The role of intense athletic activity on structural lumbar abnormalities in adolescent patients with symptomatic low back pain.

PURPOSE: To determine if adolescent athletics increases the risk of structural abnormalities in the lumbar spine. METHODS: A retrospective review of patients (ages 10-18) between 2004 and 2012 was performed. Pediatric patients with symptomatic low back pain, a lumbar spine MRI, and reported weekly athletic activity were included. Patients were stratified to an "athlete" and "non-athlete" group. Lumbar magnetic resonance and plain radiographic imaging was randomized, blinded, and evaluated by two authors for a Pfirrmann grade, herniated disc, and/or pars fracture. RESULTS: A total of 114 patients met the inclusion criteria and were stratified into 66 athletes and 48 non-athletes. Athletes were more likely to have abnormal findings compared to non-athletes (67 vs. 40 %, respectively, p = 0.01). Specifically, the prevalence of a spondylolysis with or without a slip was higher in athletes vs. non-athletes (32 vs. 2 %, respectively, p = 0.0003); however, there was no difference in the average Pfirrmann grade (1.19 vs. 1.14, p = 0.41), percentage of patients with at least one degenerative disc (39 vs. 31 %, p = 0.41), or disc herniation (27 vs. 33 %, p = 0.43). Body mass index, smoking history, and pelvic incidence (51.5° vs. 48.7°, respectively, p = 0.41) were similar between the groups. CONCLUSION: Adolescents with low back pain have a higher-than-expected prevalence of structural pathology regardless of athletic activity. Independent of pelvic incidence, adolescent athletes with low back pain had a higher prevalence of spondylolysis compared to adolescent non-athletes with back pain, but there was no difference in associated disc degenerative changes or herniation.

A population-based review of bone morphogenetic protein: associated complication and reoperation rates after lumbar spinal fusion.

OBJECT The authors compared the rates of postoperative adverse events and reoperation of patients who underwent lumbar spinal fusion with bone morphogenetic protein (BMP) to those of patients who underwent lumbar spinal fusion without BMP. METHODS The authors retrospectively analyzed the PearlDiver Technologies, Inc., database, which contains the Medicare Standard Analytical Files, the Medicare Carrier Files, the PearlDiver Private Payer Database (UnitedHealthcare), and select state all-payer data sets, from 2005 to 2010. They identified patients who underwent lumbar spinal fusion with and without BMP. The ICD-9-CM code 84.52 was used to identify patients who underwent spinal fusion with BMP. ICD-9-CM diagnosis codes identified complications that occurred during the initial hospital stay. ICD-9-CM procedural codes were used to identify reoperations within 90 days of the index procedure. The relative risks (and 95% CIs) of BMP use compared with no BMP use (control) were calculated for the association of any complication with BMP use compared with the control. RESULTS Between 2005 and 2010, 460,773 patients who underwent lumbar spinal fusion were identified. BMP was used in 30.7% of these patients. The overall complication rate in the BMP group was 18.2% compared with 18.7% in the control group. The relative risk of BMP use compared with no BMP use was 0.976 (95% CI 0.963-0.989), which indicates a significantly lower overall complication rate in the BMP group (p < 0.001). In both treatment groups, patients older than 65 years had a statistically significant higher rate of postoperative complications than younger patients (p < 0.001). CONCLUSIONS In this large-scale institutionalized database study, BMP use did not seem to increase the overall risk of developing a postoperative complication after lumbar spinal fusion surgery.

Surgical Site Infections in Spinal Surgery.

Surgical site infections (SSIs) are a potentially devastating complication of spine surgery. SSIs are defined by the Centers for Disease Control and Prevention as occurring within 30 days of surgery or within 12 months of placement of foreign bodies, such as spinal instrumentation. SSIs are commonly categorized by the depth of surgical tissue involvement (ie, superficial, deep incisional, or organ and surrounding space). Postoperative infections result in increased costs and postoperative morbidity. Because continued research has improved the evaluation and management of spinal infections, spine surgeons must be aware of these modalities. The controversies in evaluation and management of SSIs in spine surgery will be reviewed.

