Recent Global Trends and Hotspots in Occipitocervical Fusion: A Bibliometric Analysis and Visualization Study.

Occipitocervical arthrodesis has a variety of indications to treat craniocervical and atlantoaxial pathologies for which a selective cervical fusion would not provide sufficient stability. Over time, the indications for occipitocervical fusions (OCF) have evolved, as new technologies and surgical techniques were developed. In this bibliometric analysis, we aim to explore the progression of OCF literature over time, analyzing the trends in publications and citations, publishing countries and authors, keywords and topics. The Web of Science database was used for data retrieval on July 3rd, 2024, with the search "occipitocervical fusion" OR "occipito-cervical fusion" OR "occipitocervical arthrodesis" OR "occipital cervical fusion" OR "occipital cervical arthrodesis" OR ("OCF" AND "spine surgery"). Excel was used to create the citation analysis and publication trend figures, along with the publishing countries and author analysis. The bibliometric software VosViewer was used to generate the keyword co-occurrence network visualizations. Overall, 762 articles were extracted. The number of pertinent publications and citations increased until 2020 before beginning to decrease. We found that Ehlers Danlos syndrome (EDS) has become a more prevalent topic, as the association between EDS and craniocervical instability has received further scrutiny. "Dysphagia" continues to be a commonly cited topic, while, conversely, rheumatoid arthritis has decreased in publication frequency, possibly related to advances in medical management and surgical techniques. Overall, the United States of America, China, and Japan are the top publishing countries. This analysis of OCF literature provides a helpful overview of emerging trends and clinician concerns, especially as seen through the perspective of time.

The hidden risk: Intracranial hemorrhage following durotomies in spine surgery.

Objective: Intracranial hemorrhage (ICH) after durotomy in elective spine surgery, though rare, can pose a significant risk to patient outcomes. Spine surgeries bear a risk of dural tears (DT) with potential of postoperative cerebrospinal fluid leakage (PCSFL). Excessive PCSFL can precipitate a decrease in intracranial pressure, potentially leading to ICH. Literature on ICH as a postoperative complication is scarce. The aim was to assess the incidence and risk factors of ICH in patients undergoing elective spine surgery. Methods: Utilizing the 2020 National Impatient Sample (NIS) adults (>18 years) were selected by primary procedure category codes for spine fusion, discectomy, spinal cord decompression and cervicothoracic/lumbosacral nerve decompression. Exclusion criteria were trauma and malignancy. The primary outcome was occurrence of ICH. Comparative analysis and a multivariable logistic regression were used to identify independent risk. Results: In total, 40,990 patients met our criteria with an incidence of ICH at 0.08%. The ICH-group showed an increased length of stay and higher mortality compared to the control group. Spinal cord decompression, DT and PCSFL were significantly more frequent in patients with ICH. Alcohol, drug abuse and hypertension were significantly more prevalent in patients with ICH. DT, alcohol abuse and hypertension were independent risk factors for ICH. Conclusions: This study underscores the rarity and severity of ICHs following elective spine surgery, emphasizing awareness and looking for possible preventive measures. Our finding suggests that DT, as a complication of surgical techniques, as well as alcohol abuse and hypertension are significant predictors of ICH.

Historical Perspectives on the Evolution of Spino-Pelvic Fixation and its Implications on Clinical Care A Narrative Review.

STUDY DESIGN: Broad narrative review. OBJECTIVES: To review and summarize the evolution of spinopelvic fixation (SPF) and its implications on clinical care. METHODS: A thorough review of peer-reviewed literature was performed on the historical evolution of sacropelvic fixation techniques and their respective advantages and disadvantages. RESULTS: The sacropelvic junction has been a long-standing challenge due to a combination of anatomic idiosyncrasies and very high biomechanical forces. While first approaches of fusion were determinated by many material and surgical technique-related limitations, the modern idea of stabilization of the lumbosacral junction was largely initiated by the inclusion of the ilium into lumbosacral fusion. While there is a wide spectrum of indications for SPF the chosen technique remains is defined by the individual pathology and surgeons' preference. CONCLUSION: By a constant evolution of both instrumentation hardware and surgical technique better fusion rates paired with improved clinical results could be achieved.

