CO2 surgical laser for treatment of stress urinary incontinence in women: a randomized controlled trial.

BACKGROUND: Stress urinary incontinence is a common condition that can be treated conservatively and/or surgically. Given the risks of surgery, developing effective nonsurgical treatment options would be beneficial. Some studies have suggested that laser therapy may improve or cure stress urinary incontinence. However, there is a lack of sham-controlled randomized controlled trials to judge treatment efficacy. OBJECTIVE: This study aimed to compare the effects of CO2 vaginal laser vs sham therapy for treating stress urinary incontinence. STUDY DESIGN: This was a multicenter, participant-blinded, sham-controlled, parallel group (1:1) superiority randomized controlled trial performed in outpatient clinics in 2 hospitals. We included women aged 18 to 80 years with objective and subjective stress urinary incontinence. Participants had undertaken or declined supervised pelvic floor muscle training. Intervention was performed using a CO2 fractionated vaginal laser. Participants underwent 3 treatments, 4 weeks apart, with increasing energy and density settings. Sham treatment was performed using an identical technique with a deactivated pedal. The primary outcome was the subjective stress urinary incontinence rate (proportion with leak with cough, sneeze, or laughter) at 3 months after completion of treatment. Secondary outcomes included objective stress urinary incontinence, change in the disease-specific patient-reported outcomes, health-related quality of life, and adverse effects. Categorical outcomes were compared using the chi square test and continuous outcomes using analysis of covariance, adjusting for the baseline score. RESULTS: There were 52 participants who received laser and 49 who received sham treatment. One participant in each group withdrew from the study before the endpoint, and 2 participants in the laser group did not participate in the follow-up visits. Participant mean age was 53 (34-79) years. Mean body mass index was 26.1 (18.1-49.6); 90% were vaginally parous. At 3 months, there was no difference between the sham and active treatment arm in subjective stress urinary incontinence (46 [96%] vs 48 [98%]; relative risk, 0.98 [95% confidence interval, 0.91-1.05]; P=.55) or in objective stress urinary incontinence (37 [80%] vs 33 [80%]; relative risk, 0.99 [95% confidence interval, 0.81-1.23]; P=.995). Patient-reported outcomes and health-related quality of life were also comparable between the groups. Vaginal bleeding occurred in 3 participants after laser and 1 participant after sham treatment. Pain during treatment did not differ between laser and sham treatment. CONCLUSION: We were unable to show an improvement in stress urinary incontinence after CO2 vaginal laser therapy compared with sham treatment.

Nonperturbative Infrared Finiteness in a Superrenormalizable Scalar Quantum Field Theory.

We present a study of the IR behavior of a three-dimensional superrenormalizable quantum field theory consisting of a scalar field in the adjoint of SU(N) with a φ^{4} interaction. A bare mass is required for the theory to be massless at the quantum level. In perturbation theory, the critical mass is ambiguous due to IR divergences, and we indeed find that at two loops in lattice perturbation theory the critical mass diverges logarithmically. It was conjectured long ago in [R. Jackiw et al., Phys. Rev. D 23, 2291 (1981)PRVDAQ0556-282110.1103/PhysRevD.23.2291, T. Appelquist et al., Phys. Rev. D 23, 2305 (1981)PRVDAQ0556-282110.1103/PhysRevD.23.2305] that superrenormalizable theories are nonperturbatively IR finite, with the coupling constant playing the role of an IR regulator. Using a combination of Markov Chain Monte Carlo simulations of the lattice-regularized theory, frequentist and Bayesian data analysis, and considerations of a corresponding effective theory, we gather evidence that this is indeed the case.

What if there were no tapes?

