Cervical Steroid Injections Are Not Effective for Prevention of Surgical Treatment of Degenerative Cervical Myelopathy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study is to determine how often patients with degenerative cervical myelopathy (DCM) and initially treated with cervical steroid injections (CSI) and to determine whether these injections provide any benefit in delaying ultimate surgical treatment. METHODS: All patients with a new diagnosis of DCM, without previous cervical spine surgery or steroid injections, were identified in PearlDiver, a large insurance database. Steroid injection and surgery timing was identified using Current Procedural Terminology (CPT) codes. Multivariate logistic regression identified associations with surgical treatment. RESULTS: A total of 686 patients with DCM were identified. Pre-surgical cervical spine steroid injections were utilized in 244 patients (35.6%). All patients underwent eventual surgical treatment. Median time from initial DCM diagnosis to surgery was 75.5 days (mean 351.6 days; standard deviation 544.9 days). Cervical steroid injections were associated with higher odds of surgery within 1 year (compared to patients without injections, OR = 1.44, P < .001) and at each examined time point through 5 years (OR = 2.01, P < .001). In multivariate analysis comparing injection types, none of the 3 injection types were associated with decreased odds of surgery within 1 month of diagnosis. CONCLUSIONS: While cervical steroid injections continue to be commonly performed in patients with DCM, there is an overall increased odds of surgery after any type of cervical injection. Therefore injections should not be used to prevent surgical management of DCM.

What Should Clinicians Do When Health Services Are Improperly Billed in Their Names?

The Centers for Medicare and Medicaid Services mandates physicians' responsibility for making sure that reimbursement for services physicians provide to patients is accurate and appropriate. Yet the shift of physician practice ownership to various employment models has amplified a dilemma. Physicians working as employees for some US health care companies might not know about services billed in their name, much less be able to review or contest when, which, to whom, or at what costs services were billed. Although such practices violate legal standards, many employed physicians are now accountable without transparency or agency. This commentary on a case considers this set of problems in contemporary billing and reimbursement structure and practice.

Indirect Lumbar Decompression Combined With or Without Additional Direct Posterior Decompression: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: Indirect decompression via lateral lumbar interbody fusion (LLIF) can ameliorate central and foraminal lumbar stenosis. In severe central stenosis, additional posterior direct decompression is utilized. The aim of this review is to synthesize existing literature on these 2 techniques and identify significant differences in outcomes between isolated indirect decompression via LLIF and combined indirect decompression supplemented with direct posterior decompression. METHODS: A database search algorithm was utilized to query MEDLINE, COCHRANE, and EMBASE to identify literature reporting adult decompression study groups that involved an oblique or lateral fusion approach through September 2020. Improvement in outcomes measures and complication rates were pooled and tested for significance. RESULTS: A total of 110 publications were assessed with 15 studies meeting inclusion criteria, including 557 patients and 1008 levels. Mean age was 63.1 years with BMI of 27.5 kg/m2. For the combined indirect and direct decompression cohort, lumbar lordosis (LL) increased 133.9%, from 22.8o to 48.7o, while the indirect decompression cohort LL increased 8.9%, from 41.9o to 45.5o. Difference in LL improvement between cohorts was insignificant (P > .05). Oswestry Disability Index (ODI) decreased from 36.5 to 19.4 in the combined indirect and direct decompression cohort, and from 44.4 to 23.1 in the indirect decompression cohort. ODI reduction was insignificant (P = .053). CONCLUSIONS: Prior studies of both indirect decompression as well as combined indirect and direct decompression of lumbar spine stenosis are limited by small samples, heterogeneous populations, and lack of direct comparisons. Both procedures result in improved function and pain postoperatively with direct decompression restoring more lordosis in patients with worse preoperative alignment.

Narrative Review of Antiplatelet and Anticoagulant Medications for Venous Thromboembolism Prevention in Spine Surgery.

