Robotic versus nonrobotic sacroiliac joint fusion.

OBJECTIVE: Robot-assisted pedicle screw placement in spinal fusion has been well studied. However, few studies have evaluated robot-assisted sacroiliac joint (SIJ) fusion. The aim of this study was to compare surgical characteristics, accuracy, and complications between robot-assisted and fluoroscopically guided SIJ fusion. METHODS: A retrospective review of 110 patients with 121 SIJ fusions done at a single academic institution was conducted from 2014 to 2023. Inclusion criteria included adult age and a robot- or fluoroscopically guided approach to SIJ fusion. Patients were excluded if the SIJ fusion was part of a longer fusion construct, not minimally invasive, and/or had missing data. Demographics, approach type (robotic vs fluoroscopic), operative time, estimated blood loss (EBL), number of screws, intraoperative complications, 30-day complications, number of intraoperative fluoroscopic images (as a surrogate for radiation exposure), implant placement accuracy, and pain status at the first follow-up were recorded. Primary endpoints were SIJ screw placement accuracy and complications. Secondary endpoints were operative time, radiation exposure, and pain status at the first follow-up. RESULTS: Ninety patients were included who underwent a total of 101 SIJ fusions, of which 78 were robotic and 23 were fluoroscopic. The mean age of the cohort at the time of surgery was 55.9 ± 13.8 years; 46 patients were females (51.1%). No difference was found in screw placement accuracy between robotic and fluoroscopic fusion (1.3% vs 8.7%, p = 0.06). Chi-square analysis of robotic versus fluoroscopic fusion found no difference in the presence of 30-day complications (p = 0.62). Mann-Whitney U-test analysis found that robotic fusion had a significantly longer operative time than fluoroscopic fusion (72.0 vs 61.0 minutes, p = 0.01); however, robot-assisted fusions involved significantly lower radiation exposure (26.7 vs 187.4 fluoroscopic images, p < 0.001). No difference in EBL was noted (p = 0.17). No intraoperative complications were present in this cohort. Subgroup analysis comparing the 23 most recent robotic cases against the 23 fluoroscopic cases found that robotic fusion still was associated with significantly longer operative times than fluoroscopic fusion (74.0 ± 26.4 vs 61.0 ± 14.9 minutes, respectively; p = 0.047). CONCLUSIONS: SIJ screw placement accuracy did not significantly differ between robot-assisted and fluoroscopic SIJ fusion. Complications overall were low and similar between the two groups. The operative time was longer with robotic assistance, but there was markedly less radiation exposure to the surgeon and staff.

Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management.

The diagnosis and treatment of patients who have both hip and lumbar spine pathologies may be a challenge because overlapping symptoms may delay a correct diagnosis and appropriate treatment. Common complaints of patients who have both hip and lumbar spine pathologies include low back pain with associated buttock, groin, thigh, and, possibly, knee pain. A thorough patient history should be obtained and a complete physical examination should be performed to identify the primary source of pain. Plain and advanced imaging studies and diagnostic injections can be used to further delineate the primary pathology and guide the appropriate sequence of treatment. Both the surgeon and the patient should understand that although one pathology is managed, management of the other pathology may be necessary because of persistent pain. The recognition of both entities may help reduce the likelihood of misdiagnosis, and the management of both entities in the appropriate sequence may help reduce the likelihood of persistent symptoms.

Do Patients Accurately Recall Pain Levels Following Sacroiliac Joint Steroid Injection? A Cohort Study of Recall Bias in Patient-reported Outcomes.

