Do Inflammatory Cytokines Affect Patient Outcomes After ACDF?

STUDY DESIGN: Prospective cohort study. OBJECTIVE: The aim was to determine the relationship between serum inflammatory mediators, preoperative cervical spine disease severity, and clinical outcomes after anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: Given the role of the inflammatory cascade in spinal degenerative disease, it has been hypothesized that inflammatory markers may serve as a predictor of patient outcomes after surgery. MATERIALS AND METHODS: All patients over age 18 who underwent ACDF for cervical spondylosis with associated radiculopathy and/or myelopathy between 2015 and 2017 from a single institution were prospectively recruited. Preoperative serum inflammatory markers including interleukin (IL)-6, IL-8, tumor necrosis factor-α, high-mobility group box-1 (HMGB1), and white blood cells were measured and correlated to patient demographics, surgical characteristics, duration of symptoms, previous opioid use, and preoperative and 1-year postoperative patient-reported outcomes measures (PROMs) including the neck disability index (NDI), visual analog scale neck pain, visual analog scale arm pain, and Physical and Mental Component Scores of the Short Form-12 (PCS and MCS, respectively) using spearman's rho coefficient. RESULTS: A total of 77 patients were enrolled with follow-up PROMs available for 62% (n=48) of patients at a minimum of 1-year after ACDF. The absolute concentrations of IL-6 and tumor necrosis factor-α were found to be weakly correlated with one another (ρ=0.479). Preoperative symptoms lasting <1-year were weakly correlated with elevation in HMGB1 (ρ=0.421). All other patient demographics exhibited negligible correlation with the preoperative inflammatory markers. Lower preoperative PCS (ρ=0.355) and higher preoperative NDI (ρ=0.336) were weakly correlated with elevated HMGB1. Lower MCS (ρ=0.395) and higher NDI (ρ=0.317) preoperatively were weakly correlated with elevated white blood cells. Postoperative improvement in MCS (ρ=0.306) and MCS recovery ratio (ρ=0.321) exhibited a weakly positive correlation with IL-6. CONCLUSION: Preoperative cytokine levels demonstrated minimal correlation with preoperative symptoms or clinical improvement, suggesting that profiling of patient cytokines has limited utility in predicting outcomes after ACDF. LEVEL OF EVIDENCE: Level III.

Thoracolumbar Spinal Cord Stimulator Trial: Procedural Technique.

Spinal cord stimulator trials are indicated for the treatment of postlaminectomy syndrome with persistent severe back and limb pain which has failed conservative treatment options and where no further surgery is indicated. They are also indicated for refractory complex regional pain syndrome. This article details patient positioning and set up, step-by-step instructions for the procedure and postoperative management. Pearls and pitfalls are also discussed. In addition, an instructional procedure video, Supplemental Digital Content 1 (http://links.lww.com/CLINSPINE/A121) accompanies this paper.

Effects of Operating Room Size on Surgical Site Infection Following Lumbar Fusion Surgery.

BACKGROUND: Surgical site infections (SSIs) represent a devastating complication after spine surgery. Many factors have been identified, but the influence of operating room (OR) size on infection rate has not been assessed. METHODS: Two thousand five hundred and twenty-three patients who underwent open lumbar spine fusion at a single institution between 2010 and 2016 were included. Patients were dichotomized into large versus small groups based on OR volume. Bivariate logistic regression and a final multivariate model following a multicollinearity check were used to calculate odds of infection for all variables. RESULTS: A total of 63 patients (2.5%) developed SSIs with 46 (73%) in the larger OR group and 17 (27%) in the smaller OR group. The rate of SSIs in larger ORs was 3.02% compared with 1.81% in smaller ORs. Significant parameters impacting SSI in bivariate analysis included an earlier year of surgery, BMI > 30, more comorbidities, more levels decompressed and fused, smoking, and larger OR volumes. Multivariate analysis identified BMI > 30, Elixhauser scores, smoking, and increasing levels decompressed as significant predictors. Topical vancomycin was found to significantly decrease rate of infection in both analyses. CONCLUSIONS: OR size (large versus small) was ultimately not a significant predictor of infection related to rates of SSIs, although it did show a clinical trend toward significance, suggesting association. Future prospective analysis is warranted. LEVEL OF EVIDENCE: 3.

Functional and Radiological Outcomes of Combined Anterior-Posterior Approach Versus Posterior Alone in Management of Isthmic Spondylolisthesis. A Systematic Review and Meta-Analysis.

BACKGROUND: Lumbar isthmic spondylolisthesis (IS) in adults is defined as the forward slippage of a vertebra onto the top of the vertebra, resulting from a defect in the pars intraarticular, and can be low grade or high grade. Persistent back pain or neurological deficit are indications for surgical intervention. Surgery can be done from back, front, or both, with or without fusion, instrumentation, or decompression, and short or long segment. METHODS: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, several databases were searched through August 2017 for any observational or experimental studies that evaluated combined anterior-posterior approach versus posterior alone in management of IS. Primary outcome was fusion rate, whereas secondary outcomes included functional outcomes (Visual Analogue Scale [VAS] and Oswestry Disability Index [ODI] score), complication rate (infection, neurological), and reoperation rate. Descriptive, quantitative, and qualitative data were extracted. Most of the cases were low-grade IS. RESULTS: Of the 645 articles identified, 6 studies were eligible for the meta-analysis, with a total of 397 patients with IS, 198 in the combined (anterior interbody fusion [ALIF] + postero-lateral fusion [PLF]) group and 199 in the posterior (transformational interbody fusion [TLIF]/ postero-lateral interbody fusion [PLIF] + PLF) group, average age of 47.2 years, and 185:212 male : female ratio. Although the fusion rate reached 100% in some studies, the pooled odds ratio (OR) of fusion rate (OR = 1.02, 95% confidence interval [CI]: 0.294, 3.552, P = .972) did not reach statistical significance between (ALIF + PLF) versus (TLIF/PLIF + PLF). The estimated pooled standardized mean difference (SMD) showed less blood loss in the anterior approach compared to the posterior approach (SMD = -0.528, 95% CI: -0.777, -0.278, P < .001), with no difference in operative time and length of hospital stay. Despite both groups showing significant improvement in pain and functional scores at final follow up, ODI and VAS were not significantly different between groups with ODI (SMD = -0.644, 95% CI: -1.948, 0.621, P = .311) and VAS (SMD = 0.113, 95% CI: -0.173, 0.400, P = .439). The complication rate for the anterior approach was higher than the posterior, whereas reoperation rate was higher in the posterior approach than the anterior. CONCLUSIONS: No significant difference between anterior and posterior approaches was found in the global assessment of fusion rate and clinical outcomes, despite a higher rate of complications using the anterior approach. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Both anterior and posterior approach are a valid option for treatment of isthemic spondylolisthesis.

