Patients May Return to Work Sooner After Laminoplasty: Occupational Outcomes of the Cervical Spondylotic Myelopathy Surgical Trial.

BACKGROUND AND OBJECTIVES: Return-to-work (RTW) is an important outcome for employed patients considering surgery for cervical spondylotic myelopathy (CSM). We conducted a post hoc analysis of patients as-treated in the Cervical Spondylotic Myelopathy Surgical Trial, a prospective, randomized trial comparing surgical approaches for CSM to evaluate factors associated with RTW. METHODS: In the trial, patients were randomized (2:3) to either anterior surgery (anterior cervical decompression/fusion [ACDF]) or posterior surgery (laminoplasty [LP], or posterior cervical decompression/fusion [PCDF], at surgeon's discretion). Work status was recorded at 1, 3, 6, and 12 months postoperatively. For patients working full-time or part-time on enrollment, time to RTW was compared across as-treated surgical groups using discrete-time survival analysis. Multivariate logistic regression was used to assess predictors of RTW. Clinical outcomes were compared using a linear mixed-effects model. RESULTS: A total of 68 (42%) of 163 patients were working preoperatively and were analyzed. In total, 27 patients underwent ACDF, 29 underwent PCDF, and 12 underwent LP. 45 (66%) of 68 patients returned to work by 12 months. Median time to RTW differed by surgical approach (LP = 1 month, ACDF = 3 months, PCDF = 6 months; P = .02). Patients with longer length-of-stay were less likely to be working at 1 month (odds ratio 0.51; 95% CI, 0.29-0.91; P = .022) and 3 months (odds ratio 0.39; 95% CI, 0.16-0.96; P = .04). At 3 months, PCDF was associated with lower Short-Form 36 physical component summary scores than ACDF (estimated mean difference [EMD]: 6.42; 95% CI, 1.4-11.4; P = .007) and LP (EMD: 7.98; 95% CI, 2.7-13.3; P = .003), and higher Neck Disability Index scores than ACDF (EMD: 12.48; 95% CI, 2.3-22.7; P = .01) and LP (EMD: 15.22; 95% CI, 2.3-28.1; P = .014), indicating worse perceived physical functioning and greater disability, respectively. CONCLUSION: Most employed patients returned to work within 1 year. LP patients resumed employment earliest, while PCDF patients returned to work latest, with greater disability at follow-up, suggesting that choice of surgical intervention may influence occupational outcomes.

Effective and Successful Control of Symptomatic Vertebral Hemangiomas With Epidural Extension Using Stereotactic Spine Radiosurgery.

BACKGROUND AND OBJECTIVES: We present our experience in the management of symptomatic vertebral hemangiomas with epidural extension (SVHEE) using spine stereotactic radiosurgery (SSRS). METHODS: An Institutional Review Board approved retrospective review of all SVHEE patients treated with SSRS at our institution (2007-2022) was performed. Baseline patient demographics, clinical presentation, lesion volume, and Bilsky grade (to directly evaluate the epidural component) were determined. Clinical and radiographic response and treatment outcomes were subsequently evaluated at first (∼6 months) and final follow-up. RESULTS: Fourteen patients with SVHEE underwent SSRS (16-18 Gy/1-fraction); the mean follow-up was 24 months. The median lesion volume (cc) was 36.9 (range: 7.02-94.1), 31.5 (range: 6.53-69.7), and 25.15 (range: 6.01-52.5) at pre-SSRS, first, and final follow-up, respectively. Overall volume reduction was seen in the last follow-up in all 14 patients, median 29.01% (range: 6.58%-71.58%). Bilsky score was stable or improved in all patients at the last follow-up when compared with pre-SSRS score. Patients who underwent both surgical decompression and SSRS (n = 9): 8 had improved myelopathic symptoms and pain and 1 had stable radiculopathy postintervention. In the 5 patients treated with SSRS monotherapy, 2 had stable radicular pain and the other 3 improved pain and numbness. No patients experienced adverse outcomes. CONCLUSION: To our knowledge, this represents the largest series of SVHEE patients treated with SSRS, either as monotherapy or part of a multimodal/separation surgery treatment approach. We demonstrate that SSRS represents a potentially safe and effective treatment option in these patients. However, larger prospective studies and longer follow-ups are necessary to further assess the role, durability, and toxicity of SSRS in the management of these patients.

