Anterior cervical surgery for morbidly obese patients should be performed in-hospitals.

Background: Morbid obesity (MO) is defined by the World Health Organization (WHO) as Class II (i.e. Body Mass Index (BMI) >/= 35 kg/M2 + 2 comorbidities) or Class III (i.e. BMI >/= 40 kg/M2). Here, we reviewed the rates for adverse event/s (AE)/morbidity/mortality for MO patients undergoing anterior cervical surgery as inpatients/in-hospitals, and asked whether this should be considered the standard of care? Methods: We reviewed multiple studies to document the AE/morbidity/mortality rates for performing anterior cervical surgery (i.e., largely ACDF) for MO patients as inpatients/in-hospitals. Results: MO patients undergoing anterior cervical surgery may develop perioperative/postoperative AE, including postoperative epidural hematomas (PEH), that can lead to acute/delayed cardiorespiratory arrests. MO patients in-hospitals have 24/7 availability of anesthesiologists (i.e. to intubate/run codes) and surgeons (i.e. to evacuate anterior acute hematomas) who can best handle typically witnessed cardiorespiratory arrests. Alternatively, after average 4-7.5 hr. postoperative care unit (PACU) observation, Ambulatory Surgical Center (ASC) patients are sent to unmonitored floors for the remainder of their 23-hour stays, while those in Outpatient SurgiCenters (OSC) are discharged home. Either for ASC or OSC patients, cardiorespiratory arrests are usually unwitnessed, and, therefore, are more likely to lead to greater morbidity/mortality. Conclusion: Anterior cervical surgery for MO patients is best/most safely performed as inpatients/in-hospitals where significant postoperative AE, including cardiorespiratory arrests, are most likely to be witnessed events, and appropriately emergently treated with better outcomes. Alternatively, MO patients undergoing anterior cervical procedures in ASC/OSC will more probably have unwitnessed AE/cardiorespiratory arrests, resulting in poorer outcomes with higher mortality rates. Given these findings, isn't it safest for MO patients to undergo anterior cervical surgery as inpatients/in-hospitals, and shouldn't this be considered the standard of care?

"Skip" corpectomy technique in multilevel cervical spondylotic myelopathy and ossified posterior longitudinal ligament: Outcomes with over 10-years follow-up.

OBJECTIVE: Skip corpectomy is a surgical technique that includes C4 and C6 corpectomies and fusion via autografts and a cervical plate and is frequently performed in patients with CSM and OPLL. This study presents long-term clinical and radiological outcomes of 48 patients who underwent skip corpectomy with 10-year follow-up. METHODS: 48 patients who were diagnosed with CSM or OPLL were included. All patients underwent spinal canal decompression and fusion via skip corpectomy. Clinical assessment was performed using the JOA scoring system. The radiological assessment was performed using plain anteroposterior, lateral, and flexion-extension cervical spine radiographs; cervical spine MR imaging; and cervical spine CT scans. The spinal canal size, spinal cord occupation ratio, cervical lordosis, and T2 signal changes were evaluated preoperatively, and postoperatively. RESULTS: The mean follow-up period was 14.6 years (13-20 years). Preoperatively, the JOA score was 11.06 ± 3.09. The mean cervical lordosis was 2.08°±11.74 and the average SCOR was 62.1 ± 14.22. There was a significant improvement in SCOR in the early postoperative period. The average cervical lordosis increased to 13.81 ± 2.51 in the 2nd month and minimal loss of cervical lordosis was observed on the 10th year in two patients. Fusion was achieved in all patients, regardless of the graft type. None of the patients had implant failure and graft or hardware-related complications at the 10th-year follow-up. CONCLUSION: Skip corpectomy provides efficient decompression of the spinal cord and provides adequate sagittal alignment and fusion in patients with CSM and OPLL. Long-term radiological and clinical outcomes of the technique are favorable.

Perspective: Triple intraoperative neurophysiological monitoring (IONM) should be considered the standard of care (SOC) for performing cervical surgery for ossification of the posterior longitudinal ligament (OPLL).

