Evaluation of the Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system as a guide to surgical technique selection.

BACKGROUND CONTEXT: The role of fusion in degenerative spondylolisthesis (DS) is controversial. The Clinical and Radiographic Degenerative Spondylolisthesis (CARDS) classification system was developed to assist surgeons in surgical technique selection based on individual patient characteristics. This system has not been clinically validated as a guide to surgical technique selection. PURPOSE: The purpose of this study was to determine if outcomes vary with different surgical techniques across the CARDS categories. STUDY DESIGN/SETTING: Prospective cohort study performed at one Swiss and one American spine center. PATIENT SAMPLE: Five hundred eight patients with DS undergoing surgical treatment. OUTCOME MEASURES: Core Outcomes Measure Index (COMI) at 3 months and 12 months postoperatively. METHODS: Patients undergoing surgery for DS were enrolled at 2 institutions and classified according to the CARDS system using dynamic radiographs. The Core Outcome Measure Index (COMI) was completed preoperatively, and 3 and 12 months postoperatively. Surgical technique was classified as uninstrumented (decompression alone or decompression with uninstrumented fusion) or instrumented (decompression with pedicle screw instrumentation with or without interbody fusion). Unadjusted analyses and mixed effect models compared COMI scores between the two surgery technique groups (uninstrumented vs instrumented), stratified by CARDS category over time. Reoperation rates were also compared between the surgery technique groups stratified by CARDS category. Partial funding was given through NASS grant for clinical research. RESULTS: Five hundred five out of 508 patients enrolled in the study had sufficient data to be classified according to CARDS. Seven percent were classified as CARDS A, 28% as CARDS B, 48% as CARDS C, and 17% as CARDS D (CARDS A most "stable," CARDS D least "stable"). One hundred and thirty-three patients (26%) underwent decompression alone, 30 (6%) underwent decompression and uninstrumented fusion, 42 (8%) underwent decompression and posterolateral instrumented fusion, and 303 (60%) underwent decompression with posterolateral and interbody instrumented fusion. Patients in the least "stable" categories tended to be less likely to be treated with an uninstrumented technique (CARDS D 19% vs 32% for the other categories, p=.10). There were no significant differences in 3 or 12-month COMI scores between surgical technique groups stratified by CARDS category in the unadjusted or adjusted analyses. In the unadjusted analyses, there was a trend towards less improvement in 12-month COMI change score in the CARDS D patients in the uninstrumented group compared to the instrumented group (-2.7 vs -4.1, p=.10). Reoperation rates were not significantly different between the surgical technique groups stratified by CARDS category. CONCLUSIONS: In general, outcomes for uninstrumented and instrumented surgical techniques were similar across the CARDS categories. Surgeons likely took factors included in CARDS into account during surgical technique selection. This resulted in a low number of CARDS D (n=15) patients being treated with uninstrumented techniques, which limited the statistical power of this analysis. As such, this study does not validate CARDS as a useful classification system for surgical technique selection in DS.

Female Sex and Supine Proximal Lumbar Lordosis Are Associated With the Size of the LLIF "Safe Zone" at L4-L5.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: Identify demographic and sagittal alignment parameters that are independently associated with femoral nerve position at the L4-L5 disk space. SUMMARY OF BACKGROUND DATA: Iatrogenic femoral nerve or lumbar plexus injury during lateral lumbar interbody fusion (LLIF) can result in neurological complications. The LLIF "safe zone" is the anterior half to two third of the disk space. However, femoral nerve position varies and is inconsistently identifiable on magnetic resonance imaging. The safe zone is also narrowest at L4-L5. METHODS: An analysis of patients with symptomatic lumbar spine pathology and magnetic resonance imaging with a visibly identifiable femoral nerve evaluated at a single large academic spine center from January 1, 2017, to January 8, 2020, was performed. Exclusion criteria were transitional anatomy, severe hip osteoarthritis, coronal deformity with cobb >10 degrees, > grade 1 spondylolisthesis at L4-L5 and anterior migration of the psoas.Standing and supine lumbar lordosis (LL) and its proximal (L1-L4) and distal (L4-S1) components were measured. Femoral nerve position on sagittal imaging was then measured as a percentage of the L4 inferior endplate. A stepwise multivariate linear regression of sagittal alignment and LL parameters was then performed. Data are written as estimate, 95% CI. RESULTS: Mean patient age was 58.2±14.7 years, 25 (34.2%) were female and 26 (35.6%) had a grade 1 spondylolisthesis. Mean femoral nerve position was 26.6±10.3% from the posterior border of L4. Female sex (-6.6, -11.1 to -2.1) and supine proximal lumbar lordosis (0.4, 0.1-0.7) were independently associated with femoral nerve position. CONCLUSIONS: Patient sex and proximal LL can serve as early indicators of the size of the femoral nerve safe zone during a transpsoas LLIF approach at L4-L5.

