Retrospective single-centre series of 1300 consecutive cases of outpatient cervical spine surgery: complications, hospital readmissions, and reoperations.

Background: Outpatient surgery is becoming more common and is more cost-effective than inpatient surgery. Nonetheless, many surgeons and health care administrators are still hesitant to accept outpatient surgery for cervical degenerative spinal disease (C-DSD). This study assesses the types and rates of complications, hospital admissions, and reoperations after outpatient surgery of C-DSD.Methods: Complications, hospital admissions within 90 days of surgery, and reoperations within one year of surgery were recorded retrospectively in 1300 outpatients undergoing microsurgical decompression for C-DSD at the Oslofjord Clinic from 2008 to 2017. The surgical procedures performed were anterior cervical decompression and fusion (ACDF) in 1083 patients and posterior cervical foraminotomy in 217 patients.Results: The surgical mortality rate was 0%. Sixteen major complications were recorded in 15/1300 (1.2%) patients. The complications were neurological deterioration in four patients, postoperative hematoma in two, dural lesions with cerebrospinal fluid leakage in one, deep surgical-site infection in one, persistent hoarseness in three, and persistent dysphagia in five. The two potentially life-threatening hematomas were detected within the planned six-hour observation period. Two (0.2%) patients were admitted to hospital within hours of surgery completion with stroke-like signs and symptoms, and four (0.3%) patients were admitted to hospital within 90 days due to surgery-related events. The rate of reoperations for cervical radiculopathy within 12 months was 25/1171 (2%); eight patients' reoperations were due to inadequate primary decompression, one was due to recurrent disc herniation at the same level and side, and 16 were due to new-onset radiculopathy from an adjacent level or other side.Conclusions: Outpatient microsurgical decompression of the degenerative cervical spine in carefully selected patients appears to be safe and carries a low major complication rate, low hospital admission rate, and low one-year reoperation rate.

The use of surgery for cervical degenerative disease in Norway in the period 2008-2014 : A population-based study of 6511 procedures.

BACKGROUND: The incidence rate of surgical treatment of cervical degenerative diseases (CDD) has increased in the USA and a large geographic variation has been shown. Little is known about such rates in Scandinavia and Europe. The aim of this population-based study was to (1) investigate annual incidence rates of operations performed in Norway, (2) to compare trends and variations in rates for surgical indications with and without myelopathy, and (3) to compare variations in the use of surgery between residential areas. METHODS: Patients operated for CDD and recorded in the Norwegian Patient Registry from 2008 to 2014 were evaluated according to residential areas (resident county and Regional Health Authority (RHA) area), age, gender, treating hospital, and whether myelopathy was present or not. Surgical rates were adjusted for age and gender. Data from private health care were also included. RESULTS: The annual surgical rates increased by 74.1 % from 2008 to 2014 (12.5/100,000 inhabitants). The largest increase was for surgical treatment of radiculopathy, 86.5 %. Surgical rates for CDD varied in 2014 with a ratio of 1.5 between the highest and lowest RHA and with a ratio of 2.5 between the different residential counties within one RHA. The treatment rates for myelopathy were relatively stable over time, but showed an increase of 2.1/100,000 (44.6 %) from 2013 to 2014. CONCLUSIONS: Our study shows that the rate of surgical treatment for radiculopathy due to CDD has increased substantially from 2008 to 2014 for all RHAs in Norway. The incidence rate for surgical treatment of myelopathy was more stable. An unexplained and moderate geographic variation was found.

Complications and long-term outcomes after open surgery for traumatic subaxial cervical spine fractures: a consecutive series of 303 patients.