Review of mechanisms of expandable spine surgery devices.

INTRODUCTION: Expandable devices such as interbody cages, vertebral body reconstruction cages, and intravertebral body expansion devices are frequently utilized in spine surgery. Since the introduction of expandable implants in the early 2000s, the variety of mechanisms that drive expansion and implant materials have steadily increased. By examining expandable devices that have achieved commercial success and exploring emerging innovations, we aim to offer an in-depth evaluation of the different types of expandable cages used in spine surgery and the underlying mechanisms that drive their functionality. AREAS COVERED: We performed a review of expandable spinal implants and devices by querying the National Library of Medicine MEDLINE database and Google Patents database from 1933 to 2024. Five major types of mechanical jacks that drive expansion were identified: scissor, pneumatic, screw, ratchet, and insertion-expansion. EXPERT OPINION: We identified a trend of screw jack mechanism being the predominant machinery in vertebral body reconstruction cages and scissor jack mechanism predominating in interbody cages. Pneumatic jacks were most commonly found in kyphoplasty devices. Critically reviewing the mechanisms of expansion and identifying trends among effective and successful cages allows both surgeons and medical device companies to properly identify future areas of development.

Exploring tribology and material contact science in spine surgery: implications for implant design.

Tribology, an interdisciplinary field concerned with the science of interactions between surfaces in contact and their relative motion, plays a well-established role in the design of orthopedic implants, such as knee and hip replacements. However, its applications in spine surgery have received comparatively less attention in the literature. Understanding tribology is pivotal in elucidating the intricate interactions between metal, polymer, and ceramic components, as well as their interplay with the native human bone. Numerous studies have demonstrated that optimizing tribological factors is key to enhancing the longevity of joints and implants while simultaneously reducing complications and the need for revision surgeries in both arthroplasty and spinal fusion procedures. With an ever-growing and diverse array of spinal implant devices hitting the market for static and dynamic stabilization of the spine, it is important to consider how each of these devices optimizes these parameters and what factors may be inadequately addressed by currently available technology and methods. In this comprehensive review, the authors' objectives were twofold: 1) delineate the unique challenges encountered in spine surgery that could be addressed through optimization of tribological parameters; and 2) summarize current innovations and products within spine surgery that look to optimize tribological parameters and highlight new avenues for implant design and research.

Clinical presentation and extent of resection impacts progression-free survival in spinal ependymomas.

PURPOSE: Primary treatment of spinal ependymomas involves surgical resection, however recurrence ranges between 50 and 70%. While the association of survival outcomes with lesion extent of resection (EOR) has been studied, existing analyses are limited by small samples and archaic data resulting in an inhomogeneous population. We investigated the relationship between EOR and survival outcomes, chiefly overall survival (OS) and progression-free survival (PFS), in a large contemporary cohort of spinal ependymoma patients. METHODS: Adult patients diagnosed with a spinal ependymoma from 2006 to 2021 were identified from an institutional registry. Patients undergoing primary surgical resection at our institution, ≥ 1 routine follow-up MRI, and pathologic diagnosis of ependymoma were included. Records were reviewed for demographic information, EOR, lesion characteristics, and pre-/post-operative neurologic symptoms. EOR was divided into 2 classifications: gross total resection (GTR) and subtotal resection (STR). Log-rank test was used to compare OS and PFS between patient groups. RESULTS: Sixty-nine patients satisfied inclusion criteria, with 79.7% benefitting from GTR. The population was 56.2% male with average age of 45.7 years, and median follow-up duration of 58 months. Cox multivariate model demonstrated significant improvement in PFS when a GTR was attained (p <.001). Independently ambulatory patients prior to surgery had superior PFS (p <.001) and OS (p =.05). In univariate analyses, patients with a syrinx had improved PFS (p =.03) and were more likely to benefit from GTR (p =.01). Alternatively, OS was not affected by EOR (p =.78). CONCLUSIONS: In this large, contemporary series of adult spinal ependymoma patients, we demonstrated improvements in PFS when GTR was achieved.

