Avoiding and Managing Complications in Routine Lumbar Spine Surgery.

Elective lumbar surgery for common degenerative lumbar spine pathology has been consistently demonstrated to have excellent outcomes by multiple validated measures and improves patient quality of life. The rate of complication is low but not unavoidable; there is an increasing recognition of risk factors that can be mitigated to decrease complication rates. When complications occur, prompt recognition and management may minimize deleterious effects on patient outcome. There are considerations for identifying risk factors and, when possible, minimizing them and general strategies for identifying and managing common complications in lumbar spine surgery.

Which Variables Are Associated With Patient-reported Outcomes After Discectomy? Review of SPORT Disc Herniation Studies.

BACKGROUND: The Spine Patient Outcomes Research Trial (SPORT) evaluated the effects of surgery versus nonoperative treatment for lumbar intervertebral disc herniation (IDH), among other pathologies. Multiple subgroup analyses have been completed since the initial publications, which have further defined which patient factors lead to better or worse patient-reported outcomes; however, the degree to which these factors influence patient-reported outcomes has not been explored. QUESTIONS/PURPOSES: We reviewed the subgroup analyses of the SPORT IDH studies to answer the following questions: (1) What factors predicted improvement in patient-reported outcomes after operative or nonoperative treatment of lumbar IDH? (2) What factors predicted worse patient-reported outcomes compared to baseline after operative or nonoperative treatment of lumbar IDH? And (3) what factors influenced patient-reported outcomes of surgery in patients with lumbar IDH? METHODS: We conducted a MEDLINE(®) search to identify the subgroup analyses of the SPORT IDH data that were responsive to our study questions. Eleven articles were identified that met our search criteria. RESULTS: The patient factors associated with larger improvements in Oswestry Disability Index at 4 years with either surgical or nonoperative treatment included a higher baseline Oswestry Disability Index, BMI of less than 30, not being depressed, being insured, having no litigation pending, not having workers compensation, and having symptoms for less than 6 weeks, though there were others. Factors leading to improvement with surgical treatment were mostly related to anatomic characteristics of the disc herniation such as posterolateral and sequestered herniations. There were no patient or clinical factors identified that were associated with worse patient-reported outcomes compared to baseline after either operative or nonoperative treatment. At 2-year followup, the treatment effects were greater for those patients with upper-level herniations, patients not receiving workers compensation, and nondiabetic patients. In a 4-year multivariate analysis, being married, without joint problems, and having worse symptoms at baseline resulted in greater treatment effect with surgery. CONCLUSIONS: While most patients with IDH will likely see improvement with either surgical or nonoperative treatment, there are patient-related factors that can help predict which subgroups will demonstrate a greater improvement with surgery, such as not having joint problems, being married, having worsening symptoms at baseline, and not having diabetes. These results can help providers and patients when discussing treatment options. LEVEL OF EVIDENCE: Level I, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

MRI Characterization of Vascular Spinal Tumors.

STUDY DESIGN: Randomized trial. OBJECTIVE: This study described practical magnetic resonance imaging (MRI) characteristics to assist in the identification of these tumors including the corresponding statistics. SUMMARY OF BACKGROUND DATA: Identification of vascular spinal tumors using MRI allows the opportunity for angiography and preoperative embolization (PE) to improve outcomes and decrease hemorrhage. The MRI characterization reliability of these tumors has not been described. MATERIALS AND METHODS: A retrospective comparison of 40 patients, at a single institution, with known spinal tumors was conducted with 20 vascular versus 20 nonvascular cases (based on postoperative pathology). Randomized MRI T1 precontrast/postcontrast and T2 images of these tumors were blinded and reviewed by 7 spine surgeons and 5 musculoskeletal radiologists. Four criteria were reviewed: T2 hyperintensity, contrast enhancement, flow voids, and feeding vessels. The clinical relevance was evaluated by asking if the reviewer recommended PE. RESULTS: The specificity, sensitivity, and accuracy of each characteristic for surgeons were: T2 hyperintensity (65%, 85%, 75%), contrast enhancement (84%, 38%, 61%), flow voids (42%, 86%, 64%), and feeding vessels (35%, 90%, 63%). The results for the radiologists were: T2 hyperintensity (83%, 61%, 72%), contrast enhancement (87%, 32%, 60%), flow voids (44%, 93%, 69%), and feeding vessels (33%, 93%, 63%). Both the groups had low κ and intraclass correlation values. Review of angiography/PE recommendation showed that both surgeons and radiologists had a false-negative rate of 33%. CONCLUSIONS: Surgeons and radiologists have similar moderate accuracy of MRI vascularity identification. Radiologists have a higher sensitivity, but lower specificity. Even with simplified, straightforward criteria, the MRI characterization of vascular spinal tumors has low interobserver/intraobserver reliability with a false-negative rate for angiography/PE recommendation of 33%. Angiography may become more standard in the workup of spine tumors.

