Multi- versus single-level anterior cervical discectomy and fusion: comparing sagittal alignment, early adjacent segment degeneration, and clinical outcomes.

PURPOSE: The purpose of this study was to compare the rates of adjacent segment degeneration (ASD), sagittal alignment parameters, and patient-reported outcomes in patients who underwent multi-level versus single-level anterior cervical discectomy and fusion (ACDF). METHODS: A retrospective cohort analysis was performed on consecutive patients who underwent an ACDF. Pre- and post-operative radiographic assessment included ASD, change in C2-C7 lordosis, T1 angle, levels fused, sagittal vertical axis (SVA), fusion mass lordosis, proximal and distal adjacent segment lordosis. Patient-reported outcomes were obtained. RESULTS: Of the 404 that underwent an ACDF with a minimum of 6 months of follow-up (average 28 months), there was no significant difference in the rate of radiographic ASD overall (p = 0.479) or in the proximal or distal adjacent segments on multivariate analysis. Secondarily, the multi-level fusions appear to restore significantly greater amounts of lordosis compared to single-level procedures (p < 0.001) and are able to maintain the corrected cervical lordosis and fusion segment lordosis over time. From the immediate post-operative period to final follow-up, the single-level ACDFs show continuing lordosis improvement (p = 0.005) that is significantly greater than that of the multi-level constructs. There were no significant differences between pre-operative, post-operative, or change in patient-reported outcomes. CONCLUSIONS: Two years following an ACDF, patients who underwent multi-level fusions appear to restore significantly greater amounts of lordosis compared to single-level procedures, while single-level ACDFs show significantly greater amounts of lordosis improvement over time. Multi-level procedures may not be at a significantly greater risk of developing early radiographic evidence of ASD compared to single-level procedure. These slides can be retrieved under Electronic Supplementary Material.

Protect the neck: Devastating outcomes of cervical spine fractures in the elderly.

BACKGROUND: Cervical spine fractures are associated with high mortality in elderly patients. This study aims to identify patient-related and in-hospital factors contributing to this mortality. METHODS: A 3-year retrospective study of 235 patients aged 65+ presenting with cervical spine fractures was performed. Age cohorts were 65-74, 75-84, and 85+ years. Mortality was measured at 30, 90, 180 and 365-days post-discharge. RESULTS: Mortality was 11 â€‹%, 15 â€‹%, 19 â€‹%, and 22 â€‹% at 30-, 90-, 180- and 365-days respectively. Surgery and fracture pattern was not associated with mortality (p â€‹= â€‹0.37; p â€‹= â€‹0.28). Charlson Comorbidity Index (p â€‹< â€‹0.001; hazard ratio [HR] â€‹= â€‹1.3), functional dependency (p â€‹< â€‹0.001; HR â€‹= â€‹2.5) and delirium (p â€‹< â€‹0.001; HR â€‹= â€‹8.9) were associated with mortality between 0 and 365 days post-discharge. CONCLUSIONS: Mortality in cervical spine fractures is associated with CCI and delirium, but not associated with operative management or fracture pattern. This suggests the need for careful consideration in patient selection for cervical spine procedures and aggressive inpatient delirium management.

The Effect of COVID-19 on Rib Fracture Patients in Michigan.

This study aims to compare outcomes of rib fracture patients with and without COVID-19 in Michigan. Data from the Michigan Trauma Quality Improvement Program (MTQIP) identified adults hospitalized from January 1, 2020, to October 31, 2022, with at least one rib fracture and a completed COVID-19 test on admission. Patients were propensity score matched 1:1 using 20 variables. The primary outcome was hospital length of stay (LOS). Secondary outcomes were mortality, ventilator days, intensive care unit (ICU) LOS, pneumonia, and ventilator-assisted pneumonia (VAP). 13,305 total patients were identified. 232 patients matched into both the COVID+ and COVID- groups. COVID was associated with increased LOS (7 days vs. 5 days, P < 0.001). There were no significant differences between the two groups when evaluating secondary outcomes. Our study indicates that although COVID-19 infection is associated with increased LOS, COVID may not contribute to additional morbidity or mortality in traumatic rib fracture patients.

