Comparing posterior cervical foraminotomy with anterior cervical discectomy and fusion in radiculopathic patients: an analysis from the Quality Outcomes Database.

OBJECTIVE: The objective of this study was to compare clinical and patient-reported outcomes (PROs) between posterior foraminotomy and anterior cervical discectomy and fusion (ACDF) in patients presenting with cervical radiculopathy. METHODS: The Quality Outcomes Database was queried for patients who had undergone ACDF or posterior foraminotomy for radiculopathy. To create two highly homogeneous groups, optimal individual matching was performed at a 5:1 ratio between the two groups on 29 baseline variables (including demographic characteristics, comorbidities, symptoms, patient-reported scores, underlying pathologies, and levels treated). Outcomes of interest were length of stay, reoperations, patient-reported satisfaction, increase in EQ-5D score, and decrease in Neck Disability Index (NDI) scores for arm and neck pain as long as 1 year after surgery. Noninferiority analysis of achieving patient satisfaction and minimal clinically important difference (MCID) in PROs was performed with an accepted risk difference of 5%. RESULTS: A total of 7805 eligible patients were identified: 216 of these underwent posterior foraminotomy and were matched to 1080 patients who underwent ACDF. The patients who underwent ACDF had more underlying pathologies, lower EQ-5D scores, and higher NDI and neck pain scores at baseline. Posterior foraminotomy was associated with shorter hospitalization (0.5 vs 0.9 days, p < 0.001). Reoperations within 12 months were significantly more common among the posterior foraminotomy group (4.2% vs 1.9%, p = 0.04). The two groups performed similarly in PROs, with posterior foraminotomy being noninferior to ACDF in achieving MCID in EQ-5D and neck pain scores but also having lower rates of maximal satisfaction at 12 months (North American Spine Society score of 1 achieved by 65.2% posterior foraminotomy patients vs 74.6% of ACDF patients, p = 0.02). CONCLUSIONS: The two procedures were found to be offered to different populations, with ACDF being selected for patients with more complicated pathologies and symptoms. After individual matching, posterior foraminotomy was associated with a higher reoperation risk within 1 year after surgery compared to ACDF (4.2% vs 1.9%). In terms of 12-month PROs, posterior foraminotomy was noninferior to ACDF in improving quality of life and neck pain. The two procedures also performed similarly in improving NDI scores and arm pain, but ACDF patients had higher maximal satisfaction rates.

Expandable cages that expand both height and lordosis provide improved immediate effect on sagittal alignment and short-term clinical outcomes following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

Background: Failure to restore lordotic alignment is not an uncommon problem following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF), even with expandable cages that increase disc height. This study aims to investigate the effect of the expandable cage that is specifically designed to expand both height and lordosis. We evaluated the outcomes of MIS TLIF in restoring immediate postoperative sagittal alignment by comparing two different types of expandable cages. One cage is designed to solely increase disc height (Group H), while the other can expand both height and lordosis (Group HL). Methods: Patients undergoing MIS TLIF using expandable cages were retrospectively reviewed, including 40 cases in Group H and 109 cases in Group HL. Visual analog scores of back and leg pain, and Oswestry disability index were collected. Disc height, disc angle, and sagittal alignment were measured. Complications were recorded, including early subsidence which was evaluated with computed tomography. Results: Clinical and radiographic outcomes significantly improved in both groups postoperatively. Group HL showed superior improvement in segmental lordosis (4.4°±3.5° vs. 2.1°±4.8°, P=0.01) and disc angle (6.3°±3.8 vs. 2.2°±4.3°, P<0.001) compared to Group H. Overall incidence of early subsidence was 23.3%, predominantly observed during initial cases as part of the learning curve, but decreased to 18% after completion of the first 20 cases. Conclusions: Expandable cages with a design specifically aimed at increasing lordotic angle can provide favorable outcomes and effectively improve immediate sagittal alignment following MIS TLIF, compared to conventional cages that only increase in height. However, regardless of the type of expandable cage used, it is crucial to avoid applying excessive force to achieve greater disc height or lordosis, as this may contribute to subsidence and a possible reduction in lordotic alignment restoration. Long-term results are needed to evaluate the clinical outcome, fusion rate, and maintenance of the sagittal alignment.

Cervical spondylotic myelopathy and driving abilities: defining the prevalence and long-term postoperative outcomes using the Quality Outcomes Database.

