Relationships Between Expertise, Crew Familiarity and Surgical Workflow Disruptions: An Observational Study.

BACKGROUND: Teamwork is an essential factor in reducing workflow disruption (WD) in the operating room. Team familiarity (TF) has been recognized as an antecedent to surgical quality and safety. To date, no study has examined the link between team members' role and expertise, TF and WD in surgical setting. This study aimed to examine the relationships between expertise, surgeon-scrub nurse familiarity and WD. METHODS: We observed a convenience sample of 12 elective neurosurgical procedures carried out by 4 surgeons and 11 SN with different levels of expertise and different degrees of familiarity between surgeons and SN. We calculated the number of WD per unit of coding time to control for the duration of operation. We explored the type and frequency of WD, and the differences between the surgeons and SN. We examined the relationships between duration of WD, staff expertise and surgeon-scrub nurse familiarity. RESULTS: 9.91% of the coded surgical time concerned WD. The most frequent causes of WD were distractions (29.7%) and colleagues' interruptions (25.2%). This proportion was seen for SN, whereas teaching moments and colleagues' interruptions were the most frequent WD for surgeons. The WD was less high among expert surgeons and less frequent when surgeon was familiar with SN. CONCLUSIONS: The frequency of WD during surgical time can compromise surgical quality and patient safety. WD seems to decrease in teams with high levels of surgeon-scrub nurse familiarity and with development of surgical expertise. Favoring TF and giving feedback to the team about WD issues could be interesting ways to improve teamwork.

A comparison of zero-profile anchored spacer (ROI-C) and plate fixation in 2-level noncontiguous anterior cervical discectomy and fusion- a retrospective study.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is the classic surgical treatment for symptomatic cervical degenerative disc disease (CDDD). However, there is controversy over the best surgical management in patients with two noncontiguous symptomatic levels of CDDD. METHODS: From April 2011 to May 2014, 44 patients with two noncontiguous symptomatic levels of CDDD underwent skip-level ACDFs. In Group NoPlate, 23 cases underwent 2 noncontiguous levels of ACDF using zero-profile anchored spacer; and in Group Plate, 21 cases underwent 2 noncontiguous levels of ACDF using cages and plates. Operation-related paraeters for each group were recorded and compared. Japanese Orthopedic Association (JOA) scores and Neck Disability Index (NDI) scores at preoperation and postoperation were compared with at least a 2-year follow-up. Cervical lordosis was analyzed before surgery, 1 month after surgery, 3 months after surgery, and at final follow-up. RESULTS: Mean follow-up was 35.4 ± 6.5 (range 24-48) months. Significant improvement on the JOA, NDI scores and cervical lordosis was noted in each group (p < 0.05), and there were no significant difference in terms of JOA, NDI scores, cervical lordosis and fusion rate between the two groups (P > 0.05). The operation time in Group NoPlate was significantly shorter than in Group Plate (p < 0.05), and the incidence of dysphagia and adjacent segment degeneration in Group NoPlate was significantly lower than in Group Plate (p < 0.05). CONCLUSIONS: ROI-C and cages with plate fixation were both effective in two-level noncontiguous ACDF, and there were no significant difference in clinical outcomes, fusion rate, and cervical lordosis. However, ROI-C was associated with shorter operative time, lower incidence of dysphagia and adjacent segment degeneration.

Anterior cervical discectomy and fusion with stand-alone anchored cages versus posterior laminectomy and fusion for four-level cervical spondylotic myelopathy: a retrospective study with 2-year follow-up.