BACKGROUND: Sacroiliac joint (SIJ) injections are crucial in the diagnostic toolkit for evaluating SIJ pathology. Recall bias is an important component in patient-reported outcomes that has not been well studied in SIJ injection. OBJECTIVE: The purpose of this study was to characterize the accuracy, direction, and magnitude of pain level recall bias following SIJ steroid injection and study the factors that affect patient recollection. STUDY DESIGN: Prospective cohort study. SETTING: Level 1 academic medical center. METHODS: Using standardized questionnaires, baseline Numeric Rating Scale (NRS-11) scores were recorded for patients undergoing SIJ steroid injections at preinjection, at 4 hours postinjection, and at 24 hours postinjection. At a minimum of 2 weeks postinjection, patients were asked to recall their preinjection, 4-hour, and 24-hour postinjection NRS-11 scores. Actual and recalled NRS-11 scores were compared using paired t tests for each time interval. Multivariable linear regression was used to identify factors that correlated with consistent recall. RESULTS: Sixty patients with a mean age of 66 years (65% women) were included. Compared to their preinjection pain score, patients showed considerable improvement at both 4 hours (mean difference [MD] = 3.28; 95% CI, 2.68 - 3.89), and 24 hours (MD = 3.23; 95% CI, 2.44 - 4.03) postinjection. Patient recollection of preinjection symptoms was more severe than actual (MD = 0.65; 95% CI, 0.31 - 0.99). Patient recollection of symptoms was also more severe than actual at 4 hours (MD = 0.50; 95% CI .04 - 1.04) as well as at 24 hours postinjection (MD = 0.80; 95% CI, 0.16 - 1.44). The magnitude of recall bias was mild and did not exceed the minimal clinically important difference. There was a moderate correlation between actual and recalled pain levels when comparing preinjection with the 4-hour postinjection NRS-11 score (correlation coefficient [r] =0.64; P < 0.001) and moderate correlation when comparing preinjection with the 24-hour postinjection NRS-11 score (r = 0.62; P < 0.001). Linear regression models showed that at preinjection, patients with a lower body mass index and the presence of coexisting psychiatric diagnoses were better at recalling their pain (P < 0.05). Patients with a higher body mass index also experienced less pain relief when comparing preinjection with the 4-hour postinjection NRS-11 score (P < 0.05). LIMITATIONS: Recall pain scores were obtained via telephone surveys, which can lead to interview bias. One patient died, and 3 were lost to follow-up. We did not control for patient use of adjunctive pain relief modalities, which may modulate the overall response to injection. SIJ injections can also be diagnostic, so some patients may not have shared the same indication for injection or pain-generating diagnosis. CONCLUSIONS: Patients had favorable pain level responses to their SIJ steroid injection for both actual and recall surveys. Although patients demonstrated poor recall of absolute pain scores at preinjection, 4-hour postinjection, and 24-hour postinjection, they demonstrated robust recall of their net pain score improvement at both 4- and 24-hours postinjection. These findings suggest that there is utility in using patient recollection to describe the magnitude of pain relief following treatment for sacroiliac joint dysfunction.

Computed tomography assessment of robotic versus fluoroscopic implant accuracy in sacroiliac joint fusion.

OBJECTIVE: Computed tomography is considered the gold-standard imaging tool to evaluate spinal implant accuracy. However, there are no studies that evaluate the accuracy of robotic sacroiliac joint (SIJ) implant placement using CT to date. The aim of this study was to compare the accuracy of implant placement on CT between robotic and fluoroscopic navigation for SIJ fusion and the subsequent complications and clinical outcomes of suboptimally placed screws. METHODS: A retrospective analysis of SIJ fusions utilizing either robotic or fluoroscopic guidance at a single institution was conducted from 2014 to 2023. Implant placement accuracy was evaluated on intra- or postoperative CT. Primary endpoints were SIJ screw placement accuracy and complications. Secondary endpoints were pain status at the first and second follow-ups and rates of 2-year revision surgery. Statistical analysis was performed using chi-square tests. RESULTS: Sixty-nine patients who underwent 78 SIJ fusions were included, of which 63 were robotic and 15 were fluoroscopic. The mean age of the cohort at the time of surgery was 55.9 ± 14.2 years, and 35 patients (50.7%) were female. There were 135 robotically placed and 34 fluoroscopically placed implants. A significant difference was found in implant placement accuracy between robotic and fluoroscopic fusion (97.8% vs 76.5%, p < 0.001). When comparing optimal versus suboptimal implant placement, no difference was found in the presence of 30-day complications (p = 0.98). No intraoperative complications were present in this cohort. No difference was found in subjective pain status at the first (p = 0.69) and second (p = 0.45) follow-ups between optimal and suboptimal implant placement. No patients underwent 2-year revision surgery. CONCLUSIONS: Use of robotic navigation was significantly more accurate than the use of fluoroscopic navigation for SIJ implant placement. Complications overall were low and not different between optimally and suboptimally placed implants. Suboptimally placed implants did not differ in degree of subjective pain improvement or rates of revision surgery postoperatively.

Sternocleidomastoid muscular flap: treatment of persistent cerebrospinal fluid leak after anterior cervical spine surgery.

