Pain and Infection after Spine Surgery

Pain and Infection after Spine Surgery

Pain and Infection after Spine Surgery

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It is tough to be the adult in the room.  Most people only want to hear about the benefits of spine surgery.   Spine surgeons chuckle about the reactions some patients have about their outcomes.  If there is a good outcome,  it is a miracle,  a religious experience,  or luck.  If the outcomes are poor,  it is the fault of the surgeon,  hospital, society,  etc.

As a scientist,  and an outcomes predictor,  I know there are factors that make poor outcomes more likely.

In a recent meeting,  Dr. Owiocho Adogwa reviewed data on admissions to Duke University Hospital between 2008 and 2010 for elective spine surgery. The charts for 1400 patients were reviewed.  Realize that during this time,  most spine surgery patients were admitted to the hospital for procedures.   132 patients were readmitted to the hospital within 30 days.  The vast majority of these re admitted had lumbar decompression and fusion.   The most common reasons for readmissions  were pain,  and concerns for post-operative infection.  

Frankly,  this should not be a surprise,  and this study just confirms what we already know.  The paper also looked at larger cost consequences to the United States.   Hospital readmissions for elective spine surgery costed $17 billion dollars.  Of that amount,  58% of these costs were incurred by Medicare,  and another 18% by Medicaid.

Today,  Medicare no longer reimburses the hospitals for the costs associated with readmissions after elective surgery.  The Hospital systems has financial incentives to reduce the readmissions rates.  The Hospitals need to avoid readmissions to the hospital,  because the cost of readmission will not be compensated by Medicare,  Medicaid,  and now most private insurance entities.

Hospitals have become more pro-active.  There are some well know simple solutions to prevent infections,  and great care is used to analyse any infection in the post op phase to identify any factors that may be modified.  I will say the infection rates have decreased some what.  But certain factors will always increase the rates of infection.

Patients with prior infections,  uncontrolled diabetes,  and obesity will always have increased infection rates.    Secondary to the financial risks,  Hospitals  are now much less willing to assume the care for these patients.  It is an opposite situation we had 10 years ago.  Hospitals were actively seeking these patients,  as any costs associated with complications,  readmissions,  etc was reimbursed by the payers,  including Medicare and Medicaid.  From a business perspective,  there was every incentive to do as much as possible for these patients.  It was also a perfect marketing opportunity,  as the Hospitals will say things like  ” we will take care of you, no matter the cost”.   That was an easy thing to say,  as they always got paid on a cost plus basis.  For any of you who ran a business,  it was a perfect business model.  This is one of the factors why we had runaway cost increases for medical care in the USA.  

Now,  Hospitals are penalized for readmissions and infections.   To survive, Hospitals need  to prevent these complications.  Around the periphery,  they are doing good things to prevent infections.  But most Hospital Systems have come to the conclusion  it is better not to care for high risk patients, although they could never say that.    I am sure many of you do not want to think that is happening.   Then again,  think about how many Hospitals no longer advertise the presence of a “Spine Center”.   Most Hospitals have now promoted the outpatient procedures, and avoid the much more complicated,  high cost major spine fusions and reconstructions.

For the Surgeons,  there is no added compensation for caring for more complicated,  higher risk patients.  Most surgeons will still care for these folks,  as that is part of our Professional Code of Conduct.  On the other hand,  government plans, and managed care plans now recognize the added risks,  and costs, to these complicated reconstruction spine surgeries.  The criterion to schedule elective high risk Reconstruction Spine Surgery  has significantly tightened in the past 6 years.

In terms of pain control,  larger more complicated surgery has more post-operative pain.  Additionally,  patients with prior pain medication tolerance have difficulty managing the increase pain after surgery.   Emotional,  and physical support of friends and family are very important for recovery.  Prior to surgery,  these factors must be assessed.  If the patient does not have the proper understanding of the expected pain,  surgery should be postponed,  or even cancelled.    Patients who do not have the proper home environment will also have extreme difficulty in the post-operative phase.  If a proper home environment is not present,  the surgical team should discuss arranging post-operative convalescence at a designated facility.  Everything has a financial cost associated with utilization.  If the patient cannot afford the proper post-operative care,  again surgery should be post-poned or cancelled.  Remember that this is elective surgery,  in otherwords,  not emergent.    While the patient may be in pain,  they will be in even more pain when they have a poor outcome from surgery.  There are certain factors that will help improve the odds of surgery.  If the patient can not optimize their chance of a successful outcome,  most prudent Surgeons will postpone or cancel the surgery.  That could financially hurt the Surgeon’s practice.  On the other hand,  bad outcomes will also financially hurt the practice,  and a poor outcome is a difficult situation for the patient,  the Surgeon and the payer.

