Two-Attending Surgeon Teams Improve Outcomes of Single-Level Anterior Cervical Discectomy and Fusion.

Given the shift toward value-based healthcare, strategies that decrease risk in commonly performed procedures such as anterior cervical discectomy and fusion (ACDF) are of interest. The objective of this study was to analyze the effect of a two-attending surgeon team on the outcomes of patients undergoing single-level ACDF. A retrospective matched-cohort study of patients undergoing single-level ACDF for degenerative cervical spondylosis, with minimum 2-year follow-up was performed. Patients were subdivided into two cohorts: cases with procedures performed by one attending surgeon assisted by a resident physician and cases with procedures performed by an attending surgeon with another attending surgeon as first-assist. Patients were matched by age, sex, body mass index, smoking status, American Society of Anesthesia grade and Charlson Comorbidity Index. Perioperative data and complications were compared. Standard binomial and categorical comparative analysis were performed. Forty-two patients were included (21 in each group). There were 22 males and 20 females, with a mean age of 47.7 years and mean follow-up of 43.4 months. There were no differences in any demographic variable between groups, indicating successful matching. Cohort B had decreased anesthesia time (114.9 vs. 157.1 minutes, P < 0.001), operative time (58.1 vs. 98.9 minutes, P < 0.001) and blood loss (14.8 vs. 24.3 mL, P = 0.012). There were no significant differences in terms of post-operative complications including dysphagia, wound infection, neurologic or cardiovascular related complications. A two-attending surgeon team significantly reduces anesthesia time, surgical time, and blood loss in single-level ACDF procedures without an increase in complications or a decrease in fusion rates.

Long-term Outcomes of Minimally Invasive Lateral Lumbar Interbody Fusion in the Treatment of Adult Scoliosis.

The literature has shown the importance of long-term follow-up for adults with scoliosis treated surgically because complication and revision rates are high. The goal of this study was to determine long-term outcomes and complications of lateral lumbar interbody fusion (LLIF) with posterior instrumentation for adult patients with scoliosis. A retrospective review of our institution's database was performed to identify adult patients with scoliosis treated with LLIF between 2008 and 2013 with a minimum follow-up of 4 years. Medical records were reviewed for complications and revisions. Pre- and postoperative deformity Cobb angle measurements were taken as well as pelvic incidence (PI) and lumbar lordosis (LL). Functional outcome scores, including Oswestry Disability Index and visual analog scale score for back and leg pain, were assessed preoperatively and at follow-up. Standard binomial and categorical comparative analysis was performed. The 26 patients included had a mean age of 62 years, mean follow-up of 89 months, and mean of 1.8 levels per operation. Four patients (15.4%) required revisions. Mean deformity Cobb angle was 26° preoperatively and 14° postoperatively. Mean PI-LL mismatch was 11.7° preoperatively and 5.9° postoperatively. Nineteen (73%) patients had a PI-LL mismatch greater than 10° preoperatively, whereas only 2 (7.7%) had a mismatch postoperatively. Improvement was seen in all functional outcome scores. Long-term clinical results of LLIF for adults with deformity showed a low proportion of revision in the treatment of a condition with an established high rate of revision. The ability to reduce pelvic mismatch may further reduce the rate of revision. In this study, LLIF resulted in improved functional outcomes and patient satisfaction. [Orthopedics. 2022;45(3):e134-e139.].

Thyrotoxic Periodic Paralysis: A Spine Consultation.

As a consultant, the orthopaedic spine surgeon is often asked to evaluate patients with acute-onset extremity weakness. In some cases, patient's deficits can be attributed to nonspinal pathology; therefore, it is important to be aware of nonorthopaedic diagnoses when evaluating these patients. We report a case of thyrotoxic periodic paralysis that was initially confused by the consulting service with spinal pathology. A 32-year-old Hispanic man presented to our emergency department with rapid onset of lower extremity weakness. The consulting team ordered CT of the cervical and lumbar spine, as well as MRI of the lumbar spine which was aborted due to the patient's worsening tachycardia and chest pain. The spine service was subsequently consulted to evaluate the patient. Review of the metabolic panel revealed a low potassium, and additional testing led to the eventual diagnosis of thyrotoxic periodic paralysis. After correction of the patient's potassium, his weakness rapidly resolved, and no additional spinal workup was pursued. We describe this patient's presentation and outline the differential diagnosis for acute, nontraumatic extremity weakness, including both orthopaedic and other medical causes, that the spine surgeon should be aware of when evaluating patients with extremity weakness.