STUDY DESIGN: Retrospective review. OBJECTIVE: To describe a novel application of rotational sternocleidomastoid (SCM) muscle flap in management of ventral cervical durotomy. SUMMARY OF BACKGROUND DATA: Even for the most experienced surgeons, incidental durotomy is a common occurrence in spine surgery. Primary direct suture repair is indicated to avoid possible complications such as pseudomeningocele or spinocutaneous fistula formation. Significant secondary effects of these complications have been described, including airway compromise, radiculopathy, myelopathy, and infection. When primary repair is not feasible, surgeons have used alternative management techniques based on their clinical judgment. In the setting of persistent symptomatic cerebrospinal fluid leak after repair, reoperation is warranted. METHODS: A retrospective review was conducted of clinical records and radiographic data for 2 patients who underwent reoperation for management of ventral cervical durotomy encountered during anterior cervical spine surgery. SCM muscular flap was used to augment durotomy repair. RESULTS: Both patients did not have any persistent cerebrospinal fluid leak after repair with pedicled SCM muscle flap, and did not require any further surgical procedures related to the cervical spine. CONCLUSIONS: The use of a rotational SCM muscular flap may be useful in cases of ventral cervical durotomy refractory to conventional management.

Cervical spine trauma in children and adults: perioperative considerations.

A wide spectrum of cervical spine injuries, including stable and unstable injuries with and without neurologic compromise, account for a large percentage of emergency department visits. Effective treatment of the polytrauma patient with cervical spine injury requires knowledge of cervical spine anatomy and the pathophysiology of spinal cord injury, as well as techniques for cervical spine stabilization, intraoperative positioning, and airway management. The orthopaedic surgeon must oversee patient care and coordinate treatment with emergency department physicians and anesthesia services in both the acute and subacute settings. Children are particularly susceptible to substantial destabilizing cervical injuries and must be treated with a high degree of caution. The surgeon must understand the unique anatomic and biomechanical properties associated with the pediatric cervical spine as well as injury patterns and stabilization techniques specific to this patient population.

Robotic navigation system utilization for percutaneous sacroiliac screw placement: surgical setup and technique.

Sacroiliac joint (SIJ) pathology is a common cause of significant pain and disability, and operative treatment consisting of SIJ fusion can be performed in cases where non-operative measures fail to provide sustained relief. Through the years, SIJ fusion has evolved from an open invasive procedure, to more recently, being performed through minimally invasive techniques. Intraoperative navigation systems and robotic guidance are becoming popularized for SIJ fusion, as well as other routine and complex spinal cases. The utility of navigation and robotics is the enhanced ability of the surgeon to place instrumentation more accurately, with less dissection, blood less, and overall operative time. We present a technique guide for robotic instrumented SIJ fusion with intraoperative navigation that we have put into practice at our institution and found to be very beneficial to patients for the above reasons. We describe the setup and utilization of these technologies intraoperatively, and provide specific case examples to highlight our technique. The described methods have been found to be effective and reproducible, allowing for minimally invasive SIJ screw placement with high accuracy and safety. We emphasize that utilizing intraoperative navigation and robotics is not meant to substitute for surgeon knowledge of case steps or anatomy, but rather to enhance safety and efficacy. To our knowledge, robotic SIJ fusion has not been previously described in the literature.

Intravenous lidocaine in spine surgery: A meta-analysis of randomized controlled trials.

BACKGROUND: This study aimed to evaluate the role of intravenous lidocaine as a supplemental pain control modality in patients undergoing spine surgery. METHODS: We conducted a meta-analysis of randomized controlled trials (RCTs) involving the use of supplemental intravenous lidocaine in spine surgery. We developed a comprehensive search strategy to adequately screen for randomized controlled trials involving intravenous lidocaine in spine surgery. Continuous outcomes included postoperative opiate consumption and postoperative pain scores. Dichotomous outcomes included nausea, vomiting, pneumonia, delirium, and wound infection. RESULTS: A total of 3 RCTs comprising 235 patients were selected for inclusion in the meta-analysis. Cumulative morphine consumption at 48 h was not statistically significant between lidocaine and control groups. Postoperative pain was not statistically significant at any measured time points in the first and second day postoperatively. There was no statistical difference in postoperative complications including nausea, vomiting, pneumonia, delirium, or surgical site infection. CONCLUSION: Our results indicated that current literature does not support the use of intravenous lidocaine as an adjunctive measure of pain management after spine surgery. Given the relatively few numbers of studies in this field, further randomized controlled trials are needed to make a definitive conclusion on the effectiveness of lidocaine in spine surgery patients.

A Multicenter Evaluation of the Feasibility, Patient/Provider Satisfaction, and Value of Virtual Spine Consultation During the COVID-19 Pandemic.