Radiographic variables that may predict clinical outcomes in cervical disk replacement surgery.

STUDY DESIGN: Retrospective analysis of prospectively collected data. OBJECTIVE: To determine which, if any, radiographic parameters are predictive of clinical outcome after cervical disk replacement (CDR) surgery. SUMMARY OF BACKGROUND DATA: It is unclear whether radiographic parameters are predictive of outcome after CDR. METHODS: An analysis of the radiographic parameters and clinical outcomes of the CDR cohort of the Discover artificial cervical disk IDE trial was performed. Clinical outcome measures included Neck Disability Index (NDI), visual analog pain scale (neck, arm, and shoulder), and SF-36 physical component summary score scores, collected preoperatively and at regularly scheduled postoperative time periods. Patients with at least 1-year follow-up were included. The change in outcomes from baseline was determined at each follow-up interval. The following minimal clinically important difference (MCID) thresholds were applied: -7.5 for NDI, -25 for visual analog pain scale, and +4.1 for physical component summary score. Fifty-six radiographic variables were analyzed to identify factors that may be associated with a poor clinical outcome, defined as failure to achieve the MCID in NDI. RESULTS: A total of 243 patients underwent CDR at 304 levels (182 one level, 61 two level). One hundred seventy-one patients (89 female, 82 male; mean age, 44.2 y; range, 28-67 y) had at least 1-year follow-up. A preoperative disk height of <3.5 mm was associated with a 3.4 times greater risk of not achieving a MCID in NDI (P=0.018). Increasing the functional spinal unit angle by >3 degrees was associated with a 3.5 times greater risk of not achieving a MCID in NDI (P=0.016). There were 21/171 patients (25 levels) who did not achieve the NDI MCID threshold. All of these patients had at least1, and 16/21 of these patients had more than 1 abnormal radiographic finding. Seventy percent of treatment levels had severe or bridging heterotopic ossification at 3-years follow-up, the incidence of which increased linearly with time. CONCLUSIONS: Several radiographic variables are predictive of clinical outcomes, including decreased preoperative disk space height and excessive postoperative segmental lordosis.

Predictors of pain and disability outcomes in one thousand, one hundred and eight patients who underwent lumbar discectomy surgery.

BACKGROUND: A key component toward improving surgical outcomes is proper patient selection. Improved selection can occur through exploration of prognostic studies that identify variables which are associated with good or poorer outcomes with a specific intervention, such as lumbar discectomy. To date there are no guidelines identifying key prognostic variables that assist surgeons in proper patient selection for lumbar discectomy. The purpose of this study was to identify baseline characteristics that were related to poor or favourable outcomes for patients who undergo lumbar discectomy. In particular, we were interested in prognostic factors that were unique to those commonly reported in the musculoskeletal literature, regardless of intervention type. METHODS: This retrospective study analysed data from 1,108 patients who underwent lumbar discectomy and had one year outcomes for pain and disability. All patient data was part of a multicentre, multi-national spine repository. Ten relatively commonly captured data variables were used as predictors for the study: (1) age, (2) body mass index, (3) gender, (4) previous back surgery history, (5) baseline disability, unique baseline scores for pain for both (6) low back and (7) leg pain, (8) baseline SF-12 Physical Component Summary (PCS) scores, (9) baseline SF-12 Mental Component Summary (MCS) scores, and (10) leg pain greater than back pain. Univariate and multivariate logistic regression analyses were run against one year outcome variables of pain and disability. RESULTS: For the multivariate analyses associated with the outcome of pain, older patients, those with higher baseline back pain, those with lesser reported disability and higher SF-12 MCS quality of life scores were associated with improved outcomes. For the multivariate analyses associated with the outcome of disability, presence of leg pain greater than back pain and no previous surgery suggested a better outcome. CONCLUSIONS: For this study, several predictive variables were either unique or conflicted with those advocated in general prognostic literature, suggesting they may have value for clinical decision making for lumbar discectomy surgery. In particular, leg pain greater than back pain and older age may yield promising value. Other significant findings such as quality of life scores and prior surgery may yield less value since these findings are similar to those that are considered to be prognostic regardless of intervention type.