Low-Density Lipoprotein Cholesterol and Statin Usage Are Associated With Rates of Pseudarthrosis Following Single-Level Posterior Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To investigate the relationships of low-density lipoprotein cholesterol and statin usage with pseudarthrosis following single-level posterior or transforaminal lumbar interbody fusion (PLIF/TLIF). SUMMARY OF BACKGROUND DATA: Hypercholesterolemia can lead to atherosclerosis of the segmental arteries, which branch into vertebral bone through intervertebral foramina. According to the vascular hypothesis of disc disease, this can lead to ischemia of the lumbar discs and contribute to lumbar degenerative disease. Yet, little has been reported regarding the effects of cholesterol and statins on the outcomes of lumbar fusion surgery. MATERIALS AND METHODS: TriNetX, a global federated research network, was retrospectively queried to identify 52,140 PLIF/TLIF patients between 2002 and 2021. Of these patients, 2137 had high cholesterol (≥130 mg/dL) and 906 had low cholesterol (≤55 mg/dL). Perioperatively, 18,275 patients used statins, while 33,415 patients did not. One-to-one propensity score matching for age, sex, race, and comorbidities was conducted to balance the analyzed cohorts. The incidence of pseudarthrosis was then assessed in the matched cohorts within the six-month, one-year, and two-year postoperative periods. RESULTS: After propensity score matching, high-cholesterol patients had greater odds of developing pseudarthrosis six months [odds ratio (OR): 1.73, 95% confidence interval (CI): 1.28-2.33], one year (OR: 1.59, 95% confidence interval (CI): 1.20-2.10), and two years (OR: 1.57, 95% CI: 1.20-2.05) following a PLIF/TLIF procedure. Patients with statin usage had significantly lower odds of developing pseudarthrosis six months (OR: 0.74, 95% CI: 0.69-0.79), one year (OR: 0.76, 95% CI: 0.71-0.81), and two years (OR: 0.77, 95% CI: 0.72-0.81) following single-level PLIF/TLIF. CONCLUSIONS: The findings suggest that patients with hypercholesterolemia have an increased risk of developing pseudarthrosis following PLIF/TLIF while statin use is associated with a decreased risk. The data presented may underscore an overlooked opportunity for perioperative optimization in lumbar fusion patients, warranting further investigation in this area.

Radiographic Alignment Parameters for Lumbosacral Reconstruction in Patients With Altered S1 Morphology.

STUDY DESIGN: Retrospective quantitative analysis study. OBJECTIVES: Pelvic incidence has been established as central radiographic marker which determines patient-specific correction goals during surgery for adult spinal deformity. In cases with sacral doming or sacral osteotomy where the PI cannot be calculated, reliable radiographic parameters need to be established to determine surgical goals. We aim to determine multiple radiographic parameters and formulas that can be utilized when the S1 superior endplate is obscured. METHODS: Retrospective analysis was performed on 68 healthy volunteers without prior spine surgery with full-length radiographs. Pelvic incidence, sacral slope, and pelvic tilt were calculated for each patient. Additional measurements such as L4, L5, and S2 incidence, tilt, and slope were collected. A new radiographic parameter defined as the L4-Sciatic notch angle was measured. Regression analysis was performed on each value to determine its relationship with S1 based incidence, tilt, and slope. RESULTS: Mean values for L5 incidence, L4 incidence, and L4 sciatic notch angle were 21.8° ± 8.9, 4.4° ± 8.1, and 44.4° ± 12, respectively. The linear regression analysis produced the following formulas which can be utilized to determine deformity correction goals when pelvic incidence can be calculated pre-operatively: L5i = .65*S1i-11.4, L4i = .44*S1i-18.6, and L4SNA = -.34*S1i + 66.5. In settings where pelvic incidence cannot be calculated, the following formulas can be utilized: L5i = .66*S2i-32.3 and L4SNA = -.02*S2i2 + 1.1*S2i + 63.5. P-values for all regression analyses were <.001. CONCLUSION: This study provides target radiographic alignment values that can be utilized for patients with either pre-operative altered S1 endplates or in cases with intraoperative alteration of S1 (sacral osteotomy).

