Trends in cervical disc arthroplasty and revisions in the Medicare database

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1 Originl Study Trends in cervicl disc rthroplsty nd revisions in the Medicre dtbse Timothy R. Niedzielk 1, Bijn J. Ameri 1, Blze Emerson 1, Rushbh M. Vkhri 2, Mrtin W. Roche 2, John P. Mlloy IV 3 1 Deprtment of Orthopedic Surgery, Browrd Helth Medicl Center, Ft. Luderdle, FL, USA; 2 Orthopedic Reserch Institute, Holy Cross Hospitl, Ft. Luderdle, FL, USA; 3 Est Cost Orthopedics, Pompno, FL, USA Contributions: (I) Conception nd design: All uthors; (II) Administrtive support: All uthors; (III) Provision of study mterils or ptients: All uthors; (IV) Collection nd ssembly of dt: All uthors; (V) Dt nlysis nd interprettion: All uthors; (VI) Mnuscript writing: All uthors; (VII) Finl pprovl of mnuscript: All uthors. Correspondence to: Rushbh M. Vkhri, MD. Orthopedic Reserch Institute, Holy Cross Hospitl, 5597 North Dixie Highwy, Ft. Luderdle, FL 33308, USA. Emil: Rush.Vkhri@Gmil.com. Bckground: Due to incresed postopertive complictions with nterior cervicl discectomy nd fusion (ACDF), there hs been n incresing interest in the use of cervicl disc rthroplsty (CDA). Advncements in prosthetic designs nd techniques hve improved ptient reported outcome mesurements nd minimized revision rtes. There is pucity in the literture regrding recent trends in CDA utiliztion nd revision rtes. The purpose of this study ws to determine nnul primry nd revision CDA trends with the use of n dministrtive dtbse. Methods: A retrospective review from ws performed using the Medicre Stndrd Anlyticl Files from the PerlDiver supercomputer (PerlDiver Technologies, Fort Wyne, IN, USA). Ptients who underwent primry CDA were queried using Interntionl Clssifiction of Disese, ninth revision (ICD-9) nd current procedurl terminology (CPT) code nd 22856, respectively. Revision CDAs were queried using ICD-9 procedure code Primry outcomes of this study included nnul primry procedures, nnul revision incidence (RI), nd dditionl demogrphic dt such s ge, gender, geogrphic loction, Chrlson-Comorbidity Index (CCI); in ddition to length of sty (LOS), cost, nd reimbursement. Results: The query returned 2,016 nd 517 primry CDA nd revision CDA procedures were performed in the Medicre dtbse, respectively. The dt showed tht the CAGR of primry nd revision CDA procedures to be 20.54% nd 5.84% (P<0.001), respectively. RI nd RB demonstrted CAGR of 12.22% nd 9.61%, respectively. Ptients younger thn the ge of 65 represented the mjority of the ptients undergoing this procedure. Demogrphiclly, primry nd revision CDAs were found highest in the South. Conclusions: The dt demonstrtes high rte of nnul growth in CDA utiliztion (20.54%) nd revision CDA (5.84%), indicting there is n increse demnd for CDA in the United Sttes. Compred to ACDF, ptients who undergo CDA hve improved ptient reported outcome mesurements nd lower rtes of postopertive complictions. Keywords: Cervicl disc rthroplsty (CDA); Medicre; trends; revision Submitted Aug 20, Accepted for publiction Aug 30, doi: /jss View this rticle t: Introduction Anterior cervicl discectomy nd fusion (ACDF) ws first introduced by Clowrd in 1959 nd hs been considered the gold stndrd for ptients suffering from cervicl rdiculopthy or myelopthy (1). Lied et l. found tht ACDF ws lso n effective procedure in lleviting pin in ptients suffering from cervicl degenertive disc disese