Adjunctive Use of Bone Growth Stimulation Increases Cervical Spine Fusion Rates in Patients at Risk for Pseudarthrosis.

STUDY DESIGN: A prospective multicenter clinical trial (NCT03177473) was conducted with a retrospective cohort used as a control arm. OBJECTIVE: The purpose of this study was to evaluate cervical spine fusion rates in subjects with risk factors for pseudarthrosis who received pulsed electromagnetic field (PEMF) treatment. SUMMARY OF BACKGROUND DATA: Certain risk factors predispose patients to pseudarthrosis, which is associated with prolonged pain, reduced function, and decreased quality of life. METHODS: Subjects in the PEMF group were treated with PEMF for 6 months postoperatively. The primary outcome measure was fusion status at the 12-month follow-up period. Fusion status was determined using anterior/posterior, lateral, and flexion/extension radiographs and computed tomography (without contrast). RESULTS: A total of 213 patients were evaluated (PEMF, n=160; Control, n=53). At baseline, the PEMF group had a higher percentage of subjects who used nicotine ( P =0.01), had osteoporosis ( P <0.05), multi-level disease ( P <0.0001), and were >65 years of age ( P =0.01). The PEMF group showed over two-fold higher percentage of subjects that had ≥3 risk factors (n=92/160, 57.5%) compared with the control group (n=14/53, 26.4%). At the 12-month follow-up, the PEMF group demonstrated significantly higher fusion rates compared with the control (90.0% vs. 60.4%, P <0.05). A statistically significant improvement in fusion rate was observed in PEMF subjects with multi-level surgery ( P <0.0001) and high BMI (>30 kg/m 2 ; P =0.0021) when compared with the control group. No significant safety concerns were observed. CONCLUSIONS: Adjunctive use of PEMF stimulation provides significant improvements in cervical spine fusion rates in subjects having risk factors for pseudarthrosis. When compared with control subjects that did not use PEMF stimulation, treated subjects showed improved fusion outcomes despite being older, having more risk factors for pseudarthrosis, and undergoing more complex surgeries.

Civilian gunshot injuries of the spinal cord: a systematic review of the current literature.

BACKGROUND: The principles that guide management of spinal cord injury (SCI) derive from injury resulting from blunt trauma, not gunshot wounds. Civilian gunshot-induced spinal cord injury (CGSWSCI) is a common, potentially serious cause of neurological deficit; there is disagreement about whether the same approaches used for SCI caused by blunt-force trauma should apply to gunshot-induced SCI. QUESTIONS/PURPOSES: We reviewed the literature to answer the following questions regarding presentation and outcome of gunshot wound-induced SCI: (1) Are there differences in recovery prognosis between complete SCI and other patterns of SCI in CGSWSCI. (2) Does the use of steroids improve neurological recovery? (3) Does surgery to remove the bullet affect neurological recovery in CGSWSCI? (4) Does surgery result in an increased risk of complications of treatment? METHODS: We performed a systematic literature review of articles related to civilian gunshot injuries to the spine. Information relating to incidence, pattern of neurological injury, associated injuries, treatment, neurological outcome, and associated complications was extracted. Three independent reviewers assessed the strength of evidence present in the literature by examining quality, quantity, and consistency of results. RESULTS: A total of 15 articles met the predetermined inclusion criteria. Complete SCIs are associated with the worst functional recovery regardless of treatment. Steroids do not appear to have any added benefit in terms of restoring sensory and motor function. There appears to be some neurologic benefit to surgical decompression with intracanalicular bullet retrieval in patients with an incomplete lesion and a cauda equina syndrome. Complication rates are greater in operated patients. CONCLUSIONS: These findings should be interpreted with caution because of considerable heterogeneity among the studies in the literature on gunshot-induced SCI and because of generally poor-quality study design and a high associated risk of selection bias. Supportive management should be the primary method of care, whereas surgery should be an option in case of radiographic evidence of a static compression on the spinal cord. Future studies are necessary to develop better treatment guidelines for patients with gunshot wound-associated SCI.

Pulsed Electromagnetic Field Stimulation in Lumbar Spine Fusion for Patients With Risk Factors for Pseudarthrosis.

