Comparison of clinical outcomes in decompression and fusion versus decompression only in patients with ossification of the posterior longitudinal ligament: a meta-analysis.

OBJECTIVE Ossification of the posterior longitudinal ligament (OPLL) is a pathological calcification or ossification of the PLL, predominantly occurring in the cervical spine. Although surgery is often necessary for patients with symptomatic neurological deterioration, there remains controversy with regard to the optimal surgical treatment. In this systematic review and meta-analysis, the authors identified differences in complications and outcomes after anterior or posterior decompression and fusion versus after decompression alone for the treatment of cervical myelopathy due to OPLL. METHODS A MEDLINE, SCOPUS, and Web of Science search was performed for studies reporting complications and outcomes after decompression and fusion or after decompression alone for patients with OPLL. A meta-analysis was performed to calculate effect summary mean values, 95% CIs, Q statistics, and I(2) values. Forest plots were constructed for each analysis group. RESULTS Of the 2630 retrieved articles, 32 met the inclusion criteria. There was no statistically significant difference in the incidence of excellent and good outcomes and of fair and poor outcomes between the decompression and fusion and the decompression-only cohorts. However, the decompression and fusion cohort had a statistically significantly higher recovery rate (63.2% vs 53.9%; p < 0.0001), a higher final Japanese Orthopaedic Association score (14.0 vs 13.5; p < 0.0001), and a lower incidence of OPLL progression (< 1% vs 6.3%; p < 0.0001) compared with the decompression-only cohort. There was no statistically significant difference in the incidence of complications between the 2 cohorts. CONCLUSIONS This study represents the only comprehensive review of outcomes and complications after decompression and fusion or after decompression alone for OPLL across a heterogeneous group of surgeons and patients. Based on these results, decompression and fusion is a superior surgical technique compared with posterior decompression alone in patients with OPLL. These results indicate that surgical decompression and fusion lead to a faster recovery, improved postoperative neurological functioning, and a lower incidence of OPLL progression compared with posterior decompression only. Furthermore, decompression and fusion did not lead to a greater incidence of complications compared with posterior decompression only.

Characterizing the Next Generation of Neurosurgeons: A Descriptive Analysis and Publicly Available Web Application of Neurosurgery Residency Programs' Website Data.

OBJECTIVE: Neurosurgery program websites serve as a valuable resource for applicants. However, each website exists in isolation, and it can be difficult to understand the general trends in U.S. neurosurgery resident demographics. In the present study, we collected data from program websites and analyzed the trends in the demographics of the current U.S. neurosurgery residents. METHODS: We used a program list obtained from the American Association of Medical Colleges Electronic Residency Application System to extract data from the current resident complement listed in each program's website, including program, year in program, medical school, sex (male vs. female), graduate and/or PhD degrees, and assessed the trends during 7 years of resident data using linear regression. RESULTS: We identified 116 neurosurgery residency programs in the United States, with 111 providing information on their current resident complement, yielding a dataset of 1599 residents. Of these 1599 residents, 348 (22%) were female, 301 (19%) had a graduate degree in addition to an MD or DO degree, 151 (9.4%) had a PhD degree, 300 (19%) had matched at the program affiliated with their medical school, and 121 (7.6%) had graduated from a foreign medical school. The proportion of matriculating female residents had increased an average of 2.1% annually (95% confidence interval, 0.6%-3.7%) from 2015 to 2021. The other demographic data had not changed significantly during the same period. CONCLUSIONS: In addition to summarizing the current resident demographics, our analysis identified a significant increase in the proportion of female residents between 2015 (15.1%) and 2021 (25.6%). This publicly available dataset should enable additional analyses of the evolution of neurosurgery resident demographics.

Dorsal versus ventral surgery for cervical ossification of the posterior longitudinal ligament: considerations for approach selection and review of surgical outcomes.

Ossification of the posterior longitudinal ligament is a common cause of radiculopathy and myelopathy that often requires surgery to achieve decompression of the neural elements. With the evolution of surgical technique and a greater understanding of the biomechanics of cervical deformity, the criteria for selecting one approach over the other has been the subject of increased study and remains controversial. Ventral approaches typically consist of variations of the cervical corpectomy, whereas dorsal approaches include a wide range of techniques including laminoplasty, laminectomy, and laminectomy with instrumented fusion. Herein, the features and limitations of these approaches are reviewed with an emphasis on complications and outcomes.

Radiation exposure to the surgeon during percutaneous pedicle screw placement.

