Delayed Infection After Cervical Disc Arthroplasty: A Case Report and Review of the Literature.

STUDY DESIGN: Case report and literature review. OBJECTIVE: To report the relatively rare complication of delayed infection after cervical disc arthroplasty (CDA). BACKGROUND: Delayed infection of the M6 device has been a rarely reported complication, with all cases described outside of the United States. The reliability of positive intraoperative cultures remains an ongoing debate. METHODS: Cases were reviewed, and findings were summarized. A literature review was performed and discussed, with special consideration to current reports of delayed M6 infection, etiology, and utility of intraoperative cultures. RESULTS: We present a case of delayed infection 6 years after primary 1-level CDA with the M6 device. At revision surgery, gross purulence was encountered. Intraoperative cultures finalized with Staphylococcus epidermidis and Cutibacterium acnes. The patient was revised with removal of the M6 and conversion to anterior cervical discectomy and fusion. A prolonged course of intravenous antibiotics was followed by an oral course for suppression. At the final follow-up, the patient's preoperative symptoms had resolved. CONCLUSION: Delayed infection after CDA is a rare complication, with ongoing debate regarding the reliability of positive cultures. We describe an infected M6 and demonstrate the utility of implant removal, conversion to anterior cervical discectomy and fusion, and long-term antibiotics as definitive treatment. LEVEL OF EVIDENCE: Level V-case report and literature review.

Preoperative diagnosis of mental health disorder and dysphagia following anterior cervical spine surgery.

OBJECTIVE: Mental health disorders (MHDs) have been linked to worse postoperative outcomes after various surgical procedures. Past studies have also demonstrated a higher prevalence of dysphagia in both acute and community mental health settings. Dysphagia is among the most common complications following anterior cervical spine surgery (ACSS); however, current literature describing the association between an established diagnosis of an MHD and the rate of dysphagia after ACSS is sparse. METHODS: All patients who underwent ACSS between 2014 and 2020 with a minimum of 6 months of follow-up were retrospectively evaluated at a single institution. Patients were divided into cohorts depending on an established diagnosis of an MHD: the first had no established MHD (non-MHD); the second included patients with a diagnosed MHD. Outcomes were measured using pre- and postoperative patient-reported outcome scores, which included the Swallowing Quality of Life survey for dysphagia, as well as physical and mental health questionnaires. Postoperative dysphagia surveys were obtained at final follow-up for both patient cohorts. RESULTS: A total of 68 and 124 patients with and without a diagnosis of a MHD were assessed. The MHD group reported significantly worse baseline Patient-Reported Outcomes Measurement Information System depression scale scores (p < 0.001), 12-Item Short-Form Health Survey (p < 0.001), and Veterans RAND 12-Item Health Survey (p = 0.001) mental health components compared to non-MHD group. This group continued to have worse mental health status in the postoperative period, as reported by Patient-Reported Outcomes Measurement Information System depression scale scores (p = 0.024), 12-Item Short-Form Health Survey (p = 0.019), and Veterans RAND 12-Item Health Survey (p = 0.027). Postoperative assessment of Swallowing Quality of Life scores (expressed as the mean ± SD) also showed worse dysphagia outcomes in the MHD cohort (80.1 ± 12.2) than in the non-MHD cohort (86.0 ± 12.1, p = 0.001). CONCLUSIONS: ACSS is associated with significantly higher postoperative dysphagia in patients diagnosed with an MHD when compared to patients without an established mental health diagnosis. Given the high prevalence of MHDs in patients with spinal pathology, it is important for spine surgeons to take note of the increased incidence of dysphagia faced by this patient population.

Discovery of circulating blood biomarkers in patients with and without Modic changes of the lumbar spine: a preliminary analysis.