BACKGROUND: The optimal treatment for multi-level cervical spondylotic myelopathy (CSM) remains controversial. Posterior approach is most commonly used, but complicated with insufficient decompression and postoperative axial neck pain. The anterior approach is effective in neural decompression with less surgical trauma. However, the profile of the plate or the possible construct failure may cause dysphagia after surgery. Recently, anterior cervical discectomy and fusion (ACDF) with self-anchored cage is reported to have a superior result over ACDF with anterior plates and screws in three-level CSM. The purpose of the study is to compare the clinical and radiological outcomes of ACDF using stand-alone anchored cages to that of laminectomy with fusion (LF) for treating four-level CSM. METHODS: Twenty-six patients underwent four-level ACDF (Group A) and 32 patients with four-level LF (Group B) were retrospectively reviewed and followed-up for 24 months. Clinical efficacy was evaluated by comparing pre- and post-operative Japanese Orthopedic Association (JOA) and Neck Disability Index (NDI) scores. Operative time, blood loss, fusion, lordosis change and complications were evaluated. RESULTS: There was significantly less blood loss in Group A (163.4 ± 72.1 ml) than Group B (241.0 ± 112.3 ml) (P < 0.05). Both groups demonstrated significant improvements in JOA and NDI scores after surgery with similar operative time. Improvements in cervical lordosis and fused segment lordosis were more pronounced in Group A (11.3 ± 5.9°, 9.7 ± 5.3°) than Group B (5.8 ± 4.6°, 5.5 ± 4.5°) (P < 0.05). Loss of lordosis in the cervical spine and fused segment was more prominent in Group A (11.7 ± 2.2°, 6.7 ± 3.2°) than Group B (7.5 ± 3.8°, 3.7 ± 3.4°) (P < 0.05) at the final follow-up. Complication rate in Group A and Group B was 57.69 and 18.75%, respectively. CONCLUSIONS: ACDF using a stand-alone anchored cage showed similar clinical results to LF for the treatment of four-level CSM, with better lordosis correction and less blood loss. However, ACDF was associated with more loss of lordosis after surgery and more non-unions.

Mid- to long-term outcomes after cervical disc arthroplasty compared with anterior discectomy and fusion: a systematic review and meta-analysis of randomized controlled trials.

PURPOSE: To evaluate the mid- to long-term clinical outcomes after cervical disc arthroplasty (CDA) as compared with anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic cervical disc disease. METHODS: A systematic review and a meta-analysis were performed for articles published up to March 2013. Randomized controlled trials that reported mid- to long-term outcomes (≥48 months) after CDA as compared with ACDF were included. Two authors independently extracted the articles and the predefined data. RESULTS: Five US Food and Drug Administration randomized controlled trials that reported 4-6 years of follow-up data were retrieved. Patients who underwent CDA had a lower mid- to long-term rate of reoperation and had greater mid- to long-term improvements in the Neck Disability Index, neck and arm pain scores, and Short Form 36 Health Survey physical component score than did those who underwent ACDF. Segmental motion was maintained in patients who underwent CDA. The mid- to long-term rates of adjacent segment disease and neurological success were not significantly different between the two groups. CONCLUSIONS: CDA may result in better mid- to long-term functional recovery and a lower rate of subsequent surgical procedures than ACDF would. A review of the literature showed that only an insufficient number of studies had investigated adjacent segment disease; therefore, it is mandatory that adequate future research should focus in this direction.

Evaluation of a center of excellence program for spine surgery.

BACKGROUND: The Centers for Medicare and Medicaid Services and many private health plans are encouraging patients to seek orthopedic care at hospitals designated as centers of excellence. No evaluations have been conducted to compare patient outcomes and costs at centers of excellence versus other hospitals. The objective of our study was to assess whether hospitals designated as spine surgery centers of excellence by a group of over 25 health plans provided higher quality care. METHODS: Claims representing approximately 54 million commercially insured individuals were used to identify individuals aged 18-64 years with 1 of 3 types of spine surgery in 2007-2009: 1-level or 2-level cervical fusion (referred to as cervical simple fusion), 1-level or 2-level lumbar fusion (referred to as lumbar simple fusion), or lumbar discectomy and/or decompression without fusion. The primary outcomes were any complication (7 complications were captured) and 30-day readmission. The multivariate models controlled for differences in age, sex, and comorbidities between the 2 sets of hospitals. RESULTS: A total of 29,295 cervical simple fusions, 27,214 lumbar simple fusions, and 28,911 lumbar discectomy/decompressions were identified, of which 42%, 42%, and 47%, respectively, were performed at a hospital designated as a spine surgery center of excellence. Designated hospitals had a larger number of beds and were more likely to be an academic center. Across the 3 types of spine surgery (cervical fusions, lumbar fusions, or lumbar discectomies/decompressions), there was no difference in the composite complication rate [OR 0.90 (95% CI, 0.72-1.12); OR 0.98 (95% CI, 0.85-1.13); OR 0.95 (95% CI, 0.82-1.07), respectively] or readmission rate [OR 1.03 (95% CI, 0.87-1.21); OR 1.01 (95% CI, 0.89-1.13); OR 0.91 (95%, CI 0.79-1.04), respectively] at designated hospitals compared with other hospitals. CONCLUSIONS: On average, spine surgery centers of excellence had similar complication rates and readmission rates compared with other hospitals. These results highlight the importance of empirical evaluations of centers of excellence programs.

