (2012)
          Cover page: Use of Lateral Access in the Treatment of the Revision Spine PatientCreative Commons 'BY' version 4.0 license
          • Article
          • Peer Reviewed
          UC Irvine Previously Published Works (2019)

          Study design

          Retrospective database study.

          Objective

          To investigate the impact obstructive sleep apnea (OSA) has on perioperative complications, inpatient mortality, and costs in patients undergoing spinal fusions.

          Methods

          Hospitalizations for spinal fusion surgery between the years 2009 and 2011 were identified using the Nationwide Inpatient Sample and grouped into patients with and without OSA. Patient demographic data, comorbidities, hospital characteristics, hospitalization outcomes, and costs were extracted and compared. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients undergoing spinal fusion with and without OSA.

          Results

          A total of 107 451 (7.7%) OSA patients who underwent spinal fusions were identified from 2009 to 2011. Compared with patients without OSA, OSA patients were significantly older, more likely to be male, and have significantly greater comorbidity burden. Multivariable regression analysis demonstrated that OSA had a significant independent association with slightly increased respiratory (odds ratio [OR] = 1.13, confidence interval [CI] = 1.09-1.16; P < .001), urinary and renal (OR = 1.11, CI = 1.07-1.16; P < .001) or overall inpatient complications (OR = 1.05, CI = 1.02-1.05; P < .001). OSA was also independently associated with significantly lower inpatient mortality (OR = 0.39, CI = 0.33-0.45; P < .001).

          Conclusions

          While OSA confers greater comorbidity burden and is associated with slightly higher inpatient complication rates following spinal fusions, diagnosed OSA was not an independent predictor of inpatient mortality. A cautious interpretation of this finding is that on a national level, the current methods of preoperative medical optimization and inpatient management of OSA are satisfactory.
            Cover page: Outcomes and Complications After Spinal Fusion in Patients With Obstructive Sleep Apnea
            • Article
            • Peer Reviewed
            UC Irvine Previously Published Works (2014)

            Purpose

            To identify all available reconstruction methods for a total sacrectomy. Secondarily, we aimed to evaluate outcomes based on different interventions.

            Methods

            We searched PubMed to identify sacral resections for tumors requiring internal fixation for stabilization. Demographic information, fixation techniques and postoperative outcomes were abstracted.

            Results

            Twenty-three publications (43 patients) met inclusion criteria from an initial search of 856 (κ 0.93). Mean age was 37 years and follow-up was 33 months. Fixation methods included a combination of spinopelvic fixation (SPF), posterior pelvic ring fixation (PPRF), and/or anterior spinal column fixation (ASCF). For the purposes of analysis, patients were segregated based on whether they received ASCF. Postoperative complications including wound/instrument infections, GI or vascular complications were reported at a higher rate in the non-ASCF group (1.63 complications/patient vs. 0.7 complications/patient). Instrument failure was seen in 5 (16.1 %) out of the 31 patients with reported outcomes. Specifically, 1 out of 8 patients (12.5 %) with ASCF compared with 4 out of 23 patients (17.4 %) without ASCF had hardware failure. At final follow-up, 35 of 39 patients were ambulating.

            Conclusion

            While surgical treatment of primary sacral tumors remains a challenge, there have been advances in reconstruction techniques following total sacrectomy. SPF has shifted from intrapelvic rod and hook constructs to pedicle and iliac screw-rod systems for improved rigidity. PPRF and ASCF have adapted for deficiencies in the posterior ring and anterior column. A trend toward a lower rate of hardware failure emerged in the group utilizing anterior spinal column support. Despite a more involved reconstruction with ASCF, surgical complications such as infection rates and blood loss were lower compared to the group without ASCF. While we cannot definitively say one system is superior to the other, based on the data gleaned from this systematic review, it is our opinion that incorporation of ASCF in reconstructing the spinopelvic junction may lead to improved outcomes. However, most importantly, we recommend that the treating surgeon operate on patients requiring a total sacrectomy based on his or her level of comfort, as these cases can be extremely challenging even among experts.
              Cover page: Surgical techniques for spinopelvic reconstruction following total sacrectomy: a systematic review
              • Article
              • Peer Reviewed
              UC Irvine Previously Published Works (2011)
              Low back pain (LBP) is the most prevalent musculoskeletal complaint among professional and amateur golfers; however, associated radiological changes in golf-related LBP have not been examined in the literature. We suspect that Modic Type 1 changes in the lumbar spine are linked to golf-related LBP. In this retrospective case series, four middle-aged golfers (one professional and three high-level amateurs) presented to our clinic with LBP. Inflammation of the right side of endplates in the lumbar spine was suspected based on Modic Type 1 changes detected by magnetic resonance imaging (MRI) in each patient. All four cases were diagnosed with right-sided endplate inflammation and administered intradiscal steroid injections with a non-steroidal anti-inflammatory drug (NSAID). Treatment swiftly alleviated LBP and diminished Modic Type 1 changes on follow-up MRI 3-6 months later in all four patients. We suggest that Modic Type 1 changes play a significant role in the diagnosis and treatment of golf-related LBP.
                Cover page: Modic type I changes of the lumbar spine in golfersCreative Commons 'BY' version 4.0 license
                • Article
                • Peer Reviewed
                UC Irvine Previously Published Works (2020)

                Study design

                Retrospective large database study.

                Objective

                To determine the impact of cirrhosis on perioperative outcomes and resource utilization in elective spinal fusion surgery.

