Clinical Effectiveness of Anterior Cervical Discectomy and Fusion Using Tritanium C Anterior Cervical Cage vs. PEEK Cage.

Introduction: Anterior cervical discectomy and fusion (ACDF) has proven to be a clinically efficient and cost-effective method for treating patients with degenerative cervical spine conditions. New intervertebral implant products are being developed to improve fusion and stability while decreasing complications. This study assesses the effectiveness of Tritanium C (Tri-C) Anterior Cervical Cage (Stryker) in the treatment of degenerative disk disease (DDD) of the cervical spine compared with polyetheretherketone (PEEK) cages. Methods: A retrospective cohort analysis was conducted using data prospectively collected from two institutions. Patients who underwent ACDFs for DDD using either the Tri-C cage or PEEK cage were identified. The patients' demographics, comorbidities, operative variables, and baseline patient-reported outcomes (PROs) were collected. PROs included the Neck Disability Index (NDI) and numeric rating scale (NRS) for neck and arm pain. The primary outcomes included 3- and 12-month PROs as well as the rates of 90-day readmission, 90-day reoperation, and perioperative complication. The radiographic outcomes included rates of subsidence, cage movement, and successful fusion within 12 months. Multivariate linear regression models were run to identify variables predictive of 12-month PROs. Results: A total of 275 patients who underwent ACDF were included in this study and were divided into two groups: PEEK (n=213) and Tri-C (n=62). Both groups showed improvement in neck and arm pain and NDI postoperatively. When Tri-C and PEEK were compared, no significant differences were observed in the 3- or 12-month changes in neck or arm pain or NDI. Furthermore, there were no differences in the rates of 90-day readmission, 90-day reoperation, and perioperative complication. Regression analysis revealed that Tri-C vs. PEEK was not a significant predictor of any outcome. Conclusions: Our results indicate that the use of porous titanium Tri-C cage during ACDFs is an effective method for managing cervical DDD in terms of PROs, perioperative morbidity, and radiologic parameters. No significant difference was observed in any clinical outcome between patients undergoing ACDF using the Tri-C cage and those in whom the PEEK cage was used. Level of Evidence: III.

Revisiting the Posterior Approach for Cervical Radiculopathy Utilizing Endoscopic Techniques: A Favorable Short-Term Outcome and Cost Comparison With Anterior Cervical Discectomy and Fusion.

BACKGROUND: Cervical radiculopathy is a spine ailment frequently requiring surgical decompression via anterior cervical discectomy and fusion (ACDF) or posterior foraminotomy/discectomy. While endoscopic posterior foraminotomy/discectomy is gaining popularity, its financial impact remains understudied despite equivalent randomized long-term outcomes to ACDF. In a cohort of patients undergoing ACDF vs endoscopic posterior cervical foraminotomy/discectomy, we sought to compare the total cost of the surgical episode while confirming an equivalent safety profile and perioperative outcomes. METHODS: A single-center retrospective cohort study of patients with unilateral cervical radiculopathy undergoing ACDF or endoscopic cervical foraminotomy between 2018 and 2023 was undertaken. Primary outcomes included the total cost of care for the initial surgical episode (not charges or reimbursement). Perioperative variables and neurological recovery were recorded. Multivariable analysis tested age, body mass index, race, gender, insurance type, operative time, and length of stay. RESULTS: A total of 38 ACDF and 17 endoscopic foraminotomy/discectomy operations were performed. All patients underwent single-level surgery except for 2 two-level endoscopic decompressions. No differences were found in baseline characteristics and symptom length except for younger age (46.8 ± 9.4 vs 57.6 ± 10.3, P = 0.002) and more smokers (18.4% vs 11.8%, P = 0.043) in the ACDF group. Actual hospital costs for the episode of surgical care were markedly higher in the ACDF cohort (mean ±95% CI; $27,782 ± $2011 vs $10,103 ± $720, P < 0.001) driven by the ACDF approach (ß = $17,723, P < 0.001) on multivariable analysis. On sensitivity analysis, ACDF was never cost-efficient compared with endoscopic foraminotomy, and endoscopic failure rates of 64% were required for break-even cost. ACDF was associated with significantly longer operative time (167.7 ± 22.0 vs 142.7 ± 27.4 minutes, P < 0.001) and length of stay (1.1 ± 0.5 vs 0.1 ± 0.2 days, P < 0.001). No significant difference was found regarding 90-day neurological improvement, readmission, reoperation, or complications. CONCLUSION: Compared with patients treated with a single-level ACDF for unilateral cervical radiculopathy, endoscopic posterior cervical foraminotomy/discectomy can achieve a similar safety profile, pain relief, and neurological recovery at considerably less cost. These findings may help patients and surgeons revisit offering the posterior cervical foraminotomy/discectomy utilizing endoscopic techniques. CLINICAL RELEVANCE: Endoscopic posterior cervical foraminotomy/discectomy offers comparable safety, pain relief, and neurological recovery to traditional methods but at a significantly lower cost.