Perioperative outcomes of cervical disc arthroplasty: no difference between orthopaedic and neurologic surgeons.

Background: Given differences in residency training background, there has been increasing interest in characterizing differential outcomes between orthopaedic surgeons (OS) and neurosurgeons (NS) with regards to outcomes after cervical disc arthroplasty (CDA). This study aimed to assess if there were differences in perioperative outcomes of CDA between OS and NS. Methods: Patients who underwent a single-level CDA between 2012 and 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database using current procedural terminology codes. The patients were subsequently stratified into those who underwent CDA with OS versus NS, and propensity score-matched to adjust for differences in patient characteristics. Differences were assessed in medical and surgical complications, as well as operative time and healthcare utilization parameters [reoperations, readmissions, and lengths-of-stay (LOS)]. Results: A total of 2,148 patients were identified (NS: n=1,395; OS: n=753). After 1:1 propensity score matching (n=741 each), there were no differences in characteristics between patients who underwent CDA by OS versus NS (P>0.05). There were no significant differences in any of the medical or surgical complications between the two groups (P>0.05 for each). There was a significant difference in the operative time between NS and OS (103.7±36.18 vs. 98.75±36.69 minutes; P=0.009). There were no significant differences in readmissions, reoperations, or LOS between the two groups (P>0.05 for each). Conclusions: There were no differences in medical or surgical complications, as well as in reoperations, readmissions, and LOS in patients who underwent a single-level CDA between OS and NS. There was a statistically significant shorter operative time of four minutes for OS as compared to NS, which is unlikely to have clinical relevance.

New Imaging Modalities for Degenerative Cervical Myelopathy.

INTRODUCTION: Degenerative cervical myelopathy (DCM) is defined as dysfunction of the spinal cord as a result of compression from degenerative changes to surrounding joints, intervertebral disks, or ligaments. Symptoms can include upper extremity numbness and diminished dexterity, difficulty with fine manipulation of objects, gait imbalance, and incoordination, and compromised bowel and bladder function. Accurate diagnosis and evaluation of the degree of impairment due to degenerative cervical myelopathy remain a challenging clinical endeavor requiring a thorough and accurate history, physical examination, and assessment of imaging findings. METHODS: A narrative review is presented summarizing the current landscape of imaging modalities utilized in DCM diagnostics and the future direction of research for spinal cord imaging. RESULTS AND DISCUSSION: Current imaging modalities, particularly magnetic resonance imaging and, to a lesser extent, radiographs/CT, offer important information to aid in decision making but are not ideal as stand-alone tools. Newer imaging modalities currently being studied in the literature include diffusion tensor imaging, MR spectroscopy, functional magnetic resonance imaging, perfusion imaging, and positron emission tomography. These newer imaging modalities attempt to more accurately evaluate the physical structure, intrinsic connectivity, biochemical and metabolic function, and perfusion of the spinal cord in DCM. Although there are still substantial limitations to implementation, future clinical practice will likely be revolutionized by these new imaging modalities to diagnose, localize, surgically plan and manage, and follow patients with DCM.

A Retrospective Analysis of the L3-L4 Disc and Spinopelvic Parameters on Outcomes in Thoracolumbar Fusion: Was Art Steffee Right?