2 Journl of Spine Surgery, Vol 4, No 3 September (DDD) (2). Despite ll the benefits, ptients undergoing primry ACDF hve been shown to be susceptible to complictions such s hypermobility, pseudrthrosis, dysphgi, nd djcent segment degenertion (ASD) (3). These complictions long with the gol of restoring the motion segment hve led to severl new constructs nd technologies. Cervicl disc rthroplsty (CDA) hs emerged s n option for mitigting these postopertive complictions nd s solution for preserving the motion segment without dding stress onto djcent segments (4-6). CDA ccomplishes these gols by mintining disc spce height nd by preserving nturl physiologicl forces nd motion (7-9). In 2-yer follow up study by Skovrlj et l., ptients who underwent primry CDA hd men rte of reopertion of 1.0%, revision rte of 0.2%, nd removl rte of 1.2% (10). Initilly, one of the CDA implnts ws indicted for use in selective ptient popultions, specificlly ges (11). This study found better improvements in neck disbility index (NDI) nd visul nlogue scle (VAS) scores for ptients treted with CDA when compred to ACDF (11). The purpose of this study ws to determine the trends in CDA utiliztion, the rtes of CDA revision, nd demogrphic considertions in CDA nd revision CDA such s ge nd gender. Methods A retrospective review from ws performed using the Medicre Stndrd Anlyticl Files from the PerlDiver supercomputer (Perl Diver Technologies, Fort Wyne, IN, USA). PerlDiver is commercilly vilble dtbse which hs been used extensively for orthopedicrelted reserch. The dtbse is complint with the Helth Informtion Portbility nd Affordbility Act (HIPAA) nd contins the records of over 100 million ptients. Informtion such s dignosis, procedures, complictions, length of sty (LOS), chrges, nd reimbursements re vilble, in ddition to other informtion. Ptients were queried using the Interntionl Clssifiction of Disese, ninth revision (ICD-9) nd current terminology procedurl (CPT) codes. All ptients, in the dtbse, who underwent primry CDA were queried using ICD-9 procedurl codes nd CPT code Ptients who underwent revision CDA were queried using ICD-9 procedure code Following the methods by Lw et l., the primry outcomes of this study were nnul utiliztion of CDA, nnul revision incidence (RI), nd the burden of revision rtes on the helthcre system (12). Revision burden (RB) ws defined s the rtio of revisions to the sum of revision nd primry procedures of CDA (12). Furthermore, ge, gender, geogrphicl loction, Chrlson-Comorbidity Index (CCI) nd verge LOS were lso exmined in the study. Lstly, verge dy of surgery costs nd reimbursements were lso nlyzed nd compred between the different ge cohorts. Sttisticl nlysis ws performed using the progrmming lnguge R (University of Aucklnd, New Zelnd), with dt being primrily descriptive in ddition to clculting the compound nnul growth rte (CAGR) of primry nd revision CDA procedures. Results Between , totl of 2,016 nd 517 primry CDA nd revision CDA procedures were performed in the Medicre dtbse, respectively. The dt showed tht the CAGR of primry nd revision CDA procedures to be 20.54% nd 5.84% (P<0.001), respectively. RI nd RB demonstrted CAGR of 12.22% nd 9.61%, respectively (Tble 1) (Figure 1). Ptients younger thn the ge of 65, comprised mjority of the ptients undergoing primry (n=1,190; 57.64%) nd revision CDA (n=269; 52.33%) procedures, respectively; however, rtes of primry CDA decresed s ptients ged (Figure 2) (Tble 2). Averge CCI nd LOS incresed with incresing ge of ptients (Tble 3). Femles represented mjority of the gender undergoing primry (54.76%) nd revision (51.25%) CDA procedures (Tble 4). Primry CDA ws most commonly performed in the South (42.21%), followed by the West (21.73%), Midwest (19.99%), nd Northest (15.92%); wheres revision rtes for CDA showed tht ptients in the South (54.16%) hd the highest incidence followed by Northest (15.86%), Midwest (15.67%), nd the West (14.31%) (Tble 5). Cost dt showed correltion with ge with ptients under the ge of 65 incurring totl cost of $63, compred to ptients older thn the ge of 85 incurring totl cost of $102, Averge dy of surgery reimbursements in ptients younger thn 65 ws $12, compred to ptients over the ge of 85 who incurred n verge reimbursement of $18, (Figure 3). Discussion CDA is reltively new procedure with lndmrk ppers on CDA listing hernited nucleus pulposus (HNP),