Factors Associated With Return to Work Following Laminoplasty for Degenerative Cervical Myelopathy.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To identify factors predictive of returning to work within 90 days of laminoplasty for degenerative cervical myelopathy (DCM). BACKGROUND: DCM is a debilitating condition resulting from spinal canal stenosis and spinal cord compression. One surgical option for cord decompression is cervical laminoplasty. Factors influencing return to work (RTW) postsurgery are unknown. METHODS: This study included adult patients previously employed, undergoing primary elective laminoplasty for DCM, and with documented RTW status. Variables included demographic information, medical history, illness characteristics, and baseline patient-reported outcomes. The primary outcome of interest was RTW status at 90 days. Statistical analyses were conducted to identify predictors. RESULTS: Forty-six patients (67.6%) returned to work within 90 days, whereas 22 (32.3%) either RTW between 90 and 365 days (n = 3) or did not RTW within 365 days (n = 19). Significantly more patients who RTW within 90 days worked full-time (90.9% vs 64.3%, P = 0.030). Patients who RTW within 90 days had significantly lower preoperative Neck Disability Index scores (23.7 ± 17.5 vs 35.6 ± 14.3, P = 0.008) and higher preoperative modified Japanese Orthopedic Association scores (13.7 ± 2.5 vs 12.2 ± 2.7, P = 0.018) compared with those who did not RTW. No differences were found in other baseline patient-reported outcomes. Patients who RTW within 90 days had significantly lower postoperative 3-month neck pain (2.0 ± 2.1 vs 3.8 ± 2.6, P = 0.007), 3-month arm pain (1.3 ± 1.9 vs 3.6 ± 2.8, P < 0.001), 12-month neck pain (1.4 ± 1.6 vs 3.1 ± 2.4, P = 0.019) and 12-month arm pain (1.1 ± 1.8 vs 2.4 ± 2.4, P = 0.048) compared with those who did not RTW within 90 days. Higher preoperative modified Japanese Orthopedic Association scores were significantly associated with truncated time to RTW (HR: 1.14, 95% CI: 1.01-1.29, P = 0.034). CONCLUSION: Patients with better preoperative neck and arm pain and functional scores were more likely to RTW within 90 days postlaminoplasty. Preoperative functional status plays an important role in assessing RTW postlaminoplasty. This information is valuable for preoperative patient counseling.

Open Versus Endoscopic Approach for Thoracic Disk Herniations: Equivalent Short-Term Outcomes With Significantly Different Costs.