OBJECTIVE: To determine whether the L3-L4 disc angle may be a surrogate marker for global lumbar alignment in thoracolumbar fusion surgery and to explore the relationship between radiographic and patient-reported outcomes after thoracolumbar fusion surgery. METHODS: Retrospective chart review was conducted on patients who had undergone a lumbar fusion involving levels from T9 to pelvis. EuroQol-Five Dimension (EQ-5D-3L) scores and adverse events including adjacent-segment disease and degeneration, pseudoarthrosis, proximal junctional kyphosis, stenosis, and reoperation were collected. Pre- and postoperative spinopelvic parameters were measured on weight-bearing radiographs, with the L3-L4 disc angle of novel interest. Univariate logistic and linear regression were performed to assess the associations of radiographic parameters with adverse event incidence and improvement in EQ-5D-3L, respectively. RESULTS: In total, 182 patients met inclusion criteria. Univariable analysis revealed that increased magnitude of L3-L4 disc angle, anterior pelvic tilt, and pelvic incidence measures are associated with increased likelihood of developing postoperative adverse events. Conversely, increased lumbar lordosis demonstrated a decreased incidence of developing a postoperative adverse event. Linear regression showed that radiographic parameters did not significantly correlate with postoperative EQ-5D-3L scores, although scores were significantly improved postfusion in all dimensions except Self-Care (P = 0.51). CONCLUSIONS: L3-L4 disc angle magnitude may serve as a surrogate marker of global lumbar alignment. The degree of spinopelvic alignment did not correlate to improvement in EQ-5D-3L score in the present study, suggesting that quality of life metric change may not be a sensitive or specific marker of postfusion alignment.

Longer operative time associated with prolonged length of stay, non-home discharge and transfusion requirement after anterior cervical discectomy and fusion: an analysis of 24,593 cases.

BACKGROUND: Prolonged operative time of single-level ACDF has been associated with adverse postoperative outcomes. The current literature does not contain a comprehensive quantitative description of these associations PURPOSE: This study characterized the associations between single-level anterior cervical discectomy and fusion(ACDF) operative time and (1)30-day postoperative healthcare utilization, and (2)the incidence of local wound complications, need for transfusion and mechanical ventilation. DESIGN/SETTING: Retrospective database analysis PATIENT SAMPLE: The American College of Surgeons National Surgical Quality Improvement Program(ACS-NSQIP) database was queried for single-level ACDF cases(2012-2018) using current procedural terminology codes. A total of 24,593 cases were included. OUTCOME MEASURES: Primary outcomes included healthcare utilization(lengths of stay[LOS], discharge dispositions, 30-day readmissions, and reoperations) per operative time category. The secondary outcome was the incidence of wound complications, blood transfusion and need for ventilation per operative time category. METHODS: Multivariate regression determined operative time categories associated with increased risk while adjusting for patient demographics and comorbidities. Predictive spline regression models visualized the associations. RESULTS: Compared to the reference operative time of 81-100-minutes, the 101-120-minute category was associated with higher odds of LOS >2 days(OR:1.36,95%CI(1.18-1.568);p<.001) and non-home discharge(OR:1.341,95%CI(1.081-1.664);p=.008). Three-times greater odds of LOS >2 days(OR:3.367,95%CI(2.719-4.169); p<.001) and twice the odds of non-home discharge(OR:2.174,95%CI(1.563-3.022);p<.001) were detected at 181-200-minutes. The highest operative time category(≥221 minutes) was associated with the highest odds of LOS>2 days(OR:4.838,95%CI(4.032-5.804);p<.001), non-home discharge(OR:2.687,95%CI(2.045-3.531);p<.001) and reoperation(OR:1.794,95%CI(1.094-2.943);p=.021). Patients within the 201-220 and the ≥221-minute categories exhibited a significant association with greater odds of transfusion(OR:8.57,95%CI(2.321-31.639);p<.001, and OR:11.699, 95%CI(4.179-32.749);p=.001, respectively). Spline regression demonstrated that the odds of LOS >2 days, non-home discharge disposition, reoperation and bleeding requiring transfusion events began to rise, starting at 94, 91.6, 91.6, and 93.3 minutes of operative time, respectively. CONCLUSION: This study demonstrated that prolonged operative time is associated with increased odds of healthcare utilization and transfusion after single-level ACDF. Operative times greater than 91 minutes may carry higher odds of postoperative complications.

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.

Statistical performance in National Football League athletes after lumbar discectomy.