Evolution of lumbar degenerative spondylolisthesis with key radiographic features.

Spondylolisthesis is a common finding in middle-aged and older adults with back pain. The pathophysiology of degenerative spondylolisthesis is a subject of controversy regarding not only its etiology but also the mechanisms of its progression. It is theorized that degeneration of the facets and discs can lead to segmental instability, leading to displacement over time. Kirkaldy-Willis divided degenerative spondylolisthesis into three phases: dysfunction, instability, and finally, restabilization. There is a paucity of literature on the unification of the radiological hallmarks seen in spondylolisthesis within these phases. The radiographic features include (1) facet morphology/arthropathy, (2) facet effusion, (3) facet vacuum, (4) synovial cyst, (5) interspinous ligament bursitis, and (6) vacuum disc as markers of dysfunction, instability, and/or restabilization. We discuss these features, which can be seen on X-ray, CT, and MRI, with the intention of establishing a timeline upon which they present clinically. Spondylolisthesis is initiated as either degeneration of the intervertebral disc or facet joints. Early degeneration can be seen as facet vacuum without considerable arthropathy. As the vertebral segment becomes increasingly dynamic, fluid accumulates within the facet joint space. Further degeneration will lead to the advancement of facet arthropathy, degenerative disc disease, and posterior ligamentous complex pathology. Facet effusion can eventually be replaced with a vacuum in severe facet osteoarthritis. Intervertebral disc vacuum continues to accumulate with further cleft formation and degeneration. Ultimately, autofusion of the vertebra at the facets and endplates can be observed. With this review, we hope to increase awareness of these radiographical markers and their timeline, thus placing them within the framework of the currently accepted model of degenerative spondylolisthesis, to help guide future research and to help refine management guidelines.

The World Neurosurgery Global Champions Program: First-Year Experience of a Model Initiative for Reducing Disparities in Global Neurosurgical Literature.

OBJECTIVE: Most surgical journals are published in English, representing a challenge for researchers from non-Anglophone countries. We describe the implementation, workflow, outcomes, and lessons learned from the WORLD NEUROSURGERY Global Champions Program (GCP), a novel journal-specific English language editing program for articles rejected because of poor English grammar or usage. METHODS: The GCP was advertised via the journal website and social media. Applicants were selected to be a reviewer for the GCP if they demonstrated English proficiency on writing samples supplied in their application. The demographics of GCP members and characteristics and outcomes of articles edited by the GCP during its first year were reviewed. Surveys of GCP members and authors who used the service were conducted. RESULTS: Twenty-one individuals became part of the GCP, representing 8 countries and 16 languages apart from English. A total of 380 manuscripts were peer reviewed by the editor-in-chief, who determined these manuscripts to have potentially worthwhile content but needed to be rejected due to poor language. The authors of these manuscripts were informed of the existence of this language assistance program. Forty-nine articles (12.9%) were edited by the GCP in 41.6 ± 22.8 days. Of 40 articles resubmitted to WORLD NEUROSURGERY, 24 (60.0%) were accepted. GCP members and authors understood the purpose and workflow of the program and recognized improvements in article quality and the probability of acceptance through their participation. CONCLUSIONS: The WORLD NEUROSURGERY Global Champions Program mitigated a critical barrier to publication in an English language journal for authors from non-Anglophone countries. This program promotes research equity by providing a free, largely medical student and trainee operated, English language editing service. This model or a similar service can be replicated by other journals.

Management of Patients with Spine Tumors Strengthened by a Dedicated Multidisciplinary Spine Tumor Board: A 15-Year Single-Institutional Experience.