It is possible that the controversy involving prostheses implanted into women with pelvic floor problems might result in the majority of, or even all such products being restricted, banned or withdrawn in certain jurisdictions. A clear distinction between "tapes" for urinary incontinence and "mesh" for prolapse has been made in the enquiries and subsequent rulings in Australia and New Zealand. Transvaginal "mesh" will be unavailable with the range of "tapes" much more restricted in those countries from January 2018. The Chair of the all-party parliamentary group on surgical mesh implants in the United Kingdom was reported as describing the New Zealand announcement as "hugely significant" and "it's precisely what we've been calling for the UK." The title of this article has changed from a hypothetical piece to a potential reality review. Where does that leave the clinicians treating stress urinary incontinence (SUI) and the large number of female sufferers? "Tapes" (synthetic midurethral slings-MUS) have become very popular over the last 20 years since their original development and introduction in Scandanavia. Evidence-based medicine has shown their advantages over previous surgeries, in terms of ease of use, safety and efficacy. This article outlines the options which countries potentially rejecting the use of tapes, must now resort to for women with SUI. Those countries considering such action need the note of caution that none of the options are as good as tapes.

Exotic grasses and nitrate enrichment alter soil carbon cycling along an urban-rural tropical forest gradient.

Urban areas are expanding rapidly in tropical regions, with potential to alter ecosystem dynamics. In particular, exotic grasses and atmospheric nitrogen (N) deposition simultaneously affect tropical urbanized landscapes, with unknown effects on properties like soil carbon (C) storage. We hypothesized that (H1) soil nitrate (NO3 (-) ) is elevated nearer to the urban core, reflecting N deposition gradients. (H2) Exotic grasslands have elevated soil NO3 (-) and decreased soil C relative to secondary forests, with higher N promoting decomposer activity. (H3) Exotic grasslands have greater seasonality in soil NO3 (-) vs. secondary forests, due to higher sensitivity of grassland soil moisture to rainfall. We predicted that NO3 (-) would be positively related to dissolved organic C (DOC) production via changes in decomposer activity. We measured six paired grassland/secondary forest sites along a tropical urban-to-rural gradient during the three dominant seasons (hurricane, dry, and early wet). We found that (1) soil NO3 (-) was generally elevated nearer to the urban core, with particularly clear spatial trends for grasslands. (2) Exotic grasslands had lower soil C than secondary forests, which was related to elevated decomposer enzyme activities and soil respiration. Unexpectedly, soil NO3 (-) was negatively related to enzyme activities, and was lower in grasslands than forests. (3) Grasslands had greater soil NO3 (-) seasonality vs. forests, but this was not strongly linked to shifts in soil moisture or DOC. Our results suggest that exotic grasses in tropical regions are likely to drastically reduce soil C storage, but that N deposition may have an opposite effect via suppression of enzyme activities. However, soil NO3 (-) accumulation here was higher in urban forests than grasslands, potentially related to of aboveground N interception. Net urban effects on C storage across tropical landscapes will likely vary depending on the mosaic of grass cover, rates of N deposition, and responses by local decomposer communities.

Randomized trial of a single incision versus an outside-in transobturator midurethral sling in women with stress urinary incontinence: 12 month results.

OBJECTIVE: The objective of the study was to evaluate objective and subjective outcomes of MiniArc and Monarc (American Medical Systems, Minnetonka, MN) midurethral sling (MUS) in women with stress incontinence at 12 months. STUDY DESIGN: A total of 225 women were randomized to receive MiniArc or Monarc. Women with intrinsic sphincter deficiency, previous MUS, or untreated detrusor overactivity were excluded. Objective cure was defined as negative cough stress test with a comfortably full bladder. Subjective cure was defined as no report of leakage with coughing or exercise on questionnaire. Validated questionnaires, together with urodynamic and clinical cough stress test, were used to evaluate the objective and subjective outcomes following surgery. Participants and clinicians were not masked to treatment allocation. Outcomes were compared with exact binomial tests (eg, Fisher exact test for dichotomous data) for categorical data and Student t tests or exact versions of Wilcoxon tests for numerical data as appropriate. RESULTS: There was no statistically significant difference in the subjective (92.2% vs 94.2%; P = .78; difference, 2.0%; 95% confidence interval, -2.7% to +6.7%) or objective (94.4% vs 96.7%; P = .50; difference, 2.3%; 95% confidence interval, -1.5% to +6.1%) cure rates between MiniArc and Monarc at 12 m, respectively, with a significant improvement in overactive bladder outcomes and incontinence impact from baseline in both arms. CONCLUSION: MiniArc outcomes are not inferior to Monarc MUS outcomes at 12 months' follow-up in women without intrinsic sphincter deficiency.

