Age is Associated with Level of First-Time Anterior Cervical Discectomy and Fusion: An Ordinal Analysis of Factors Influencing Timing of Cervical Degeneration.

BACKGROUND: Symptomatic cervical spondylosis is often treated with anterior cervical discectomy and fusion (ACDF). However, few factors can predict which cervical level will degenerate and require intervention. This analysis evaluates preprocedural factors associated with level of first-time single-level ACDF. METHODS: We performed a retrospective analysis of patients who underwent single-level ACDF without prior history of spine surgery. Mann Whitney U-tests and Spearman rank-order correlation were performed for analyses of associations between variables of interest and ACDF level. Adjusted odds-ratios were calculated by proportional-odds logistic regression, with age, sex, body mass index, current tobacco use, history of neck trauma, preoperative radicular symptoms, and preoperative myelopathic symptoms as covariates. RESULTS: One hundred forty-one patients met inclusion criteria, and age demonstrated a negative correlation with ACDF level, such that younger patients tended to have ACDF performed at inferior subaxial levels (P = 0.0006, rho = -0.31, moderately strong relationship). Patients with preoperative radicular symptoms and myelopathic symptoms were more likely to have ACDF performed at inferior (P = 0.0001) and superior (P < 0.0001) levels, respectively. Patient sex, body mass index, current tobacco use, and history of neck trauma were not predictive of ACDF level. When adjusting for the above variables in a proportional-odds ordinal logistic regression model, a one-year increase in age conferred a 4% increase in the odds of requiring an ACDF at a given superior level compared to the adjacent inferior level. CONCLUSIONS: Age is correlated with level of first-time single level ACDF. Individual subaxial levels may have unique biomechanical properties that influence degeneration.

Cervical Nerve Root Block Using a Curved Blunt Needle and Posterior Approach.

BACKGROUND: Cervical transforaminal epidural steroid injections have become less popular due to the risk of catastrophic complications they pose. However, cervical nerve root blocks are useful for surgical planning in patients with cervical radicular pain syndromes. OBJECTIVES: Our aim was to find a method of performing cervical selective nerve root blocks that removed the risk of catastrophic complications. STUDY DESIGN: Retrospective case review. SETTING: Academic multidisciplinary spine center. METHODS: Among patients, 50 consecutive cases were retrospectively reviewed for immediate pain scores and follow-up results. In the intervention, a posterior approach using a curved blunt needle was employed for cervical selective nerve root blocks to minimize the risk of arterial injection. To measure the outcomes, we used quantitative pain severity scores and qualitative responses. RESULTS: This technique detailed in this study has a high immediate analgesic effect that can be used for diagnostic purposes. It is not known if this technique has prognostic value with respect to surgery. The prolonged response rate is about 50%, which is in line with other techniques. LIMITATIONS: This study had no control group. CONCLUSION(S): Cervical selective nerve root blocks using a curved blunt needle and a posterior approach are effective in selectively identifying nerves that cause clinical symptoms. This technique minimizes the risk of arterial or spinal cord impingement and therefore may be safer than transforaminal selective nerve root blocks.

Ultrasound-guided erector spinae plane blocks for pain management after open lumbar laminectomy.