BACKGROUND AND OBJECTIVES: Open thoracic diskectomy often requires significant bone resection and fusion, whereas an endoscopic thoracic diskectomy offers a less invasive alternative. Therefore, we sought to compare one-level open vs endoscopic thoracic diskectomy regarding (1) perioperative outcomes, (2) neurological recovery, and (3) total cost. METHODS: A single-center, retrospective, cohort study using prospectively collected data of patients undergoing one-level thoracic diskectomy was undertaken from 2018 to 2023. The primary exposure variable was open vs endoscopic. The primary outcome was perioperative outcomes and neurological recovery. Secondary outcomes were total cost of care. Multivariable regression analysis controlled for age, body mass index, sex, symptom onset, disk characteristics, operative time, and length of stay. RESULTS: Of 29 patients undergoing thoracic diskectomy, 17 were open and 12 were endoscopic. Preoperative demographics, symptoms, and radiographic findings were comparable between the cohorts. Perioperatively, open surgery had significantly higher mean length of stay (4.9 ± 1.5 vs 0.0 ± 0.0 days, P < .001), median (IQR) longer operative time (342.8 [68.4] vs 141.5 [36] minutes, P < .001), and more blood loss (350 [390] vs 6.5 [20] mL; P < .001). 16 (94%) open patients required fusion vs 0 endoscopic (P < .001). Postoperative opioid use (P = .119), readmission (P = .665), reoperation (P = .553), and rate of neurological improvement (P > .999) were similar between the 2 groups. Financially, open surgical median costs were 7x higher than endoscopic ($59 792 [$16 118] vs $8128 [$1848]; P < .001), driven by length of stay (ß = $2261/night, P < .001), open surgery (ß = $24 106, P < .001), and number of pedicle screws (ß = $1829/screw, P = .002) on multivariable analysis. On sensitivity analysis, open surgery was never cost-efficient against endoscopic surgery and excess endoscopic revision rates of 86% above open revision rates were required for break-even costs between the surgical approaches. CONCLUSION: Endoscopic thoracic diskectomy was associated with decreased length of stay, operative time, blood loss, and total cost compared with the open approach, with similar neurological outcomes. These findings may help patients and surgeons seek endoscopic approach as a less morbid and less costly alternative.

Syndromic surveillance of respiratory infections during protracted conflict: experiences from northern Syria 2016-2021.

OBJECTIVE: Northern Syria faces a large burden of influenza-like illness (ILI) and severe acute respiratory illness (SARI). This study aimed to investigate the trends of Early Warning and Response Network (EWARN) reported ILI and SARI in northern Syria between 2016 and 2021 and the potential impact of SARS-CoV-2. METHODS: We extracted weekly EWARN data on ILI/ SARI and aggregated cases and consultations into 4-week intervals to calculate case positivity. We conducted a seasonal-trend decomposition to assess case trends in the presence of seasonal fluctuations. RESULTS: It was observed that 4-week aggregates of ILI cases (n = 5,942,012), SARI cases (n = 114,939), ILI case positivity, and SARI case positivity exhibited seasonal fluctuations with peaks in the winter months. ILI and SARI cases in individuals aged ≥5 years surpassed those in individuals aged <5 years in late 2019. ILI cases clustered primarily in Aleppo and Idlib, whereas SARI cases clustered in Aleppo, Idlib, Deir Ezzor, and Hassakeh. SARI cases increased sharply in 2021, corresponding with a severe SARS-CoV-2 wave, compared with the steady increase in ILI cases over time. CONCLUSION: Respiratory infections cause widespread morbidity and mortality throughout northern Syria, particularly with the emergence of SARS-CoV-2. Strengthened surveillance and access to testing and treatment are critical to manage outbreaks among conflict-affected populations.

Paediatric anterior cruciate ligament injury.

The number of paediatric anterior cruciate ligament injuries is rising at a greater rate than in the adult population, as a result of the increased participation of children and adolescents in sports. This review explores the key presentations, diagnostic and management plans, and prevention methods associated with paediatric anterior cruciate ligament injuries. This injury presents as an acute pop and effusion, with limitations in gait, and can be extremely debilitating. Clinical examination and magnetic resonance imaging are used to diagnose the injury. The pivot shift and Lachman test remain the most valid exams when suspecting an anterior cruciate ligament tear. Management of the injury can be surgical or non-surgical depending on the severity of the tear and associated injuries. The surgical approach chosen is determined by the patient's Tanner classification, considering potential damage to the physes of the bone. Management plans should include rehabilitation consisting of strength, proprioception and neuromuscular training, to maximise the patient's recovery. Injury prevention programmes, consisting of strength training and neuromuscular training, should be followed by young athletes to reduce anterior cruciate ligament injuries. Compliance and earlier implementation coupled with an understanding of the biomechanics of anterior cruciate ligament injuries and verbal feedback maximise the benefit of neuromuscular training.