Acute development of spinal lumbar synovial facet cyst within 1 week after lumbar decompression: illustrative case.

BACKGROUND: Synovial facet cysts can sometimes develop in patients with lumbar spinal stenosis after decompressive laminectomy. The etiology of spinal lumbar synovial cysts is still unclear, but their formation is associated with underlying spinal instability, facet joint arthropathy, and degenerative spondylolisthesis. OBSERVATIONS: A 61-year-old-male patient presented with neurogenic claudication due to lumbar spinal stenosis. Radiographic studies showed grade I spondylolisthesis and radiological predictors of delayed spinal instability. He underwent lumbar decompression and shortly thereafter developed spinal instability and recurrent symptoms, with formation of a new spinal lumbar synovial facet cyst. He required revisional decompression, cyst excision, and posterolateral spinal fusion for definitive treatment. LESSONS: The literature reports postoperative spinal instability in up to one-third of patients with lumbar spinal stenosis and stable degenerative spondylolisthesis who undergo decompressive laminectomy. Close radiographic monitoring and early advanced imaging may be prudent in this patient population if they develop new postoperative neurological symptoms and show radiographic predictors of instability on preoperative imaging. Posterolateral spinal fusion with instrumentation should be considered in addition to lumbar decompression in this select group of patients who demonstrate radiographic predictors of delayed spinal instability if they are medically capable of tolerating a spinal fusion procedure.

Keys to diagnosis and management of spinal epidural abscesses: 9 years of institutional experience.

OBJECTIVE: Spinal epidural abscesses (SEA's) are a challenge to diagnose, particularly if there are non-contiguous (skip) lesions. There is also limited data to predict which patients can be treated with antibiotics alone and which require surgery. We sought to assess which demographics, clinical and laboratory findings can guide both diagnosis and management of SEA's. METHODS: All patients with SEA (ICD9 324.1, ICD10 G06.1) between April 2011-May 2019 at a single tertiary center were included. A retrospective EMR review was completed. Patient and disease characteristics were compared using appropriate statistical tests. RESULTS: 108 patients underwent initial surgical treatment versus 105 that were treated medically initially; 22 (21 %) of those failed medical management. Patients who failed medical management had significantly higher CRP, longer symptom duration, and had higher rates of concurrent non-spinal infections. 9% of patients had skip lesions. Patients with skip lesions had significantly higher WBC, ESR, as well as higher rates of bacteremia and concurrent non-spinal infections. Demographic characteristics and proportion with IVDU, smoking, malignancy, and immunosuppression were similar among the three treatment groups. CONCLUSIONS: 21 % of SEA patients failed initial medical management; they had significantly greater CRP, longer symptom duration, more commonly had neurologic deficits, and concurrent non-spinal infections. 9% of patients had skip lesions; they had significantly higher WBC, ESR, rates of bacteremia and infections outside the spine. These variables may guide diagnostic imaging, and identify those at risk of failing of medical management, and therefore require more involved clinical evaluation, and consideration for surgical intervention.

Patient-Reported Allergies, a Marker of Preoperative Pain and Disability in Elective Spine Surgery.

STUDY DESIGN: Retrospective review. OBJECTIVE: Previous literature demonstrates mixed results regarding the relationship between patient-reported allergies and pain, function, and satisfaction scores. The objective of this study was to investigate the correlation between patient-reported allergies and preoperative Oswestry Disability Index (ODI), Neck Disability Index (NDI), and Patient-Reported Outcomes Measurement System (PROMIS) scores. METHODS: All patients undergoing elective cervical, lumbar procedures between May 2017 and October 2018 were included. Baseline demographic information was recorded, as well as all reported allergies or adverse reactions. Preoperative PROMIS, ODI, and NDI scores were recorded. Hierarchical multiple linear regressions were used to assess the relationship between total number of allergies and the preoperative pain and function scores. RESULTS: A total of 570 patients were included (476 lumbar, 94 cervical). The mean number of allergies reported was 1.89 ± 2.32. The mean preoperative ODI and NDI scores were 46.39 ± 17.67 and 43.47 ± 16.51, respectively. The mean preoperative PROMIS Physical Health and PROMIS Mental Health scores were 37.21 ± 6.54 and 43.89 ± 9.26, respectively. Hierarchical multiple linear regression showed that total number of reported allergies shared a statistically significant negative relationship with all of the following scores: ODI (B = 0.83, P = .02), NDI (B = 1.45, P = .02), PROMIS Physical Health (B = -0.29, P = .013), and PROMIS Mental Health (B = -0.38, P = .024). CONCLUSIONS: Patient-reported allergies share a statistically significant negative relationship with preoperative pain and function scores; as patients have increasing total number of allergies, the ODI/NDI scores become worse (increase) and the PROMIS scores become worse (decrease).

