Construct length analysis of type B and C cervical and thoracolumbar fractures.

Objectives: The purpose of this study is to identify if construct length affects the rate of surgical complications and instrumentation revision following surgical fixation of subaxial and thoracolumbar Type B and C fractures. This study evaluates the effect of ankylosing spondylitis/diffuse idiopathic skeletal hyperostosis (AS/DISH) within this population on outcomes. Methods: Retrospective review of 91 cervical and 89 thoracolumbar Type B and C fractures. Groups were divided by construct length for analysis: short-segment (constructs spanning two or less segments adjacent to the fracture) and long-segment (constructs spanning more than two segments adjacent to the vertebral fracture). Results: For cervical fractures, construct length did not impact surgical complications (P = 0.641), surgical hardware revision (P = 0.167), or kyphotic change (P = 0.994). For thoracolumbar fractures, construct length did not impact surgical complications (P = 0.508), surgical hardware revision (P = 0.224), and kyphotic change (P = 0.278). Cervical Type B fractures were nonsignificantly more likely to have worsened kyphosis (P = 0.058) than Type C fractures. Assessing all regions of the spine, a diagnosis of AS/DISH was associated with an increase in kyphosis (P = 0.030) and a diagnosis of osteoporosis was associated with surgical hardware failure (P = 0.006). Conclusion: Patients with short-segment instrumentation have similar surgical outcomes and changes in kyphosis compared to those with long-segment instrumentation. A diagnosis of AS/DISH or osteoporosis was associated with worse surgical outcomes.

The Impact of Outpatient Physical Therapy on Patient-Reported Outcomes after Lumbar Fusion: Perspective from A Bundled Care Dataset.

OBJECTIVE/BACKGROUND: As value-based care grows in popularity across the United States, more payers have turned toward bundled payment models for surgical procedures. Though episode costs in spine are highly variable, physical therapy (PT) has been identified as a driver of 90-day cost. The goal of this study is to assess the impact of postoperative PT on patient-reported outcomes and cost after lumbar fusion surgery using bundled insurance data. METHODS: Bundled payment information of lumbar fusion episodes-of-care (EOC) from 2019 to 2021 was reviewed at a single, urban, tertiary care center. EOC comprised a 210-day period surrounding the date of the procedure, beginning 30 days preoperatively and ending 180 days postoperatively. Patients were grouped into physical therapy (PT) and no physical therapy (no PT) groups based on the presence of physical therapy claims. RESULTS: Bivariate analysis of surgical outcomes revealed similar overall complication rates (p=0.413), 30-day readmissions (p=0.366) and 90-day readmissions (p=0.774). Patients that did not participate in postoperative PT had significantly better preoperative PCS (p=0.003), six-month postoperative PCS (p=0.001), and six-month ΔPCS (p=0.026) compared to patients who participated in postoperative PT. At one-year follow-up, patients who did not participate in PT had less leg pain (p=0.041) than those who did participate in PT. CONCLUSIONS: Our study finds that PT after lumbar fusion is not associated with significant improvement in ODI, PCS, MCS, or VAS pain scores. Additionally, the number of PT sessions a patient attends has no correlation with improvement in these outcomes.

A Comparison of Clinical Outcomes Between Anterior Cervical Discectomy and Fusion Versus Posterior Cervical Laminoplasty for Multilevel Cervical Myelopathy.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: To compare patient-reported outcomes and surgical outcomes after anterior cervical discectomy and fusion (ACDF) versus cervical laminoplasty for multilevel cervical spondylotic myelopathy. BACKGROUND: Treatment options for multilevel cervical spondylotic myelopathy include ACDF and cervical laminoplasty. Given that the literature has been mixed regarding the optimal approach, especially in patients without kyphosis, there is a need for additional studies investigating outcomes between ACDF and cervical laminoplasty. METHODS: A retrospective review was conducted of adult patients undergoing 3 or 4-level surgery. Patients with preoperative kyphosis based on C2-C7 Cobb angles were excluded. The electronic medical record and institutional databases were reviewed for baseline characteristics, surgical outcomes, and patient-reported outcomes. RESULTS: A total of 101 patients who underwent ACDF and 52 patients who underwent laminoplasty were included in the study. The laminoplasty cohort had a higher overall Charlson Comorbidity Index (3.10 ± 1.43 vs 2.39 ± 1.57, P = 0.011). Both groups had a comparable number of levels decompressed, C2-C7 lordosis, and diagnosis of myelopathy versus myeloradiculopathy. Patients who underwent laminoplasty had a longer length of stay (2.04 ± 1.15 vs 1.48 ± 0.70, P = 0.003) but readmission, complication, and revision rates were similar. Both groups had similar improvement in myelopathy scores (∆modified Japanese Orthopedic Association: 1.11 ± 3.09 vs 1.06 ± 3.37, P = 0.639). ACDF had greater improvement in Neck Disability Index (∆Neck Disability Index: -11.66 ± 19.2 vs -1.13 ± 11.2, P < 0.001), neck pain (∆Visual Analog Scale-neck: -2.69 ± 2.78 vs -0.83 ± 2.55, P = 0.003), and arm pain (∆Visual Analog Scale-arm: -2.47 ± 3.15 vs -0.48 ± 3.19, P = 0.010). These findings persisted in multivariate analysis except for Neck Disability Index. CONCLUSION: ACDF and cervical laminoplasty appear equally efficacious at halting myelopathic progression. However, patients who underwent ACDF had greater improvements in arm pain at 1 year postoperatively. Longitudinal studies evaluating the efficacy of laminoplasty to mitigate adjacent segment disease are indicated to establish a robust risk-benefit assessment for these 2 procedures. LEVEL OF EVIDENCE: III.