OBJECTIVE: Cervical spondylotic myelopathy (CSM) can cause significant difficulty with driving and a subsequent reduction in an individual's quality of life due to neurological deterioration. The positive impact of surgery on postoperative patient-reported driving capabilities has been seldom explored. METHODS: The CSM module of the Quality Outcomes Database was utilized. Patient-reported driving ability was assessed via the driving section of the Neck Disability Index (NDI) questionnaire. This is an ordinal scale in which 0 represents the absence of symptoms while driving and 5 represents a complete inability to drive due to symptoms. Patients were considered to have an impairment in their driving ability if they reported an NDI driving score of 3 or higher (signifying impairment in driving duration due to symptoms). Multivariable logistic regression models were fitted to evaluate mediators of baseline impairment and improvement at 24 months after surgery, which was defined as an NDI driving score < 3. RESULTS: A total of 1128 patients who underwent surgical intervention for CSM were included, of whom 354 (31.4%) had baseline driving impairment due to CSM. Moderate (OR 2.3) and severe (OR 6.3) neck pain, severe arm pain (OR 1.6), mild-moderate (OR 2.1) and severe (OR 2.5) impairment in hand/arm dexterity, severe impairment in leg use/walking (OR 1.9), and severe impairment of urinary function (OR 1.8) were associated with impaired driving ability at baseline. Of the 291 patients with baseline impairment and available 24-month follow-up data, 209 (71.8%) reported postoperative improvement in their driving ability. This improvement seemed to be mediated particularly through the achievement of the minimal clinically important difference (MCID) in neck pain and improvement in leg function/walking. Patients with improved driving at 24 months noted higher postoperative satisfaction (88.5% vs 62.2%, p < 0.01) and were more likely to achieve a clinically significant improvement in their quality of life (50.7% vs 37.8%, p < 0.01). CONCLUSIONS: Nearly one-third of patients with CSM report impaired driving ability at presentation. Seventy-two percent of these patients reported improvements in their driving ability within 24 months of surgery. Surgical management of CSM can significantly improve patients' driving abilities at 24 months and hence patients' quality of life.

Does diabetes affect outcome or reoperation rate after lumbar decompression or arthrodesis? A matched analysis of the Quality Outcomes Database data set.

OBJECTIVE: Diabetes mellitus (DM) is a known risk factor for postsurgical and systemic complications after lumbar spinal surgery. Smaller studies have also demonstrated diminished improvements in patient-reported outcomes (PROs), with increased reoperation and readmission rates after lumbar surgery in patients with DM. The authors aimed to examine longer-term PROs in patients with DM undergoing lumbar decompression and/or arthrodesis for degenerative pathology. METHODS: The Quality Outcomes Database was queried for patients undergoing elective lumbar decompression and/or arthrodesis for degenerative pathology. Patients were grouped into DM and non-DM groups and optimally matched in a 1:1 ratio on 31 baseline variables, including the number of operated levels. Outcomes of interest were readmissions and reoperations at 30 and 90 days after surgery in addition to improvements in Oswestry Disability Index, back pain, and leg pain scores and quality-adjusted life-years at 90 days after surgery. RESULTS: The matched decompression cohort comprised 7836 patients (3236 [41.3] females) with a mean age of 63.5 ± 12.6 years, and the matched arthrodesis cohort comprised 7336 patients (3907 [53.3%] females) with a mean age of 64.8 ± 10.3 years. In patients undergoing lumbar decompression, no significant differences in nonroutine discharge, length of stay (LOS), readmissions, reoperations, and PROs were observed. In patients undergoing lumbar arthrodesis, nonroutine discharge (15.7% vs 13.4%, p < 0.01), LOS (3.2 ± 2.0 vs 3.0 ± 3.5 days, p < 0.01), 30-day (6.5% vs 4.4%, p < 0.01) and 90-day (9.1% vs 7.0%, p < 0.01) readmission rates, and the 90-day reoperation rate (4.3% vs 3.2%, p = 0.01) were all significantly higher in the DM group. For DM patients undergoing lumbar arthrodesis, subgroup analyses demonstrated a significantly higher risk of poor surgical outcomes with the open approach. CONCLUSIONS: Patients with and without DM undergoing lumbar spinal decompression alone have comparable readmission and reoperation rates, while those undergoing arthrodesis procedures have a higher risk of poor surgical outcomes up to 90 days after surgery. Surgeons should target optimal DM control preoperatively, particularly for patients undergoing elective lumbar arthrodesis.

Impact of Educational Background on Preoperative Disease Severity and Postoperative Outcomes Among Patients With Cervical Spondylotic Myelopathy.

