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.

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.

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.

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.

Functional analysis of fruitless gene expression by transgenic manipulations of Drosophila courtship.

A gal4-containing enhancer-trap called C309 was previously shown to cause subnormal courtship of Drosophila males toward females and courtship among males when driving a conditional disrupter of synaptic transmission (shi(TS)). We extended these manipulations to analyze all features of male-specific behavior, including courtship song, which was almost eliminated by driving shi(TS) at high temperature. In the context of singing defects and homosexual courtship affected by mutations in the fru gene, a tra-regulated component of the sex-determination hierarchy, we found a C309/tra(F) combination also to induce high levels of courtship between pairs of males and "chaining" behavior in groups; however, these doubly transgenic males sang normally. Because production of male-specific FRU(M) protein is regulated by TRA, we hypothesized that a fru-derived transgene encoding the male (M) form of an Inhibitory RNA (fru(MIR)) would mimic the effects of tra(F); but C309/fru(MIR) males exhibited no courtship chaining, although they courted other males in single-pair tests. Double-labeling of neurons in which GFP was driven by C309 revealed that 10 of the 20 CNS clusters containing FRU(M) in wild-type males included coexpressing neurons. Histological analysis of the developing CNS could not rationalize the absence of tra(F) or fru(MIR) effects on courtship song, because we found C309 to be coexpressed with FRU(M) within the same 10 neuronal clusters in pupae. Thus, we hypothesize that elimination of singing behavior by the C309/shi(TS) combination involves neurons acting downstream of FRU(M) cells.