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Background Context: Cervical epidural steroid injections (CESIs) are commonly used in management of cervical pathology. While severe complications have been reported, they are rare, and thus their incidence and risk factors have not been well characterized., Purpose: To determine the incidence of complications 7, 30, and 90 days after CESI and to identify associated risk factors., Study Design: Retrospective cohort study of a large, national administrative claims database (Meritive TM Marketscan®)., Patient Sample: The study included 229,412 patients (mean age 52.2 ± 11.3 years, 57.1% female) undergoing 448,209 CESIs from 2008 to 2015., Outcome Measures: Complication rates following CESI, and risk factors for complication., Methods: Adults undergoing a CESI with active enrollment for one year prior to and 90 days after CESI were included. Patients with neoplasm, fracture, infection, inflammatory spondyloarthropathy or prior cervical surgery within one year preceding CESI were excluded. Multivariable repeated measures logistic regression models were used to identify risk factors for complications at 7, 30, and 90 days. Complications were stratified into procedural and medical complications. Each time point was modeled separately with Bonferroni adjustment for the multiple time points., Results: Complications increased from 1.7% to 4.1%, to 8.0% within 7, 30, and 90 days, respectively. Procedural complications occurred in 0.6% of cases within 7 days, with neurologic complications occurring in 0.5% of cases. Medical complications occurred in 1.1%, 3.6%, and 7.2% within 7, 30 and 90 days, respectively. After multivariable risk adjustment, a transforaminal approach was associated with greater odd for procedural complications within 7 days relative to an interlaminar approach (p<0.001), with an odds ratio (95% confidence interval) of 1.55 (1.35, 1.77). The transforaminal approach also was associated with greater odds of neurologic complications at 7 days [1.69 (1.45, 1.95); p<0.001]. A myelopathy diagnosis was not associated with risk of overall, procedural, medical, or neurological complications. The most influential factors independently associated with greater odds of any complication within 30 days included anticoagulant prescription [5.40 (4.55, 6.41); p<0.001] and history of venous thromboembolism [3.01 (2.40, 3.77); p<0.001]. The factors most strongly associated with procedural complications at 7 days included history of neurologic deficit [3.04 (2.65, 3.50); p<0.001] and antiplatelet medication prescription [2.21 (1.49, 3.27); p=0.003]., Conclusions: Complications following CESIs are infrequent. Neurologic complications were most common among procedural complications at 0.5% at 7 days. The transforaminal approach was associated with higher procedural complication rate compared to the interlaminar approach. Procedural and neurological complications were also associated with multiple factors including obesity, existing neurologic deficit, anxiety, and antiplatelet medication prescription. Attention should be given to these factors to mitigate procedural complications., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Patients undergoing lumbar spine surgery have high rates of preoperative opioid use, which is associated with inferior outcomes and higher risks for opioid dependency postoperatively., Purpose: Determine whether there are identifiable subgroups of patients that follow distinct patterns in pre- and postoperative opioid dosing. Examine how preoperative patterns in opioid dosing relate to postoperative opioid patterns, opioid cessation, and the risk for adverse events., Study Design/setting: Retrospective analysis of an administrative claims database (Meritive TM Marketscan® Research Databases 2007-2015)., Patient Sample: The 9,768 patients undergoing primary single level lumbar fusion., Outcome Measures: Primary: daily morphine milligram equivalent (MME) opioid dosing calculated from prescriptions dispensed for 1 year before and after surgery; secondary: 90-day all-cause readmission and complications, 90-day acute postoperative pain, 90-day and 1-year reoperation, surgical costs, length of stay, and discharge disposition., Methods: Distinct patient subgroups defined by patterns of daily MME pre- and postoperatively were identified via group-based trajectory modeling. Associations between these groups and outcomes were assessed with multivariable logistic regression with risk adjustment for patient and surgical factors., Results: Among primary single level lumbar fusion patients, 59.5% filled an opioid prescription in the 3 months preceding surgery, whereas 40.5% were opioid naïve (Naïve). Five distinct subgroups of daily MME were identified among those filling opioids preoperatively: (1) Naïve to 3m (21.2% of patients): no opioids until 3 months preoperatively, escalating to 15 MME/day; (2) Low to 3m (11.4%): very low or as needed dose until 3 months preoperatively, escalating to 15 MME/day; (3) 6m Rise (6.9%): no opioids until 6 months preoperatively, escalating to >30 MME/day; (4) Medium (9.8%): increased linearly from 10 to 25 MME/day across the year before surgery; (5) High (10.0%): increased linearly from 60 to >80 MME/day across the year before surgery. These five preoperative opioid groups were related to postoperative opioids filled in a dose-response manner. The two preoperative patient groups with chronic Medium to High-dose opioid dosing were associated with increased adverse events, including all-cause readmission, reoperation, and pneumonia, whereas a low baseline group with a large, earlier preoperative rise in opioid dosing (6m Rise) had increased encounters for acute postoperative pain. Postoperatively, only 9.5% of patients did not fill an opioid prescription. Five distinct postoperative subgroups were identified based on their patterns in daily MME: Two groups ceased filling