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• BMP use in spinal fusions decreased from 2006 to 2015 for Medicare patients. • There was significant state and region-level geographic variation in BMP use. • BMP use was associated with increased hospital costs but similar Medicare payments. Bone morphogenic protein (BMP) promotes bony fusion but increases costs. Recent trends in BMP use among Medicare patients have not been well-characterized. To assess utilization trends, complication, payments, and costs associated with BMP use in spinal fusion in a Medicare-insured population. Retrospective cohort study. Total of 316,070 patients who underwent spinal fusion in a 20% sample of Medicare-insured patients, 2006 to 2015. Utilization trends across time and geography, complications, payments, and costs. Patients were stratified by fusion type and diagnosis. Multivariable logistic and linear regression were used to adjust for the effect of baseline characteristics on complications and total payments or cost, respectively. BMP was used in 60,249 cases (19.1%). BMP utilization rates decreased from 23.1% in 2006 to 12.0% in 2015, most significantly in anterior cervical (7.5%–3.1%), posterior cervical (17.0%–8.3%), and posterior lumbar fusions (31.5%–15.8%). There are significant state- and region-level geographic differences in BMP utilization. Across all years, states with the highest BMP use were Indiana (28.5%), Colorado (26.6%), and Nevada (25.7%). States with the lowest BMP use were Maine (2.3%), Vermont (8.2%), and Mississippi (10.4%). After multivariate risk adjustment, BMP use was associated with decreased overall complications in thoracic (odds ratios [OR] [95% confidence intervals [CI]): 0.89 [0.81–0.99]) and anterior lumbar fusions (OR [95% CI]: 0.89 [0.84–0.95]), as well as increased reoperation rates in anterior cervical (OR [95% CI]: 1.11 [1.04–1.19]), posterior cervical (OR (95% CI): 1.14 (1.04–1.25)), thoracic (OR (95% CI): 1.32 (1.23–1.41)), and posterior lumbar fusions (OR (95% CI): 1.11 (1.06–1.16)). BMP use was also associated with greater total costs, independent of fusion type, after multivariate risk adjustment (p<.0001). Payments, however, were comparable between groups in anterior and posterior cervical fusion with or without BMP. BMP use was associated with greater total payments in thoracic, anterior lumbar, and posterior lumbar fusions. Notably, the difference in payments was smaller than the associated cost increase in all fusion types. BMP use has declined across all fusion types over the last decade, after a peak in 2007. While BMP is associated with greater costs, reimbursement does not increase proportionally with BMP cost. [ABSTRACT FROM AUTHOR]

Anterior cervical discectomy and fusion (ACDF) is effective for the treatment of single-level cervical spondylotic myelopathy (CSM). However, the data surrounding multilevel CSM have remained controversial. One alternative is laminoplasty, although evidence comparing these strategies has remained sparse. In the present report, we retrospectively reviewed the readmission and reoperation rates for patients who had undergone ACDF or laminoplasty for multilevel CSM from a national longitudinal administrative claims database. We queried the MarketScan Commercial Claims and Encounters database to identify patients who had undergone ACDF or laminoplasty for multilevel CSM from 2007 to 2016. The patients were stratified by operation type. Patients aged <18 years, patients with a history of tumor or trauma, and patients who had undergone anteroposterior approach were excluded from the present study. A total of 5445 patients were included, of whom 1521 had undergone laminoplasty. A matched cohort who had undergone ACDF was identified. The overall 90-day postoperative complication rate was greater in the laminoplasty cohort (odds ratio, 1.48; 95% confidence interval, 1.18–1.86; P < 0.0001). The mean length of stay and 90-day readmission rates were greater in the laminoplasty cohort. The hospital and total payments of the index hospitalization were greater in the ACDF cohort, as were the total payments for ≤2 years after the index hospitalization. In the present administrative claims database study, no difference was found in the reoperation rate between ACDF and laminoplasty. ACDF resulted in fewer complications and readmissions compared with laminoplasty but was associated with greater costs. Additional prospective research is required to investigate the factors driving the higher costs of ACDF in this population and the long-term clinical outcomes. [ABSTRACT FROM AUTHOR]

