Cervical Sagittal Alignment in Patients with Cervical Spondylotic Myelopathy: An Observational Study From the Canadian Spine Outcomes and Research Network.

STUDY DESIGN: Prospective cohort study. OBJECTIVE: Among patients with CSM, we aimed to evaluate the extent to which: (1) Preoperative cervical sagittal alignment is associated with health-related quality of life, function, and symptoms; (2) Surgery leads to changes in cervical sagittal alignment; and (3) Postoperative cervical sagittal alignment is associated with health-related quality of life, function, and symptoms at 12 months of follow-up. SUMMARY OF BACKGROUND DATA: The importance of maintaining or improving cervical sagittal alignment in the surgical management of patients with CSM has not been established. METHODS: We measured C2-C7 Cobb angle, T1 slope, and C2-C7 cervical sagittal vertical axis (cSVA). We tested for associations with Neck Disability Index, Pain Scales for neck and arm pain, EuroQol 5D, Short Form 12 Physical and Mental Component Summaries, and modified Japanese Orthopaedic Association scores. We adjusted for potential confounders using multiple linear regression, and we performed various prespecified subgroup (cSVA > 40 mm, surgical approach) and sensitivity analyses. RESULTS: Among 250 patients, adjusted analyses yielded significant inverse associations prior to surgery between each of cSVA and T1 slope with SF12 Physical Component Summaries (T1 slope: -0.14, 95% CI -0.26 to -0.01, P = 0.03; C2-C7 cSVA: -0.13, 95% CI --0.21 to -0.05 P < 0.01). Surgery was associated with a small but statistically significant increase in cSVA across the cohort (+5.8 mm [SD 11.7], P < 0.01) but no change in Cobb angle or T1 slope. At 12-months after surgery, there were no significant associations between alignment parameters or change in alignment and any measures of health-related quality of life, function, or symptoms. Results were consistent across subgroup and sensitivity analyses. CONCLUSION: Increased cSVA and T1 slope were associated with inferior health-related quality of life at presentation among patients with CSM, but no significant associations were observed following surgical treatment.Level of Evidence: 3.

Does preoperative DVT chemoprophylaxis in spinal surgery affect the incidence of thromboembolic complications and spinal epidural hematomas?

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary embolus (PE) remain common surgical complications, often affecting patients without any prior warning. Postoperative spinal epidural hematomas (SEH) may have a devastating impact on a patient's recovery from a routine procedure. The effect of preoperative DVT prophylaxis administration on elective spinal patients has not previously been studied. STUDY DESIGN: Retrospective cohort analysis. OBJECTIVE: To correlate the incidence of preoperative DVT prophylaxis administration and the rate of postoperative DVT, PE, and SEH after elective spinal surgery. SUMMARY OF BACKGROUND DATA: Earlier studies have shown a postoperative DVT rate in elective spinal patients of between 0.3% and 31%, a PE rate of 0.2% to 0.9%, and a SEH rate of approximately 0.1%. METHODS: About 3870 patient notes, from 2004 to 2008 elective spinal procedures, were reviewed. DVT, PE, and SEH rates were compared between those patients receiving and not receiving preoperative DVT prophylaxis. RESULTS: The 36.9% of patients received preoperative DVT prophylaxis, and 19 patients suffered and DVT and/or PE. Nine of these had received preoperative prophylaxis, giving an odds ratio of 0.91. Sixteen patients suffered a SEH, and this gave an odds ratio of 1.33. The SEH's presented with a median postoperative time of 4 days. CONCLUSIONS: Preoperative DVT prophylaxis does not influence the rate of postoperative DVT or PE among elective spinal patients. It probably does not influence SEH rate, and it is noted that SEH may present quite late, in contrast to currently accepted time courses.

Evidence-Based Recommendations for Spine Surgery.

: This next issue of Evidence-Based Recommendations for Spine Surgery examines six articles that seek to address pressing and relevant issues in contemporary spine surgery. These articles explore the safety and efficacy of tranexamic acid during lumbar surgery, the utility of post-operative MRI after spinal decompression surgery, the role of teriparatide for fusion support in osteoporotic patients, sagittal spinopelvic alignment in adults, the comparative effectiveness of lumbar disk arthroplasty and prognostic factors for satisfaction after lumbar decompression surgery. These important publications are examined rigorously - both clinically and methodologically - and recommendations regarding impact on clinical practice are provided.Level of Evidence: N/A.

The cost effectiveness of minimally invasive spine surgery in the treatment of adult degenerative scoliosis: a comparison of transpsoas and open techniques.

