How Do Patients With Predominant Neck Pain Improve After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?

BACKGROUND: The presence of predominant pain in the arm vs the neck as a predictor of postoperative outcomes after anterior cervical discectomy and fusion (ACDF) has been seldom reported; therefore, the purpose of this study was to determine whether patients with predominant neck pain improve after surgery compared to patients with predominant arm pain or those with mixed symptoms in patients undergoing ACDF for radiculopathy. METHODS: A retrospective cohort study was conducted on patients who underwent ACDF at a single center from 2016 to 2018. Patients were split into groups based on preoperative neck and arm pain scores: neck (N) pain dominant group (visual analog scale [VAS] neck ≥ VAS arm by 1.0 point); neutral group (VAS neck < VAS arm by 1.0 point); or arm (A) pain dominant group (VAS arm ≥ VAS neck by 1.0 point), using a threshold difference of 1.0 point. Subsequently, individuals were substratified into 2 groups based on the arm to neck pain ratio (ANR): non-arm pain dominant defined as ANR ≤1.0 and arm pain dominant (APD) defined as ANR >1.0. Patient-reported outcome measurements including Neck Disability Index (NDI), Physical Component Score-12, and Mental Component Score (MCS-12) were compared between groups. RESULTS: No significant differences between groups when stratifying patients using a threshold difference of 1.0 point. When stratifying patients using the ANR, those in the APD group had significantly higher postoperative MCS-12 (P = 0.008) and NDI (P = 0.011) scores. In addition, the APD group showed a greater magnitude of improvement for MCS-12 and NDI scores (P = 0.043 and P = 0.038, respectively). Multiple linear regression showed that the A and the APD groups were both independent predictors of improvement in NDI. CONCLUSION: Patients with dominant arm pain showed significantly greater improvement in terms of MCS-12 and NDI scores compared to patients with dominant neck pain. CLINICAL RELEVANCE: To compare the impact of ACDF on arm and neck pain in the context of cervical radiculopathy using patient-reported outcome measures as an objective measurement.

Does the Size or Location of Lumbar Disc Herniation Predict the Need for Operative Treatment?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The goal of this study was to determine whether the absolute size (mm2), relative size (% canal compromise), or location of a single-level, lumbar disc herniation (LDH) on axial and sagittal cuts of magnetic resonance imaging (MRI) were predictive of eventual surgical intervention. METHODS: MRIs of 89 patients were reviewed, and patients were split into groups based on type of management received (34 nonoperative vs 55 microdiscectomy). Radiographic characteristics-including size of disc herniation (mm2), size of spinal canal (mm2), location of herniation on axial (central, paracentral, foraminal) and sagittal (disc level, suprapedicle, pedicle, infrapedicle) planes, and type of herniation (bulge, protrusion, extrusion, sequestration)-were measured by 2 independent, orthopedic spine fellows and compared between groups via univariate and multivariate analyses. RESULTS: The operative group showed a significantly higher percentage of canal compromise (39.5% vs 31.1%, P = .001) compared to the nonoperative group. Multiple logistic regression analysis showed higher odds of eventual operative intervention for a disc protrusion (odds ratio [OR] 6.30 [1.99, 19.86], P = .002) or disc extrusion (OR 11.5 [1.63, 81.2], P = .014) for Rater 1 and a higher odds of eventual surgical management for a paracentral location for both Rater 1 and Rater 2 (OR = 3.39 [1.25, 9.22], P = .017, and OR = 5.46 [1.77, 16.8], P = .003, respectively). CONCLUSIONS: Disc herniations in a paracentral location were more likely to undergo operative treatment than those more centrally located, on axial MRI views.

Cervical Total Disc Replacement: Long-Term Outcomes.

Degenerative disc disease and associated cervical spondylosis or stenosis are common conditions encountered in clinical practice. These conditions may cause progressive cervical radicular or myelopathic symptoms leading to significant impairment. Although anterior cervical discectomy and fusion (ACDF) has been a reliable surgical treatment of cervical myelopathy and radiculopathy, but limitations include loss of cervical range of motion, the concern for adjacent segment degeneration and disease, pseudoarthrosis, complications related to the choice of intervertebral graft, dysphagia, as well as standard anterior cervical approach risk. Cervical total disc arthroplasty has emerged as an alternative operative procedure to ACDF.

Do Patients with Back Pain-Dominant Symptoms Improve After Lumbar Surgery for Radiculopathy or Claudication?