Minimally Invasive Posterior Cervical Foraminotomy as an Alternative to Anterior Cervical Discectomy and Fusion for Unilateral Cervical Radiculopathy: A Systematic Review and Meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: The aim of this study was to evaluate clinical outcomes, complications, and reoperations of minimally invasive posterior cervical foraminotomy (MI-PCF) for unilateral cervical radiculopathy without myelopathy, in comparison to anterior cervical decompression and fusion (ACDF). SUMMARY OF BACKGROUND DATA: ACDF is a standard treatment for cervical radiculopathy secondary to lateral disc herniation or foraminal stenosis. Recent studies have suggested MI-PCF to be an effective alternative to ACDF. However, concern for reoperation and whether similar improvements in clinical outcomes can be achieved has led to a debate in the literature. METHODS: We comprehensively searched PubMed, CINAHL Plus, and SCOPUS utilizing terms related to MI-PCF. Two independent reviewers assessed potential studies and extracted data on clinical outcome scores (neck disability index [NDI], visual analog scale [VAS]-neck, and VAS-arm), reoperation proportion, and complications. Studies included were on noncentral cervical pathology, published in the last 10 years, had a sample size of >10 patients, and reported data on minimally invasive techniques for posterior cervical foraminotomy. Heterogeneity and publication bias analyses were performed. The pooled proportions of each outcome were compared to those of ACDF obtained from two previously published studies. RESULTS: Fourteen studies were included with data of 1216 patients. The study population was 61.8% male, with a mean age of 51.57 years, and a mean follow-up of 30 months. MI-PCF resulted in a significantly greater improvement in VAS-arm scores compared to ACDF, and similar improvements in VAS-neck and NDI scores. Proportions of complications and reoperations were similar between the two cohorts. The most common complications were transient neuropraxia, wound-related, and durotomy. CONCLUSION: Our findings suggest that MI-PCF may be utilized as a safe and effective alternative to ACDF in patients with unilateral cervical radiculopathy without myelopathy, without concern for increased reoperations or complications. LEVEL OF EVIDENCE: 3.

Low energy chronic traumatic spondylolisthesis of the axis.

OBJECTIVE: The aim of this study is to present a unique case of a patient who presented to our Emergency Department with evidence of a chronic traumatic spondylolisthesis of the axis with severe displacement treated with anterior cervical discectomy and fusion (ACDF) of C2-C3 as well as and posterior cervical fusion (PCF) of C1-C3. METHODS: One patient with an untreated traumatic spondylolisthesis of the axis with Levine type II injury pattern and 1.2 cm of anterior subluxation underwent ACDF C2-C3 and PCF C1-C3. RESULTS: The patient recovered well, radiographs demonstrated reduction of the anterior subluxation, and the patient reported a neck disability index (NDI) score of 20 at 6-month follow-up with full neurologic function intact. The patient was then lost to follow-up. CONCLUSION: In this report, we present an alcoholic patient with a history of many falls who presented with a Levine type II traumatic spondylolisthesis of the axis with signs of chronicity seen on magnetic resonance imaging (MRI). We were able to partially reduce the anterior displacement with traction, but needed both anterior and posterior cervical approaches to achieve adequate reduction and stabilization of the injury.

Cervical Spinal Stenosis with Coexisting Rotator Cuff Tear: A Nationwide Review of Records from 2005 to 2014.