STUDY DESIGN: In-vitro radiation exposure study. OBJECTIVE: To determine the radiation exposure to the eyes, extremities, and deep tissue during percutaneous pedicle screw placement. SUMMARY OF BACKGROUND DATA: Image-guided minimally invasive spinal surgery is typically performed with the use of fluoroscopy, exposing the surgeon and patient to ionizing radiation. The radiation dose to the surgeon has not been reported and risk to the surgeon performing this procedure over the long term is uncertain. METHODS: Percutaneous pedicle screws were placed in a cadaveric specimen from L2-S1 bilaterally using a cannulated pedicle screw system. Two fluoroscopes were used in the anteroposterior and lateral planes. The surgeon wore a thermolucent dosimeter ring on the right hand and badge over the left chest beneath the lead apron. Complete surgical time was recorded and a computed tomography scan was performed to assess screw placement. Radiation exposure was measured for total time of fluoroscopy use; average exposure per screw, surgical level, and dose to the eyes was calculated. This data was used to define the safety of percutaneous pedicle screw placement. RESULTS: Total fluoroscope time for placement of 10 percutaneous pedicle screws was 4 minutes 56 seconds (29 s per screw). The protected dosimeter recorded less than the reportable dose. The ring dosimeter recorded 103 mREM, or 10.3 mREM per screw placed. All screws were within the bone confines with acceptable trajectory. Exposure to the eyes was 2.35 mREM per screw. CONCLUSIONS: On the basis of this data, percutaneous pedicle screw placement seems to be safe. A surgeon would exceed occupational exposure limit for the eyes and extremities by placing 4854 and 6396 screws percutaneously, respectively. Lead protected against radiation exposure during screw placement. The "hands-off" technique used in this study is recommended to minimize radiation exposure. Lead aprons, thyroid shields, and leaded glasses are recommended for this procedure.

Late-week surgery and discharge to specialty care associated with higher costs and longer lengths of stay after elective lumbar laminectomy.

OBJECTIVE: In a healthcare landscape in which costs increasingly matter, the authors sought to distinguish among the clinical and nonclinical drivers of patient length of stay (LOS) in the hospital following elective lumbar laminectomy-a common spinal surgery that may be reimbursed using bundled payments-and to understand their relationships with patient outcomes and costs. METHODS: Patients ≥ 18 years of age undergoing laminectomy surgery for degenerative lumbar spinal stenosis within the Cleveland Clinic health system between March 1, 2016, and February 1, 2019, were included in this analysis. Generalized linear modeling was used to assess the relationships between the day of surgery, patient discharge disposition, and hospital LOS, while adjusting for underlying patient health risks and other nonclinical factors, including the hospital surgery site and health insurance. RESULTS: A total of 1359 eligible patients were included in the authors' analysis. The mean LOS ranged between 2.01 and 2.47 days for Monday and Friday cases, respectively. The LOS was also notably longer for patients who were ultimately discharged to a skilled nursing facility (SNF) or rehabilitation center. A prolonged LOS occurring later in the week was not associated with greater underlying health risks, yet it nevertheless resulted in greater costs of care: the average total surgical costs for lumbar laminectomy were 20% greater for Friday cases than for Monday cases, and 24% greater for late-week cases than for early-week cases ultimately transferred to SNFs or rehabilitation centers. A Poisson generalized linear model fit the data best and showed that the comorbidity burden, surgery at a tertiary care center versus a community hospital, and the incidence of any postoperative complication were associated with significantly longer hospital stays. Discharge to home healthcare, SNFs, or rehabilitation centers, and late-week surgery were significant nonclinical predictors of LOS prolongation, even after adjusting for underlying patient health risks and insurance, with LOSs that were, for instance, 1.55 and 1.61 times longer for patients undergoing their procedure on Thursday and Friday compared to Monday, respectively. CONCLUSIONS: Late-week surgeries are associated with a prolonged LOS, particularly when discharge is to an SNF or rehabilitation center. These findings point to opportunities to lower costs and improve outcomes associated with elective surgical care. Interventions to optimize surgical scheduling and perioperative care coordination could help reduce prolonged LOSs, lower costs, and, ultimately, give service line management personnel greater flexibility over how to use existing resources as they remain ahead of healthcare reforms.

The Role of Additional Spine Surgery in the Management of Failed Back Surgery Syndrome, Complex Regional Pain Syndrome, and Intractable Pain in the Setting of Previous or Concurrent Spinal Cord Stimulation: Indications and Outcomes.

