Spine Journal最新文献

In the past, many health reform efforts have been touted as a means to tangentially reduce healthcare disparities. Few have shown any demonstrable efficacy in this arena. There is reasonable concern that the machinations of Medicare's Transforming Episode Accountability Model (TEAM) may also exert unintended effects on health access and delivery, potentially worsening existent disparities for racial and ethnic minorities as well as other vulnerable populations. As TEAM has yet to be implemented, this review intends to prognosticate potential pitfalls and behaviors that may be motivated by this project that could otherwise lead to worsening healthcare disparities within spine fusion care. We present a narrative review with our prognostications regarding mechanisms and behaviors that may be influenced by TEAM and that could result in worsening healthcare disparities and/or reduced access to care for vulnerable populations. These are informed by published experiences with other health reform efforts including centers of excellence, bundled payment programs, Accountable Care Organizations and Comprehensive Care for Joint Replacement. Based on previous published experiences with similar health reform initiatives, we believe there are several areas in which TEAM may potentiate or worsen existing healthcare disparities. These include the areas of access to care, undertreatment and healthcare segregation, as well as adverse behaviors such as cherry picking, lemon dropping and asymmetric pressure on small hospitals and safety-net institutions. There remain several aspects of TEAM that could limit access to care and aggravate healthcare disparities. Some of these behaviors could result in implicit or explicit undertreatment, restricted access to care and worsened healthcare segregation with negative feedback loops that continue to syphon resources from smaller hospitals and safety-net hospitals resulting in deterioration in the quality of care and general health of the already vulnerable populations these facilities serve.

Background context: Degenerative lumbar disorders (DLD) accompanied by sciatica frequently impair mobility and reduce functional capacity. Although patient-reported outcome measures (PROMs) and standardized tests are widely applied, real-world indicators of physical activity remain insufficiently examined. Modern smartphones can continuously record step counts, offering an accessible means of assessing daily movement patterns. However, the reliability of this approach in individuals with DLD-related sciatica has not yet been clearly determined.

Purpose: This study aimed to assess whether smartphone-derived daily step count accurately reflects real-life physical performance in patients with sciatica secondary to DLD and to explore how it correlates with established subjective and objective outcome measures.

Study design: Prospective observational cohort study PATIENT SAMPLE: 50 patients with sciatica secondary to DLD scheduled for microsurgery OUTCOME MEASURES: Physical performance was determined using smartphone-based daily step count, physical capacity by the 6-minute Walking Test application (6WT-app) and subjective disability by a set of paper-based patient-reported outcome measures (PROMs) prior to microsurgery.

Methods: Participants' step counts, 6WT results, and PROMs (COMI-Back, ODI) were analyzed. Activity data were standardized using age- and sex-specific reference values (z-scores) to categorize impairment levels. Correlations among all measures were calculated using Spearman coefficients.

Results: Mean daily step count was 4602 steps (SD 1074, z-score -1.1), and mean 6WT distance was 398 meters (SD 88, z-score -1.4). Most patients (58%) showed moderate impairment in both metrics. Step count correlated strongly with 6WT (r = 0.70) and moderately with ODI (r = -0.63) and COMI-Back (r = -0.65), with weaker correlations for back (r = -0.50) and leg pain (r = -0.30). Stratification revealed small discrepancies between physical capacity and real-life performance, suggesting that both variables might capture distinct aspects of disability CONCLUSION: Smartphone-based step counting provides a valid, objective indicator of physical performance in sciatica patients with DLD. Its association with both functional test results and self-reported disability suggests that smartphone data can serve as a practical complement to existing evaluation methods.

Background context: Cervical laminoplasty (LMP) is a standard surgical procedure for treating ossification of the posterior longitudinal ligament (OPLL). However, postlaminoplasty kyphosis (PLK) remains an unresolved problem. Although a restricted cervical extension range of motions (ROM) and sagittal imbalance have been reported as risk factors for PLK, these factors do not fully explain its occurrence. Deep sensory disturbance (DSD) of the lower extremities has been reported as a cause of habitual neck flexion while walking or ascending stairs, as patients visually compensate for impaired proprioception; however, its association with PLK has not been clearly established.

Purpose: To investigate whether lower extremity DSD is associated with an increased risk of PLK in patients with cervical OPLL.

Study design/setting: Retrospective multicenter observational study.

Patient sample: A total of 190 patients with radiographically and clinically diagnosed cervical OPLL who underwent cervical LMP involving more than 3 levels between 2008 and 2023 at 2 university hospitals and 5 general hospitals in Japan.

Outcome measures: Postoperative kyphosis progression was defined as a decrease of ≥9° in the C2-7 lordotic angle on lateral radiographs. Risk factors were assessed using demographic, clinical, and radiographic variables, including cervical ROM, sagittal vertical axis (SVA), and the presence of DSD.

Methods: Radiographic measurements and clinical data were retrospectively reviewed. Patients were classified into PLK and non-PLK groups based on changes in the C2-7 angle. Multivariate logistic regression analysis was performed to identify independent risk factors for PLK.