Quantitative Comparison of Misregistration in Abdominal and Pelvic Organs Between PET/MRI and PET/CT: Effect of Mode of Acquisition and Type of Sequence on Different Organs.

OBJECTIVE: The objective of our study was to quantitatively compare misregistration in selected abdominopelvic organs between PET/CT acquisitions and simultaneous and sequential PET/MRI acquisitions. SUBJECTS AND METHODS: PET/MR images of 15 healthy volunteers and seven patients with bladder cancer were acquired. Ten clinical PET/CT studies acquired during the same time frame of body mass index-matched control subjects were chosen. PET/MRI and PET/CT registration of selected abdominopelvic organs was measured and compared. RESULTS: The overall mean misregistration with PET/MRI was significantly higher than that with PET/CT (p < 0.001). Sequential PET/MRI acquisition was significantly inferior to PET/CT (p = 0.02), whereas there was no significant difference between simultaneous PET/MRI acquisition and PET/CT (p = 0.38). Simultaneous PET/MRI acquisition was significantly better than sequential PET/MRI acquisition (p < 0.001). The mean misregistration for all organs with the T1-weighted volumetric interpolated breath-hold examination (VIBE) sequence (2.39 cm) was significantly inferior to PET/CT (p < 0.001). Although the T2-weighted HASTE breath-hold sequence was significantly inferior to PET/CT (p = 0.04), the T2 HASTE non-breath-hold sequence and T2 STIR sequence (0.18 cm) were significantly superior to both PET/CT and the T1 VIBE sequence (p < 0.001). Within the same sequence (T1 VIBE breath-hold sequence), the mean misregistrations with sequential and simultaneous PET/MRI acquisitions were both significantly greater than with PET/CT (p < 0.001), whereas simultaneous PET/MRI acquisition was superior to sequential PET/MRI acquisition (p < 0.001). CONCLUSION: In the abdominopelvic organs, sequentially obtained PET/MRI data have significantly higher misregistration than both PET/CT data and simultaneously acquired PET/MRI data. Simultaneously obtained PET/MRI data are statistically noninferior to PET/CT. Nonradial T1 VIBE has the highest misregistration, whereas T2 STIR and T2 HASTE non-breath-hold are significantly better than both PET/CT and T1 VIBE.

Functional outcomes following surgical management of pain, exposure or extrusion following a suburethral tape insertion for urinary stress incontinence.

INTRODUCTION AND HYPOTHESIS: Surgical revision of a tape inserted for urinary stress incontinence may be indicated for pain, or tape exposure or extrusion. This study assesses the clinical outcomes of revision surgery. METHODS: A retrospective review of 47 consecutive women who underwent surgical revision for the indications of pain, tape exposure or tape extrusion. RESULTS: Forty-seven women underwent revision. 29 women (62 %) had initial tape placement at another institution. Mean interval between placement and revision was 30 months. 39 women (83 %) had an identifiable tape exposure or extrusion with or without pain, while 8 women (17 %) presented with pain alone. 11 (23 %) of the tapes were infected clinically and histologically at revision, 10 of the 11 (90 %) being of a multifilament type. In 23 (49 %) cases, the revision aimed to completely remove the tape. Partial excision 24 (51 %) was reserved for localised exposures or extrusions where infection was not suspected. A concomitant continence procedure was performed in 9(19 %) at the time of tape revision. None of these 9 women has experienced recurrent stress urinary incontinence (SUI) compared with 11 out of 38 women (29 %) requiring further stress incontinence surgery when no continence procedure was performed (Fisher's exact p = 0.092). Eight out of 47 underwent revision surgery for pain with no identifiable exposure or extrusion; pain subsequently resolved in all 8 women. CONCLUSIONS: Excision is an effective treatment for tape exposure and pain whether infection is present or not. Tapes of a multifilament type are strongly associated with infection. When infection is present, complete sling removal is necessary. A concomitant procedure to prevent recurrent SUI should be considered if tape excision is planned and infection is not suspected.