BACKGROUND: Patient selection for surgical treatment of subaxial cervical spine fractures (S-CS-fx) may be challenging and is dependent on fracture morphology, the integrity of the discoligamentous complex, neurological status, comorbidity, risks of surgery and the expected long-term outcomes. The purpose of this study is to evaluate complications and long-term outcomes in a consecutive series of 303 patients with S-CS-fx treated with open surgical fixation. METHODS: Medical charts were retrospectively reviewed. The surviving patients participated in a prospective long-term follow-up, including clinical history, physical examination and updated cervical CT. Patients with ankylosing spondylitis were excluded from this study. RESULTS: The median patient age was 48 years (range 14.7-93.9), and 74 % were males. Preoperatively, 43 % had spinal cord injury (SCI), and 27 % exhibited isolated radiculopathy. The median time from injury to surgery was 2 days (range 0-136). The risks of SCI deterioration and new-onset radiculopathy after surgery were 2.0 % and 1.3 %, respectively. Surgical mortality (death within 30 days after surgery) was 2.3 %. The reoperation rate was 7.3 %. At the long-term follow-up conducted a median of 2.6 years after trauma (range 0.5-9.1), 256 (99.2 %) of the patients who had survived and were living in Norway participated. Of the patients with American Injury Severity Scale (AIS) A-D at presentation, 51 % had improved one or more AIS grades. At the time of follow-up, 89 % of the patients with preoperative radiculopathy were without symptoms. Furthermore, 11 % of the patients reported severe neck stiffness, 5 % reported severe neck pain (Visual Analog Scale (VAS) ≥7), 6 % reported hoarseness, and 9 % reported dysphagia at the follow-up. The stable fusion rate, as evaluated using cervical-CT, was 98 %. CONCLUSIONS: In this large consecutive series of patients with S-CS-fx treated with open surgical fixation, the surgical mortality was 2.3 %, the risk of neurological deterioration was 3.3 % and the reoperation rate (any cause) was 7.3 %. The neurological long-term results were good, with 51 % improvement in AIS grade and resolution of radiculopathy in 89 % of the patients. Stable fusion was excellent and was achieved in 98 % of the follow-up group.

Minimally invasive microsurgical resection of primary, intradural spinal tumours using a tubular retraction system.

STUDY DESIGN: This is a retrospective review of prospectively collected data. BACKGROUND: Primary, intradural spinal tumours have traditionally been microsurgically resected following macrosurgical laminectomy or laminoplasty. We hypothesize that approach-related morbidity can be reduced with less-invasive approaches; we have therefore implemented a minimally invasive approach, with the assistance of a tubular retraction system, for microsurgical resection of primary intradural spinal tumours. METHODS: From January 2007 to December 2009, 54 patients underwent surgery for a spinal intradural tumour. Of these, nine patients who underwent minimally invasive posterior unilateral transmuscular surgery using a tubular retraction system were included in this study. Resection grade and surgery-related complications were retrospectively reviewed. RESULTS: All tumours were totally resected (verified by postoperative magnetic resonance imaging). There were no post-operative complications. Eight of the nine patients were mobilized on the day of surgery or on post-operative day 1. One patient was mobilized on post-operative day 2. CONCLUSIONS: Selected primary, intradural spinal tumours can be safely and successfully resected using a minimally invasive posterior unilateral transmuscular approach with the assistance of a tubular retraction system.

Anterior cervical discectomy with fusion in patients with cervical disc degeneration: a prospective outcome study of 258 patients (181 fused with autologous bone graft and 77 fused with a PEEK cage).