3 524 Niedzielk et l. CDA trends Tble 1 Annul trends in cervicl disc rthroplsty (CDA) vs. revision CDA in the Medicre popultion from Yers Primry CDA Revision CDA Revision incidence (%) Revision burden (%) Totl 2, CAGR 20.54% 5.84% Primry CDA Revision CDA Figure 1 Annul trends of primry cervicl disc rthroplsty (CDA) utiliztion nd revision CDA within the Medicre dtbse from rdiculopthy/myelopthy, spondylosis, nd loss of disc height s the min indictions for use of the implnt (13-15). The purpose of this study ws to exmine the trends in CDA utiliztion nd revision rtes by nlyzing comprehensive Medicre dtbse between The study illustrtes tht CDA utiliztion hs been incresing through the exmined study period, wheres RI hs decresed. For yers, ACDF hs been the gold stndrd in tretment for symptomtic cervicl disese (16). However, the process of fusion hs been shown to impct cervicl rnge of motion (ROM) in ptients (17,18). Wu et l. found tht ptients who underwent primry ACDF hd sttisticlly significnt reduced ROM postopertively compred to preopertive mesurements (18). Compred to ACDF, the literture hs shown tht ptients undergoing CDA hve either mintined or hd improved ROM. In 5-yer prospective study performed by Ryu et l., ptients who underwent single level CDA plcement hd slight increse of 2º in erly postopertive ROM t the

4 Journl of Spine Surgery, Vol 4, No 3 September < >85 Figure 2 Annul trends of primry cervicl disc rthroplsty utiliztion by ge in the Medicre popultion from Tble 2 Primry revision cervicl disc rthroplsty by gender in the Medicre popultion Age Primry CDA Revision CDA Unknown <65 1, >85 16, unvilble dt. CDA, cervicl disc rthroplsty. superior djcent level (16). This incresed ROM ws constnt t 5-yer postopertively (16). In nother 2-yer prospective rndomized multicenter clinicl tril, cervicl ROM ws compred to ptients undergoing either CDA or ACDF. The 24-month outcome results illustrted tht ptients undergoing primry CDA hd mintined their originl ROM, wheres this ws reduced in the ACDF group. No significnt difference ws noted between the groups on their NDI score or VAS scores for pin. Furthermore, one ptient in the CDA group required revision procedure, compred to four ptients in the ACDF group. The trend towrds low reopertion rtes of ptients undergoing primry CDA found in this study is consistent with the findings in the literture. Skovrlj et l. reported tht the rtes of surgicl interventions following primry CDA re low (men, 2.4%; rnge, 0 4.1%) nd these reopertions were minly ttributed to poor ptient selection nd surgicl technique (10). In ddition to minimizing postopertive complictions, dvncements in CDA hve led to improved postopertive outcomes nd should be considered s n intervention for ptients with cervicl DDD. Jwhr et l. found tht ptients bove the ge of 50 undergoing CDA hd greter overll success, higher VAS scores nd NDI scores when compred to ACDF (19). A met-nlysis performed by Xie et l. in compring the sfety nd efficcy of CDA to ACDF in treting DDD found significnt differences between these procedures in terms of neurologicl success, rnge of motion, VAS scores of the neck nd rm, rtes of dverse events, nd reopertions (4). This