Impact of Preoperative Intervertebral Disc Degeneration on Patient-Reported Outcome Measures After Lumbar Fusion.

OBJECTIVE: The Pfirrmann scoring system classifies lumbosacral disc degeneration based on magnetic resonance imaging signal intensity. The relationship between pre-existing disc degeneration and patient-reported outcome measures (PROMs) after one-level lumbar fusion is not well documented. The purpose of this study was to investigate the relationship between the severity of preoperative intervertebral disc degeneration and preoperative and postoperative PROMs in patients undergoing one-level lumbar fusion. METHODS: All adult patients who underwent posterior lumbar decompression and fusion or transforaminal lumbar interbody fusion between 2014 and 2022 were included. Patient demographics and comorbidities were extracted from medical records. Lumbar intervertebral discs on sagittal magnetic resonance imaging T2-weighted images were assessed by 2 independent graders utilizing Pfirrmann criteria. Grades I-III were categorized as low-grade disc degeneration, while IV-V were considered high grade. Multivariable linear regression assessed the impact of disc degeneration on PROMs. RESULTS: A total of 150 patients were included, of which 69 (46%) had low-grade disc degeneration, while 81 (54%) had high-grade degeneration. Patients with high-grade degeneration had increased preoperative visual analog scale (VAS)-Leg scores (6.10 vs. 4.54, P = 0.005) and displayed greater 1-year postoperative improvements in VAS-Back scores (-2.11 vs. -0.66, P = 0.002). Multivariable regression demonstrated Pfirrmann scores as independent predictors for both preoperative VAS-Leg scores (P = 0.004) and postoperative VAS-Back improvement (P = 0.005). CONCLUSIONS: In patients undergoing one-level lumbar fusion, higher Pfirmann scores were associated with increased preoperative leg pain and greater 1-year postoperative improvement in back pain. Further studies into the relationship of preoperative disc degeneration and their impact on postoperative outcomes may help guide clinical decision-making and patient expectations.

Which women develop urgency or urgency urinary incontinence following midurethral slings?

INTRODUCTION AND HYPOTHESIS: De novo urgency has a negative impact on women after midurethral sling (MUS). We aimed to identify risk factors for de novo urgency (dU) and urgency urinary incontinence (dUUI) following MUS, using multivariate analysis. METHODS: We investigated 358 consecutive women with only stress urinary incontinence (SUI) [or urodynamic stress incontinence (USI)] and 598 women with both SUI (or USI) and urgency (but not UUI) who underwent MUS with a mean follow-up of 50 months. Women who developed dU or dUUI at long-term follow-up were compared to those who did not. RESULTS: dU occurred in 27.7 % (99/358) and dUUI occurred in 13.7 % (82/598) of women at long-term follow-up after midurethral sling. Intrinsic sphincter deficiency {odds ratio (OR) dU 3.94 [95 % confidence interval (CI) 1.50-10.38]; OR dUUI 2.5 (1.31-4.80)}, previous stress incontinence surgery [sling: OR dU 3.69 (1.45-9.37); colposuspension: OR dUUI 2.5 (1.23-5.07)], previous prolapse surgery [OR dU 2.45 (1.18-5.10)], preexisting detrusor overactivity [OR dU 1.99 (1.15-3.48); OR dUUI 1.85 (1.31-2.60)] increased the risk, whereas performing concomitant apical prolapse surgery [OR dU 0.5 (0.41-0.81); OR dUUI 0.29 (0.087-0.97)] significantly decreased the risk. Women are more likely to not recommend surgery when they experienced dU (18.2 vs 0.8 %, p < 0.0001) or dUUI (20.7 vs 2.1 %, p < 0.0001). CONCLUSIONS: Urodynamic parameters, history of prior incontinence or prolapse surgery and concomitant apical prolapse operation were important predictors of dU or dUUI following MUS.

Does Facet Distraction Affect Patient Outcomes After ACDF?