Background: Triple Intraoperative Neurophysiological Monitoring (IONM) should be considered the standard of care (SOC) for performing cervical surgery for Ossification of the Posterior Longitudinal Ligament (OPLL). IONM's three modalities and their alerts include; Somatosensory Evoked Potentials (SEP: =/> 50% amplitude loss; =/>10% latency loss), Motor Evoked Potentials (MEP: =/> 70% amplitude loss; =/>10-15% latency loss), and Electromyography (loss of EMG, including active triggered EMG (t-EMG)). Methods: During cervical OPLL operations, the 3 IONM alerts together better detect intraoperative surgical errors, enabling spine surgeons to immediately institute appropriate resuscitative measures and minimize/avoid permanent neurological deficits/injuries. Results: This focused review of the literature regarding cervical OPLL surgery showed that SEP, MEP, and EMG monitoring used together better reduced the incidence of new nerve root (e.g., mostly C5 but including other root palsies), brachial plexus injuries (i.e., usually occurring during operative positioning), and/or spinal cord injuries (i.e., one study of OPLL patients documented a reduced 3.79% incidence of cord deficits utilizing triple IONM vs. a higher 14.06% frequency of neurological injuries occurring without IONM). Conclusions: Triple IONM (i.e., SEP, MEP, and EMG) should be considered the standard of care (SOC) for performing cervical OPLL surgery. However, the positive impact of IONM on OPLL surgical outcomes critically relies on spinal surgeons' immediate response to SEP, MEP, and/or EMG alerts/significant deterioration with appropriate resuscitative measures to limit/avert permanent neurological deficits.

The Early Effects of Longus Colli Muscle and Anterior Longitudinal Ligament Reconstructions on Swallowing Function after Anterior Cervical Surgery: A Six-Month Follow-Up Study.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is the gold standard surgery used to treat cervical degenerative disease. Dysphagia and hoarseness are the two most common complications that occur after anterior cervical surgery (ACS). In this study, we aim to evaluate the early effects of longus colli muscle (LCM) and anterior longitudinal ligament (ALL) reconstructions on swallowing function after ACS. METHODS: We recruited 91 patients (35 males and 56 females; mean age: 49.41 ± 8.60 years [range: 26-72 years]) who have undergone either ACDF or anterior cervical corpectomy and fusion (ACCF) between August 2019 and October 2021. Patients were divided into LCM and ALL suture group (Group A), and LCM and ALL non-suture group (Group B). Assessments of the incidence of dysphagia and the swallowing quality of life (SWAL-QOL) were completed in 2 days, 1 week, 1 month, 3 months and 6 months after surgery. Average prevertebral soft tissue thickness (APSTT) were measured on lateral cervical spine radiographs taken with X-rays 2 days, 1 month, 3 months and 6 months after surgery. RESULTS: In the 2-day, 1-week and 1-month postoperative follow-up, the incidence of dysphagia in group A was significantly lower than that in group B (p < 0.05), and the SWAL-QOL scores of group A were significantly higher than those of group B (p < 0.05). In the 3-month and 6-month postoperative follow-up, no significant differences were found between groups A and B in terms of the incidence of dysphagia (p > 0.05). In the 6-month postoperative follow-up, no significant differences were found between the groups in terms of SWAL-QOL scores (p > 0.05). There were no significant differences in APSTT between groups during postoperative follow-up (p > 0.05). CONCLUSION: The reconstructions of LCM and ALL in ACS can effectively improve short-term postoperative swallowing function.

A Novel Intraoperative Posture-Adjustment Apparatus for Correction of Cervical Lordosis in Anterior Cervical Surgery.