The Postoperative Airway Compromise Score-First Steps to Developing a Postoperative Tool for the Assessment of Upper Airway-Related Complications Following Anterior Cervical Spine Surgery.

BACKGROUND: Acute upper airway compromise is a rare but catastrophic complication after anterior cervical discectomy and fusion. This study aims to develop a score to identify patients at risk of acute postoperative airway compromise (PAC). METHODS: Potential risk factors for acute PAC were selected by a modified Delphi process. Ten patients with acute PAC were identified of 1466 patients who underwent elective anterior cervical discectomy and fusion between July 2014 and May 2019. A comparison group was created by a randomized selection process (non-PAC group). Factors associated with PAC and a P value of < 0.10 were entered into a logistic regression model and coefficients contributed to each risk factor's overall score. Calibration of the model was evaluated using the Hosmer-Lemeshow goodness-of-fit test. Quantitative discrimination was calculated, and the final model was internally validated with bootstrap sampling. RESULTS: We identified 18 potential risk factors from our Delphi process, of which 6 factors demonstrated a significant association with airway compromise: age >65 years, current smoking status, American Society of Anesthesiologists class >2, history of a bleeding disorder, surgery of upper subaxial cervical spine (above C4), and duration of surgery >179 minutes. The final prediction model included 5 predictors with very strong performance characteristics. These 5 factors formed the PAC score, with a range from 0 to 100. A score of 20 yielded the greatest balance of sensitivity (80%) and specificity (88%). CONCLUSIONS: The acute PAC score demonstrates strong performance characteristics. The PAC score might help identify patients at risk of upper airway compromise caused by surgical site abnormalities.

Ongoing decision-making dilemma for treatment of de novo spinal infections: a comparison of the Spinal Infection Treatment Evaluation Score with the Spinal Instability Spondylodiscitis Score and Spine Instability Neoplastic Score.

OBJECTIVE: De novo spinal infections are an increasing medical problem. The decision-making for surgical or nonsurgical treatment for de novo spinal infections is often a non-evidence-based process and commonly a case-by-case decision by single physicians. A scoring system based on the latest evidence might help improve the decision-making process compared with other purely radiology-based scoring systems or the judgment of a single senior physician. METHODS: Patients older than 18 years with an infection of the spine who underwent nonsurgical or surgical treatment between 2019 and 2021 were identified. Clinical data for neurological status, pain, and existing comorbidities were gathered and transferred to an anonymous spreadsheet. Patients without an MR image and a CT scan of the affected spine region were excluded from the investigation. A multidisciplinary expert panel used the Spine Instability Neoplastic Score (SINS), Spinal Instability Spondylodiscitis Score (SISS), and Spinal Infection Treatment Evaluation Score (SITE Score), previously developed by the authors' group, on every clinical case. Each physician of the expert panel gave an individual treatment recommendation for surgical or nonsurgical treatment for each patient. Treatment recommendations formed the expert panel opinion, which was used to calculate predictive validities for each score. RESULTS: A total of 263 patients with spinal infections were identified. After the exclusion of doubled patients, patients without de novo infections, or those without CT and MRI scans, 123 patients remained for the investigation. Overall, 70.70% of patients were treated surgically and 29.30% were treated nonoperatively. Intraclass correlation coefficients (ICCs) for the SITE Score, SINS, and SISS were 0.94 (95% CI 0.91-0.95, p < 0.01), 0.65 (95% CI 0.91-0.83, p < 0.01), and 0.80 (95% CI 0.91-0.89, p < 0.01). In comparison with the expert panel decision, the SITE Score reached a sensitivity of 96.97% and a specificity of 81.90% for all included patients. For potentially unstable and unstable lesions, the SISS and the SINS yielded sensitivities of 84.42% and 64.07%, respectively, and specificities of 31.16% and 56.52%, respectively. The SITE Score showed higher overall sensitivity with 97.53% and a higher specificity for patients with epidural abscesses (75.00%) compared with potentially unstable and unstable lesions for the SINS and the SISS. The SITE Score showed a significantly higher agreement for the definitive treatment decision regarding the expert panel decision, compared with the decision by a single physician for patients with spondylodiscitis, discitis, or spinal osteomyelitis. CONCLUSIONS: The SITE Score shows high sensitivity and specificity regarding the treatment recommendation by a multidisciplinary expert panel. The SITE Score shows higher predictive validity compared with radiology-based scoring systems or a single physician and demonstrates a high validity for patients with epidural abscesses.