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim of this study is to determine if there is a correlation between the amount of facet distraction and postoperative patient-reported outcomes after ACDF. METHODS: A retrospective cohort analysis of patients undergoing 1 to 3 level ACDF for degenerative pathologies at a single academic center was performed. Each patient received upright, lateral cervical spine x-rays at the immediate postoperative time point from which interfacet distance (facet distraction) was measured. Patient-reported outcome measures including NDI, PCS-12, MCS-12, VAS Neck, and VAS Arm pain scores were obtained preoperatively and at short-term (<3 months) and long-term (>1 year) follow-up. Receiver operating curves were generated to evaluate the possibility of a critical interfacet distraction distance. Univariate and multivariate analysis were performed to compare outcomes between groups based on the degree of facet distraction. RESULTS: A total of 229 patients met the inclusion criteria. Receiver operating curves failed to yield a critical interfacet distraction distance associated with worse post-operative outcomes. Patients were instead grouped based on facet distraction distance below and above the third quartile (0.8mm-2.0 mm, 2.0mm-3.7 mm), with 173 and 56 patients in each respective group. Univariate analysis did not detect any statistically significant differences in outcome measures, recovery ratio, or % MCID achievement at short- and long-term follow-up between groups. Multivariate analysis also failed to demonstrate any significant differences between the facet distraction groups. CONCLUSION: Increased interfacet distance did not correlate with increased neck pain or disability after an ACDF.

SIR Flat CAP (Safety In Radiology - Flat-Packed Compact Airborne Precaution): A Low-Cost, Portable, Negative-Pressure Isolation Barrier Shield for Protecting Frontline Healthcare Workers.

Introduction Multiple barrier shields have been described since the start of the COVID-19 pandemic. Most of these are bulky and designed for use in the main anesthetic or radiology departments. We developed a portable, negative-pressure barrier shield designed specifically for portable ultrasound examinations. A novel supine cough generation model was developed together with a reverse qualitative fit test to simulate real-world aerosol droplet generation and dispersion for evaluating the effectiveness of the barrier shield. We report the technical specifications of this design, named "SIR Flat CAP" from Safety In Radiology - Flat-packed Compact Airborne Precaution, as well as its performance in reducing the spread of droplets and aerosols.  Methods The barrier shield was constructed using 1 mm acrylic panels, clear packing tape, foam double-sided tape, and surgical drapes. Negative pressure was provided via hospital wall suction. A supine cough generation model was developed to simulate cough droplet dispersal. A reverse qualitative fit test was used to assess for airborne transmission of microdroplets. Results The supine cough generation model was able to replicate similar results to previously reported supine human cough generation dispersion. The use of the barrier shield with negative-pressure suction prevented the escape of visible droplets, and no airborne microdroplets were detected by reverse qualitative fit testing from the containment area. Conclusions The barrier shield significantly reduces the escape of visible and airborne droplets from the containment area, providing an additional layer of protection to front-line sonographers.

Utility of Seated Lateral Radiographs in the Diagnosis and Classification of Lumbar Degenerative Spondylolisthesis.