OBJECTIVE: It is currently unknown how a lumbar disk herniation (LDH) impacts a professional athlete's performance and/or career. No studies have evaluated the effects of LDH on National Football League (NFL) skill position players. Our objective was to determine if NFL athletes who sustain an LDH and subsequently undergo discectomy can return to competitive play with no significant effects on performance. DESIGN: Retrospective cohort study. SETTING: National Football League. PATIENTS: During a 22-year period (1986-2008), offensive skill position players in the NFL (quarterbacks, running backs, wide receivers, and tight ends) who sustained an LDH and subsequently underwent a lumbar discectomy were included in this study. INTERVENTION: Lumbar discectomy. MAIN OUTCOME MEASURES: Performance-based outcomes were analyzed, and data were recorded for games played, yards gained, and touchdowns scored. RESULTS: : Data were analyzed for 23 NFL offensive skill position players who had an LDH and underwent discectomy. Seventy-four percent of players returned to competitive play in the NFL. The average length of career after treatment was 36 games over a 4.1-year period. There was no significant difference in performance when comparing pre-injury and post-injury statistics. CONCLUSIONS: Although an LDH has career-threatening implications for NFL athletes, 74% of players who underwent lumbar discectomy returned to competitive play in the NFL. There was no significant change in performance when comparing pre-injury and post-injury statistics.

Epidemiology, Treatment, and Performance-Based Outcomes in American Professional Baseball Players With Symptomatic Spondylolysis and Isthmic Spondylolisthesis.

BACKGROUND: Repetitive lumbar hyperextension and rotation during athletic activity affect the structural integrity of the lumbar spine. While many sports have been associated with an increased risk of developing a pars defect, few previous studies have systematically investigated spondylolysis and spondylolisthesis in professional baseball players. PURPOSE: To characterize the epidemiology and treatment of symptomatic lumbar spondylolysis and isthmic spondylolisthesis in American professional baseball players. We also sought to report the return-to-play (RTP) and performance-based outcomes associated with the diagnosis of a pars defect in this elite athlete population. STUDY DESIGN: Descriptive epidemiology study. METHODS: A retrospective cohort study was conducted among all Major and Minor League Baseball (MLB and MiLB, respectively) players who had low back pain and underwent lumbar spine imaging between 2011 and 2016. Players with radiological evidence of a pars defect (with or without listhesis) were included. Analyses were conducted to assess the association between player-specific characteristics and RTP time. Baseball performance metrics were also compared before and after the injury episode to determine whether there was an association between the diagnosis of a pars defect and diminished player performance. RESULTS: During the study period of 6 MLB seasons, 272 professional baseball players had low back pain and underwent lumbar spine imaging. Overall, 75 of these athletes (27.6%) received a diagnosis of pars defect. All affected athletes except one (98.7%) successfully returned to professional baseball, with a median RTP time of 51 days. Players with spondylolisthesis returned to play faster than those with spondylolysis, MLB athletes returned faster than MiLB athletes, and position players returned faster than pitchers. Athletes with a diagnosed pars defect did not show a significant decline in performance after returning to competition after their injury episode. CONCLUSION: Lumbar pars defects were a common cause of low back pain in American professional baseball players. The vast majority of affected athletes were able to return to competition without demonstrating a significant decline in baseball performance.

Validation of Patient-reported Outcomes Measurement Information System Computer Adaptive Tests in Lumbar Disk Herniation Surgery.

INTRODUCTION: Inadequate validation, floor/ceiling effects, and time constraints limit utilization of standardized patient-reported outcome measures. We aimed to validate Patient-reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) for patients treated surgically for a lumbar disk herniation. METHODS: PROMIS, CATs, Oswestry Disability Index, and Short Form-12 measures were administered to 78 patients treated with lumbar microdiskectomy for symptomatic disk herniation with radiculopathy. RESULTS: PROMIS CATs demonstrated convergent validity with legacy measures; PROMIS scores were moderately to highly correlated with the Oswestry Disability Index and Short Form-12 physical component scores (r = 0.41 and 0.78, respectively). PROMIS CATs demonstrated similar responsiveness to change compared with legacy measures. On average, the PROMIS CATs were completed in 2.3 minutes compared with 5.7 minutes for legacy measures. DISCUSSION: The PROMIS CATs demonstrate convergent and known groups' validity and are comparable in responsiveness to legacy measures. These results suggest similar utility and improved efficiency of PROMIS CATs compared with legacy measures. LEVELS OF EVIDENCE: Level II.