Comparison of Length of Stay and Discharge Disposition after Short-Segment Lumbar Fusion Surgery at Tertiary Care and Non-Tertiary Care Hospitals: A Propensity Score Matched Analysis.

STUDY DESIGN: A retrospective study. OBJECTIVE: To compare the perioperative and postoperative outcomes among lumbar fusion patients treated at an orthopaedic specialty hospital (OSH), a hybrid community hospital (HCH), and a conventional community hospital in comparison to a tertiary care hospital (TCH). SUMMARY OF BACKGROUND DATA: In spine surgery, strategies to reduce length of stay (LOS) include a myriad of pre-, intra-, and postoperative strategies that require a multidisciplinary infrastructure. The sum of these efforts has led to the creation of orthopedic specialty hospitals and protocols that have been adopted by community hospitals as well. There is a notable lack of information regarding the results of these efforts across different healthcare institution models. METHODS: This was a retrospective study of patients undergoing elective one or two-level lumbar fusion between 2017 and 2022 at a large urban TCH, an OSH, a HCH, and a conventional CH. Data was collected on patient characteristics, demographics, comorbidities, BMI, smoking status, surgical type, surgical levels, surgery duration, hospital length of stay, readmissions, reoperations, and discharge status within a year. Patients across the four surgical settings were matched based on age, BMI, CCI, type of procedure, and number of levels fused. RESULTS: A total of 1435 patients met the inclusion criteria. Length of hospital stay was significantly longer at TCH compared to OSH, HCH, and CH by an average of 1-2 days (P<0.001). 90-day readmissions were higher at TCH compared to OSH (P=0.001). TCH patients also were less likely to be discharged home than OSH and HCH patients (P=0.001 and P=0.016, respectively). No significant differences were noted in 1-year reoperation rates across all hospital models. CONCLUSION: Shorter lengths of stays and more home discharges at the orthopaedic specialty hospital and community hospital settings did not compromise surgical quality or postoperative outcomes.

Riluzole for Degenerative Cervical Myelopathy: A Secondary Analysis of the CSM-PROTECT Trial.

Importance: The modified Japanese Orthopaedic Association (mJOA) scale is the most common scale used to represent outcomes of degenerative cervical myelopathy (DCM); however, it lacks consideration for neck pain scores and neglects the multidimensional aspect of recovery after surgery. Objective: To use a global statistical approach that incorporates assessments of multiple outcomes to reassess the efficacy of riluzole in patients undergoing spinal surgery for DCM. Design, Setting, and Participants: This was a secondary analysis of prespecified secondary end points within the Efficacy of Riluzole in Surgical Treatment for Cervical Spondylotic Myelopathy (CSM-PROTECT) trial, a multicenter, double-blind, phase 3 randomized clinical trial conducted from January 2012 to May 2017. Adult surgical patients with DCM with moderate to severe myelopathy (mJOA scale score of 8-14) were randomized to receive either riluzole or placebo. The present study was conducted from July to December 2023. Intervention: Riluzole (50 mg twice daily) or placebo for a total of 6 weeks, including 2 weeks prior to surgery and 4 weeks following surgery. Main Outcomes and Measures: The primary outcome measure was a difference in clinical improvement from baseline to 1-year follow-up, assessed using a global statistical test (GST). The 36-Item Short Form Health Survey Physical Component Score (SF-36 PCS), arm and neck pain numeric rating scale (NRS) scores, American Spinal Injury Association (ASIA) motor score, and Nurick grade were combined into a single summary statistic known as the global treatment effect (GTE). Results: Overall, 290 patients (riluzole group, 141; placebo group, 149; mean [SD] age, 59 [10.1] years; 161 [56%] male) were included. Riluzole showed a significantly higher probability of global improvement compared with placebo at 1-year follow-up (GTE, 0.08; 95% CI, 0.00-0.16; P = .02). A similar favorable global response was seen at 35 days and 6 months (GTE for both, 0.07; 95% CI, -0.01 to 0.15; P = .04), although the results were not statistically significant. Riluzole-treated patients had at least a 54% likelihood of achieving better outcomes at 1 year compared with the placebo group. The ASIA motor score and neck and arm pain NRS combination at 1 year provided the best-fit parsimonious model for detecting a benefit of riluzole (GTE, 0.11; 95% CI, 0.02-0.16; P = .007). Conclusions and Relevance: In this secondary analysis of the CSM-PROTECT trial using a global outcome technique, riluzole was associated with improved clinical outcomes in patients with DCM. The GST offered probability-based results capable of representing diverse outcome scales and should be considered in future studies assessing spine surgery outcomes.