STUDY DESIGN: Retrospective cohort study. PURPOSE: Our goal was to determine which radiographic images are most essential for degenerative spondylolisthesis (DS) classification and instability detection. OVERVIEW OF LITERATURE: The heterogeneity in DS requires multiple imaging views to evaluate vertebral translation, disc space, slip angle, and instability. However, there are several restrictions on frequently used imaging perspectives such as flexion-extension and upright radiography. METHODS: We assessed baseline neutral upright, standing flexion, seated lateral radiographs, and magnetic resonance imaging (MRI) for patients identified with spondylolisthesis from January 2021 to May 2022 by a single spine surgeon. DS was classified by Meyerding and Clinical and Radiographic Degenerative Spondylolisthesis classifications. A difference of >10° or >8% between views, respectively, was used to characterize angular and translational instability. Analysis of variance and paired chi-square tests were utilized to compare modalities. RESULTS: A total of 136 patients were included. Seated lateral and standing flexion radiographs showed the greatest slip percentage (16.0% and 16.7%), while MRI revealed the lowest (12.2%, p <0.001). Standing flexion and lateral radiographs when seated produced more kyphosis (4.66° and 4.97°, respectively) than neutral upright and MRI (7.19° and 7.20°, p <0.001). Seated lateral performed similarly to standing flexion in detecting all measurement parameters and categorizing DS (all p >0.05). Translational instability was shown to be more prevalent when associated with seated lateral or standing flexion than when combined with neutral upright (31.5% vs. 20.2%, p =0.041; and 28.1% vs. 14.6%, p =0.014, respectively). There were no differences between seated lateral or standing flexion in the detection of instability (all p >0.20). CONCLUSIONS: Seated lateral radiographs are appropriate alternatives for standing flexion radiographs. Films taken when standing up straight do not offer any more information for DS detection. Rather than standing flexion-extension radiographs, instability can be detected using an MRI, which is often performed preoperatively, paired with a single seated lateral radiograph.

Clinical Outcomes of Robotic Versus Freehand Pedicle Screw Placement After One-to Three-Level Lumbar Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The purpose of this study is to compare patient-reported outcome measures (PROMs) for patients undergoing one-to three-level lumbar fusion using robotically assisted vs freehand pedicle screw placement. METHODS: Patients who underwent either robotically assisted or freehand pedicle screw placement for one-to three-level lumbar fusion surgery from January 1, 2014 to August 31, 2020 at a single academic institution were identified. Propensity score matching was performed based on demographic variables. Clinical and surgical outcomes were compared between groups. Recovery Ratios (RR) and the proportion of patients achieving the minimally clinically important difference (%MCID) were calculated for Oswestry Disability Index, PCS-12, MCS-12, VAS Back, and VAS Leg at 1 year. Surgical outcomes included complication and revision rates. RESULTS: A total of 262 patients were included in the study (85 robotic and 177 freehand). No significant differences were found in ΔPROM scores, RR, or MCID between patients who underwent robotically assisted vs freehand screw placement. The rates of revision (1.70% freehand vs 1.18% robotic, P = 1.000) and complications (.57% freehand vs 1.18% robotic, P = .546) were not found to be statically different between the 2 groups. Controlling for demographic factors, procedure type (robotic vs freehand) did not emerge as a significant predictor of ΔPROM scores on multivariate linear regression analysis. CONCLUSIONS: Robotically assisted pedicle screw placement did not result in significantly improved clinical or surgical outcomes compared to conventional freehand screw placement for patients undergoing one-to three-level lumbar fusion.

The Implication of Preoperative Central Stenosis on Patient-Reported Outcomes After Lumbar Decompression Surgery.

OBJECTIVE: To assess the impact of central stenosis severity on patient-reported outcomes after lumbar decompression. METHODS: Patient diagnosis, demographics, and surgical characteristics were collected via query search and manual chart review of electronic medical records. The inclusion criteria were posterior lumbar decompressions from 2014-2020, with accessible magnetic resonance imaging reports. As previously validated by Lee et al., central stenosis was determined on magnetic resonance imaging and graded as none, mild, moderate, or severe. Patients were dichotomized into 2 groups to improve statistical power for comparisons: none or mild central stenosis and moderate or severe central stenosis. Patient-reported outcome measures (PROMs) were compared between cohorts at 1 year postoperatively. Statistical significance was set at P < 0.05. RESULTS: On bivariate analysis, no significant differences were noted between cohorts with regard to preoperative, 1-year postoperative, and delta PROMs. In addition, no significant difference in the number of patients attaining minimal clinically important difference (MCID) for each PROM was noted between cohorts. With the exception of mental score of the Short Form-12 survey, all intragroup preoperative to postoperative PROMs indicated significant improvement (all P < 0.05) after lumbar decompression surgery. Multivariate regression identified moderate or severe central canal stenosis as a significant independent predictor of improvement in visual analog scale back (estimate = -1.464, P = 0.045). CONCLUSIONS: We demonstrate that patients with moderate or severe central spinal stenosis may have more improvement in back pain than those with mild or no central stenosis after lumbar spine decompression surgery.

