Table-mounted Versus Self-retaining Retraction: An Assessment of Postoperative Dysphagia Following Anterior Cervical Spine Surgery.

STUDY DESIGN: Retrospective study. OBJECTIVE: To determine whether there are significant differences in postoperative dysphagia when using table-mounted versus self-retaining retractor tools. SUMMARY OF BACKGROUND DATA: Retraction of prevertebral structures during anterior cervical spine surgery (ACSS) is commonly associated with postoperative dysphagia or dysphonia. Retractors commonly used include nonfixed self-retaining retraction devices or fixed table-mounted retractor arms. However, there is a paucity of literature regarding differences in dysphagia between retractor types. METHODS: Patients who underwent ACSS and adhered to a minimum of 6-month follow-up were retrospectively evaluated. Patient-reported outcomes (PROs) were compared between table-mounted and self-retaining retractor groups at the preoperative and final postoperative time points, including the SWAL-QOL survey for dysphagia. Categorical dysphagia was assessed using previously defined values for the minimum clinically important difference (MCID). RESULTS: Overall, 117 and 75 patients received self-retaining or table-mounted retraction. Average follow-up was significantly longer in the self-retaining cohort (14.8±15.0 mo) than in the table-mounted group (9.4±7.8, P=0.005). No differences were detected in swallowing function (P=0.918) or operative time (P=0.436), although 3-level procedures were significantly shortened with table-mounted retraction (P=0.005). Multivariate analysis trended toward worse swallow function with increased operative levels (P=0.072) and increased retraction time (P=0.054), although the retractor used did not predict swallowing function (P=0.759). However, categorical rates of postoperative dysphagia were lower with table-mounted retraction (13.3% vs. 27.4%, P=0.033). CONCLUSIONS: There was no significant difference observed in long-term swallowing dysfunction between patients who underwent ACSS with self-retaining and table-mounted retractors, although the rate of dysphagia was lower with table-mounted retraction. In addition, the greater number of operated levels per case in the table-mounted group at a similar time suggests improved efficiency.

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

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

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

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

The impact of novel inflammation-preserving treatment towards lumbar disc herniation resorption in symptomatic patients: a prospective, multi-imaging and clinical outcomes study.

PURPOSE: We performed a prospective one-year multi-imaging study to assess the clinical outcomes and rate of disc resorption in acute lumbar disc herniation (LDH) patients undergoing inflammation-preserving treatment (i.e. no NSAIDS, steroids). METHODS: All patients received gabapentin to relieve leg pain, 12 sessions of acupuncture. Repeat MRI was performed, every 3 months, after 12 sessions of treatment continued for those without 40% reduction in herniated disc sagittal area. Disc herniations sizes were measured on sagittal T2W MRI sequences, pre-treatment and at post-treatment intervals. Patients were stratified to fast, medium, slow, and prolonged recovery groups in relation to symptom resolution and disc resorption. RESULTS: Ninety patients (51% females; mean age: 48.6 years) were assessed. Mean size of disc herniation was 119.54 ± 54.34 mm2, and the mean VAS-Leg score was 6.12 ± 1.13 at initial presentation. A total of 19 patients (21.1%) improved at the time of the repeat MRI (i.e. within first 3 months post-treatment). 100% of all patient had LDH resorption within one year (mean: 4.4. months). There was no significant difference at baseline LDH between fast, medium, slow, and prolonged resorption groups. Initial LDH size was weakly associated with degree of leg pain at baseline and initial gabapentin levels. Surgery was avoided in all cases. CONCLUSION: This is the first study to note inflammation-preserving treatment, without conventional anti-inflammatory and steroid medications, as safe and effective for patients with an acute LDH. Rate of disc resorption (100%) was higher than comparative recent meta-analysis findings (66.7%) and no patient underwent surgery.

