Race and insurance status may be significant predictors of mortality following cervical spondylotic myelopathy surgery

Shearwood McClelland III

Recent literature has associated posterior-only approaches to the treatment of cervical spondylotic myelopathy with increased mortality. According to a paper presented at the 2016 meeting of the International Society for the Advancement of Spinal Surgery (ISASS: 6-8 April, Las Vegas, USA), non-caucasian race and non-private medical insurance are independently predictive of receiving posterior-only approaches in the USA.

Commenting on the importance of the study, lead author, Shearwood McClelland III, told Spinal News International that, “This study is the first to examine the impact of patient demographics on the surgical approach to cervical spondylotic myelopathy; this is important because the morbidity and mortality of surgery differs markedly according to the surgical approach chosen.” The authors conclude, therefore, that non-caucasian race and non-private medical insurance may significantly increase the risk of mortality in the treatment of cervical spondylotic myelopathy.

Aiming to determine the effect of race and insurance status on the surgical approaches used for treatment, researchers used records from the US Nationwide Inpatient Sample (NIS) hospital discharge database from 2001 to 2010. The database contains resources on all discharges from a stratified random sample of hospitals across the USA. The database was searched using a number of diagnosis and treatment codes, to discover how different patients with cervical spondylosis with myelopathy had been treated. The researchers searched for treatment by anterior cervical discectomy, posterior only approaches, combined anterior and posterior approaches or decompression of the spinal canal, all including fusion/refusion at C2 or below. The NIS database also recorded demographic information, the source of admission and primary payer details.

Of the 220,736 adult admissions for cervical spondylotic myelopathy treated by surgery, a multivariate analysis revealed that those patient variables which increased the likelihood of treatment by anterior-only surgical treatment were female sex (OR=1.39; CI=1.34-1.43), private insurance (1.19; CI=1.14-1.25) and non-trauma centre admission type (OR=1.29-1.39; CI=1.16-1.56). Those factors reducing the chance of treatment by anterior approaches included no-charge insurance type (OR=0.48; CI=0.37-0.62), hispanic race (OR=0.64; CI=0.59-0.70) and black race (0.76; CI=0.72-0.80), as well as trauma centre admission type (OR=0.76; CI=0.72-0.80) and admission from court/law enforcement (OR=0.11; CI=0.04-0.32).

Non-caucasian races were shown to predict treatment by posterior-only approaches, including hispanic race (OR=1.51; CI=1.38-1.66), asian/pacific island race (OR=1.40; CI=1.15-1.70) and black race (OR=1.39; CI=1.32-1.47). Non-private insurance status, trauma centre admission type and admission from another hospital were among the other factors associated with an increased risk of treatment by posterior-only surgical approaches. A decreased chance of receiving this treatment was correspondingly found for variables including female sex (OR=1.39; CI=1.34-1.43), private insurance (OR=1.19; CI=1.14-1.25) and non-trauma centre admission type (OR=1.29-1.39; CI=1.16-1.56).

McClelland told Spinal News International that, “The main limitation of this study is its reliance on the Nationwide Inpatient Sample database, which comprises only US patients and does not include federal hospitals.”

Future research should be directed towards patient outcomes associated with these techniques, claims McClelland, who told Spinal News International that, “The implications of this study should spur future prospective investigations by surgeons. Patients should also be made aware of the different approaches, and should have a firm understanding during preoperative counselling as to the reason their surgeon recommends a particular operative approach for their condition.”