- Clinical Professor of Neurosurgery, The Albert Einstein College of Medicine, Bronx, N.Y. 10451, and Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, N.Y. 11501
Nancy E. Epstein
Clinical Professor of Neurosurgery, The Albert Einstein College of Medicine, Bronx, N.Y. 10451, and Chief of Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, N.Y. 11501
DOI:10.4103/2152-7806.98575Copyright: © 2012 Epstein NE. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Epstein NE. Iliac crest autograft versus alternative constructs for anterior cervical spine surgery: Pros, cons, and costs. Surg Neurol Int 17-Jul-2012;3:
How to cite this URL: Epstein NE. Iliac crest autograft versus alternative constructs for anterior cervical spine surgery: Pros, cons, and costs. Surg Neurol Int 17-Jul-2012;3:. Available from: http://sni.wpengine.com/surgicalint_articles/iliac-crest-autograft-versus-alternative-constructs-for-anterior-cervical-spine-surgery-pros-cons-and-costs/
Background:Grafting choices available for performing anterior cervical diskectomy/fusion (ACDF) procedures have become a major concern for spinal surgeons, and their institutions. The “gold standard”, iliac crest autograft, may still be the best and least expensive grafting option; it deserves to be reassessed along with the pros, cons, and costs for alternative grafts/spacers.
Methods:Although single or multilevel ACDF have utilized iliac crest autograft for decades, the implant industry now offers multiple alternative grafting and spacer devices; (allografts, cages, polyether-etherketone (PEEK) amongst others). While most studies have focused on fusion rates and clinical outcomes following ACDF, few have analyzed the “value-added” of these various constructs (e.g. safety/efficacy, risks/complications, costs).
Results:The majority of studies document 95%-100% fusion rates when iliac crest autograft is utilized to perform single level ACDF (X-ray or CT confirmed at 6-12 postoperative months). Although many allograft studies similarly quote 90%-100% fusion rates (X-ray alone confirmed at 6-12 postoperative months), a recent “post hoc analysis of data from a prospective multicenter trial” (Riew KD et. al., CSRS Abstract Dec. 2011; unpublished) revealed a much higher delayed fusion rate using allografts at one year 55.7%, 2 years 87%, and four years 92%.
Conclusion:Iliac crest autograft utilized for single or multilevel ACDF is associated with the highest fusion, lowest complication rates, and significantly lower costs compared with allograft, cages, PEEK, or other grafts. As spinal surgeons and institutions become more cost conscious, we will have to account for the “value added” of these increasingly expensive graft constructs.
Keywords: Allograft, cages, anterior cervical spine surgery, costs, efficacy, explantation, iliac crest autograft, polyether-etherketone, single-level diskectomy/fusion (1-level ACDF)
Grafting choices available for single level (1-level ACDF) or multilevel anterior cervical diskectomy/fusion (multilevel ACDF) procedures have been increasingly impacted by the manufacturing industry. The author reviews the pros, cons, and lower costs for utilizing iliac crest autograft, considered the “gold standard”, and compares this to alternative spacers and grafts (allograft, cages, PEEK (polyether-etherketone), and others).[
Previous to plating, 1-level anterior diskectomies were performed with or without fusion with varying levels of success. In 2007, Xie and Hurlbert evaluated the necessity for interbody fusion for patients with radiculopathy following 1-level ACD (anterior diskectomy).[
Also in 2007, Nandoe, Tewarie, Bartels et. al. evaluated the long-term outcomes for ACD and compared these with published data regarding long-term outcomes for those undergoing ACDF.[
In an additional 2007 study, Wright and Eisenstein evaluated 97 consecutive patients one year following ACDF performed at one or two levels utilizing iliac autograft (tricortical-Smith Robinson technique) without instrumentation; patients were immobilized in semi-rigid collars for two postoperative months.[
Again in 2007, Nabhan, Pape, Pitzen et. al. performed a randomized, controlled, prospective study, utilizing radiographic assessment (1, 6, and 12 weeks, 6 mos, 1 and 2 years postoperatively) of fusion following 1-level ACD fused with a stand-alone cage (19 patients) or with cage and plate fixation (18 patients).[
An additional 2007 study performed by Lind, Zoega, and Rosen, 24 patients with radiculopathy were randomized to undergo ACDF without plates utilizing either a fusion cage or autograft.[
Subsequently, in 2009, Konduru and Findlay reexamined the various studies regarding the relative efficacy of ACD or ACDF.[
Summary: Multiple studies involving ACD or ACDF performed without plates for 1-level anterior cervical disease, particularly addressing radiculopathy, have yielded comparable clinical outcomes. However, ACD were associated with higher rates of kyphosis, a complication avoided by ACDF.
