Histopathological examination of intervertebral disc specimens: a cost-benefit analysis.
01 Nov 2007-Canadian Journal of Neurological Sciences (Cambridge University Press)-Vol. 34, Iss: 4, pp 451-455
TL;DR: In routine cases, histopathological examination of disc specimens is not justified, and the decision to send specimens for pathological examination should be based on the surgeon's judgment.
Abstract: But: Dans les hopitaux nord- americains, les specimens de disques intervertebraux sont examines de routine en anatomopathologie. Cependant, des etudes recentes ont remis en question la pertinence de cette pratique dans les cas ou l'indication chirurgicale est une pathologie benigne comme une maladie discale degenerative. Cette etude porte sur le ratio cout-benefice de cette pratique. Methodes : Nous avons effectue une analyse cout-benefice de l'examen anatomopathologique fait de routine entre 1996 et 2004 sur 1775 specimens provenant de discectomies faites de routine (indications chirurgicales non neoplasiques et non infectieuses) et 70 specimens provenant de discectomies chez des patients chez qui on soupconnait une neoplasie ou une infection. La revue des dossiers a permis de determiner si les constatations anatomopathologiques etaient significatives au point de vue clinique, c'est-a-dire si elles avaient influence le traitement du patient. Nous avons calcule le cout total. Une revue de la litterature nous a permis de comparer nos resultats a ceux d'autres chercheurs. Resultats : Nous avons decouvert 4 comptes rendus anatomopathologiques inattendus parmi les 1775 specimens provenant des cas de routine, dont un etait significatif au point de vue clinique, a un cout de 42 165,25$par trouvaille anatomopathologique et de 168 625 $ par trouvaille anatomopathologique significative au point de vue clinique. Pour les chirurgies qui n'etaient pas faites de routine, le cout par constatation anatomopathologique anormale etait de 116,67$. Conclusions : Quand il s'agit de cas de routine, l'examen anatomopathologique des specimens de disques n'est pas justifie. La decision de demander un examen anatomopathologique de ces specimens chirurgicaux devrait etre basee sur le jugement du chirurgien.
Citations
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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 "Histopathological examination of in..."
...(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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...Why should we classify histological changes in excised disc material? There is a substantial bulk of literature [27,29,30,80,81] suggesting that routine histopathological examination of disc specimen is not justified for reasons of cost effectiveness....
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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: Routine pathological examination of surgical specimens from patients undergoing knee arthroscopy had limited cost-effectiveness because of the low prevalence of findings that altered patient management and gross and histological examination should be done at the discretion of the orthopaedic surgeon rather than being mandatory.
Abstract: Background: While the clinical value of routine pathologic examination of tissues removed during orthopaedic procedures has not been determined, limited cost-effectiveness and a low prevalence of findings that alter patient management have been previously demonstrated with arthroscopy. The purpose of this study was to examine the clinical value and cost-effectiveness of routine histological examination of knee arthroscopy specimens.
Methods: Retrospective chart analysis of 3797 consecutive knee arthroscopies by two surgeons from 2004 to 2013 at three affiliated hospitals within one health-care system was undertaken. Pathology reports regarding tissue removed during partial meniscectomies and anterior cruciate ligament reconstructions were reviewed to determine if the results altered patient care. The total costs of histological examination were estimated in 2012-adjusted U.S. dollars. The cost per health effect was determined by calculating the cost per discrepant and discordant diagnosis.
Results: The prevalence of concordant diagnoses was 99.3% (3769 of 3797), the prevalence of discrepant diagnoses was 0.7% (twenty-seven of 3797), and the prevalence of discordant diagnoses was 0.026% (one of 3797). The total cost of histological examinations was estimated to be $371,810. The total cost of the pathology cost per discrepant diagnosis was $13,771, and the cost per discordant diagnosis was $371,810.
Conclusions: Routine pathological examination of surgical specimens from patients undergoing knee arthroscopy had limited cost-effectiveness because of the low prevalence of findings that altered patient management. Histological examination of surgical specimens from arthroscopic knee surgery did not alter patient care and increased costs. We suggest that gross and histological examination of tissue removed during knee arthroscopy should be done at the discretion of the orthopaedic surgeon rather than being mandatory.
12 citations
TL;DR: This study showed limited clinical utility in routinely sending specimens from primary shoulder arthroplasty cases for pathology examination, and calculation using a traditional life-year value of $50,000 showed that the standard for cost-effectiveness is not met.