                Methods

                Elective spinal fusion hospitalizations in patients with and without cirrhosis were identified using ICD-9-CM codes between the years of 2009 and 2011 using the Nationwide Inpatient Sample database. Main outcome measures were in-hospital neurologic, respiratory, cardiac, gastrointestinal, renal and urinary, pulmonary embolism, wound-related complications, and mortality. Length of stay and inpatient costs were also collected. Multivariable logistic regressions were conducted to compare the in-hospital outcomes of patients with and without cirrhosis undergoing spinal fusion.

                Results

                A total of 1 214 694 patients underwent elective spinal fusions from 2009 to 2011. Oh these, 6739 were cirrhotic. Cirrhosis was a significant independent predictor for respiratory (odds ratio [OR] = 1.43, confidence interval [CI] 1.29-1.58; P < .001), gastrointestinal (OR = 1.72, CI 1.48-2.00; P < .001), urinary and renal (OR = 1.90, CI 1.70-2.12; P < 0.001), wound (OR = 1.36, CI 1.17-1.58; P < 0.001), and overall inpatient postoperative complications (OR = 1.43, CI 1.33-1.53; P < .001). Cirrhosis was also independently associated with significantly greater inpatient mortality (OR = 2.32, CI 1.72-3.14; P < .001). Cirrhotic patients also had significantly longer lengths of stay (5.35 vs 3.35 days; P < .001) and inpatient costs ($36 738 vs $29 068; P < .001).

                Conclusions

                Cirrhosis is associated with increased risk of perioperative complications, mortality and greater resource utilization. Cirrhotic patients undergoing spinal fusion surgeries should be counseled on these increased risks. Current strategies for perioperative management of cirrhotic patients undergoing spinal fusion surgery need improvement.
                  Cover page: Impact of Cirrhosis on Morbidity and Mortality After Spinal Fusion
                  • Article
                  • Peer Reviewed
                  UC Irvine Previously Published Works (2023)
                  Background Physician assistants/associates (PAs) and nurse practitioners (NPs), together known as advanced practice providers (APPs), practice with a high degree of clinical autonomy and professional respect, and play a critical role in team-based care. Aligning APP care delivery models to promote top-of-license practice is essential to improving ambulatory capacity and bottom-line expectations at academic medical centers (AMCs) in the 21st century and beyond. This administrative quality improvement study assesses the downstream impact of restructuring our APP care models to promote independent practice sessions. Methods Our AMC formed an APP oversight committee in April 2021 to optimize the ambulatory care model, realign APP funds flow, and set performance standards to which PAs and NPs are being held accountable. We conducted a one-year retrospective review of internal data from July 2021 to June 30, 2022. Certified registered nurse anesthetists (CRNAs) were excluded from this analysis. Results  APP productivity year-over-year (YOY) aggregate data across all School of Medicine (SOM) departments, demonstrated a 53% increase in work relative value units (wRVUs), 84% increase in payments, and 79% increase in charges from the prior fiscal year (July to June). Regarding APP ambulatory clinical effort (YOY), there was a 45% increase in the number of APP completed visits (92% return patient visits, 8% new visits). An increase in APP productivity did not adversely impact patient satisfaction, physician-generated wRVUs, or delay programmatic expansion efforts. Lastly, in a recent engagement survey, the majority of PA and NP respondents (78%) reported working either "most of the time" or "always" at the top-of-license. Conclusion This quality improvement study demonstrates that enhancement of PA and NP utilization through top-of-license initiatives can be achieved without jeopardizing physician wRVUs or performance. While we acknowledge, there are differences between healthcare institutions in terms of care delivery and compensation models, organizational culture, and distribution of clinical resources, there remains an opportunity among hospitals and health systems to optimize this critical and essential APP workforce.
                    Cover page: Optimal Use of Advanced Practice Providers at an Academic Medical Center: A First Year Retrospective ReviewCreative Commons 'BY' version 4.0 license
                    • Article
                    • Peer Reviewed
                    UC Irvine Previously Published Works (2018)

                    Supplemental intrathecal morphine (ITM) represents an option to manage postoperative pain after spine surgery due to ease of administration and ability to confer effective short-term analgesia at low dosages. However, whether ITM increases risk of surgical site infections (SSI), cerebrospinal fluid (CSF) leak, and incidental dural tears (IDT) has not been investigated. Therefore, this study was performed to determine the rates of SSI, CSF leak, and IDT in patients that received ITM.

                    Patients that underwent posterior instrumented fusion from January 2010 to 2016 that received ITM were compared to controls with respect to demographic, medical, surgical, and outcome data. Fisher's exact test was used to compare rates of SSI, CSF leak, and IDT between groups. Poisson regression was used to analyze complication rates after adjusting for the influence of covariates and potential confounders.

                    A total of 512 records were analyzed. ITM was administered to 78 patients prior to wound closure. The remaining 434 patients compromised the control group. IDT was significantly more common among patients receiving ITM (P=0.009). Differences in rates of CSF leak and SSI were not statistically significant (P=0.373 and P=0.564, respectively). After compensating for additional variables, Poisson regression revealed a significant increase in rates of IDT (P=0.007) according to ITM injection and advanced age (P=0.014). There was no significant difference in rates of CSF leak or SSI after accounting for the additional variables (P>0.05).

                    ITM for pain control in posterior instrumented spinal fusion surgery was linked to increased likelihood of IDT but not CSF leaks or SSI. Age was also noted to be a significant predictor of IDT. Spine surgeons should weigh potential risks against benefits when deciding whether to administer ITM for postoperative pain management following spine surgery.

                      Cover page: Complications associated with intrathecal morphine in spine surgery: a retrospective study.
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