Reducing Radiation and Lowering Costs With a Standardized Care Pathway for Nonoperative Thoracolumbar Fractures.

STUDY DESIGN: Retrospective observational study. OBJECTIVE: There is marked variation in the management of nonoperative thoracolumbar (TL) compression and burst fractures. This was a quality improvement study designed to establish a standardized care pathway for TL fractures treated with bracing, and to then evaluate differences in radiographs, length of stay (LOS), and cost before and after the pathway. METHODS: A standardized pathway was established for management of nonoperative TL burst and compression fractures (AOSpine classification type A1-A4 fractures). Bracing, radiographs, costs, complications, and LOS before and after pathway adoption were analyzed. Differences between the neurosurgery and orthopedic spine services were compared. RESULTS: Between 2012 and 2015, 406 nonoperative burst and compression TL fractures were identified. A total of 183 (45.1%) were braced, 60.6% with a custom-made thoracolumbosacral orthosis (TLSO) and 39.4% with an off-the-shelf TLSO. The number of radiographs significantly reduced after initiation of the pathway (3.23 vs 2.63, P = .010). A total of 98.6% of braces were custom-made before the pathway; 69.6% were off-the-shelf after the pathway. The total cost for braced patients after pathway adoption decreased from $10 462.36 to $8928.58 (P = .078). Brace-associated costs were significantly less for off-the-shelf TSLO versus custom TLSO ($1352.41 vs $3719.53, respectively, P < .001). The mean LOS and complication rate did not change significantly following pathway adoption. The orthopedic spine service braced less frequently than the neurosurgery service (40.7% vs 52.2%, P = .023). CONCLUSIONS: Standardized care pathways can reduce cost and radiation exposure without increasing complication rates in nonoperative management of thoracolumbar compression and burst fractures.

A 5-Year Review of Hospital Costs and Reimbursement in the Surgical Management of Degenerative Spondylolisthesis.

BACKGROUND: To evaluate charges, expenses, reimbursement, and hospital margins with noninstrumented posterolateral fusion in situ (PLF), posterolateral fusion with pedicle screws (PPS), and PPS with interbody device (PLIF) in degenerative spondylolisthesis with spinal stenosis. METHODS: A retrospective chart review was performed from 2010 to 2014 based on ICD-9 diagnoses of degenerative spondylolisthesis with spinal stenosis in patients undergoing single-level fusions. All charges, expenses, reimbursement, and margins were obtained through financial auditing. A multivariate linear regression model was used to compare demographics, charges, etc. A 1-way analysis of variance with Tukey post hoc analysis was used to analyze reimbursements and margins based upon insurances. RESULTS: Two hundred thirty-three patients met inclusion criteria. The overall charges and expenses for PLF were significantly less compared to both types of instrumented fusions (P < .0001). Medicare and private insurance were the most common insurance types; Medicare and private insurance mean reimbursements for PLF were $36,903 and $47,086, respectively; for PPS, $37,450 and $53,851, and for PLIF $40,171 and $51,640. Hospital margins for PPS and PLIF in Medicaid patients were negative (-$3,702 and -$6,456). Hospital margins were largest for both worker's compensation and private insurance patients in all fusion groups. Hospital margins with Medicare for PLF, PPS, and PLIF were $24,347, $19,205, and $23,046, respectively. Hospital margins for private insurance for PLF, PPS, and PLIF were $37,569, $36,834, and $33,134, respectively. CONCLUSIONS: As more instrumentation is used, the more it costs both the hospital and the insurance companies; hospital margins did not increase correspondingly. CLINICAL RELEVANCE: Improved understanding of related costs and margins associated with lumbar fusions to help transition to more cost effective spine centers.

Percutaneous Doxycycline Foam Injections: Novel Treatment Method for Vertebral Aneurysmal Bone Cysts.

Aneurysmal bone cysts (ABCs) are among the most aggressive benign bone tumors, often occurring in both long bones and the spine. Treatment remains controversial as recurrence rates continue to be high. Treatment options include curettage with or without bone grafting, arterial embolization, en block resection with or without instrumentation or arthrodesis, radiation, and intralesional drug injections (steroids, calcitonin, doxycycline). We present the case of a patient with a thoracic vertebral ABC who underwent 2 rounds of doxycycline foam percutaneous injections. At the 1-year follow up appointment, all symptoms had been resolved. Repeat computed tomography and magnetic resonance imaging demonstrated that the ABC had nearly filled in completely with new bone. Our case demonstrates successful use of this percutaneous, less invasive method in the management of vertebral ABCs.