The Effect of Changes in Segmental Lordosis on Global Lumbar and Adjacent Segment Lordosis After L5-S1 Anterior Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVE: Restoration of lordosis in lumbar fusion reduces low back pain, decreases adjacent segment degeneration, and improves postoperative outcomes. However, the potential effects of changes in segmental lordosis on adjacent-level and global lordosis remain less understood. This study aims to examine the relationships between segmental (SL), adjacent-level, and global lumbar lordosis following L5-S1 Anterior Lumbar Interbody Fusion (ALIF). METHODS: 80 consecutive patients who underwent single-level L5-S1 ALIF were divided into 3 groups based on the degree of change (∆) in index-level segmental lordosis: <5° (n = 23), 5°-10° (n = 29), >10° (n = 28). Radiographic parameters measured included global lumbar, segmental, and adjacent level lordosis, sacral slope, pelvic tilt, pelvic incidence, and PI-LL mismatch. RESULTS: Patients with ∆SL 5°-10° or ∆SL >10° both showed significant increases in global lumbar lordosis from preoperative to final follow-up. However, patients with ∆SL >10° showed statistically significant losses in adjacent level lordosis at both immediate postoperative and final follow-up compared to preoperative. When comparing patients with ∆SL >10° to those with ∆SL 5-10°, there were no significant differences in global lumbar lordosis at final follow-up, due to significantly greater losses of adjacent level lordosis in these patients. CONCLUSION: The degree of compensatory loss of lordosis at the adjacent level L4-L5 correlated with the extent of segmental lordosis creation at the index L5-S1 level. This may suggest that the L4 to S1 segment acts as a "harmonious unit," able to accommodate only a certain amount of lordosis and further increases in segmental lordosis may be mitigated by loss of adjacent-level lordosis.

Usage Trends and Safety Profile of Recombinant Human Bone Morphogenetic Protein-2 for Spinal Column Tumor Surgery: A National Matched Cohort Analysis.

STUDY DESIGN: Retrospective Cohort Analysis. OBJECTIVE: The purpose of this study is to investigate national rates of rhBMP-2 utilization in spinal tumor surgery and examine its association with postoperative complications, revisions, and carcinogenicity. METHODS: All patients diagnosed with primary or metastatic spinal tumors with subsequent surgical intervention involving a spinal fusion procedure were identified in PearlDiver. Patients were 1:1 matched into 2 cohorts according to rhBMP-2 usage. Postoperative complications and revisions were examined at 1 month, 3 months, 6 months, and 1 year after fusion. New cancer incidence following spinal tumor surgery was assessed until 5 years postoperatively. RESULTS: A total of 11,198 patients underwent fusion surgery after resection of spinal tumors between 2005 and 2020, with 909 cases reporting the use of rhBMP-2 (8.1%). An annualized analysis revealed that the proportion of spine tumor fusion procedures utilizing rhBMP-2 has been significantly decreasing (R2 = .859, P < .001), with the most recent annual utilization rate at 1.1%. At least 3 months after surgery, significantly increased incidences of surgical site (11.4% vs 3.3%, P = .03) and systemic infections (8.1% vs 1.6%, P = .02) were observed in patients who underwent fusion with rhBMP-2. Across all time points, no significant differences were observed in survival, implant removal, revision rates, or new cancer diagnoses. CONCLUSION: This analysis demonstrated significantly declining national utilization rates. Spinal tumor cases utilizing rhBMP-2 sustained greater rates of surgical site and systemic infections. rhBMP-2 usage did not significantly reduce the risk of mortality, implant failure, or reoperation.

Does disc distraction after cervical total disc arthroplasty impact range of motion and patient-reported outcomes?

OBJECTIVE: Total disc arthroplasty (TDA) has been established as a safe and effective alternative to anterior cervical discectomy and fusion for the treatment of cervical spine pathology. However, there remains a paucity of studies in the literature regarding the amount of disc height distraction that can be tolerated, as well as its impact on kinematic and clinical outcomes. METHODS: Patients who underwent 1- or 2-level cervical TDA with a minimum follow-up of 1 year with lateral flexion/extension and patient-reported outcome measures (PROMs) were included. Middle disc space height was measured on preoperative and 6-week postoperative lateral radiographs to quantify the magnitude of disc space distraction, and patients were grouped into < 2-mm distraction and > 2-mm distraction groups. Radiographic outcomes included operative segment lordosis, segmental range of motion (ROM) on flexion/extension, cervical (C2-7) ROM on flexion/extension, and heterotopic ossification (HO). General health and disease-specific PROMs were compared at the preoperative, 6-week, and final postoperative time points. The independent-samples t-test and chi-square test were used to compare outcomes between groups, while multivariate linear regression was used to adjust for baseline differences. RESULTS: Fifty patients who underwent cervical TDA at 59 levels were included in the analysis. Distraction < 2 mm was seen at 30 levels (50.85%), while distraction > 2 mm was observed at 29 levels (49.15%). Radiographically, after adjustment for baseline differences, C2-7 ROM was significantly greater in the patients who underwent TDA with < 2-mm disc space distraction at final follow-up (51.35° ± 13.76° vs 39.19° ± 10.52°, p = 0.002), with a trend toward significance in the early postoperative period. There were no significant postoperative differences in segmental lordosis, segmental ROM, or HO grades. After the authors controlled for baseline differences, < 2-mm distraction of the disc space led to significantly greater improvement in visual analog scale (VAS)-neck scores at 6 weeks (-3.68 ± 3.12 vs -2.24 ± 2.70, p = 0.031) and final follow-up (-4.59 ± 2.74 vs -1.70 ± 3.03, p = 0.008). CONCLUSIONS: Patients with < 2-mm disc height difference had increased C2-7 ROM at final follow-up and significantly greater improvement in neck pain after controlling for baseline differences. Limiting differences in disc space height to < 2 mm affected C2-7 ROM but not segmental ROM, suggesting that less distraction may result in more harmonious kinematics between all cervical levels.