Resource Utilization Following Anterior Versus Posterior Cervical Decompression and Fusion for Acute Central Cord Syndrome.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study is to compare the impact of anterior cervical decompression and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for the treatment of acute traumatic central cord syndrome (CCS) on hospital episodes of care in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination. SUMMARY OF BACKGROUND DATA: Acute traumatic CCS is the most common form of spinal cord injury in the United States. CCS is commonly treated with surgical decompression and fusion. Hospital resource utilization based on surgical approach remains unclear. METHODS: Patients undergoing ACDF and PCDF for acute traumatic CCS were identified using the 2019 Medicare Provider Analysis and Review Limited Data Set and Centers for Medicare and Medicaid Services 2019 Impact File. Multivariate models for hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. Subanalysis of accommodation and revenue center cost drivers was performed. RESULTS: There were 1474 cases that met inclusion criteria: 673 ACDF (45.7%) and 801 PCDF (54.3%). ACDF was independently associated with a decreased cost of $9802 ( P <0.001) and a 59.2% decreased risk of discharge to nonhome destinations (adjusted odds ratio: 0.408, P <0.001). The difference in length of stay was not statistically significant. On subanalysis of cost drivers, ACDF was associated with decreased charges ($55,736, P <0.001) compared with PCDF, the largest drivers being the intensive care unit ($15,873, 28% of total charges, P <0.001) and medical/surgical supply charges ($19,651, 35% of total charges, P <0.001). CONCLUSIONS: For treatment of acute traumatic CCS, ACDF was associated with almost $10,000 less expensive cost of care and a 60% decreased risk of discharge to nonhome destination compared with PCDF. The largest cost drivers appear to be ICU and medical/surgical-related. These findings may inform value-based decisions regarding the treatment of acute traumatic CCS. However, injury and patient clinical factors should always be prioritized in surgical decision-making, and increased granularity in reimbursement policies is needed to prevent financial disincentives in the treatment of patients with CCS better addressed with posterior approach-surgery.

Posterior pelvic ring injuries, lumbosacral junction instabilities and stabilization techniques for spinopelvic dissociation: a narrative review.

INTRODUCTION: From transiliac Harrington rods to minimally invasive (MIS) percutaneous 3D-navigated transsacral-transiliac screw (TTS) fixation, concepts of fixation methods in pelvic injuries with spinopelvic dissociation (SPD) are steadily redefined. This narrative review examines the literature of recent years regarding surgical treatment options and trends in SPD, outlining risks and benefits of each treatment option and addressing biomechanical aspects of sacral injuries and common classification systems. MATERIALS AND METHODS: A literature search on the search across relevant online databases was conducted. As a scale for quality assessment, the SANRA-scoring system was taken into account. RESULTS: Sacral Isler type 1 injuries of the LPJ in U- and H-type fractures are frequently treated with stand-alone TTS. Fractures with higher instability (Isler types 2 and 3) require unilateral or bilateral LPF, subject to side involvement, as a buttressing construct, or triangular fixation as additional compression and neutralization, determined by fracture radiation. A more comprehensive classification from which to derive stabilization options is provided by the 2023 301SPD classification. MIS techniques are on the rise and offer shorter OR time, less blood loss, fewer infections, and fewer wound complications. It is advisable to implement MIS techniques as much as possible, as long as decompression is not required and closed fracture reduction succeeds satisfactorily. CONCLUSION: SPD is characteristic of severe injuries, mostly in polytraumatized patients. The complication rates are decreasing due to the increasing adaptation of MIS techniques.

