Effect of device constraint: a comparative network meta-analysis of ACDF and cervical disc arthroplasty.

BACKGROUND CONTEXT: Clinical trials have demonstrated that cervical disc arthroplasty (CDA) is an effective and safe alternative treatment to anterior cervical discectomy and fusion (ACDF) for cervical degenerative disc disease in the appropriately indicated patient population. Various devices for CDA exist, differing in the level of device constraint. PURPOSE: To investigate outcomes following Anterior Cervical Discectomy and Fusion (ACDF) versus CDA stratified based on the level of device constraint: Constrained, Semiconstrained, and Unconstrained. STUDY DESIGN: Systematic review and network meta-analysis. PATIENT SAMPLE: 2,932 CDA patients (979 Constrained, 1,214 Semiconstrained, 739 Unconstrained) and 2,601 ACDF patients from 41 studies that compared outcomes of patients undergoing CDA or ACDF at a single level at a minimum of 2 years follow-up. OUTCOME MEASURES: Outcomes of interest included the development of adjacent segment degeneration (ASD), index and adjacent segment reoperation rates, range of motion (ROM), high-grade heterotopic ossification (HO, McAfee Grades 3/4), and patient-reported outcomes (NDI/VAS). METHODS: CDA devices were grouped based on the degrees of freedom (DoF) allowed by the device, as either Constrained (3 DoF), Semiconstrained (4 or 5 DoF), or Unconstrained (6 DoF). A random effects network meta-analysis was conducted using standardized mean differences (SMD) and log relative risk (RR) were used to analyze continuous and categorical data, respectively. RESULTS: Semiconstrained (p=.03) and Unconstrained CDA (p=.01) demonstrated a significantly lower risk for ASD than ACDF. All levels of CDA constraint demonstrated a significantly lower risk for subsequent adjacent segment surgery than ACDF (p<.001). Semiconstrained CDA also demonstrated a significantly lower risk for index level reoperation than both ACDF and Constrained CDA (p<.001). Unconstrained devices retained significantly greater ROM than both Constrained and Semiconstrained CDA (p<.001). As expected, all levels of device constraint retained significantly greater ROM than ACDF (p<.001). Constrained and Unconstrained devices both demonstrated significantly lower levels of disability on NDI than ACDF (p=.02). All levels of device constraint demonstrated significantly less neck pain than ACDF (p<.05), while Unconstrained CDA had significantly less arm pain than ACDF (p=.02) at final follow-up greater than 2 years. CONCLUSION: Cervical Disc Arthroplasty, particularly the unconstrained and semiconstrained designs, appears to be more effective than ACDF in reducing the risk of adjacent segment degeneration and the need for further surgeries, while also allowing for greater range of motion and better patient-reported outcomes. Less constrained CDA conferred a lower risk for index level reoperation, while also retaining more range of motion than more constrained devices.

Return-to-Play Outcomes of Athletes After Operative and Nonoperative Treatment of Lumbar Disc Herniation.

PURPOSE OF REVIEW: Lumbar disc herniation (LDH) is a common injury experienced by athletes and has important clinical considerations for athletes including the timing of return to sport. Lumbar disc herniation may result in loss of individual training and playing time for athletes. Current literature is inconclusive on whether surgical or conservative treatment of LDH is superior in athletes. Our aim was to review the literature to identify return-to-play (RTP) rates and performance outcomes following operative and nonoperative treatment of LDH in the athletic population. RECENT FINDINGS: Athletes have unique measurements of successful treatment for LDH such as time to return to their sport and performance outcomes that are not as applicable as traditional metrics. It is suggested that surgical treatment may provide a quicker return to sport than nonoperative care in athletes. Additionally, conflicting findings have been seen in career length and performance status based on sport, often due to short and tumultuous career patterns. These differences may be seen based on the unique physical demands of each sport, different motivations to prolong sport, or other confounding factors that could not be controlled for or unrelated to LDH. Recent literature on RTP outcomes in athletes treated for LDH show variable results based on sport. Further research is needed to assist physicians and athletes in making the decision to undergo conservative or surgical treatment of LDH in the athletic population.

Nonoperative Management in Intact Burst Fracture Patient With Thoracolumbar Injury Classification and Severity Score of 5: A Case Report.

Thoracolumbar fractures are a common consequence of trauma, often a result of motor vehicle accidents or falls. Burst fractures are a morphology of thoracolumbar fracture in which compressive force causes retropulsion of the posterior elements of the vertebral body, potentially leading to neurological deficits. The Thoracolumbar Injury Classification and Severity (TLICS) score is a decision-making tool to help surgeons decide between nonoperative and operative management. For assigned scores of 4, management is at the discretion of the surgeon, and for scores ≥ 5, operative treatment is recommended. Burst fracture patients that are neurologically intact are given a score of 5 if there is a posterior ligamentous complex (PLC) injury and are recommended to undergo operative management. Here we present a neurologically intact patient with an L4 burst fracture with PLC injury that was managed conservatively and demonstrated successful clinical, functional, and radiographic recovery.

Effect of local retropharyngeal steroids on fusion rate after anterior cervical discectomy and fusion.

BACKGROUND CONTEXT: Anterior cervical discectomy and fusion (ACDF) is considered the gold standard surgical intervention for cervical myelopathy and radiculopathy. Obtaining a solid fusion is an important goal of ACDF, and doing so has correlated with favorable clinical outcomes. A common complication after surgery is postoperative dysphagia. Multiple techniques have been utilized in attempt to prevent and treat dysphagia, including use of retropharygeal steroids. PURPOSE: To examine the effects of retropharyngeal steroids on fusion rate in ACDF. STUDY DESIGN: Case control METHODS: Forty-two patients who received local retropharyngeal steroids during ACDF surgery were the sample patient population. The control group consisted of matched cases based on number of spinal levels treated and age at approximately 1:2 case to control ratio. Data were collected on demographic variables, as well as operative and postoperative courses. Radiographic data were collected and fusion determined by <2 mm motion on flexion/extension views and bridging bone. Data were compared between case and control populations. Continuous variables were compared using Student's t test and nominal/ordinal values were compared using Z-test. Fusion status was assessed using Pearson chi-squared test. RESULTS: A total of 121 patients were reviewed based on matching status and sufficient follow-up. The case and control groups were successfully matched based on age, spinal levels treated, and smoking status. The case group had an overall fusion rate of 64.7%, whereas the control group had a fusion rate of 91%. When analyzed at each level of attempted fusion, the case group had a fusion rate of 81% compared to 93% in the control group. There was a single patient in the case group that developed esophageal rupture and retropharygeal abscess requiring surgical intervention with irrigation, debridement and repair at 8 months after index operation. CONCLUSIONS: The use of retropharyngeal steroids to mitigate postoperative dysphagia is associated with a decreased rate of radiographic fusion in ACDF surgery.

Pendulum Exercises After Hip Arthroscopy: A Video Technique.

Advanced hip joint-preserving arthroscopic techniques have been shown to improve patient-reported functional outcomes with low rates of postoperative complications. Prior work has shown that formation of adhesive scar is a potential source of persistent pain and cause for revision surgery. As resources for postoperative in-studio physical therapy become scarce, a home-based strategy to avoid scar formation without adding formal therapy cost may be beneficial. The purpose of this technical note is to introduce a patient-centered educational video technique for home-caregiver delivery of manual hip pendulum exercises in the postoperative setting. This video technique offers access to our method for pendulum exercise as part of early recovery after advanced hip arthroscopy.