BACKGROUND: Currently, few studies have examined whether patients with back or leg pain-predominant symptoms fare better clinically after lumbar spine surgery; therefore, the purpose of this study was to determine whether patients with back pain-dominant symptoms improved to a similar degree as patients with mixed or leg pain-dominant symptoms after lumbar surgery. METHODS: A retrospective cohort study was conducted at a single academic center, in which patients were stratified into three groups: (1) back pain-dominant group (B) (visual analog score [VAS] back - VAS leg ≥ 1.0 point), (2) neutral group (N) (VAS back - VAS leg < 1.0 point), or (3) leg pain-dominant group (L) (VAS leg - VAS back ≥ 1.0 point), using a VAS threshold difference of 1.0 point. As a secondary analysis, the VAS leg-to-back pain (LBR) ratio was used to further stratify patients: (1) nonleg pain-dominant (NLPD) group (LBR ≤ 1.0) or (2) leg pain-dominant (LPD) group (LBR > 1.0). Patient outcomes, including physical component score of the short form-12 survey (PCS-12), mental component score of the short form-12 survey (MCS-12), and Oswestry Disability Index (ODI), were identified and compared between groups using univariate and multivariate analysis. RESULTS: There were no significant differences in preoperative, postoperative, or delta scores for PCS-12 or ODI scores between groups. In patients undergoing decompression surgery, those with back pain-dominant or mixed symptoms (B, N, or NLPD groups) did not improve with respect to MCS-12 scores after surgery (P > .05), and those with leg pain-dominant symptoms (LPD group) had greater delta MCS-12 scores (P = .046) and greater recovery rates (P = .035). Multiple linear regression did not find LPD to be an independent predictor of PCS-12 or ODI scores. CONCLUSION: Patients undergoing lumbar decompression surgery and leg pain-dominant symptoms noted a greater improvement in MCS-12 scores; however, there were no differences in PCS-12 or ODI scores. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Patients undergoing lumbar decompression surgery demonstrate no major clinically significant differences when split up by pain-dominance groups.

Patient Outcomes Following Short-segment Lumbar Fusion Are Not Affected by PI-LL Mismatch.

STUDY DESIGN: This is a retrospective cohort study. OBJECTIVE: The objective of this study was to further elucidate the relationship between pelvic incidence-lumbar lordosis (PI-LL) mismatch and surgical outcomes in patients undergoing short segment lumbar fusions for degenerative lumbar disease. SUMMARY OF BACKGROUND DATA: There are few studies examining the relationship between spinopelvic parameters and patient reported outcome measurements (PROMs) in short segment lumbar degenerative disease. MATERIALS AND METHODS: A retrospective review was conducted at single academic institution. Patients undergoing 1- or 2-level lumbar fusion were retrospectively identified and separated into 2 groups based on postoperative PI-LL mismatch ≤10 degrees (NM) or PI-LL mismatch >10 degrees (M). Outcomes including the Physical Component Score (PCS)-12, Mental Component Score (MCS)-12, Oswestry Disability Index (ODI), Visual Analog Scale (VAS) back and leg scores were analyzed. Absolute PROM scores, the recovery ratio and the percentage of patients achieving minimum clinically important difference between groups were compared and a multiple linear regression analysis was performed. RESULTS: A total of 306 patients were included, with 59 patients in the NM group and 247 patients in the M group. Patients in the M group started with a higher degree of PI-LL mismatch compared with the NM group (22.2 vs. 7.6 degrees, P<0.001) and this difference increased postoperatively (24.7 vs. 2.5 degrees, P<0.001). There were no differences between the 2 groups in terms of baseline, postoperative, or Δ outcome scores (P>0.05). In addition, having a PI-LL mismatch was not found to be an independent predictor of any PROM on multivariate analysis (P>0.05). CONCLUSION: The findings in this study show that even though patients in the M group had a higher degree of mismatch preoperatively and postoperatively, there was no difference in PROMs. LEVEL OF EVIDENCE: Level III.