BACKGROUND: Lumbar spinal fusion surgeries are increasing steadily due to an aging and ever-growing population. Patients undergoing lumbar spinal fusion surgery may present with risk factors that contribute to complications, pseudarthrosis, prolonged pain, and reduced quality of life. Pulsed electromagnetic field (PEMF) stimulation represents an adjunct noninvasive treatment intervention that has been shown to improve successful fusion and patient outcomes following spinal surgery. METHODS: A prospective, multicenter study investigated PEMF as an adjunct therapy to lumbar spinal fusion procedures in patients at risk for pseudarthrosis. Patients with at least 1 of the following risk factors were enrolled: prior failed fusion, multilevel fusion, nicotine use, osteoporosis, or diabetes. Fusion status was determined by radiographic imaging, and patient-reported outcomes were also evaluated. RESULTS: A total of 142 patients were included in the analysis. Fusion status was assessed at 12 months follow-up where 88.0% (n = 125/142) of patients demonstrated successful fusion. Fusion success for patients with 1, 2+, or 3+ risk factors was 88.5%, 87.5%, and 82.3%, respectively. Significant improvements in patient-reported outcomes using the Short Form 36, EuroQol 5 Dimension (EQ-5D) survey, Oswestry Disability Index, and visual analog scale for back and leg pain were also observed compared with baseline scores (P < 0.001). A favorable safety profile was observed. PEMF treatment showed a positive benefit-risk profile throughout the 6-month required use period. CONCLUSIONS: The addition of PEMF as an adjunct treatment in patients undergoing lumbar spinal surgery provided a high rate of successful fusion with significant improvements in pain, function, and quality of life, despite having risk factors for pseudarthrosis. CLINICAL RELEVANCE: PEMF represents a useful tool for adjunct treatment in patients who have undergone lumbar spinal surgery. Treatment with PEMF may result in improved fusion and patient-reported outcomes, regardless of risk factors. TRIAL REGISTRATION: NCT03176303.

Contributing factors to surgical site infections.

Surgical site infections (SSIs) are the most common nosocomial infections. These complications lead to revision surgery, delayed wound healing, increased use of antibiotics, and increased length of hospital stay, all of which have a significant impact on patients and the cost of health care. Such intraoperative factors as proper skin preparation, adherence to sterile technique, surgical duration, and traffic in the operating room contribute more to SSIs than do patient-related risk factors such as diabetes mellitus, obesity, and preexisting colonization with methicillin-resistant Staphylococcus aureus. Surgeons have a responsibility to understand the current evidence regarding the factors that affect the rates of SSIs so as to provide the highest level of patient care.

Cauda equina syndrome after a TLIF resulting from postoperative expansion of a hydrogel dural sealant.

BACKGROUND: DuraSeal(™) (Coviden, Waltham, MA, USA), a hydrogel sealant, is primarily used as an adjunct to a dural repair. Its use has also been described to seal off an annulotomy after a transforaminal lumbar interbody fusion when recombinant human bone morphogenetic protein-2 (rhBMP-2) is used. This aids in the reduction of postoperative radiculitis caused by rhBMP-2. However, as a result of its hydrophilic properties, DuraSeal(™) has the potential to swell, which could lead to compression of the thecal sac. CASE DESCRIPTION: We report a 57-year-old woman who developed cauda equina after a transforaminal lumbar 47 interbody fusion (TLIF) procedure in which the expansion of the DuraSeal(™) was believed to be the causative factor. The patient developed urinary retention, bowel incontinence, and paresthesias in the saddle region on postoperative Day 3. She underwent emergent exploration and decompression of the thecal sac. The gel-like DuraSeal™ material was causing significant compression of the thecal sac. LITERATURE REVIEW: Multiple reports have documented that DuraSeal(™), used as an adjunct to dural repair, can swell leading to compression of the spinal cord and/or neural elements. Our case demonstrates the use of DuraSeal(™) both over a site of a dural repair and over an annulotomy site, through which a TLIF was performed, is associated with the risk of developing postoperative cauda equina syndrome as a result of swelling of the DuraSeal(™). CLINICAL RELEVANCE: Those using DuraSeal™ to seal off the annulotomy after a TLIF procedure performed with rhBMP-2 should use the product with an understanding of the potential postoperative swelling of the product and resulting neurologic sequela, particularly if DuraSeal(™) is used concomitantly at the site of dural repair.

CT and MRI-based diagnosis of craniocervical dislocations: the role of the occipitoatlantal ligament.

