129 - Impact of Race and Insurance Status on Surgical Approach for Cervical...

General Session: Cervical-1

Presented by: S. McClelland III - View Audio/Video Presentation (Members Only)


S. McClelland III(1), B.J. Marascalchi(2), P.G. Passius(1), T.S. Protopsaltis(1), A.K. Frempong-Boadu(3), T.J. Errico(1)

(1) New York University, Division of Spine Surgery, Hospital for Joint Diseases, New York, NY, United States
(2) Johns Hopkins Hospital, Anesthesiology, Baltimore, MD, United States
(3) New York University, Neurosurgery, New York, NY, United States


Introduction: Cervical spondylotic myelopathy (CSM) is one of the most common spinal disorders treated by spine surgeons, with operative management consisting of three approaches: anterior-only, posterior-only, or combined anterior-posterior. It is unknown whether the operative approach used differs based on patient demographics and/or insurance status. To address this issue, factors potentially impacting the operative approach chosen were assessed in CSM patients on a nationwide level.

Methods: The Nationwide Inpatient Sample from 2001-2010 was used for analysis. Admissions having a diagnosis code of 721.1 and a primary procedure code of 81.02/81.03 (anterior cervical discectomy and fusion/refusion at C2 or below), 81.32/81.33 (posterior only fusion/refusion at C2 or below), 81.02/81.03 or 81.32/81.33 (combined anterior and posterior fusion/refusion at C2 or below), and 3.09 (decompression of the spinal canal including laminoplasty) were included. Analysis was adjusted for several variables including patient age, race, sex, primary payer for care, and admission source/type.

Results: Multivariate analyses revealed that non-Caucasian race [Black (OR=1.39; 95%CI=1.32-1.47; p< 0.0001), Hispanic (OR=1.51; 95%CI=1.38-1.66; p< 0.0001), Asian/Pacific Islander (OR=1.40; 95%CI=1.15-1.70; p=0.0007), Native American (OR=1.33; 95%CI=1.02-1.73; p=0.037)] and increasing age (OR=1.03; p< 0.0001) were predictive of receiving posterior-only approaches. Female sex (OR=1.39; 95%CI=1.34-1.43; p< 0.0001), private insurance (OR=1.19; 95%CI=1.14-1.25; p< 0.0001), and non-trauma center admission type (OR=1.29-1.39; 95%CI=1.16-1.56; p< 0.0001) were independently predictive of increased likelihood of receiving an anterior-only approach. Hispanic race (OR=1.35; 95% CI=1.14-1.59; p=0.0004) and admission source [another hospital (OR=1.65; 95% CI=1.20-2.27; p=0.0023), other health facility (OR=1.68; 95% CI=1.13-2.51; p=0.011)] were the only variables predictive of increased combined anterior-posterior approaches, with Native American race (OR=0.32; 95% CI=0.13-0.78; p=0.013) decreasing the likelihood of a combined anterior-posterior approach. Neither insurance status, sex, or admission type were predictive for receipt of combined anterior-posterior approaches.

Conclusions: Private insurance status, female sex, and Caucasian race independently predict receipt of anterior-only CSM approaches, while non-Caucasian race (Black, Hispanic, Asian/Pacific Islander, Native American) and non-private insurance predict receiving posterior-only CSM approaches. Given recent literature demonstrating posterior-only approaches as predictive of increased mortality in CSM (Kaye et al., 2015), our findings indicate that for CSM patients, non-Caucasian race significantly increases mortality risk, while private insurance status significantly decreases the risk of mortality. Further study will be needed to address these issues.