Increased cage angle effects on radiographic outcomes after stand-alone anterior lumbar interbody fusion.

OBJECTIVE: Anterior lumbar interbody fusion (ALIF) is a well-accepted surgical technique used to treat various lumbar degenerative pathologies. Recently, hyperlordotic cages have been introduced to create higher degrees of lordosis to the lumbar spine. There are little data currently available to define the radiographic benefits that these cages provide with stand-alone ALIF. The goal of the present study was to assess the effect of increasing cage angles on postoperative subsidence, sagittal alignment, and foraminal and disc height in patients who underwent single-level stand-alone ALIF surgery. METHODS: A retrospective cohort study was performed of consecutive patients who underwent single-level ALIF by a single spine surgeon. Radiographic analysis included global lordosis, operative level of segmental lordosis, cage subsidence, sacral slope, pelvic tilt, pelvic incidence, pelvic incidence-lumbar lordosis mismatch, edge loading, foraminal height, posterior disc height, anterior disc height, and adjacent-level lordosis. Multivariate linear and logistic regressions were performed to analyze the relationship between cage angle and radiographic outcomes. RESULTS: Seventy-two patients were included in the study and divided into three groups based on cage angle: < 10° (n = 17), 10°-15° (n = 36), and > 15° (n = 19). Within the entire study cohort, there were significant improvements in disc and foraminal height, as well as segmental and global lordosis, at the final follow-up after single-level ALIF. However, when stratified by cage angle groups, patients with > 15° cages did not have any additional significant changes in global or segmental lordosis compared with those patients with smaller cage angles, but patients with > 15° cages showed greater risk of subsidence while also having significantly less improvements in foraminal height, posterior disc height, and average disc height compared with the other groups. CONCLUSIONS: Patients with < 15° stand-alone ALIF cages showed improved average foraminal and disc (posterior, anterior, and average) height without sacrificing improvements in sagittal parameters or increasing risk of subsidence when compared to patients with hyperlordotic cages. The use of hyperlordotic cages > 15° did not provide spinal lordosis commensurate with the lordotic angle of the cage and had a greater risk of subsidence. Although this study was limited by a lack of patient-reported outcomes to correlate with radiographic results, these findings support the judicious use of hyperlordotic cages in stand-alone ALIF.

Medicare Reimbursement Rates and Utilization Trends in Sacroiliac Joint Fusion.

INTRODUCTION: Sacroiliac joint (SIJ) fusion is a surgical treatment option for SIJ pathology in select patients who have failed conservative management. More recently, minimally invasive surgical (MIS) techniques have been developed. This study aimed to determine the trends in procedure volume and reimbursement rates for SIJ fusion. METHODS: Publicly available Medicare databases were assessed using the National Summary Data Files for 2010 to 2020. Files were organized according to current procedural terminology (CPT) codes. CPT codes specific to open and MIS SI joint fusion (27279 and 27280) were identified and tracked. To track surgeon reimbursements, the CMS Medicare Physician Fee Schedule Look-Up Tool was used to extract facility prices. Descriptive statistics and linear regression were used to evaluate trends in procedure volume, utilization, and reimbursement rates. Compound annual growth rates were calculated, and discrepancies in inflation were corrected for using the Consumer Price Index. RESULTS: A total of 33,963 SIJ fusions were conducted in the Medicare population between 2010 and 2020, with an overall increase in procedure volume of 2,350.9% from 318 cases in 2010 to 7,794 in 2020. Since the introduction of the 27279 CPT code in 2015, 8,806 cases (31.5%) have been open and 19,120 (68.5%) have been MIS. Surgeon reimbursement for open fusions increased nominally by 42.8% (inflation-adjusted increase of 20%) from $998 in 2010 to $1,425 in 2020. Meanwhile, reimbursement for MIS fusion experienced a nominal increase of 58.4% (inflation-adjusted increase of 44.9%) from $582 in 2015 to $922 in 2020. CONCLUSION: SIJ fusion volume in the Medicare population has increased substantially in the past 10 years, with MIS SIJ fusion accounting for most of the procedures since the introduction of the 27279 CPT code in 2015. Reimbursement rates for surgeons have also increased for both open and MIS procedures, even after adjusting for inflation.

