Projections of Single-level and Multilevel Spinal Instrumentation Procedure Volume and Associated Costs for Medicare Patients to 2050.

BACKGROUND: Instrumented spinal fusions can be used in the treatment of vertebral fractures, spinal instability, and scoliosis or kyphosis. Construct-level selection has notable implications on postoperative recovery, alignment, and mobility. This study sought to project future trends in the implementation rates and associated costs of single-level versus multilevel instrumentation procedures in US Medicare patients aged older than 65 years in the United States. METHODS: Data were acquired from the Centers for Medicare & Medicaid Services from January 1, 2000, to December 31, 2019. Procedure costs and counts were abstracted using Current Procedural Terminology codes to identify spinal level involvement. The Prophet machine learning algorithm was used, using a Bayesian Inference framework, to generate point forecasts for 2020 to 2050 and 95% forecast intervals (FIs). Sensitivity analyses were done by comparing projections from linear, log-linear, Poisson and negative-binomial, and autoregressive integrated moving average models. Costs were adjusted for inflation using the 2019 US Bureau of Labor Statistics' Consumer Price Index. RESULTS: Between 2000 and 2019, the annual spinal instrumentation volume increased by 776% (from 7,342 to 64,350 cases) for single level, by 329% (from 20,319 to 87,253 cases) for two-four levels, by 1049% (from 1,218 to 14,000 cases) for five-seven levels, and by 739% (from 193 to 1,620 cases) for eight-twelve levels (P < 0.0001). The inflation-adjusted reimbursement for single-level instrumentation procedures decreased 45.6% from $1,148.15 to $788.62 between 2000 and 2019, which is markedly lower than for other prevalent orthopaedic procedures: total shoulder arthroplasty (-23.1%), total hip arthroplasty (-39.2%), and total knee arthroplasty (-42.4%). By 2050, the number of single-level spinal instrumentation procedures performed yearly is projected to be 124,061 (95% FI, 87,027 to 142,907), with associated costs of $93,900,672 (95% FI, $80,281,788 to $108,220,932). CONCLUSIONS: The number of single-level instrumentation procedures is projected to double by 2050, while the number of two-four level procedures will double by 2040. These projections offer a measurable basis for resource allocation and procedural distribution.

Disparities in postoperative complications and perioperative events based on insurance status following elective spine surgery: A systematic review and meta-analysis.

Background: Increasing evidence demonstrates disparities among patients with differing insurance statuses in the field of spine surgery. However, no pooled analyses have performed a robust review characterizing differences in postoperative outcomes among patients with varying insurance types. Methods: A comprehensive literature search of the PUBMED, MEDLINE(R), ERIC, and EMBASE was performed for studies comparing postoperative outcomes in patients with private insurance versus government insurance. Pooled incidence rates and odds ratios were calculated for each outcome and meta-analyses were conducted for 3 perioperative events and 2 types of complications. In addition to pooled analysis, sub-analyses were performed for each outcome in specific government payer statuses. Results: Thirty-eight studies (5,018,165 total patients) were included. Compared with patients with private insurance, patients with government insurance experienced greater risk of 90-day re-admission (OR 1.84, p<.0001), non-routine discharge (OR 4.40, p<.0001), extended LOS (OR 1.82, p<.0001), any postoperative complication (OR 1.61, p<.0001), and any medical complication (OR 1.93, p<.0001). These differences persisted across outcomes in sub-analyses comparing Medicare or Medicaid to private insurance. Similarly, across all examined outcomes, Medicare patients had a higher risk of experiencing an adverse event compared with non-Medicare patients. Compared with Medicaid patients, Medicare patients were only more likely to experience non-routine discharge (OR 2.68, p=.0007). Conclusions: Patients with government insurance experience greater likelihood of morbidity across several perioperative outcomes. Additionally, Medicare patients fare worse than non-Medicare patients across outcomes, potentially due to age-based discrimination. Based on these results, it is clear that directed measures should be taken to ensure that underinsured patients receive equal access to resources and quality care.