INTRODUCTION: Surgical treatment improves quality of life in patients with adult degenerative scoliosis (ADS). However, open ADS surgeries are complex, large magnitude operations associated with a high rate of complications. The lateral transpsoas interbody fusion technique is a less invasive alternative to open ADS surgery, but less invasive techniques tend to be more expensive. The objective of this study was to evaluate the cost effectiveness of the transpsoas technique for patients with ADS over a 12-month time horizon from a public payer perspective. METHODS: A cost-effectiveness analysis was performed based on a consecutive case series of patients who underwent ADS surgeries between 2006 and 2012. Effectiveness was expressed as the difference in patient reported preoperative and 12-month postoperative health-related quality of life (HRQOL), which was measured in quality-adjusted life years. Health-care resource use was tabulated based on a clinical chart review on an item-by-item basis. Unit cost data were obtained from published provincial costs in Alberta, Canada. All costs were adjusted to 2015 Canadian dollars. The base case analysis included costs for the surgery, initial hospitalization, and treatment for complications over a 12-month follow-up period. The uncomplicated case analysis included costs for the surgery and initial hospitalization only. The joint uncertainty surrounding the cost and HRQOL differences was estimated using bootstrapping with 10,000 replicates. RESULTS: A total of 10 open technique and 12 transpsoas technique T11-pelvis fusions were included in the analysis. In the base case analysis, the transpsoas technique was less costly compared with the open technique, total cost of $83,513 (95% CI: $72,772-$94,253) versus $111,381 (95% CI: $36,340-$186,423), respectively (incremental cost $27,869), and was associated with 0.06 more quality-adjusted life years and/or patient. However, in the uncomplicated case, the open technique was less costly compared with the transpsoas technique ($47,795 [95% CI: $39,003-$56,586] vs $76,510 [95% CI: $72,273-$80,746]), respectively, with an incremental cost of $28,715. Based on the probabilistic analysis of 10,000 bootstrap iterations for the base case analysis, the transpsoas technique was more effective and less costly compared with the open technique 57% of time. One-way deterministic sensitivity analysis by adjusting bone-morphogenetic protein-2 dosage further improved cost effectiveness of the transpsoas technique by lowering overall costs. CONCLUSIONS: Transpsoas surgeries were associated with better outcomes in terms of HRQOL and lower costs over 1-year follow-up period compared with more invasive open technique. This study should be viewed as a pilot evaluation and should be replicated in a larger prospective multicenter controlled study.

Performance Indicators in Spine Surgery.

STUDY DESIGN: Systematic review. OBJECTIVE: To elucidate how performance indicators are currently used in spine surgery. SUMMARY OF BACKGROUND DATA: The Patient Protection and Affordable Care Act has given significant traction to the idea that healthcare must provide value to the patient through the introduction of hospital value-based purchasing. The key to implementing this new paradigm is to measure this value notably through performance indicators. METHODS: MEDLINE, CINAHL Plus, EMBASE, and Google Scholar were searched for studies reporting the use of performance indicators specific to spine surgery. We followed the Prisma-P methodology for a systematic review for entries from January 1980 to July 2016. All full text articles were then reviewed to identify any measure of performance published within the article. This measure was then examined as per the three criteria of established standard, exclusion/risk adjustment, and benchmarking to determine if it constituted a performance indicator. RESULTS: The initial search yielded 85 results among which two relevant studies were identified. The extended search gave a total of 865 citations across databases among which 15 new articles were identified. The grey literature search provided five additional reports which in turn led to six additional articles. A total of 27 full text articles and reports were retrieved and reviewed. We were unable to identify performance indicators. The articles presenting a measure of performance were organized based on how many criteria they lacked. We further examined the next steps to be taken to craft the first performance indicator in spine surgery. CONCLUSION: The science of performance measurement applied to spine surgery is still in its infancy. Current outcome metrics used in clinical settings require refinement to become performance indicators. Current registry work is providing the necessary foundation, but requires benchmarking to truly measure performance. LEVEL OF EVIDENCE: 1.

Orthosis versus no orthosis for the treatment of thoracolumbar burst fractures without neurologic injury: a multicenter prospective randomized equivalence trial.