Are Patient Outcomes Affected by the Presence of a Fellow or Resident in Lumbar Decompression Surgery?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to determine whether the presence of a fellow or resident (F/R) compared to a physician assistant (PA) affected surgical variables or short-term patient outcomes. SUMMARY OF BACKGROUND DATA: Although orthopedic spine fellows and residents must participate in minimum number of decompression surgeries to gain competency, the impact of trainee presence on patient outcomes has not been assessed. METHODS: One hundred and seventy-one patients that underwent a one- to three-level lumbar spine decompression procedure at a high-volume academic center were retrospectively identified. Operative reports from all cases were examined and patients were placed into one of two groups based on whether the first assist was a F/R or a PA. Univariate analysis was used to compare differences in total surgery duration, 30-day and 90-day readmissions, infection and revision rates, patient-reported outcome measures (Short Form-12 Physical Component Score and Mental Component Score, Oswestry Disability Index, Visual Analog Scale [VAS] Back, VAS Leg) between groups. Multiple linear regression was used to assess change in each patient reported outcome and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission. RESULTS: Seventy-eight patients were included in the F/R group compared to 93 patients in the PA group. There were no differences between groups for total surgery time, 30-day or 90-day readmissions, infection, or revision rates. Using univariate analysis, there were no differences between the two groups pre- or postoperatively (P > 0.05). Using multivariate analysis, presence of a surgical trainee did not significantly influence any patient reported outcome and did not affect infection, revision, or 30- and 90-day readmission rates. CONCLUSION: This is one of the first studies to show that the presence of an orthopedic spine fellow or resident does not affect patient short-term outcomes in lumbar decompression surgery. LEVEL OF EVIDENCE: 3.

Does Cervical Spondylolisthesis Influence Patient-Reported Outcomes After Anterior Cervical Discectomy and Fusion Surgery?

BACKGROUND: No prior work has explored whether the presence of degenerative spondylolisthesis impacts patient-reported outcome measurements (PROMs) after an anterior cervical discectomy and fusion (ACDF); therefore, the goal of the current study was to determine whether the presence of a spondylolisthesis affects PROMs after an ACDF. METHODS: A retrospective cohort study was conducted on patients over the age of 18 who underwent a 1- or 2-level ACDF. All patients received preoperative standing lateral x-rays and were placed into 1 of 2 groups based on the presence of cervical spondylolisthesis from C2-T1: (1) no spondylolisthesis (NS) group or (2) spondylolisthesis (S) group. Preoperative, postoperative, and delta (postoperative minus preoperative) were recorded and compared between groups via univariate and multivariate analysis. Outcomes reported were the Physical Component Scores of the Short Form-12 (PCS-12), the Mental Component Scores of the Short Form-12 (MCS-12), the Neck Disability Index (NDI), and visual analog scale (VAS) Arm/Neck. RESULTS: A total of 202 patients were included in the final analysis with 154 in the NS group and 48 in the S group. Both patient cohorts reported significant postoperative improvement in PCS-12, NDI, and VAS Arm/Neck. When comparing outcome scores between groups, only MCS-12 delta scores were different between groups, with the S group exhibiting a greater mean delta score (8.3 vs 1.3, P = 0.024) than the NS group after ACDF. Multiple linear regression analysis indicated having spondylolisthesis at baseline was a significant predictor of greater change in MCS-12 than the NS group (ß = 4.841; 95% CI, 0.876, 8.805; P = 0.017). CONCLUSION: Both groups demonstrated significant postoperative improvement in PCS-12, NDI, or VAS Neck/Arm pain scores with no significant differences between groups. Patients with spondylolisthesis were found to have significantly greater improvement scores in MCS-12 scoring than those without spondylolisthesis after ACDF surgery.

How do C2 tilt and C2 slope correlate with patient reported outcomes in patients after anterior cervical discectomy and fusion?

BACKGROUND/CONTEXT: C2 tilt and C2 slope are quick and easy measurements to obtain on lateral radiographs and may be used to determine overall cervical sagittal alignment; however, the influence of these measurements on patient outcomes has not been well established in literature. PURPOSE: To determine if C2 tilt and/or C2 slope predict patient outcomes better compared with conventional radiographic measures after an anterior cervical discectomy and fusion (ACDF). STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: A total of 249 patients who underwent 1 to 3 level ACDF to address radiculopathy and/or myelopathy at a single academic institution between 2011 and 2015 were identified. Patients with less than 1 year of follow-up were excluded. OUTCOME MEASURES: Patient Reported Outcomes: Neck Disability Index (NDI), Physical Component Score-12 (PCS-12), and Mental Component Score (MCS-12), Visual Analog Score (VAS) Neck and Arm scores Cervical radiographic measurements: C2 tilt, C2 slope, C2-C7 lordosis, cervical SVA, T1 slope, T1 slope minus cervical lordosis (TS-CL), and C2-C7 ROM METHODS: Pearson correlation tests were performed to assess for significant associations between radiographic measurements and patient outcomes. Multiple linear regression models were developed adjusting for demographics and radiographic parameters to determine which factors were predictive of patient outcomes. RESULTS: C2 tilt and TS-CL correlated with all postoperative physical outcome scores (NDI, PCS-12, VAS Neck and ARM; p<.05), however no association was seen between C2 slope and postoperative outcomes. After accounting for the presence of subaxial deformity, C2 tilt and TS-CL remained strongly correlated to patient outcome scores. With multiple linear regression, C2 tilt was a significant predictor for NDI, whereas TS-CL was a significant predictor for PCS-12, VAS Neck and VAS Arm. CONCLUSIONS: C2 tilt significantly correlated with well-described conventional cervical parameters as well as postoperative physical outcomes measures, especially NDI, on multivariate analysis. C2 tilt may provide an easy and practical tool for predicting physical outcomes after ACDF.