BACKGROUND: Patients with spine tumors frequently require timely, multistep, and multidisciplinary care. A Spine Tumor Board (STB) provides a consistent forum wherein diverse specialists can interact, facilitating complex coordinated care for these patients. This study aims to present a single, large academic center's STB experience specifically reviewing case diversity, recommendations, and quantifying growth over time. METHODS: All patient cases discussed at STB from May 2006 (STB inception) to May 2021 were evaluated. Collected data submitted by presenting physicians and formal documentation completed during the STB are summarized. RESULTS: A total of 4549 cases were reviewed by STB over the study period, representing 2618 unique patients. Over the course of the study, a 266% increase in number of cases presented per week was observed (4.1 to 15.0). Cases were presented by surgeons (74%), radiation oncologists (18%), neurologists (2%), and other specialists (6%). The most common pathologic diagnoses discussed were spinal metastases (n = 1832; 40%), intradural extramedullary tumors (n = 798; 18%), and primary glial tumors (n = 567; 12%). Treatment recommendations included surgery, radiation therapy, or systemic therapy for 1743 cases (38%), continued routine follow-up/expectant management for 1592 cases (35%), supplementary imaging to better clarify the diagnosis for 549 cases (12%), and variable tailored recommendations for the remainder of cases (18%). CONCLUSIONS: Care of patients with spine tumors is complex. We believe that the formation of a stand-alone STB is instrumental to accessing multidisciplinary input, enhancing confidence in management decisions for both patients and providers, assisting with care orchestration, and improving quality of care for patients with spine tumors.

Stratification of spine patients based on self-reported clinical symptom classes: Evaluation of long-term outcomes and subsequent interventions.

Background: Prior work by our group developed a stratification tool based on four PROMIS domains for patients with low back pain (LBP). Our study aimed to evaluate the ability of our previously developed symptom classes to predict long-term outcomes, and determine whether there were differential treatment effects by intervention. Methods: This was a retrospective cohort study of adult patients with LBP seen in spine clinics in a large health system between November 14, 2018 and May 14, 2019 who completed patient-reported outcomes as part of routine care at baseline and again at 12-months follow-up. Latent class analysis identified symptom classes based on PROMIS domain scores (physical function, pain interference, social role satisfaction, and fatigue) that were ≥1 standard deviation worse (meaningfully worse) than the general population. The ability of the profiles to predict long-term outcomes at 12-months was evaluated through multivariable models. Differences in outcomes by subsequent treatments (physical therapy, specialist visits, injections, and surgery) were investigated. Results: There were 3,236 adult patients (average age 61.1 ± 14.2, 55.4% female) included in the study with three distinct classes identified: mild symptoms (n = 986, 30.5%), mixed (n = 798, 24.7%) with poor scores on physical function and pain interference but better scores on other domains, and significant symptoms (n = 1,452, 44.9%). The classes were significantly associated with long-term outcomes, with patients with significant symptoms improving the most across all domains. Utilization differed across classes, with the mixed symptom class receiving more PT and injections and significant symptom class receiving more surgeries and specialist visits. Conclusions: Patients with LBP have distinct clinical symptom classes which could be utilized to stratify patients into groups based on risk of future disability. These symptom classes can also be used to provide estimates of the effectiveness of different interventions, further increasing the clinical utility of these classes in standard care.

Leveraging published randomized controlled trials to inform clinical trial design: a simulation-based study of laminectomy versus laminectomy and fusion.

OBJECTIVE: The US-based Spinal Laminectomy versus Instrumented Pedicle Screw (SLIP) trial reported improvement in disability following laminectomy with fusion versus laminectomy alone for patients with lumbar spondylolisthesis. Despite using similar methods, a concurrent Swedish trial investigating the same question did not reach the same conclusion. The authors performed a simulation-based analysis to elucidate potential causes of these divergent results. METHODS: The mean and standard deviation of the preoperative and 2-year postoperative Oswestry Disability Index (ODI) scores for each study group (laminectomy with fusion and laminectomy alone) were collected from the spondylolisthesis stratum of the Swedish trial and used to create a MATLAB simulator using linear transformations to predict postoperative ODI distributions. Applying this simulator to both varied and published preoperative ODI distributions from the SLIP trial, the authors simulated the results of the US-based trial using treatment effects from the Swedish study and compared simulated US results to those published in the SLIP trial. RESULTS: Simulated US results showed that as preoperative disability increased, the difference in postoperative ODI scores grew between treatment groups and increasingly favored laminectomy alone (p < 0.0001). In 100 simulations of a similarly sized US trial, the average mean change in ODI scores postoperatively was significantly higher than was published for laminectomy alone in the SLIP trial (-21.3 vs -17.9), whereas it was significantly lower than published for fusion (-16.9 vs -26.3). CONCLUSIONS: The expected benefit of surgical treatments for spondylolisthesis varied according to preoperative disability. Adapting Swedish-estimated treatment effects to the US context mildly overapproximated the improvement in postoperative disability scores for laminectomy, but more severely underapproximated the improvement reported for laminectomy and fusion in the SLIP trial. The observed heterogeneity between these studies is influenced more by patient response to fusion than response to laminectomy. This analysis paves the way for future studies on the impact of preoperative treatment group heterogeneity, differences in surgical methods, and empirical design on reported clinical benefits. Although bayesian reanalysis of published randomized controlled trial data is susceptible to biases that typically limit post hoc analyses, the authors' method offers a simple and cost-effective approach to improve the understanding of published clinical trial results and their implications for future studies.