High fusion rates, often ranging up to 100%, have been variously reported for 1-level ACDF utilizing different grafts (autogaft/allograft/cages/polyether-etherketone [PEEK]) and plate designs (constrained or fixed/semi-constrained/ dynamic plates) [
Constrained, Semi-constrained, and dynamic plates
The three major types of anterior cervical plates, constrained, semi-constrained, and dynamic, allow for differing degrees of motion that impact graft settling, graft shielding (prevention of compression on graft/vertebral interfaces), and ultimately, fusion.
Constrained (fixed) plates (e.g. Orion, Medtronic, Memphis, TN, USA), consist of a plate with screws firmly fixed to the plate so that there is no “toggle” or motion; this most severely limits or “constrains” graft settling, and provides the greatest degree of graft shielding, thus decreasing fusion rates. The semi-constrained plates (e.g. Atlantis, Medtronic, Memphis, TN, USA) consist of a plate with a screw that toggles 17 degrees cephalad/caudad: the “toggling” fosters some motion, thereby allowing for mild graft settling, while also mildly limiting stress shielding. Alternatively, dynamic plates (e.g. ABC, Aesculap, Tuttinglen, Germany) allow for the most motion, thereby maximizing graft settling and minimizing stress shielding. To attain “dynamization”, the ABC plate utilizes a slotted design which allows the screw heads to migrate (up to 10 mm in the largest plates) in both the cephalad (screws placed maximally superiorly and migrating inferiorly) and caudad (screw placed maximally inferiorly and migrating superiorly) directions.
Summary: There is increasing evidence that points to the superiority of dynamic plates over constrained and semi-constrained plates. As the screws are able to migrate within the slotted plate design, stress shielding is limited while graft compression is maximized.
1-LEVEL ANTERIOR CERVICAL DISKECTOMY WITHOUT FUSION; 1-LEVEL ANTERIOR CERVICAL DISCECTOMY WITH FUSION; 1-LEVEL ACDF WITH FUSION AND PLATING
In Fraser and Hartl's meta-analysis involving 21 papers with a minimum of 25 cases/paper, and 1-year follow-up, the overall fusion rate was 89.5% [2682 patients]: the fusion rate for 1-level anterior diskectomy without fusion (ACD) 84.9%, 1-level anterior diskectomy with fusion (ACDF) 92.1%, and plated 1-level ACDF was 97.1%.[
In Kaiser, Haid, Subach et al., series, for 1-level plated ACDF utilizing constrained Orion, semi-constrained Atlantis Plates (both Medtronic, Memphis, TN, USA), and constrained Codman Plates (Codman and Shurtless, Inc., Raynham, MA, USA)], the fusion rate utilizing cortical allograft (for both groups) was 96% compared with 90% fusion rates for non-plated 1-level ACDF.[
In Samartzis, Shen, Goldberg et al., series, patients underwent 1-level ACDF utilizing either allograft or autograft and constrained Orion plates (Medtronic, Memphis, TN, USA).[
Summary: Although plated 1-level ACDF correlated with higher fusion rates versus non-plated 1-ACDF, these differences were not significant: 96% vs. 90%. Nevertheless, one must consider the “value added” of the plates, which includes a reduction in the risk of anterior graft extrusion. Therefore, the evidence supports the ACDF as the procedure of choice with the added use of plates to prevent graft extrusion.