The attainment of a patient acceptable symptom state in patients undergoing revision spine fusion.

INTRODUCTION: Revision lumbar fusion is most commonly due to nonunion, adjacent segment disease (ASD), or recurrent stenosis, but it is unclear if diagnosis affects patient outcomes. The primary aim of this study was to assess whether patients achieved the patient acceptable symptom state (PASS) or minimal clinically important difference (MCID) after revision lumbar fusion and assess whether this was influenced by the indication for revision. METHODS: We retrospectively identified all 1-3 level revision lumbar fusions at a single institution. Oswestry Disability Index (ODI) was collected at preoperative, three-month postoperative, and one-year postoperative time points. The MCID was calculated using a distribution-based method at each postoperative time point. PASS was set at the threshold of ≤ 22. RESULTS: We identified 197 patients: 56% with ASD, 28% with recurrent stenosis, and 15% with pseudarthrosis. The MCID for ODI was 10.05 and 10.23 at three months and one year, respectively. In total, 61% of patients with ASD, 52% of patients with nonunion, and 65% of patients with recurrent stenosis achieved our cohort-specific MCID at one year postoperatively with ASD (p = 0.78). At one year postoperatively, 33.8% of ASD patients, 47.8% of nonunion patients, and 37% of patients with recurrent stenosis achieved PASS without any difference between indication (p = 0.47). CONCLUSIONS: The majority of patients undergoing revision spine fusion experience significant postoperative improvements regardless of the indication for revision. However, a large proportion of these patients do not achieve the patient acceptable symptom state. While revision spine surgery may offer substantial benefits, these results underscore the need to manage patient expectations.

Postoperative opioid consumption patterns diverge between propensity matched patients undergoing traumatic and elective cervical spine fusion.

BACKGROUND CONTEXT: Prolonged opioid therapy following spine surgery is an ongoing postoperative concern. While prior studies have investigated postoperative opioid use patterns in the elective cervical surgery patient population, to our knowledge, opioid use patterns in patients undergoing surgery for traumatic cervical spine injuries have not been elucidated. PURPOSE: The purpose of this study was to compare opioid use and prescription patterns in the postoperative pain management of patients undergoing traumatic and elective cervical spine fusion surgery. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: Adult patients with traumatic cervical injuries who underwent primary anterior cervical discectomy and fusion (ACDF) or posterior cervical decompression and fusion (PCDF) during their initial hospital admission. The propensity matched, control group consisted of adult elective cervical fusion patients who underwent primary ACDF or PCDF. OUTCOME MEASURES: Demographic data, surgical characteristics, spinal disease diagnosis, location of cervical injury, procedure type, operative levels fused, and Prescription Drug Monitoring Program (PDMP) data. PDMP data included the number of opioid prescriptions filled, preoperative opioid use, postoperative opioid use, and use of perioperative benzodiazepines, muscle relaxants, or gabapentin. Opioid consumption data was collected in morphine milligram equivalents (MME) and standardized per day. METHODS: A 1:1 propensity match was performed to match traumatic injury patients undergoing cervical fusion surgery with elective cervical fusion patients. Traumatic injury patients were matched based on age, sex, CCI, procedure type, and cervical levels fused. Pre- and postoperative opioid, benzodiazepine, muscle relaxant, and gabapentin use were assessed for the traumatic injury and elective patients. T- or Mann-Whitney U tests were used to compare continuous data and Chi-Squared or Fisher's Exact were used to compare categorical data. Multivariate stepwise regression using MME per day 0 - 30 days following surgery as the dependent outcome was performed to further evaluate associations with postoperative opioid use. RESULTS: A total of 48 patients underwent fusion surgery for a traumatic cervical spine injury and 48 elective cervical fusion with complete PDMP data were assessed. Elective patients were found to fill more prescriptions (3.19 vs. 0.65, p=.023) and take more morphine milligram equivalents (MME) per day (0.60 vs. 0.04, p=.014) within 1 year prior to surgery in comparison to traumatic patients. Elective patients were also more likely to use opioids (29.2% vs. 10.4%, p=.040) and take more MMEs per day (0.70 vs. 0.05, p=.004) within 30 days prior to surgery. Within 30 days postoperatively, elective patients used opioids more frequently (89.6% vs. 52.1%, p<.001) and took more MMEs per day (3.73 vs. 1.71, p<.001) than traumatic injury patients. Multivariate stepwise regression demonstrated preoperative opioid use (Estimate: 1.87, p=.013) to be correlated with higher postoperative MME per day within 30 days of surgery. Surgery after traumatic injury was correlated with lower postoperative MME use per day within 30 days of surgery (Estimate: -1.63 p=.022). CONCLUSION: Cervical fusion patients with a history of traumatic spine injury consume fewer opioids in the early postoperative period in comparison to elective cervical fusion patients, however both cohorts consumed a similar amount after the initial 30-day postoperative period. Preoperative opioid use was also a risk factor for higher consumption in the short-term postoperative period. These results may aid physicians in further understanding patients' postoperative care needs based on presenting injury characteristics and highlights the need for enhanced follow-up care for traumatic cervical spine injury patients after fusion surgery.