Intradiscal vacuum phenomenon and spinal degeneration: a cross-sectional analysis of 219 subjects.

INTRODUCTION: Intradiscal vacuum phenomenon (IVP) is the collection of gas within the intervertebral discs. It has been reported with various spinal disorders. The exact role of IVP in spinal degeneration leading to low back pain (LBP) is unclear. We aimed to obtain the prevalence of IVP in patients with LBP. Our second aim was to understand whether IVP was associated with intervertebral disc degeneration (IVDD), Modic changes, and subchondral sclerosis (SS). METHODS: A total of 12.450 consecutive patients with chronic LBP were evaluated in terms of having abdominal computed tomography (CT) scan concomitant with lumbar spine magnetic resonance imaging (MRI) using radiological database of three spine centers. We excluded the patients with a history of malignancy, metabolic disease, spinal infection, traumatic or osteoporotic spine fracture, and spine surgery. All lumbar levels were evaluated in terms of IVDD and Modic changes on MRI, while they were evaluated in terms of IVP and SS on CT scans. RESULTS: We included 219 patients. Severe IVDD, Modic changes, IVP, and SS were seen in 53.9% (n: 118), 38.8% (n: 85), 26.5% (n: 58), and 16% (n: 35) of the patients, respectively. Intradiscal vacuum phenomenon was closely associated with severe IVDD (OR: 8.204), Modic changes (OR: 3.547) and SS (OR: 4.231). DISCUSSION: Intradiscal vacuum phenomenon was closely associated with severe IVDD, Modic changes, and SS. Further prospective clinical and laboratory studies are necessary to better delineate the pathogenesis of IVP.

A Retrospective Analysis of the L3-L4 Disc and Spinopelvic Parameters on Outcomes in Thoracolumbar Fusion: Was Art Steffee Right?

OBJECTIVE: To determine whether the L3-L4 disc angle may be a surrogate marker for global lumbar alignment in thoracolumbar fusion surgery and to explore the relationship between radiographic and patient-reported outcomes after thoracolumbar fusion surgery. METHODS: Retrospective chart review was conducted on patients who had undergone a lumbar fusion involving levels from T9 to pelvis. EuroQol-Five Dimension (EQ-5D-3L) scores and adverse events including adjacent-segment disease and degeneration, pseudoarthrosis, proximal junctional kyphosis, stenosis, and reoperation were collected. Pre- and postoperative spinopelvic parameters were measured on weight-bearing radiographs, with the L3-L4 disc angle of novel interest. Univariate logistic and linear regression were performed to assess the associations of radiographic parameters with adverse event incidence and improvement in EQ-5D-3L, respectively. RESULTS: In total, 182 patients met inclusion criteria. Univariable analysis revealed that increased magnitude of L3-L4 disc angle, anterior pelvic tilt, and pelvic incidence measures are associated with increased likelihood of developing postoperative adverse events. Conversely, increased lumbar lordosis demonstrated a decreased incidence of developing a postoperative adverse event. Linear regression showed that radiographic parameters did not significantly correlate with postoperative EQ-5D-3L scores, although scores were significantly improved postfusion in all dimensions except Self-Care (P = 0.51). CONCLUSIONS: L3-L4 disc angle magnitude may serve as a surrogate marker of global lumbar alignment. The degree of spinopelvic alignment did not correlate to improvement in EQ-5D-3L score in the present study, suggesting that quality of life metric change may not be a sensitive or specific marker of postfusion alignment.

