Object Administrative databases are increasingly being used to establish benchmarks for quality of care and to compare performance across peer hospitals. As proposals for accountable care organizations are being developed, readmission rates will be increasingly scrutinized. The purpose of the present study was to assess whether the all-cause readmissions rate appropriately reflects the University of California, San Francisco (UCSF) Medical Center hospital's clinically relevant readmission rate for spine surgery patients and to identify predictors of readmission. Methods Data for 5780 consecutive patient encounters managed by 10 spine surgeons at UCSF Medical Center from October 2007 to June 2011 were abstracted from the University HealthSystem Consortium (UHC) using the Clinical Data Base/Resource Manager. Of these 5780 patient encounters, 281 patients (4.9%) were rehospitalized within 30 days of the previous discharge date. The authors performed an independent chart review to determine clinically relevant reasons for readmission and extracted hospital administrative data to calculate direct costs. Univariate logistic regression analysis was used to evaluate possible predictors of readmission. The two-sample t-test was used to examine the difference in direct cost between readmission and nonreadmission cases. Results The main reasons for readmission were infection (39.8%), nonoperative management (13.4%), and planned staged surgery (12.4%). The current all-cause readmission algorithm resulted in an artificially high readmission rate from the clinician's point of view. Based on the authors' manual chart review, 69 cases (25% of the 281 total readmissions) should be excluded because 39 cases (13.9%) were planned staged procedures; 16 cases (5.7%) were unrelated to spine surgery; and 14 surgical cases (5.0%) were cancelled or rescheduled at index admission due to unpredictable reasons. When these 69 cases are excluded, the direct cost of readmission is reduced by 29%. The cost variance is in excess of $3 million. Predictors of readmission were admission status (p < 0.0001), length of stay (p = 0.0001), risk of death (p < 0.0001), and age (p = 0.021). Conclusions The authors' findings identify the potential pitfalls in the calculation of readmission rates from administrative data sets. Benchmarking algorithms for defining hospitals' readmission rates must take into account planned staged surgery and eliminate unrelated reasons for readmission. When this is implemented in the calculation method, the readmission rate will be more accurate. Current tools overestimate the clinically relevant readmission rate and cost.

Study design: Systematic review.Clinical question: Does single-level unconstrained, semiconstrained, or fully constrained cervical artificial disc replacement (C-ADR) improve health outcomes compared with single-level anterior cervical discectomy and fusion (ACDF) in the long-term?Methods: A systematic review was undertaken for articles published up to October 2011. Electronic databases and reference lists of key articles were searched to identify US Food and Drug Administration (FDA) studies reporting long-term (≥ 48 months) follow-up results of C-ADR compared with ACDF. Non-FDA trials and FDA trials reporting outcomes at short-term or mid-term follow-up periods were excluded. Two independent reviewers assessed the strength of evidence using the GRADE criteria and disagreements were resolved by consensus.Results: Two FDA trials reporting outcomes following C-ADR (Bryan disc, Prestige disc) versus ACDF at follow-up periods of 48 months and 60 months were found (follow-up rates are 68.7% [318/463] and 50.1% [271/541], respectively). Patients in the C-ADR group showed a higher rate of overall success, greater improvements in Neck Disability Index, neck and arm pain scores, and SF-36 PhysicalComponent Scores at long-term follow-up compared with those in the ACDF group. The rate of adjacent segment disease was less in the C-ADR group versus the ACDF group at 60 months (2.9% vs 4.9%). Normal segmental motion was maintained in the C-ADR group. Furthermore, rates of revision and supplemental fixation surgical procedures were lower in the arthroplasty group.Conclusions: C-ADR is a viable treatment option for cervical herniated disc/spondylosis with radiculopathy resulting in improved clinical outcomes, maintenance of normal segmental motion, and low rates of subsequent surgical procedures at 4 to 5 years follow-up. More studies with long-term follow-up are warranted.

Nontraumatic neck pain is a leading cause of disability, with nearly 50% of individuals experiencing ongoing or recurrent symptoms. Radiographs are appropriate as initial imaging for cervical or neck pain in the absence of "red flag" symptoms or if there are unchanging chronic symptoms; however, spondylotic changes are commonly identified and may result in both false-positive and false-negative findings. Noncontrast CT can be complementary to radiographs for evaluation of new or changing symptoms in the setting of prior cervical spine surgery or in the assessment of extent of ossification in the posterior longitudinal ligament. Noncontrast MRI is usually appropriate for assessment of new or increasing radiculopathy due to improved nerve root definition. MRI without and with contrast is usually appropriate in patients with new or increasing cervical or neck pain or radiculopathy in the setting of suspected infection or known malignancy. Imaging may be appropriate; however, it is not always indicated for evaluation of cervicogenic headache without neurologic deficit.

Patients with grade II ependymoma have significantly longer PFS than patients with grade I ependymoma. The extent of resection did not affect PFS in grade I ependymoma but it did in grade II. Contrary to its higher grade, WHO grade II ependymoma carries a better prognosis than WHO grade I ependymoma.