OBJECTIVE: Cervical alignment is a crucial factor related to the success of anterior cervical surgical procedures. In patients with severe spinal cord compression, a traditional neck pillow (TNP) may not adequately correct cervical position during surgery. Therefore, the aim of this study was to introduce this innovative intraoperative posture-adjustment apparatus (IPAA), and explored its clinical and radiological results in cervical angle correction against TNP in patients who had undergone anterior cervical surgery. METHODS: The clinical and radiological data of 86 patients who underwent anterior cervical surgery with a minimum follow-up period of 1 year were retrospectively reviewed. Of these, 58 patients underwent IPAA, whereas 28 underwent TNP. Radiological parameters such as the degree of C2-C7 lordosis (CL), functional spinal unit angle (FSUA), C7 slope (C7S), fusion rate, and adjacent segment disease (ASD) were recorded and compared between the groups. Clinical outcomes including the Japanese Orthopaedic Association (JOA), neck disability index (NDI), visual analogue scale (VAS) for neck and arm were recorded. Complications such as kyphosis, dysphagia, Braden Scale score, revision surgery, hematoma, cerebrospinal fluid leakage, wound infection, and deep venous thrombosis were also recorded. The independent t-test or Mann-Whitney U test was used to compare continuous data, and categorical variables were assessed using the Pearson's chi-square test or Fisher's exact test. RESULTS: Compared with the pre-operative data, the post-operative CL, FSUA, and C7S were significantly increased in both groups. CL, FSUA, and C7S in the IPAA group (14.44 ± 4.94°, 7.36 ± 2.91°, 16.54 ± 4.63°) were significantly higher than those in the TNP group (7.17 ± 8.19°, 4.99 ± 5.36°, 14.19 ± 4.48°; P < 0.05). Although there were no significant differences between the groups in terms of VAS arm and JOA scores, the post-operative and final follow-up NDI and VAS neck scores in the IPAA group were significantly lower than those in the TNP group (p < 0.05). At the last follow-up, the TNP group had significantly more kyphotic patients than the IPAA group (2 vs. 0, p = 0,041). There was no significant difference between the groups in terms of fusion rate, ASD, or complications such as dysphagia, Braden's Scale score, revision surgery, hematoma, cerebrospinal fluid leakage, wound infection, or deep venous thrombosis. CONCLUSION: IPAA was shown to be more effective than TNP in adjusting cervical alignment (CL, FSUA, and C7S). These findings suggest that IPAA could be used as an alternative way to TNP in neck setting and cervical alignment adjustment and IPAA could potentially improve clinical outcomes after anterior cervical surgery.

Efficacy of Tracheal Traction Exercise for Prevention of Laryngopharyngeal Complications Following Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: Tracheal traction exercise (TTE) has been proposed as a preventative measure for laryngopharyngeal complications following anterior cervical discectomy and fusion. However, the exact effects of TTE remain controversial. Therefore, we conducted a systematic review and meta-analysis of randomized controlled trials to evaluate the efficacy of TTE. METHODS: We systematically searched PubMed, Web of Science, Embase, Cochrane, ClinicalTrials.gov, China National Knowledge Infrastructure, WANFANG DATA, VIP citation databases, and Chinese BioMedical Literature Database for randomized controlled trials (published between January 1, 2000, and January 23, 2023, without language restrictions) comparing the TTE group to the control group (non-TTE group). We assessed the risk of bias using Cochrane risk of bias assessment tool. Our primary end points were operation duration, the number of patients with postoperative dysphagia, and Visual Analog Scale (VAS) for laryngopharyngeal pain. We used a fixed-effects model to assess the pooled data. RESULTS: Of the 823 identified studies, 5 were eligible and included in our analysis (N = 542 participants). Compared with the control group, TTE reduced the incidence of postoperative dysphagia (relative risk = 0.41, 95% confidence interval [CI]: 0.28, 0.61, P < 0.05) and operation duration (weighted mean difference = -10.24, 95% CI: -14.48, -6.00, P < 0.05). However, no significant difference was observed in postoperative VAS between the 2 groups (weighted mean difference = -0.11, 95% CI: -0.23, 0.11, P = 0.08 > 0.05). CONCLUSIONS: TTE can effectively reduce operation duration and postoperative dysphagia. However, it does not result in a significant difference in postoperative VAS.

[Mode establishment and preliminary clinical application of anterior cervical surgery in outpatient setting].

Objective: To establish the mode of anterior cervical surgery in outpatient setting, and evaluate its preliminary effectiveness. Methods: A clinical data of patients who underwent anterior cervical surgery between January 2022 and September 2022 and met the selection criteria was retrospectively analyzed. The surgeries were performed in outpatient setting ( n=35, outpatient setting group) or in inpatient setting ( n=35, inpatient setting group). There was no significant difference between the two groups ( P>0.05) in age, gender, body mass index, smoking, history of alcohol drinking, disease type, the number of surgical levels, operation mode, as well as preoperative Japanese Orthopaedic Association (JOA) score, visual analogue scale score of neck pain (VAS-neck), and visual analogue scale score of upper limb pain (VAS-arm). The operation time, intraoperative blood loss, total hospital stay, postoperative hospital stay, and hospital expenses of the two groups were recorded; JOA score, VAS-neck score, and VAS-arm score were recorded before and immediately after operation, and the differences of the above indexes between pre- and post-operation were calculated. Before discharge, the patient was asked to score satisfaction with a score of 1-10. Results: The total hospital stay, postoperative hospital stay, and hospital expenses were significantly lower in the outpatient setting group than in the inpatient setting group ( P<0.05). The satisfaction of patients was significantly higher in the outpatient setting group than in the inpatient setting group ( P<0.05). There was no significant difference between the two groups in operation time and intraoperative blood loss ( P>0.05). The JOA score, VAS-neck score, and VAS-arm score of the two groups significantly improved at immediate after operation when compared with those before operation ( P<0.05). There was no significant difference in the improvement of the above scores between the two groups ( P>0.05). The patients were followed up (6.67±1.04) months in the outpatient setting group and (5.95±1.90) months in the inpatient setting group, with no significant difference ( t=0.089, P=0.929). No surgical complications, such as delayed hematoma, delayed infection, delayed neurological damage, and esophageal fistula, occurred in the two groups. Conclusion: The safety and efficiency of anterior cervical surgery performed in outpatient setting were comparable to that performed in inpatient setting. Outpatient surgery mode can significantly shorten the postoperative hospital stay, reduce hospital expenses, and improve the patients' medical experience. The key points of the outpatient mode of anterior cervical surgery are minimizing damage, complete hemostasis, no drainage placement, and fine perioperative management.