Rotator cuff tear (RCT) and cervical spinal stenosis (CSS) are common pathologies in the elderly. Both conditions may present with lateral shoulder pain and weakness or numbness of the upper extremity, potentially affecting patients' ability to live independently. Few data are available on the incidence of CSS among patients with concurrent RCT. The purpose of this study was to investigate the incidence of CSS among RCT patients, demographics, and surgical management using a national insurance database. The Medicare database was used to identify patients with RCT and concomitant CSS by ICD-9 codes from 2005-2014. Trends based on age, gender, and body mass index (BMI) were assessed. Utilization of open and arthroscopic rotator cuff repair (RCR) was compared. A total of 86,501 patients were identified. The number of patients diagnosed with RCT and CSS significantly increased (p< 0.0001). The incidence of CSS in patients with RCT increased from 9% to 13% (p < 0.05). Females < 64 years were more likely to exhibit combined pathology than age-matched males (OR 1.15, 95% CI 1.12 to 1.18) or females > 65 years (OR 1.64, 96% CI 1.61 to 1.67). A BMI of 30-40 kg/m2 demonstrated the highest incidence (43%, p < 0.0001). Arthroscopic RCR increased by 2% (p = 0.03) in RCT-CSS. The incidence of CSS in RCT patient is increasing. Orthopedic surgeons should maintain high clinical suspicion for concurrent CSS pathology in patients with RCT, particularly in obese female patients > 65 years with several medical comorbidities. Further investigation into the influence of these concurrent pathologies on patient outcomes is warranted.

Risk Factors for Pseudarthrosis in Minimally-Invasive Transforaminal Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort study (level of evidence: 4). PURPOSE: To describe the potential comorbid, operative, and radiographic risk factors for the development of clinically-relevant pseudarthrosis following minimally-invasive transforaminal lumbar interbody fusion (MIS-TLIF). OVERVIEW OF LITERATURE: MIS-TLIF has shown long-term clinical outcomes with decreased perioperative morbidity and earlier return to work, similar to those of open TLIF. However, unsuccessful fusion still remains a concern. The impacts of various patient, operative, and radiographic risk factors have not been evaluated for their potential association with pseudarthrosis related to MIS-TLIF. METHODS: Between 2012 and 2015, 204 consecutive patients underwent one or two-level MIS-TLIF at St. Joseph's University Medical Center, Paterson, NJ, USA; they had a minimum of 1 year of follow-up. The patients were divided into two cohorts: those who developed clinically-relevant pseudarthrosis and those who did not. Clinically-relevant pseudarthrosis was determined by both evidence on computed tomography and presence of continued clinical symptoms at 1-year follow-up. RESULTS: Revision surgery was the only identified non-radiographic factor associated with pseudarthrosis. Disc angle had the highest (R 2=0.8), followed by anterior disc height (R 2=0.79). Although posterior disc height and the ratio of anterior to posterior disc height showed a marked relationship with the outcome, the R 2-values were <0.3, thus indicating a less-strong correlation. The overall pseudarthrosis rate was 8%. No statistically significant differences were identified between the two cohorts with respect to mean age, sex, medical comorbidities, smoking status, or number of levels fused. CONCLUSIONS: Clinically-relevant pseudarthrosis is not uncommon following MIS-TLIF. In the current study, undergoing revision surgery, disc angle, and anterior disc height were observed to be associated with clinically-relevant pseudarthrosis. This study demonstrated that the patient population may benefit from an alternate approach.

Short-Segment Fixation With Percutaneous Pedicle Screws in the Treatment of Unstable Thoracolumbar Vertebral Body Fractures.

Clinical care of patients with unstable thoracolumbar vertebral body fractures may be challenging, especially in the setting of polytrauma patients who require other acute intervention. Compared with the traditional open approach, percutaneous short-segment fixation constructs place less surgical burden on patients regarding operative time and blood loss. Between 2008 and 2012, 32 patients with a mean age of 49 years (range, 19-80 years) underwent percutaneous short-segment fixation at the authors' institution and had a minimum of 6 months of complete clinical and radiographic follow-up. Load-sharing classification scores were determined. Outcomes evaluated included anterior body height, posterior body height, local kyphosis, regional kyphosis, thoracolumbar junctional kyphosis, mean operative time, and total blood loss. Standard binomial and categorical comparative analyses were performed. All load-sharing classification scores were 7 or less, and 11 of the 32 patients were polytrauma patients requiring surgery. No difference was seen between preoperative and late measurements of anterior body height, posterior body height, local kyphosis, regional kyphosis, or thoracolumbar junctional kyphosis. There were no complications, revisions, or anterior corpectomies. Only 2 patients (6%) underwent elective removal of hardware at 1 year. Mean operative time was 43 minutes (range, 33-56 minutes), and mean estimated blood loss was less than 50 mL. Percutaneous short-segment fixation prevented loss of vertebral body height and progression of kyphosis in the treatment of unstable thoracolumbar fractures with load-sharing classification scores of 7 or less. This study shows that these fractures with a load-sharing classification score of 6 and 7 may be stabilized using fewer screws than traditional methods in some patients and allow polytrauma patients to undergo other acute treatment. [Orthopedics. 2018; 41(6):e802-e806.].