BACKGROUND: Anterior cervical discectomy with fusion (ACDF) is challenging with respect to both patient selection and choice of surgical procedure. The aim of this study was to evaluate the clinical outcome of ACDF, with respect to both patient selection and choice of surgical procedure: fusion with an autologous iliac crest graft (AICG) versus fusion with an artificial cage made of polyetheretherketone (PEEK). METHODS: This was a non-randomized prospective single-center outcome study of 258 patients who underwent ACDF for cervical disc degeneration (CDD). Fusion was attained with either tricortical AICG or PEEK cages without additional anterior plating, with treatment selected at surgeon's discretion. Radicular pain, neck-pain, headache and patient satisfaction with the treatment were scored using the visual analogue scale (VAS). RESULTS: The median age was 47.5 (28.3-82.8) years, and 44% of patients were female. 59% had single-level ACDF, 40% had two level ACDF and 1% had three-level ACDF. Of the patients, 181 were fused with AICG and 77 with a PEEK-cage. After surgery, the patients showed a significant reduction in radicular pain (DeltaVAS = 3.05), neck pain (DeltaVAS = 2.30) and headache (DeltaVAS = 0.55). Six months after surgery, 48% of patients had returned to work: however 24% were still receiving workers' compensation.Using univariate and multivariate analyses we found that high preoperative pain intensity was significantly associated with a decrease in pain intensity after surgery, for all three pain categories. There were no significant correlations between pain relief and the following patient characteristics: fusion method (AICG or PEEK-cage), sex, age, number of levels fused, disc level fused, previous neck surgery (except for neck pain), previous neck trauma, or preoperative symptom duration. Two hundred out of the 256 (78%) patients evaluated the surgical result as successful. Only 27/256 (11%) classified the surgical result as a failure. Patient satisfaction was significantly associated with pain relief after surgery. CONCLUSIONS: ACDF is an effective treatment for radicular pain in selected patients with CDD after six months follow up. Because of similar clinical outcomes and lack of donor site morbidity when using PEEK, we now prefer fusion with PEEK cage to AICG. Lengthy symptom duration was not a negative prognostic marker in our patient population. The number of patients who returned to work 6 months after surgery was lower than expected.

Minimally Invasive Microsurgical Resection of Primary, Intradural Spinal Tumors is Feasible and Safe: A Consecutive Series of 83 Patients.

BACKGROUND: To date, the traditional approach to intraspinal tumors has been open laminectomy or laminoplasty followed by microsurgical tumor resection. Recently, however, minimally invasive approaches have been attempted by some. OBJECTIVE: To investigate the feasibility and safety of minimally invasive surgery (MIS) for primary intradural spinal tumors. METHODS: Medical charts of 83 consecutive patients treated with MIS for intradural spinal tumors were reviewed. Patients were followed up during the study year, 2015, by either routine history/physical examination or by telephone consultation, with a focus on tumor status and surgery-related complications. RESULTS: Mean age at surgery was 53.7 yr and 52% were female. There were 49 schwannomas, 18 meningeomas, 10 ependymomas, 2 hemangioblastomas, 1 neurofibroma, 1 paraganglioma, 1 epidermoid cyst, and 1 hemangiopericytoma. The surgical mortality was 0%. In 87% of cases, gross total resection was achieved. The complication rate was 11%, including 2 cerebrospinal fluid leakages, 1 asymptomatic pseudomeningocele, 2 superficial surgical site infections, 1 sinus vein thrombosis, and 4 cases of neurological deterioration. There were no postoperative hematomas, and no cases of deep vein thrombosis or pulmonary embolism. Ninety-three percent of patients were ambulatory and able to work at the time of follow-up. CONCLUSION: This study both demonstrates that it is feasible and safe to remove select, primary intradural spinal tumors using MIS, and augments the previous literature in favor of MIS for these tumors.

[Chronic whiplash syndrome is no indication for craniocervical fixation]. / Kronisk nakkeslengsyndrom er ingen indikasjon for kraniocervikal fiksasjon.

Throughout many years, a large number of publications have focused on structural changes in soft tissues in the cervical spine in patients with whiplash associated disorders I-II. In recent years the development in MRI techniques have made it possible to visualize the small ligaments in the craniocervical junction; a small number of publications have investigated the association between signal changes in these ligaments and whiplash associated disorders I-II. The results are, however, not conclusive, and no prospective studies have demonstrated any causal connection between type of whiplash injury and signal changes in these ligaments. Craniocervical fixation is major surgery with a moderate level of perioperative complications. There is also a theoretical risk of increasing the degenerative process in the level below the fixation. The indications for craniocervical fixation are now serious conditions like instability caused by rheumatic arthritis, tumours and fractures. The scientific evidence for introducing a new indication for craniocervical fixation is lacking, and craniocervical fixation in WAD I-II must be considered experimental surgery.