A Comparison of Patient-Centered Outcome Measures to Evaluate Dysphagia and Dysphonia After Anterior Cervical Discectomy and Fusion.

OF BACKGROUND DATA: Dysphagia and dysphonia are the most common complications after anterior cervical diskectomy and fusion (ACDF). No consensus system exists currently in the spine literature for the classification of these conditions postoperatively. OBJECTIVE: The purpose of this analysis was to evaluate the validity and reliability of the Eating Assessment Tool (EAT-10) in the assessment of dysphagia when compared with the Bazaz score. A secondary goal was to assess the Voice Handicap Index (VHI-10) scores among patients following ACDF. METHODS: Patients treated with ACDF (one, two, or three level) for cervical radiculopathy and/or cervical myelopathy at two tertiary hospitals were administered patient-reported outcome metrics preoperatively as well as at multiple time points postoperatively. The metrics administered included the EAT-10, VHI-10, Bazaz, Neck Disbability Index, and EuroQol Five Dimensions questionnaire (EQ-5D)/visual analog scale. RESULTS: One hundred patients were included in this study. Eighty-nine percentage had a 1-year follow-up, and 100% had a 12-week follow-up. Mean Neck Disbability Index, EQ-5D, and EQ-visual analog scale scores all improved from baseline at both 6 months and 1 year postoperatively. Both the EAT-10 and VHI-10 demonstrated excellent internal reliability (α = 0.95 and α = 0.90, respectively). Analysis of variance of EAT-10 and VHI-10 scores by time point demonstrated a statistically significant relationship (P < 0.0001). The EAT-10 and VHI-10 scores were statistically greater on postoperative day 1 than at all other times (Tukey posthoc, P < 0.0001 and P < 0.004, respectively). Across all time points, 176 instances of clinically significant dysphagia (EAT-10 ≥ 3) were noted, 57 (32%) of which were classified as "None" on the Bazaz classification. CONCLUSIONS: The EAT-10 score is an accurate measure for mild to severe dysphagia and better captured significant dysphagia that would have otherwise been missed when the Bazaz score is used. EAT-10 and VHI-10 are better measures of postoperative dysphagia and dysphonia than the current metrics used in spine surgery. STUDY DESIGN: This was a prospective cohort study of consecutive patients.

Predicting Clinical Outcomes Following Surgical Correction of Adult Spinal Deformity.

BACKGROUND: Deformity reconstruction surgery has been shown to improve quality of life (QOL) in cases of adult spinal deformity (ASD) but is associated with significant morbidity. OBJECTIVE: To create a preoperative predictive nomogram to help risk-stratify patients and determine which would likely benefit from corrective surgery for ASD as measured by patient-reported health-related quality of life (HRQoL). METHODS: All patients aged 25-yr and older with radiographic evidence of ASD and QOL data that underwent thoracolumbar fusion between 2008 and 2014 were identified. Demographic and clinical parameters were obtained. The EuroQol 5 dimensions questionnaire (EQ-5D) was used to measure HRQoL preoperatively and at 12-mo postoperative follow-up. Logistic regression of preoperative variables was used to create the prognostic nomogram. RESULTS: Our sample included data from 191 patients. Fifty-one percent of patients experienced clinically relevant postoperative improvement in HRQoL. Seven variables were included in the final model: preoperative EQ-5D score, sex, preoperative diagnosis (degenerative, idiopathic, or iatrogenic), previous spinal surgical history, obesity, and a sex-by-obesity interaction term. Preoperative EQ-5D score independently predicted the outcome. Sex interacted with obesity: obese men were at disproportionately higher odds of improving than nonobese men, but obesity did not affect odds of the outcome among women. Model discrimination was good, with an optimism-adjusted c-statistic of 0.739. CONCLUSION: The predictive nomogram that we developed using these data can improve preoperative risk counseling and patient selection for deformity correction surgery.