STUDY DESIGN: Retrospective review of a prospectively maintained database. OBJECTIVE: Assess differences in preoperative status and postoperative outcomes among patients of different educational backgrounds undergoing surgical management of cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Patient education level (EL) has been suggested to correlate with health literacy, disease perception, socioeconomic status (SES), and access to health care. METHODS: The CSM data set of the Quality Outcomes Database (QOD) was queried for patients undergoing surgical management of CSM. EL was grouped as high school or below, graduate-level, and postgraduate level. The association of EL with baseline disease severity (per patient-reported outcome measures), symptoms >3 or ≤3 months, and 24-month patient-reported outcome measures were evaluated. RESULTS: Among 1141 patients with CSM, 509 (44.6%) had an EL of high school or below, 471 (41.3%) had a graduate degree, and 161 (14.1%) had obtained postgraduate education. Lower EL was statistically significantly associated with symptom duration of >3 months (odds ratio=1.68), higher arm pain numeric rating scale (NRS) (coefficient=0.5), and higher neck pain NRS (coefficient=0.79). Patients with postgraduate education had statistically significantly lower Neck Disability Index (NDI) scores (coefficient=-7.17), lower arm pain scores (coefficient=-1), and higher quality-adjusted life-years (QALY) scores (coefficient=0.06). Twenty-four months after surgery, patients of lower EL had higher NDI scores, higher pain NRS scores, and lower QALY scores ( P <0.05 in all analyses). CONCLUSIONS: Among patients undergoing surgical management for CSM, those reporting a lower educational level tended to present with longer symptom duration, more disease-inflicted disability and pain, and lower QALY scores. As such, patients of a lower EL are a potentially vulnerable subpopulation, and their health literacy and access to care should be prioritized.

Gender disparities in postoperative outcomes following elective spine surgery: a systematic review and meta-analysis.

OBJECTIVE: Several studies have described disparities between male and female patients following spine surgery, but no pooled analyses have performed a robust review characterizing differences in postoperative outcomes based on gender. The purpose of this study was to broadly assess the effects of gender on postoperative outcomes following elective spine surgery. METHODS: Between November 2022 and March 2023, PubMed, MEDLINE, ERIC, and Embase were queried using artificial intelligence-assisted software for relevant cohort studies. Cohort studies with a minimum sample of 100 patients conducted in the United States since 2010 were eligible. Studies related to trauma, tumors, infections, and spinal cord pathology were excluded. Independent extraction by multiple reviewers was performed using Nested Knowledge software. A fixed- or random-effects model was used if heterogeneity among included studies in a meta-analysis was < 50% or ≥ 50%, respectively. Risk of bias was assessed independently by multiple reviewers using the Newcastle-Ottawa Scale. Pooled effect sizes were calculated for readmission, nonroutine discharge (NRD), length of stay (LOS), extended LOS, reoperation, mortality, all medical complications (individual analyses for cardiovascular, deep venous thrombosis/pulmonary embolism, genitourinary, neurological, respiratory, and systemic infection complications), and wound-related complications. For each outcome, two subanalyses were performed with studies that used either center-based (single- or multi-institution) or high-volume (national or state-wide) databases. RESULTS: Across 124 included studies, male patients had an increased incidence of mortality (OR 0.54, p < 0.0001) and all medical complications (OR 0.80, p = 0.0114), specifically cardiovascular (OR 0.68, p < 0.0001) and respiratory (OR 0.76, p = 0.0008) complications. Female patients were more likely to experience a wound-related surgical complication (OR 1.16, p = 0.0183). These findings persisted in the high-volume database subanalyses. Only center-based subanalyses showed that female patients were at greater odds of experiencing an NRD (OR 1.18, p = 0.0476), longer LOS (SMD 0.23, p = 0.0036), and extended LOS (OR 1.28, p < 0.0001). CONCLUSIONS: Males are more likely to experience death and medical complications, whereas females were more likely to face wound-related surgical complications. At the institution level, females more often experience NRD and longer hospital stays. These findings may better inform preoperative expectation management and provide more detailed postoperative risk assessments based on the patient's gender.

Finite element modeling to predict the influence of anatomic variation and implant placement on performance of biological intervertebral disc implants.