The Impact of the Preoperative Mental Health Component Summary (MCS) Score on Short-term Outcomes after Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study is to characterize the relationship between preoperative MCS and surgical outcomes after lumbar spine surgery including inpatient complications, length of stay, readmissions, and reoperations. SUMMARY OF BACKGROUND DATA: As the prevalence of mental health disorders in the United States increases, it is important to identify risks associated with poor mental health status in the surgical spine patient. The mental health component summary (MCS) of the Short Form-12 has been used extensively as an indication of a patient's mental health status and psychological well-being. METHODS: Adult patients older than or equal to 18 years who underwent primary one to three level lumbar fusion surgery at our academic medical institution from 2017 to 2021 were retrospectively identified. Preoperative MCS score was used to analyze outcomes in patients based on a cutoff (<45.6). A score >45.6 indicated better preoperative mental health and a score <45.6 indicated worse preoperative mental health. RESULTS: Patients with lower preoperative MCS scores had longer hospital stays (3.86 + 2.16 vs. 3.55 + 1.42 days, P=0.010) and were more likely to have inpatient renal complications (3.09% vs. 7.19%, P=0.006). Patients with lower preoperative MCS scores also had lower Activity Measure for Post-Acute Care (AM-PAC) scores (17.1 + 2.85 vs. 17.6 + 2.49, P=0.030). Ninety-day surgical readmissions, medical readmissions, and reoperations were not significantly different between groups (P>0.05). CONCLUSION: Our study suggests that patients with lower preoperative mental health scores (MCS < 45.6) were independently more likely to experience more renal complications and longer length of stay after primary lumbar fusion. Additionally, higher MCS scores may correlate with better postoperative mobility and daily activity scores. Nevertheless, long-term outcomes are not significantly different between patients of better or worse preoperative mental health.

Circulating microRNAs May Be Predictive of Degenerative Cervical Myelopathy.

STUDY DESIGN: Basic Science. OBJECTIVE: The objective of this study was to identify a unique serum profile of circulating miRNAs and inflammatory markers in patients with degenerative cervical myelopathy (DCM) compared to healthy controls (HC). SUMMARY OF BACKGROUND DATA: Currently, DCM is diagnosed with a combination of history, physical examination, and close correlation to advanced imaging. To date, no serum marker has been identified to be diagnostic of this condition. METHODS: Whole venous blood was collected from patients with DCM as well as healthy age- and sex-matched controls. miRNA was extracted from venous blood and a screening analysis was initially conducted to identify miRNA dysregulation in DCM patients. RT-qPCR was used to analyze the expression of 2 specific miRNAs based on screening analysis and literature review. Bioinformatics analysis was used to identify gene networks and potential targets of the miRNA. In addition, the serum inflammatory profile of DCM and HC groups was differentiated using a pro-inflammatory panel. RESULTS: Thirty-six patients were enrolled in the DCM group (36.1% male, 61.5±9.5 y) while 35 patients were enrolled in the HC group (31.4% male, 57.5±8.9 y). Of the 15 total miRNAs differentially expressed between DCM and HC groups, two were selected for further analysis: miR-223-3p (upregulated) and miR-451a (downregulated). Functional gene network analysis revealed the highest-ranking gene network was involved in neurological disease, while the most overexpressed miRNA in this network (miR-233-3p) was noted to have over 100 targets including CDKN1B and the insulin receptor. Serum cytokine analysis showed significant upregulation of several pro-inflammatory cytokines in the DCM cohort compared to the HC group. CONCLUSION: DCM patients demonstrated a set of unique circulating miRNAs in addition to a different serum inflammatory profile compared to HC. These miRNAs may potentially serve as targets for future therapeutic intervention or diagnostic/prognostic testing.

Does Paraspinal Muscle Mass Predict Lumbar Lordosis before and after Decompression for Degenerative Spinal Stenosis?

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: The purpose of this study was to determine if muscle mass and quality of the lumbar paraspinal muscles was associated with improvements in lumbar lordosis and other sagittal parameters after isolated posterior lumbar decompression surgery for lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: Over time, either due to degenerative changes or other spinal conditions, individuals may develop sagittal imbalance. In patients with lumbar spinal stenosis, sagittal imbalance can further exacerbate symptoms of pain and radiculopathy. Sarcopenia of paraspinal muscles has been implicated in previous spine research as a variable with influence on surgical outcomes. METHODS: Sagittal parameters were measured on preoperative and postoperative lateral lumbar radiographs and included lumbar lordosis (LL), sacral slope (SS), and pelvic tilt (PT). Preoperative MRI images were evaluated at the base of the L4 vertebral body to assess muscles mass of the psoas muscle and paravertebral muscles (PVM) and Goutallier grade of the PVM. Patients were divided into 3 muscle size groups based on PVM normalized for body size (PVM/BMI): Group A (smallest), Group B, and Group C (largest). RESULTS: Patients in Group C had greater LL preoperatively (51.5° vs. 47.9° vs. 43.2, P=0.005) and postoperatively (52.2° vs. 48.9° vs. 45.7°, P=0.043). There was no significant difference in the ∆LL values between groups (P>0.05). Patients in Group C had larger SS preoperatively (35.2° vs. 32.1° vs. 30.0°, P=0.010) and postoperatively (36.1° vs. 33.0° vs. 31.7°, P=0.030). Regression analysis showed that PVM/BMI was a significant predictor of LL preoperatively (P=0.039) and postoperatively (P=0.031), as well as SS preoperatively (P=0.001) and postoperatively (P<0.001). CONCLUSION: Muscle mass of the paravertebral muscles significantly impacts lumbar lordosis and sacral slope in patients with lumbar spinal stenosis before and after posterior lumbar decompression. These findings highlight a need to address risk factors for poor muscle quality in patients with sagittal imbalance.