BACKGROUND: Craniocervical dislocations are rare, potentially devastating injuries. A diagnosis of craniocervical dislocations may be delayed as a result of their low incidence and paucity of diagnostic criteria based on CT and MRI. Delay in diagnosis may contribute to neurological injury from secondary displacement resulting from instability. The purpose of this study was to define CT and MRI-based diagnostic criteria for craniocervical dislocations to facilitate early injury recognition and stabilization. QUESTIONS/PURPOSES: Using CT and MRI, we (1) described the bony articular displacements characterize craniocervical injuries; (2) described the ligamentous injuries that characterize craniocervical injuries; and (3) determined whether neurologic injuries were associated with bony or ligamentous injury. METHODS: Using a prospectively collected spinal cord injury database, we identified 18 patients with acute, traumatic occipitocervical injuries. We reviewed CT scans and MR images to document the height of the occipitoatlantal and atlantoaxial joints and integrity of craniocervical ligaments. Medical records were reviewed for neurological status. The primary measurements were number of patients with articular displacement, location of bony displacement, and number of patients with ligamentous injury. RESULTS: Thirteen of 18 patients had displacement outside the normal range. Six patients demonstrated displacement of both occipitoatlantal and atlantoaxial joints, whereas five patients presented with displacement through the atlantoaxial joints only. Two patients had an abnormal basion-dental interval only. Of 17 patients with MR images, the cruciate ligament was injured in 11 patients, indeterminate in four, and intact in two. All five patients with occipitoatlantal articular displacement had injury to the occipitoatlantal capsule. No patient had occipitoatlantal capsular injury without occipitoatlantal articular displacement. Three cases of complete spinal cord injury were found after occipitoatlantal-atlantoaxial dislocations. Three patients with occipitoatlantal-atlantoaxial dislocations were neurologically intact. The five patients with atlantoaxial dislocations and patients without displacement or ligamentous injury were neurologically intact. Five patients had cruciate ligament rupture or indeterminate injury but no joint diastasis. CONCLUSIONS: The occipitoatlantal joint capsules stabilize the occipitoatlantal joint; disruption of the occipitoatlantal capsule may suggest the presence of instability. Based on these findings, we identified two distinct injury patterns: isolated atlantoaxial injuries (Type I) and combined occipitoatlantal-atlantoaxial injuries (Type II). Occipitoatlantal joint capsule integrity differentiated these subsets and Type II injuries had a higher percentage of complete spinal cord injuries on presentation.

Preoperative risk stratification reduces the incidence of perioperative complications after total knee arthroplasty.

The purpose of this study was to validate a screening and management protocol to identify and reduce risk of renal, pulmonary, and delirium complications. A cohort study comparing incidence of perioperative complications on a consecutive series of patients undergoing total knee arthroplasty with a historical control group was conducted. The study cohort was evaluated prospectively to identify and reduce noncardiac medical complications. Medical records were reviewed for in-hospital complications. There were 623 patients in the study cohort and 493 patients in the control population. There was a statistically significant decrease in the incidence of delirium (control, 10.4% vs study, 0.8%; P = .0001), renal (4.9% vs 0.6%, P = .0001), cardiac (16.3% vs 2.1%, P = .0001), and pulmonary complications (5.7% vs 0.8%, P = .0001) in the screened patients vs control. Preoperative screening and management for medical complications resulted in a significant decrease in renal, pulmonary, delirium, and cardiac complications.

Does the Size or Location of Lumbar Disc Herniation Predict the Need for Operative Treatment?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The goal of this study was to determine whether the absolute size (mm2), relative size (% canal compromise), or location of a single-level, lumbar disc herniation (LDH) on axial and sagittal cuts of magnetic resonance imaging (MRI) were predictive of eventual surgical intervention. METHODS: MRIs of 89 patients were reviewed, and patients were split into groups based on type of management received (34 nonoperative vs 55 microdiscectomy). Radiographic characteristics-including size of disc herniation (mm2), size of spinal canal (mm2), location of herniation on axial (central, paracentral, foraminal) and sagittal (disc level, suprapedicle, pedicle, infrapedicle) planes, and type of herniation (bulge, protrusion, extrusion, sequestration)-were measured by 2 independent, orthopedic spine fellows and compared between groups via univariate and multivariate analyses. RESULTS: The operative group showed a significantly higher percentage of canal compromise (39.5% vs 31.1%, P = .001) compared to the nonoperative group. Multiple logistic regression analysis showed higher odds of eventual operative intervention for a disc protrusion (odds ratio [OR] 6.30 [1.99, 19.86], P = .002) or disc extrusion (OR 11.5 [1.63, 81.2], P = .014) for Rater 1 and a higher odds of eventual surgical management for a paracentral location for both Rater 1 and Rater 2 (OR = 3.39 [1.25, 9.22], P = .017, and OR = 5.46 [1.77, 16.8], P = .003, respectively). CONCLUSIONS: Disc herniations in a paracentral location were more likely to undergo operative treatment than those more centrally located, on axial MRI views.