Background: Tissue-engineered intervertebral disc (TE-IVD) constructs are an attractive therapy for treating degenerative disc disease and have previously been investigated in vivo in both large and small animal models. The mechanical environment of the spine is notably challenging, in part due to its complex anatomy, and implants may require additional mechanical support to avoid failure in the early stages of implantation. As such, the design of suitable support implants requires rigorous validation. Methods: We created a FE model to simulate the behavior of the IVD cages under compression specific to the anatomy of the porcine cervical spine, validated the FE model using an animal model, and predicted the effects of implant location and vertebral angle of the motion segment on implant behavior. Specifically, we tested anatomical positioning of the superior vertebra and placement of the implant. We analyzed corresponding stress and strain distributions. Results: Results demonstrated that the anatomical geometry of the porcine cervical spine led to concentrated stress and strain on the posterior side of the cage. This stress concentration was associated with the location of failure of the cages reported in vivo, despite superior mechanical properties of the implant. Furthermore, placement of the cage was found to have profound effects on migration, while the angle of the superior vertebra affected stress concentration of the cage. Conclusions: This model can be utilized both to inform surgical procedures and provide insight on future cage designs and can be adopted to models without the use of in vivo animal models.

Feasibility of High-Fidelity Simulator Models for Minimally Invasive Spine Surgery in a Resource-Limited Setting: Experience From East Africa.

BACKGROUND: Spine surgery is a rapidly evolving specialty with a continuous need to learn new skills. In resource-limited settings such as Africa, the need for training is greater. The use of simulation-based training is important in different stages of skill acquisition, especially for high-stake procedures such as spine surgery. Among the available methods of simulation, the use of synthetic models has gained popularity among trainers. METHOD: Twenty participants of a neurosurgery training course, most of whom (65%) were neurosurgery residents and fellows, were recruited. They had hands-on training sessions using a high-fidelity lumbar degenerative spine simulation model and hands-on theater experience. After this, they completed a survey to compare their experience and assess the effectiveness of the lumbar spine model in stimulating real patient and surgery experiences. RESULTS: The participants were from four African countries, and the majority were neurosurgery residents. There were varying levels of experience among the participants in minimally invasive spine surgery, with the majority either having no experience or having only observed the procedure. All the participants said that the high-fidelity lumbar spine model effectively simulated real minimally invasive spine setup and real bone haptics and was effective in learning new techniques. Most of the participants agreed that the model effectively simulated real dura and nerve roots (95%), real muscle (90%), real bleeding from bones and muscles (95%), and real cerbrospinal fluid in the subarachnoid space. Among them, 95% agreed that the model is effective in lumbar minimally invasive spine training in resource-limited settings. CONCLUSION: With the development of new and better surgical techniques, the use of high-fidelity models provides a good opportunity for learning and training, especially in resource-poor settings where there is a paucity of training facilities and personnel.

Evaluating the Feasibility and Outcomes of a Scoliosis Surgical Camp in a Resource-Limited Setting in Sub-Saharan Africa.

BACKGROUND: In sub-Saharan Africa, the estimated prevalence of scoliosis ranges from 3.3% to 5.5%. The management of these deformities is restricted due to lack of infrastructure and access to deformity spine surgeons. Utilizing surgical camps has been demonstrated to be efficient in transferring skills to low-resource environments; however, this has not been documented concerning deformity surgery. METHODS: We conducted a cross-sectional study. The scoliosis camp was held at a major referral spine center in East Africa. We documented information about the organization of the course. We also collected clinical and demographic patient data. Finally, we assessed the knowledge and confidence among surgeon participants on the management scoliosis. RESULTS: The camp lasted 5 days and consisted of lectures and case discussions, followed by casting and surgical sessions. Five patients were operated during the camp. All the patients in the study were diagnosed with AIS, except one with a congenital deformity. The primary curve in the spine was in the thoracic region for all patients. Six months postoperative Scoliosis Research Society-22R Scoring System (SRS-22R) score ranged from 3.3-4.5/5. 87.5% of the participants found the course content satisfactory. CONCLUSIONS: To the best of our knowledge, this is the first time an African scoliosis camp has been established. The study highlights the difficulty of conducting such a course and illustrates the feasibility of executing these complex surgeries in a resource-limited environment.

Accelerated transformation programme for healthcare services: structure, function and the lessons learnt.