Do racial disparities exist in a spine surgery practice that serves a predominately minority population? Outcomes of transforaminal lumbar interbody fusion: A retrospective review.

Background: Racial minority status is associated with inferior peri-operative outcomes following spinal fusion. Findings have largely been reported within institutions serving few minority patients. This study aimed to identify if racial disparities exist for transforaminal lumbar interbody fusion (TLIF) procedures within an urban academic medical center which serves a majority non-White population. Methods: This is a retrospective review of patients who underwent a TLIF procedure at our institution between 06/2016-10/2019. Primary outcome measures included length of stay (LOS), discharge disposition, 30-day return to the emergency department (ED), 30-day readmission rate, and 30-day complication rates. One-hundred-fifty-six patients (female: male, 99: 57) met inclusion criteria. Demographic and clinical data (body mass index (BMI), comorbidities, preoperative lab values) were compared. Results: The mean LOS was 6.2, 5.9, and 6 days in the White, Hispanic, and Black cohorts, respectively (p = 0.92). There were no differences in discharge disposition between groups (p = 0.52). Thirty-day post-operative complication rates did not differ between groups (p > 0.07). Readmission rates did not differ between groups (p > 0.05). ED visits were more prevalent in the Hispanic group with 16 visits as compared to 8 and 4 in the White and Black groups respectively (p = 0.01). Conclusions: We found no racial disparities in terms of LOS, discharge disposition, or 30-day readmission rates. Hispanic patients demonstrated an increased utilization of the ED in the early post-operative period. Efforts to overcome language barriers, communicate instructions clearly, and outline post-operative expectations and plans may prevent the need for post-operative ED visits.

Management and outcomes of adult traumatic cervical spondyloptosis: A case report and systematic review.

STUDY DESIGN: Systematic Review. OBJECTIVE: To elucidate treatment modalities and outcomes of patients with traumatic cervical spondyloptosis (TCS). SUMMARY: Traumatic cervical spondyloptosis (TCS) is rare and typically leads to devastating neurological injury. Management strategies vary from case to case. METHODS: A systematic review of the literature identified cases of adult TCS, and data was analyzed to characterize the patient population and to assess factors that influenced clinical outcome. In addition, an illustrative case is presented in which closed reduction of a severe C7-T1 spondyloptosis injury was guided with the use of cone beam computerized tomography (O-Arm) to overcome difficulties with visualizing the cervicothoracic junction region. RESULTS: In addition to our case, we identified 52 cases of adult TCS from 34 articles. Patient age ranged from 18 to 73 (average 45.6) with male a predominance (n = 37, 71.2%). Neurological function on presentation was most commonly ASIA E (34.6%), followed by ASIA D (21.2%) and ASIA A (19.2%). The most frequently affected levels were C7-T1 (44.2%) followed by C6-7 (33.0%). Closed reduction was attempted in 42 (80.8%) patients. A total of 49 (94.2%) patients underwent surgical treatment, with 31 (63.3%) undergoing single-approach procedures. The presence of neurological injury, cervical level of injury, and age were not significant predictors of successful closed reduction. Similarly, successful closed reduction, age, cervical level of injury, and neurological injury were not predictors of a single-approach treatment. CONCLUSION: TCS is rare and most frequently appears at or near the cervicothoracic junction and in males. The presentation is typically that of severe neurological injury, but partial neurological recovery occurs in many patients. No predictors of successful closed reduction or single approach surgery are identified. We postulate that the use of intraoperative multiplanar imaging technology like the O-Arm may enhance the ability to achieve a successful closed reduction given the predilection for the injury to occur at the cervicothoracic junction. Prospective study of the durability of constructs by single or combined approaches is warranted.

Cigarette smoking and complications in elective thoracolumbar fusions surgery: An analysis of 58,304 procedures.