The Role of L1PA in Patient Reported Outcomes in Patients Undergoing Single Level Lumbar Fusion for Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine whether the L1 pelvic angle (L1PA) can be used to predict quality of life outcomes for adults one year after L4-L5 fusion to treat degenerative spondylolisthesis. SUMMARY OF BACKGROUND DATA: L1PA is beneficial in the evaluation of pre and postoperative quality of life outcomes in patients undergoing surgery for spinal deformity. No studies have examined its utility in surgical patients with degenerative spinal disease. METHODS: Patients undergoing L4-L5 posterolateral decompression and fusion or transforaminal lumbar interbody fusion for degenerative lumbar spondylolisthesis were grouped by preoperative and postoperative L1PA, and further stratified by cut offs of>7.2° and <7.2° based on previous literature. We also stratified patients by presence of an ideal calculated L1PA, defined as (0.5xPelvic Incidence)-21 +/- 5°, as proposed by prior literature. Preoperative, one year postoperative and Δ (postoperative minus preoperative) patient reported outcome measures (PROMs) and radiographic measurements were collected. RESULTS: Twenty-four patients were identified with preoperative L1PAs <7.2° and 132 with L1PAs>7.2°. Eighteen patients were identified with postoperative L1PAs <7.2° and 138 with L1PAs>7.2°. Sixty-five and fifty-seven patients were identified as having ideal calculated pre and postoperative L1PAs, respectively. When using absolute cutoffs, L1PA correlated with pelvic tilt, pelvic incidence, and pelvic incidence-lumbar lordosis mismatch (PI-LL). When using calculated L1PAs, L1PA correlated with lumbar lordosis, PI-LL, pelvic tilt and sacral slope. With respect to PROMs, no statistically significant differences existed between cohorts both preoperatively and at 1 year postoperatively on either univariate and multivariate analyses. CONCLUSION: L1PA may be a helpful radiographic consideration that translates to clinically relevant outcomes in spinal deformity. However, it does not appear as predictive of patient outcomes after single level fusion for patients with L4-L5 degenerative spondylolisthesis. Further studies are warranted to investigate the role of L1PA in degenerative spine patients.

Preoperative Electrodiagnostic Study Findings Differ Between Patients With Double-crush Syndrome and Carpal Tunnel Syndrome: A Propensity Matched Analysis.

INTRODUCTION: Double-crush syndrome (DCS) represents a condition that involves peripheral nerve compression in combination with spinal nerve root impingement. The purpose of this study was to compare electrodiagnostic study (EDS) results in patients undergoing carpal tunnel release (CTR) for carpal tunnel syndrome with those undergoing both CTR and anterior cervical diskectomy and fusion for DCS. METHODS: Patients receiving an isolated CTR were compared with those undergoing CTR and anterior cervical diskectomy and fusion within two years of CTR. The latter group was defined as our DCS cohort. Electrodiagnostic study results were collected which included sensory and motor nerve conduction data as well as electromyogram (EMG) findings. All electrodiagnostic studies were done before CTR in both sets of patients. RESULTS: Fifty-four patients with DCS and 137 CTR-only patients were included. Patients with DCS were found to have decreased sensory onset latency (3.51 vs 4.01; P = 0.015) and peak latency (4.25 vs 5.17; P = 0.004) compared with the CTR-only patients. Patients with DCS had slower wrist motor velocity (30.5 vs 47.7; P = 0.012), decreased elbow motor latency (9.62 vs 10.6; P = 0.015), and faster elbow motor velocity (56.0 vs 49.4; P = 0.031). EMG results showed that patients with DCS were more likely to have positive findings in the biceps (31.9% vs 1.96%; P < 0.001) and triceps (24.4% vs 2.97%; P < 0.001), but not abductor pollicis brevis (APB) (45.7% vs 37.9%; P = 0.459). CONCLUSION: We identified changes on EDS between patients with and without DCS. In patients with DCS, sensory nerve studies showed shorter peak and onset latency than in CTR-only patients. Interestingly, DCS and CTR-only patients had different patterns of wrist and elbow motor nerve conduction. Providers observing positive EMG findings proximal to the APB should raise their suspicion for possible cervical radiculopathy and when present with carpal tunnel syndrome-like symptoms, should also consider DCS in their diagnostic differential.