Rates of Postoperative Complications and Approach-related Neurological Symptoms After L4-L5 Lateral Transpsoas Lumbar Interbody Fusion Compared With Upper Lumbar Levels.

STUDY DESIGN: This was a retrospective comparative study. OBJECTIVE: To compare the likelihood of approach-related complications for patients undergoing single-level lateral lumbar interbody fusion (LLIF) at L4-L5 to those undergoing the procedure at upper lumbar levels. SUMMARY OF BACKGROUND DATA: LLIF has been associated with a number of advantages when compared with traditional interbody fusion techniques. However, potential risks with the approach include vascular or visceral injury, thigh dysesthesias, and lumbar plexus injury. There are concerns of a higher risk of these complications at the L4-L5 level compared with upper lumbar levels. MATERIALS AND METHODS: A retrospective cohort review was completed for consecutive patients undergoing single-level LLIF between 2004 and 2019 by a single surgeon. Indication for surgery was symptomatic degenerative lumbar stenosis and/or spondylolisthesis. Patients were divided into 2 cohorts: LLIF at L4-L5 versus a single level between L1 and L4. Baseline characteristics, intraoperative complications, postoperative approach-related neurological symptoms, and patient-reported outcomes were compared and analyzed between the cohorts. RESULTS: A total of 122 were included in analysis, of which 58 underwent LLIF at L4-L5 and 64 underwent LLIF between L1 and L4. There were no visceral or vascular injuries or lumbar plexus injuries in either cohort. There was no significant difference in the rate of postoperative hip pain, anterior thigh dysesthesias, and/or hip flexor weakness between the cohorts (53.5% L4-L5 vs. 37.5% L1-L4; P =0.102). All patients reported complete resolution of these symptoms by 6-month postoperative follow-up. DISCUSSION: LLIF surgery at the L4-L5 level is associated with a similar infrequent likelihood of approach-related complications and postoperative hip pain, thigh dysesthesias, and hip flexor weakness when compared with upper lumbar level LLIF. Careful patient selection, meticulous use of real-time neuromonitoring, and an understanding of the anatomic location of the lumbar plexus to the working corridor are critical to success.

YouTube as a source of information on pediatric scoliosis: a reliability and educational quality analysis.

PURPOSE: To assess the reliability and educational quality of YouTube videos related to pediatric scoliosis. METHODS: In December 2020, searches of "pediatric scoliosis", "idiopathic scoliosis", "scoliosis in children", and "curved spine in children" were conducted using YouTube. The first 50 results of each search were analyzed according to upload source and content. The Journal of the American Medical Association (JAMA) Benchmark Criteria were used to assess reliability (score 0-4), and educational quality was evaluated using the Global Quality Score (GQS; score 0-5) and Pediatric Scoliosis-Specific Score (PSS; score 0-15). Differences in scores based on upload source and content were determined by Analysis of Variance (ANOVA) or Kruskal-Wallis tests. Multivariate linear regressions identified any independent predictors of reliability and educational quality. RESULTS: After eliminating duplicates, 153 videos were analyzed. Videos were viewed 28.5 million times in total, averaging 186,160.3 ± 1,012,485.0 views per video. Physicians (54.2%) and medical sources (19.0%) were the most common upload sources, and content was primarily categorized as disease-specific (50.0%) and patient experience (25.5%). Videos uploaded by patients achieved significantly lower JAMA scores (p = 0.004). Conversely, academic or physician-uploaded videos scored higher on PSS (p = 0.003) and demonstrated a trend towards improved GQS (p = 0.051). Multivariate analysis determined longer video duration predicted higher scores on all measures. However, there were no independent associations between upload source or content and assessment scores. CONCLUSION: YouTube contains a large repository of videos concerning pediatric scoliosis; however, the reliability and educational quality of these videos were low. LEVEL OF EVIDENCE: V.

Catastrophic acute failure of pelvic fixation in adult spinal deformity requiring revision surgery: a multicenter review of incidence, failure mechanisms, and risk factors.