Risk Factors Associated With Development of Urinary Retention Following Posterior Lumbar Spinal Fusion: Special Attention to the Use of Glycopyrrolate in Anesthesia Reversal.

STUDY DESIGN: The study is designed as a retrospective cohort study. OBJECTIVE: The aim of this study was to identify modifiable and nonmodifiable risk factors of postoperative urinary retention in spine surgery patients. SUMMARY OF BACKGROUND DATA: Postoperative urinary retention is a common complication in patients undergoing operative procedures requiring anesthesia. Current studies have shown significant risk factors for postoperative urinary retention, but most are nonmodifiable and subsequently of limited usefulness in preventing this complication. Several new studies have shown possible modifiable risk factors, but current data are inconsistent in terms of their statistical significance. METHODS: A total of 814 consecutive patients who underwent open posterior lumbar laminectomy and fusion were included in the retrospective cohort study. Pre, intra-, and postoperative characteristics were collected in all patients to identify risk factors for postoperative urinary retention. RESULTS: Glycopyrrolate use (odds ratio [OR] 2.60; P = 0.001), decreased body mass index (OR 0.96; P = 0.018), previous diagnosis of benign prostate hyperplasia (OR 3.34; P ≤ 0.001), and postoperative urinary tract infection (OR 5.60, P = 0.005) were associated with postoperative urinary retention. Previous history of lumbar spine surgery (OR 0.55; P = 0.019) was associated with decreased rates of postoperative urinary retention. CONCLUSION: Glycopyrrolate use, benign prostate hyperplasia, and postoperative urinary tract infection were independent risk factors for postoperative urinary retention. The use of glycopyrrolate is a potentially modifiable risk factor for postoperative urinary retention.Level of Evidence: 3.

Obesity does not impact clinical outcome but affects cervical sagittal alignment and adjacent segment degeneration in short term follow-up after an anterior cervical decompression and fusion.

BACKGROUND CONTEXT: Obesity increases complications and cost following spine surgery. However, the impact on sagittal alignment and adjacent segment degeneration (ASD) after anterior cervical decompression and fusion is less understood. PURPOSE: To compare clinical and radiographic outcomes after anterior cervical decompression and fusion between obese and nonobese patients. STUDY DESIGN: Retrospective cohort study. PATIENT SAMPLE: In all, 467 patients that underwent an anterior cervical decompression and fusion procedure from January 2008 through December 2015 were assessed. Surgery indications were radiculopathy, myelopathy, or myeloradiculopathy that had failed nonoperative treatments. Exclusion criteria included patients who had postoperative follow-up less than 6 months. Of 467 patients originally identified, 399 fulfilled the inclusion and exclusion criteria. OUTCOME MEASURES: The following patient-reported outcomes were obtained: Neck Disability Index and Visual Analog Scale scores for the neck and arm pain. Radiographic assessments included: C2-C7 lordosis, T1 angle, levels fused, sagittal vertical axis (SVA), fusion mass lordosis, proximal and distal adjacent segment lordosis, ASD, and presence of fusion. METHODS: Plain radiographs were performed preoperatively, immediately postoperatively, and final follow-up. Demographic information was collected on all patients. Baseline patient characteristics were compared using chi-squared analysis and independent sample t tests for categorical and continuous data, respectively. For analysis, patients were divided into 4 groups based on obesity stratification as defined by Center for Disease Control: body mass index (BMI) <25 kg/m2 (normal weight), BMI≥25 kg/m2 to <30 kg/m2 (overweight), ≥30 kg/m2 to <35 kg/m2 (Class I obesity), BMI≥35 kg/m2 to <40 kg/m2 (Class II obesity), and BMI≥40 kg/m2 (Class III obesity). Additionally, obese (≥30 kg/m2) and nonobese (<30 kg/m2) patients were compared in a separate analysis. Multivariate analysis was used to compare clinical and radiographic outcomes among all BMI classes, as well as between BMI≥30 kg/m2 versus BMI<30 kg/m2 study groups. Multivariate analyses controlled for differences in baseline patient characteristics and included age, sex, smoking, American Society of Anesthesiologists Physical Status Score, diabetes mellitus, and number of levels. RESULTS: Of the 399 patients assessed, 97 were identified as normal weight, 157 as overweight, 81 with Class I obesity, 45 with Class II obesity, and 19 with Class III obesity. On multivariate analysis, despite having similar SVA measurements on preoperative radiographs, increase in BMI was associated with increase in postoperative SVA (p=0.041) along with significantly larger SVA in immediate postoperative (p=0.004) and final follow-up radiographs (p=0.003) for patients with BMI≥30 kg/m2 versus BMI<30 kg/m2. Furthermore, patients with BMI≥30 kg/m2 had smaller preoperative (p=0.012), immediate postoperative (p=0.017), and final lordosis (p<0.001) in addition to smaller immediate postoperative (p=0.025) and final fusion segment lordosis (p=0.015) and smaller preoperative (p=0.024) and final distal lordosis (p=0.021) compared with patients with BMI<30 kg/m2. Additionally, greater BMI was associated with lower final Visual Analog Scale neck scores (p=0.008). Radiographic early ASD rates were higher in patients BMI≥30 kg/m2 versus BMI<30 kg/m2 (p=0.028). CONCLUSIONS: Overall, obese patients who underwent anterior cervical decompression and fusion had similar patient-reported outcomes compared with nonobese patients but had worse radiographic parameters and higher rates of ASD development compared with nonobese patients. This underscores the importance of patient selection and surgical approach for both patient populations.