Guidelines for cortical screw versus pedicle screw selection from a fatigued decompressive lumbar laminectomy model show similar stability and less bone mineral density dependency.

BACKGROUND: Traditional pedicle screws are the gold standard for lumbar spine fixation; however, cortical screws along the midline cortical bone trajectory may be advantageous when lumbar decompression is required. While biomechanic investigation of both techniques exists, cortical screw performance in a multi-level lumbar laminectomy and fusion model is unknown. Furthermore, longer-term viability of cortical screws following cyclic fatigue has not been investigated. METHODS: Fourteen human specimens (L1-S1) were divided into cortical and pedicle screw treatment groups. Motion was captured for the following conditions: intact, bilateral posterior fixation (L3-L5), fixation with laminectomy at L3-L5, fixation with laminectomy and transforaminal lumbar interbody fusion at L3-L5 both prior to, and following, simulated in vivo fatigue. Following fatigue, screw pullout force was collected and "effective shear stress" [pullout force/screw surface area] (N/mm2) was calculated; comparisons and correlations were performed. FINDINGS: In flexion-extension and lateral bending, all operative constructs significantly reduced motion compared to intact (P < 0.05), regardless of pedicle or cortical screws; only posterior fixation with and without laminectomy significantly reduced motion in axial rotation (P < 0.05). Pedicle screws significantly increased average pullout strength (944.2 N vs. 690.2 N, P < 0.05), but not the "effective shear stress" (1.01 N/mm2 vs. 1.1 N/mm2, P > 0.05). INTERPRETATION: In a posterior laminectomy and fusion model, cortical screws provided equivalent stability to pedicle screw fixation, yet had significantly lower screw pullout force. No differences in "effective shear stress" warrant further investigation of the effect of screw length/diameter in the aforementioned screw trajectories.

Development of a Telemedicine Neurological Examination for Spine Surgery: A Pilot Trial.

STUDY DESIGN: This was a prospective cohort study. OBJECTIVE: The objective of this study was to design and test a novel spine neurological examination adapted for telemedicine. SUMMARY OF BACKGROUND DATA: Telemedicine is a rapidly evolving technology associated with numerous potential benefits for health care, especially in the modern era of value-based care. To date, no studies have assessed whether. METHODS: Twenty-one healthy controls and 20 patients with cervical or lumbar spinal disease (D) were prospectively enrolled. Each patient underwent a telemedicine neurological examination as well as a traditional in-person neurological examination administered by a fellowship trained spine surgeon and a physiatrist. Both the telemedicine and in-person tests consisted of motor, sensory, and special test components. Scores were compared via univariate analysis and secondary qualitative outcomes, including responses from a satisfaction survey, were obtained upon completion of the trial. RESULTS: Of the 20 patients in the D group, 9 patients had cervical disease and 11 patients had lumbar disease. Comparing healthy control with the D group, there were no significant differences with respect to all motor scores, most sensory scores, and all special tests. There was a high rate of satisfaction among the cohort with 92.7% of participants feeling "very satisfied" with the overall experience. CONCLUSIONS: This study presents the development of a viable neurological spine examination adapted for telemedicine. The findings in this study suggest that patients have comparable motor, sensory, and special test scores with telemedicine as with a traditional in-person examination administered by an experienced clinician, as well as reporting a high rate of satisfaction among participants. To our knowledge, this is the first telemedicine neurological examination for spine surgery. Further studies are warranted to validate these findings.

Worker's Compensation Terminology.