In Nunley, Jawahar, Kerr et al., prospective randomized study 1-level ACDF were performed in 28 patients while 2-3 level ADF were completed in 38 patients, 50% of patients received dynamic, and 50% received static/fixed plates.[
In Balabhdra, Kim and Zhang series of 1-level ACDF performed utilizing dense cancellous allograft and dynamic ABC plates (Aesculap, Tuttlingen, Germany), a 96% fusion rate was achieved in 66 patients.[
In 2011, Epstein cited 100% fusion rate for 60 patients undergoing 1-level ACDF utilizing iliac autograft and dynamic plates (ABC; Aesculap, Tuttlingen, Germany) [Figures
Three months following a single-level anterior diskectomy and fusion, the lateral X-ray shows an iliac autograft (single arrow) within the anterior 2/3 of the interspace. Note the clear lack of lucency between the cephalad and caudad graft/vertebral end plate junctions, but the difficulty directly visualizing bony trabeculation that is better defined on CT. Additionally, the dynamic ABC plate (Aesculap, Tuttlingen, Germany) is adequately placed, while the screws have migrated (curved arrows), approximately 2-3 mm both cephalad and caudad, in the slotted design of the plates
In another lateral radiograph obtained 3.5 months following a single-level anterior diskectomy and fusion, the posterior margin of the iliac crest autograft within the disc space (single large arrow) is visualized and the lack of lucency of the cephalad graft/vertebral body interface is noted. Here, the screws within the plate have migrated 3-4 mm inferiorly, while superiorly there has been only 2 mm of migration
The coronal 2D-CT scan, obtained 3 months following a single-level anterior diskectomy and fusion without plating, confirmed fusion. Observe the bony bridging and trabeculation crossing the disc space (large arrow), accompanied by the total lack of lucency at the cephalad and caudad graft/vertebral junctions
The sagittal 2D-CT scan obtained 6 months following a single-level anterior diskectomy and fusion readily demonstrates adequate placement of the graft within the anterior 2/3 of the disc space (double tipped arrow), accompanied by cephalad and caudad fusion (absence of lucency and presence of bony trabeculation: single arrows) of the graft/vertebral body interfaces
This sagittal 2D-CT study documents adequate placement of the graft (double tipped arrow) and fusion 3 months following a single-level anterior diskectomy and fusion. The 2D-CT readily confirms the absence of lucency and presence of bony trabeculation at the cephalad and caudad graft/vertebral end plates
Intraoperative photograph showings the anterior exposure for a single-level anterior diskectomy and fusion. A dynamic ABC plate (Aesculap, Tuttlingen, Germany) is seen, with the four screws in place (large curved arrow). Note that when applying these plates, the width of the central plate is typically that of the graft itself
In Epstein's study of 116 patients undergoing single level anterior corpectomy (e.g. corpectomy defined as for example, C5-C7 with removal of both the C5/C6 and C6/C7 disc and intervening vertebral body of C6) and fusion utilizing iliac autograft and dynamic plates, 3 developed plate/graft extrusion or pseudarthrosis.[
Summary: Evidence supports the use of Dynamic Plates for performing ACDF as they appear to increase fusion rates by decreasing graft shielding and increasing graft compression while also preventing graft extrusion.
Miller and Block evaluated results of four different ACDF constructs (allograft, autograft, a cage, and disc arthroplasty) obtained from 20 studies.[
Summary: The data do not clearly indicate that cages are superior to allograft or autograft fusions. Rather they appear to demonstrate that results are at least comparable. Further evaluation of these fusion rates utilizing CT and not just X-ray alone would likely indicate a higher failure rate for cages than has previously been reported. Furthermore, the quality of these studies and their ties to industry warrant further consideration.