Does the Duration of Cervical Radicular Symptoms Impact Outcomes After Anterior Cervical Discectomy and Fusion?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To compare clinical outcomes after anterior cervical discectomy and fusion (ACDF) based on preoperative duration of radiculopathy symptoms. SUMMARY OF BACKGROUND DATA: There is no clear indication of when outcomes after ACDF become less effective in the setting of acute versus chronic symptoms from cervical nerve root compression. MATERIALS AND METHODS: A retrospective cohort study of consecutive patients who underwent an ACDF between 2008 and 2015 for radiculopathy was performed. Patients were divided into 3 groups: radicular symptoms lasting for <6 months, symptoms lasting for 6-12 months, and those with symptoms for ≥12 months. Neck Disability Index (NDI) and Visual Analog Scale (VAS) scores for both the neck and arms were obtained at preoperative and final postoperative visits. Radiographs were assessed for adjacent segment degeneration, fusion, and subsidence. Bivariate and multivariate regressions were subsequently used to compare outcomes between groups. RESULTS: A total of 379 patients were included. Patients with symptoms lasting for 6-12 months and those with symptoms lasting for ≥12 months had worse preoperative VAS neck pain compared with patients with symptoms lasting for < 6 months (P=0.000 and P=0.004, respectively). Patients with symptoms lasting for ≥12 months had worse baseline functional status compared with patients with symptoms lasting for <6 months (P=0.009). At final follow-up, there were no significant differences in VAS neck, VAS arm, or NDI between symptom duration groups. However, differences in outcomes were noted when considering the type of preoperative symptom. Patients with pain symptoms of ≥12 months had worse preoperative VAS neck (P=0.001), VAS arm (P=0.008), and NDI (P<0.001) and had significantly worse final VAS arm (P=0.019) and NDI (P=0.016) compared with patients with preoperative pain symptoms lasting for <6 months. The overall reoperation rate was 4.5%. Fusion was achieved in 97.6% of the patients, and subsidence was observed in 5.5%. There were no significant differences in the risk of adjacent segment degeneration, reoperations, fusion rates, or subsidence rates based on preoperative symptom duration. CONCLUSIONS: Despite worse preoperative neck pain and functional status in patients with preoperative duration of symptoms >6 months, there were no differences in final clinical outcomes across groups.