Injuries to the spine comprise a high percentage of workplace injuries. Spine surgeons' evaluation of injured workers requires attention to facts specific to worker's compensation claims including whether the injury occurred in the scope of employment, whether a work incident was causally related to the injury, and whether the injury contributed to a significant degree to the patient's overall medical condition. An injured worker's compensation is subject to state-specific guidelines and is largely dependent on the degree of disability and whether the disability is temporary or permanent. Here, we review the background, organization, and key terms used in the worker's compensation system.

Is the Neck Disability Index an Appropriate Measure for Changes in Physical Function After Surgery for Cervical Spondylotic Myelopathy?

BACKGROUND: The Neck Disability Index (NDI) is a 10-item questionnaire about symptoms relevant to cervical spine pathology, originally validated in the physical therapy literature. It is unclear if all of the items apply to spine surgery. The purpose of this study was to determine if improvements in the composite NDI score or specific NDI domains are appropriate measures for tracking changes in physical function after surgical intervention for cervical spondylotic myelopathy (CSM). METHODS: A retrospective cohort review of patients treated at a major academic medical center was undertaken. Baseline and postoperative standardized outcome measurement scores, including composite NDI, NDI subdomain, and SF-12 physical component score (PCS), were collected. Wilcoxon signed-rank test was used to determine whether patients exhibited improvement in each of the outcome measures included. Multiple linear regression was performed to determine whether change in NDI composite or subdomain scores predicted change in physical function after surgery for CSM-compared with the well-validated PCS score-controlling for factors such as age, sex, etc. RESULTS: Baseline data were collected on 118 patients. All outcome measures exhibited significant improvement after surgery based on the Wilcoxon signed-rank test. On linear regression, work (ß = -2.419 [-3.831, -1.006]; P = .001) and recreation (ß = -1.354 [-2.640, -0.068]; P = .039), as well as the NDI composite score (ß = -0.223 [-0.319, -0.127]; P < .001), were significant predictors of change in physical function over time. CONCLUSIONS: Although the NDI composite score did predict change in PCS over time, only 2 of the 10 NDI subdomains were found to be associated with change in physical function over time. Based on these results, the item bank and composite scoring of the NDI are inappropriate for evaluating quality of life in studies of surgically treated cervical spondylotic myelopathy patients. CLINICAL RELEVANCE: NDI may not be a valid tool in the determination of physical function changes after surgery for CSM. LEVEL OF EVIDENCE: III.

Comparing Patient-reported Outcomes to Patient Satisfaction After a Microdiscectomy for Patient's With a Lumbar Disk Herniation.

STUDY DESIGN: A retrospective cohort study. OBJECTIVE: The objective of this study was to determine if patient satisfaction is predicted by improvement in health-related quality of life (HRQOL) metrics. SUMMARY OF BACKGROUND DATA: Patient satisfaction is becoming an increasingly common proxy for treatment quality; however, the correlation between patient satisfaction and HRQOL outcome metrics following a lumbar disk herniation is unclear. METHODS: Patients enrolled in the Spine Patient Outcomes Research Trial (SPORT) study were prospectively enrolled at 13 institutions. A retrospective subgroup analysis of prospectively collected data from the SPORT trial was performed. Receiver operating characteristic curves were used to determine if improvement in HRQOL metrics could accurately identify patient satisfaction. HRQOL metrics included: Short Form-36 (SF-36), Oswestry Disability Index (ODI), Sciatica Bothersomeness Index, Back Pain Bothersomeness Scale, and Leg Pain Bothersomeness Scale. RESULTS: A total of 709 patients who underwent surgery and 319 patients treated without surgery were included. In the surgical cohort, receiver operating characteristic curve analysis demonstrated that SF-36 Physical Component Summary improvement had moderate accuracy [area under the curve (AUC)=0.77 (95% confidence interval, CI: 0.73-0.82)] at predicting satisfaction at 3 months, and it had excellent accuracy at predicting satisfaction at 2 years [AUC=0.81 (95% CI: 0.77-0.85)] and 4 years [AUC=0.81 (95% CI: 0.76-0.85)]. Absolute Physical Component Summary score had excellent accuracy at 3 months [AUC=0.83 (95% CI: 0.79-0.87)], 2 years [AUC=0.87 (95% CI: 0.84-0.9)] and 4 years [AUC=0.84 (95% CI: 0.8-0.89)]. Similarly improvement in the ODI had moderate accuracy of predicting satisfaction at 3 months [AUC=0.77 (95% CI: 0.72-0.81)], 2 years [AUC=0.78 (95% CI: 0.74-0.82)] and 4 years [AUC=0.78 (95% CI: 0.73-0.83)], and the absolute ODI score had excellent accuracy at 3 months [AUC=0.85 (95% CI: 0.82-0.89)], 2 years [AUC=0.89 (95% CI: 0.86-0.92)], and 4 years [AUC=0.88 (95% CI: 0.85-0.92)]. CONCLUSIONS: HRQOL metrics can accurately predict patient satisfaction with symptoms at 3 months, 2 years, and 4 years after surgical intervention for a lumbar disk herniation. Absolute outcome scores were somewhat more predictive than change scores.