Study Design: This was retrospective cohort study. Purpose: The current investigation uses a large, multi-institutional dataset to compare short-term morbidity and mortality rates between current smokers and nonsmokers undergoing thoracolumbar fusion surgery. Overview of Literature: The few studies that have addressed perioperative complications following thoracolumbar fusion surgeries are each derived from small cohorts from single institutions. Materials and Methods: A retrospective study was conducted on thoracolumbar fusion patients in the American College of Surgeons National Surgical Quality Improvement Program database (2006-2016). The primary outcome compared the rates of overall morbidity, severe postoperative morbidity, infections, pneumonia, deep venous thrombosis (DVT), pulmonary embolism (PE), transfusions, and mortality in smokers and nonsmokers. Results: A total of 57,677 patients were identified. 45,952 (78.8%) were nonsmokers and 12,352 (21.2%) smoked within 1 year of surgery. Smokers had fewer severe complications (1.6% vs. 2.0%, P = 0.014) and decreased discharge to skilled nursing facilities (6.3% vs. 11.5%, P < 0.001) compared to nonsmokers. They had lower incidences of transfusions (odds ratio [OR] = 0.9, confidence interval [CI] = 0.8-1.0, P = 0.009) and DVT (OR = 0.7, CI = 0.5-0.9, P = 0.039) as well as shorter length of stay (LOS) (OR = 0.9, CI = 0.9-0.99, P < 0.001). They had a higher incidence of postoperative pneumonia (OR = 1.4, CI = 1.1-1.8, P = 0.002). There was no difference in the remaining primary outcomes between smoking and nonsmoking cohorts. Conclusions: There is a positive correlation between smoking and postoperative pneumonia after thoracolumbar fusion. The incidence of blood transfusions, DVT, and LOS was decreased in smokers. Early postoperative mortality, severe complications, discharge to subacute rehabilitation facilities, extubation failure, PE, SSI, and return to OR were not associated with smoking.

MRI and Anatomical Determinants Affecting Neuroforaminal Stenosis Evaluation: A Descriptive Observational Study.

Purpose: Neuroforaminal stenosis (NFS), a narrowing of the intervertebral foramen, is a cause of disability in the aging population. Formal magnetic resonance imaging (MRI) classification of NSF has been developed recently and contradictory findings have been reported. This study aims to assess whether in-plane, anatomically conformed two-dimensional (2D) views of the neuroforamen characterize NFS more accurately than traditional axial, coronal, and sagittal views in healthy individuals with and without simulated scoliosis. Patients and methods: This observational study was approved by the designated institutional review board at our academic tertiary care center. Four volunteers underwent lumbar spine MRI twice, once in the supine position and once with intentionally introduced hip tilt. The latter resulted in lumbar curvature mimicking positioning errors approximating degenerative lumbar scoliosis. Anatomically oriented cuts such as axial with endplate correction and coronally obliqued parasagittals, also called coronal obliques, were performed. Standard sagittal and axial views were also performed in both the supine and rotated groups. Results: Coronal oblique and anatomically oriented axial views demonstrated the highest correlation with true neuroforaminal caliber. Deviation from anatomical congruence resulted in false measurements of neuroforaminal size. The hip-tilt studies produced MR that were less favorable to characterization of the caliber of neuroforamina. Coronal sections demonstrated reliability only when performed at the mid-pedicular lines. Standard axial views were reliable only when taken at the upper one-third of the neuroforamen. Coronal oblique views demonstrated superiority when evaluating consecutive neuroforamen on one image compared to non-obliqued parasagittal slices. Conclusion: To minimize error in neuroforaminal analysis, imaging specialists should perform anatomically oriented cuts to conform to individual patient anatomy. When this cannot be performed due to a patient's spine rotation or position, the MRI reader should view oblique, axial, and coronal images simultaneously and dynamically for proper foraminal characterization.

The Effect of a Multidisciplinary Spine Clinic on Time to Care in Patients with Chronic Back and/or Leg Pain: A Propensity Score-Matched Analysis.