OBJECTIVE: Spinal cord stimulation (SCS) is both relatively safe and reversible. Although SCS is generally regarded as a last resort, some of these patients will undergo additional spinal surgery after the device has been implanted or after its removal. We present a descriptive study of subsequent spinal surgery after SCS implantation. METHODS: A retrospective review of patients who had undergone percutaneous or paddle SCS lead placement at our institution from 2009 to 2016 was performed. Patients who had only undergone trials or who had not undergone spine surgery after SCS implantation were excluded. RESULTS: We identified 22 patients (5.7%) who had undergone spine surgery during the course of SCS treatment or after SCS removal, or both, of a total 383 patients who had undergone paddle and/or percutaneous SCS implantation. The most common additional spine interventions included lumbosacral decompression and fusion (n = 15; 42%). Of 36 surgeries, the most frequent indications for subsequent intervention were stenosis or restenosis (n = 16; 73%) and spine deformity (n = 6; 27%). The median EuroQol-5D index was 0.397 preoperatively and 0.678 postoperatively. CONCLUSIONS: To the best of our knowledge, the present study is the first to describe spine surgery in the setting of SCS implantation. Our results have indicated that spine surgery subsequent to, or concurrent with, SCS implantation appears to occur in few patients. Our study results suggest a modest improvement in quality of life outcomes. Therefore, clinicians should remember that patients might require further spine surgery despite the use of SCS implantation and, thus, might require reevaluation by the spine team.

Heterogeneity of Reporting Outcomes in the Spine Surgery Literature.

STUDY DESIGN: Review of spine surgery literature between 2005 and 2014 to assess the reporting of patient outcomes by determining the variability of use of patient outcomes metrics in the following categories: pain and disability, patient satisfaction, readmission, and depression. OBJECTIVE: Expose the heterogeneity of outcomes reporting and discuss current initiatives to create more homogenous outcomes databases. SUMMARY OF BACKGROUND DATA: There has been a recent focus on the reporting of quality metrics associated with spine surgery outcomes. However, little consensus exists on the optimal metrics that should be used to measure spine surgery outcomes. MATERIALS AND METHODS: A PubMed search of all spine surgery manuscripts from January 2005 through December 2014 was performed. Linear regression analyses were performed on individual metrics as well as outcomes categories as a fraction of total papers reviewing surgical outcomes. RESULTS: Outcomes reporting has increased significantly between January 1, 2005 and December 31, 2014 [175/2871 (6.1%) vs. 764/5603 (13.6%), respectively; P<0.001; R=98.1%]. For the category of pain and disability reporting, Visual Analog Score demonstrated a statistically significant decrease in use from 2005 through 2014 [56/76 (73.7%) vs. 300/520 (57.7%), respectively; P<0.001], whereas Oswestry Disability Index increased significantly in use [19/76 (25.0%) vs. 182/520 (35.0%), respectively; P<0.001]. For quality of life, EuroQOL-5 Dimensions increased significantly in use between 2005 and 2014 [4/23 (17.4%) vs. 30/87 (34.5%), respectively; P<0.01]. In contrast, use of 36 Item Short Form Survey significantly decreased [19/23 (82.6%) vs. 57/87 (65.5%), respectively; P<0.01]. For depression, only the Zung Depression Scale underwent a significant increase in usage between 2005 and 2014 [0/0 (0%) vs. 7/13 (53.8%), respectively; P<0.01]. CONCLUSIONS: Although spine surgery outcome reporting has increased significantly over the past 10 years, there remains considerable heterogeneity in regards to individual outcomes metrics utilized. This heterogeneity makes it difficult to compare outcomes across studies and to accurately extrapolate outcomes to clinical practice.

Cervical laminoplasty.

Laminoplasty was developed to treat multilevel pathology of the cervical spine, namely ossification of the posterior longitudinal ligament and cervical spondylotic myelopathy. Laminoplasty was popularized in the 1980s, and since then many variations on the theme have been developed. All are similar in that they expand the cervical canal while leaving the protective dorsal elements in place. Advocates claim that this prevents the formation of the "postlaminectomy" membrane, maintains spinal alignment, and should aid in maintaining cervical range of motion. The aforementioned are all potential shortcomings of laminectomy or laminectomy and fusion. The procedure has proven to be essentially equal to other cervical decompressive procedures in the neutral or lordotic spine, and outcome has been shown to be durable.