Proton Pump Inhibitor Use Affects Pseudarthrosis Rates and Influences Patient-Reported Outcomes.

STUDY DESIGN: Retrospective cohort review. OBJECTIVES: Cervical pseudarthrosis is a frequent cause of need for revision anterior cervical discectomy and fusion (ACDF) and may lead to worse patient-reported outcomes. The effect of proton pump inhibitors on cervical fusion rates are unknown. The purpose of this study was to determine if patients taking PPIs have higher rates of nonunion after ACDF. METHODS: A retrospective cohort review was performed to compare patients who were taking PPIs preoperatively with those not taking PPIs prior to ACDF. Patients younger than 18 years of age, those with less than 1-year follow-up, and those undergoing surgery for trauma, tumor, infection, or revision were excluded. The rates of clinically diagnosed pseudarthrosis and radiographic pseudarthrosis were compared between PPI groups. Patient outcomes, pseudarthrosis rates, and revision rates were compared between PPI groups using either multiple linear or logistic regression analysis, controlling for demographic and operative variables. RESULTS: Out of 264 patients, 58 patients were in the PPI group and 206 were in the non-PPI group. A total of 23 (8.71%) patients were clinically diagnosed with pseudarthrosis with a significant difference between PPI and non-PPI groups (P = .009). Using multiple linear regression, PPI use was not found to significantly affect any patient-reported outcome measure. However, based on logistic regression, PPI use was found to increase the odds of clinically diagnosed pseudarthrosis (odds ratio 3.552, P = .014). Additionally, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores (P = .022). CONCLUSIONS: PPI use was found to be a significant predictor of clinically diagnosed pseudarthrosis following ACDF surgery. Furthermore, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores.

Fusion technique does not affect short-term patient-reported outcomes for lumbar degenerative disease.

BACKGROUND/CONTEXT: Degenerative lumbar disease can be addressed via an anterior or posterior approach, and with or without the use of an interbody cage. Although several studies have compared the type of approach and technique, there is a lack of literature assessing patient-reported outcome measures (PROMs) and radiographic parameters between different fusion techniques. PURPOSE: To determine whether the surgical approach and fusion technique for lumbar degenerative disease had an effect on short-term PROMs and radiographic parameters. STUDY DESIGN/SETTING: Retrospective Cohort Study. PATIENT SAMPLE: Three hundred and ninety-one patients who underwent a 1-3 level lumbar spine fusion procedure at a high-volume academic center were retrospectively identified. Patients were divided into three groups based on the type of fusion they underwent: posterolateral fusion (PLF), anterior lumbar interbody fusion (ALIF), or transforaminal lumbar interbody fusion (TLIF). OUTCOME MEASURES: PROMs: Short Form-12 (SF-12) Physical Component Score (PCS) and Mental Component Score (MCS), Oswestry Disability Index (ODI), Visual Analog Score (VAS) Back, VAS Leg. Spinopelvic measurements: Pelvic Tilt (PT), Sacral Slope (SS), Pelvic Incidence (PI), Lumbar Lordosis (LL), Segmental Lordosis (SL), PI-LL mismatch. METHODS: Patients with less than 1-year follow-up were excluded from the cohort. Pre- and postoperative spinopelvic measurements were obtained for all patients. Univariate analysis (Chi-squared/Fisher's exact test or ANOVA test with post-hoc Bonferroni test) was used to compare among the three groups in the PROMs and radiographic spinopelvic parameters. Multiple linear regression was used to determine if fusion technique was an independent predictor of change in each patient outcome. RESULTS: Two hundred and sixteen patients were included in the PLF group, 33 patients in the ALIF group, and 142 patients in the TLIF group. The PLF group was significantly older at baseline (p<.001) and had lower preoperative diagnosis rates of degenerative scoliosis and disc herniations (p<.001), whereas the ALIF group underwent a higher proportion of three-level fusions (p<.001). There was no significant difference in spinopelvic parameters preoperatively, however the ALIF group showed significantly more improvement in SL postoperatively (p=.004) than the PLF and TLIF groups. Within each group, SL improved for the PLF and ALIF groups (p=.002 for both), but not for the TLIF group (p=.238). Comparing patient outcomes, the ALIF group reported lower preoperative VAS Leg scores (p=.031), however, this difference resolved postoperatively. Stratifying for preoperative diagnosis, there were no significant differences in outcomes, except for a greater improvement in VAS Leg scores for degenerative scoliosis patients undergoing ALIF. Using multivariate analysis, fusion technique was not found to be a significant predictor of change in any patient outcome or in odds of revision. CONCLUSIONS: Lumbar degenerative disease can be treated with several different fusion techniques, however, the relationship between type of fusion and PROMs is not established. Based on the findings in this study, the ALIF group showed greater improvement in SL compared with the PLF and TLIF groups, however, there was no difference noted in overall LL, PI-LL mismatch or other spinopelvic parameters. Despite these radiographic findings, patient outcome measures remained similar between all three fusion types.