Abstract: Background The annual number of shoulder arthroplasty procedures is continuing to increase. Specimens from shoulder arthroplasty cases are routinely sent for pathologic examination. This study sought to evaluate the clinical utility and associated costs of routine pathologic examination of tissue removed during primary shoulder arthroplasty cases and to determine cost-effectiveness of this practice. Methods This is a retrospective review of primary shoulder arthroplasty cases. Patients whose humeral head was sent for routine pathologic examination were included. Cases were determined to have concordant, discrepant, or discordant diagnoses based on preoperative/postoperative diagnosis and pathology diagnosis. Costs were estimated in 2015 U.S. dollars, and cost-effectiveness was determined by the cost per discrepant diagnosis and cost per discordant diagnosis. Results We identified 714 cases of primary shoulder arthroplasty in 646 patients who met inclusion criteria. The prevalence of concordant diagnoses was 94.1%, the prevalence of discrepant diagnoses was 5.9%, and no cases had discordant diagnoses. There were 172 cases that had biceps tendon specimens sent for pathology examination, and none led to a change in patient care. Total estimated costs were $77,309.34 in 2015 U.S. dollars. Cost per discrepant diagnosis for humeral head specimens was $1424.09, and cost per discordant diagnosis is at least $59,811.78. Discussion/Conclusion Primary shoulder arthroplasty has a high rate of concordant diagnosis. Discrepant diagnoses were 5.9% in our study, and there were no discordant diagnoses. This study showed limited clinical utility in routinely sending specimens from primary shoulder arthroplasty cases for pathology examination, and calculation using a traditional life-year value of $50,000 showed that the standard for cost-effectiveness is not met.
7 citations
TL;DR: The costs of routine histopathological examination of tissue specimens removed during total ankle replacement outweigh clinical benefits, and such examination should be left to the discretion of the operating surgeon.
Abstract: Background:Routine histopathological examination has previously been scrutinized as a source of extraneous cost in orthopedic foot and ankle care. As an increasingly prevalent joint replacement operation, total ankle replacement poses a notable cost to the health care market in an era of cost containment. The purpose of this study was to compare the costs and benefits of routine histopathological examination of specimens removed during total ankle replacement. We hypothesized that a new diagnosis would rarely be found and such examination would seldom alter patient care.Methods:A retrospective review was conducted of all total ankle replacement operations between 2006 and July 2014 at the investigators’ institution. Medical records for 90 patients, undergoing a total of 95 total ankle replacement operations, were reviewed to determine the clinical and pathological diagnoses for each operation and, subsequently, the rates of discrepancy and discordance. Professional charges were determined using estimated ...
1 citations
References
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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
"Histopathological examination of in..." refers background in this paper
...The following cases were excluded: (1) three specimens obtained during myelomeningocele or lipomeningocele repair; (2) three synovial cysts erroneously coded as disc material; (3) three reports in which no recognizable material for pathological examination was identified; (4) four specimens for which the indication for surgery was not available...
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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: 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.
Abstract: BACKGROUND
After decompression of cervical and lumbar nerve roots for radicular pain, pathological evaluation of the extracted disc material is commonly performed. Although histological examination rarely detects clinically significant unsuspected disease, it remains a common practice in most hospitals in the United States. To determine the cost-effectiveness of this routine practice, we conducted a retrospective study. The results are contained within this report.
METHODS
Using the University Neurosurgery database, we retrospectively identified 1,387 patients who had spinal decompression surgery (laminectomy and/or discectomy). These cases were broadly classified into routine and non-routine cases depending on the preoperative diagnosis. Benign and noninfectious cases were classified as routine; malignant and all other cases were classified as nonroutine. We reviewed the medical records and pathology reports of these routine and nonroutine cases in an attempt to study the efficacy of the pathological evaluation of the disc material. The cost-benefit value of histopathology in these cases was analyzed, retrospectively.
RESULTS
In all routine cases, the histopathology was consistent with benign disc disease and yielded no additional information that could have altered the treatment plan. In the nonroutine cases, however, histopathology was significant in the management of the patient. The cost factor for pathological study was the same for both case groups.
CONCLUSIONS
Pathological study of intervertebral disc specimens is cost beneficial only in cases with significant preoperative clinical diagnoses. Pathological evaluation of routine herniated nucleus pulposus extracted during decompressive surgeries is not warranted.
19 citations
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...
19 citations
"Histopathological examination of in..." refers background in this paper
...The following cases were excluded: (1) three specimens obtained during myelomeningocele or lipomeningocele repair; (2) three synovial cysts erroneously coded as disc material; (3) three reports in which no recognizable material for pathological examination was identified; (4) four specimens for which the indication for surgery was not available...
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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
"Histopathological examination of in..." refers background in this paper
...The following cases were excluded: (1) three specimens obtained during myelomeningocele or lipomeningocele repair; (2) three synovial cysts erroneously coded as disc material; (3) three reports in which no recognizable material for pathological examination was identified; (4) four specimens for which the indication for surgery was not available...
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