The Relationship Between Disc Herniation Morphology and Patient-Reported Outcomes after Microdiscectomy.

OBJECTIVE: Determine if herniation morphology based on the Michigan State University Classification is associated with differences in (1) patient-reported outcome measures (or (2) surgical outcomes after a microdiscectomy. METHODS: Adult patients undergoing single-level microdiscectomy between 2014 and 2021 were identified. Demographics and surgical characteristics were collected through a query search and manual chart review. The Michigan State University classification, which assesses disc herniation laterality (zone A was central, zone B/C was lateral) and degree of extrusion into the central canal (grade 1 was up to 50% of the distance to the intra-facet line, grade >1 was beyond this line), was identified on preoperative MRIs. patient-reported outcome measures were collected at preoperative, 3-month, and 1-year postoperative time points. RESULTS: Of 233 patients, 84 had zone A versus 149 zone B/C herniations while 76 had grade 1 disc extrusion and 157 had >1 grade. There was no difference in surgical outcomes between groups (P > 0.05). Patients with extrusion grade >1 were found to have lower Physical Component Score at baseline. On bivariate and multivariable logistic regression analysis, extrusion grade >1 was a significant independent predictor of greater improvement in Physical Component Score at three months (estimate = 7.957; CI: 4.443-11.471, P < 0.001), but not at 1 year. CONCLUSIONS: Although all patients were found to improve after microdiscectomy, patients with disc herniations extending further posteriorly reported lower preoperative physical function but experienced significantly greater improvement three months after surgery. However, improvement in Visual Analog Scale Leg and back, ODI, and MCS at three and twelve months was unrelated to laterality or depth of disc herniation.

Relating preoperative MCS-12 to microdiscectomy outcomes.

PURPOSE: To determine the impact of poor mental health on patient-reported and surgical outcomes after microdiscectomy. METHODS: Patients ≥ 18 years who underwent a single-level lumbar microdiscectomy from 2014 to 2021 at a single academic institution were retrospectively identified. Patient-reported outcomes (PROMs) were collected at preoperative, three-month, and one-year postoperative time points. PROMs included the Oswestry Disability Index (ODI), Visual Analog Scale Back and Leg (VAS Back and VAS Leg, respectively), and the mental and physical component of the short form-12 survey (MCS and PCS). The minimum clinically important differences (MCID) were employed to compare scores for each PROM. Patients were categorized as having worse mental health or better mental health based on a MCS threshold of 50. RESULTS: Of 210 patients identified, 128 (61%) patients had a preoperative MCS score ≤ 50. There was no difference in 90-day surgical readmissions or spine reoperations within one year. At 3- and 12-month time points, both groups demonstrated improvements in all PROMs (p < 0.05). At three months postoperatively, patients with worse mental health had significantly lower PCS (42.1 vs. 46.4, p = 0.004) and higher ODI (20.5 vs. 13.3, p = 0.006) scores. Lower mental health scores were associated with lower 12-month PCS scores (43.3 vs. 48.8, p < 0.001), but greater improvements in 12-month ODI (- 28.36 vs. - 18.55, p = 0.040). CONCLUSION: While worse preoperative mental health was associated with lower baseline and postoperative PROMs, patients in both groups experienced similar improvements in PROMs. Rates of surgical readmissions and reoperations were similar among patients with varying preoperative mental health status.

Postoperative C5 Palsy after Anterior or Posterior Decompression for Degenerative Cervical Myelopathy: A Subgroup Analysis of the Multicenter, Prospective, Randomized, Phase III, CSM-Protect Clinical Trial.

STUDY DESIGN: Retrospective cohort study of prospectively accrued data. OBJECTIVE: To evaluate a large, prospective, multicentre dataset of surgically-treated DCM cases on the contemporary risk of C5 palsy with surgical approach. SUMMARY OF BACKGROUND DATA: The influence of surgical technique on postoperative C5 palsy after decompression for degenerative cervical myelopathy (DCM) is intensely debated. Comprehensive analyses are needed using contemporary data and accounting for covariates. METHODS: Patients with moderate to severe DCM were prospectively enrolled in the multicenter, randomized CSM-Protect clinical trial and underwent either anterior or posterior decompression between Jan 31, 2012, to May 16, 2017. The primary outcome was the incidence of postoperative C5 palsy, defined as onset of muscle weakness by at least one grade in manual muscle test at the C5 myotome with slight or absent sensory disruption after cervical surgery. Two comparative cohorts were made based on anterior or posterior surgical approach. Multivariate hierarchical mixed-effects logistic regression was used to estimate odds ratios (OR) with 95% confidence intervals (CI) for C5 palsy. RESULTS: A total of 283 patients were included, and 53.4% underwent posterior decompression. The total incidence of postoperative C5 palsy was 7.4% and was significantly higher in patients that underwent posterior decompression compared to anterior decompression (11.26% vs. 3.03%, P=0.008). After multivariable regression, posterior approach was independently associated with greater than four times the likelihood of postoperative C5 palsy (P=0.017). Rates of C5 palsy recovery were comparable between the two surgical approaches. CONCLUSION: The odds of postoperative C5 palsy are significantly higher after posterior decompression compared to anterior decompression for DCM. This may influence surgical decision-making when there is equipoise in deciding between anterior and posterior treatment options for DCM. LEVEL OF EVIDENCE: Therapeutic Level II.