Results: Of the 190 patients, 50 (26.3%) exhibited kyphosis progression. DSD was significantly more prevalent in the PLK group. Multivariate analysis identified DSD, decreased preoperative cervical extension ROM, and increased preoperative C2-7 SVA as independent risk factors for PLK. Patients with DSD demonstrated greater preoperative C2-7 SVA and reduced cervical extension ROM.

Conclusions: DSD in the lower extremities is a significant independent risk factor for PLK in patients with cervical OPLL, likely due to habitual downward gaze for visual compensation during walking. These findings underscore the importance of considering DSD in postoperative rehabilitation strategies aimed at preventing PLK.

Background context: Patients with Medicaid often experience reduced access to specialty care compared to those with Medicare or private insurance. Previous studies have assessed Medicaid acceptance in orthopaedic specialties; however, national-level data on access to spine surgery across different insurance types remain limited.

Purpose: To evaluate how insurance type-Medicaid, Medicare, and Blue Cross/Blue Shield (BCBS)-impacts access to fellowship-trained orthopaedic spine surgeons and appointment wait times.

Study design: Cross-sectional audit (mystery caller) study.

Patient sample: Fellowship-trained orthopaedic spine surgeons listed in the American Academy of Orthopaedic Surgeons public directory.

Outcome measures: The primary outcomes were insurance acceptance and the number of business days until the earliest new patient appointment. Secondary measures included total call time, hold time, and number of phone transfers.

Methods: From December 9-13, 2024, trained callers contacted 304 orthopaedic spine surgeon offices across 45 states using a standardized clinical vignette. Each office was called three times-once for Medicaid, once for Medicare, and once for Blue Cross/Blue Shield (BCBS)-in a randomized order, resulting in a total of 912 calls placed. Poisson mixed-effects regression was used to estimate the association between insurance type and wait times, adjusting for physician and practice characteristics.

Results: Of 304 physicians called, 192 were successfully contacted and met the inclusion criteria. Among eligible practices, 101 (52%) accepted Medicaid, 182 (95%) accepted Medicare, and 190 (99%) accepted BCBS insurance. If a physician accepted Medicaid insurance, the mean wait time for a new patient appointment was 26.6 business days (95% CI: 25.6-27.6). Patients with Medicare or BCBS insurance waited 23.1 (95% CI: 22.4-23.8) and 22.1 (95% CI: 21.5-22.7) business days for a new patient appointment, which was significantly fewer days than patients with Medicaid (IRR: 0.90 [95% CI: 0.83-0.98], p=0.01; IRR: 0.88 [95% CI: 0.81-0.94], p<0.01, respectively). Additionally, academic affiliation was associated with a 124% longer wait time (IRR: 2.24 [95% CI: 1.25-4.03], p<0.01).

Conclusion: Patients with Medicaid experienced decreased access to care and longer wait times for a new patient appointment when seeking care with an orthopaedic spine surgeon compared to patients with Medicare or BCBS insurance. Additionally, academic practice affiliation was associated with the most significant increase in wait time for a new patient appointment. The present findings highlight a critical disparity in care faced by an already vulnerable patient population and further emphasize the need for additional research to implement novel solutions.

Background context: Segmental motor paralysis is a well-recognized complication following anterior cervical spine surgery. While risk factors have been identified, little is known about the factors that influence recovery outcomes, and there has been no systematic analysis of the relationship between onset timing and recovery patterns.

Purpose: This study aimed to investigate the clinical course of segmental motor paralysis after anterior cervical spine surgery, identify risk factors for persistent paralysis, and determine the relationship between paralysis onset timing and recovery patterns.

Study design/setting: This multicenter, retrospective cohort study was conducted at three spine centers affiliated with the Institute of Science Tokyo Group between January 2011 and March 2021.

Patient sample: Among the 1,428 patients who underwent anterior cervical procedures with complete 2-year follow-up data available, 93 patients who developed segmental motor paralysis after anterior cervical spine surgery were identified who met the inclusion criteria.

Outcome measures: Recovery was defined as a return to preoperative muscle strength, as determined by manual muscle testing. Independent risk factors for persistent paralysis were identified using multivariate logistic regression analysis. Patients were categorized into onset time groups of day 0, day 1, days 2 to 4, and day 5 or later.

Methods: Clinical and operative characteristics were compared between recovery and nonrecovery groups. Muscle strength recovery patterns were analyzed over 2 years. Risk factors for persistent paralysis were determined through univariate and multivariate analyses. No external funding was received for this study, and the authors report no study-specific conflicts of interest.

Results: At 2-year follow-up, persistent paralysis had occurred in 18 (19.4%) patients. Day 1 onset demonstrated the highest nonrecovery rate at 42.1% compared to 10.7% to 21.1% for other onset times (p=.044). Independent risk factors for persistent paralysis included a lower manual muscle testing score at onset (OR 7.38, p<.001) and a greater number of surgical levels (OR 1.86, p=.032).

Conclusions: This first systematic analysis reveals that paralysis onset on day 1 after anterior cervical spine surgery is associated with a poorer prognosis. Initial muscle weakness severity and multilevel surgery are key predictors of persistent paralysis. These findings may inform future preventive strategies.