Outpatient Cervical and Lumbar Spine Surgery is Feasible and Safe: A Consecutive Single Center Series of 1449 Patients.

BACKGROUND: There is an increasing demand for surgery of degenerative spinal disease. Limited healthcare resources draw attention to the need for cost-effective treatments. Outpatient surgery, when safe and feasible, is more cost effective than inpatient surgery. OBJECTIVE: To study types and rates of complications after outpatient lumbar and cervical spine decompressions. METHODS: Complications were recorded prospectively in 1449 (1073 lumbar, 376 cervical) outpatients undergoing microsurgical decompression for degenerative spinal disease at the private Oslofjord Clinic from 2008 to 2013. RESULTS: Surgical mortality was 0%. A total of 51 (3.5%) minor and major complications were recorded in 51 patients. Three (0.2%) patients had to be admitted to a hospital the day of surgery. Twenty-two (1.5%) patients were admitted to a hospital within 3 months due to surgery-related events. The encountered complications were postoperative hematoma (0.6%), neurological deterioration (0.3%), deep wound infection (0.9%), dural lesions with cerebrospinal fluid leakage (1.0%), persistent dysphagia (0.1%), persistent hoarseness (0.1%), and severe pain/headache (0.4%). All of the life-threatening hematomas were detected within 6 and 3 hours after cervical and lumbar surgery, respectively. CONCLUSION: This series of 1449 consecutive outpatient microsurgical spine decompressions adds to the growing literature in favor of outpatient spinal surgery in properly selected patients. In our study, 99.8% of the patients were successfully discharged either to their homes or to a hotel on the day of surgery. The overall complication rate was 3.5%, surgical mortality was 0%, and only 1.5% had to be admitted to a hospital within 3 months after surgery.

The Long-term Outcome After Resection of Intraspinal Nerve Sheath Tumors: Report of 131 Consecutive Cases.

BACKGROUND: The existing literature on recurrence rates and long-term clinical outcome after resection of intraspinal nerve sheath tumors is limited. OBJECTIVE: To evaluate progression-free survival, overall survival, and long-term clinical outcome in a consecutive series of 131 patients with symptomatic intraspinal nerve sheath tumors. METHODS: Medical charts were retrospectively reviewed. Surviving patients voluntarily participated in a clinical history and physical examination that focused on neurological function and current tumor status. RESULTS: Follow-up data are 100% complete; median follow-up time was 6.1 years. All patients (100%) had surgery as the first line of treatment; gross total resection was performed in 112 patients (85.5%) and subtotal resection in 19 patients (14.5%). Five-year progression-free survival was 89%. The following risk factors for recurrence were identified: neurofibroma, malignant peripheral nerve sheath tumor, subtotal resection, neurofibromatoses/schwannomatosis, and advancing age at diagnosis. More than 95% of patients had neurological function compatible with an independent life at follow-up. The rate of tumor recurrence in nonneurofibromatosis patients undergoing total resection of a single schwannoma was 3% (3/93), in comparison with a recurrence rate of 32% (12/38) in the remaining patients. CONCLUSION: Gross total resection is the gold standard treatment for patients with intraspinal nerve sheath tumors. In a time of limited health care resources, we recommend that follow-up be focused on the subgroup of patients with a high risk of recurrence. The benefit of long-term, yearly magnetic resonance imaging follow-up with respect to recurrence in nonneurofibromatosis patients undergoing gross total resection of a single schwannoma is, in our opinion, questionable. 1NF2, neurofibromatosis 2NST, nerve sheath tumorOS, overall survivalPFS, progression-free survivalSTR, subtotal resectionWHO, World Health Organization.