Clinical Efficacy Analysis of the New PRUNUS Spine Plate System for Anterior Cervical Spine Surgery.

OBJECTIVE: Although the role of anterior cervical titanium plate system in stabilizing the spine sequence and promoting bone graft fusion has been widely recognized, more and more attention has been paid to the design of the plate itself and the complications caused by it. In order to solve the problems of poor stability of internal fixation, plate displacement and screw looseness, we designed the new PRUNUS spine plate system. Hence, the present study was conducted to describe observe and evaluate the clinical efficacy of a new type of three-leaf reinforced cervical anterior screw plate system (PRUNUS nailing system) developed for anterior cervical surgery. METHODS: A retrospective analysis of 56 patients from June 2018 to October 2019 was used. Twenty-seven patients with cervical spine disease treated with new PRUNUS nail plate internal fixation were selected as the observation group, and 29 patients with cervical spine disease treated with conventional cervical anterior screw fixation were selected as the control group. Postoperative follow-up was performed. Cervical stability, internal fixation position and bone graft fusion were evaluated according to imaging data. The operative time, intraoperative blood loss, cervical Cobb angle, pain visual analogue scale (VAS), and Japanese orthopaedic association (JOA) were compared between the two groups. Spinal function scores and neurological improvement rates were used to evaluate the clinical efficacy of the new PRUNUS spine plate. RESULTS: The patients were followed up for 5-18 months, with an average of 7.33 months. The average operative time of the observation group was 98.4 ± 9.2 min, and the mean intraoperative blood loss was 65.3 ± 10.6 ml, which were significant different from the control group's 109.7 ± 9.4 minutes (P < 0.05), 72.9 ± 15.6 ml (P < 0.05). Comparison between the two groups in postoperative and final follow-up of cervical Cobb angle, JOA score and improvement rate, VAS score and preoperative comparison showed no significant differences (P > 0.05). CONCLUSION: The new PRUNUS spine plate system can be applied to the anterior cervical spine surgery, and its clinical efficacy was similar to the traditional cervical anterior plate. But PRUNUS simplified the operation process, especially suitable for the surgical treatment of anterior cervical revision and osteoporosis patients.

Analysis of the curative effect of cervical spondylotic radiculopathy with osseous foraminal stenosis using ultrasonic osteotome in anterior cervical surgery.

PURPOSE: To explore the clinical efficacy and operation points of cervical radiculopathy with osseous foraminal stenosis treated with ultrasonic osteotome in anterior cervical surgery. METHODS: From January 2018 to June 2021，a retrospective analysis of 23 patients with cervical radiculopathy with bony foraminal stenosis during this period was retrospectively analyzed. Anterior Cervical Discectomy and Fusion (ACDF) was used for all cases in this group. Intraoperative use of ultrasonic osteotome to decompress the nerve in the intervertebral foramina. The operation time, intraoperative blood loss and complication rate were recorded in this group of patients. Interbody fusion was evaluated using Brantigan criteria. The IC-PACS imaging system was used to measure the intervertebral foramen area (IFA) before and after surgery to evaluate the range of decompression. The VAS (Visual Analogue Scale, VAS) score and NDI (Neck Disability Index, NDI) score before and after surgery were recorded to evaluate the clinical efficacy. RESULTS: All enrolled patients were followed up regularly for 1 year or more. The mean operative time was 61.5 ± 8.0 minutes. The average intraoperative blood loss was 88.3 ± 12.8 ml, and the average hospital stay was 8.1 ± 1.7d. Twenty one cases of successful fusion were followed up 1 year after operation, and the fusion rate was 91.3%. IFA expanded from 25.1 ± 4.0 mm2 before operation to 57.9 ± 3.4 mm2 at 1 year after operation, and the difference was statistically significant (P < 0.001). The VAS score and NDI score of patients 3 days after surgery, 3 months after surgery, and 1 year after surgery were significantly lower than those before surgery (P < 0.001). There was 1 case of dysphagia and 1 case of Cage subsidence after operation, and the complication rate was 8.6%. CONCLUSION: Anterior cervical surgery using ultrasonic osteotome in the treatment of cervical radiculopathy with bony foraminal stenosis has reliable clinical efficacy and high safety, and is worthy of clinical promotion.