OBJECTIVE: There are few prior reports of acute pelvic instrumentation failure in spinal deformity surgery. The objective of this study was to determine if a previously identified mechanism and rate of pelvic fixation failure were present across multiple institutions, and to determine risk factors for these types of failures. METHODS: Thirteen academic medical centers performed a retrospective review of 18 months of consecutive adult spinal fusions extending 3 or more levels, which included new pelvic screws at the time of surgery. Acute pelvic fixation failure was defined as occurring within 6 months of the index surgery and requiring surgical revision. RESULTS: Failure occurred in 37 (5%) of 779 cases and consisted of either slippage of the rods or displacement of the set screws from the screw tulip head (17 cases), screw shaft fracture (9 cases), screw loosening (9 cases), and/or resultant kyphotic fracture of the sacrum (6 cases). Revision strategies involved new pelvic fixation and/or multiple rod constructs. Six patients (16%) who underwent revision with fewer than 4 rods to the pelvis sustained a second acute failure, but no secondary failures occurred when at least 4 rods were used. In the univariate analysis, the magnitude of surgical correction was higher in the failure cohort (higher preoperative T1-pelvic angle [T1PA], presence of a 3-column osteotomy; p < 0.05). Uncorrected postoperative deformity increased failure risk (pelvic incidence-lumbar lordosis mismatch > 10°, higher postoperative T1PA; p < 0.05). Use of pelvic screws less than 8.5 mm in diameter also increased the likelihood of failure (p < 0.05). In the multivariate analysis, a larger preoperative global deformity as measured by T1PA was associated with failure, male patients were more likely to experience failure than female patients, and there was a strong association with implant manufacturer (p < 0.05). Anterior column support with an L5-S1 interbody fusion was protective against failure (p < 0.05). CONCLUSIONS: Acute catastrophic failures involved large-magnitude surgical corrections and likely resulted from high mechanical strain on the pelvic instrumentation. Patients with large corrections may benefit from anterior structural support placed at the most caudal motion segment and multiple rods connecting to more than 2 pelvic fixation points. If failure occurs, salvage with a minimum of 4 rods and 4 pelvic fixation points can be successful.

Preoperative Multifidus Muscle Quality is Associated With Patient Reported Outcomes After Lateral Lumbar Interbody Fusion.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: Lateral lumbar interbody fusion (LLIF) commonly involves a transpsoas approach. Despite the association between LLIF, postoperative iliopsoas weakness, and iatrogenic neuropraxia, no study has yet examined the effect of psoas or multifidus muscle quality on patient-reported outcomes (PROs). METHODS: This study retrospectively reviewed patients who underwent LLIF with 1-year minimum follow-up. Psoas and multifidus muscle qualities were graded on preoperative magnetic resonance imaging using two validated classification systems for muscle atrophy. Average muscle quality was calculated as the mean score from all levels (L1-2 through L5-S1). Univariate and multivariate statistics were utilized to investigate the relationship between psoas/multifidus muscle quality and preoperative, 6-weeks postoperative, and final postoperative PROs. RESULTS: 74 patients (110 levels) with a mean follow-up of 18.71 ± 8.02 months were included for analysis. Greater multifidus atrophy was associated with less improvement on ODI, SF12, and VR12 (P < .05) on univariate analysis. On multivariate analysis, worse multifidus atrophy predicted less improvement on SF12 and VR12 (P < .05). CONCLUSION: Despite the direct manipulation of the psoas muscle inherent to LLIF, preoperative psoas muscle quality did not affect postoperative outcomes. Rather, the extent of preoperative multifidus fatty infiltration and atrophy was more likely to predict postoperative pain and disability. These findings suggest that multifidus atrophy may be more pertinent than psoas atrophy in its association with patient-reported outcome measures after LLIF.

Validation of Veterans RAND 12-Item Physical Function Survey in Minimally Invasive Transforaminal Lumbar Interbody Fusion.

BACKGROUND: Veterans RAND 12-item (VR-12) physical component score (PCS) has been validated in both veteran and US citizen populations; however, its use for spine surgery populations has not been evaluated. This study aims to correlate the VR-12 PCS survey with legacy patient-reported outcome measures (PROMs) in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). METHODS: A prospective surgical database was retrospectively assessed for MIS TLIFs performed at 1 level from March 2015 to June 2019. Inclusion criteria were elective procedures for degenerative spinal pathology. Patients were excluded if they had surgery for metastatic, traumatic, or infectious etiologies or had incomplete preoperative 12-item Short Form (SF-12) PCS or Patient-Reported Outcomes Measurement Information System physical function (PROMIS-PF) survey. Additionally, patients with any incomplete VR-12 PCS surveys through 1 year were excluded. Demographics and perioperative characteristics were recorded. Mean postoperative PROM scores and score difference from preoperative baseline were calculated at each postoperative timepoint through 1 year. The relationship of VR-12-PCS with SF-12-PCS and PROMIS PF was evaluated with a Pearson's correlation coefficient and time-independent partial correlation. RESULTS: A total of 59 patients underwent single-level MIS TLIFs. The cohort was 44.1% women with an average age of 53.8 years, and 52.5% were obese (body mass index ≥30 kg/m2). The VR-12 PCS, SF-12 PCS, and PROMIS PF surveys had significant improvements from baseline to the 6 month through 1 year postoperative timepoints (P ≤ 0.001, all). All timepoints revealed strong VR-12-PCS correlations with SF-12-PCS and PROMIS PF (all P ≤ 0.001). CONCLUSION: VR-12 PCS, SF-12 PCS, and PROMIS PF scores all indicate statistically significant improvements in physical function for patients following MIS TLIF. VR-12 PCS was strongly correlated with the historically validated SF-12 PCS system as well as with the more recent PROMIS PF survey. Our observations give weight to utilizing the VR-12 PCS survey as a valid measure of physical function among patients undergoing MIS TLIF. CLINICAL RELEVANCE: This study validates VR-12 PCS to measure physical function for TLIF patients.