In 2011, Riew, Heller, Sasso, et al., presented (Cervical Spine Research Society Abstract, Dec. 2011, Phoenix, AZ, unpublished) a post-hoc analysis of their data obtained from a prospective, randomized, multicenter study originally designed to compare cervical disc arthroplasty with 1-level ACDF (allograft/plates). Utilizing X-rays alone (AP, lateral, flexion/extension films reviewed by radiologists blinded to the study design at 6, 12, 24, and 48 months postoperatively), they discovered a much lower initial fusion rate, but a high delayed fusion rate for the single-level allograft/plated fusions than had previously been reported. The fusion rate at one year was only 55.7% while it increased to, 87% at 2 years, and 92.3% at 4 years. Their interpretation of these data was not that the value/safety/efficacy of these allograft constructs should be revisited, but rather, that if patients failed to fuse early (typically defined as within the first 6 postoperative months, otherwise they were deemed pseudarthroses), they would not necessarily require additional surgery as the majority would go on to eventually fuse. This meant that patients with pseudarthrosis did not require additional surgery, but rather would go on to spontaneously fuse without bracing or further treatment.
Summary: Recent evidence showed much lower 1-year fusion rates for allograft/plated 1-ACDF then had previously been reported. As a result of this low fusion rate the authors should have reevaluated their use of allograft for the l-level ACDF constructs.
Animal studies with cages
An in-vivo goat model was utilized by Sinclair, Konz, Dawson et al., to assess host-bone response and fusion rates for PEEK versus porous tantalum interbody cervical fusion devices both of which contained iliac crest autograft .[
In another goat model (caprine model), Cunningham, Sefter, Hu et al., looked at four different models for performing ACDF; autograft alone, autograft with a cage, autologous growth factors with a cage, or autograft and a plate .[
Good results were also achieved in Steffen, Voss, and Morgan's study of a canine model in which single-level intervertebral cages were applied with hollow centers containing autograft; the 9 dogs who survived 12 months exhibited early radiographic subsidence (defined as the penetration of the cages past the vertebral end plates), but uniform fusion.[
In a sheep model, Scholz, Schleicher, Eindorf, et al., evaluated cages “augmented with mineralized collagen matrix (MCM) and platelet-rich plasma as an osteoconductive/inductive construct” for ACDF by examining three groups: titanium cage with cancellous autograft, titanium cage with MCM, and titanium cage with MCM and platelet-rich plasma.[
Summary: In these animal studies, none of the other constructs was superior to autograft. Additionally, cages were not superior to other constructs.
Cages with autograft
Although some of the animal-based data were promising, the clinical fusion data utilizing tantalum cages and porous blocks for 1-level ACDF typically were not. Kepler and Rawlins authored one of the few studies citing success utilizing mesh cages with autologous cancellous bone graft (from the manubrium or iliac crest); they observed a 98.4% fusion rate.[
In Kasliwai, Baskin, and Traynelis study, 39 patients undergoing 1-level ACDF were divided into three treatment groups; 11 received autograft, 13 had porous tantalum ring devices with the central cavity packed with cancellous iliac crest autograft, and 15 received a porous tantalum block.[
Similarly, Song, Taghavi, Hsu et al., observed higher fusion rates for ACDF utilizing autograft compared with fusion cages which were associated with both lower and slower fusion rates. At 6 weeks, early fusion was observed between bone chips, at 3 months initial bridging between graft/host was documented, at 3-6 months anterior spur formation occurred, at 12 months “kissing” lesions were noted and finally, at 1-2 postoperative years, bony incorporation was documented .[
Summary: Clinically, cage constructs were associated with “both lower and slower fusion rates”. Furthermore the cages were associated with device fragmentation and erosion (pistoning) into the adjacent vertebrae (more severe than simply subsidence). Thus it appears that ACDF with a dynamic plate and autograft was superior to cages for anterior cervical fusion.