Sorry to be the adult in the room.    It is a lot easier to talk about the successful outcomes.  On the other hand,  the surgeon that is aware of the factors needed for a good result will be much more likely to delivery that successful outcome.

Citations

  • Elsamadicy AA, Adogwa O, Cheng J, Bagley C. Pretreatment of Depression Before Cervical Spine Surgery Improves Patients' Perception of Postoperative Health Status: A Retrospective, Single Institutional Experience. World Neurosurg. 2016 Mar;87:214-9. PubMed PMID: 26706296

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Author and Contributor to www.Spine-Health.com – July, 2015

www.Spine-Health.com/author/john-h-shim-md-facs

Chief of Surgery, Mease Countryside and Mease Dunedin Hospitals, Safety Harbor and Dunedin, Florida. 2014-2016.

Orthopaedic Section Chief Mease Countryside Hospital; Safety Harbor, Florida Mease Dunedin Hospital; Dunedin, Florida.2008-2013

Board Member Morton Plant Mease Research Council

Co-Director of Mease Neuro-Ortho Spine Center Mease Dunedin Hospital; Dunedin, Florida.

One of “6 Spine Physicians Ranked #1 on Google” – December 2016

Top Ten Most Liked Spine Surgeons on the Internet – July 2016

2016 Spine Surgeons to Know list – January 2016

2014 Spine Specialists to know list – September 2014

One of Ten Leaders of Certified Spine Programs – December 2011

 

The Best Orthopedics in Tampa

The information provided on this website does not provide or should be considered medical advice. It is not a substitute for diagnosis or treatment of any condition. The information provided is for informational purposes only. You should not rely solely on the information provided on this website in making a decision to pursue a specific treatment or advice. You should consult directly with a professional healthcare provider.

As a condition of using the information on this website, ShimSpine and its physicians are not responsible for any advice, diagnosis, treatment or outcome you may obtain.

ShimSpine.com is completely self-funded. No outside funds are accepted or used. This website does not utilize paid advertising as a source of revenue.
Outpatient Spine Surgery Considerations. www.Spine-Health.com. January 2016.

What is Spinal Stenosis? www.Spine-Health.com. October 2015.

Surgeon insights on the Changing Landscape of Orthopedic Care. OrthopedicToday. June 2014

Chapter 33: Interspinous Spacers. Shim JH, Mazza JS, Kim DH Published in Minimally Invasive Percutaneous Spinal Techniques. Elsevier Health Sciences, Philadelphia, Pennsylvania. (Published 2011)

Chapter 35: Minimally Invasive Percutaneous Lumbar Fusion Technique.Shim JH, Mazza JS, Kim DH Published in Minimally Invasive Percutaneous Spinal Techniques. Elsevier Health Sciences, Philadelphia, Pennsylvania. (Published 2011)

March 2010 Minimally Invasive Transforaminal Lumbar Interbody Fusion American Academy of Orthopaedic Surgeons Annual Meeting New Orleans, Louisiana February 2010

February 2010 A Review of Dynamic Stabilization in the Lumbar Spine Selby Spine Symposium; Park City, Utah

November 2009 Lumbar Spinal Stenosis Community Based Lecture; Tampa, Florida

September 2009 Instructor/Proctor Minimally Invasive Lumbar Cadaver Lab; Tampa, Florida

February 2009 New Spinal Technology: Cervical Disc Replacement and Interspinous Spacers. Selby Spine Symposium; Park City, Utah

February 2008 The Degenerative Spine: The Role of Dynamic Lumbar Stablization and Interspinous Spacers Selby Spine Symposium; Park City, Utah

October 2008 Emerging Technology and Techniques in Spinal Surgery Orthopaedics in the 21st Century Symposium; Morton Plant Mease Healthcare; Largo, Florida

September 2007 Emerging Technology in Spinal Surgery Orthopaedics in the 21st Century Symposium; Morton Plant Mease Healthcare; Largo, Florida

October 2006 Emerging Technology and Techniques in Spinal Surgery Orthopaedics in the 21st Century Symposium; Morton Plant Mease Healthcare; Largo, Florida

May 2005 The Role of Kyphoplasty in the Treatment of Vertebral Compression Fractures Mease Neurosciences Symposium; Clearwater, Florida
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