Elective Single-Level Primary Anterior Cervical Decompression and Fusion for Degenerative Spondylotic Cervical Myelopathy Is Associated With Decreased Resource Utilization Versus Posterior Cervical Decompression and Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare elective single-level anterior cervical discectomy and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for degenerative cervical myelopathy (DCM) in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination in Medicare patients. A sub-analysis of potential cost drivers was also performed. BACKGROUND: In the era of value-based medicine, there is substantial interest in reducing the cost of care. Both ACDF and PCDF are used to treat DCM but carry different morbidity and risk profiles that can impact hospital resource utilization. However, this has not been assessed on a national level. METHODS: Patients undergoing single-level elective ACDF and PCDF surgery were identified using the 2019 Medicare Provider Analysis and Review (MedPAR) Limited Data Set (LDS) and Centers for Medicare and Medicaid Services (CMS) 2019 Impact File. Multivariate models of hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. A univariate sub-analysis of 9 revenue centers was performed. RESULTS: In all, 3942 patients met the inclusion criteria. The mean cost of elective single-level cervical fusion for myelopathy was $18,084±10,783, and the mean length of stay was 2.45±2.95 d. On multivariate analysis, ACDF was independently associated with decreased cost of $5,814 ( P <0.001), shorter length of stay by 1.1 days ( P <0.001), and decreased risk of nonhome discharge destination by 58% (adjusted odds ratio: 0.422, P <0.001).On sub-analysis of 9 revenue centers, medical/surgical supply ($10,497, 44%), operating room charges ($5401, 23%), and accommodations ($3999, 17%) were the largest drivers of charge differences. CONCLUSIONS: Single-level elective primary ACDF for DCM was independently associated with decreased cost, decreased hospital length of stay, and a lower rate of nonhome discharge compared with PCDF. Medical and surgical supply, operating room, and accommodation differences between ACDF and PCDF are potential areas for intervention. Increased granularity in reimbursement structures is warranted to prevent the creation of disincentives to the treatment of patients with DCM with pathology that is better addressed with PCDF. LEVEL OF EVIDENCE: Level-III Retrospective Cohort Study.

Revisiting Anticoagulation in Spine Surgery: Balancing Venous Thromboembolic Events and Epidural Hematoma.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: Venous thromboembolic events (VTE) and post-operative epidural hematoma (EDH) are significant complications after spine surgery. Guidelines for chemoprophylaxis are controversial and variability amongst surgeons remains. The objective of this study was to establish the incidence of clinical VTE and EDH at our institution and evaluate the association of chemoprophylaxis with clinical VTE and EDH. METHODS: We conducted a retrospective cohort study of patients undergoing spine surgery at a high-volume tertiary care center in Seattle, WA between January 2016 and December 2019. The Premier Health Care Database and Agency for Healthcare Research and Quality (AHRQ) patient indicators PSI-9 (Perioperative hemorrhage and hematoma) and PSI-12(Perioperative PE or DVT) were used to identify patients experiencing VTE and/or post-operative EDH. The primary outcome was the incidence of clinical VTE and EDH in post-operative spine patients. Secondary outcomes included the association of chemoprophylaxis with clinical VTE and EDH. RESULTS: From 2016 to 2019, 4587 patients underwent spine surgery, totaling 4764 hospital stays. The incidence of clinical VTE was .21% (10/4764) and the incidence of EDH was .10% (5/4764). Most hemorrhages occurred prior to the initiation of chemoprophylaxis. One patient with EDH received chemoprophylaxis prior to hemorrhage. CONCLUSIONS: The rate of post-operative clinical VTE and EDH in spine surgery is low. Despite early initiation of chemoprophylaxis after major spine surgery we did not appreciate a high rate of EDH. We attribute our low rate of clinical VTE to multimodal prophylaxis with SCDs, early mobilization and chemoprophylaxis on post-operative day 1.