How Do Patients With Predominant Neck Pain Improve After Anterior Cervical Discectomy and Fusion for Cervical Radiculopathy?

BACKGROUND: The presence of predominant pain in the arm vs the neck as a predictor of postoperative outcomes after anterior cervical discectomy and fusion (ACDF) has been seldom reported; therefore, the purpose of this study was to determine whether patients with predominant neck pain improve after surgery compared to patients with predominant arm pain or those with mixed symptoms in patients undergoing ACDF for radiculopathy. METHODS: A retrospective cohort study was conducted on patients who underwent ACDF at a single center from 2016 to 2018. Patients were split into groups based on preoperative neck and arm pain scores: neck (N) pain dominant group (visual analog scale [VAS] neck ≥ VAS arm by 1.0 point); neutral group (VAS neck < VAS arm by 1.0 point); or arm (A) pain dominant group (VAS arm ≥ VAS neck by 1.0 point), using a threshold difference of 1.0 point. Subsequently, individuals were substratified into 2 groups based on the arm to neck pain ratio (ANR): non-arm pain dominant defined as ANR ≤1.0 and arm pain dominant (APD) defined as ANR >1.0. Patient-reported outcome measurements including Neck Disability Index (NDI), Physical Component Score-12, and Mental Component Score (MCS-12) were compared between groups. RESULTS: No significant differences between groups when stratifying patients using a threshold difference of 1.0 point. When stratifying patients using the ANR, those in the APD group had significantly higher postoperative MCS-12 (P = 0.008) and NDI (P = 0.011) scores. In addition, the APD group showed a greater magnitude of improvement for MCS-12 and NDI scores (P = 0.043 and P = 0.038, respectively). Multiple linear regression showed that the A and the APD groups were both independent predictors of improvement in NDI. CONCLUSION: Patients with dominant arm pain showed significantly greater improvement in terms of MCS-12 and NDI scores compared to patients with dominant neck pain. CLINICAL RELEVANCE: To compare the impact of ACDF on arm and neck pain in the context of cervical radiculopathy using patient-reported outcome measures as an objective measurement.

Cervical Total Disc Replacement: Long-Term Outcomes.

Degenerative disc disease and associated cervical spondylosis or stenosis are common conditions encountered in clinical practice. These conditions may cause progressive cervical radicular or myelopathic symptoms leading to significant impairment. Although anterior cervical discectomy and fusion (ACDF) has been a reliable surgical treatment of cervical myelopathy and radiculopathy, but limitations include loss of cervical range of motion, the concern for adjacent segment degeneration and disease, pseudoarthrosis, complications related to the choice of intervertebral graft, dysphagia, as well as standard anterior cervical approach risk. Cervical total disc arthroplasty has emerged as an alternative operative procedure to ACDF.

Are Patient Outcomes Affected by the Presence of a Fellow or Resident in Lumbar Decompression Surgery?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study was to determine whether the presence of a fellow or resident (F/R) compared to a physician assistant (PA) affected surgical variables or short-term patient outcomes. SUMMARY OF BACKGROUND DATA: Although orthopedic spine fellows and residents must participate in minimum number of decompression surgeries to gain competency, the impact of trainee presence on patient outcomes has not been assessed. METHODS: One hundred and seventy-one patients that underwent a one- to three-level lumbar spine decompression procedure at a high-volume academic center were retrospectively identified. Operative reports from all cases were examined and patients were placed into one of two groups based on whether the first assist was a F/R or a PA. Univariate analysis was used to compare differences in total surgery duration, 30-day and 90-day readmissions, infection and revision rates, patient-reported outcome measures (Short Form-12 Physical Component Score and Mental Component Score, Oswestry Disability Index, Visual Analog Scale [VAS] Back, VAS Leg) between groups. Multiple linear regression was used to assess change in each patient reported outcome and multiple binary logistic regression was used to determine significant predictors of revision, infection, and 30- or 90-day readmission. RESULTS: Seventy-eight patients were included in the F/R group compared to 93 patients in the PA group. There were no differences between groups for total surgery time, 30-day or 90-day readmissions, infection, or revision rates. Using univariate analysis, there were no differences between the two groups pre- or postoperatively (P > 0.05). Using multivariate analysis, presence of a surgical trainee did not significantly influence any patient reported outcome and did not affect infection, revision, or 30- and 90-day readmission rates. CONCLUSION: This is one of the first studies to show that the presence of an orthopedic spine fellow or resident does not affect patient short-term outcomes in lumbar decompression surgery. LEVEL OF EVIDENCE: 3.