Incidence of traumatic cervical spine fractures in the Norwegian population: a national registry study.

BACKGROUND: The incidence of cervical spine fractures (CS-fx) in the general population is sparingly assessed. The aim of the current study was to estimate the incidence of traumatic CS-fx and of open surgery of cervical spine injuries in the Norwegian population. METHODS: The Norwegian Patient Register (NPR) is an administrative database that contains activity data from all Norwegian government-owned hospitals and outpatient clinics. The diagnoses and procedures are coded according to the International Statistical Classification of Diseases and Related Health Problems (ICD-10) and the NOMESCO Classification of Surgical Procedures (NCSP), respectively. We retrieved information on all severe traumatic cervical spine injuries between 2009 and 2012 from the NPR. Updated information on the date of death is included through routine linkage to the General Register Office. RESULTS: Between 2009 and 2012, a total of 3 248 patients met our criteria for severe traumatic cervical spine injury. A total of 2 963 patients had one or more CS-fx, and 285 had severe non-fracture cervical spine injuries. The median age was 54 years, and 69% of the patients were male. The incidence of CS-fx and severe non-fracture injuries in the total Norwegian population was 16.5/100 000/year, and the incidence of CS-fx was 15.0/100 000/year. A total of 18% of the patients were treated with open surgery, resulting in an estimated incidence of surgery for acute traumatic cervical spine injury of 3.0/100 000/ year in the Norwegian population. The 1- and 3-month mortality rates were 4% and 6%, respectively.

The epidemiology of traumatic cervical spine fractures: a prospective population study from Norway.

AIM: The aim of this study was to estimate the incidence of traumatic cervical spine fractures (CS-fx) in a general population. BACKGROUND: The incidence of CS-fx in the general population is largely unknown. METHODS: All CS-fx (C0/C1 to C7/Th1) patients diagnosed with cervical-CT in Southeast Norway (2.7 million inhabitants) during the time period from April 27, 2010-April 26, 2011 were prospectively registered in this observational cohort study. RESULTS: Over a one-year period, 319 patients with CS-fx at one or more levels were registered, constituting an estimated incidence of 11.8/100,000/year. The median age of the patients was 56 years (range 4-101 years), and 68% were males. The relative incidence of CS-fx increased significantly with age. The trauma mechanisms were falls in 60%, motorized vehicle accidents in 21%, bicycling in 8%, diving in 4% and others in 7% of patients. Neurological status was normal in 79%, 5% had a radiculopathy, 8% had an incomplete spinal cord injury (SCI), 2% had a complete SCI, and neurological function could not be determined in 6%. The mortality rates after 1 and 3 months were 7 and 9%, respectively. Among 319 patients, 26.6% were treated with open surgery, 68.7% were treated with external immobilization with a stiff collar and 4.7% were considered stable and not in need of any specific treatment. The estimated incidence of surgically treated CS-fx in our population was 3.1/100,000/year. CONCLUSIONS: This study estimates the incidence of traumatic CS-fx in a general Norwegian population to be 11.8/100,000/year. A male predominance was observed and the incidence increased with increasing age. Falls were the most common trauma mechanism, and SCI was observed in 10%. The 1- and 3-month mortality rates were 7 and 9%, respectively. The incidence of open surgery for the fixation of CS-fx in this population was 3.1/100,000/year. LEVEL OF EVIDENCE: This is a prospective observational cohort study and level II-2 according to US Preventive Services Task Force.

Surgical management of acute odontoid fractures: surgery-related complications and long-term outcomes in a consecutive series of 97 patients.