Cage subsidence-A multifactorial matter!

STUDY DESIGN: Retrospective cohort study OBJECTIVE: Wider cages are associated with improved decompression and reduced subsidence, but variation in cage physical properties limits consistent outcome analysis after thoracolumbar interbody fusion. This study investigated cage subsidence and its relationship to lateral and posterior approaches with a focus on the hypothesis that the larger surface area of lateral cages results in lower subsidence rates. METHODS: This study retrospectively reviewed 194 patients who underwent interbody fusion between 2016 and 2019 with a primary outcome of cage subsidence. Secondary outcomes were cage distribution (patients, approaches, expandability), cage dimensions, t­scores, length of hospital stay, blood loss, surgical time, and pelvic incidence-lumbar lordosis (PI-LL) mismatch. RESULTS: Medical records were reviewed for 194 patients receiving 387 cages at 379 disc levels. Subsidence was identified in 35.1% of lateral cages, 40.9% of posterior cages, and 36.3% of all cages. Lower surface area (p = 0.008) and cage expandability were associated with subsidence risk. Lower anteroposterior cage length proved to be a significant factor in the subsidence of posteriorly placed cages (p = 0.007). Osteopenic and osteoporotic patients experienced cage subsidence 36.8% of the time compared to 3.5% of patients with normal t­scores (p = 0.001). Cage subsidence correlated with postoperative deterioration of the PI-LL mismatch (p = 0.03). Patients receiving fusion augmentation with bone morphogenic protein experienced higher fusion rates (p < 0.01). CONCLUSION: Cage subsidence is a common complication that can significantly impact operative outcomes following thoracolumbar interbody fusion. Low t­scores, smaller surface area, cage expandability, and lower cage length in posterior approaches contribute significantly to cage subsidence.

Impact of Race/Ethnicity on Hospital Resource Utilization After Elective Anterior Cervical Decompression and Fusion for Degenerative Myelopathy.

INTRODUCTION: With the advent of bundled care payments for spine surgery, there is increasing scrutiny on the costs and resource utilization associated with surgical care. The purpose of this study was to compare (1) the total cost of the hospital episode of care and (2) discharge destination between White, Black, and Hispanic patients receiving elective anterior cervical decompression and fusion for degenerative cervical myelopathy (DCM) in Medicare patients. METHODS: The 2019 Medicare Provider Analysis and Review Limited Data Set and the 2019 Impact File were used for this project. Multivariate models were created for total cost and discharge destination, controlling for confounders found on univariate analysis. We then performed a subanalysis for differences in specific cost-center charges. RESULTS: There were 11,506 White (85.4%), 1,707 Black (12.7%), and 261 Hispanic (1.9%) patients identified. There were 6,447 males (47.8%) and 7,027 females (52.2%). Most patients were between 65 to 74 years of age (n = 7,101, 52.7%). The mean cost of the hospital episode was $20,919 ± 11,848. Most patients were discharged home (n = 11,584, 86.0%). Race/ethnicity was independently associated with an increased cost of care (Black: $783, Hispanic: $1,566, P = 0.001) and an increased likelihood of nonhome discharge (Black: adjusted odds ratio: 1.990, P < 0.001, Hispanic: adjusted odds ratio: 1.822, P < 0.001) compared with White patients. Compared with White patients, Black patients were charged more for accommodations ($1808), less for supplies (-$1780), and less for operating room (-$1072), whereas Hispanic patients were charged more ($3556, $7923, and $5162, respectively, P < 0.05). CONCLUSION: Black and Hispanic race/ethnicity were found to be independently associated with an increased cost of care and risk for nonhome discharge after elective anterior cervical decompression and fusion for DCM compared with White patients. The largest drivers of this disparity appear to be accommodation, medical/surgical supply, and operating room-related charges. Further analysis of these racial disparities should be performed to improve value and equity of spine care for DCM.