Chronic back and leg pain are leading causes of disability worldwide. The purpose of this study was to compare the care in a unidisciplinary (USC) versus multidisciplinary (MSC) spine clinic, where patients are evaluated by different specialists during the same office visit. Adult patients presenting with a chief complaint of back and/or leg pain between June 2018 and July 2019 were assessed for eligibility. The main outcome measures included the first treatment recommendations, the time to treatment order, and the time to treatment occurrence. A 1:1 propensity score-matched analysis was performed on 874 patients (437 in each group). For all patients, the most common recommendation was physical therapy (41.4%), followed by injection (14.6%), and surgery (9.7%). Patients seen in the MSC were more likely to be recommended injection (p < 0.001) and less likely to be recommended surgery as first treatment (p = 0.001). They also had significantly shorter times to the injection order (log-rank test, p = 0.004) and the injection occurrence (log-rank test, p < 0.001). In this study, more efficient care for patients with back and/or leg pain was delivered in the MSC setting, which was evidenced by the shorter times to the injection order and occurrence. The impact of the MSC approach on patient satisfaction and health-related quality-of-life outcome measures warrants further investigation.

Is the Use of Intraoperative 3D Navigation for Thoracolumbar Spine Surgery a Risk Factor for Post-Operative Infection?

Pedicle screw fixation is a technique used to provide rigid fixation in thoracolumbar spine surgery. Safe intraosseous placement of pedicle screws is necessary to provide optimal fixation as well as to avoid damage to adjacent anatomic structures. Despite the wide variety of techniques available, none thus far has been able to fully eliminate the risk of malpositioned screws. Intraoperative 3-dimensional navigation (I3DN) was developed to improve accuracy in the placement of pedicle screws. To our knowledge, no previous studies have investigated whether infection rates are higher with I3DN. A single-institution, retrospective study of patients age > 18 undergoing thoracolumbar fusion and instrumentation was carried out and use of I3DN was recorded. The I3DN group had a significantly greater rate of return to the operating room for culture-positive incision and drainage (17 (4.1%) vs. 1 (0.6%), p = 0.025). In multivariate analysis, the use of I3DM did not reach significance with an OR of 6.49 (0.84−50.02, p = 0.073). Post-operative infections are multifactorial and potential infection risks associated with I3DN need to be weighed against the safety benefits of improved accuracy of pedicle screw positioning.

A Multidisciplinary Spine Surgical Indications Conference Leads to Alterations in Surgical Plans in a Significant Number of Cases: A Case Series.

STUDY DESIGN: Case series. OBJECTIVE: To evaluate the impact of a multidisciplinary spine surgery indications conference (MSSIC) on surgical planning for elective spine surgeries. SUMMARY OF BACKGROUND DATA: Identifying methods for pairing the proper patient with the optimal intervention is of the utmost importance for improving spine care and patient outcomes. Prior studies have evaluated the utility of multidisciplinary spine conferences for patient management, but none have evaluated the impact of a MSSIC on surgical planning and decision making. METHODS: We implemented a mandatory weekly MSSIC with all spine surgeons at our institution. Each elective spine surgery in the upcoming week is presented. Subsequently, a group consensus decision is achieved regarding the best treatment option based on the expertise and opinions of the participating surgeons. We reviewed cases presented at the MSSIC from September 2019 to December 2019. We compared the surgeon's initial proposed surgery for a patient with the conference attendees' consensus decision on the best treatment and measured compliance rates with the group's recommended treatment. RESULTS: The conference reviewed 100 patients scheduled for elective spine surgery at our indications conference during the study period. Surgical plans were recommended for alteration in 19 cases (19%) with the proportion statistically significant from zero indicated by a binomial test (P < 0.001). The median absolute change in the invasiveness index of the altered procedures was 3 (interquartile range [IQR] 1-4). Participating surgeons complied with the group's recommendation in 96.5% of cases. CONCLUSION: In conjunction with other multidisciplinary methods, MSSICs can lead to surgical planning alterations in a significant number of cases. This could potentially result in better selection of surgical candidates and procedures for particular patients. Although long-term patient outcomes remain to be evaluated, this care model will likely play an integral role in optimizing the care spine surgeons provide patients. LEVEL OF EVIDENCE: 4.