BACKGROUND CONTEXT: Thoracolumbar burst fractures have good outcomes when treated with early ambulation and orthosis (TLSO). If equally good outcomes could be achieved with early ambulation and no brace, resource utilization would be decreased, especially in developing countries where prolonged bed rest is the default option because bracing is not available or affordable. PURPOSE: To determine whether TLSO is equivalent to no orthosis (NO) in the treatment of acute AO Type A3 thoracolumbar burst fractures with respect to their functional outcome at 3 months. STUDY DESIGN: A multicentre, randomized, nonblinded equivalence trial involving three Canadian tertiary spine centers. Enrollment began in 2002 and 2-year follow-up was completed in 2011. PATIENT SAMPLE: Inclusion criteria included AO-A3 burst fractures between T11 and L3, skeletally mature and older than 60 years, 72 hours from their injury, kyphotic deformity lower than 35°, no neurologic deficit. One hundred ten patients were assessed for eligibility for the study; 14 patients were not recruited because they resided outside the country (3), refused participation (8), or were not consented before independent ambulation (3). OUTCOME MEASURES: Roland Morris Disability Questionnaire score (RMDQ) assessed at 3 months postinjury. The equivalence margin was set at δ=5 points. METHODS: The NO group was encouraged to ambulate immediately with bending restrictions for 8 weeks. The TLSO group ambulated when the brace was available and weaned from the brace after 8 to 10 weeks. The following competitive grants supported this work: VHHSC Interdisciplinary Research Grant, Zimmer/University of British Columbia Research Fund, and Hip Hip Hooray Research Grant. Aspen Medical provided the TLSOs used in this study. The authors have no financial or personal relationships that could inappropriately influence this work. RESULTS: Forty-seven patients were enrolled into the TLSO group and 49 patients into the NO group. Forty-six participants per group were available for the primary outcome. The RMDQ score at 3 months postinjury was 6.8 ± 5.4 (standard deviation [SD]) for the TLSO group and 7.7 ± 6.0 (SD) in the NO group. The 95% confidence interval (-1.5 to 3.2) was within the predetermined margin of equivalence. Six patients required surgical stabilization, five of them before initial discharge. CONCLUSIONS: Treating these fractures using early ambulation without a brace avoids the cost and patient deconditioning associated with a brace and complications and costs associated with long-term bed rest if a TLSO or body cast is not available.

A scoring system for elective triage of referrals: Spine Severity Score.

BACKGROUND CONTEXT: The Spine Severity Score (SSS) is a 15-point scoring system devised for the purpose of triaging elective surgical spine referrals. From the referral letter and the accompanying radiology report, a total score is calculated based on clinical, pathological, and radiological criteria; a maximum score of 5 can be obtained within each category. A higher total score represents a referral that should be seen more urgently. PURPOSE: To report interrater and intrarater reliability for the SSS and compare the scoring system against the traditional system for triage, that is, the surgeon's clinical experience. STUDY DESIGN: A prospective cross-comparison design was used to evaluate the reliability and convergent validity of the SSS using spine case referrals. METHODS: Four spine surgeons (experts) and three administrative assistants (nonexperts) at the University of Calgary scored 25 referrals. A second iteration of scoring was performed with a minimum time interval elapsed of 6 weeks. Raters were instructed to choose the most concerning (the one with the highest associated score) descriptor in each category that was thought relevant to the individual referral. No further instructions were given on how to interpret the referral letter or the radiology report. The surgeons also scored the referrals using their own preexisting four-point scoring systems. The results were analyzed with independent and dependent t tests, Pearson product moment correlation coefficient, and generalizability and decision analysis. RESULTS: An independent-measures t test (p>.05) revealed no statistical differences between experts and nonexperts (ie, interrater reliability) for both Iterations 1 and 2 on total scores of the SSS and a moderately strong relationship between their ratings across iterations (r=0.79, p<.001). Similarly, a paired-samples t test (p>.05) indicated a nonsignificant mean difference between Total SSS ratings at Time 1 and Time 2 (ie, intrarater reliability) and a high degree of agreement (r=0.96, p<.001) between the two iterations. These results were confirmed with correlational analyses. Pearson product moment correlation coefficients between the gold standard and the mean score were calculated from expert ratings on Total SSS at Time 1 (r=0.71, p<.001) and at Time 2 (r=0.69, p<.001). CONCLUSIONS: The SSS is a reliable scoring system for triage of elective spine referrals, even among nonexperts. We have been able to demonstrate strong interrater and intrarater reliability for the SSS and moderately strong correlation with the traditional triage system.

Multiple-level thoracolumbar burst fractures in teenaged patients.

The purpose of this study was to examine the characteristics of multiple-level burst fractures in teenaged patients. Five teenaged patients were identified with this injury pattern. The mean age at injury was 17.6 years. All five patients underwent a posterior fusion and an attempted decompression through ligamentotaxis. One of the five went on to have an anterior decompression. Four of the five patients had spinal instrumentation. Neurologic deficit was present in four patients. The proximal fracture was most often responsible for the neurologic deficit when present. The average length of follow-up was 4.5 years. There was no significant neurologic recovery after hospital discharge. Three of the five patients had minimal or no back pain at latest follow-up. The authors conclude that multiple burst fractures should be treated individually based on their clinical and radiographic characteristics.