Cervical sagittal balance: a predictor of neck pain after anterior cervical spine surgery?

PURPOSE: To determine the possible relation between cervical sagittal balance and neck pain in patients having anterior cervical spine (ACS) surgery. MATERIALS AND METHODS: Retrospective monocentric study on 85 patients who underwent ACS surgery between 2014 and 2016. Clinically, all patients were assessed using the Neck Disability Index (NDI). Radiological assessment was achieved by MRI or CT-scan of the cervical spine allowing measurement of radiological parameters for preoperative cervical sagittal balance. These same criteria were measured postoperatively using X-rays. RESULTS: There is a statistically significant increase in the Cobb angle postoperatively (10.34 degrees) compared to preoperatively (6.68 degrees) (p < 0.05). Concomitantly, there is a statistically significant decrease in NDI postoperatively (22.69%) compared to preoperatively (42.31%) (p < 0.01). There is a negative correlation between Cobb angle and NDI (r= -0.31) (p < 0.05). CONCLUSION: An improvement in the cervical sagittal balance after ACS surgery is accompanied by a reduction of neck pain. Radiological parameters of cervical sagittal balance may be taken into account when planning surgery in order to maintain cervical alignment and thereby limit the occurrence of neck pain.

Computed Tomography Osteoabsorptiometry Evaluation of Cervical Endplate Subchondral Bone Mineral Density.

STUDY DESIGN: Basic Science. OBJECTIVE: Poor subchondral bone mineral density (sBMD) has been linked with subsidence of cervical interbody devices or grafts, which are traditionally placed centrally on the endplates. Considering that sBMD reflects long-term stress distributions, we hypothesize that the cervical uncovertebral joints are denser than the central endplate region. This study sought to investigate density distributions using computed tomography osteoabsorptiometry (CT-OAM). METHODS: Twelve human cervical spines from C3-C7 (60 vertebrae, 120 endplates) were imaged with CT and segmented to create 3D reconstructions. The superior and inferior endplates were isolated, and the sBMD of the whole endplate, endplate center, and uncus was evaluated using CT-OAM. Density distributions were compared across the subaxial cervical spine. RESULTS: The uncinate region of the inferior and superior endplates was significantly denser than the central endplate across all vertebral levels (P < .01). When comparing sBMD of the whole inferior and superior endplates, the superior endplate was significantly denser than the inferior endplate (P < .0001). However, the inferior uncus was denser than the superior uncus (P = .035). When assessing sBMD by vertebral level, peak densities were observed at C4 and C5, while C7 was, on average, significantly less dense than all other vertebrae. CONCLUSION: The subchondral bone of the cervical uncovertebral joints is significantly denser than the central endplates. While the superior endplate in its entirety is denser than the inferior endplate, the inverse was true for the uncovertebral joints. This study serves as a basis for future investigations of new implant designs and their implications on subsidence.

Do patients with Hirayama disease require surgical treatment? A review of the literature.

The main clinic characteristic of Hirayama disease (HD) is atrophy of the distal muscles in the upper limbs. Recently, an increasing number of HD cases have been reported. Many HD patients have persistently progressive symptoms and conservative treatments failed. This article aims to review the current status of the field and summarizes the main surgical treatment options for patients with HD. A comprehensive search of the PubMed and the Web of Science databases was conducted from their inception to September 15th, 2022. Search terms included "juvenile muscular atrophy of upper extremity", "Hirayama disease" and "surgery". A total of 169 relevant publications were identified and 29 articles were finally reviewed. Current surgical treatments for HD are either anterior cervical surgery or posterior cervical surgery. The two approaches can effectively stop the disease. However, no studies have compared the advantages and limitations of the two surgical methods. The previous view that HD can be improved with conservative treatment has been challenged. In many studies, surgical treatment has been shown to improve the hand function in patients with HD. However, there is still controversy about the methods of anterior and posterior cervical surgery. Future research could focus on exploring the advantages and limitations of different surgeries.