Comparative analysis of 3 different construct systems for single-level anterior cervical discectomy and fusion: stand-alone cage, iliac graft plus plate augmentation, and cage plus plating.

STUDY DESIGN: A retrospective cohort-nested longitudinal study. OBJECTIVE: To evaluate radiologic and clinically functional outcomes after single-level anterior cervical discectomy and fusion (ACDF) using 3 different fusion construct systems applying an accurate and reliable methodology. SUMMARY OF BACKGROUND DATA: ACDF is an established procedure that uses 3 different fusion construct systems: cage alone (CA), iliac tricortical bone block with plate (IP), and cage with plate construct (CP). The outcome of a previous study is quite different and did not correlate with experimental studies. METHODS: ACDF was performed on 158 patients (90 male and 68 female), who were followed up for >12 months. The patients were divided into the following 3 treatment groups: CA, IP, and CP. Factors related to outcome were also evaluated. Fusion rate, subsidence rate, and cervical angles were used to measure radiologic outcome. The Odom criteria and the visual analog scale were used to evaluate the clinical outcome. RESULTS: The fusion rate was higher for patients in the IP (87.1%) and CP (79.5%) groups than for those in the CA group (63.2%) after 12 months of follow-up (P=0.019). The subsidence rate was lower for patients in the IP (28.1%) and CP (38.5%) groups than for those in the CA group (58.6%) (P=0.010). Subsidence occurred for the anterior height regardless of constructs. Radiating arm pain showed greater relief in the CP group than in the CA group (P=0.015). It improved more in the CP group than in the IP group, but the differences were not statistically significant (P=0.388). Other clinical outcomes did not show significant differences. CONCLUSIONS: The trend of excellent radiologic outcome was observed for IP≥CP>CA. Plating may play a key role in the support of anterior height. As a result, plating prevents segmental kyphosis and subsidence and promotes bone fusion. Although the overall clinical outcomes were not different among the 3 groups, except for arm pain, more favorable trends regarding clinical outcome were observed for CP≥IP>CA.

Polyetheretherketone interbody cages versus autogenous iliac crest bone grafts with anterior fixation for cervical disc disease.

OBJECTIVE: The aim of this study was to compare the fusion rate, operation time, recovery of disc space height, clinical duration and improvement, return to activities of daily living, and complication rate associated with anterior cervical discectomy with interbody fusion by using polyetheretherketone cages or autogenous iliac crest bone grafts as disc replacement in a series of 60 patients. MATERIALS AND METHODS: Between November 2006 and February 2010 a retrospective analytical observational cohort study was carried out in 60 consecutive patients surgically treated with anterior cervical discectomy with interbody fusion for degenerative disc desease at the Neurosurgical Department of the Hospital Italiano de Buenos Aires. The patients were divided into 2 groups for the assessment of clinical characteristics, demographics, fusion rates, duration of surgical procedure, neurological and functional outcomes, imaging results, and complications. Group A included patients treated with autogenous iliac crest bone grafts, and group B included patients treated with polyetheretherketone cages. RESULTS: The mean age of the patients was 50.8 years. Female patients comprised the majority in both groups (63.3%). Cervicobrachialgia was the most common presentation. Clinical improvement, fusion rates, and recovery of disc space height were similar in both groups. The operation time was significantly shorter in the polyetheretherketone group (P<0.001). Twenty percent (n=6) of the patients in group A suffered complications, >80% of which were associated with iliac crest bone graft harvesting. Patients in group B had no complications (P<0.05). CONCLUSIONS: Although outcomes were very successful in both groups in terms of fixation stability, recovery of disc space, return to activities of daily living and work, and remission of symptoms, operation time was considerably shorter for patients in the polyetheretherketone group, who had none of the complications associated with iliac crest bone graft harvesting, both differences being statistically significant.

Can we define success criteria for lumbar disc surgery? : estimates for a substantial amount of improvement in core outcome measures.

