Advertisement

Outcomes Following Surgical Management of Cauda Equina Syndrome: Does Race Matter?

  • Amit Jain
  • Emmanuel Menga
  • Addisu Mesfin
Article
  • 54 Downloads

Abstract

Cauda equina syndrome (CES) is a surgical emergency requiring urgent spinal decompression. Our objective is to analyze the association between race and in-hospital outcomes (complications, mortality, length of stay, and discharge disposition) in patients with CES. This is a retrospective cohort study of CES patients identified via the Nationwide Inpatient Sample (NIS) from 2000 to 2010 in inpatient hospitalizations in the USA. The patient sample includes 46,017 patients ≥18 undergoing spine surgery for CES. Using ICD9-CM codes, patient records with a diagnosis of CES from 2003 to 2010 were selected from the NIS database and sorted by mortality, complications, length of hospital stay, and discharge status. Demographic information (age, gender, race, and insurance status) and hospital characteristics were evaluated. African-American patients were 1.38-fold (p < 0.02; 95% odds ratio [OR] 1.05–1.83) more likely than Caucasian patients to develop complications based on a multivariate logistic regression model adjusted for patient age, insurance status, surgical approach, and hospital size. There was no difference in mortality among patients of various races in both univariate and multivariate analysis. A multivariate linear regression model adjusted for insurance status, surgical approach, and hospital size revealed that, compared to Caucasian patients, length of hospitalization in African-American patients was 1.92 days longer (p < 0.01), 1.34 days longer (p < 0.01) in Hispanic patients, and 2.24 days longer (p < 0.01) in Asian-American patients. African-American patients were 0.59-fold (p < 0.01; 95% OR 0.494–0.708) less likely than Caucasian patients to have routine discharge to home. African-American patients hospitalized for surgical management of CES experience significantly more complications, longer length of hospitalizations, and higher discharge to non-home locations, compared to Caucasian patients.

Keywords

Cauda equina syndrome Race Disparities Complication Nationwide inpatient sample 

Notes

Compliance with Ethical Standards

Conflict of Interest

Dr. Jain declares he has no conflict of interest. Dr. Menga declares he has no conflict of interest. Dr. Mesfin has received research funding from Globus.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human participants or animals performed by any of the authors.