PURPOSE: The following study aimed to determine the existence of blood biomarkers in symptomatic patients with or without lumbar Modic changes (MC). METHODS: A cross-sectional sub-analyses of a prospective cohort was performed. Fasting blood samples were collected from patients with and without lumbar MC who had undergone spinal fusion or microdiscectomy. An 80-plex panel and CCL5/RANTES were used to assess preoperative plasma cytokine concentrations. Patient demographics and imaging phenotypes were also assessed. RESULTS: Thirty-one subjects were analysed (n = 18 no MC; n = 13 MC). No significant differences were found in age, sex, body mass index, smoking and alcohol history, and surgical procedure (i.e. fusion, decompression) between the two groups (p > 0.05). Several statistically significant blood biomarkers in MC patients were identified, including elevated levels of C-C Motif Chemokine Ligand 5 (CCL5, p = 0.0006), while Macrophage Migration Inhibitory Factor (MIF) was significantly lower (p = 0.009). Additionally, C-X-C Motif Chemokine Ligand 5 (CXCL5, p = 0.052), Pentraxin 3 (PTX3, p = 0.06) and Galectin-3 (Gal-3, p = 0.07) showed potential relevance. Moreover, MC patients exhibited significantly higher levels of disc degeneration (p = 0.0001) and displacement severity (p = 0.020). Based on multivariate analyses and controlling for disc degeneration/displacement, CCL5 (OR 1.02; 95% CI 1.002-1.033; p = 0.028) and MIF (OR 0.60; 95% CI 0.382-0.951; p = 0.030) were independently associated with MC patients. CONCLUSION: This "proof-of-concept" study is the first to identify specific and significantly circulating blood biomarkers associated with symptomatic patients with lumbar MC, independent of disc alterations of degeneration and/or bulges/herniations. Specifically, differences in CCL5 and MIF protein levels were significantly noted in MC patients compared to those without MC.

Risk of Subsequent Fusion After Isolated Decompression of Lumbar Facet Cysts.

INTRODUCTION: Lumbar facet cysts represent a potential source of nerve root compression in elderly patients. Isolated decompression without fusion has proven to be a reasonable treatment option in properly indicated patients. However, the risk of lumbar fusion after isolated decompression and facet cyst excision has yet to be elucidated. METHODS: The PearlDiver database was reviewed for patients undergoing isolated laminectomy for lumbar facet cyst from January 2015 to December 2018 using Current Procedural Terminology coding. Patients undergoing concomitant fusion or additional decompression, as well as those diagnosed with preexisting spondylolisthesis or without a minimum of 5-year follow-up, were excluded. Rates of subsequent lumbar fusion and potential risk factors for subsequent fusion were identified. Statistical analysis included descriptive statistics, chi square test, and multivariate logistic regression. Results were considered significant at P < 0.05. RESULTS: In total, 10,707 patients were ultimately included for analysis. At 5-year follow-up, 727 (6.79%) of patients underwent subsequent lumbar fusion after initial isolated decompression. Of these, 301 (2.81% of total patients, 41.4% of fusion patients) underwent fusion within the first year after decompression. Multivariate analysis identified chronic kidney disease, hypertension, and osteoarthritis as risk factors for requiring subsequent lumbar fusion at 5 years following the index decompression procedure ( P < 0.033; all). CONCLUSION: Patients undergoing isolated decompression for lumbar facet cysts undergo subsequent lumbar fusion at a 5-year rate of 6.79%. Risk factors for subsequent decompression include chronic kidney disease, hypertension, and osteoarthritis. This study will assist spine surgeons in appropriately counseling patients on expected postoperative course and potential risks of isolated decompression.

Internal hemipelvectomy: A single institution's learning curve and longitudinal experience.