Blood loss and transfusion risk in robotic-assisted knee arthroplasty: A retrospective analysis.

BACKGROUND: The purpose of this study was to compare total blood loss and the risk of receiving a blood transfusion in robotic-assisted total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) against conventional jig-based techniques. METHODS: Robotic TKA (n = 50) and UKA (n = 50) patients were matched to contemporary controls for TKA (n = 50) and UKA (n = 50) and retrospectively analysed. RESULTS: Robotic TKA patients experienced 23.7% less blood loss compared to conventional TKA patients (911.0 ml vs 1193.7 ml, p < 0.01), and were associated with an 83% relative risk reduction of receiving a transfusion (2% of patients vs 12%, p = 0.02). Robotic UKA patients did not demonstrate less blood loss compared to corresponding controls (821.7 ml vs 854.7 ml, p = 0.69). Both UKA groups received no transfusions. CONCLUSIONS: Robotic surgical systems in TKA reduces blood loss and lowers the risk of requiring a blood transfusion. In UKA, robotic-assisted arthroplasty did not reduce blood loss compared to conventional arthroplasty.

Weaponizing water as an instrument of war in Syria: Impact on diarrhoeal disease in Idlib and Aleppo governorates, 2011-2019.

OBJECTIVES: Investigate the weaponization of water during the Syrian conflict and the correlation of attacks on water, sanitation, and hygiene (WASH) infrastructure in Idlib and Aleppo governorates with trends in waterborne diseases reported by Early Warning and Response surveillance systems. METHODS: We reviewed literature and databases to obtain information on attacks on WASH in Aleppo and Idlib governorates between 2011 and 2019. We plotted weekly trends in waterborne diseases from two surveillance systems operational in Aleppo and Idlib governorates between 2015 and early 2020. RESULTS: The literature review noted several attacks on water and related infrastructure in both governorates, suggesting that WASH infrastructure was weaponized by state and non-state actors. Most interference with WASH in the Aleppo governorate occurred before 2019 and in the Idlib governorate in the summer of 2020. Other acute diarrhea represented >90% of cases of diarrhea; children under 5 years contributed 50% of cases. There was substantial evidence (p < 0.001) of an overall upward trend in cases of diarrheal disease. CONCLUSIONS: Though no direct correlation can be drawn between the weaponization of WASH and the burden of waterborne infections due to multiple confounders, this research introduces important concepts on attacks on WASH and their potential impacts on waterborne diseases.

The unique invasiveness of glioblastoma and possible drug targets on extracellular matrix.

Glioblastoma, or glioblastoma multiforme (GBM), is described as one of the most invasive cancer types. Although GBM is a rare disease, with a global incidence of <10 per 100,000 people, its prognosis is extremely poor. Patient survival without treatment is ~6 months, which can be extended to around 15 months with the standard treatment protocol. Given the propensity of GBM cells to show widespread local invasion, beyond the margins seen through the best current imaging techniques, tumor margins cannot be clearly defined. Recurrence is inevitable, as the highly invasive nature of GBM means complete surgical resection of the tumor is near impossible without extensive damage to healthy surrounding brain tissue. Here, we outline GBM cell invasion in the unique environment of the brain extracellular matrix (ECM), as well as a deeper exploration of the specific mechanisms upregulated in GBMs to promote the characteristic highly invasive phenotype. Among these is the secretion of proteolytic enzymes for the destruction of the ECM, as well as discussion of a novel theory of amoeboid invasion, termed the "hydrodynamic mode of invasion". The vast heterogeneity of GBM means that there are significant redundancies in invasive pathways, which pose challenges to the development of new treatments. In the past few decades, only one major advancement has been made in GBM treatment, namely the discovery of temozolomide. Future research should look to elucidate novel strategies for the specific targeting of the invasive cells of the tumor, to reduce recurrence rates and improve patient overall survival.