References

  1. 1.
    DeLong WB, Polissar N, Neradilek B. Timing of surgery in cauda equina syndrome with urinary retention: meta-analysis of observational studies. J Neurosurg Spine. 2008;8(4):305–20.CrossRefPubMedGoogle Scholar
  2. 2.
    Arrigo RT, Kalanithi P, Boakye M. Is cauda equina syndrome being treated within the recommended time frame? Neurosurgery. 2011;68(6):1520–6.CrossRefPubMedGoogle Scholar
  3. 3.
    Floman Y, Wiesel SW, Rothman RH. Cauda equina syndrome presenting as a herniated lumbar disk. Clin Orthop Relat Res. 1980;147:234–7.Google Scholar
  4. 4.
    Fairbank J, Hashimoto R, Dailey A, Patel AA, Dettori JR. Does patient history and physical examination predict MRI proven cauda equina syndrome? Evid Based Spine Care J. 2011;2(4):27–33.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Lavy C, James A, Wilson-MacDonald J, Fairbank J. Cauda equina syndrome. BMJ. 2009;338:b936. doi: 10.1136/bmj.b936.CrossRefPubMedGoogle Scholar
  6. 6.
  7. 7.
    Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. J Natl Med Assoc. 2002;94(8):666–8.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Alosh H, Li D, Riley LH 3rd, Skolasky RL. Health care burden of anterior cervical spine surgery: national trends in hospital charges and length of stay, 2000 to 2009. J Spinal Disord Tech. 2013.Google Scholar
  9. 9.
    Skolasky RL, Maggard AM, Thorpe Jr RJ, Wegener ST, Riley 3rd LH. United States hospital admissions for lumbar spinal stenosis: racial and ethnic differences, 2000 through 2009. Spine (Phila Pa 1976). 2013;38(26):2272–8.CrossRefGoogle Scholar
  10. 10.
    Alosh H, Riley 3rd LH, Skolasky RL. Insurance status, geography, race, and ethnicity as predictors of anterior cervical spine surgery rates and in-hospital mortality: an examination of United States trends from 1992 to 2005. Spine (Phila Pa 1976). 2009;34(18):1956–62.CrossRefGoogle Scholar
  11. 11.
    Lad SP, Huang KT, Bagley JH, Hazzard MA, Babu R, Owens TR, Ugiliweneza B, Patil CG, Boakye M. Disparities in the outcomes of lumbar spinal stenosis surgery based on insurance status. Spine (Phila Pa 1976). 2013;38(13):1119–27.CrossRefGoogle Scholar
  12. 12.
    Zavatsky JM, Peters AJ, Nahvi FA, Bharucha NJ, Trobisch PD, Kean KE, Richard S, Bucello Y, Valdevit A, Lonner BS. Disease severity and treatment in adolescent idiopathic scoliosis: the impact of race and economic status. Spine J. 2013.Google Scholar
  13. 13.
    Lad SP, Bagley JH, Kenney KT, Ugiliweneza B, Kong M, Bagley CA, Gottfried ON, Isaacs RE, Patil CG, Boakye M. Racial disparities in outcomes of spinal surgery for lumbar stenosis. Spine (Phila Pa 1976). 2013;38(11):927–35.CrossRefGoogle Scholar
  14. 14.
    Nuño M, Drazin DG, Acosta Jr FL. Differences in treatments and outcomes for idiopathic scoliosis patients treated in the United States from 1998 to 2007: impact of socioeconomic variables and ethnicity. Spine J. 2013;13(2):116–23.CrossRefPubMedGoogle Scholar
  15. 15.
    Schoenfeld AJ, Sieg RN, Li G, Bader JO, Belmont Jr PJ, Bono CM. Outcomes after spine surgery among racial/ethnic minorities: a meta-analysis of the literature. Spine J. 2011;11(5):381–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Dykes DC, White 3rd AA. Getting to equal: strategies to understand and eliminate general and orthopaedic healthcare disparities. Clin Orthop Relat Res. 2009;467(10):2598–605.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Selim AJ, Fincke G, Ren XS, Deyo RA, Lee A, Skinner K, Kazis L. Racial differences in the use of lumbar spine radiographs: results from the Veterans Health Study. Spine (Phila Pa 1976). 2001;26(12):1364–9.CrossRefGoogle Scholar
  18. 18.
  19. 19.
    Nandyala SV, Marquez-Lara A, Fineberg SJ, Hassanzadeh H, Singh K. Complications after lumbar spine surgery between teaching and nonteaching hospitals. Spine (Phila Pa 1976). 2014;39(5):417–23.CrossRefGoogle Scholar
  20. 20.
    McCarthy MJ, Aylott CE, Grevitt MP, Hegarty J. Cauda equina syndrome: factors affecting long-term functional and sphincteric outcome. Spine (Phila Pa 1976). 2007;32(2):207–16.CrossRefGoogle Scholar
  21. 21.
    Gooding BW, Higgins MA, Calthorpe DA. Does rectal examination have any value in the clinical diagnosis of cauda equina syndrome? Br J Neurosurg. 2013;27(2):156–9.CrossRefPubMedGoogle Scholar
  22. 22.
    Mills AM, Shofer FS, Boulis AK, Holena DN, Abbuhl SB. Racial disparity in analgesic treatment for ED patients with abdominal or back pain. Am J Emerg Med. 2011;29(7):752–6.CrossRefPubMedGoogle Scholar
  23. 23.
    Tamayo-Sarver JH, Hinze SW, Cydulka RK, Baker DW. Racial and ethnic disparities in emergency department analgesic prescription. Am J Public Health. 2003;93(12):2067–73.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Tamayo-Sarver JH, Dawson NV, Hinze SW, Cydulka RK, Wigton RS, Albert JM, Ibrahim SA, Baker DW. The effect of race/ethnicity and desirable social characteristics on physicians’ decisions to prescribe opioid analgesics. Acad Emerg Med. 2003;10(11):1239–48.CrossRefPubMedGoogle Scholar
  25. 25.