How to Write an Effective Results Section.

Developing a well-written research paper is an important step in completing a scientific study. This paper is where the principle investigator and co-authors report the purpose, methods, findings, and conclusions of the study. A key element of writing a research paper is to clearly and objectively report the study's findings in the Results section. The Results section is where the authors inform the readers about the findings from the statistical analysis of the data collected to operationalize the study hypothesis, optimally adding novel information to the collective knowledge on the subject matter. By utilizing clear, concise, and well-organized writing techniques and visual aids in the reporting of the data, the author is able to construct a case for the research question at hand even without interpreting the data.

How to Write an Effective Introduction.

Ideally, the Introduction is an essential attention grabbing section of a research paper. If written correctly, the Introduction peaks the reader's interest as well as serves as a roadmap for the rest of the paper. An effective Introduction builds off related empirical research and demonstrates a gap in which the current study fills. Finally, the Introduction proposes the research question(s) which will be answered in subsequent sections of the paper. A strong Introduction also requires the use of a simple and well-organized format as well as the avoidance of common pitfalls.

How to Write an Effective Materials and Methods Section for Clinical Studies.

The Materials and methods section of a research paper is oftentimes the first and easiest part to write. It details the steps taken to answer a research hypothesis, the success of which determines whether or not the study can be replicated. Arranging the section in chronological order, writing succinctly, and consistently using the third-person passive voice adds clarity and improves readability. Furthermore, utilizing headers, tables, and flow charts to break down difficult and complex experiments into logical subsections makes it easier for the reader to grasp complicated designs.

Ossification of the posterior longitudinal ligament in the cervical spine: a review.

Ossification of the posterior longitudinal ligament (OPLL) is a rare pathologic process of lamellar bone deposition that can result in spinal cord compression. While multiple genetic and environmental factors have been related to the development of OPLL, the pathophysiology remains poorly understood. Asymptomatic patients may be managed conservatively and patients with radiculopathy or myelopathy should be considered for surgical decompression. Multiple studies have demonstrated the morphology and size of the OPLL as well as the cervical alignment have significant implications for the appropriate surgical approach and technique. In this review, we aim to address all the available literature on the etiology, history, presentation, and management of OPLL in an effort to better understand OPLL and give our recommendations for the treatment of patients presenting with OPLL.

How to Write Effective Discussion and Conclusion Sections.

With the exponential increase in research in the field of spine surgery, publishing peer-reviewed articles has become both more desirable and competitive in the past decade. Constructing an impactful manuscript has many important factors, one of which is a well-written Discussion section. A research study can ask a pressing question, have a meticulous methodology and report compelling results; however, without a thoughtful and well-informed analysis of the meaning of the study's findings and their potential influence on the field, the paper will be uninteresting and weak. Thus, formulating an effective Discussion section is crucial to improving the likelihood of the study's publication and its impact.

Biologic injections for osteoarthritis and articular cartilage damage: can we modify disease?

OBJECTIVE: The purpose of the present investigation is to conduct a systematic review of the literature to review the clinical results of platelet rich plasma (PRP) and mesenchymal stem cell treatments (MSC) (biologics) for articular cartilage lesions and osteoarthritis of the knee. METHODS: A search of the PubMed, EMBASE, and Cochrane databases was performed to identify studies involving biologic therapy for osteoarthritis or osteochondral defects. Only Level I-III clinical trials with at least 3-month follow-up were included. Outcome data was gathered on any patient-completed surveys, 2nd look arthroscopy, follow-up imaging, biopsy/histology results, and any adverse effects of treatment. RESULTS: Thirty-three articles met our inclusion criteria. There was a total of 21 PRP studies in the study. All PRP studies showed clinical improvement with PRP therapies in outcomes surveys measuring patient satisfaction, pain, and function. Two studies reported no significant difference in improvement compared to hyaluronic acid (HA). Similarly, the 7/9 MSC studies showed improvement. One study found BM-MSC implantation was not significantly superior to matrix assisted chondrocyte implantation (MACI), while one reported peripheral blood stem cells (PBSC) did not significantly improve outcomes over HA. Of the three studies looking at a combination of MSC/PRP, two found MSC/PRP combination did not improve outcomes compared to MSC or PRP therapy alone. The one PRP study that had a 2nd look arthroscopy reported increases cartilage regeneration with PRP. All 8 MSC studies with follow-up MRI and all 7 MSC studies with 2nd look arthroscopy showed improvement in cartilage regeneration in terms of coverage, fill of the defect, and/or firmness of the new cartilage. CONCLUSION: Current data suggests that, of the two treatments, MSC provides more significant disease modifying effect; however, further research needs to be done to compare these two treatments and determine if there is a synergetic effect when combined.