Patient Outcomes Following Short-segment Lumbar Fusion Are Not Affected by PI-LL Mismatch.

STUDY DESIGN: This is a retrospective cohort study. OBJECTIVE: The objective of this study was to further elucidate the relationship between pelvic incidence-lumbar lordosis (PI-LL) mismatch and surgical outcomes in patients undergoing short segment lumbar fusions for degenerative lumbar disease. SUMMARY OF BACKGROUND DATA: There are few studies examining the relationship between spinopelvic parameters and patient reported outcome measurements (PROMs) in short segment lumbar degenerative disease. MATERIALS AND METHODS: A retrospective review was conducted at single academic institution. Patients undergoing 1- or 2-level lumbar fusion were retrospectively identified and separated into 2 groups based on postoperative PI-LL mismatch ≤10 degrees (NM) or PI-LL mismatch >10 degrees (M). Outcomes including the Physical Component Score (PCS)-12, Mental Component Score (MCS)-12, Oswestry Disability Index (ODI), Visual Analog Scale (VAS) back and leg scores were analyzed. Absolute PROM scores, the recovery ratio and the percentage of patients achieving minimum clinically important difference between groups were compared and a multiple linear regression analysis was performed. RESULTS: A total of 306 patients were included, with 59 patients in the NM group and 247 patients in the M group. Patients in the M group started with a higher degree of PI-LL mismatch compared with the NM group (22.2 vs. 7.6 degrees, P<0.001) and this difference increased postoperatively (24.7 vs. 2.5 degrees, P<0.001). There were no differences between the 2 groups in terms of baseline, postoperative, or Δ outcome scores (P>0.05). In addition, having a PI-LL mismatch was not found to be an independent predictor of any PROM on multivariate analysis (P>0.05). CONCLUSION: The findings in this study show that even though patients in the M group had a higher degree of mismatch preoperatively and postoperatively, there was no difference in PROMs. LEVEL OF EVIDENCE: Level III.

Do Patients with Back Pain-Dominant Symptoms Improve After Lumbar Surgery for Radiculopathy or Claudication?

BACKGROUND: Currently, few studies have examined whether patients with back or leg pain-predominant symptoms fare better clinically after lumbar spine surgery; therefore, the purpose of this study was to determine whether patients with back pain-dominant symptoms improved to a similar degree as patients with mixed or leg pain-dominant symptoms after lumbar surgery. METHODS: A retrospective cohort study was conducted at a single academic center, in which patients were stratified into three groups: (1) back pain-dominant group (B) (visual analog score [VAS] back - VAS leg ≥ 1.0 point), (2) neutral group (N) (VAS back - VAS leg < 1.0 point), or (3) leg pain-dominant group (L) (VAS leg - VAS back ≥ 1.0 point), using a VAS threshold difference of 1.0 point. As a secondary analysis, the VAS leg-to-back pain (LBR) ratio was used to further stratify patients: (1) nonleg pain-dominant (NLPD) group (LBR ≤ 1.0) or (2) leg pain-dominant (LPD) group (LBR > 1.0). Patient outcomes, including physical component score of the short form-12 survey (PCS-12), mental component score of the short form-12 survey (MCS-12), and Oswestry Disability Index (ODI), were identified and compared between groups using univariate and multivariate analysis. RESULTS: There were no significant differences in preoperative, postoperative, or delta scores for PCS-12 or ODI scores between groups. In patients undergoing decompression surgery, those with back pain-dominant or mixed symptoms (B, N, or NLPD groups) did not improve with respect to MCS-12 scores after surgery (P > .05), and those with leg pain-dominant symptoms (LPD group) had greater delta MCS-12 scores (P = .046) and greater recovery rates (P = .035). Multiple linear regression did not find LPD to be an independent predictor of PCS-12 or ODI scores. CONCLUSION: Patients undergoing lumbar decompression surgery and leg pain-dominant symptoms noted a greater improvement in MCS-12 scores; however, there were no differences in PCS-12 or ODI scores. LEVEL OF EVIDENCE: 3. CLINICAL RELEVANCE: Patients undergoing lumbar decompression surgery demonstrate no major clinically significant differences when split up by pain-dominance groups.

