Elsevier

World Neurosurgery

Volume 114, June 2018, Pages e151-e157
World Neurosurgery

Original Article
Variability in Treatment for Patients with Cervical Spine Fracture and Dislocation: An Analysis of 107,152 Patients

https://doi.org/10.1016/j.wneu.2018.02.119Get rights and content

Highlights

  • There remains significant variation in the treatment of cervical spinal injuries.

  • Interhospital treatment variation has decreased from 2000 to 2011.

  • Rates of halo/tong placement have fallen in all hospital types examined.

  • Decreases in variability require more research in optimal treatment strategies.

Background

Cervical spine injuries are a common cause of morbidity and mortality; however, the optimal treatment of many of these injuries is debated, and previous studies have shown substantial variation in treatment. We sought to examined treatment variation in arthrodesis and halo/tong placement in cervical spine injury patients over a 12-year period.

Methods

Data from the Healthcare Cost and Utilization Project National Inpatient Sample, from 2000 to 2011, were used for this study. Patients were identified with a cervical vertebral facture or dislocation based on the International Classification of Diseases, 9th Revision codes. Using χ2 analysis, spinal arthrodesis rates and halo/tong placement rates were compared between hospitals based on teaching status for patients with and without spinal cord injury (SCI).

Results

The records of 107,152 patients with cervical fractures were examined. From 2000 to 2011, the overall arthrodesis rates fell from 25.2% to 20.6% (P < 0.001), and halo/tong placement rates fell from 13.2% to 3.6% (P < 0.001). In patients with cervical fracture without SCI, arthrodesis rates fell from 17.6% to 13.9% (P < 0.001), in cervical fracture patients with SCI, arthrodesis rates rose from 50.0% to 58.9% (P < 0.001), and in cervical dislocation patients, arthrodesis rates rose from 47.6% to 57.5% (P < 0.001). During the 12-year period, teaching hospitals had higher arthrodesis rates compared with nonteaching hospitals for patients with cervical fractures with SCI (57.3% vs. 53.4%, P = 0.001) and higher halo/tong placement rates for patients with cervical dislocations (2.7% vs. 1.7%, P = 0.004). Individual hospital variation showed a 3.5-fold variation in arthrodesis rates in 2000 to 2002, which fell to 3.0-fold by 2009 to 2011.

Conclusions

Arthrodesis rates for cervical fracture patients significantly decreased, and arthrodesis rates for cervical dislocation and SCI patients increased from 2000 to 2011, with variability in treatment based on hospital teaching status. Rates of halo/tong placement rapidly decreased for cervical spine trauma at both teaching and nonteaching hospitals. Individual hospital treatment variation also decreased over the study period. Further clinical studies examining the optimal treatment for spine trauma may lead to continued decreases in treatment variability.

Introduction

Cervical spine trauma is a major cause of mortality, morbidity, and healthcare expense in the United States. Approximately 55% of spinal cord injuries (SCIs) are due to cervical trauma,1 and 4.3% of all trauma AU: explain use of while versus and admissions are due to cervical spine injuries.2 Based on local resources, physician preference, the patient's medical condition, and the patient's injury, preferred treatment may include arthrodesis, halo placement, or cervical orthosis.3

Although overall cervical spine surgery rates have been shown to vary nearly 10-fold between geographic regions,4 those data largely reflect the treatment of cervical degenerative disease.5, 6 Using data from 1998 to 2002, Daniels et al.7 previously demonstrated a smaller 2.9-fold to 5.2-fold variability in rates of arthrodesis for cervical spine trauma patients depending on whether there was a cervical dislocation or associated SCI. Numerous studies have examined optimal treatment for cervical spine trauma8, 9, 10, 11, 12; however, data regarding the rate of spinal arthrodesis for cervical spine injuries since 2002 have not yet been reported.

In this study, we sought to examine trends in arthrodesis and halo/tong placement rates since 2000 and to study treatment variation based on hospital teaching status. We hypothesized that arthrodesis rates would vary between hospitals based on teaching status but that such variation would decrease over time.

Section snippets

Data Source

The Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) dataset was used.13 The dataset includes deidentifiable demographic information; International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis and procedural codes; and hospital characteristics from approximately 1000 hospitals in 46 participating states of the United States. NIS data from 2000 to 2011 were evaluated. The annual NIS volume ranged from 7 million to 8 million

Patient Population

From 2000 to 2011, 120,613 patients were identified with a cervical spine injury. The 5197 patients who were transferred to another hospital and 7978 who died during hospitalization were excluded from analysis.

Of the remaining 107,152 patients, 87,785 (81.9%) had cervical fracture without SCI, 10,645 (9.9%) had cervical fracture with SCI, and 10,549 (9.8%) had cervical dislocation. The mean ages of patients with cervical fracture without SCI, cervical fracture with SCI, and cervical dislocation

Discussion

This study revealed significant variation in treatment for cervical trauma patients based on hospital teaching status, with significantly increasing rates of arthrodesis for cervical dislocation and SCI patients. Conversely, there was a decrease in arthrodesis rates for patients without SCI, and a precipitous drop in the use of halo/tong placement for all cervical injury patterns regardless of teaching status or diagnosis.

Daniels et al.7 previously investigated the treatment of 28,518 cervical

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  • Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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