The Kingdom of Saudi Arabia's (KSA) Ministry of Health's (MOH) healthcare transformation strategy aims to improve the quality of life of Saudi citizens in line with the 'Vision 2030' strategic objectives. The MOH is reforming the way healthcare will be managed in the future and is in the process of transferring healthcare service delivery responsibilities to clusters with ratified boards, while also moving the MOH from a provision of service model to a regulatory one. Several early pathfinding clusters were initiated in the eastern central and western regions. To ensure northern and southern regions were not left behind, the early innovation, while awaiting cluster nomination status, the northern and southern business units of Health Holding Company implemented the accelerated transformation programme (ATP). The ATP's remit was to develop capabilities and stimulate local engagement and ownership in the healthcare transformation process. This paper summarises the process of healthcare transformation undertaken in the northern and southern regions of KSA to date. It reviews the success in engaging with local healthcare professional communities in a standardised way and the learning from previous clusters, and elaborates on emerging implementation issues and how we may overcome them and introduce the lessons learnt from this journey.

Algorithmic Patient Selection for Minimally Invasive Versus Open Lumbar Interbody Fusion Surgery.

Evidenced-based data-driven decision-making algorithms guide patient and approach selection for adult spinal deformity surgery. Algorithms are continually refined as surgical goals and intraoperative technology evolve.

Adjunctive Diagnostic Studies Completed Following Detection of Candidemia in Children: Secondary Analysis of Observed Practice From a Multicenter Cohort Study Conducted by the Pediatric Fungal Network.

BACKGROUND: Adjunctive diagnostic studies (aDS) are recommended to identify occult dissemination in patients with candidemia. Patterns of evaluation with aDS across pediatric settings are unknown. METHODS: Candidemia episodes were included in a secondary analysis of a multicenter comparative effectiveness study that prospectively enrolled participants age 120 days to 17 years with invasive candidiasis (predominantly candidemia) from 2014 to 2017. Ophthalmologic examination (OE), abdominal imaging (AbdImg), echocardiogram, neuroimaging, and lumbar puncture (LP) were performed per clinician discretion. Adjunctive diagnostic studies performance and positive results were determined per episode, within 30 days from candidemia onset. Associations of aDS performance with episode characteristics were evaluated via mixed-effects logistic regression. RESULTS: In 662 pediatric candidemia episodes, 490 (74%) underwent AbdImg, 450 (68%) OE, 426 (64%) echocardiogram, 160 (24%) neuroimaging, and 76 (11%) LP; performance of each aDS per episode varied across sites up to 16-fold. Longer durations of candidemia were associated with undergoing OE, AbdImg, and echocardiogram. Immunocompromised status (58% of episodes) was associated with undergoing AbdImg (adjusted odds ratio [aOR] 2.38; 95% confidence intervals [95% CI] 1.51-3.74). Intensive care at candidemia onset (30% of episodes) was associated with undergoing echocardiogram (aOR 2.42; 95% CI 1.51-3.88). Among evaluated episodes, positive OE was reported in 15 (3%), AbdImg in 30 (6%), echocardiogram in 14 (3%), neuroimaging in 9 (6%), and LP in 3 (4%). CONCLUSIONS: Our findings show heterogeneity in practice, with some clinicians performing aDS selectively, potentially influenced by clinical factors. The low frequency of positive results suggests that targeted application of aDS is warranted.

The effect of the Dar es Salaam neurosurgery training course on self-reported neurosurgical knowledge and confidence.

Introduction: The Muhimbili Orthopaedic Institute in collaboration with Weill Cornell Medicine organises an annual neurosurgery training course in Dar es Salaam, Tanzania. The course teaches theory and practical skills in neurotrauma, neurosurgery, and neurointensive care to attendees from across Tanzania and East Africa. This is the only neurosurgical course in Tanzania, where there are few neurosurgeons and limited access to neurosurgical care and equipment. Research question: To investigate the change in self-reported knowledge and confidence in neurosurgical topics amongst the 2022 course attendees. Material and methods: Course participants completed pre and post course questionnaires about their background and self-rated their knowledge and confidence in neurosurgical topics on a five point scale from one (poor) to five (excellent). Responses after the course were compared with those before the course. Results: Four hundred and seventy participants registered for the course, of whom 395(84%) practiced in Tanzania. Experience ranged from students and newly qualified professionals to nurses with more than 10 years of experience and specialist doctors. Both doctors and nurses reported improved knowledge and confidence across all neurosurgical topics following the course. Topics with lower self-ratings prior to the course showed greater improvement. These included neurovascular, neuro-oncology, and minimally invasive spine surgery topics. Suggestions for improvement were mostly related to logistics and course delivery rather than content. Discussion and conclusion: The course reached a wide range of health care professionals in the region and improved neurosurgical knowledge, which should benefit patient care in this underserved region.