Influence of Preoperative Depressive Burden on Achieving a Minimal Clinically Important Difference Following Lumbar Decompression.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: This study evaluates the association of preoperative mental health with the rate of achieving minimal clinically important difference (MCID) in patient-reported outcomes following lumbar decompression (LD). SUMMARY OF BACKGROUND DATA: Research is scarce regarding the influence of preoperative depression on the rate of achieving MCID for mental health, physical function, and pain among LD patients. METHODS: A surgical registry was retrospectively reviewed for primary LD surgeries. Patients were grouped by depressive symptom severity according to the preoperative Patient Health Questionnaire 9 score. The association of Patient Health Questionnaire 9 subgroups with demographic and surgical variables was analyzed, and differences among subgroups were assessed. Achievement rates of MCID for physical function, pain, disability, and mental health were compared among groups at each time point using previously established MCID thresholds. RESULTS: Of the 321 subjects, 69.8% were male, and 170 subjects had minimal preoperative depressive symptoms, 86 had moderate, and 65 had severe. Patients in moderate and severe groups demonstrated a significantly greater rate of MCID achievement for disability at 6 weeks and 3 months postoperatively. The severe group demonstrated a significantly higher rate of achieving MCID for mental health at the 1-year time point. CONCLUSIONS: Patients with any range of preoperative depressive symptom severity had a similar rate of achieving MCID for pain and physical function throughout 1 year following LD. The severe depressive symptom group had a higher rate of MCID achievement with disability at 6 weeks and with mental health at 1 year. This study demonstrates that patients with any preoperative depressive symptom severity have an indistinguishable ability to attain MCID by 1 year following LD. LEVEL OF EVIDENCE: Level III.

Longitudinal assessment of segmental motion of the cervical spine following total disc arthroplasty: a comparative analysis of devices.

OBJECTIVE: Total disc arthroplasty (TDA) has been shown to be an effective and safe treatment for cervical degenerative disc disease at short- and midterm follow-up. However, there remains a paucity of literature reporting the differences between individual prosthesis designs with regard to device performance. In this study, the authors evaluated the long-term maintenance of segmental range of motion (ROM) at the operative cervical level across a diverse range of TDA devices. METHODS: In this study, the authors retrospectively evaluated all consecutive patients who underwent 1- or 2-level cervical TDA between 2005 and 2020 at a single institution. Patients with a minimum of 6 months of follow-up and lateral flexion/extension radiographs preoperatively, 2 months postoperatively, and at final follow-up were included. Radiographic measurements included static segmental lordosis, segmental range of motion (ROM) on flexion/extension, global cervical (C2-7) ROM on flexion/extension, and disc space height. The paired t-test was used to evaluate improvement in radiographic parameters. Subanalysis between devices was performed using one-way ANCOVA. Significance was determined at p < 0.05. RESULTS: A total of 85 patients (100 discs) were included, with a mean patient age of 46.01 ± 8.82 years and follow-up of 43.56 ± 39.36 months. Implantations included 22 (22.00%) M6-C, 51 (51.00%) Mobi-C, 14 (14.00%) PCM, and 13 (13.00%) ProDisc-C devices. There were no differences in baseline radiographic parameters between groups. At 2 months postoperatively, PCM provided significantly less segmental lordosis (p = 0.037) and segmental ROM (p = 0.039). At final follow-up, segmental ROM with both the PCM and ProDisc-C devices was significantly less than that with the M6-C and Mobi-C devices (p = 0.015). From preoperatively to 2 months postoperatively, PCM implantation led to a significant loss of lordosis (p < 0.001) and segmental ROM (p = 0.005) relative to the other devices. Moreover, a significantly greater decline in segmental ROM from 2 months postoperatively to final follow-up was seen with ProDisc-C, while segmental ROM increased significantly over time with Mobi-C (p = 0.049). CONCLUSIONS: Analysis by TDA device brand demonstrated that motion preservation differs depending on disc design. Certain devices, including M6-C and Mobi-C, improve ROM on flexion/extension from preoperatively to postoperatively and continue to increase slightly at final follow-up. On the other hand, devices such as PCM and ProDisc-C contributed to greater segmental stiffness, with a gradual decline in ROM seen with ProDisc-C. Further studies are needed to understand how much segmental ROM is ideal after TDA for preservation of physiological cervical kinematics.