The adjustable aiming device for caspar pin insertion in anterior cervical spine surgery.

BACKGROUND: Creating a rectangular disc space is an important step during anterior cervical discectomy and fusion or cervical total disc replacement. The study aims to determine the accuracy of Caspar pin insertion by using a novel Adjustable Caspar Pin Aiming Device in anterior cervical procedures. METHODS: Forty Caspar pins were placed using an Adjustable Caspar Pin Aiming Device in 20 human cadaveric cervical vertebral bodies from C3 to C7 after performing anterior discectomies. Accuracy of pin placement was assessed by lateral fluoroscopy, considering superior endplate slope (SE), inferior endplate slope (IE), Caspar pin slope (CP), and endplate-Caspar pin slope difference (SE/CP, IE/CP). RESULTS: The mean superior endplate slope (SE), inferior endplate slope (IE), and Caspar pin slope (CP) were 10.82 ± 2.3°, 10.32 ± 3.2°, and 15.58 ± 7.9°, respectively. The average superior endplate-Caspar pin slope difference (SE/CP) and inferior endplate-Caspar pin slope difference (IE/CP) were 6.6 ± 0.8° and 7.7 ± 0.8°, respectively. The greatest slope difference was observed at the superior and inferior endplates of C3. No cervical endplate violations occurred. CONCLUSION: Adjustable Caspar Pin Aiming Device allowed for a highly accurate Caspar pin placement with the average endplate-Caspar pin slope difference of less than 7.7°. It results in accurate placement of the superior and inferior Caspar pins parallel to the index vertebral endplates. Furthermore, it appears to facilitate the safe and effective insertion of Caspar pins for anterior cervical procedures.

The effectiveness of reducing endotracheal cuff pressure after retractor placement to decrease postoperative laryngeal dysfunction in anterior cervical surgery: a meta-analysis.

OBJECTIVE: The authors sought to determine if a consensus could be reached regarding the effectiveness of endotracheal tube cuff pressure (ETTCP) reduction after retractor placement in reducing postoperative laryngeal dysfunction after anterior cervical fusion surgery. METHODS: A literature search of MEDLINE (PubMed), EMBASE, Cochrane Central, Google Scholar, and Scopus databases was performed. Quantitative analysis was performed on data from articles comparing groups of patients with either reduced or unadjusted ETTCP after retractor placement in the context of anterior cervical surgery. The incidence and severity of postoperative recurrent laryngeal nerve palsy (RLNP), dysphagia, and dysphonia were compared at several postsurgical time points, ranging from 24 hours to 3 months. Heterogeneity was assessed using the chi-square test, I2 statistics, and inverted funnel plots. A random-effects model was used to provide a conservative estimate of the level of effect. RESULTS: Nine studies (7 randomized, 1 prospective, and 1 retrospective) were included in the analysis. A total of 1671 patients were included (1073 [64.2%] in the reduced ETTCP group and 598 [35.8%] in the unadjusted ETTCP group). In the reduced ETTCP group, the severity of dysphagia, measured by the Bazaz-Yoo system in 3 randomized studies at 24 hours and at 4-8 weeks, was significantly lower (24 hours [standardized mean difference: -1.83, p = 0.04] and 4-8 weeks [standardized mean difference: -0.40, p = 0.05]). At 24 hours, the odds of developing dysphonia were significantly lower (OR 0.51, p = 0.002). The odds of dysphagia (24 hours: OR 0.77, p = 0.24; 1 week: OR 0.70, p = 0.47; 12 weeks: OR 0.58, p = 0.20) were lower, although not significantly, in the reduced ETTCP group. The odds of a patient having RLNP were significantly lower at all time points (24 hours: OR 0.38, p = 0.01; 12 weeks: OR 0.26, p = 0.03) when 3 randomized and 2 observational studies were analyzed. A subgroup analysis using only randomized studies demonstrated a similar trend in odds of having RLNP, yet without statistical significance (24 hours: OR 0.79, p = 0.60). All other statistically significant findings persisted with removal of any observational data. CONCLUSIONS: Based on the current best available evidence, reduction of ETTCP after retractor placement in anterior cervical surgery may be a protective measure to decrease the severity of dysphagia and the odds of developing RLNP or dysphonia.