PURPOSE: Lumbar spine surgery is associated with significant postoperative pain. The benefits of erector spinae plane blocks (ESPBs) combined with multimodal analgesia has not been adequately studied. We evaluated the analgesic effects of bilateral ESPBs as a component of multimodal analgesia after open lumbar laminectomy. METHODS: Analgesic effects of preoperative, bilateral, ultrasound-guided ESPBs combined with standardized multimodal analgesia (n = 25) was compared with multimodal analgesia alone (n = 25) in patients undergoing one or two level open lumbar laminectomy. Other aspects of perioperative care were similar. The primary outcome measure was cumulative opioid consumption at 24 h. Secondary outcomes included opioid consumption, pain scores, and nausea and vomiting requiring antiemetics on arrival to the post-anesthesia care unit (PACU), at 24 h, 48 h, and 72 h after surgery, as well as duration of the PACU and hospital stay. RESULTS: Opioid requirements at 24 h were significantly lower with ESPBs (31.9 ± 12.3 mg vs. 61.2 ± 29.9 mg, oral morphine equivalents). Pain scores were significantly lower with ESPBs in the PACU and through postoperative day two. Patients who received ESPBs required fewer postoperative antiemetic therapy (n = 3, 12%) compared to those without ESPBs (n = 12, 48%). Furthermore, PACU duration was significantly shorter with ESPBs (49.7 ± 9.5 vs. 79.9 ± 24.6 min). CONCLUSIONS: Ultrasound-guided, bilateral ESPBs, when added to an optimal multimodal analgesia technique, reduce opioid consumption and pain scores, the need for antiemetic therapy, and the duration of stay in the PACU after one or two level open lumbar laminectomy.

Isolating Neurologic Deficits in Cervical Spondylotic Myelopathy: A Case-Controlled Study, Using the NIH Toolbox Motor Battery.

Background and Objectives: Patients with cervical spondylotic myelopathy (CSM) have motor impairments, including weakness, imbalance, and loss of dexterity. The reliable assessment of these symptoms is critical for treatment decisions. This study aimed to determine, for the first time, the use of the NIH Toolbox motor battery (NIHTBm) in the objective assessment of motor deficits in patients with CSM. Methods: Patients with symptoms and MRI evidence of CSM and age-matched healthy controls (HC), with no evidence of spinal disorder or surgery were included in this case-control study based on our inclusion and exclusion criteria. We performed motor tests, dexterity, gait speed, grip strength, and balance tests, using the NIHTBm in patients with CSM and HCs. Motor impairment rates were determined in patients with CSM based on the NIHTBm scores. We determined the association between NIHTBm scores and patient-reported outcome scores; patient-reported outcome measures (the modified Japanese Orthopedic Association [mJOA] and Nurick grade) to determine the association. One-way analysis of variance was used to analyze group differences and the Spearman rank correlation to determine the relationship between assessment scores. Results: We enrolled 24 patients with CSM with a mean age (SD) of 57.96 (10.61) years and 24 age-matched HCs with a mean age (SD) of 53.17 (6.04) years in this study. Overall, we observed a significant decrease in the motor function T-scores mean (SD): dexterity 31.54 (14.82) vs 51.54 (9.72), grip strength 32.00 (17.47) vs 56.79 (8.46), balance 27.58 (16.65) vs 40.21 (6.35), and gait speed 0.64 (0.18) vs 0.99 (0.17) m/s, in patients with CSM compared with that in HCs. The lower extremity dysfunction scores on the NIHTBm, balance (ρ = -0.67) and gait speed (ρ = -0.62), were associated with higher Nurick grades. We observed a similar but weaker association with the Nurick grades and NIHTBm tests: dexterity (ρ = -0.49) and grip strength (ρ = -0.31) scores. The total motor mJOA showed a positive but weak association with NIHTBm scores, gait speed (ρ = 0.38), balance (ρ = 0.49), grip strength (ρ = 0.41), and dexterity (ρ = 0.45). Discussion: Patients with CSM had significantly lower NIHTBm scores compared with HCs. The results from the NIHTBm are consistent with the clinical presentation of CSM showing patients have motor impairments in both upper and lower extremities. As a neurologic-specific scale, NIHTBm should be used in the evaluation and clinical management of patients with CSM.

Anticoagulation in Elective Spine Cases: Rates of Hematomas Versus Thromboembolic Disease.