would help to explin the incresing populrity of CDA use in the study with the disproportionte increse in revisions, potentilly showing improved survivorship. Our dt lso demonstrtes tht CDA use in older ptients is lso incresing. Annul use hs incresed t n verge rte of 17.97% in the ge brcket, 4.60% in the ge brcket, nd 7.44% in the ge brcket. These findings suggest tht surgeon comfort with performing CDA in the elderly popultion continues to rise s well. The results of this study re consistent with tht of Lu et l. who found tht from , the number of primry CDA procedures performed incresed by 11.8% utilizing the Ntionwide Inptient Smple (NIS) dtbse (20). The study is not without limittions. Being dtbse nlysis study, the vlidity of the study nd results re

5 526 Niedzielk et l. CDA trends Tble 3 Chrlson-Comorbidity Index (CCI) nd length of sty of ptients by ge in the Medicre popultion undergoing primry cervicl disc rthroplsty Vrible Age brekdown Unknown < >84 CCI ± SD 1.56± ± ± ± ± ±2 6.75±2.1 LOS ± SD 3± ± ± ± ± ± ±5.34 SD, stndrd devition; LOS, length of sty. Tble 4 Primry vs. revision cervicl disc rthroplsty by gender in the Medicre popultion Gender Primry CDA (%) Revision CDA (%) Femle 1,104 (54.76) 265 (51.25) Mle 900 (44.64) 248 (47.96) Tble 5 Primry vs. revision cervicl disc rthroplsty by region in the Medicre popultion Region Primry CDA (%) Revision CDA (%) Midwest 403 (19.99) 81 (15.67) Northest 321 (15.92) 82 (15.86) Unknown, unvilble dt. CDA, cervicl disc rthroplsty. South 851 (42.21) 280 (54.16) West 438 (21.73) 74 (14.31) CDA, cervicl disc rthroplsty. $125, $105, $102, $85, $89, $96, $65, $63, $68, $73, $45, $25, $5, $21, $20, $18, $12, $12, $14, < >85 Cost Reimbursement Figure 3 Dy of surgery cost nd reimbursements for ptients undergoing primry cervicl disc rthroplsty within the Medicre dtbse. relint on the ccurcy of procedurl coding within the dtbse (21). This trnsltes to the fct tht miscoding nd noncoding by providers is potentil source of error. It is estimted tht 1.3% of coding errors re currently present within the Medicre popultion (21). Secondly, the study utilized only single insurer s dt in the nlysis, nd my not represent true cross sectionl representtion of the number of ptients undergoing primry nd revision CDA in the United Sttes (22). Additionlly, comorbidities such s dibetes nd smoking were not strtified s vribles tht could potentilly impct the incidence of CDA revision rtes (11). Lstly, selection bis my lso be present s ptients in the study my enter or exit the dtbse s nturl mnifesttion (22). Conclusions The study illustrtes the incresing nnul growth of CDA utiliztion within the Medicre dtbse, indicting tht there is n incresed ptient demnd for nd/or surgeon

6 Journl of Spine Surgery, Vol 4, No 3 September comfort with CDA in the United Sttes. This my be ttributble to the decresed postopertive complictions seen in ptients undergoing primry CDA compred to those undergoing ACDF, nd improved clinicl outcome mesurements. The study illustrtes recent trends in CDA utiliztion nd increses the wreness of the procedure. Further prospective studies re wrrnted on determining the efficcy of this incresingly populr procedure. Acknowledgements None. Footnote Conflicts of Interest: The uthors hve no conflicts of interest to declre. Ethicl Sttement: Due to the retrospective nture of the study, i.e., vi HIPAA complint dtbse without ptient identifiers no Institutionl Review Bord (IRB) pprovl ws needed. References 1. Founts KN, Kpslki EZ, Nikolkkos LG, et l. Anterior cervicl discectomy nd fusion ssocited complictions. Spine (Phil P 1976) 2007;32: Lied B, Roenning PA, Sundseth J, et l. Anterior cervicl