    Burgess DJ, Nelson DB, Gravely AA, Bair MJ, Kerns RD, Higgins DM, van Ryn M, Farmer M, Partin MR. Racial differences in prescription of opioid analgesics for chronic non-cancer pain in a national sample of veterans. J Pain. 2014.Google Scholar
  26. 26.
    Jeffrey Kao MC, Minh LC, Huang GY, Mitra R, Smuck M. Trends in ambulatory physician opioid prescription in the United States, 1997–2009. PM R. 2014.Google Scholar
  27. 27.
    Zhan C, Miller MR. Excess length of stay, charges, and mortality attributable to medical injuries during hospitalization. JAMA. 2003;290(14):1868–74.CrossRefPubMedGoogle Scholar
  28. 28.
    Cai X, Cram P, Vaughan-Sarrazin M. Are African American patients more likely to receive a total knee arthroplasty in a low-quality hospital? Clin Orthop Relat Res. 2012;470(4):1185–93.CrossRefPubMedGoogle Scholar
  29. 29.
    SooHoo NF, Farng E, Zingmond DS. Disparities in the utilization of high-volume hospitals for total hip replacement. J Natl Med Assoc. 2011;103(1):31–5.CrossRefPubMedGoogle Scholar
  30. 30.
    SooHoo NF, Zingmond DS, Ko CY. Disparities in the utilization of high-volume hospitals for total knee replacement. J Natl Med Assoc. 2008;100(5):559–64.CrossRefPubMedGoogle Scholar
  31. 31.
    Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28(11):1504–10.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Blair IV, Steiner JF, Fairclough DL, Hanratty R, Price DW, Hirsh HK, Wright LA, Bronsert M, Karimkhani E, Magid DJ, Havranek EP. Clinicians’ implicit ethnic/racial bias and perceptions of care among black and Latino patients. Ann Fam Med. 2013;11(1):43–52.CrossRefPubMedPubMedCentralGoogle Scholar
  33. 33.
    Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, Banaji MR. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231–8.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. Am J Public Health. 2012;102(5):988–95.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Haider AH, Sexton J, Sriram N, Cooper LA, Efron DT, Swoboda S, Villegas CV, Haut ER, Bonds M, Pronovost PJ, Lipsett PA, Freischlag JA, Cornwell 3rd EE. Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. JAMA. 2011;306(9):942–51.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Nandyala SV, Marquez-Lara A, Fineberg SJ, Singh K. Perioperative characteristics and outcomes of patients undergoing anterior cervical fusion in July: analysis of the “July effect”. Spine (Phila Pa 1976). 2014;39(7):612–7.CrossRefGoogle Scholar
  37. 37.
    Singh JA, Lu X, Rosenthal GE, Ibrahim S, Cram P. Racial disparities in knee and hip total joint arthroplasty: an 18-year analysis of national medicare data. Ann Rheum Dis. 2013.Google Scholar
  38. 38.
    Irgit K, Nelson CL. Defining racial and ethnic disparities in THA and TKA. Clin Orthop Relat Res. 2011;469(7):1817–23.CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Hausmann LR, Mor M, Hanusa BH, Zickmund S, Cohen PZ, Grant R, Kresevic DM, Gordon HS, Ling BS, Kwoh CK, Ibrahim SA. The effect of patient race on total joint replacement recommendations and utilization in the orthopedic setting. J Gen Intern Med. 2010;25(9):982–8.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Daniels EW, Gordon Z, French K, Ahn UM, Ahn NU. Review of medicolegal cases for cauda equina syndrome: what factors lead to an adverse outcome for the provider? Orthopedics. 2012;35(3):e414–9.PubMedGoogle Scholar
  41. 41.
    Todd NV. Causes and outcomes of cauda equina syndrome in medico-legal practice: a single neurosurgical experience of 40 consecutive cases. Br J Neurosurg. 2011;25(4):503–8.CrossRefPubMedGoogle Scholar
  42. 42.
    Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur Spine J. 2011;20(5):690–7.CrossRefPubMedGoogle Scholar
  43. 43.
    Chau AM, Xu LL, Pelzer NR, Gragnaniello C. Timing of surgical intervention in cauda equina syndrome: a systematic critical review. World Neurosurg. 2013.Google Scholar
  44. 44.
    Devivo MJ. Epidemiology of traumatic spinal cord injury: trends and future implications. Spinal Cord. 2012;50(5):365–72.CrossRefPubMedGoogle Scholar
  45. 45.
    Selvarajah S, Hammond ER, Haider AH, Abularrage CJ, Becker D, Dhiman N, Hyder O, Gupta D, Black 3rd JH, Schneider EB. The burden of acute traumatic spinal cord injury among adults in the United States: an update. J Neurotrauma. 2014;31(3):228–38.CrossRefPubMedGoogle Scholar
  46. 46.
    Romano PS, Chan BK, Schembri ME, Rainwater JA. Can administrative data be used to compare postoperative complication rates across hospitals? Med Care. 2002;40(10):856–67.CrossRefPubMedGoogle Scholar
  47. 47.
    McCarthy EP, Iezzoni LI, Davis RB, et al. Does clinical evidence support ICD-9-CM diagnosis coding of complications? Med Care. 2000;38(8):868–76.CrossRefPubMedGoogle Scholar

Copyright information

© W. Montague Cobb-NMA Health Institute 2017

Authors and Affiliations

  1. 1.Department of Orthopaedic SurgeryJohns Hopkins UniversityBaltimoreUSA
  2. 2.Department of Orthopaedic SurgeryUniversity of Texas San AntonioSan AntonioUSA
  3. 3.Department of Orthopaedic SurgeryUniversity of RochesterRochesterUSA
  4. 4.School of Medicine and DentistryUniversity of RochesterRochesterUSA

Personalised recommendations