Perioperative Medical Management of Spine Surgery Patients With Osteoporosis.

Management of spine surgery patients with osteoporosis is challenging because of the difficulty of instrumenting and the potential complications, including nonunion and adjacent level fractures. Treatment of this patient population should involve a multidisciplinary approach including the spine surgeon, primary care physician, endocrinologist, and physical therapist. Indication for preoperative treatment before spinal fusion surgery is unclear. All patients should receive calcium and vitamin D. Hormone replacement therapy, including estrogen or selective estrogen receptor modulators, should be considered for elderly female patients with decreased bone mass. Bisphosphonates or intermittent parathyroid hormone are reserved for those with significant bone loss in the spine. Pretreatment with antiresorption medications affect bone remodeling, which is a vital part of graft incorporation and fusion. Although there have been numerous animal studies, there is limited clinical evidence. Accordingly, surgery should be delayed, if possible, to treat the osteoporosis before the intervention. Treatment may include bisphosphonates, as well as newer agents, such as recombinant parathyroid hormone. Further clinical data are needed to understand the relative advantages/disadvantage of antiresorptive vs anabolic agents, as well as the impact of administration of these medications before vs after fusion surgery. Future clinical studies will enable better understanding of the impact of current therapies on biomechanics and fusion outcomes in this unique and increasingly prevalent patient population.

Cervical arthroplasty: a critical review of the literature.

BACKGROUND CONTEXT: Cervical disc arthroplasty (CDA) is a motion-preserving procedure that is an alternative to fusion. Proponents of arthroplasty assert that it will maintain cervical motion and prevent or reduce adjacent segment degeneration. Accordingly, CDA, compared with fusion, would have the potential to improve clinical outcomes. Published studies have varying conclusions on whether CDA reduces complications and/or improves outcomes. As many of these previous studies have been funded by CDA manufacturers, we wanted to ascertain whether there was a greater likelihood for these studies to report positive results. PURPOSE: To critically assess the available literature on cervical arthroplasty with a focus on the time of publication and conflict of interest (COI). STUDY DESIGN/SETTING: Review of the literature. METHODS: All clinical articles about CDA published in English through August 1, 2013 were identified on Medline. Any article that presented CDA clinical results was included. Study design, sample size, type of disc, length of follow-up, use of statistical analysis, quality-of-life (QOL) outcome scores, COI, and complications were recorded. A meta-analysis was conducted stratifying studies by COI and publication date to identify differences in complication rates reported. RESULTS: Seventy-four studies were included that investigated 8 types of disc prosthesis and 22 met the criteria for a randomized controlled trial (RCT). All Level Ib RCTs reported superior quality-of-life outcomes for CDA versus anterior cervical discectomy and fusion (ACDF) at 24 months. Fifty of the 74 articles (68%) had a disclosure section, including all Level Ib RCTs, which had significant COIs related to the respective studies. Those studies without a COI reported mean weighted average adjacent segment disease rates of 6.3% with CDA and 6.2% with ACDF. In contrast, the reverse was reported by studies with a COI, for which the averages were 2.5% with CDA and 6.3% with ACDF. Those studies with a COI (n=31) had an overall weighted average heterotopic ossification rate of 22%, whereas those studies with no COI (n=43) had a rate of 46%. CONCLUSIONS: Associated COIs did not influence QOL outcomes. Conflicts of interest were more likely to be present in studies published after 2008, and those with a COI reported greater adjacent segment disease rates for ACDF than CDA. In addition, heterotopic ossification rates were much lower in studies with COI versus those without COI. Thus, COIs did not affect QOL outcomes but were associated with lower complication rates.

Comparative effectiveness of ventral vs dorsal surgery for cervical spondylotic myelopathy.

