Cost—benefit value of microscopic examination of intervertebral discs
01 Sep 1998-Journal of Neurosurgery (Journal of Neurosurgery Publishing Group)-Vol. 89, Iss: 3, pp 378-381
TL;DR: Histological examination of intervertebral disc specimens is cost beneficial only if there is a significant preoperative clinical diagnosis, and no cost-benefit analysis of this practice was made.
Abstract: Object. Given the virtual absence of histologically detected, clinically unsuspected disease in intervertebral disc specimens, some authors have advocated that histological examination be discontinued. However, the examination of intervertebral disc specimens remains common practice in most pathology laboratories. No cost—benefit analysis of this practice has been made; therefore, the authors' goal in this study was perform such an analysis. Methods. Using the University of Iowa surgical pathology database, 1109 patients who had undergone a laminectomy were identified retrospectively. These cases were classified into four categories based on the patients' preoperative clinical diagnosis and final histopathological diagnosis: insignificant clinical diagnosis/insignificant pathological diagnosis (ICIP), significant clinical diagnosis/insignificant pathological diagnosis (SCIP), significant clinical diagnosis/significant pathological diagnosis (SCSP), and insignificant clinical diagnosis/significant patholog...
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TL;DR: This study demonstrated that histological disc alterations in surgical specimens can be graded in a reliable manner based on a quantitative histologic degeneration score (HDS), and increased BMI was identified as a positive risk factor for the development of symptomatic, clinically significant disc degeneration.
Abstract: Although histopathological grading systems for disc degeneration are frequently used in research, they are not yet integrated into daily care routine pathology of surgical samples. Therefore, data on histopathological changes in surgically excised disc material and their correlation to clinical parameters such as age, gender or body mass index (BMI) is limited to date. The current study was designed to correlate major physico-clinical parameters from a population of orthopaedic spine center patients (gender, age and BMI) with a quantitative histologic degeneration score (HDS). Excised lumbar disc material from 854 patients (529 men/325 women/mean age 56 (15-96) yrs.) was graded based on a previously validated histologic degeneration score (HDS) in a cohort of surgical disc samples that had been obtained for the treatment of either disc herniation or discogenic back pain. Cases with obvious inflammation, tumor formation or congenital disc pathology were excluded. The degree of histological changes was correlated with sex, age and BMI. The HDS (0-15 points) showed significantly higher values in the nucleus pulposus (NP) than in the annulus fibrosus (AF) (Mean: NP 11.45/AF 7.87), with a significantly higher frequency of histomorphological alterations in men in comparison to women. Furthermore, the HDS revealed a positive significant correlation between the BMI and the extent of histological changes. No statistical age relation of the degenerative lesions was seen. This study demonstrated that histological disc alterations in surgical specimens can be graded in a reliable manner based on a quantitative histologic degeneration score (HDS). Increased BMI was identified as a positive risk factor for the development of symptomatic, clinically significant disc degeneration.
70 citations
Cites background from "Cost—benefit value of microscopic e..."
...(2) A possible lack of clinical interest in the excised disc material due to unfavorable cost effectiveness and missing therapeutic consequences [27-30]....
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TL;DR: Routine histologic examinations of routine operative specimens during elective primary arthroplasties increase medical cost but rarely alter patient management and are not cost-effective.
Abstract: Background
Many hospitals require all operative specimens be sent to pathologists for routine examination. Although previous studies indicate this practice increases medical cost, it remains unclear whether it alters patient management and whether it is cost-effective.
36 citations
TL;DR: In this article, the histologic features of 985 extradural spinal surgery specimens were retrospectively reviewed and synovial metaplasia was described as a reactive change not previously reported.
Abstract: A number of pathologic changes have been reported in spinal surgery specimens. The frequency of many of these is not well defined. We retrospectively reviewed the histologic features of 985 extradural spinal surgery specimens. Of the cases, 1.6% were identified clinically as synovial cysts. In addition, synovial tissue was seen in another 5.3% of cases, often embedded within disk material. Neovascularization of disk tissue was present in 8.1% of cases, chondrocyte clusters in 18.3%, and calcium pyrophosphate crystals in 2.8%, predominantly within disk material. With the exception of crystal deposits, all of these changes were significantly more common in the lumbar spine. A better understanding of cell-based degenerative changes will become essential with increasing research into cell-based therapies for spinal disk disease. We report data on the frequency of different pathologic changes and describe synovial metaplasia as a reactive change not previously reported.
25 citations
TL;DR: Routine histologic examination of excised dorsal and volar carPal ganglions may be unnecessary if the preoperative and intraoperative evaluations are consistent with a diagnosis of carpal ganglion.
Abstract: Purpose Although histologic evaluation is performed routinely on tissue removed during the excision of carpal ganglions, the necessity of this evaluation is uncertain. We evaluated the use of routine histologic evaluation of excised carpal ganglions and performed a cost-benefit analysis. Methods A retrospective review identified 160 consecutive carpal ganglion (102 dorsal, 58 volar) excisions performed over the past 7 years by 2 surgeons. The preoperative evaluation, surgical findings, and results of the pathologic assessment were evaluated for patients treated with a typical carpal ganglion excision. Results In 156 of 160 patients the preoperative and intraoperative data were highly suggestive of a carpal ganglion; the pathology reports confirmed the diagnosis in all of these patients. No new information was provided by pathologic assessment. In 4 patients the preoperative and intraoperative assessments were less certain; the pathologic assessments in these patients also were equivocal. No malignancy or condition requiring additional treatment was identified. At our institution the total cost of pathologic evaluation for a carpal ganglion including processing and interpretation fees is $352. Conclusions Routine histologic examination of excised dorsal and volar carpal ganglions may be unnecessary if the preoperative and intraoperative evaluations are consistent with a diagnosis of carpal ganglion. Type of study/level of evidence Therapeutic, Level IV.