Prolonged length of stay and discharge disposition to rehabilitation facilities following single-level posterior lumbar interbody fusion for acquired spondylolisthesis.

BACKGROUND: Acquired lumbar spondylolisthesis is often treated with interbody fusion. However, few studies have evaluated predictors for prolonged length of stay (LOS) and disposition to rehabilitation facilities after posterior single-level lumbar interbody fusion for acquired spondylolisthesis. METHODS: The American College of Surgeons National Quality Improvement Program database was queried for adults with acquired spondylolisthesis who underwent single-level lumbar interbody fusion through a posterior approach (posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion [TLIF]). We utilized multivariate logistic regression analysis to identify predictors of prolonged LOS and disposition in this patient population. RESULTS: Among 2080 patients identified, 700 (33.7%) had a prolonged LOS (≥4 days), and 306 (14.7%) were discharged postoperatively to rehabilitation facilities. Predictors for prolonged LOS included: American Society of Anesthesiologist (ASA) class ≥3, anemia, prolonged operative time, perioperative blood transfusion, pneumonia, urinary tract infections, and return to the operating room. The following risk factors predicted discharge to postoperative rehabilitation facilities: age ≥65 years, male sex, ASA class ≥3, modified frailty score ≥2, perioperative blood transfusion, and prolonged LOS. CONCLUSION: Multiple partial-overlapping risk factors predicted prolonged LOS and discharge to rehabilitation facilities after single-level TLIF/PLIF performed for acquired spondylolisthesis.

A safe, reliable, inexpensive and novel technique to localize in the mid thoracic spine in the prone position: Proof of concept and technical illustration.

Intraoperative localization within the thoracic spine in the prone position may be particularly difficult on account of absence of common landmarks such as the sacrum or the C2 vertebra, thus increasing the potential for wrong-level surgery that may lead to patient morbidity and potential litigation. Some current localization methods involve implantation of markers that are invasive and serve to add to procedural expense while yet still failing to entirely eliminate errors. We describe a novel, non-invasive, and inexpensive technique for intraoperative localization of the thoracic spine in the prone position using an esophageal temperature probe. Following patient positioning, anteroposterior fluoroscopy is used to localize the radiopaque tip of the esophageal probe relative to the thoracic spine. After determining the probe tip's location, it becomes the counting reference for all subsequent intraoperative fluoroscopic localizations during surgery. As the probe tip is generally visible in the same fluoroscopic image as the surgical level, error from parallax created when moving the fluoroscopy machine from an anatomic landmark either above or below is avoided and a shorter fluoroscopy time is needed. Use of an esophageal temperature probe as a landmark in localizing spinal level may serve as a reliable and It offers a safe, reliable, and inexpensive technique for proper localization of thoracic spine levels.

Early Medical Complications and Delayed Discharge after Spinopelvic Fusion: A Comparative Analysis of 887 NSQIP Cases from 2006 to 2016.