BACKGROUND AND PURPOSE: A successful outcome after lumbar discectomy indicates a substantial improvement. To use the cutoffs for minimal clinically important difference (MCID) as success criteria has a large potential bias, simply because it is difficult to classify patients who report that they are "moderately improved". We propose that the criteria for success should be defined by those who report that they are "completely recovered" or "much better". METHODS: A cohort of 692 patients were operated for lumbar disc herniation and followed for one year in the Norwegian Registry for Spine Surgery. The global perceived scale of change was used as an external criterion, and success was defined as those who reported that they were "completely recovered" or "much better". Criteria for success for each of (1) the Oswestry disability index (ODI; score range 0-100 where 0 = no disability), (2) the numerical pain scale (NRS; range 0-10 where 0 = no pain) for back and leg pain, and (3) the Euroqol (EQ-5D; -0.6 to 1 where 1 = perfect health) were estimated by defining the optimal cutoff point on receiver operating characteristic curves. RESULTS: The cutoff values for success for the mean change scores were 20 (ODI), 2.5 (NRS back), 3.5 (NRS leg), and 0.30 (EQ-5D). According to the cutoff estimates, the proportions of successful outcomes were 66% for the ODI and 67% for the NRS leg pain scale. INTERPRETATION: The sensitivity/specificity values for the ODI and leg pain were acceptable, whereas they were very low for the EQ-5D. The cutoffs for success can be used as benchmarks when comparing data from different surgical units.

Expert's comment concerning Grand Rounds case entitled "L5-S1 disc replacement after two previous fusion surgeries for scoliosis" (by S. Jehan, S. Elsayed, J. Webb and B. Boszczyk).

The attempt to preserve motion below a long fusion is certainly praiseworthy even if it is clearly understood with the patient that the result might be only temporary, buying some good years in the most active part of life. The analysis of the case presented here suggests that such an approach could be recommended in the right patient, with the right team. More experience and reports are necessary to evolve from an anecdotal report to a new path in the treatment of adult scoliosis.

L5-S1 disc replacement after two previous fusion surgeries for scoliosis.

Following scoliosis surgery, lumbar motion segment degeneration below the level of fusion is not uncommon. Especially long fusions extending to the mid and lower lumbar spine increase the likelihood of degeneration of the remaining motion segments. The management for these patients is controversial and depends on the clinical presentation and level of degeneration. The increasing confidence in motion-preserving technology leads to a dilemma on whether to fuse the remaining lumbar levels or risk utilising disc arthroplasty to preserve the remaining motion segments and facilitate coronal balance in patients with previous long fusion for scoliosis. We present an interesting case of a 44-year-old lady, who underwent two-stage corrective surgery for progressive idiopathic scoliosis at the age of 22 years. In the first stage, she had T11-L3 anterior fusion, whilst in the second stage posterior fusion was done from T5 to L3. At 22 years after the initial surgery, she presented with worsening low back pain and bilateral L4 radicular symptoms. MRI scan confirmed severe disc degeneration at L3-4 and L5-S1 levels with preserved L4-5 disc. She initially underwent L3-L4 decompression and posterolateral fusion at that level, which relieved her radicular symptoms. However, she had persistent pain at the lumbosacral junction with Modic I changes. The options of an anterior L5-S1 fusion or disc replacement were considered and discussed with the patient. The disc replacement option was decided upon with the patient, as anterior fusion was judged to increase the risk of coronal imbalance. At the 1-year follow-up, she reported significant improvement in the back pain. The radiographs at 1 year showed satisfactory position and function of the artificial disc replacement. The disc was flexed laterally, accommodating the coronal balance of the spine. We conclude that L5-S1 motion segment can be preserved with artificial disc replacement in patients with previous long fusion for scoliosis surgery. The real difficulty arises when choosing between disc replacement and extension of fusion. In our patient, the disc replacement has worked well so far. However, the disc is clearly at a mechanical disadvantage, and loss of function in the mid- or long term would not be surprising.

Intraoperative neuromonitoring for one-level lumbar discectomies is low yield and cost-ineffective.