Towards Predicting Length of Stay and Identification of Cohort Risk Factors Using Self-Attention-Based Transformers and Association Mining: COVID-19 as a Phenotype.

Predicting length of stay (LoS) and understanding its underlying factors is essential to minimizing the risk of hospital-acquired conditions, improving financial, operational, and clinical outcomes, and better managing future pandemics. The purpose of this study was to forecast patients' LoS using a deep learning model and to analyze cohorts of risk factors reducing or prolonging LoS. We employed various preprocessing techniques, SMOTE-N to balance data, and a TabTransformer model to forecast LoS. Finally, the Apriori algorithm was applied to analyze cohorts of risk factors influencing hospital LoS. The TabTransformer outperformed the base machine learning models in terms of F1 score (0.92), precision (0.83), recall (0.93), and accuracy (0.73) for the discharged dataset and F1 score (0.84), precision (0.75), recall (0.98), and accuracy (0.77) for the deceased dataset. The association mining algorithm was able to identify significant risk factors/indicators belonging to laboratory, X-ray, and clinical data, such as elevated LDH and D-dimer levels, lymphocyte count, and comorbidities such as hypertension and diabetes. It also reveals what treatments have reduced the symptoms of COVID-19 patients, leading to a reduction in LoS, particularly when no vaccines or medication, such as Paxlovid, were available.

Telemedical Support Using Smartphones for Spine Surgery in Low- and Middle-Income Countries.

Objective: Low- and middle-income countries (LMICs) face many challenges compared to industrialized nations, most notably in regard to the health care system. Patients often have to travel long distances to receive medical care with few reliable transportation mechanisms. In time-critical emergencies, this is a significant disadvantage. One specialty that is particularly affected by this is spine surgery. Within this field, traumatic injuries and acutely compressive pathologies are often time-critical. Increasing global networking capabilities through internet access offers the possibility for telemedical support in remote regions. Recently, high-performance cameras and processors became available in commercially available smartphones. Due to their wide availability and ease of use, this could provide a unique opportunity to offer telemedical support in LMICs. Methods: We conducted a feasibility study with a neurosurgical institution in east Africa. To ensure telemedical support, a commercially available smartphone was selected as the experimental hardware. Preoperatively, resolution, contrast, brightness, and color reproduction were assessed under theoretical conditions using a test chart. Intraoperatively, the image quality was assessed under different conditions. In the first step, the instrumentation table was displayed, and the mentor surgeon marked an instrument that the mentee surgeon should recognize correctly. In the next evaluation step, the surgical field was shown on film and the mentor surgeon marked an anatomical structure, and in the last evaluation step, the screen of the X-ray machine was captured, and the mentor surgeon again marked an anatomical structure. Subjective image quality was rated by two independent reviewers using the similar modified Likert scale as before on a scale of 1-5, with 1 indicating inadequate quality and 5 indicating excellent quality. Results: The image quality during the video calls was rated as sufficient overall. When evaluating the test charts, a quality of 97% ± 5 on average was found for the chart with the white background and a quality of 84% ± 5 on average for the chart with the black background. The color reproduction, the contrast, and the reproduction of brightness were rated excellent. Intraoperatively, the visualization of the instrument table was also rated excellent. Visualization of the operative site was rated 1.5 ± 0.5 on average and it was not possible to recognize relevant anatomical structures with the required confidence for surgical procedures. Image quality of the X-ray screen was rated 1.5 ± 0.9 on average. Conclusion: Current generation smartphones have high imaging performance, high computing power, and excellent connectivity. However, relevant anatomical structures during spine surgery procedures and on the X-ray screen in the operating room could not be identified with reliability to provide adequate surgical support. Nevertheless, our study showed the potential in smartphones supporting surgical procedures in LMICs, which could be helpful in other surgical fields.

Sleep Disturbances in Cervical Spondylotic Myelopathy: Prevalence and Postoperative Outcomes-an Analysis From the Quality Outcomes Database.

