Case study
Operative fusion of multilevel cervical spondylotic myelopathy: Impact of patient demographics

https://doi.org/10.1016/j.jocn.2016.12.027Get rights and content

Highlights

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    Female sex, private insurance status, and elective admission type are each independent predictors in CSM for receipt of a 3+ level fusion.

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    Patient age, race and income are not predictive for 3+ level fusions in CSM.

Abstract

Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in patients older than age 55, with operative management being a widely adopted approach. Previous work has shown that private insurance status, gender and patient race are predictive of the operative approach patients receive (anterior-only, posterior-only, combined anterior–posterior). The Nationwide Inpatient Sample from 2001 to 2010 was used to assess the potential role of multilevel CSM as a contributing factor in determining which operative approach CSM patients receive, as it is rare for an anterior-only approach to be sufficient for CSM patients requiring fusion of four or more involved levels. Multivariate analyses revealed that female sex (OR = 3.78; 95% CI = 2.08–6.89; p < 0.0001), private insurance (OR = 5.02; 95% CI = 2.26–11.12; p < 0.0001), and elective admission type (OR = 4.12; 95% CI = 1.65–10.32; p = 0.0025) were predictive of increased receipt of a 3+ level fusion in CSM. No other variables, including patient age, race, income, or admission source were predictive of either increased or decreased likelihood of receiving fusion of at least three levels for CSM. In conclusion, female sex, private insurance status, and elective admission type are each independent predictors in CSM for receipt of a 3+ level fusion, while patient age, race and income are not. Given the propensity of fusions greater than three levels to require posterior approaches and the association between posterior CSM approaches and increased morbidity/mortality, these findings may prove useful as to which patient demographics are predictive of increased morbidity and mortality in operative treatment of CSM.

Introduction

One of the most common spinal disorders treated by spine surgeons, cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in patients older than age 55 [3], [13]. Surgical management of CSM has consisted predominantly of three approaches: anterior-only, posterior-only, or a combined anterior–posterior approach [5]. Previous work has shown that private insurance status, gender and patient race are predictive of the operative approach patients receive, and that posterior-only fusion has significantly increased mortality [7], [11], [12]. The potential role of multilevel CSM as a contributing factor to these findings is currently unknown, as it is rare for an anterior-only approach to be sufficient for CSM patients requiring fusion of four or more involved levels [8]. To address this issue, a database of CSM patients was analyzed on a nationwide level.

Section snippets

Data source

The data source for this study was the Nationwide Inpatient Sample (NIS) hospital discharge database (overview available at http://www.hcup-us.ahrq.gov/nisoverview.jsp) covering the years 2001 through 2010, which was obtained from Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality (Rockville, MD) [6]. The NIS represents approximately 20% of all inpatient admissions to nonfederal hospitals in the United States (US). For these years, the NIS contains data on 100%

Results

Patient characteristic findings in the NIS database for operative CSM in the United States from 2001 through 2010 were similar to previously published work [12]. The demographics of CSM patients with at least three levels fused over this time period can be found in Table 1; 75.6% were Caucasian, 14.7% were Black, 5.3% were Hispanic, and 43.6% had private insurance. The total operative CSM incidence of patients with at least three levels fused between 2001 and 2010 increased from 5 to 56 per

Discussion

Until recent work, there has been little focus on the potential impact of socioeconomic and demographic factors on the management of CSM patients; however a study recently found non-Caucasian race and absence of private insurance status each predictive of receiving a posterior-only operative approach [12]. While provocative, it is fair to inquire whether these findings are influenced by an increased likelihood of these patient populations having more than three levels of disease requiring

Conclusions

Female sex, private insurance status, and elective admission type are each independent predictors in CSM for receipt of a 3+ level fusion, while patient age, race and income are not. Given the propensity of fusions greater than three levels to require posterior approaches and the association between posterior CSM approaches and increased morbidity/mortality [7], these findings may prove useful as to which patient demographics are predictive of increased morbidity and mortality in operative

References (15)

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