Perioperative Chanage in Cervical Lordosis and Health-Related Quality-of-Life Outcomes.

BACKGROUND: Surgeons have scrutinized spinal alignment and its impact on improving clinical outcomes following anterior cervical discectomy and fusion (ACDF). The primary analysis of this study examines the relationship between change in perioperative cervical lordosis (CL) and health-related quality-of-life (HRQOL) outcomes after ACDF. Secondary analysis evaluates the effects of fusion construct length on outcomes in patients grouped by preoperative cervical alignment. METHODS: A retrospective cohort study was performed on an institutional database including patients who underwent 1- to 3-level ACDF. C2-C7 CL was measured preoperatively and at final follow-up. For primary analysis, patients were classified based on their perioperative cervical lordotic correction: (1) kyphotic, (2) maintained, and (3) restored. For secondary analysis, patients were categorized based on their preoperative C2-C7 CL: (1) kyphotic, (2) neutral, and (3) lordotic. Demographics and perioperative change in patient-reported outcome measures were compared between groups. RESULTS: A total of 308 patients were included. A significant difference was noted among maintained, restored, and kyphotic groups in terms of delta physical compositeshort form-12 score (ΔPCS-12) (9.0 vs 10.3 vs 1.5; P = 0.04) and delta visual analog scale score (ΔVAS) for arm pain (-0.9 vs -3.8 vs -0.6; P = 0.03). Regression analysis revealed significantly greater improvement of PCS-12 (ß: 8.6; P = 0.03) and VAS arm (ß: -2.0; P = 0.03) scores in restored patients compared with kyphotic patients. The length of fusion construct in patients grouped by preoperative cervical alignment had no significant impact on the clinical outcomes on regression analysis. CONCLUSIONS: Significantly greater PCS-12 and VAS arm improvement were seen in patients whose cervical sagittal alignment was restored to neutral/lordotic compared with those who remained kyphotic. Multivariate analysis demonstrated no association between construct length and perioperative outcomes. CLINICAL RELEVANCE: The results of this study highlight the importance of sagittal alignment and restoration of CL after short-segment ACDF. Irrespective of preoperative sagittal alignment, the length of ACDF fusion construct does not have a significant impact on clinical outcomes.

Comparison of Outcomes Including or Excluding the Level of Listhesis After ACDF in the Setting of Degenerative Spondylolisthesis.

STUDY DESIGN: This was a retrospective cohort study. OBJECTIVE: The goal of this study is to evaluate the outcomes of patients with cervical degenerative spondylolisthesis (DS) undergoing anterior cervical discectomy and fusion (ACDF), specifically comparing surgeries that include versus exclude the DS level. SUMMARY OF BACKGROUND DATA: DS has been extensively studied in the lumbar spine associated with both back and leg pain leading to worse patient quality of life measures. Conversely, there is a relative dearth of literature regarding surgical and clinical outcomes in the setting of cervical DS. MATERIALS AND METHODS: A total of 315 patients undergoing ACDF between 2014 and 2018 with minimum of 1-year postoperative patient-reported outcome measures (PROMs) were retrospectively reviewed. Forty-six patients were found to have DS and were categorized based on whether an ACDF was performed at the same level (SL) or at a different level (DL) than the spondylolisthesis. Patient demographics, surgical parameters, preoperative and postoperative radiographs, and PROMs were compared between groups. RESULTS: Of the 315 patients, a total of 46 met the inclusion criteria including 21 SL and 25 DL patients. There were no significant differences in patient demographics between the groups. The SL cohort had a significantly worse preoperative sagittal vertical axis (SL: 34.4 vs. 26.1, P=0.025) but no difference in postoperative or delta sagittal vertical axis. Both patient cohorts reported significant postoperative improvement in all PROMs, except Short-Form 12 Mental Component Score in the SL group. There were no differences between the groups regarding Visual Analog Scale Neck, Visual Analog Scale Arm, Neck Disability Index, or Short-Form 12 Physical Component Score. Regression analysis demonstrated SL to be a significant negative predictor for improvement in Short-Form 12 Mental Component Score (ß: -11.27, P=0.10). CONCLUSION: Patients treated only at their neurologically symptomatic levels, excluding asymptomatic listhesis in their construct, can expect equivalent radiographic as well as physical function, disability, and pain outcomes 1 year after ACDF compared with patients whose listhetic level was included in their construct. LEVEL OF EVIDENCE: Level III.