OBJECTIVE: To assess the feasibility, patient/provider satisfaction, and perceived value of telehealth spine consultation after rapid conversion from traditional in-office visits during the COVID-19 pandemic. METHODS: Data were obtained for patients undergoing telehealth visits with spine surgeons in the first 3 weeks after government restriction of elective surgical care at 4 sites (March 23, 2020, to April 17, 2020). Demographic factors, technique-specific elements of the telehealth experience, provider confidence in diagnostic and therapeutic assessment, patient/surgeon satisfaction, and perceived value were collected. RESULTS: A total of 128 unique visits were analyzed. New (74 [58%]), preoperative (26 [20%]), and postoperative (28 [22%]) patients were assessed. A total of 116 (91%) visits had successful connection on the first attempt. Surgeons felt very confident 101 times (79%) when assessing diagnosis and 107 times (84%) when assessing treatment plan. The mean and median patient satisfaction was 89% and 94%, respectively. Patient satisfaction was significantly higher for video over audio-only visits (P < 0.05). Patient satisfaction was not significantly different with patient age, location of chief complaint (cervical or thoracolumbar), or visit type (new, preoperative, or postoperative). Providers reported that 76% of the time they would choose to perform the visit again in telehealth format. Sixty percent of patients valued the visit cost as the same or slightly less than an in-office consultation. CONCLUSIONS: This is the first study to demonstrate the feasibility and high patient/provider satisfaction of virtual spine surgical consultation, and appropriate reimbursement and balanced regulation for spine telehealth care is essential to continue this existing work.

Assessment of Surgical Procedural Time, Pedicle Screw Accuracy, and Clinician Radiation Exposure of a Novel Robotic Navigation System Compared With Conventional Open and Percutaneous Freehand Techniques: A Cadaveric Investigation.

STUDY DESIGN: Cadaveric study. OBJECTIVE: To evaluate accuracy, radiation exposure, and surgical time of a new robotic-assisted navigation (RAN) platform compared with freehand techniques in conventional open and percutaneous procedures. METHODS: Ten board-certified surgeons inserted 16 pedicle screws at T10-L5 (n = 40 per technique) in 10 human cadaveric torsos. Pedicle screws were inserted with (1) conventional MIS technique (L2-L5, patient left pedicles), (2) MIS RAN (L2-L5, patient right pedicles), (3) conventional open technique (T10-L1, patient left pedicles), and (4) open RAN (T10-L1, patient right pedicles). Output included (1) operative time, (2) number of fluoroscopic images, and (3) screw accuracy. RESULTS: In the MIS group, compared with the freehand technique, RAN allowed for use of larger screws (diameter: 6.6 ± 0.6 mm vs 6.3 ± 0.5 mm; length: 50.3 ± 4.1 mm vs 46.9 ± 3.5 mm), decreased the number of breaches >2 mm (0 vs 7), fewer fluoroscopic images (0 ± 0 vs 108.3 ± 30.9), and surgical procedure time per screw (3.6 ± 0.4 minutes vs 7.6 ± 2.0 minutes) (all P < .05). Similarly, in the open group, RAN allowed for use of longer screws (46.1 ± 4.1 mm vs 44.0 ± 3.8 mm), decreased the number of breaches >2 mm (0 vs 13), fewer fluoroscopic images (0 ± 0 vs 24.1 ± 25.8) (all P < .05), but increased total surgical procedure time (41.4 ± 8.8 minutes vs 24.7 ± 7.0 minutes, P = .000) while maintaining screw insertion time (3.31.4 minutes vs 3.1 ± 1.0 minutes, P = .650). CONCLUSION: RAN significantly improved accuracy and decreased radiation exposure in comparison to freehand techniques in both conventional open and percutaneous surgical procedures in cadavers. RAN significantly increased setup time compared with both conventional procedures.

Differentiating Hip Pathology From Lumbar Spine Pathology: Key Points of Evaluation and Management.

The diagnosis and treatment of patients who have both hip and lumbar spine pathologies may be a challenge because overlapping symptoms may delay a correct diagnosis and appropriate treatment. Common complaints of patients who have both hip and lumbar spine pathologies include low back pain with associated buttock, groin, thigh, and, possibly, knee pain. A thorough patient history should be obtained and a complete physical examination should be performed in these patients to identify the primary source of pain. Plain and advanced imaging studies and diagnostic injections can be used to further delineate the primary pathology and guide the appropriate sequence of treatment. Both the surgeon and the patient should understand that, although one pathology is managed, the management of the other pathology may be necessary because of persistent pain. The recognition of both entities may help reduce the likelihood of misdiagnosis, and the management of both entities in the appropriate sequence may help reduce the likelihood of persistent symptoms.