Preoperative Hounsfield Units Predict Pedicle Screw Loosening in Osteoporotic Patients Following Short Segment Lumbar Fusion.

STUDY DESIGN: Retrospective Cohort. OBJECTIVE: (1) To determine if vertebral HU values obtained from preoperative CT predict postoperative outcomes following 1-3 level lumbar fusion and (2) to investigate whether decreased BMD values determined by HU predict cage subsidence and screw loosening. SUMMARY OF BACKGROUND DATA: In light of suboptimal screening for osteoporosis, vertebral computerized tomography(CT) Hounsfield Units(HU), have been investigated as a surrogate for bone mineral density(BMD). METHODS: In this retrospective study, adult patients who underwent 1-3 level posterior lumbar decompression and fusion(PLDF) or transforaminal lumbar interbody and fusion(TLIF) for degenerative disease between the years 2017-2022 were eligible for inclusion. Demographics and surgical characteristics were collected. Outcomes assessed included 90-day readmissions, 90-day complications, revisions, patient reported outcomes(PROMs), cage subsidence, and screw loosening. Osteoporosis was defined as HU of ≤110 on preoperative CT at L1. RESULTS: We assessed 119 patients with a mean age of 59.1, of whom 80.7% were white and 64.7% were nonsmokers. The majority underwent PLDF(63%) compared to TLIF(37%), with an average of 1.63 levels fused. Osteoporosis was diagnosed in 37.8% of the cohort with a mean HU in the osteoporotic group of 88.4 compared to 169 in non-osteoporotic patients. Although older in age, osteoporotic individuals did not exhibit increased 90-day readmissions, complications, or revisions compared to non-osteoporotic patients. A significant increase in the incidence of screw loosening was noted in the osteoporotic group with no differences observed in subsidence rates. On multivariable linear regression osteoporosis was independently associated with less improvement in visual analog scale(VAS) scores for back pain. CONCLUSIONS: Osteoporosis predicts screw loosening and increased back pain. Clinicians should be advised of the importance of preoperative BMD optimization as part of their surgical planning and the utility of vertebral CT HU as a tool for risk stratification. LEVEL OF EVIDENCE: 3.

The impact of robotic assistance for lumbar fusion surgery on 90-day surgical outcomes and 1-year revisions.

Objectives: To evaluate the (1) 90-day surgical outcomes and (2) 1-year revision rate of robotic versus nonrobotic lumbar fusion surgery. Methods: Patients >18 years of age who underwent primary lumbar fusion surgery at our institution were identified and propensity-matched in a 1:1 fashion based on robotic assistance during surgery. Patient demographics, surgical characteristics, and surgical outcomes, including 90-day surgical complications and 1-year revisions, were collected. Multivariable regression analysis was performed. Significance was set to P < 0.05. Results: Four hundred and fifteen patients were identified as having robotic lumbar fusion and were matched to a control group. Bivariant analysis revealed no significant difference in total 90-day surgical complications (P = 0.193) or 1-year revisions (P = 0.178). The operative duration was longer in robotic surgery (287 + 123 vs. 205 + 88.3, P ≤ 0.001). Multivariable analysis revealed that robotic fusion was not a significant predictor of 90-day surgical complications (odds ratio [OR] = 0.76 [0.32-1.67], P = 0.499) or 1-year revisions (OR = 0.58 [0.28-1.18], P = 0.142). Other variables identified as the positive predictors of 1-year revisions included levels fused (OR = 1.26 [1.08-1.48], P = 0.004) and current smokers (OR = 3.51 [1.46-8.15], P = 0.004). Conclusion: Our study suggests that robotic-assisted and nonrobotic-assisted lumbar fusions are associated with a similar risk of 90-day surgical complications and 1-year revision rates; however, robotic surgery does increase time under anesthesia.

Evaluation of perioperative care and drivers of cost in geriatric thoracolumbar trauma.