The operative microscope, a commonly used tool in neurosurgery, is critical in many supratentorial tumor cases. However, use of operating microscope for supratentorial tumor varies by surgeon. To assess complication rates, readmissions, and costs associated with operative microscope use in supratentorial resections. A retrospective analysis was conducted using a national administrative database to identify patients with glioma or brain metastases who underwent supratentorial resection between 2007 and 2016. Univariate and multivariate analyses were used to assess 30-day complications, readmissions, and costs between patients who underwent resection with and without use of microscope. The cohort included 12,058 glioma patients and 5433 metastasis patients. Rates of microscope use varied by state from 19.0% to 68.6%. Microscope use was associated with $5228.90 in additional costs of index hospitalization among glioma patients (P <0.001), and $2824.00 among metastasis patients (P <0.001). Rates of intraoperative cerebral edema were lower among the microscope cohort than among the nonmicroscope cohort (P <0.027). Microscope use was associated with a slight reduction in 30-day rates of neurological complications (14.7% vs. 16.7%, P = 0.048), specifically in nonspecific cerebrovascular complications. There were no differences in rates of other complications, readmissions, or 30-day postoperative costs. Use of operative microscope for supratentorial resections varies by state and is associated with higher cost of surgery. Microscope use may be associated with lower rates of intraoperative cerebral edema and some cerebrovascular complications, but is not associated with significant differences in other complications, readmissions, or 30-day costs. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective 1:1 propensity score-matched analysis on a national longitudinal database between 2007 and 2016.Objective: The aim of this study was to compare complication rates, revision rates, and payment differences between navigated and conventional posterior lumbar fusion (PLF) procedures with instrumentation.Summary Of Background Data: Stereotactic navigation techniques for spinal instrumentation have been widely demonstrated to improve screw placement accuracies and decrease perforation rates when compared to conventional fluoroscopic and free-hand techniques. However, the clinical utility of navigation for instrumented PLF remains controversial.Methods: Patients who underwent elective laminectomy and instrumented PLF were stratified into "single level" and "3- to 6-level" cohorts. Navigation and conventional groups within each cohort were balanced using 1:1 propensity score matching, resulting in 1786 navigated and conventional patients in the single-level cohort and 2060 in the 3 to 6 level cohort. Outcomes were compared using bivariate analysis.Results: For the single-level cohort, there were no significant differences in rates of complications, readmissions, revisions, and length of stay between the navigation and conventional groups. For the 3- to 6-level cohort, length of stay was significantly longer in the navigation group (P < 0.0001). Rates of readmissions were, however, greater for the conventional group (30-day: P = 0.0239; 90-day: P = 0.0449). Overall complications were also greater for the conventional group (P = 0.0338), whereas revision rate was not significantly different between the 2 groups. Total payments were significantly greater for the navigation group in both the single level and 3- to 6-level cohorts (P < 0.0001).Conclusion: Although use of navigation for 3- to 6-level instrumented PLF was associated with increased length of stay and payments, the concurrent decreased overall complication and readmission rates alluded to its potential clinical utility. However, for single-level instrumented PLF, no differences in outcomes were found between groups, suggesting that the value in navigation may lie in more complex procedures.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Objective To characterize cranioplasty complications and costs at a population level using a longitudinal national claims database. Methods We identified patients undergoing cranioplasty between 2007 and 2014 in the MarketScan national database. We evaluated age, autograft usage, cranioplasty size, and cranioplasty timing stratified by postoperative outcomes. We further analyzed associated costs. A subset analysis of adult patients with emergent indications, including stroke and trauma, was performed. Results We identified 8275 patients (mean age 44.0 years ± 20.0, 45.2% male), including 13.8% children (<18 years old), 76.0% adults (18–64 years old), and 10.2% elderly adults (≥65 years old). Overall complication rate was 36.6%, mortality rate was 0.5%, and 30-day readmission rate was 12.0%. Elderly patients had the highest complication rate ( P < 0.0001). Large cranioplasties (>5 cm) had higher complication rates than small cranioplasties (≤5 cm; P = 0.047). In patients with emergent indications ( n = 1282), size did not influence complications, although large cranioplasties showed higher infection risk ( P = 0.02). Autograft use did not affect outcomes but was associated with higher complication risk, including infections, in the subset with emergent indications ( P < 0.001, P = 0.001). Late (>90 days) cranioplasty timing had higher complication rates in the overall cohort and the subset with emergent indications ( P < 0.001, P < 0.001). Index costs of care were mainly driven by hospital payments in both the overall cohort and the cohort with emergent indications. Conclusions A high complication rate is associated with cranioplasty in the United States. Older age, large cranioplasties, and delayed cranioplasties increased complication risk overall. Among patients with emergent indications, complications were associated with delayed time to cranioplasty and autograft usage. [ABSTRACT FROM AUTHOR]