Severe complications and management of a patient with myasthenia gravis undergoing anterior cervical spinal surgery: a case report.

Surgical management of patients with comorbid long-term myasthenia gravis (MG) is particularly challenging and MG thus represents an independent risk factor for perioperative complications. However, few studies have reported on the perioperative assessment, prevention measures, and risks in MG patients undergoing major surgery, especially for anterior cervical spine surgery. We herein report the rare case of a 62-year-old man with a 20-year history of MG, who was admitted to our hospital with diagnosis of degenerative cervical spondylosis. He safely underwent anterior cervical corpectomy of C4, discectomy of C5-6, and fusion of C3-6. Intraoperative motor evoked potential was recorded to detect significant improvement after decompression. However, the patient suffered from progressive dysphagia, bucking, and hyperpyrexia 20 days after the initial operation. Imaging revealed titanium cage sliding and graft dislodgement. Secondary surgery was performed for posterior internal fixation from C2-7 and anterior revision from C3-6 after Halo-Vest traction, antibiotic treatment, and immunoglobulin therapy. He underwent a series of postoperative treatments, including cervicothoracolumbosacral orthosis, atomization inhalation, chest physiotherapy, antibiotics, and nutritional support. His condition improved markedly and he had no recurrence of symptoms during the 6-month follow-up. It is the rare reported case of anterior cervical spinal surgery in a patient with MG. This rare case indicates a relative contraindication to anterior-only approaches especially with multiple levels for MG patients with cervical spondylosis. Posterior approach, intraoperative monitoring, osteoporosis, postoperative strong brace protection, and supportive management should be considered for patients who were on large doses of steroids for long duration of time, given the lack of sufficient bone mineral density.

Medicolegal corner (spine): Contraindicated use of DuraSeal in anterior cervical spine led to quadriplegia.

BACKGROUND: The package insert for DuraSeal (Integra LifeSciences, Princeton NJ) states it is Contraindicated for use in the anterior cervical spine (confined space): "Do not apply DuraSeal® hydrogel to confined bony structures where nerves are present since neural compression may result due to hydrogel swelling (…up to 12% of its size in any direction)." Further, it should not be used to treat massive unrepaired cerebrospinal fluid (CSF) leaks in any location; "…(it) is indicated as an adjunct to sutured dural repair during spine surgery to provide watertight closure," but it is not to be used "...for a gap greater than 2 mm…." METHODS: A spinal surgeon interpreted a geriatric patient's MR as showing severe C3-C4 to C5-C6 anterior cord compression due to disc disease/spondylosis. However, he never reviewed the CT report/images that documented marked ossification of the posterior longitudinal ligament (OPLL) with multiple signs of dural penetrance. RESULTS: The anterior C4, C5 corpectomy, and C3-C6 strut fusion/plating resulted in a massive, irreparable cerebrospinal fluid (CSF) leak. Despite the contraindications, the surgeon mistakenly applied DuraSeal which caused the patient's postoperative quadriplegia (i.e., as documented on the delayed postoperative MR scan). Following a secondary surgery consisting of a laminectomy/posterior fusion, the patient was still quadriplegic. Further, as he requested no postoperative MR scan and performed no subsequent corrective surgery (i.e., anterior removal of DuraSeal), the patient remained permanently quadriplegic. CONCLUSION: DuraSeal is directly contraindicated for use in the anterior cervical spine, with/without a CSF leak. Here, utilizing DuraSeal for anterior cervical OPLL surgery resulted in permanent quadriplegia, and was below the standard of care.

Delayed onset postoperative retropharyngeal hematoma after anterior cervical surgery with a sequela of tracheal stricture: a case report.