opioids within the year following surgery (33.6% of patients), and three groups declined in opioid dosage following surgery but plateaued at low (0-5 MME/day, 29.1%), medium (10-15 MME/day, 12.0%), or high (70-75 MME/day), 13.1%) doses by 1 year. Patients within the higher preoperative opioid groups were more likely to belong to the postoperative groups that were unable to cease filling opioids., Conclusions: Identification of a patient's preoperative time trend in daily opioid use may provide significant prognostic value and help guide pain management and risk reduction efforts., Level of Evidence: III., Competing Interests: Funding disclosure statement No financial support was procured for this study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Understanding patient-specific trends in costs and healthcare resource utilization (HCRU) surrounding lumbar spine surgery is critically needed to better inform surgical decision making and the development of targeted interventions., Purpose: 1) Identify subgroups of patients following distinct patterns in direct healthcare payments pre- and postoperatively, 2) determine whether these patterns are associated with patient and surgical factors, and 3) examine whether preoperative payment patterns are related to postoperative payments, healthcare resource utilization (HCRU), and adverse events., Study Design/setting: Retrospective analysis of an administrative claims database (IBM Marketscan Research Databases 2007-2015)., Patient Sample: Adults undergoing primary single-level decompression surgery for lumbar stenosis (n=12,394)., Outcome Measures: Direct healthcare payments, HCRU payments (15 categories), 90-day complications and all-cause readmission, 2-year reoperation METHODS: Group-based trajectory modeling is an application of finite mixture modeling that is able to identify meaningful subgroups within a population that follow distinct developmental trajectories over time. We used this technique to identify subgroups of patients following distinct profiles in preoperative direct healthcare payments. A separate analysis was performed to identify distinct profiles in payments postoperatively. Patient and surgical factors associated with these payment profiles were assessed with multinomial logistic regression, and associations with adverse events were assessed with risk-adjusted multivariable logistic regression., Results: We identified 4 preoperative patient payment subgroups following distinct profiles in payments: Pre-Low (5.8% of patients), Pre-Early-Rising (4.8%), Pre-Medium (26.1%), and Pre-High (63.3%). Postoperatively, 3 patient subgroups were identified: Post-Low (8.9%), Post-Medium (29.6%), and Post-High (61.4%). Patients following the higher-cost pre- and postoperative payment profiles were older, more likely female, and had a greater physical and mental comorbidity burden. With each successively higher preoperative payment profile, patients were increasingly likely to have high postoperative payments, use more HCRU (particularly high-cost services such as inpatient admissions, ER, and SNF/IRF care), and experience postoperative adverse events. Following risk adjustment for patient and surgical factors, patients following the Pre-High payment profile had 209.5 (95% CI: 144.2, 309.7; p<.001) fold greater odds for following the Post-High payment profile, 1.8 (1.3, 2.5; p=.003) fold greater odds for 90-day complications, and 1.7 (1.2, 2.6; p=.035) fold greater odds for 2-year reoperation relative to patients following the Pre-Low payment profile., Conclusions: There are identifiable subgroups of patients who follow distinct profiles in direct healthcare payments surrounding lumbar decompression surgery. These payment profiles are related to patient age, sex, and physical and mental comorbidities. Notably, preoperative payment profiles may provide prognostic value, as they are associated with postoperative costs, HCRU, and adverse events., Level of Evidence: III., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background Context: Improved understanding of the pre- and postoperative trends in costs and healthcare resource utilization (HCRU) is needed to better inform patient expectations and aid in the development of strategies to minimize the significant healthcare burden associated with lumbar spine surgery., Purpose: Examine the time course of costs and HCRU in the 2 years preceding and following elective lumbar spine surgery for stenosis in a large national claims cohort., Study Design/setting: Retrospective analysis of an administrative claims database (IBM® Marketscan® Research Databases 2007-2015)., Patient Sample: Adult patients undergoing elective primary single-level lumbar surgery for stenosis with at least 2 years of continuous health plan enrollment pre- and postoperatively., Outcome Measures: Functional measures, including monthly rates of HCRU (15 categories), monthly gross covered payments (including payments made by the health plan and deductibles and coinsurance paid by the patient) overall, by HCRU category, and by spine versus non-spine-related., Methods: All available patients were utilized for analysis of HCRU. For analysis of payments, only patients on noncapitated health plans providing accurate financial information were analyzed. Payments were converted to 2015 United States dollars using the medical care component of the consumer price index. Trends in payments and HCRU were plotted on a monthly basis pre- and post-surgery and assessed with regression models. Relationships with demographics, surgical factors, and comorbidities were assessed with multivariable repeated measures generalized estimating equations., Results: Median monthly healthcare payments 2 years prior to surgery were $275 ($22, $868). Baseline HCRU at 2 years preoperatively was stable or only gradually rising (office visits, prescription drug use), but began an increasingly steep rise in many categories 