BACKGROUND AND OBJECTIVES: Wide margin resection for pelvic tumors via internal hemipelvectomy is among the most technically challenging procedures in orthopedic oncology. As such, surgeon experience and technique invariably affect patient outcomes. The aim of this clinical study was to assess how an individual surgeon's experiences and advancements in technology and techniques in the treatment of internal hemipelvectomy have impacted patient outcomes at our institution. METHODS: This study retrospectively examined a single tertiary academic institution's consecutive longitudinal experience with internal hemipelvectomy for primary sarcoma or pelvic metastases over a 26-year period between the years 1994 and 2020. Outcomes were assessed using two separate techniques. The first stratified patients into cohorts based on the date of surgery with three distinct "eras" ("early," "middle," and "modern"), which reflect the implementation of new techniques, including three-dimensional (3D) computer navigation and cutting guide technology into our clinical practice. The second method of cohort selection grouped patients based on each surgeon's case experience with internal hemipelvectomy ("inexperienced," "developing," and "experienced"). Primary endpoints included margin status, complication profiles, and long-term oncologic outcomes. Whole group multivariate analysis was used to evaluate variables predicting blood loss, operative time, tumor-free survival, and mortality. RESULTS: A total of 72 patients who underwent internal hemipelvectomy were identified. Of these patients, 24 had surgery between 1994 and 2007 (early), 28 between 2007 and 2015 (middle), and 20 between 2016 and 2020 (modern). Twenty-eight patients had surgery while the surgeon was still inexperienced, 24 while developing, and 20 when experienced. Evaluation by era demonstrated that a greater proportion of patients were indicated for surgery for oligometastatic disease in the modern era (0% vs. 14.3% vs. 35%, p = 0.022). Fewer modern cases utilized freehand resection (100% vs. 75% vs. 55%, p = 0.012), while instead opting for more frequent utilization of computer navigation (0% vs. 25% vs. 20%, p = 0.012), and customized 3D-printed cutting guides (0% vs. 0% vs. 25%, p = 0.002). Similarly, there was a decline in the rate of massive blood loss observed (72.2% vs. 30.8% vs. 35%, p = 0.016), and interdisciplinary collaboration with a general surgeon for pelvic dissection became more common (4.2% vs. 32.1% vs. 85%, p < 0.001). Local recurrence was less prevalent in patients treated in middle and modern eras (50% vs. 15.4% vs. 25%, p = 0.045). When stratifying by case experience, surgeries performed by experienced surgeons were less frequently complicated by massive blood loss (66.7% vs. 40% vs. 20%, p = 0.007) and more often involved a general surgeon for pelvic dissection (17.9% vs. 37.5% vs. 65%, p = 0.004). Whole group multivariate analysis demonstrated that the use of patient-specific instrumentation (PSI) predicted lower intraoperative blood loss (p = 0.040). However, surgeon experience had no significant effect on operative time (p = 0.125), tumor-free survival (p = 0.501), or overall patient survival (p = 0.735). CONCLUSION: While our institution continues to utilize neoadjuvant and adjuvant therapies following current guideline-based care, we have noticed changing trends from early to modern periods. With the advent of new technologies, we have seen a decline in freehand resections for hemipelvectomy procedures, and a transition to utilizing more 3D navigation and customized 3D cutting guides. Furthermore, we have employed the use of an interdisciplinary team approach more regularly for these complicated cases. Although our results do not demonstrate a significant change in perioperative outcomes over the years, our institution's willingness to treat more complex cases likely obscures the benefits of surgeon experience and recent technological advances for patient outcomes.

The Effect of Intraoperative Prone Position on Psoas Morphology and Great Vessel Anatomy: Consequences for Prone Lateral Approach to the Lumbar Spine.

BACKGROUND: This study sought to quantify radiographic differences in psoas morphology, great vessel anatomy, and lumbar lordosis between supine and prone intraoperative positioning to optimize surgical planning and minimize the risk of neurovascular injury. METHODS: Measurements on supine magnetic resonance imaging and prone intraoperative computed tomography with O-arm from L2 to L5 levels included the anteroposterior and mediolateral proximity of the psoas, aorta, inferior vena cava (IVC), and anterior iliac vessels to the vertebral body. Psoas transverse and longitudinal diameters, psoas cross-sectional area, total lumbar lordosis, and segmental lordosis were assessed. RESULTS: Prone position produced significant psoas lateralization, especially at more caudal levels (P < 0.001). The psoas drifted slightly anteriorly when prone, which was non-significant, but the magnitude of anterior translation significantly decreased at more caudal segments (P = 0.038) and was lowest at L5 where in fact posterior retraction was observed (P = 0.032). When prone, the IVC (P < 0.001) and right iliac vein (P = 0.005) migrated significantly anteriorly, however decreased anterior displacement was seen at more caudal levels (P < 0.001). Additionally, the IVC drifted significantly laterally at L5 (P = 0.009). Mean segmental lordosis significantly increased when prone (P < 0.001). CONCLUSION: Relative to the vertebral body, the psoas demonstrated substantial lateral mobility when prone, and posterior retraction specifically at L5. IVC and right iliac vein experienced significant anterior mobility-particularly at more cephalad levels. Prone position enhanced segmental lordosis and may be critical to optimizing sagittal restoration.