BACKGROUND: Intraoperative neuromonitoring is a common, well-established modality used in spine surgery to prevent intraoperative neural injury. Neuromonitoring use in lumbar discectomy, however, is based on surgeon preference, without evidence-based data. The purpose of this research was to determine intraoperative utility and overall cost effectiveness of neuromonitoring for lumbar discectomy. METHODS: We retrospectively reviewed adult patients who underwent a lumbar discectomy, with at least 1 month of follow-up at a single tertiary care center. Patient age, sex, body mass index (BMI), lumbar level operated, and operative time and cost were collected. Neuromonitoring and operative reports were reviewed for any electromyography (EMG) abnormalities noted intraoperatively, pre- and post-operative motor exam and post-operative pain relief were collected. RESULTS: Ninety-one (47 with and 44 without neuromonitoring) lumbar discectomy cases were reviewed. There was no significant difference between mean age, sex, and BMI between the two groups. There was a significant (p = 0.006) increase in operating room time (174 min; with vs. 144 min; without neuromonitoring). Neuromonitoring was associated with a significant (p = 0.006) overall operative cost ($21,949; with vs. $18,064; without). Of the 47 cases with neuromonitoring; one had abnormal intraoperative EMG activity, which returned to normal by case conclusion. No patient in either group demonstrated new post-operative motor weakness. There was no difference in the number of patients who endorsed post-operative pain relief between the two groups. CONCLUSIONS: Neuromonitoring for lumbar discectomy confers greater operative time and cost, without any difference in neurological outcome.

Posterior percutaneous endoscopic versus traditional surgery for cervical disc herniation: A protocol for systematic review and meta analysis.

BACKGROUND: Posterior percutaneous endoscopic cervical diskectomy (P-PECD) can be used posterior microdiscectomy for cervical disc herniation. But only some small sample sizes of clinical studies have evaluated the efficacy and safety of P-PECD. This study aim to evaluated the efficacy and safety of P-PECD compared with traditional open surgery. METHODS: We will search the following seven electronic databases from their initiation to the May 1, 2020: PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM) and Wanfang database. All randomized controlled trials, non-randomized controlled trials and retrospective case controls that compared the efficacy and safety of P-PECD and traditional open surgery in the treatment of cervical disc herniation will be included. The pooled odds ratio with 95% credible intervals (CIs) was used for the dichotomous variables. The mean difference with 95% CIs was used for the continuous variables. All analyses were conducted by Comprehensive Meta Analysis 2.0. A 2-tailed P value < 0.05 is considered statistically significant. RESULTS: The results of systematic review and meta-analysis will be submitted to a peer-reviewed journal. CONCLUSION: Our study will provide clarity regarding for clinicians to choices best surgical approach for patients with cervical disc herniation. Any changes that need to be made during the process of this study will be explained in the final full-text publication. PROTOCOL REGISTRATION NUMBER: CRD42020164011.

Comparison of 2-year follow-up results of the hybrid surgery using Mobi-C combined with ROI-C and anterior cervical discectomy and fusion for the treatment of contiguous two-level cervical degenerative disc diseases.

Although the Mobi-C artificial disc and the ROI-C cervical cage have been widely used in the treatment of cervical degenerative disc diseases (CDDD), few reports addressed the features of combined application of both devices. This study is aimed at comparing the clinical and radiological outcomes of treating contiguous two-level CDDD using Mobi-C and ROI-C combined in a hybrid surgery (HS) with anterior cervical discectomy and fusion (ACDF) using ROI-C. We reviewed ninety-one patients who underwent HS (n = 48) or ACDF (n = 43) surgery for symptomatic contiguous two-level CDDD. >2 years' clinical and radiological outcomes were reviewed and evaluated retrospectively. At the last follow-up, significant improvement in the mean VAS, JOA, and NDI scores was found both in the HS and ACDF groups (p < 0.05), while the differences between groups were not significant (p > 0.05). The global range of motion (ROM) in the HS group was significantly larger than that in the ACDF group (p < 0.05). The local lordosis improved significantly after surgery in all patients (p < 0.05). Bone resorption and heterotopic ossification (HO) were found after surgery. The result showed that, for the selected patients, HS may provide an alternative approach for the treatment of contiguous two-level CDDD. HS also offers the benefit of both greater global ROM and greater ROM at the Mobi-C index level. Some degree of bone resorption may be an integral component in the early stage of bony fusion in the cage index level. Further studies and long-term follow-up are still needed.