STUDY DESIGN: Prospective observational study, level of evidence 1 for prognostic investigations. OBJECTIVES: To evaluate the prevalence of sleep impairment and predictors of improved sleep quality 24 months postoperatively in cervical spondylotic myelopathy (CSM) using the quality outcomes database. SUMMARY OF BACKGROUND DATA: Sleep disturbances are a common yet understudied symptom in CSM. MATERIALS AND METHODS: The quality outcomes database was queried for patients with CSM, and sleep quality was assessed through the neck disability index sleep component at baseline and 24 months postoperatively. Multivariable logistic regressions were performed to identify risk factors of failure to improve sleep impairment and symptoms causing lingering sleep dysfunction 24 months after surgery. RESULTS: Among 1135 patients with CSM, 904 (79.5%) had some degree of sleep dysfunction at baseline. At 24 months postoperatively, 72.8% of the patients with baseline sleep symptoms experienced improvement, with 42.5% reporting complete resolution. Patients who did not improve were more like to be smokers [adjusted odds ratio (aOR): 1.85], have osteoarthritis (aOR: 1.72), report baseline radicular paresthesia (aOR: 1.51), and have neck pain of ≥4/10 on a numeric rating scale. Patients with improved sleep noted higher satisfaction with surgery (88.8% vs 72.9%, aOR: 1.66) independent of improvement in other functional areas. In a multivariable analysis including pain scores and several myelopathy-related symptoms, lingering sleep dysfunction at 24 months was associated with neck pain (aOR: 1.47) and upper (aOR: 1.45) and lower (aOR: 1.52) extremity paresthesias. CONCLUSION: The majority of patients presenting with CSM have associated sleep disturbances. Most patients experience sustained improvement after surgery, with almost half reporting complete resolution. Smoking, osteoarthritis, radicular paresthesia, and neck pain ≥4/10 numeric rating scale score are baseline risk factors of failure to improve sleep dysfunction. Improvement in sleep symptoms is a major driver of patient-reported satisfaction. Incomplete resolution of sleep impairment is likely due to neck pain and extremity paresthesia.

The Efficacy of Blended Learning in a Pediatric Spine Deformity Management Program in Sub-Saharan Africa.

INTRODUCTION: Our study assessed the efficacy of blended learning, which combines in-person learning and e-learning, in a pediatric scoliosis training program through an international collaborative effort. METHODS: The course comprised two parts: the online portion, where participants reviewed educational materials for 3 weeks and met with faculty once/week for discussion, and the in-person session, where participants reviewed cases in a team-based approach and came to a consensus on treatment strategy, followed by discussion with an international expert. All participants completed a needs assessment (NA) and clinical quiz at three points: before the course, after the online session, and after the in-person session, which covered various topics in pediatric spine deformity. RESULTS: Thirty-six surgeons enrolled in the course from 13 College of Surgeons of East, Central and Southern Africa countries. The NA assessment scores improved significantly over the course of the surveys from 67.3, to 90.9, to 94.0 (P = 0.02). The clinical quiz scores also improved from 9.91, to 11.9, to 12.3 (P = 0.002). CONCLUSION: The blended learning approach in a pediatric spine deformity program is effective and feasible and shows a statistically significant change in participants' confidence and knowledge base in these complex pathologies. This approach should be explored further with larger numbers and/or other spinal pathologies.

Variation in Cervical Pedicle Morphology: Important Considerations for Posterior Cervical Procedures.

BACKGROUND: Safe posterior cervical spine surgery requires in-depth understanding of the surgical anatomy and common variations. The cervical pedicle attachment site to the vertebral body (VB) affects the location of exiting nerve roots and warrants preoperative evaluation. The relative site of attachment of the cervical pedicle has not been previously described. OBJECTIVE: To describe the site of the pedicle attachment to the VB in the subaxial cervical spine. METHODS: Cervical spine computed tomography scans without any structural, degenerative, or traumatic pathology as read by a board-certified neuroradiologist during 2021 were reviewed. Multiplanar reconstructions were created and cross-registered. The pedicle's attachment to the VB was measured relative to the VB height using a novel calculation system. RESULTS: Fifty computed tomography scans met inclusion criteria yielding 600 total pedicles between C3-T1 (100 per level). The average patient age was 26 ± 5.3 years, and 21/50 (42%) were female. 468/600 (78%) pedicles attached in the cranial third of the VB, 132/600 (22%) attached in the middle third, and 0 attached to the caudal third. The highest prevalence of variant anatomy occurred at C3 (36/100 C3 pedicles; 36%). CONCLUSION: In the subaxial cervical spine, pedicles frequently attach to the top third of the VB, but significant variation is observed. The rate of variation is highest at C3 and decreases linearly with caudal progression down the subaxial cervical spine to T1. This is the first report investigating this morphological phenomenon.

Cervicothoracic junction instrumentation strategies following separation surgery for spinal metastases.