Stand-Alone Cage Versus Anterior Plating for 1-Level and 2-Level Anterior Cervical Discectomy and Fusion: A Randomized Controlled Trial.

STUDY DESIGN: Prospective, randomized controlled trial. OBJECTIVE: The aim was to compare perioperative and radiographic outcomes between stand-alone and anterior plated 1 and 2-level anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: ACDF with interbody spacer and separate plate/screw construct (PLATE) may be associated with a higher incidence of postoperative dysphagia, increased operative time, and other complications. Therefore, some have opted to utilize an interbody cage with integrated screws and no plate (CAGE) with good results. MATERIALS AND METHODS: Patients with 1-level to 2-level degenerative disease were prospectively enrolled and randomized into 1 of 2 treatment arms consisting of either PLATE or CAGE reconstruction. Patients were followed for a minimum of 1 year postoperatively. Primary endpoints included improvement on patient-reported outcome metrics, construct integrity, cervical alignment, successful arthrodesis, and subsequent revision surgeries. RESULTS: Forty-six patients were included: 12 with 1-level PLATE, 12 with 1-level CAGE, 12 with 2-level PLATE, and 10 with 2-level CAGE. For 1-level ACDF, PLATE patients reported worse swallow function on Swallowing Quality of Life Questionnaire at 6 weeks (P=0.050) and 6 months (P=0.042). Pseudarthrosis requiring revision was observed in one PLATE patient. For 2-level ACDF CAGE patients reported worse disability on neck disability index (P=0.037) at 6 weeks, as well as worse neck disability index (P=0.017) and visual analog scale neck (P=0.010) at 6 months. However, PLATE patients reported worse swallow function on Swallowing Quality of Life Questionnaire at 6 weeks (P=0.038). There were no differences in the rates of fusion, loss of disc height correction, subsidence, or in sagittal parameters between cohorts for both 1-level and 2-level ACDF. CONCLUSION: There was greater incidence of transient postoperative dysphagia in both single and 2-level PLATE cohorts. However, early postoperative outcomes were worse for 2-level CAGE in certain patient-reported metrics. This suggests that although anterior instrumentation may be associated with a higher likelihood of dysphagia, it may also lead to higher short-term stability and improved patient-reported outcomes for 2-level fusion.

Segmental range of motion after cervical total disc arthroplasty at long-term follow-up: a systematic review and meta-analysis.

OBJECTIVE: As an alternative procedure to anterior cervical discectomy and fusion, total disc arthroplasty (TDA) facilitates direct neural decompression and disc height restoration while also preserving cervical spine kinematics. To date, few studies have reported long-term functional outcomes after TDA. This paper reports the results of a systematic review and meta-analysis that investigated how segmental range of motion (ROM) at the operative level is maintained with long-term follow-up. METHODS: PubMed and MEDLINE were queried for all published studies pertaining to cervical TDA. The methodology for screening adhered strictly to the PRISMA guidelines. All English-language prospective studies that reported ROM preoperatively, 1 year postoperatively, and/or at long-term follow-up of 5 years or more were included. A meta-analysis was performed using Cochran's Q and I2 to test data for statistical heterogeneity, in which case a random-effects model was used. The mean differences (MDs) and associated 95% confidence intervals (CIs) were reported. RESULTS: Of the 12 studies that met the inclusion criteria, 8 reported the long-term outcomes of 944 patients with an average (range) follow-up of 99.86 (60-142) months and were included in the meta-analysis. There was no difference between preoperative segmental ROM and segmental ROM at 1-year follow-up (MD 0.91°, 95% CI -1.25° to 3.07°, p = 0.410). After the exclusion of 1 study from the comparison between preoperative and 1-year ROM owing to significant statistical heterogeneity according to the sensitivity analysis, ROM significantly improved at 1 year postoperatively (MD 1.92°, 95% CI 1.04°-2.79°, p < 0.001). However, at longer-term follow-up, the authors again found no difference with preoperative segmental ROM, and no study was excluded on the basis of the results of further sensitivity analysis (MD -0.22°, 95% CI -1.69° to -1.23°, p = 0.760). In contrast, there was a significant decrease in ROM from 1 year postoperatively to final long-term follow-up (MD -0.77°, 95% CI -1.29° to -0.24°, p = 0.004). CONCLUSIONS: Segmental ROM was found to initially improve beyond preoperative values for as long as 1 year postoperatively, but then ROM deteriorated back to values consistent with preoperative motion at long-term follow-up. Although additional studies with further longitudinal follow-up are needed, these findings further support the notion that cervical TDA may successfully maintain physiological spinal kinematics over the long term.