BACKGROUND: Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction. OBJECTIVE: To determine the feasibility of a randomized clinical trial comparing the clinical effectiveness and costs of ventral vs dorsal decompression with fusion surgery for treating CSM. METHODS: A nonrandomized, prospective, clinical pilot trial was conducted. Patients ages 40 to 85 years with degenerative CSM were enrolled at 7 sites over 2 years (2007-2009). Outcome assessments were obtained preoperatively and at 3 months, 6 months, and 1 year postoperatively. A hospital-based economic analysis used costs derived from hospital charges and Medicare cost-to-charge ratios. RESULTS: The pilot study enrolled 50 patients. Twenty-eight were treated with ventral fusion surgery and 22 with dorsal fusion surgery. The average age was 61.6 years. Baseline demographics and health-related quality of life (HR-QOL) scores were comparable between groups; however, dorsal surgery patients had significantly more severe myelopathy (P<.01). Comprehensive 1-year follow-up was obtained in 46 of 50 patients (92%). Greater HR-QOL improvement (Short-Form 36 Physical Component Summary) was observed after ventral surgery (P=.05). The complication rate (16.6% overall) was comparable between groups. Significant improvement in the modified Japanese Orthopedic Association scale score was observed in both groups (P<.01). Dorsal fusion surgery had significantly greater mean hospital costs ($29 465 vs $19 245; P<.01) and longer average length of hospital stay (4.0 vs 2.6 days; P<.01) compared with ventral fusion surgery. CONCLUSION: Surgery for treating CSM was followed by significant improvement in disease-specific symptoms and in HR-QOL. Greater improvement in HR-QOL was observed after ventral surgery. Dorsal fusion surgery was associated with longer length of hospital stay and higher hospital costs. The pilot study demonstrated feasibility for a larger randomized clinical trial.

Minimally invasive surgical treatment of Bertolotti's Syndrome: case report.

OBJECTIVE: This article aims to provide more insight into the presentation, diagnosis, and treatment of Bertolotti's syndrome, which is a rare spinal disorder that is very difficult to recognize and diagnose correctly. The syndrome was first described by Bertolotti in 1917 and affects approximately 4 to 8% of the population. It is characterized by an enlarged transverse process at the most caudal lumbar vertebra with a pseudoarticulation of the transverse process and the sacral ala. It tends to present with low back pain and may be confused with facet and sacroiliac joint disease. METHODS: In this case report, we describe a 40-year-old man who presented with low back pain and was eventually diagnosed with Bertolotti's syndrome. The correct diagnosis was made based on imaging studies which included computed tomographic scans, plain x-rays, and magnetic resonance imaging scans. The patient experienced temporary relief when the abnormal pseudoarticulation was injected with a cocktail consisting of lidocaine and steroids. In order to minimize the trauma associated with surgical treatment, a minimally invasive approach was chosen to resect the anomalous transverse process with the accompanying pseudoarticulation. RESULTS: The patient did well postoperatively and had 97% resolution of his pain at 6 months after surgery. CONCLUSION: As with conventional surgical approaches, a complete knowledge of anatomy is required for minimally invasive spine surgery. This case is an example of the expanding utility of minimally invasive approaches in treating spinal disorders.

Techniques for the ventral correction of postsurgical cervical kyphotic deformity.

Progressive kyphotic deformity of the cervical spine may be a late sequela of congenital cervical anomalies, degenerative disc disease, neoplasm, cervical trauma, and surgical procedures. Of these, postsurgical kyphosis is the most common and can occur after ventral and dorsal surgeries of the cervical spine. The purpose of this article is to review the causes and clinical presentation of postsurgical cervical kyphosis and to focus on the operative planning and ventral correction techniques.

Surgical management of osseous hemangioblastoma of the thoracic spine: technical case report.

OBJECTIVE AND IMPORTANCE: Spinal hemangioblastomas usually occur as isolated, intramedullary, central nervous system masses, often as a component of von Hippel-Lindau syndrome. They may occasionally occur extradurally and give the appearance of vertebral hemangioma. Rarely, they may be purely osseous lesions. The surgical management of these lesions has not been elaborated. We present a case and discuss the management of multilevel osseous hemangioblastoma of the thoracic spine. CLINICAL PRESENTATION: A 50-year-old woman with a history of thoracic hemangioblastoma 3 years earlier presented with progressive paraparesis. Imaging revealed circumferential tumor involvement of T7 to T9, inclusive. There was severe spinal cord compression. INTERVENTION: The patient underwent surgery via a bilateral lateral extracavitary approach to the tumor. This permitted a complete spondylectomy of T7, T8, and T9; complete tumor removal; and decompression of the spinal cord. Pathological analysis confirmed hemangioblastoma. The spine was reconstructed with an interbody expandable cage and pedicle screw fixation, all placed via the dorsal approach. The patient improved neurologically after the operation. CONCLUSION: Although extremely rare, hemangioblastomas may occur in a purely osseous location. They may resemble vertebral hemangioma. Treatment should include aggressive surgical removal, although arduous, if appropriate. A bilateral lateral extracavitary approach is ideal for complete spondylectomy. With this technique, ventral and dorsal reconstruction of the spine through the same incision is possible.