INTRODUCTION: The effect of pelvic fixation on postoperative medical complications, blood transfusion, length of hospital stay, and discharge disposition is poorly understood. Determining factors that predispose patients to increased complications after spinopelvic fusion will help surgeons to plan these complex procedures and optimize patients preoperatively. METHODS: We conducted a retrospective cohort study using data from the ACS-NSQIP database between 2006 and 2016 of patients who underwent lumbar fusion with and without spinopelvic fixation. Data regarding demographics, complications, hospital stay, and discharge disposition were collected. RESULTS: A total of 57,417 (98.5%) cases of lumbar fusion without spinopelvic fixation (LF) and 887 (1.5%) cases of lumbar fusion with spinopelvic fixation (SPF) were analyzed. The transfusion rate in the SPF group was 59.3% vs 13% in the LF group (p < 0.001). The mean length of stay (LOS) and discharge to skilled nursing facility (SNF) were significantly different (LOS: SPF 6.5 days vs LF 3.5 days p < 0.001; SNF: SPF 21.3% vs LF 10.4% p < 0.001). After controlling for demographic differences, the overall complication rates were not significantly different between the groups (p = 0.531). The odds ratio for transfusion in the SPF group was 2.9 (p < 0.001). The odds ratio for increased LOS and increased care discharge disposition were elevated in the SPF group (LOS OR: 1.3, p < 0.012, Discharge disposition OR: 1.8, p < 0.001). CONCLUSIONS: Patients who underwent SPF had increased complications, transfusion rate, LOS, and discharge to SNF or subacute rehab facilities as compared with patients who underwent LF. SPF remains an effective technique for achieving lumbosacral arthrodesis. Surgeons should consider the implications of the associated complication profile for SPF and the value of preoperative optimization in a select cohort of patients.

Retained bullet in the cervical spinal canal and the associated surgical management conundrum: case report and review of the literature.

INTRODUCTION: Gunshot wounds (GSW) to the cervical spine remain uncommon. Surgery often does not yield significant neurological improvement and the decision to utilize surgery depends on a number of factors. We describe the case of a 28 year-old male suffering a complete spinal cord injury (SCI) secondary to a bullet lodged in the cervical spinal canal. We present the unique radiological findings and review the indications for and utility of spine surgery for cervical GSW. CASE PRESENTATION: The patient was a 28 year-old male involved in a motor vehicle accident immediately after sustaining a gunshot wound to the cervical spine. Neurologic exam revealed a complete SCI at the C4 level. CT scan revealed a retained bullet in the spinal canal at the C4/5 level without vascular injury or unstable vertebral fracture. He was managed nonoperatively, however, he remained ventilator dependent and ultimately expired secondary to cardiac arrest from a suspected pulmonary embolism. DISCUSSION: We present a case of complete SCI secondary to a retained bullet in the cervical spine. These cases can be managed both operatively and nonoperatively. Given the high risk of morbidity and overall poor neurological recovery after surgical intervention for SCI secondary to GSW, physicians must understand the appropriate indications for surgical intervention. These indications include, but are not limited to, progressive neurological deficit, cerebrospinal fluid leak, spinal instability, and acute lead toxicity.

Spinal Epidural Abscess: A Review of Presentation, Management, and Medicolegal Implications.

Spinal epidural abscess (SEA) is a rare condition associated with significant morbidity and mortality. Despite advances in diagnostic medicine, early recognition of SEAs remains elusive. The vague presentation of the disease, coupled with its numerous risk factors, the diagnostic requirement for obtaining advanced imaging, and the necessity of specialized care constitute extraordinary challenges to both diagnosis and treatment of SEA. Once diagnosed, SEAs require urgent or emergent medical and/or surgical management. As SEAs are a relatively rare pathology, high-quality data are limited and there is no consensus on their optimal management. This paper focuses on presenting the treatment modalities that have been successful in the management of SEAs and providing a critical assessment of how specific SEA characteristics may render one infection more amenable to primary surgical or medical interventions. This paper reviews the relevant history, epidemiology, clinical presentation, radiology, microbiology, and treatment of SEAs and concludes by addressing the medicolegal implications of delayed treatment of the disease.

Early Experience Managing a High-volume Academic Orthopaedic Department During the Coronavirus Pandemic in New York City.

Our orthopaedic surgery department at Montefiore Medical Center and Albert Einstein College of Medicine is located within the Bronx, a borough of New York City, and serves a densely populated urban community. Since the beginning of the novel coronavirus outbreak in New York City, the medical center was forced to rapidly adapt to the projected influx of critically ill patients. The aim of this report is to outline how our large academic orthopaedic surgery department adopted changes and alternative practices in response to the most daunting challenge to public health in our region in over a century. We hope that this report provides insight for others facing similar challenges.