The Effect of Oblique Magnetic Resonance Imaging on Surgical Decision Making for Patients Undergoing an Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy.

BACKGROUND: The purpose of this study was to determine if oblique magnetic resonance imaging (MRI) sequences affect the surgical treatment recommendations for patients with cervical radiculopathy. METHODS: In this cohort study consecutive clinical cases of persistent cervical radiculopathy requiring surgical intervention were randomized, blinded, and reviewed by 6 surgeons. Initially each surgeon recommended treatment based on the history, physical examination, and axial, coronal and sagittal preoperative magnetic resonance (MR) images; when reviewing the cases the second time, the surgeons were provided oblique MR images. This entire process was then repeated after 2 months. Change in surgical recommendation, interobserver and intraobserver reliability and the average number of levels fused was determined. RESULTS: The addition of the oblique images resulted in the surgical recommendation being altered in 49.2% (59/120) of cases; however, the addition of oblique images did not substantially improve the interobserver reliability of the treatment recommendation (κ = .57 versus.57). Similarly, the overall intraobserver reliability using only traditional MRI sequences (κ = .64) was only slightly improved by the addition of oblique images (κ = .66). Lastly, the addition of oblique images did not change the average number of levels fused (traditional MRI = 1.38, oblique MRI = 1.41, P = .53), or the total number of 3-level fusions recommended (6 versus 6, P = 1.00). CONCLUSIONS: The additional oblique images resulted in a change to the surgical plan in almost 50% of cases; however, it had no substantial effect on the reliability of surgical decision making. Further studies are needed to see if this alteration in treatment affects clinical outcomes. LEVEL OF EVIDENCE: 3.

Postoperative stroke after anterior cervical discectomy and fusion in patients with carotid artery stenosis: a statewide database analysis.

BACKGROUND: Carotid artery injury and stroke secondary to prolonged retraction remains an extremely rare complication in anterior cervical discectomy and fusion (ACDF). However, multiple studies have demonstrated that carotid artery retraction during the surgical approach may alter the normal blood flow, leading to a significant reduction in the cross-sectional area of the vessel. Others have suggested that dislodgment of atherosclerotic plaques following manipulation of the carotid artery can be a potential risk for intracranial embolus and stroke. PURPOSE: We aimed to evaluate: (1) the incidence of postoperative stroke following ACDF and (2) incidence of other postoperative complications in a cohort of patients who had a diagnosis of carotid artery stenosis (CAS) versus those who did not. PATIENT SAMPLE: This study utilized the Statewide Planning and Research Cooperative System database from January 1, 2009 to December 31, 2013. All patients who underwent (ACDF) and had a preoperative diagnosis of CAS were identified using the International Classification of Disease, ninth revision codes. Those who had a previous history of stroke were excluded. Patients who had CAS were propensity score matched to patients without history of CAS for demographics and Charlson/Deyo comorbidity scores. OUTCOME MEASURES: Incidence of postoperative stroke and other complications were compared between the cohorts. The threshold for statistical significance was set at a p<.05. This study received no funding. The authors report no conflict of interests relevant to this study. RESULTS: There were 34,975 patients who underwent an ACDF in the study time period. After excluding those under the age of 18 and with history of previous stroke, there were 61 patients who had CAS that were compared with a propensity-matched cohort. The CAS cohort had a significantly higher incidence of postoperative stroke during their hospitalization (6.6% vs 0%, p<.042). The CAS cohort also had higher rates of acute renal failure (27.9% vs 4.9%, p = .01) and sepsis (18% vs 4.9%, p = .023). There were no stroke related deaths. CONCLUSIONS: Patients with CAS who underwent ACDF had a statistically significant greater incidence of developing a postoperative stroke. To the best of our knowledge, no previous study has evaluated the development of postoperative stroke in patients with CAS undergoing ACDF. Larger, multicenter studies are needed to estimate the true incidence of stroke in this specific patient population. However, our results may illustrate the importance of preoperative optimization, approach-selection, and postoperative stroke surveillance in patients with a history of CAS who undergoes ACDF.