OBJECTIVE: The cervicothoracic junction (CTJ) is a challenging region to stabilize after tumor resection for metastatic spine disease. The objective of this study was to describe the outcomes of patients who underwent posterolateral decompression and instrumented fusion (i.e., separation surgery across the CTJ for instability due to metastatic disease). METHODS: The authors performed a single-institution retrospective study of a prospectively collected cohort of patients who underwent single-approach posterior decompression and instrumented fusion across the CTJ for metastatic spine disease between 2011 and 2018. Adult patients (≥ 18 years old) who presented with mechanical instability, myelopathy, and radiculopathy secondary to metastatic epidural spinal cord compression (MESCC) of the CTJ (C7-T1) from 2011 to 2018 were included. RESULTS: Seventy-nine patients were included, with a mean age of 62.1 years. The most common primary malignancies were non-small cell lung (n = 17), renal cell (11), and prostate (8) carcinoma. The median number of levels decompressed and construct length were 3 and 7, respectively. The average operative time, blood loss, and length of stay were 179.2 minutes, 600.5 ml, and 7.7 days, respectively. Overall, 58 patients received adjuvant radiation, and median dose, fractions, and time from surgery were 27 Gy, 3 fractions, and 20 days, respectively. All patients underwent lateral mass and pedicle screw instrumentation. Forty-nine patients had tapered rods (4.0/5.5 mm or 3.5/5.5 mm), 29 had fixed-diameter rods (3.5 mm or 4.0 mm), and 1 had both. Ten patients required anterior reconstruction with poly-methyl-methacrylate. The overall complication rate was 18.8% (6 patients with wound-related complications, 7 with hardware-related complications, 1 with both, and 1 with other). For the 8 patients (10%) with hardware failure, 7 had tapered rods, all 8 had cervical screw pullout, and 1 patient also experienced rod/screw fracture. The average time to hardware failure was 146.8 days. The 2-year cumulative incidence rate of hardware failure was 11.1% (95% CI 3.7%-18.5%). There were 55 deceased patients, and the median (95% CI) overall survival period was 7.97 (5.79-12.60) months. For survivors, the median (range) follow-up was 12.94 (1.94-71.80) months. CONCLUSIONS: Instrumented fusion across the CTJ demonstrated an 18.8% rate of postoperative complications and an 11% overall 2-year rate of hardware failure in patients who underwent metastatic epidural tumor decompression and stabilization.

Decompression alone versus decompression with fusion in patients with lumbar spinal stenosis with degenerative spondylolisthesis: a systematic review and meta-analysis.

INTRODUCTION: Surgical decompression is standard care in the treatment of degenerative spondylolisthesis in patients with symptomatic lumbar spinal stenosis, but there remains controversy over the benefits of adding fusion. The persistent lack of consensus on this matter and the availability of new data warrants a contemporary systematic review and meta-analysis of the literature. METHODS: Multiple online databases were systematically searched up to October 2022 for randomized controlled trials (RCTs) and prospective studies comparing outcomes of decompression alone versus decompression with fusion for lumbar spinal stenosis in patients with degenerative spondylolisthesis. Primary outcome was the Oswestry Disability Index. Secondary outcomes included leg and back pain, surgical outcomes, and radiological outcomes. Pooled effect estimates were calculated and presented as mean differences (MD) with their 95% confidence intervals (CI) at two-year follow-up. RESULTS: Of the identified 2403 studies, eventually five RCTs and two prospective studies were included. Overall, most studies had a low or unclear risk of selection bias and most studies were focused on low grade degenerative spondylolisthesis. All patient-reported outcomes showed low statistical heterogeneity. Overall, there was high-quality evidence suggesting no difference in functionality at two years of follow-up (MD - 0.31, 95% CI - 3.81 to 3.19). Furthermore, there was high-quality evidence of no difference in leg pain (MD - 1.79, 95% CI - 5.08 to 1.50) or back pain (MD - 2.54, 95% CI - 6.76 to 1.67) between patients undergoing decompression vs. decompression with fusion. Pooled surgical outcomes showed less blood loss after decompression only, shorter length of hospital stay, and a similar reoperation rate compared to decompression with fusion. CONCLUSION: Based on the current literature, there is high-quality evidence of no difference in functionality after decompression alone compared to decompression with fusion in patients with degenerative lumbar spondylolisthesis at 2 years of follow-up. Further studies should focus on long-term comparative outcomes, health economic evaluations, and identifying those patients that may benefit more from decompression with fusion instead of decompression alone. This review was registered at Prospero (CRD42021291603).