Tag: Spinal

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Outcomes After Decompression Only Versus Decompression and Fusion for Lumbar Facet Cysts: A Systematic Review and Meta-Analysis

Neurosurgery 97:536–544, 2025

This meta-analysis compared decompression only (DO) versus decompression and fusion (DF) for lumbar facet cysts. DF reduced cyst recurrence and improved back pain resolution but had longer hospital stays. Reoperation and radiculopathy resolution rates were similar between groups. Most studies lacked standardized criteria for choosing DF over DO.

• Lumbar facet cysts (LFCs) are associated with facet degeneration and segmental instability; surgical management is debated between decompression only (DO) and decompression with fusion (DF).

• This systematic review and meta-analysis included 9 comparative studies with 3393 patients (DO: 1940, DF: 1453).

• Spondylolisthesis rates were significantly higher in the DF group (65.8% vs 24.3% in DO).

• DO had higher odds of cyst recurrence (6.3% vs 0%) and lower odds of back pain resolution (56.6% vs 74.5%) compared to DF.

• Reoperation rates (DO 7.2%, DF 5.9%) and radiculopathy resolution (DO 77.3%, DF 87.2%) were similar between groups.

• Length of hospital stay was shorter in the DO group.

• Criteria for choosing DF vs DO varied and were often not clearly defined across studies.

• The study concludes DF reduces cyst recurrence and improves back pain resolution but has longer hospital stays; reoperation and radiculopathy outcomes are comparable.

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Cavernous venous malformations in and around the central nervous system. Part 1: Dural and extradural

J Neurosurg 140:735–745, 2024

Cavernous-type malformations are venous lesions that occur in multiple locations throughout the body, and when present in the CNS, they have canonically been referred to as cavernomas, cavernous angiomas, and cerebral cavernous malformations. Herein all these lesions are referred to as “cavernous venous malformations” (CavVMs), which is congruent with the current International Society for the Study of Vascular Anomalies classification system.

Even though histologically similar, depending on their location relative to the dura mater, these malformations can have different features. In Part 1 of this review, the authors discuss and review pertinent clinical knowledge with regard to CavVMs as influenced by anatomical location, starting with the dural and extradural malformations. They particularly emphasize dural CavVMs (including those in the cavernous sinus), orbital CavVMs, and spinal CavVMs. The genetic and histopathological features of CavVMs in these locations are reviewed, and commonalities in their presumed mechanisms of pathogenesis support the authors’ conceptualization of a spectrum of a single disease entity. Illustrative cases for each subtype are presented, and the pathophysiological and genetic features linking dural and extradural to intradural CavVMs are examined.

A new classification is proposed to segregate CavVMs based on the location from which they arise, which guides their natural history and treatment.

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Minimally Invasive Transforaminal Lumbar Interbody Fusion: Cost of a Surgeon’s Learning Curve

World Neurosurg. (2022) 162:e1-e7

Minimally invasive transforaminal interbody fusion has become an increasingly common approach in adult degenerative spine disease but is associated with a steep learning curve. We sought to evaluate the impact of the learning experience on mean procedure time and mean cost associated with each procedure.

METHODS: We studied the first 100 consecutive minimally invasive transforaminal interbody fusion procedures of a single surgeon. We performed multivariable linear regression models, modeling operating time, and costs in function of the procedure order adjusted for patients’ age, sex, and number of surgical levels. The number of procedures necessary to attain proficiency was determined through a k-means cluster analysis. Finally, the total excess operative time and total excess cost until obtaining proficiency was evaluated.

RESULTS: Procedure order was found to impact procedure time and mean costs, with each successive case being associated with progressively less procedure time and cost. On average, each successive case was associated with a reduction in procedure time of 0.97 minutes (95% confidence interval 0.54e1.40; P < 0.001) and an average adjusted reduction in overall costs of $82.75 (95% confidence interval $35.93e129.57; P < 0.001). An estimated 58 procedures were needed to attain proficiency, translating into an excess procedure time of 2604.2 minutes (average of 45 minutes per case), overall costs associated with the learning experience of $226,563.8 (average of $3974.80 per case), and excess surgical cost of $125,836.6 (average of $2207.66 per case).

CONCLUSIONS: Successive cases were associated with progressively less procedure time and mean overall and surgical costs, until a proficiency threshold was attained.

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Robotic-Assisted vs Nonrobotic-Assisted Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Cost-Utility Analysis

Neurosurgery 90:192–198, 2022

Management of degenerative disease of the spine has evolved to favor minimally invasive techniques, including nonrobotic-assisted and robotic-assisted minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF). Value-based spending is being increasingly implemented to control rising costs in the US healthcare system. With an aging population, it is fundamental to understand which procedure(s) may be most cost-effective.

OBJECTIVE: To compare robotic and nonrobotic MIS-TLIF through a cost-utility analysis.

METHODS: We considered direct medical costs related to surgical intervention and to the hospital stay, as well as 1-yr utilities. We estimated costs by assessing all cases involving adults undergoing robotic surgery at a single institution and an equal number of patients undergoing nonrobotic surgery, matched by demographic and clinical characteristics. We adopted a willingness to pay of $50 000/quality-adjusted life year (QALY). Uncertainty was addressed by deterministic and probabilistic sensitivity analyses.

RESULTS: Costs were estimated based on a total of 76 patients, including 38 undergoing robot-assisted and 38 matched patients undergoing nonrobot MIS-TLIF. Using point estimates, robotic surgery was projected to cost $21 546.80 and to be associated with 0.68 QALY, and nonrobotic surgery was projected to cost $22 398.98 and to be associated with 0.67 QALY. Robotic surgery was found to be more cost-effective strategy, with costeffectiveness being sensitive operating room/materials and room costs. Probabilistic sensitivity analysis identified robotic surgery as cost-effective in 63% of simulations.

CONCLUSION: Our results suggest that at a willingness to pay of $50 000/QALY, robotic assisted MIS-TLIF was cost-effective in 63% of simulations. Cost-effectiveness depends on operating room and room (admission) costs, with potentially different results under distinct neurosurgical practices.

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