Postlaminectomy lumbopelvic sagittal changes in patients with developmental lumbar spinal stenosis grouped into Roussouly lumbopelvic sagittal profiles: 2- to 10-year prospective follow-up.

OBJECTIVE: Roussouly lumbopelvic sagittal profiles are associated with distinct pathologies or distinct natural histories and prognoses. The associations between developmental lumbar spinal stenosis (DLSS) and native lumbopelvic sagittal profiles are unknown. Moreover, the relative effects of multilevel decompression on lumbar sagittal alignment, geometrical parameters of the pelvis, and compensatory mechanisms for each of the Roussouly subtypes are unknown. This study aimed to explore the association between DLSS and native lumbar lordosis (LL) subtypes. It also attempts to understand the natural history of postlaminectomy lumbopelvic sagittal changes and compensatory mechanisms for each of the Roussouly subtypes and to define the critical lumbar segment or specific lordosis arc that is recruited after relief of the stenosis effect. METHODS: A total of 418 patients with multilevel DLSS were grouped into various Roussouly subtypes, and lumbopelvic sagittal parameters were prospectively compared at follow-up intervals of preoperative to < 2 years, 2 to < 5 years, and 5 to ≥ 10 years after laminectomy. The variables analyzed included LL, upper lordosis arc from L1 to L4, lower lordosis arc from L4 to S1, and segmental lordosis from L1 to S1. Pelvic parameters included pelvic incidence, sacral slope, pelvic tilt, and pelvic incidence minus LL values. RESULTS: Of the 329 patients who were followed up throughout this study, 33.7% had Roussouly type 1 native lordosis, whereas the incidence rates of types 2, 3, and 4 were 33.4%, 21.9%, and 10.9%, respectively. LL was not reduced in any of the Roussouly subtypes after multilevel decompressions. Instead, LL increased by 4.5° (SD 11.9°-from 27.3° [SD 11.5°] to 31.8° [SD 9.8°]) in Roussouly type 1 and by 3.1° (SD 11.6°-from 41.3° [SD 9.5°] to 44.4° [SD = 9.7°]) in Roussouly type 2. The other Roussouly types showed no significant changes. Pelvic tilt decreased significantly-by 2.8°, whereas sacral slope increased significantly-by 2.9° in Roussouly type 1 and by 1.7° in Roussouly type 2. The critical lumbar segment that recruits LL differs between Roussouly subtypes. Increments and changes were sustained until the final follow-up. CONCLUSIONS: The study findings are important in predicting patient prognosis, LL evolution, and the need for prophylactic or corrective deformity surgery. Multilevel involvement in DLSS and the high prevalence of Roussouly types 1 and 2 suggest that spinal canal dimensions are closely linked to the developmental evolution of LL.

Could gas-filled pseudocyst mimick extruded disc herniation?

There are case reports and small case series in the literature reporting gas-filled pseudocysts (GFP). However, a systematic review presenting overall view of the disease and its management is still lacking. In the present study, we aimed to make a systematic review of GFP cases, and present an exemplary case of ours. Our second aim was to discuss current theories for pathogenesis of GFP. A systematic review of GFP was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline. Two large-scaled data search engines were used. A total of 53 articles were retrieved from the literature and presented with an exemplary case of ours. Mean age of the historical cohort was 59.47 years. There were 66 male (54.1%) and 56 female (45.9%) patients. The most prevalent clinical presentation was radicular sign/symptom in lower limbs with (29.1%) or without low back pain (LBP) (67%). Gas-filled pseudocyst has most commonly been diagnosed at the lower lumbar spine (L4-L5, 45.3%; L5-S1, 37.7%). Surgery was the treatment of choice in most of the patients (80%). In the whole cohort, 79.1% of the patients had complete recovery. Gas-filled pseudocysts are rarely observed in daily practice. They present mostly in men at the age of 60s. Precise differential diagnosis determination using appropriate imaging would help clinicians treat the patients properly. Gas-filled pseudocysts should be treated similarly to other spinal pathologies causing nerve root compression.

The change in postoperative opioid prescribing after lumbar decompression surgery following state-level opioid prescribing reform.