Cervical Total Disk Arthroplasty.

In the United States, cervical total disk arthroplasty (TDA) is US Federal Drug Administration (FDA) approved for use in both 1 and 2-level constructions for cervical disk disease resulting in myelopathy and/or radiculopathy. TDA designs vary in form, function, material composition, and even performance in?vivo. However, the therapeutic goals are the same: to remove the painful degenerative/damaged elements of the intervertebral discoligamenous joint complex, to preserve or restore the natural range of spinal motion, and to mitigate stresses on adjacent spinal segments, thereby theoretically limiting adjacent segment disease (ASDis). Cervical vertebrae exhibit complex, coupled motions that can be difficult to artificially replicate. Commonly available TDA designs include ball-and-socket rotation-only prostheses, ball-and-trough rotation and anterior-posterior translational prostheses, as well as unconstrained elastomeric disks that can rotate and translate freely in all directions. Each design has its respective advantages and disadvantages. At this time, available clinical evidence does not favor 1 design philosophy over another. The superiority of cervical TDA over the gold-standard anterior cervical discectomy and fusion is a subject of great controversy. Although most studies agree that cervical TDA is at least as effective as anterior cervical discectomy and fusion at reducing or eliminating preoperative pain and neurological symptoms, the clinical benefits of motion preservation- that is, reduced incidence of ASDis-are far less clear. Several short-to-mid-term studies suggest that disk arthroplasty reduces the radiographic incidence of adjacent segment degeneration; however, the degree to which this is clinically significant is disputed. At this time, TDA has not been clearly demonstrated to reduce symptomatic?ASDis.

The Effect of Local Versus Intravenous Corticosteroids on the Likelihood of Dysphagia and Dysphonia Following Anterior Cervical Discectomy and Fusion: A Single-Blinded, Prospective, Randomized Controlled Trial.

BACKGROUND: Dysphagia and dysphonia are the most common postoperative complications following anterior cervical discectomy and fusion (ACDF). Although most postoperative dysphagia is mild and transient, severe dysphagia can have profound effects on overall patient health and on surgical outcomes. The purpose of this study was to compare the efficacy of local to intravenous (IV) steroid administration during ACDF on postoperative dysphagia and dysphonia. METHODS: This was a single-blinded, prospective, randomized clinical trial. Seventy-five patients undergoing ACDF with cervical plating were randomized into 3 groups: control (no steroid), IV steroid (10 mg of IV dexamethasone at the time of closure), or local steroid (40 mg of local triamcinolone). Patient-reported outcome measures (PROMs) were collected for dysphagia, dysphonia, and neck pain postoperatively for 1 year. RESULTS: Patient demographics were similar. Postoperative day 1 PROMs showed significantly lower scores for dysphonia (p = 0.015) and neck pain (p = 0.034) in the local steroid group. At 2 weeks postoperatively, the local steroid cohort showed significantly decreased prevalence of severe dysphagia (Eating Assessment Tool-10 [EAT-10], severe dysphagia, p = 0.027) compared with the control and IV steroid groups. Both steroid groups had significantly less severe dysphagia when compared with the control group at the 6-week and 3-month time points. At 1 year postoperatively, both steroid groups had significantly reduced dysphagia rates (p = 0.014) compared with the control group. CONCLUSIONS: Both local and IV steroid administration after cervical plating in ACDF yielded better PROMs for dysphagia compared with a control group. This finding is particularly evident in the reduced number of patients who reported severe dysphagia symptoms following ACDF with local steroid application within the first 2 postoperative weeks. Future studies should attempt to stratify dysphagia severity when reporting outcomes related to anterior cervical spine surgery. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.