6 to 12 months prior to surgery. Monthly payments began an increasingly steep rise 6 months prior to surgery, reaching a peak of $1,402 ($634, $2,827) in the month prior to surgery. This was driven by an increase in radiology, office visits, PT, injections, prescription medications, ER encounters, and inpatient admissions. Payments dropped dramatically immediately following surgery. Over the remainder of the 2 years, the median total payments declined only slightly, as a continued decline in spine-related payments was offset by gradually increased non-spine related payments as patients aged. By 2 years postoperatively, the percentage of patients using PT and injections returned to within 1% of the baseline levels observed 2 years preoperatively; however, spine-related prescription medication use remained elevated, as did other categories of HCRU (radiology, office visits, lab/diagnostic services, and also rare events such as inpatient admissions, ER encounters, and SNF/IRF). Patients with a fusion component to their surgeries had higher payments and HCRU preoperatively, and this did not resolve postoperatively. Variations in payments and HCRU were also evident among plan types, with patients on comprehensive medical plans-predominantly employer-sponsored supplemental Medicare coverage-utilizing more inpatient, ER, and inpatient rehabilitation & skilled nursing facilities. Patients on high-deductible plans had fewer payments and HCRU across all categories; however, we are unable to distinguish whether this is because they used fewer of these services or if they were paying for these services out of pocket without submitting to the payer. By 2 years postoperatively, 51% of patients had no spine-related monthly payments, while 33% had higher and 16% had lower monthly payments relative to 2 years preoperatively., Conclusions: This is the first study to characterize time trends in direct healthcare payments and HCRU over an extended period preceding and following spine surgery. Differences among plan types potentially highlight disparities in access to care and plan-related financial mediators of patients' healthcare resource utilization., Competing Interests: Declarations of Competing Interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background Context: Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain., Purpose: This study sought to determine: (1) the proportion of patients having surgery following CESI, and (2) the timing of and factors associated with subsequent surgery., Study Design: Retrospective analysis of a large, national administrative claims database., Patient Sample: The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof., Outcome Measures: The primary outcome was the time from index CESI to surgery., Methods: Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year before CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models., Results: Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35 to 54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery., Conclusions: Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background Context: Lumbosacral epidural steroid injections (ESIs) have increased dramatically despite a narrowing of the clinical indications for use. One potential indication is to avoid or delay surgery, yet little information exists regarding surgery rates after ESI., Purpose: The purpose of this research was to determine the proportion of patients having surgery after lumbar ESI for disc herniation or stenosis and to identify the timing and factors associated with this progression., Study Design/setting: This study was a retrospective review of nationally representative administrative claims data from the Truven Health MarketScan databases from 2007 to 2014., Patient Sample: The study cohort was comprised of 179,025 patients (54±15 years, 48% women) having lumbar ESIs for diagnoses of stenosis and/or herniation., Outcome Measures: The primary outcome measure was the time from ESI to surgery., Methods: Inclusion criteria were ESI for stenosis and/or herniation, age ≥18 years, and health plan enrollment for 1 year before ESI to screen for exclusions. Patients were followed longitudinally until they progressed to surgery or had a lapse in enrollment, at which time they were censored. Rates of surgery were assessed with the Kaplan-Meier survival curves. Demographic and treatment factors associated with surgery were assessed with multivariable Cox proportional hazard models. No external funding was procured for this research and the authors' conflicts of interest are not pertinent to the present work., Results: Within 6 months, 12.5% of ESI patients underwent lumbar surgery. By 1 year, 16.9% had surgery, and by 5 years, 26.1% had surgery. Patients with herniation had surgery at rates of up to five-fold to seven-fold higher, with the highest rates of surgery in younger patients and those with both herniation and stenosis. Other concomitant spine diagnoses, male sex, previous tobacco use, and residence a rural areas or regions other than the Northeastern United States were associated with higher surgery rates. Medical comorbidities (previous treatment for drug use, congestive heart failure, obesity, chronic obstructive pulmonary disease, hypercholesterolemia, and other cardiac complications) were associated with lower surgery rates., Conclusions: In the long term, more than one out of every four patients undergoing ESI for lumbar herniation or stenosis subsequently had surgery, and nearly one of six had surgery within the first year. After adjusting for other patient demographics and comorbidities, patients with herniation were more likely have surgery than those with stenosis. The improved understanding of the progression from lumbar ESI to surgery will help to better inform discussions regarding the value of ESI and aid in the shared decision-making process., (Copyright © 2018 Elsevier Inc. All rights reserved.)