Does Cervical Spondylolisthesis Influence Patient-Reported Outcomes After Anterior Cervical Discectomy and Fusion Surgery?

BACKGROUND: No prior work has explored whether the presence of degenerative spondylolisthesis impacts patient-reported outcome measurements (PROMs) after an anterior cervical discectomy and fusion (ACDF); therefore, the goal of the current study was to determine whether the presence of a spondylolisthesis affects PROMs after an ACDF. METHODS: A retrospective cohort study was conducted on patients over the age of 18 who underwent a 1- or 2-level ACDF. All patients received preoperative standing lateral x-rays and were placed into 1 of 2 groups based on the presence of cervical spondylolisthesis from C2-T1: (1) no spondylolisthesis (NS) group or (2) spondylolisthesis (S) group. Preoperative, postoperative, and delta (postoperative minus preoperative) were recorded and compared between groups via univariate and multivariate analysis. Outcomes reported were the Physical Component Scores of the Short Form-12 (PCS-12), the Mental Component Scores of the Short Form-12 (MCS-12), the Neck Disability Index (NDI), and visual analog scale (VAS) Arm/Neck. RESULTS: A total of 202 patients were included in the final analysis with 154 in the NS group and 48 in the S group. Both patient cohorts reported significant postoperative improvement in PCS-12, NDI, and VAS Arm/Neck. When comparing outcome scores between groups, only MCS-12 delta scores were different between groups, with the S group exhibiting a greater mean delta score (8.3 vs 1.3, P = 0.024) than the NS group after ACDF. Multiple linear regression analysis indicated having spondylolisthesis at baseline was a significant predictor of greater change in MCS-12 than the NS group (ß = 4.841; 95% CI, 0.876, 8.805; P = 0.017). CONCLUSION: Both groups demonstrated significant postoperative improvement in PCS-12, NDI, or VAS Neck/Arm pain scores with no significant differences between groups. Patients with spondylolisthesis were found to have significantly greater improvement scores in MCS-12 scoring than those without spondylolisthesis after ACDF surgery.

How do C2 tilt and C2 slope correlate with patient reported outcomes in patients after anterior cervical discectomy and fusion?

BACKGROUND/CONTEXT: C2 tilt and C2 slope are quick and easy measurements to obtain on lateral radiographs and may be used to determine overall cervical sagittal alignment; however, the influence of these measurements on patient outcomes has not been well established in literature. PURPOSE: To determine if C2 tilt and/or C2 slope predict patient outcomes better compared with conventional radiographic measures after an anterior cervical discectomy and fusion (ACDF). STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: A total of 249 patients who underwent 1 to 3 level ACDF to address radiculopathy and/or myelopathy at a single academic institution between 2011 and 2015 were identified. Patients with less than 1 year of follow-up were excluded. OUTCOME MEASURES: Patient Reported Outcomes: Neck Disability Index (NDI), Physical Component Score-12 (PCS-12), and Mental Component Score (MCS-12), Visual Analog Score (VAS) Neck and Arm scores Cervical radiographic measurements: C2 tilt, C2 slope, C2-C7 lordosis, cervical SVA, T1 slope, T1 slope minus cervical lordosis (TS-CL), and C2-C7 ROM METHODS: Pearson correlation tests were performed to assess for significant associations between radiographic measurements and patient outcomes. Multiple linear regression models were developed adjusting for demographics and radiographic parameters to determine which factors were predictive of patient outcomes. RESULTS: C2 tilt and TS-CL correlated with all postoperative physical outcome scores (NDI, PCS-12, VAS Neck and ARM; p<.05), however no association was seen between C2 slope and postoperative outcomes. After accounting for the presence of subaxial deformity, C2 tilt and TS-CL remained strongly correlated to patient outcome scores. With multiple linear regression, C2 tilt was a significant predictor for NDI, whereas TS-CL was a significant predictor for PCS-12, VAS Neck and VAS Arm. CONCLUSIONS: C2 tilt significantly correlated with well-described conventional cervical parameters as well as postoperative physical outcomes measures, especially NDI, on multivariate analysis. C2 tilt may provide an easy and practical tool for predicting physical outcomes after ACDF.