Non-mobile Adjacent Level Cervical Spondylolisthesis Does Not Always Require Fusion in Patients Undergoing ACDF.

STUDY DESIGN: Retrospective review of a prospectively maintained database. OBJECTIVE: Compare outcomes following anterior cervical decompression and fusion (ACDF) between patients with no adjacent level spondylolisthesis (NAS) and adjacent level spondylolisthesis (AS). SUMMARY OF BACKGROUND DATA: There are no prior studies evaluating the effect of preoperative adjacent-level cervical spondylolisthesis on outcomes following anterior cervical discectomy and fusion (ACDF). METHODS: A retrospective review of consecutive patients who underwent ACDF for degenerative cervical disease was performed. Adjacent level spondylolisthesis was defined on radiographs as anterior displacement (> 1 mm) of the vertebra in relation to an adjacent "to be fused" level. Patients were categorized as either AS or NAS. Preoperative and 1-year postoperative outcomes including Short Form-12 Physical and Mental Component Scores, Neck Disability Index, Visual Analog Score for arm and neck pain, and rate of revision surgery were compared between the two groups. Radiographic changes were also analyzed for patients with AS. RESULTS: A total of 264 patients met the inclusion criteria. There were 53 patients (20.1%) with AS and 211 patients (79.9%) with NAS. Both groups improved significantly from baseline with respect to all patient outcomes and there were no significant differences between the two groups. After accounting for confounding variables, the presence of an AS was not a predictor of any postoperative outcome. Revision rates did not differ between the two groups. CONCLUSION: Patients with an AS had similar postoperative clinical outcomes compared with NAS. Furthermore, the presence of an AS was not a predictor of poorer clinical outcomes. This is the first study to investigate the effect of AS in patients undergoing ACDF and suggests that an adjacent-level spondylolisthesis does not need to be included in a fusion construct if it is not part of the primary symptom generating pathology. LEVEL OF EVIDENCE: 3.

Avoiding and Managing Complications in Routine Lumbar Spine Surgery.

Elective lumbar surgery for common degenerative lumbar spine pathology has been consistently demonstrated to have excellent outcomes by multiple validated measures and improves patient quality of life. The rate of complication is low but not unavoidable; there is an increasing recognition of risk factors that can be mitigated to decrease complication rates. When complications occur, prompt recognition and management may minimize deleterious effects on patient outcome. There are considerations for identifying risk factors and, when possible, minimizing them and general strategies for identifying and managing common complications in lumbar spine surgery.

Enhancing Evaluation of Cervical Spine: Thresholds for Normal CT Relationships in the Subaxial Cervical Spine.