Biomechanical Analysis of Intervertebral Cement Extravasation in Vertebral Motion Segments.

Kyphoplasty is a therapeutic option for pain relief in the setting of compression fractures. Cement extravasation into adjacent disks is a common occurrence. The biomechanical and clinical consequences of cement in the disks currently are unknown. This study investigated the biomechanical effects of cement extravasation into the intervertebral disk in a human cadaveric model. Seven thoracolumbar and lumbar embalmed human cadaveric motion segments were evaluated in axial rotation, right and left lateral bending, and flexion and extension. Stiffness was calculated at baseline and following injection of 1 mL of cement into the intervertebral disk. There was a 13.4% (P=.041) increase in stiffness in axial rotation compared with preinjection motion segments. No significant difference was observed in lateral bending or flexion and extension. In this model, cement extravasation into the disk space increased stiffness in axial rotation. [Orthopedics. 2017; 40(2):e300-e304.].

Use of 3D CT-based navigation in minimally invasive lateral lumbar interbody fusion.

OBJECTIVE Lateral lumbar interbody fusion (LLIF) is an increasingly popular technique used to treat degenerative lumbar disease. The technique of using an intraoperative cone-beam CT (iCBCT) and an image-guided navigation system (IGNS) for LLIF cage placement has been previously described. However, other than a small feasibility study, there has been no clinical study evaluating its accuracy or safety. Therefore, the purpose of this study was to evaluate the accuracy and safety of image-guided spinal navigation in LLIF. METHODS An analysis of a prospectively acquired database was performed. Thirty-one consecutive patients were identified. Accuracy was initially determined by comparison of the planned trajectory of the IGNS with post-cage placement intraoperative fluoroscopy. Accuracy was subsequently confirmed by postprocedural CT and/or radiography. Cage placement was graded based on a previously described system separating the disc space into quarters. RESULTS The mean patient age was 63.9 years. A total of 66 spinal levels were treated, with a mean of 2.1 levels (range 1-4) treated per patient. Cage placement was noted to be accurate using IGNS in each case, as confirmed with intraoperative fluoroscopy and postoperative imaging. Sixty-four (97%) cages were placed within Quarters 1 to 2 or 2 to 3, indicating placement of the cage in the anterior or middle portions of the disc space. There were no instances of misguidance by IGNS. There was 1 significant approach-related complication (psoas muscle abscess) that required intervention, and 8 patients with transient, mild thigh paresthesias or weakness. CONCLUSIONS LLIF can be safely and accurately performed utilizing iCBCT and IGNS. Accuracy is acceptable for multilevel procedures.

Fat Thickness as a Risk Factor for Infection in Lumbar Spine Surgery.

Body mass index does not account for body mass distribution. This study tested the hypothesis that subcutaneous fat thickness is a better indicator than body mass index of the risk of surgical site infection in lumbar spine procedures performed through a midline posterior approach. Charts were reviewed for previously identified risk factors for surgical site infection (age, diabetes, smoking, obesity, albumin level, multilevel procedures, previous surgery, and operative time) in 149 adult patients who underwent lumbar spine procedures through a midline posterior approach. Subcutaneous fat thickness was measured with a novel automated technique. Regression analysis was used to determine associations between risk factors and fat thickness with surgical site infection. In the study group, 15 surgical site infections occurred (10.1%). Bivariate analysis showed a significant association between surgical site infection and body mass index (P=.01), obesity (P=.02), and fat thickness (P=.002). With multivariate analysis, body mass index and obesity did not show significance, but fat thickness remained significant (P=.026). For every 1-mm thickness of subcutaneous fat there was a 6% (odds ratio, 1.06; 95% confidence interval, 1.02-1.10) increase in the odds of surgical site infection, and patients with fat thickness of greater than 50 mm had a 4-fold increase in the odds of surgical site infection compared with those with fat thickness of less than 50 mm. Body mass index and fat thickness were moderately correlated (r2=0.44). These results confirm the hypothesis that local subcutaneous fat thickness is a better indicator than body mass index of the risk of surgical site infection in lumbar spine procedures. [Orthopedics. 2016; 39(6):e1124-e1128.].

Guideline summary review: an evidence-based clinical guideline for the diagnosis and treatment of adult isthmic spondylolisthesis.