Outcomes of 1-level ACDF
Samartzis, Shen, Goldberg, et al., observed good/excellent outcomes in 91.3% of patients undergoing 1-level ACDF performed with plates (31 patients) or without plates (38 patients) (fixed/semi-constrained).[
Bhadra, Raman, Casey, et al., reported on the outcomes for 4 different 1-level ADF constructs: (1) fixed-plates and autograft, (2) fixed-plate, cage, and bone substitute, (3) cage alone, and (4) disc arthroplasty.[
In Epstein's study of 60 patients undergoing autograft/dynamic-plated 1-level ACDF, outcomes were measured utilizing Odom's Criteria, Nurick Grades, and the SF-36 outcomes questionnaire (obtained up to 24 months postoperatively).[
In Jacobs, Willems, Kruyt et al., when outcomes were compared across 33 studies involving 2267 patients undergoing one or two-level anterior diskectomy alone (ACD) or with fusion (ACDF): graft, cement, cage, and plates), there was “… little or no difference in pain relief between the techniques”.[
Summary: Comparable outcomes are largely being reported for 1-level ACDF utilizing a multitude of grafting (autograft, allograft, PEEK, cages) and plating techniques (constrained, semi-constrained, dynamic). Nevertheless, iliac crest autograft remains the “gold standard”, and in many instances, still produced the highest fusion rates.
Complications attributed to rhBMP-2 (Infuse: Medtronic, Memphis, TN, USA)
In Vaidya, Carp, Sethi et al., despite comparable long-term outcomes following 1-level ACDF performed utilizing rhBMP-2 (Infuse: Medtronic, Memphis, TN, USA), and PEEK cages (Polyether-etherketone (Depuy Spine, Raynham, MA, USA) in 22 patients versus allograft spacers/DBM (demineralized bone matrix) in 24 patients, the three fold greater cost and incidence of severe postoperative dysphagia (1-6 postoperative weeks) associated with rhBMP-2 and PEEK cages led the authors to choose only allograft in the future.[
Furthermore, Carragee, Hurwitz, and Weiner noted that there were “increasingly, reports of frequent and occasionally catastrophic complications associated with the use of recombinant human bone morphogenic protein (rhBMP-2) in spinal fusion surgeries”.[
Other complications of ACDF
The frequency of complications attributed to anterior cervical surgery vary. In Epstein's 2007 study involving graft/plate extrusions and pseudarthroses (dynamic X-ray/2D-CT confirmed) following 116 dynamic-plated single level anterior corpectomy (removal of single vertebral body, not just a one-level disc removal) and fusions, there were 2 major, and 3 minor complications.[
In Fehlings, Smith, Kopjar et al., comprehensive prospective, multicenter study, the risks and frequency of perioperative (within 30 days) and delayed (31 days to 2 years following surgery) complications attributed to spondylotic myelopathy (CSM) requiring 302 cervical operations (anterior only, posterior only, and combined 360-degree procedures) were evaluated.[
Summary: Complications of 1-level ACDF include neurological deficits, vertebral artery injury, cerebrospinal fluid fistula, graft or plate extrusion, pseudarthrosis, and infection.
Complications of iliac crest autograft: Typically overestimated
High complication rates (some approaching 90%) are often reported for autograft harvesting for anterior cervical surgery related to donor site morbidity.
