Clinicians have used ERAS protocols in various specialties since 1997 but implementation in neurosurgery is behind.
After undergoing surgery for a ruptured disk, Golden State Warriors’ coach Steve Kerr publicly discouraged others from getting back surgery. That’s because even after the surgery, Kerr continued to experience pain, including debilitating headaches, dizziness, and pain behind his eyes.
Kerr suffered from an incidental durotomy during his spine surgery, causing the cerebrospinal fluid (CSF) around his spine to leak. How frequent incidental durotomies is a source of debate. Rates recorded in hospital administrative databases are speculated to be widely underreported while a series of studies have found incidence rates as low as 2% to upwards of 20%. In one study of 318 pediatric patients, there was an overall incidence rate of 1.9%, while 18.5% of revision operations resulted in an incidental durotomy.
While there’s no consensus on the incidence rate, it’s clear that incidental durotomies have significant impact on patient outcomes and healthcare costs when they do occur.
A 2020 study published in Spine compared the risk complications of patients with dural tears to those without as well as rates of systemic complications. Researchers found that the 10,646 patients who had incurred a dural tear during lumbar decompression and/or lumbar fusion surgery were significantly more likely to experience a 90-day postoperative complication, including venothromboembolic (VTE) events, deep venous thrombosis and pulmonary embolism.
Dural tear patients were also 6 times more likely to develop meningitis; 2.2 to 2.6 times more likely to develop wound complications, infections, and pressure sores; and twice as likely to develop a hematoma as well as respiratory, and gastrointestinal complications than patients without a dural tear.
What’s more, patients with a dural tear had a 200% greater length of hospital stay than patients without a dural tear and were twice as likely to be readmitted.
A 2015 study published in Spine found similar results. Researchers noted that the 802 lumbar spinal stenosis patients who had incurred incidental durotomies during their surgeries had significantly greater odds of experiencing additional complications – especially involving the respiratory and nervous system – than the 16,430 patients who did not incur a durotomy during surgery.
Costs of Care
As the rate of complications increase, so does cost of care. In fact, average in-hospital costs of patients with an incidental durotomy were found to be over $10,388, compared to only around $6,240 for those without a durotomy, resulting in a 66% increase in costs, or over $4,000, according to a 2017 Spine study.
Similarly, the 2020 Spine study found that patients with dural tears had medical costs 120% greater than those without. These patients had an average 90-day total cost that was $10,092 higher than those without dural tears.
In concurrence with these results, a study by Nandyala et al in Spine queried data from the Nationwide Inpatient Sample from 2008 to 2011 and noted that patients who had incurred an incidental durotomy during a cervical spine procedure had an additional average total hospital cost of $10,798 and an average additional length of stay of nearly two days.
Interestingly, however, these numbers were found to be much lower among lumbar spine patients. Patients with a durotomy resulting from a lumbar spine procedure incurred additional total hospital costs of $1,913 and an additional length of stay of only 1.3 days. Adjusting for individual patient demographics, comorbidities and hospital-specific variables, lumbar spine patients had an average additional cost of $2,412, compared to $7,638 for the cervical spine patients.
Lastly, in their study titled “The Economic Implications of an Incidental Durotomy,” researchers noted that patients who incurred an incidental durotomy during their surgery had an increase in hospital charges of 17.82%, or $13,720.
These charges were believed to have been split nearly evenly among charges that occurred during surgery and charges from the postoperative period, with the average increase in operating room charges amounting to $7,280.
However, researchers found no significant increase in surgeon-based charges for the durotomy group, or for any increase in hospital-based charges the first-year post-surgery. While there was also no evidence for any increase in hospital-based incremental charges between discharge and day 30, discharge and day 90 and discharge and one year, there was found to be a significant increase in the total hospital charges during these increments, and these charges resulted solely from the increase in charges at the initial hospitalization. The most significant of these charges occurred between the initial hospitalization and 30 days post-surgery, with the difference between the dural tear and no dural tear group being around $12,270.