discectomy with fusion in ptients with cervicl disc degenertion: prospective outcome study of 258 ptients (181 fused with utologous bone grft nd 77 fused with PEEK cge). BMC Surg 2010;10: Yue WM, Brodner W, Highlnd TR. Long-term results fter nterior cervicl discectomy nd fusion with llogrft nd plting: 5- to 11-yer rdiologic nd clinicl followup study. Spine (Phil P 1976) 2005;30: Xie L, Liu M, Ding F, et l. Cervicl disc rthroplsty (CDA) versus nterior cervicl discectomy nd fusion (ACDF) in symptomtic cervicl degenertive disc diseses (CDDDs): n updted met-nlysis of prospective rndomized controlled trils (RCTs). Springerplus 2016;5: Zhng J, Meng F, Ding Y, et l. Hybrid Surgery Versus Anterior Cervicl Discectomy nd Fusion in Multilevel Cervicl Disc Diseses: A Met-Anlysis. Medicine (Bltimore) 2016;95:e Zhong ZM, Li M, Hn ZM, et l. Does cervicl disc rthroplsty hve lower incidence of dysphgi thn nterior cervicl discectomy nd fusion? A met-nlysis. Clin Neurol Neurosurg 2016;146: Burkus JK, Hid RW, Trynelis VC, et l. Longterm clinicl nd rdiogrphic outcomes of cervicl disc replcement with the Prestige disc: results from prospective rndomized controlled clinicl tril. J Neurosurg Spine 2010;13: Prk JB, Wtthnphisit T, Riew KD. Timing of development of djcent-level ossifiction fter nterior cervicl rthrodesis with pltes. Spine J 2007;7: Yng JY, Song HS, Lee M, et l. Adjcent level ossifiction development fter nterior cervicl fusion without plte fixtion. Spine (Phil P 1976) 2009;34: Skovrlj B, Lee DH, Cridi JM, et l. Reopertions Following Cervicl Disc Replcement. Asin Spine J 2015;9: Vccro A, Beutler W, Peppelmn W, et l. Clinicl outcomes with selectively constrined SECURE-C cervicl disc rthroplsty: two-yer results from prospective, rndomized, controlled, multicenter investigtionl device exemption study. Spine (Phil P 1976) 2013;38: Lw TY, Sbeh KG, Ross S, et l. Trends in totl nkle rthroplsty nd revisions in the Medicre dtbse. Ann Trnsl Med 2018;6: Leven D, Meike J, Rdcliff K, et l. Cervicl disc replcement surgery: indictions, technique, nd technicl perls. Curr Rev Musculoskelet Med 2017;10: Vieweg U, Grochull F. editors. Mnul of Spine Surgery. Berlin Heidelberg: Springer, Murtgh R, Cstellvi AE. Motion preservtion surgery in the spine. Neuroimging Clin N Am 2014;24: Pisno A, Helgeson M. Cervicl disc replcement surgery: biomechnicl properties, postopertive motion, nd postopertive ctivity levels. Curr Rev Musculoskelet Med 2017;10: Kiser MG, Hid RW Jr, Subch BR, et l. Anterior cervicl plting enhnces rthrodesis fter discectomy nd fusion with corticl llogrft. Neurosurgery 2002;50:229-36; discussion Wu XD, Wng XW, Yun W, et l. The effect of multilevel nterior cervicl fusion on neck motion. Eur Spine J 2012;21: Jwhr A, Nunley P. Totl disc rthroplsty nd nterior cervicl discectomy nd fusion in cervicl spine: competitive or complimentry? Review of the literture. Globl Spine J 2012;2: Lu Y, McAnny SJ, Hecht AC, et l. Utiliztion trends

7 528 Niedzielk et l. CDA trends of cervicl rtificil disc replcement fter FDA pprovl compred with nterior cervicl fusion: doption of new technology. Spine (Phil P 1976) 2014;39: Cncienne JM, Dempsey IJ, Holzgrefe RE, et l. Is Heptitis C Infection Associted With Higher Risk of Complictions After Totl Shoulder Arthroplsty? Clin Orthop Relt Res 2016;474: Burrus MT, Werner BC, Cncienne JM, et l. Shoulder rthroplsty in ptients with Prkinson's disese is ssocited with incresed complictions. J Shoulder Elbow Surg 2015;24: Cite this rticle s: Niedzielk TR, Ameri BJ, Emerson B, Vkhri RM, Roche MW, Mlloy JP 4th. Trends in cervicl disc rthroplsty nd revisions in the Medicre dtbse. J Spine Surg 2018;4(3): doi: /jss