BACKGROUND: Among the several complications associated with anterior cervical discectomy and fusion (ACDF), airway compromise is considered one of the serious life-threatening conditions and usually requires emergent treatment, including airway establishment and hematoma evacuation surgery. Postoperative retropharyngeal hematoma commonly occurred during the on immediate phase with airway compromise, but have a rarity on late onset of this complication. Enlightened by this existing fact, we report the first case of delayed onset postoperative retropharyngeal hematoma after anterior cervical surgery with a sequela of tracheal stricture. CASE PRESENTATION: A 55-year-old male underwent ACDF for disc herniation at C5-6 that had not responded to conservative treatment over 3 months. The symptoms significantly improved after surgery, and he was discharged on postoperative day 3. On the 7 days after ACDF, the patient complained of sudden-onset left-deviated neck swelling. The follow-up plain radiographs and neck-enhanced computed tomography (CT) scans showed anterior and right lateral displacement of the airway including the trachea by a large retropharyngeal hematoma. We performed an emergent forceful endotracheal intubation that was maintained for 2 days until the patient underwent hematoma evacuation surgery. On the second day after hematoma evacuation surgery, the patient complained of hoarseness with a foul breath odor. Laryngoscopy showed tracheal ischemic mucosal damage that had been induced by forceful endotracheal intubation. Antibiotics and systemic corticosteroids were administered, and the symptoms improved. One month after hematoma evacuation surgery, he complained of dyspnea on exertion, and laryngoscopy showed tracheal stricture. The patient underwent bronchoscopic dilatation and is doing well without recurrence of symptoms. CONCLUSIONS: Early surgery to remove the delayed onset retropharyngeal hematoma, rather than forceful endotracheal intubation followed by delayed surgery, might yield better results and avoid unexpected complications of tracheal stricture.

The aiming device for cervical distractor pin insertion: a proof-of-concept, feasibility study.

BACKGROUND: Restoration of cervical lordosis after anterior discectomy and fusion is a desirable goal. Proper insertion of the vertebral distraction or Caspar pin can assist lordotic restoration by either putting the tips divergently or parallel to the index vertebral endplates. With inexperienced surgeons, the traditional free-hand technique for Caspar pin insertion may require multiple insertion attempts that may compromise the vertebral body and increase radiation exposure during pin localization. Our purpose is to perform a proof-of-concept, feasibility study to evaluate the effectiveness of a pin insertion aiming device for vertebral distraction pin insertion. METHODS: A Smith-Robinson approach and anterior cervical discectomy were performed from C3 to C7 in 10 human cadaveric specimens. Caspar pins were inserted using a novel pin insertion aiming device at C3-4, C4-5, C5-6, and C6-7. The angles between the cervical endplate slope and Caspar pin alignment were measured with lateral cervical imaging. RESULTS: The average Superior Endplate-to-Caspar Pin angle (SE-CP) and the average Inferior Endplate-to-Caspar Pin angle (IE-CP) were 6.2 ± 2.0° and 6.3 ± 2.2° respectively. For the proximal pins, the SE-CP and the IE-CP were 4.0 ± 1.1°and 5.2 ± 2.4° respectively. For the distal pins, the SE-CP and the IE-CP were 7.7 ± 1.4° and 6.2 ± 2.0° respectively. No cervical endplate violations occurred. CONCLUSION: The novel Caspar pin insertion aiming device can control the pin entry points and pin direction with the average SE-CP and average IE-CP of 6.2 ± 2.0° and 6.3 ± 2.2°, respectively. The study shows that the average different angles between the Caspar pin and cervical endplate are less than 7°.

A Novel Anterior Cervical X-Shape-Corpectomy and Fusion for Cervical Spinal Stenosis at C4-C6 Level: A Technical Note.

OBJECTIVE: Anterior cervical corpectomy and fusion (ACCF) is employed in patients with localized cervical spinal stenosis (CSS). However, there are some disadvantages such as subsidence of the titanium mesh cage, slow fusion rates, breakage of the plate and screws, and donor-site complications. For patients with small posterior osteophytes, ossified or hypertrophy of the posterior longitudinal ligaments or ligamentum flavum, the range of decompression from the classic anterior cervical discectomy and fusion (ACDF) cannot meet the clinical requirements. However, employing ACCF is controversial. Therefore, it is necessary to seek a novel, safe and effective surgery that can combine the strengths of ACDF and ACCF. Our objective was to describe a novel anterior approach cervical surgery and investigate its clinical outcomes on segmental CSS at the C4-C6 levels 6 months postoperatively. METHODS: A novel anterior cervical X-shape-corpectomy and fusion (ACXF) was performed to correct the CSS. RESULTS: The patient's neurologic function and myodynamia of the extremities were improved significantly 3 and 6 months after surgery with good bony fusion. Neck pain also was relieved. Immediately postoperative and after 6-month images indicated no significant spinal stenosis. The patient's cervical curvature was improved after surgery without significant implant subsidence or loss of adjacent intervertebral height. There were no postoperative complications. CONCLUSIONS: ACXF may be a safe and effective procedure for segmental CSS and an alternative for ACCF, as it has a wide operative field of view, sufficient decompression range, excellent transverse vertebral bony fusion, less internal fixation-related complications, and graft subsidence and no donor-site complications.