BACKGROUND: The purpose of this study was to determine the incidence of surgery for odontoid fractures and to study surgical mortality, surgical morbidity, and long-term outcome in a large, contemporary, consecutive, single-institution, surgical series of odontoid fractures. METHODS: This is a retrospective study of all odontoid fractures treated by open surgery at our hospital during 2002 to 2009. The fractures were classified according to Grauer. Follow-up data, clinical examinations, and cervical computed tomographies were collected in 2010. RESULTS: This study included 97 consecutive patients with a median age of 73.0 years. The incidence of open fixation of odontoid fractures in this population was 0.45 per 100,000, and the incidence increased with age. The fractures were classified as type IIA in 3 patients, type IIB in 63 patients, type IIC in 8 patients, and type III in 23 patients. Anterior fixation and posterior fixation were performed in 41 and 56 patients, respectively. Immediate postoperative neurologic status was unchanged or improved in 97% of the patients. None of the patients developed postoperative hematoma, wound infection, deep venous thrombosis, or pulmonary embolism. Eleven patients underwent resurgery during the follow-up period; five had suboptimal reposition after the first surgery, one had suboptimal position of an anterior odontoid screw, two had rupture of fixation materials, and three developed pseudarthrosis. Overall survival (OS) rates after 1, 12, and 24 months were 96%, 84%, and 75%, respectively. Fifty-seven patients were available for follow-up evaluation with a mean time of 37 months. Radiologic follow-up showed definite bony fusion in 82% of the patients and uncertain bony fusion in 18% of the patients. Flexion-extension radiographs were obtained in 6 of the 10 patients with uncertain bony fusion; 5 of these were defined as stable (fibrous union) and 1 was unstable. Multivariate logistic regression demonstrated increased odds of nonbony fusion in more displaced fractures (OR, 1.44; 95% CI, 1.04-2.16; p = 0.04) and when using the anterior fusion technique (OR, 0.17; 95% CI, 0.03-0.75; p = 0.02). There was no significant association between neck pain and fusion method (Mann-Whitney U test, p = 0.86). Patients treated with a posterior fusion approach had significantly more neck stiffness than patients who underwent fusion with an anterior odontoid screw (Fisher's exact test, p = 0.04). CONCLUSIONS: The annual incidence of open fixation of odontoid fractures was 0.45 per 100,000 inhabitants, and the incidence increased with age. The median age at time of surgery was 73.0 years, and the surgical mortality was 4%. Increased odds of nonbony fusion were observed in more displaced fractures and after anterior screw fixations. There were no significant differences between patients treated with anterior screw fixation versus posterior wiring with respect to neck pain, but patients fused with a posterior approach reported significantly more neck stiffness.

Long-term outcome after resection of intraspinal ependymomas: report of 86 consecutive cases.

OBJECTIVE: To evaluate progression-free survival, overall survival (OS) and long-term clinical outcome in a consecutive series of 86 patients with intraspinal ependymomas. METHODS: Medical charts were retrospectively reviewed. Surviving patients voluntarily participated in a clinical history and physical examination that focused on neurological function and current tumor status. RESULTS: Follow-up data are nearly 100% complete; mean follow-up time was 82 months. Eighty-five patients (99%) had surgery as a first-line treatment; 14 (17%) of these patients received adjuvant radiotherapy. Of the 85 patients who underwent primary surgery, gross total resection was performed in 60 patients (71%) and subtotal resection in 25 patients (29%). Ten-year progression-free survival rate was 75%; 5-year OS, 97%; and 10-year OS, 91%. Reduced preoperative neurological function and older age at diagnosis were significantly associated with increased risk of death. At follow-up, spontaneous regression of residual tumor after primary surgery may have occurred in 7 of 19 patients (37%). More than 75% of patients had neurological function compatible with an independent life at follow-up. Good preoperative neurological function was significantly associated with favorable outcome. It was not possible to evaluate the effect of radiotherapy on progression-free survival and OS. CONCLUSION: Gross total resection remains the optimal treatment for patients with spinal ependymoma. Patients should be monitored with a clinical examination and magnetic resonance imaging at regular intervals up to 10 years after surgery.