BACKGROUND CONTEXT: The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Adult Isthmic Spondylolisthesis features evidence-based recommendations for diagnosing and treating adult patients with isthmic spondylolisthesis. The guideline is intended to reflect contemporary treatment concepts for symptomatic isthmic spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of June 2013. NASS' guideline on this topic is the only guideline on adult isthmic spondylolisthesis accepted in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse. PURPOSE: The purpose of the guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for adult patients with isthmic spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. STUDY DESIGN: This is a guideline summary review. METHODS: This guideline is the product of the Adult Isthmic Spondylolisthesis Work Group of NASS' Evidence-Based Clinical Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questionsto address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members utilized NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Adult Isthmic Spondylolisthesis guideline was accepted into the National Guideline Clearinghouse and will be updated approximately every 5 years. RESULTS: Thirty-one clinical questions were addressed, and the answers are summarized in this article. The respective recommendations were graded according to the levels of evidence of the supporting literature. CONCLUSIONS: The evidence-based clinical guideline has been created using techniques of evidence-based medicine and best available evidence to aid practitioners in the diagnosis and treatment of adult patients with isthmic spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flowchart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx and will remain updated on a timely schedule.

Multiple Adjacent Isolated Thoracic Spinous Process Fractures in High-Energy Trauma.

Isolated thoracic spinous process fractures involving multiple adjacent vertebral segments are a rare occurrence in the setting of high-energy trauma. These findings should prompt further investigation to exclude other concomitant osseous or ligamentous injuries. Evaluation by computed tomography is often most useful to detect these fractures. Proper treatment of extensive multilevel injury is poorly defined in the literature. In our experience, conservative management consisting of initial bracing with graduated lifting restrictions has produced excellent functional results.

Delayed presentation of pharyngeal erosion after anterior cervical discectomy and fusion.

Dysphagia after anterior cervical discectomy and fusion (ACDF) is common, with a prevalence ranging between 28% and 57% of cases. However, nearly all cases resolve spontaneously within 2 years, thus identifying patients who require more detailed or invasive work-up is a challenging task for clinicians. A review of literature reveals a paucity of case reports detailing work-up and successful management options. The authors performed a clinical and radiographic review of a case of a 47-year-old female who presented with persistent dysphagia 3 years following anterior cervical spine surgery and was found to have an erosive pharyngeal defect with exposed spinal hardware. The diagnosis was made with direct laryngoscopy and treatment consisted of plate removal and pharyngeal repair, followed by revision fusion with deformity correction. This case and the accompanying pertinent review of the literature highlight the importance of a thorough evaluation of dysphagia, especially in the mid- and late-term postoperative period following ACDF, when most cases of dysphagia should have been resolved. Correctly identifying the underlying etiology of dysphagia may lead to improved revision of ACDF outcomes. Unresolved dysphagia should be a red flag for surgeons as it may be the presentation of erosive esophageal/pharyngeal damage, a rare but serious complication following ACDF.

Patient impressions of reimbursement for orthopedic spine surgeons.

The study aim was to understand patient impressions of reimbursement to orthopedic spine surgeons. Our findings revealed that the majority of patients significantly overestimate the amount surgeons are reimbursed per procedure. Despite this, most feel that surgeons are appropriately compensated. Additionally, many patients are unaware of the global billing period.

Cost-effectiveness of MRI to assess for posttraumatic ligamentous cervical spine injury.

Magnetic resonance imaging (MRI) has been shown to be sensitive in identifying ligamentous injury to the cervical spine. The major drawbacks to its routine use are cost and availability. The purpose of this study was to compare the cost of using MRI to rule out ligamentous injury of the cervical spine with the cost of immobilization in a cervical collar and outpatient follow-up. Neurologically intact and nonobtunded patients with neck pain and normal findings on radiographs evaluated for ligamentous injury of the cervical spine were studied. Patients were either evaluated with MRI or immobilized in a cervical collar and followed up for repeat clinical and radiographic evaluation as outpatients. The authors gathered year 2011 fees from their institution and 2011 Medicare reimbursement data and compared the costs of MRI with the costs of cervical collar and outpatient follow-up. In addition, the median income of the local community was used to estimate opportunity costs associated with cervical collar immobilization. After 7 days of lost wages at the median local income, MRI became a less costly option when comparing hospital fees. Alternatively, when considering Medicare reimbursement, MRI became less costly after only 2 days of lost wages at the median local income. On the basis of these findings, MRI of the cervical spine is less costly than other current management strategies when opportunity costs are considered.