OBJECTIVE: On August 31, 2017, the state of Ohio implemented legislation limiting the dosage and duration of opioid prescriptions. Despite the widespread adoption of such restrictions, few studies have investigated the effects of these reforms on opioid prescribing and patient outcomes. In the present study, the authors aimed to evaluate the effect of recent state-level reform on opioid prescribing, patient-reported outcomes (PROs), and postoperative emergency department (ED) visits and hospital readmissions after elective lumbar decompression surgery. METHODS: This study was a retrospective cohort study of patients who underwent elective lumbar laminectomy for degenerative disease at one of 5 hospitals within a single health system in the years prior to and after the implementation of the statewide reform (September 1, 2016-August 31, 2018). Patients were classified according to the timing of their surgery relative to implementation of the prescribing reform: before reform (September 1, 2016-August 31, 2017) or after reform (September 1, 2017- August 31, 2018). The outcomes of interest included total outpatient opioids prescribed in the 90 days following discharge from surgery as measured in morphine-equivalent doses (MEDs), total number of opioid refill prescriptions written, patient-reported pain at the first postoperative outpatient visit as measured by the Numeric Pain Rating Scale, improvement in patient-reported health-related quality of life as measured by the Patient-Reported Outcomes Measurement Information System-Global Health (PROMIS-GH) questionnaire, and ED visits or hospital readmissions within 90 days of surgery. RESULTS: A total of 1031 patients met the inclusion criteria for the study, with 469 and 562 in the before- and after-reform groups, respectively. After-reform patients received 26% (95% CI 19%-32%) fewer MEDs in the 90 days following discharge compared with the before-reform patients. No significant differences were observed in the overall number of opioid prescriptions written, PROs, or postoperative ED or hospital readmissions within 90 days in the year after the implementation of the prescribing reform. CONCLUSIONS: Patients undergoing surgery in the year after the implementation of a state-level opioid prescribing reform received significantly fewer MEDs while reporting no change in the total number of opioid prescriptions, PROs, or postoperative ED visits or hospital readmissions. These results demonstrate that state-level reforms placing reasonable limits on opioid prescriptions written for acute pain may decrease patient opioid exposure without negatively impacting patient outcomes after lumbar decompression surgery.

Effect of Ventral vs Dorsal Spinal Surgery on Patient-Reported Physical Functioning in Patients With Cervical Spondylotic Myelopathy: A Randomized Clinical Trial.

Importance: Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction worldwide. It remains unknown whether a ventral or dorsal surgical approach provides the best results. Objective: To determine whether a ventral surgical approach compared with a dorsal surgical approach for treatment of cervical spondylotic myelopathy improves patient-reported physical functioning at 1 year. Design, Setting, and Participants: Randomized clinical trial of patients aged 45 to 80 years with multilevel cervical spondylotic myelopathy enrolled at 15 large North American hospitals from April 1, 2014, to March 30, 2018; final follow-up was April 15, 2020. Interventions: Patients were randomized to undergo ventral surgery (n = 63) or dorsal surgery (n = 100). Ventral surgery involved anterior cervical disk removal and instrumented fusion. Dorsal surgery involved laminectomy with instrumented fusion or open-door laminoplasty. Type of dorsal surgery (fusion or laminoplasty) was at surgeon's discretion. Main Outcomes and Measures: The primary outcome was 1-year change in the Short Form 36 physical component summary (SF-36 PCS) score (range, 0 [worst] to 100 [best]; minimum clinically important difference = 5). Secondary outcomes included 1-year change in modified Japanese Orthopaedic Association scale score, complications, work status, sagittal vertical axis, health resource utilization, and 1- and 2-year changes in the Neck Disability Index and the EuroQol 5 Dimensions score. Results: Among 163 patients who were randomized (mean age, 62 years; 80 [49%] women), 155 (95%) completed the trial at 1 year (80% at 2 years). All patients had surgery, but 5 patients did not receive their allocated surgery (ventral: n = 1; dorsal: n = 4). One-year SF-36 PCS mean improvement was not significantly different between ventral surgery (5.9 points) and dorsal surgery (6.2 points) (estimated mean difference, 0.3; 95% CI, -2.6 to 3.1; P = .86). Of 7 prespecified secondary outcomes, 6 showed no significant difference. Rates of complications in the ventral and dorsal surgery groups, respectively, were 48% vs 24% (difference, 24%; 95% CI, 8.7%-38.5%; P = .002) and included dysphagia (41% vs 0%), new neurological deficit (2% vs 9%), reoperations (6% vs 4%), and readmissions within 30 days (0% vs 7%). Conclusions and Relevance: Among patients with cervical spondylotic myelopathy undergoing cervical spinal surgery, a ventral surgical approach did not significantly improve patient-reported physical functioning at 1 year compared with outcomes after a dorsal surgical approach. Trial Registration: ClinicalTrials.gov Identifier: NCT02076113.