STUDY DESIGN: This was a narrative review. OBJECTIVE: The objective of this study was to identify commonly utilized venous thromboembolism (VTE) prophylactic measures, spine surgeon perspective, and provide pharmacologic recommendations from the literature. SUMMARY OF BACKGROUND DATA: Considered a preventable cause of morbidity and mortality, VTE remains an important iatrogenic diagnosis of concern. Reported rates of VTE following spine surgery vary widely (0.3%-31.0%). MATERIALS AND METHODS: A MEDLINE query identified literature reporting on VTE prevention and outcomes in the setting of spine surgery. Findings extracted from the included articles were summarized in a narrative review format to identify salient aspects of the current literature. RESULTS: Sixty articles were summarized. Many anticoagulation medications that are described in the literature target factors involved in the coagulation cascade common pathway including aspirin and other antiplatelet medications, heparins, and warfarin. Newer direct inhibitors of thrombin and factor Xa are now being utilized for VTE prevention, although with limited use specifically in spine surgery. CONCLUSIONS: Perioperative management of antiplatelet and anticoagulation medications in spine surgery requires evidence-based protocols that can account for patient comorbidities and surgery-specific features. Future studies should prospectively focus on establishing stronger recommendations based on pathology, surgical indications, patient comorbidities, region of the spine, and broad surgical intervention to enable effective prophylaxis for VTE. LEVEL OF EVIDENCE: Level II.

Fusion rate for stand-alone lateral lumbar interbody fusion: a systematic review.

BACKGROUND: Lateral lumbar interbody fusion (LLIF) is used to treat multiple conditions, including spondylolisthesis, degenerative disc disorders, adjacent segment disease, and degenerative scoliosis. Although many advocate for posterior fixation with LLIF, stand-alone LLIF is increasingly being performed. Yet the fusion rate for stand-alone LLIF is unknown. PURPOSE: Determine the fusion rate for stand-alone LLIF. STUDY DESIGN: Systematic review. METHODS: We queried Cochrane, EMBASE, and MEDLINE for literature on stand-alone LLIF fusion rate with a publication cutoff of April 2020. LLIF surgery was considered stand-alone when not paired with supplemental posterior fixation. Cohort fusion rate differences were calculated and tested for significance (p<0.05). All reported means were pooled. RESULTS: A total of 2,735 publications were assessed. Twenty-two studies met inclusion criteria, including 736 patients and 1,103 vertebral levels. Mean age was 61.7 years with BMI 26.5 kg/m2. Mean fusion rate was 85.6% (range, 53.0%-100.0%), which did not differ significantly by number of levels fused (1-level, 2-level, and ≥3-level). Use of rhBMP-2 was reported in 39.3% of subjects, with no difference in fusion rates between studies using rhBMP-2 (87.7%) and those in which rhBMP-2 was not used (83.9%, odds ratio=1.37, p=0.448). Fusion rate did not differ with the addition of a lateral plate, or by underlying diagnosis. All-complication rate was 42.2% and mean reoperation rate was 11.1%, with 2.3% reoperation due to pseudarthrosis. Of the studies comparing stand-alone to circumferential fusion, pooled fusion rate was found to be 80.4% versus 91.0% (p=0.637). CONCLUSIONS: Stand-alone LLIF yields high fusion rates overall. The wide range of reported fusion rates and lower fusion rates in studies involving subsequent surgical reoperation highlights the importance of proper training in this technique and employing a rigorous algorithm when indicating patients for stand-alone LLIF. Future research should focus on examining risk factors and patient-reported outcomes in stand-alone LLIF.

Synapses lacking astrocyte appear in the amygdala during consolidation of Pavlovian threat conditioning.

There is growing evidence that astrocytes, long held to merely provide metabolic support in the adult brain, participate in both synaptic plasticity and learning and memory. Astrocytic processes are sometimes present at the synaptic cleft, suggesting that they might act directly at individual synapses. Associative learning induces synaptic plasticity and morphological changes at synapses in the lateral amygdala (LA). To determine whether astrocytic contacts are involved in these changes, we examined LA synapses after either threat conditioning (also called fear conditioning) or conditioned inhibition in adult rats by using serial section transmission electron microscopy (ssTEM) reconstructions. There was a transient increase in the density of synapses with no astrocytic contact after threat conditioning, especially on enlarged spines containing both polyribosomes and a spine apparatus. In contrast, synapses with astrocytic contacts were smaller after conditioned inhibition. This suggests that during memory consolidation astrocytic processes are absent if synapses are enlarging but present if they are shrinking. We measured the perimeter of each synapse and its degree of astrocyte coverage, and found that only about 20-30% of each synapse was ensheathed. The amount of synapse perimeter surrounded by astrocyte did not scale with synapse size, giving large synapses a disproportionately long astrocyte-free perimeter and resulting in a net increase in astrocyte-free perimeter after threat conditioning. Thus astrocytic processes do not mechanically isolate LA synapses, but may instead interact through local signaling, possibly via cell-surface receptors. Our results suggest that contact with astrocytic processes opposes synapse growth during memory consolidation.