Microdiscectomy compared with standard discectomy: an old problem revisited with new outcome measures within the framework of a spine surgical registry.

Studies comparing the relative merits of microdiscectomy and standard discectomy report conflicting results, depending on the outcome measure of interest. Most trials are small, and few have employed validated, multidimensional patient-orientated outcome measures, considered essential in outcomes research. In the present study, data were collected prospectively from six surgeons participating in a surgical registry. Inclusion criteria were: lumbar/lumbosacral degenerative disease; discectomy/sequestrectomy without additional fusion/stabilisation; German or English-speaking. Before and 3 and 12 months after surgery, patients completed the Core Outcome Measures Index comprising questions on leg/buttock pain, back pain, back-related function, symptom-specific well-being, general quality-of-life, and social and work disability. At follow-up, they rated overall satisfaction, global outcome, and perceived complications. Compliance with the registry documentation was excellent: 87% for surgeons (surgery forms), 91% for patients (for 12 months follow-up). 261 patients satisfied the inclusion criteria (225 microdiscectomy, 36 standard discectomy). The standard discectomy group had significantly greater blood-loss than the microdiscectomy (P < 0.05). There were no group differences in the proportion of surgical complications or duration of hospital stay (P > 0.05). The groups did not differ in relation to any of the patient-orientated outcomes or individual outcome domains (P > 0.05). Though not equivalent to an RCT, the study included every single eligible patient in our Spine Center and allowed surgeons to use their regular procedure; it hence had extremely high external validity (relevance/generalisability). There was no clinically relevant difference in outcome after lumbar disc excision dependent on the use of the microscope. The decision to use the microscope should rest with the surgeon.

Changing Trends and Challenges of Spine Surgery in a Developing Country.

BACKGROUND: Spine conditions are common and the surgery is evolving even in developed economies. This study aims to review the changing trends and challenges of spine surgery, particularly from a low-income country. METHODS: This is a retrospective study of patients who were surgically treated for spine conditions in Enugu, Nigeria. Patient records from 2006 to 2016 were reviewed. Relevant clinical information was extracted from the operation theater logbooks and patient case files. RESULTS: A total of 463 spine surgical procedures were carried out on the same number of patients. The number of treated patients has been on the increase and shows a male predominance. Pediatric spine cases accounted for 1.5%, adult/middle aged patients accounted for 77.8%. Degenerative conditions, trauma, and neoplasms were the most frequent indications for operation, accounting for 52.3%, 30.5%, and 11.4%, respectively. The most commonly operated region was cervical and lumbar regions among male (49.3%) and female (51.8%) patients, respectively. Spine fixation was required in 137 patients (29.6%). A paradigm shift from trauma to degenerative conditions among patients was noted after 2010. Prior to 2009, spine wiring techniques were the most common spine stabilizing method, but from 2011 to 2013 anterior cervical discectomy and anterior cervical discectomy and fusion predominated, and thereafter pedicle screws predominated. Cost implications, lack of trained personnel, and lack of and basic equipment pose significant challenges to spine care. CONCLUSIONS: The trend in spinal surgery has improved rapidly and consistently in Nigeria over the 10 years of the study and is related to increasing expertise, more available facilities, and implant availability.

Assessment of the Reliability of the Fiberoptic Endoscopic Evaluation of Swallowing as an Outcome Measure in Patients Undergoing Revision Anterior Cervical Discectomy and Fusion.

BACKGROUND: Dysphagia is one of the most common complications of anterior cervical spine surgery, and there is a need to establish that the means of testing for it are reliable and valid. The objective of this study was to measure observer variability of the fiberoptic endoscopic evaluation of swallowing (FEES) test, specifically when used for evaluation of dysphagia in patients undergoing revisionary anterior cervical decompression and fusion (ACDF). METHODS: Images from patients undergoing revision ACDF at a single institution were collected from May 1, 2010, through July 1, 2014. Two senior certified speech pathologists independently evaluated the swallowing function of patients preoperatively and at 2 weeks postoperatively. Their numeric evaluations of the Rosenbeck Penetration-Aspiration Scale and the Swallowing Performance Scale during the FEES were then compared for interrater reliability. RESULTS: Positive agreement between raters was 94% for the preoperative Penetration-Aspiration Scale (prevalence-adjusted bias-adjusted κ, 0.77). The postoperative Penetration-Aspiration Scale showed reliability coefficients for κ, Kendall's W, and intraclass correlation coefficient (ICC) of 0.34 (fair agreement), 0.70 (extremely strong agreement), and 0.35 (poor agreement), respectively. The preoperative Swallowing Performance Scale showed strong agreement, with a Kendall's W coefficient of 0.68, and fair reliability, with an ICC of 0.40. The postoperative Swallowing Performance Scale indicated extremely strong agreement between raters, with a Kendall's W of 0.82, and good agreement, with an ICC of 0.53. CONCLUSIONS: The FEES test appears to be a reliable assessor of dysphagia in patients undergoing ACDF and may be a useful measure for exploring outcomes in this population.