Patient-specific prediction model for clinical and quality-of-life outcomes after lumbar spine surgery.

OBJECTIVE: Patient demographics, comorbidities, and baseline quality of life (QOL) are major contributors to postoperative outcomes. The frequency and cost of lumbar spine surgery has been increasing, with controversy revolving around optimal management strategies and outcome predictors. The goal of this study was to generate predictive nomograms and a clinical calculator for postoperative clinical and QOL outcomes following lumbar spine surgery for degenerative disease. METHODS: Patients undergoing lumbar spine surgery for degenerative disease at a single tertiary care institution between June 2009 and December 2012 were retrospectively reviewed. Nomograms and an online calculator were modeled based on patient demographics, comorbidities, presenting symptoms and duration of symptoms, indication for surgery, type and levels of surgery, and baseline preoperative QOL scores. Outcomes included postoperative emergency department (ED) visit or readmission within 30 days, reoperation within 90 days, and 1-year changes in the EuroQOL-5D (EQ-5D) score. Bootstrapping was used for internal validation. RESULTS: A total of 2996 lumbar surgeries were identified. Thirty-day ED visits were seen in 7%, 30-day readmission in 12%, 90-day reoperation in 3%, and improvement in EQ-5D at 1 year that exceeded the minimum clinically important difference in 56%. Concordance indices for the models predicting ED visits, readmission, reoperation, and dichotomous 1-year improvement in EQ-5D were 0.63, 0.66, 0.73, and 0.84, respectively. Important predictors of clinical outcomes included age, body mass index, Charlson Comorbidity Index, indication for surgery, preoperative duration of symptoms, and the type (and number of levels) of surgery. A web-based calculator was created, which can be accessed here: https://riskcalc.org/PatientsEligibleForLumbarSpineSurgery/. CONCLUSIONS: The prediction tools derived from this study constitute important adjuncts to clinical decision-making that can offer patients undergoing lumbar spine surgery realistic and personalized expectations of postoperative outcome. They may also aid physicians in surgical planning, referrals, and counseling to ultimately lead to improved patient experience and outcomes.

Artificial Intelligence and Robotics in Spine Surgery.

STUDY DESIGN: Narrative review. OBJECTIVES: Artificial intelligence (AI) and machine learning (ML) have emerged as disruptive technologies with the potential to drastically affect clinical decision making in spine surgery. AI can enhance the delivery of spine care in several arenas: (1) preoperative patient workup, patient selection, and outcome prediction; (2) quality and reproducibility of spine research; (3) perioperative surgical assistance and data tracking optimization; and (4) intraoperative surgical performance. The purpose of this narrative review is to concisely assemble, analyze, and discuss current trends and applications of AI and ML in conventional and robotic-assisted spine surgery. METHODS: We conducted a comprehensive PubMed search of peer-reviewed articles that were published between 2006 and 2019 examining AI, ML, and robotics in spine surgery. Key findings were then compiled and summarized in this review. RESULTS: The majority of the published AI literature in spine surgery has focused on predictive analytics and supervised image recognition for radiographic diagnosis. Several investigators have studied the use of AI/ML in the perioperative setting in small patient cohorts; pivotal trials are still pending. CONCLUSIONS: Artificial intelligence has tremendous potential in revolutionizing comprehensive spine care. Evidence-based, predictive analytics can help surgeons improve preoperative patient selection, surgical indications, and individualized postoperative care. Robotic-assisted surgery, while still in early stages of development, has the potential to reduce surgeon fatigue and improve technical precision.