Introduction: As the population of elderly patients continues to rise, the number of these individuals presenting with thoracolumbar trauma is expected to increase. Research question: To investigate thoracolumbar fusion outcomes for patients with vertebral fractures as stratified by decade. Secondarily, we examined the variability of cost across age groups by identifying drivers of cost of care. Materials and methods: We queried the United States Nationwide Inpatient Sample(NIS) for adult patients undergoing spinal fusion for thoracolumbar fractures between 2012 and 2017. Patients were stratified by decade 60-69(sexagenarians), 70-79(septuagenarians) and 80-89(octogenarians). Bivariable analysis followed by multivariable regression was performed to assess independent predictors of length of stay(LOS), hospital cost, and discharge disposition. Results: A total of 2767 patients were included, of which 46%(N = 1268) were sexagenarians, 36% septuagenarians and 18%(N = 502) octogenarians. Septuagenarians and octogenarians had shorter LOS compared to sexagenarians(ß = -0.88 days; p = 0.012) and(ß = -1.78; p < 0.001), respectively. LOS was reduced with posterior approach(-2.46 days[95% CI: 3.73-1.19]; p < 0.001), while Hispanic patients had longer LOS(+1.97 [95% CI: 0.81-3.13]; p < 0.001). Septuagenarians had lower total charges $12,185.70(p = 0.040), while the decrease in charges in octogenarians was more significant, with a decrease of $26,016.30(p < 0.001) as compared to sexagenarians. Posterior approach was associated with a decrease of $24,337.90 in total charges(p = 0.026). Septuagenarians and octogenarians had 1.72 higher odds(p < 0.001) and 4.16 higher odds(p < 0.001), respectively, of discharge to a skilled nursing facility. Discussion and conclusions: Healthcare utilization in geriatric thoracolumbar trauma is complex. Cost reductions in the acute hospital setting may be offset by unaccounted costs after discharge. Further research into this phenomenon and observed racial/ethnic disparities must be pursued.

A Longitudinal Evaluation of Coronavirus Disease 2019 and Its Effects on Spinal Decompressions With or Without Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: The objectives were to (1) compare the safety of spine surgery before and after the emergence of coronavirus disease 2019 (COVID-19) and (2) determine whether patients with a history of COVID-19 were at increased risk of adverse events. SUMMARY AND BACKGROUND DATA: The COVID-19 pandemic had a tremendous impact on several health care services. In spine surgery, elective cases were canceled and patients received delayed care due to the uncertainty of disease transmission and surgical outcomes. As new coronavirus variants arise, health care systems require guidance on how to provide optimal patient care to all those in need of our services. PATIENTS AND METHODS: A retrospective review of patients undergoing spine surgery between January 1, 2019 and June 30, 2021 was performed. Patients were split into pre-COVID or post-COVID cohorts based on local government guidelines. Inpatient complications, 90-day readmission, and 90-day mortality were compared between groups. Secondary analysis included multiple logistic regression to determine independent predictors of each outcome. RESULTS: A total of 2976 patients were included for analysis with 1701 patients designated as pre-COVID and 1275 as post-COVID. The pre-COVID cohort had fewer patients undergoing revision surgery (16.8% vs 21.9%, P < 0.001) and a lower home discharge rate (84.5% vs 88.2%, P = 0.008). Inpatient complication (9.9% vs 9.2%, P = 0.562), inpatient mortality (0.1% vs 0.2%, P = 0.193), 90-day readmission (3.4% vs 3.2%, P = 0.828), and 90-day mortality rates (0.8% vs 0.8%, P = 0.902) were similar between groups. Patients with positive COVID-19 tests before surgery had similar complication rates (7.7% vs 6.1%, P = 1.000) as those without a positive test documented. CONCLUSIONS: After the emergence of COVID-19, patients undergoing spine surgery had a greater number of medical comorbidities, but similar rates of inpatient complications, readmission, and mortality. Prior COVID-19 infection was not associated with an increased risk of postsurgical complications or mortality. LEVEL OF EVIDENCE: Level III.

Radiology Reports Do Not Accurately Portray the Severity of Cervical Neural Foraminal Stenosis.

STUDY DESIGN: Retrospective study. OBJECTIVE: (1) To compare cervical magnetic resonance imaging (MRI) radiology reports to a validated grading system for cervical foraminal stenosis (FS) and (2) to evaluate whether the severity of cervical neural FS on MRI correlates to motor weakness or patient-reported outcomes. BACKGROUND: Radiology reports of cervical spine MRI are often reviewed to assess the degree of neural FS. However, research looking at the association between these reports and objective MRI findings, as well as clinical symptoms, is lacking. PATIENTS AND METHODS: We retrospectively identified all adult patients undergoing primary 1 or 2-level anterior cervical discectomy and fusion at a single academic center for an indication of cervical radiculopathy. Preoperative MRI was assessed for neural FS severity using the grading system described by Kim and colleagues for each level of fusion, as well as adjacent levels. Neural FS severity was recorded from diagnostic radiologist MRI reports. Motor weakness was defined as an examination grade <4/5 on the final preoperative encounter. Regression analysis was conducted to evaluate whether the degree of FS by either classification was related to patient-reported outcome measure severity. RESULTS: A total of 283 patients were included in the study, and 998 total levels were assessed. There were significant differences between the MRI grading system and the assessment by radio-logists (P< 0.001). In levels with moderate stenosis, 28.9% were classified as having no stenosis by radiology. In levels with severe stenosis, 29.7% were classified as having mild-moderate stenosis or less. Motor weakness was found similarly often in levels of moderate or severe stenosis (6.9% and 9.2%, respectively). On regression analysis, no associations were found between baseline patient-reported outcome measures and stenosis severity assessed by radiologists or MRI grading systems. CONCLUSION: Radiology reports on the severity of cervical neural FS are not consistent with a validated MRI grading system. These radiology reports underestimated the severity of neural foraminal compression and may be inappropriate when used for clinical decision-making. LEVEL OF EVIDENCE: Level III.