A Comparison of Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion in Patients with Two-Level Cervical Degenerative Disc Disease: 5-Year Follow-Up Results.

OBJECTIVE: To present a long-term clinical and radiographic comparison between the Prestige LP cervical disc replacement and the Zero-P spacer cervical disc fusion in the treatment of patients with symptomatic 2-level cervical degenerative disease. METHODS: In total, 36 patients in the anterior cervical discectomy and fusion (ACDF) group and 24 patients in the cervical disc arthroplasty (CDA) group were analyzed before surgery and at 1 week and 3, 6, 12, 24, and 60 months after surgery. Clinical assessments included the Japanese Orthopaedic Association score, visual analog scale, and Neck Disability Index scores. Radiographic assessments included cervical lordosis, range of motion (ROM) of the total cervical spine, functional spinal unit (FSU), and superior and inferior adjacent segments. Complications including heterotopic ossification and adjacent-segment degeneration (ASD) at 5-year follow-up were collected as well. RESULTS: Mean follow-up period was 65.6 months. Both the ACDF and CDA groups showed significant clinical improvements in terms of Japanese Orthopaedic Association score, visual analog scale, and Neck Disability Index (P < 0.05), but there was no significant difference between groups at the last follow-up period. A significant increase of cervical lordosis was observed in the CDA group after surgery whereas a significant difference was not observed between groups. ROM of the total cervical spine and FSU were maintained during the follow-up, and a significant decrease was observed in the ACDF group after surgery (P < 0.05). The ROM of the superior adjacent segment did not show any difference whereas the ROM of the inferior adjacent segment in the ACDF group presented a significant increase at 6 months and 1 year after surgery and a significant decrease at the last follow-up period. A total of 8 (33.3%) patients in the CDA group had an occurrence of heterotopic ossification. ASD was observed in 2 (8.3%) patients who underwent CDA surgery and 8 (22.2%) patients who underwent ACDF surgery. CONCLUSIONS: The use of the Prestige-LP and ZERO-P Spacer implantations is safe and effective. At 5 years after surgery, CDA with Prestige-LP is superior in terms of ROM of the total cervical spine, FSU, and inferior adjacent segment. It also has a relatively low occurrence rate of ASD. This procedure may be a suitable choice for the treatment of contiguous 2-level CDDD.

Three-Dimensional, High-Definition Exoscopic Anterior Cervical Discectomy and Fusion: A Valid Alternative to Microscope-Assisted Surgery.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) remains one of the most commonly taught procedures during residency and one of the most frequently performed by neurosurgeons. Neurosurgeons use microscopes to perform surgery and to train other surgeons. Although the microscope provides excellent illumination and magnification, its use will be limited to 2 people: the surgeon and the assistant. Consequently, the scrub nurse and residents watching 2-dimensional images on monitors will have a reduced perception of the surgical field depth and anatomical details. The exoscope has been introduced as an alternative to microscopes and endoscopes. We used a 3-dimensional (3D), high-definition exoscope (3D Vitom [Karl Storz, Tuttlingen, Germany]) in 2 patients undergoing 2-level ACDF for cervical myeloradiculopathy. METHODS: The exoscope was used during soft tissue dissection, discectomy, osteophytectomy, and cage insertion. Microsurgical drilling of the posterior osteophytes, which will usually require adequate magnification and proper microscope angulation, was also performed using the exoscope. RESULTS: The exoscope provided a 3D view of the surgical field similar to that provided by a microscope and allowed us to effectively and safely perform the required surgical steps. The main advantage of 3D exoscope-assisted surgery, compared with microscope-assisted surgery, is the possibility to generate videos with a similar view and image quality as perceived by the surgeon. Therefore, the didactic capabilities of exoscopic videos are greater than those provided by microscopic videos. Exoscopes are also smaller compared with microscopes, allowing for comfortable use from the early surgical steps to device implantation. CONCLUSION: We believe that exoscope-assisted surgery could become a safe and effective alternative to microscope-assisted surgery in ACDF.