BACKGROUND: Very little normative computed tomography (CT) scan data exist defining expected relationships of vertebral structures in the intact cervical spine. Better understanding of normal relationships should improve sensitivity of injury detection, particularly for facet subluxation. The purpose of this paper was to describe the normal anatomical relationships and most sensitive measurements to detect abnormal alignment in the subaxial cervical spine. METHODS: A group of 30 CT scans with no documented cervical spine injury were utilized from an established database in a trauma population. Twenty-two anatomical measurements were made for each level of the subaxial cervical spine using Microview software. For the purposes of measurement, the upper confidence limit of normal was reported as two standard deviations from the mean. RESULTS: The novel, CT based measurements of bone articulation were generally smaller and had lower confidence intervals compared to traditional radiographic measurements of midline structures (such as interspinous distance, interlaminar widening, disc space widening). The upper limit of normal of facet joint height was reported (1.54 mm anterior, 1.27 mm posterior, and 2.0 mm midportion), which may help identify distractive-flexion injuries. The upper limit of normal vertebral translation (2.0 mm) was also reported to identify translation/rotation injuries. CONCLUSIONS: Normal CT measurements for the subaxial cervical spine, especially in the facets, were found to have small confidence limits and variation. Based upon these findings, we conclude that facet measurements and translation may be better screening tools than traditional radiographic criteria based upon midline structures. Using these measurements may improve detection of cervical spine injuries warranting further imaging or investigation and reducing missed injuries. CLINICAL RELEVANCE: Improved understanding of normal anatomic measures in the subaxial spine will allow for better screening and identification of injuries.

Change in Angular Alignment Is Associated With Early Dysphagia After Anterior Cervical Discectomy and Fusion.

STUDY DESIGN: Retrospective analysis of a prospective cohort. OBJECTIVE: Change in cervical angular alignment may be associated with dysphagia. SUMMARY OF BACKGROUND DATA: Bony deformities of the cervical spine may be associated with secondary contractures of soft tissues in the neck. Acute surgical deformity correction causes in changes in soft tissue tension in the anterior neck, resulting in dysphagia. METHODS: The study population included patients undergoing 1 and 2 level elective anterior cervical discectomy and fusion for cervical myelopathy or radiculopathy. Preoperative and postoperative radiographs at 2 weeks were measured by a blinded observer for C2-C7 endplate angle, C2-C7 posterior vertebral body length, and occipital condyle plumb line distance on upright lateral radiographs at 2, 6, and 12 weeks postoperatively. Patients were prospectively queried about dysphagia incidence and severity using a numeric rating scale. Multiple linear regression analysis was used to determine the effect of change in radiographic parameters controlling for demographic characteristics. RESULTS: The study population included 25 patients with complete radiographs. The mean change in C2-C7 angle was -0.6 degrees (SD 9), the mean change in C2-C7 length was 1.7 mm (SD 26), the mean change in occipital condyle plumb line distance was 2.3 mm (SD 20).Multiple linear regression analysis was performed including operative time, age, sex, number of levels, and change in radiographic parameters as independent variables and using dysphagia score as the dependent variable. The change in C2-C7 angle and operative time were the only statistically significant predictors of change in dysphagia at 2 and 6 weeks postoperatively. CONCLUSIONS: These results indicate that lordotic change in spinal alignment and longer operative times are associated with increased postoperative dysphagia. Surgeons should counsel patients in whom a large angular correction is expected about the possibility for postoperative dysphagia. Furthermore, future studies on dysphagia incidence should include radiographic alignment as an independent predictor of dysphagia.

High Incidence of Undiagnosed Cervical Myelopathy in Patients With Hip Fracture Compared With Controls.

OBJECTIVES: To identify the incidence of undiagnosed cervical myelopathy in patients who fall and develop hip fractures compared with age-matched controls. DESIGN: Prospective, case-control study. SETTING: University level 1 Trauma Center. PATIENTS/PARTICIPANTS: Consecutive patients who presented with hip fractures after a fall. A total of 159 patients were screened; 66 patients (38 arthroplasty, 28 fracture) were eligible for enrollment in the study. Exclusion criteria included cognitive impairment, known diagnosis of cervical myelopathy, previous cervical spine surgery, inability to comply with examination, or refusal to participate. The control group was age-matched elderly patients who underwent total hip arthroplasty (THA). INTERVENTION: Patient interview and physical examination for cervical myelopathy. MAIN OUTCOME MEASUREMENTS: Myelopathy was diagnosed by clinical history elements (Japanese Orthopaedic Association score ≤15) and pathologic reflexes. Comparison of the incidence of myelopathy in the study population with the control population was performed using Fisher exact test. RESULTS: There were no statistically significant differences between the fracture and THA groups in mean patient age or male/female ratio. There was a statistically significant increased incidence of myelopathy in hip fracture patients (18%) compared with the THA group (0%, P = 0.01). CONCLUSIONS: Hip fracture is a complex multifactorial process, and most patients (60%) were excluded due to known cognitive impairment. However, 18% of previously undiagnosed patients who were cognitively intact manifested clinical findings consistent with cervical spondylotic myelopathy. Consideration should be given to screening for undiagnosed myelopathy among patients with hip fracture to reduce the risk of subsequent fractures. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.