STUDY DESIGN: Retrospective cohort study with propensity matched cohorts. OBJECTIVE: The purpose of this study was to evaluate the association of anticoagulation with VTE and hematoma complications after spine surgery. SUMMARY OF BACKGROUND DATA: One of the major complications of surgery is VTE which can range in presentation. Spine surgery is an especially complex balance between minimizing the risk of a VTE event and also the increased risk of a hematoma which can lead to devastating neurological outcomes. METHODS: The elective spine surgery cases at a single academic center between 2015 and 2017 were identified. A total of 3790 patients were initially identified. Two hundred sixty patients were excluded. The cohort was then matched using a propensity score. This matched a single patient who did not receive anticoagulation to a single patient who did within the institution. This left a total of 1776 patients with 888 patients in each arm. RESULTS: The incidence of VTE, PE, and unplanned reoperation for hematoma in this cohort was 0.96%, 0.34%, and 1.13%, respectively. Predicted odds of VTE and PE were not significantly different; however, the odds of an unplanned reoperation for hematoma (odds ratio [OR] = 7.535, 95% confidence interval [CI]: 2.004-28.340, P = 0.002) were greater for those who received pharmacological anticoagulation in our institutional cohort. CONCLUSION: In this study, anticoagulation does not lead to lower rates of VTE events, but it increases the risk of symptomatic hematomas which require a return trip to the OR. While this was not a randomized controlled trial, we attempted to correct for this with propensity matching. Future randomized control trials would be needed.Level of Evidence: 3.

Vancomycin Powder Regimen for Prevention of Surgical Site Infection in Complex Spine Surgeries.

STUDY DESIGN: In total, 496 patients of a single surgeon cohort examining the surgical-site infection (SSI) rates with the addition of vancomycin powder in both diabetic and revision spine surgery cases. A historical control group of 652 patients were compared from the same surgeon over an earlier time period before the inception of using vancomycin powder prophylaxis. OBJECTIVE: The objective of this study was to describe and compare the rates of infection in high-risk patient populations while using vancomycin powder. SUMMARY OF BACKGROUND DATA: Vancomycin powder may not decrease an already low rate of infection. Therefore, use of vancomycin powder in high-risk patients with a higher rate of infection would potentially show benefit of vancomycin powder. MATERIALS AND METHODS: In total, 496 patient charts were collected from a database of cases. Patients were included in the cohort if they had revision spinal operation or if they were diabetic. Patients in the time period July 2010 to August 2013 were included in the vancomycin protocol where 1 g of vancomycin powder was added to the wound before wound closure. Cases were considered positive if there was a positive culture or if there was sufficient clinical suspicion to treat. As a control to this cohort, 692 charts were reviewed from a earlier time period of the same surgeon and institution. RESULTS: In total, 28 patients of 496 (5.6%) patients in the cohort returned to the operating room for seroma, hematoma, draining wound, or infection. Sixteen of these patients (16/496, 3.2%) had a culture positive infection or were treated as an infection. This rate was significantly lower than the historical rate before the protocol. CONCLUSIONS: Although vancomycin does seem to be useful in decreasing SSIs, it is not a panacea. SSIs in high-risk patients were not completely eliminated by the vancomycin protocol.

Factors influencing oxygen store during denitrogenation in the healthy patient.

STUDY OBJECTIVE: To define the various factors that influence the rate of effective preoxygenation. DESIGN: Prospective, randomized study. SETTING: Procedure room in a teaching hospital. SUBJECTS: 14 ASA physical status I volunteers who performed 4 sessions of breathing in random order. Of these volunteers, 7 performed two extra sessions using vital capacity breathing, which were also completed in random order. INTERVENTIONS: Using the circle system, volunteers breathed with a mouthpiece and nose-clip until expired nitrogen reached 5%, using either a fresh gas flow of 5 L/min or 10 L/min or a system flushed with O(2). MEASUREMENTS: End-expired levels of O(2), nitrogen, and CO(2) were recorded. MAIN RESULTS: Minute ventilation, functional residual capacity, and age were significant factors for rate of denitrogenation. However, height and weight were not significant factors in predicting time to denitrogenation. At low flow rates, flushing with O(2) significantly decreased the time of denitrogenation. There appeared to be little clinical benefit of flushing with O(2) when a 10 L/min O(2) flow was used. CONCLUSIONS: A high gas flow rate appears critical to achieving rapid preoxygenation.