Risk Assessment of Anterior Lumbar Interbody Fusion Access in Degenerative Spinal Conditions.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: Develop an evidence-based preoperative risk assessment scoring system for patients undergoing anterior lumbar interbody fusion (ALIF). SUMMARY OF BACKGROUND DATA: ALIF may hold advantages over other fusion techniques in sagittal restoration and fusion rates, though it introduces unique risks to vascular and abdominal structures and thus possibly increased risk of operative morbidity. METHODS: Primary, 1 or 2-level ALIFs were identified in a surgical registry. Baseline characteristics were recorded. Axial magnetic resonance imagings at L4-L5 and L5-S1 were reviewed for vascular confluence/bifurcation or anomalous structures, and measured for operative window size/slope. To assess favorable outcomes, a clinical grade was calculated: (clinical grade=blood loss×operative duration), higher value indicating poorer outcome. To establish a risk scoring system, a base risk score algorithm was established and stratified into 5 categories: high, high to intermediate, intermediate, intermediate to low, and low. Modifiers to base risk score included age, body mass index, operative level, history of bone morphogenic protein use, calcified vasculature, spondylolisthesis grade, working window size and slope, and abnormal vasculature. Modifiers were weighted for contribution to surgical risk. A total risk score was calculated and evaluated for strength of association with clinical outcome grades by Pearson correlation coefficient. RESULTS: A total of 65 patients were included. Mean clinical outcome grade was 5.6, mean total risk score 21.3±21.5. Multilevel procedures (L4-S1) mean total risk score was 57.3±7.8. L4-L5 mean total risk score was 23.6±5.2; L5-S1 mean total risk score 8.3±6.6. Correlation analysis demonstrated a significant and strong relationship (| r |=0.753; P <0.001) between total risk scores and clinical outcome grades. CONCLUSION: Calculated ALIF risk scores significantly correlated with operative duration and blood loss. This scoring system represents a potential framework to facilitate clinical decision-making and risk assessment for potential ALIF candidates with degenerative spinal pathologies.

ISSLS PRIZE in Clinical Science 2022: Epidemiology, risk factors and clinical impact of juvenile Modic changes in paediatric patients with low back pain.

PURPOSE: It's a long-held belief that Modic changes (MC) occur only in adults, with advanced age, and are highly associated with pain and adverse outcomes. The following study addressed the epidemiology, risk factors and clinical relevance of MC in young paediatric patients. METHODS: Two hundred and seven consecutive patients with no history of deformities, neoplasms, trauma, or infections were included in this ambispective study. MRIs were utilized to assess MCs and types, and other degenerative disc/endplate abnormalities. Subject demographics, duration of symptoms, clinic visits, conservative management (physical therapy, NSAIDs, opioids, injections) and surgery were noted. RESULTS: The mean age was 16.5 years old (46.9% males), 14% had MCs and they occurred throughout the spine. Subject baseline demographics were similar between MCs and non-MCs patients (p > 0.05). Modic type 2 (50%) was the most common type (type 1:27.1%; type 3:18.8%; mixed:4.7%). Multivariate analyses noted that endplate damage (OR: 11.36), disc degeneration (OR: 5.81), disc space narrowing (OR: 5.77), Schmorl's nodes (OR: 4.30) and spondylolisthesis (OR: 3.55) to be significantly associated with MCs (p < 0.05). No significant differences in conservative management were noted between Modic and non-MCs patients (p > 0.05). Among surgery patients (n = 44), 21% also had MCs (p = 0.134). Symptom-duration was significantly greater in MC patients (p = 0.049). CONCLUSION: Contrary to traditional dogma, robust evidence now exists noting that MCs and their types can develop in children. Our findings give credence to the "Juvenile" variant of MCs, whereby its implications throughout the lifespan need to be assessed. Juvenile MCs have prolonged symptoms and related to specific structural spine phenotypes.