Cost-effectiveness of a Bone-anchored Annular Closure Device Versus Conventional Lumbar Discectomy in Treating Lumbar Disc Herniations.

STUDY DESIGN: Cost-utility analysis of an annular closure device (ACD) based on data from a prospective, multicenter randomized controlled trial (RCT) OBJECTIVE.: The aim of this study was to determine the cost-effectiveness of a novel ACD in a patient population at high risk for recurrent herniation following discectomy. SUMMARY OF BACKGROUND DATA: Lumbar disc herniation patients with annular defect widths ≥6 mm are at high risk for recurrent herniation following limited discectomy. Recurrent herniation is associated with worse clinical outcomes and greater healthcare costs. A novel ACD may reduce the incidence of recurrent herniation and the associated burdens. METHODS: A decision analytical modeling approach with a Markov method was used to evaluate the cost-effectiveness of the ACD versus conventional discectomy. Health states were created by projecting visual analogue scale (VAS) onto Oswestry Disability Index (ODI). Direct costs were calculated based on Humana and Medicare 2014 claims to represent private and public payer data, respectively. Indirect costs were calculated for lost work days using 2016 US average annual wages. The incremental cost-effectiveness ratio (ICER) in dollars per quality-adjusted life year (QALY) was compared to willingness-to-pay thresholds. Sensitivity analyses were also conducted. RESULTS: Patients with the ACD had less symptomatic reherniations, reoperations, and complications and gained 0.0328 QALYs within the first 2 years. Total direct medical costs for the ACD group were similar to control. When productivity loss was considered, using the ACD became $2076 cheaper, per patient, than conventional discectomy. Based on direct costs alone, the ICER comparing ACD to control equaled $6030 per QALY. When indirect costs are included, the ICER became negative, which indicates that superior quality of life was attained at less cost. CONCLUSION: For lumbar disc herniations patients with annular defects ≥6 mm, the ACD was, at 2 years, a highly cost-effective surgical modality compared to conventional lumbar discectomy. LEVEL OF EVIDENCE: 1.

Surgical approach to cervical spondylotic myelopathy on the basis of radiological patterns of compression: prospective analysis of 129 cases.

This is a prospective analysis of 129 patients operated for cervical spondylotic myelopathy (CSM). Paucity of prospective data on surgical management of CSM, especially multilevel CSM (MCM), makes surgical decision making difficult. The objectives of the study were (1) to identify radiological patterns of cord compression (POC), and (2) to propose a surgical protocol based on POC and determine its efficacy. Average follow-up period was 2.8 years. Following POCs were identified: POC I: one or two levels of anterior cord compression. POC II: one or two levels of anterior and posterior compression. POC III: three levels of anterior compression. POC III variant: similar to POC III, associated with significant medical morbidity. POC IV: three or more levels of anterior compression in a developmentally narrow canal or with multiple posterior compressions. POC IV variant: similar to POC IV with one or two levels, being more significant than the others. POC V: three or more levels of compression in a kyphotic spine. Anterior decompression and reconstruction was chosen for POC I, II and III. Posterior decompression was chosen in POC III variant because they had more incidences of preoperative morbidity, in spite of being radiologically similar to POC III. Posterior surgery was also performed for POC IV and IV variant. For POC IV variant a targeted anterior decompression was considered after posterior decompression. The difference in the mJOA score before and after surgery for patients in each POC group was statistically significant. Anterior surgery in MCM had better result (mJOA = 15.9) versus posterior surgery (mJOA = 14.96), the difference being statistically significant. No major graft-related complications occurred in multilevel groups. The better surgical outcome of anterior surgery in MCM may make a significant difference in surgical outcome in younger and fitter patients like those of POC III whose expectations out of surgery are more. Judicious choice of anterior or posterior approach should be made after individualizing each case.