Reliability and Clinical Utility of the CARDS Classification for Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study is to determine the reliability and clinical utility of the of the proposed CARDS classification for degenerative spondylolisthesis. BACKGROUND: The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system was recently proposed as an alternative to the Meyerding system for classifying degenerative spondylolisthesis (DS). Unlike Meyerding, CARDS considers other relevant radiographic findings such as disk space collapse and segmental kyphosis to stratify DS into 4 radiographically discreet types. Currently, no studies have been conducted to assess the clinical utility of the CARDS system. METHODS: A total of 78 consecutive surgical patients with L4-L5 DS were rated as CARDS types A through D and Fleiss' κ for interobserver agreement was calculated. Then, demographics as well as preoperative and postoperative outcome scores (ODI, SF-12 mental and physical, VAS) were collected. The Kruskal-Wallis test was used to detect significant differences amongst CARDS types. An unpaired t test was used to compare individual CARDS types with all other subtypes combined. RESULTS: Grading showed: 4 type A, 19 type B, 45 type C, and 8 type D (k=0.63). There was a statistically significant difference in preoperative back pain (P=0.046) between groups. CARDS type D had the highest mean back pain scores (8.8) of all subtypes which was significantly higher than mean back pain for all other subtypes combined (P=0.016). CARDS D showed the largest degree of improvement in all outcome measures. There was a trend towards an increased improvement in ODI (P=0.074) and SF-12 MCS (P=0.095) in the CARDS D subtype relative to the rest of the cohort. CONCLUSIONS: The CARDS classification system represents a reliable method for classifying cases of DS. Our results indicate that kyphotic segmental alignment (CARDS D) may be a less common, yet clinically distinct subset of DS characterized by worse preoperative back pain. CARDS type D cases may also show a greater degree of improvement in multiple outcome measures following surgical intervention.

C1 fractures: a review of diagnoses, management options, and outcomes.

The atlas is subject to fracture under axial load, often due to traumatic injuries such as shallow dives and automobile accidents. These fractures account for 2-13 % of injuries to the cervical spine [Marcon RM et al. Clinics (Sao Paulo) 68(11):1455-61, 2013]. Fractures of the C1 vertebra are often difficult to diagnose, as there is often no neurological deficit or easily identifiable findings on radiographs. However, injuries to the atlas can be associated with vertebral artery injury and atlantoaxial or atlanto-occipital instability, making prompt and accurate diagnosis imperative. A detailed understanding of the anatomy, inherent stability, and common injury patterns is essential for any surgeon treating spinal trauma. This chapter explores the diagnosis and management of C1 fractures, as well as outcomes after treatment.

Advances in the understanding of cervical spine deformity.

Cervical spine deformities pose substantial challenges for spine surgeons. The anatomy and biomechanics of the cervical spine play an important role in the decision-making process regarding treatment. The etiology of cervical deformities can be congenital, developmental, iatrogenic, degenerative, or inflammatory. Dropped head syndrome has been recently described but is poorly understood. Patients have variable presentations ranging from neck pain to an inability to maintain head position and neural compromise. Radiographic angles are important to monitor the deformity and plan the surgical correction. Treatment is focused on relieving pain, preventing and improving neurologic compromise, and improving overall spinal alignment and balance. The surgical approach and the level of fusion should be individualized on a case-by-case basis. The surgeon can greatly improve a patient's quality of life by understanding the nature of the patient's deformity and fully considering all treatment options.

The integration of radiosurgery for the treatment of patients with metastatic spine diseases.

Significant evidence emerging in the spinal oncology literature recommends radiosurgery as a primary modality of treatment of spinal metastasis. Improvements in the methods of delivering radiation have increased the ability to provide a higher and more exacting dose of radiation to a tumor bed than previously. Using treatment-planning software, radiation is contoured around a specific lesion with the intent of administering a tumoricidal dose. Combined with a minimally invasive, tumor-load reducing surgery, this advanced form of radiation therapy can provide better local control of the tumor compared with conventional external beam radiation.