In Konduru and Findaly's 2009 review of multiple “prospective randomized trials”, they noted that “if a fusion procedure is undertaken, the use of interbody spacers does have the advantage of avoiding donor site complications” which included pain amongst other factors.[
In Dimitriou, Mataliotakis, Angoules et al., the overall complication rate of 19.37% was cited for harvesting iliac crest bone graft (1249 complications in 6449 patients), and included infection, hematoma, fracture, and hypertrophic scar.[
Nevertheless, some studies cite a much lower morbidity rate for autograft harvesting, while others question whether “industrial bias” impacts the reporting of high donor site morbidity. When Wright and Eisenstein reviewed the results of ACDF utilizing iliac crest autograft, 51 at 1-level, and 43 at 2-levels, they noted that “only 2 of the 97 patients had pain related to the donor site”.[
In 2011, when Carragee, Hurwitz and Weiner reported on the “… frequent and occasionally catastrophic complications associated with use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in spinal fusion surgeries”, they also noted that, “the reported morbidity of iliac crest donor site pain was found to have serious potential design bias”.[
Summary: Carraggee et. al. have questioned whether “bias” introduced by industry contributed to the over reporting of morbidity associated with iliac crest autograft harvesting.
Changing frequency of 1-level ACDF in the USA
Single-level anterior cervical diskectomy and fusion (1-level ACDF) is one of the most frequently performed cervical operations in the United States.[
More surgeons, more operations, more variations: Where are the data to prove the “Value Added”
In 2012, McGuire, Harrast, Herkowitz et al., studied the geographic variation for cervical surgery.[
Summary: There are more 1-ACDF being performed by more surgeons in the USA. Furthermore, the marked differences in the frequencies of these procedures depend in part upon where you live.
Cost comparisons of various approaches to 1-Level ACDF
Although most 1-level ACDF studies focus on outcomes and fusion rates, few compare costs of less expensive and more expensive combinations of spacers, plates/instruments, and supplies. The “value-added” of different plates (constrained, semi-constrained, dynamic), spacers (autograft, allograft, cages (wire mesh), and polyether-etherketone [PEEK], among others), and bone graft supplements, bone morphogenetic protein [BMP], demineralized bone matrix [DBM], and beta tri-calcium phosphate [B-TCP]) is typically not explored.
One study documented comparable costs for 3 different spacers/constructs for 1-level ACDF; (1) plate/cage/bone substitute, (2) cage alone, and (3) disc arthroplasty.[
In a second study, the costs/effectiveness of autograft spacer/cervical spine locking plates [CSLP; Synthes-North America, West Chester, PA, USA] in 26 patients versus the Syncage C [Titanium Box, Synthes, Paoli, PA, USA] filled with autograft cancellous bone in 27 patients were compared.[
A third study utilized cage/mesh/autograft cancellous bone/plate in 27 patients versus iliac autograft spacer/plate in 27 patients, determining that surgical costs were comparable.[
In a fourth study, Epstein's series of 60 patients undergoing 1-ACDF utilizing iliac autograft with plates, the autograft construct cost $0.00 when compared to allograft (up to $2,552/graft), or to cages (range up to $7,928), and simply incurred an additional 45 minutes of operative time (total average 3.4 hours) for the grafting procedure, and average additional LOS.[
Summary: Iliac autograft, utilized to perform 1-level ACDF costs $0.00, while other spacers like allograft may cost (without overhead; what the hospital actually pays) up to $2,552 for grafts, with cages costing up to $7,928. Nevertheless, the different constructs have other pros and cons, and in many instances, actual hospital costs may equalize as long as BMP/INFUSE is not utilized.
Cost benefit using more complex approaches
Cost-benefit analyses were performed in two other studies that compared the least expensive (e.g. autograft spacer) versus the more expensive (e.g. allograft spacer/BMP, PEEK/rhBMP-2, allograft spacer/DBM) instruments and supplies for performing 1-3 level ADF.[
Summary: It appears that utilization of PEEK with BMP have a higher cost and complication rate. In Carragge et. al. study, they reported a 40% incidence of complications following the use of rhBMP-2 /Infuse for anterior cervical surgery, resulting in postoperative neck swelling, seroma, and hematoma.[
Thus, it appears that ACDF using dynamic plates and autografts are the most cost effective treatment for anterior cervical discectomy. Where feasible, Scoville's posterior laminotomy approach to lateral cervical discs should be considered a viable alternative as this avoids the multiple unique risks of anterior cervical surgery, and criticallly, the necessity for simultaneous fusion.