Incidence of Neuraxial Abnormalities Is Approximately 8% Among Patients With Adolescent Idiopathic Scoliosis: A Meta-analysis.

BACKGROUND: Several studies have sought to address the role of routine preoperative MRI in patients with adolescent idiopathic scoliosis (AIS) undergoing deformity correction. Despite similar results regarding the prevalence of neuraxial anomalies detected on MRI, published conclusions conflict and give opposing recommendations. Lack of consensus has led to important variations in use of MRI before spinal surgery for patients with AIS. QUESTIONS/PURPOSES: This systematic review and meta-analysis of studies about patients with AIS evaluated (1) the overall proportion of neuraxial abnormalities; (2) the patient factors and curve characteristics that may be associated with abnormalities; and (3) the proportion of patients who underwent neurosurgical intervention before scoliosis surgery and the kinds of neuraxial lesions that were identified. METHODS: We performed a search of four electronic databases (PubMed, EMBASE, CINAHL Plus, and SCOPUS) utilizing search terms related to routine MRI and AIS, yielding 206 articles. Studies included had at least 20 participants, patients with ages 11 to 21 years, and a Methodological Index for Non-Randomized Studies (MINORS) study quality score of 8 and 16 points for noncomparative and comparative studies, respectively. Non-English manuscripts, animal studies, and those that did not include patients with AIS solely were excluded. Eighteen articles with 4746 patients were included for analysis of the overall proportion of neuraxial abnormalities, 12 articles with 3028 patients for analysis by sex, eight articles with 1603 patients for right main thoracic curve, eight articles with 665 patients for a left main thoracic curve, and 13 articles with 3063 patients and 230 (7.5%) abnormalities for number of neurosurgical interventions before scoliosis correction. The mean MINORS score for studies included was 14 (range, 10-20). Each study was analyzed for the proportion of patients identified with neuraxial abnormalities and associations with specific demographics. We determined the proportion of patients who underwent surgical interventions before scoliosis surgery as well as the types of neuraxial lesions identified. The articles were assessed for heterogeneity and publication bias. Because all groups were determined to be heterogeneous, a random-effects model was used for each group in this meta-analysis; with this analysis, an overlap of 95% confidence intervals suggests no difference at the p < 0.05 level, but this analytic approach does not provide p values. RESULTS: The pooled proportion of neuraxial abnormalities detected on MRI was 8% (95% confidence interval [CI], 6%-12%). With the numbers available, we found no difference in the proportion of male and female patients with neuraxial abnormalities (18% [95% CI, 11%-29%] versus 9% [95% CI, 6%-12%], respectively). Likewise, there was no difference in the proportion of pooled neuraxial abnormalities in right and left curves (9% [95% CI, 6%-14%] versus 15% [95% CI, 5%-35%], respectively). In the subset of abnormalities analyzed for number of neurosurgical interventions before scoliosis correction, the pooled proportion showed that 33% (95% CI, 24%-43%) underwent neurosurgical intervention before deformity correction. The most common abnormalities of the 367 found on MRI were syringomyelia in 127 patients (35%), Arnold-Chiari Type 1 malformation with syrinx in 103 patients (28%), and isolated Arnold-Chiari Type 1 malformation in 91 patients (25%). CONCLUSIONS: The proportion of patients with AIS who have neuraxial abnormalities is high (8%) and a large number undergo surgical intervention before scoliosis reconstruction. We did not find any particular demographic variables that indicated an increased risk of abnormality. Clinicians should consider advanced imaging before surgical intervention in the treatment of a patient with an idiopathic diagnosis. Preventable variables need to be identified by future studies to establish a better working treatment protocol for these patients. LEVEL OF EVIDENCE: Level III, diagnostic study.