22 citations
TL;DR: Pathological study of intervertebral disc specimens is cost beneficial only in cases with significant preoperative clinical diagnoses, and routine evaluation of routine herniated nucleus pulposus extracted during decompressive surgeries is not warranted.
19 citations
References
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TL;DR: It is concluded that Histologic examination of nonroutine cases is cost-effective, whereas in most routine cases with adequate clinical history, histologic examination is not cost- effective.
Abstract: To study the cost-effectiveness of the histologic examination of tonsil and adenoid specimens, the histologic diagnoses for all routine (2,700) and nonroutine (71) tonsil and adenoid specimens during a 10-year period were reviewed. There were 27 routine cases (1%) and 56 nonroutine cases (79%) with a diagnosis other than normal, tonsillitis, or hyperplasia. Twelve of the 27 routine cases did not have a significant clinical history, and a potentially significant pathologic diagnosis was made in only 6 cases; in none of these cases did the pathologic diagnosis affect patient care. In all nonroutine cases, the pathologic diagnosis affected patient care. The average charge per case to detect potentially significant disease in routine and nonroutine cases was $64,718 and $525, respectively. We conclude that histologic examination of nonroutine cases is cost-effective, whereas in most routine cases with adequate clinical history, histologic examination is not cost-effective.
70 citations
TL;DR: The elimination of routine pathologic examination of surgical discectomy specimens would not have lowered the standard of care; the pathologist's report had no discernible influence on patient management.
Abstract: A retrospective review of 508 charts of patients undergoing laminectomy for all reasons was carried out with special attention to the preoperative diagnosis, postoperative diagnosis, pathologic diagnosis, and discharge diagnosis. The elimination of routine pathologic examination of surgical discectomy specimens would not have lowered the standard of care; the pathologist's report had no discernible influence on patient management. Unusual clinical features will continue to require careful examination of surgical specimens by the pathologist. Millions of healthcare dollars can be saved by eliminating this routine examination, which is based on outmoded routines. Hospital medical staffs who wish to change this practice must revise their hospital bylaws in keeping with the standards of the The Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
41 citations
TL;DR: Before definitive policy conclusions can be made, additional studies are needed to better define the trade-off between cost and the value of information and the incidence of detecting clinically significant disease.
Abstract: Although the histologic examination of routine tissues, such as hernia sacs and intervertebral disks, has shown a low incidence of detecting clinically significant unsuspected disease, the cost-effectiveness of histologic examination has not been determined. By using a theoretical model that assumed variable costs and gains in life expectancy secondary to detecting clinically significant disease, a threshold incidence of disease detection at which histologic examination is cost-effective was determined. By using the University of Iowa (Iowa City) cost of examination (approximately $25), at least I of every 2,000 examinations would have to show clinically significant disease for histologic examination to be cost-effective. This threshold incidence decreases as production costs decrease or life-year values increase. Before definitive policy conclusions can be made, additional studies are needed to better define the trade-off between cost and the value of information and the incidence of detecting clinically significant disease.
38 citations
TL;DR: If the symptoms, physical examination, radiographic diagnostic studies, and surgical findings are consistent with those of cervical disc herniation or spondylosis, the chance of an unexpected, clinically important pathologic finding within the disc specimen is extremely small.
Abstract: Study Design. A retrospective chart review was performed from 1990-1994. Objectives. To evaluate the outcome of pathologic examination on cervical disc specimens submitted after anterior cervical discectomy. Summary of Background Data. This study is the first to review the outcome of pathologic examination of disc specimens after anterior cervical discectomy and fusion. Methods. Charts were reviewed based on the procedure code of anterior cervical fusion and the main diagnoses of cervical disc and spondylosis. The following data were recorded for each patient: symptoms, examination, diagnostic studies, operative procedure, operative findings, and pathology report. Statistical analysis was performed. Results. Five hundred six disc levels in 394 patients reviewed. All patients had symptoms and examination results consistent with cervical radiculopathy. All patients, had cervical radiographs and some combination of myelography, computed tomography, or magnetic resonance imaging. Findings at the time of surgery included the presence of either a herniated disc or degenerative spondylitic changes. The pathologic examination results of all specimens reported fibrocartilaginous tissue consistent with disc material with the presence of degenerative changes. No infectious, benign, or malignant process was identified at the time of surgery or on gross and histologic examination of any of the disc specimens. Using confidence intervals (95%) for exact proportions and given 500 negatives, the chance the next occurrence would be positive would be 0.0060 or 0.60% or six of 1000. Conclusions. This study shows that if the symptoms, physical examination, radiographic diagnostic studies, and surgical findings are consistent with those of cervical disc herniation or spondylosis, the chance of an unexpected, clinically important pathologic finding within the disc specimen is extremely small. The time and expense involved in routine pathologic examination of cervical disc specimens can be avoided.
16 citations