1-level ACDF performed at a single institution
In a 2008 study involving 102 single-level ACDF performed at a single institution, Epstein et al., analyzed the variations in surgical/hospital costs and the extent to which surgeons choices affected these costs [
Total Costs associated with individual patients ranged widely from a minimum of $21,626 to a maximum of $97,086 (difference of $75,460: factor of 4.8) [
The decision or choices [e.g. instrumentation] made by surgeons directly impacted the Surgical Costs.[
Fifteen spinal surgeons performed all 102 cases in this series.[
Summary Surgeons choices and the choice of surgeons impact the Total Hospital Costs. They influence In-patient Costs as their individual postoperative results utilize different amounts of hospital materials (e.g. studies, tests), and longer lengths of stay. The Surgical Costs, on the other hand, are largely influenced by the individual surgeon's choice of implants; we unfortunately do not yet know the “value added” of these more expensive alternatives.
In a series analyzing patients undergoing elective major colorectal surgery, few patients required perioperative transfusions; therefore, the authors stopped requesting routine preoperative cross matching of blood.[
Summary: Operative waste or explantation, defined as the implantation of a device, its alteration, and removal prior to closing, is an extremely underreported problem. Although there should be a reasonable/anticipated “cost of doing business”, it likely should not exceed 5%.
Costs of permanently implanted versus explanted devices following 1-ACDF
Little is known about the costs of permanently implanted devices utilized to perform 1-ACDF while even less has been documented about the costs of explanted devices, defined as those devices that are initially implanted but are removed and discarded prior to wound closure (altered, bent, screwed in, or otherwise changed so that they must be discarded).[
Six surgeons performed 76 (87.3%) of 87 cases in this series (7-25 cases each), and all surgeons explanted devices in 12.5% to 46.2% of their cases. The 5 remaining surgeons who performed 4 or fewer operations per surgeon also demonstrated high explantation rates.[
Summary: Explantation, the implantation (alteration so it cannot be used again) but removal of instrumentation prior to closing, occurs during spinal surgery; but at what cost? In 2009, the total costs of explantation added to the total budget for all implanted devices utilized to perform 87 1-ACDF; this substantial operative waste must be curtailed.
Education measures to reduce explantation for Single-level ADF
Determining in 2009, that explantation of instrumentation substantially added to the costs of performing 1-ACDF, Epstein et al., prospectively evaluated the costs/frequency of explanting instrumentation in 1-ACDF in 2010 at the same single institution before and after surgeon-education.[
Summary: At one institution in 2010, educating surgeons (two meetings) regarding the need to avoid explanting devices utilized for 1-level ACDF surgery, substantially reduced the cost of explanted devices from 20.0% to 5.8%
More spinal surgeons and greater interest from industry in promoting spinal instrumentation has led to an over-use of many spinal implants [
Furthermore, little attention has been paid to the “value added” of these constructs, much less their costs. However, with the escalating cost of medical care, spine surgeons in the future must participate in correlating fusion rates and outcomes with relative costs of different instrumentation systems utilized to perform 1-ACDF [
Opportunities for cost saving should also extend to minimizing the rate of explantation, the placement, adjustment (no longer reusable), and removal of a device, prior to closure. Should there be an acceptable explantation rate for spinal procedures allocated to the cost of doing business? Although the spine literature has not readily addressed this issue, a hypothetical 5%-10% explantation rate for spinal procedures may be appropriate. Establishing an acceptable rate alone could substantially reduce the present added costs of “explantation” incurred during anterior cervical surgery as discussed in this series.
Furthermore, the costs and frequency of explantation involving 1-ACDF may represent only the “tip of the iceberg” as it is likely that much higher costs will be identified for more extensive spinal procedures. These findings should encourage more institutions to develop and institute “surgeon-education” and “enhanced practices” to reduce the costs/frequency of such explantation during all spine operations.
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