Patients With Preoperative Cervical Deformity Experience Similar Clinical Outcomes to Those Without Deformity Following 1-3 Level Anterior Cervical Decompression and Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim was to compare the outcomes of patients with incompletely corrected cervical deformity against those without deformity following short-segment anterior cervical decompression and fusion for clinically significant radiculopathy or myelopathy. SUMMARY OF BACKGROUND DATA: Cervical deformity has increasingly been recognized as a driver of disability and has been linked to worse patient-reported outcomes measures (PROMs) after surgery. METHODS: Patients 18 years or above who underwent 1-3 level anterior cervical decompression and fusion to address radiculopathy and/or myelopathy at a single institution between 2014 and 2018 with at least 1 year of PROMs were reviewed. Patients were categorized based on cervical deformity into 2 groups: sagittal vertebral axis (cSVA) ≥40 mm as the deformity group, and cSVA <40 mm as the nondeformity group. Patient demographics, surgical parameters, preoperative and postoperative radiographs, and minimum 1-year PROMs were compared. RESULTS: Of the 230 patients, 191 (83%) were in the nondeformity group and 39 (17%) in the deformity group. Patients with deformity were more likely to be male (69.2% vs. 40.3%, P<0.001) and have a greater body mass index (32.8 vs. 29.7, P=0.028). The deformity group had significantly greater postoperative cSVA (44.2 vs. 25.1 mm, P<0.001) but also had significantly greater ∆cSVA (-4.87 vs. 0.25 mm, P=0.007) than the nondeformity group. Both groups had significant improvements in visual analog scale arm, visual analog scale neck, Short-Form 12 Physical Component Score, and neck disability index (NDI) (P<0.001). However, the deformity group experienced significantly greater ∆NDI and ∆mental component score (MCS)-12 scores (-19.45 vs. -11.11, P=0.027 and 7.68 vs. 1.32, P=0.009). CONCLUSIONS: Patients with preoperative cervical sagittal deformity experienced relatively greater improvements in NDI and MCS-12 scores than those without preoperative deformity. These results suggest that complete correction of sagittal alignment is not required for patients to achieve significant clinical improvement. LEVEL OF EVIDENCE: III.

Does change in focal lordosis after spinal fusion affect clinical outcomes in degenerative spondylolisthesis?

Study Design: Retrospective cohort study. Objective: The objective of this study is to determine the effect of focal lordosis and global alignment and proportion (GAP) scores on patient reported outcome measures (PROMs) after posterior lumbar fusion for patients with 1- or 2-level lumbar degenerative spondylolisthesis (DS). Summary of Background Data: In patients with DS, improvements in spinopelvic parameters are believed to improve clinical outcomes. However, the effect of changing focal lordosis in patients with 1-or 2-level degenerative lumbar spondylolisthesis is unclear. Materials and Methods: Postoperative spinopelvic parameters and perioperative focal lordosis changes were measured for 162 patients at a single academic center from January 2013 to December 2017. Patients were divided into three groups: >2° (lordotic group), between 2° and -2° (neutral group), and -2°° (kyphotic group). Patients were then reclassified based on GAP scores. Recovery ratios (RR) and the number of patients achieving the minimal clinically important difference (MCID) were calculated for PROMs. Standard descriptive statistics were reported for patient demographics and outcomes data. Multiple linear regression analysis controlled for confounders. Alpha was set at P < 0.05. Results: There was no significant association between change in focal lordosis and surgical complications including adjacent segment disease (P = 0.282), instrumentation failure (P = 0.196), pseudarthrosis (P = 0.623), or revision surgery (P = 0.424). In addition, the only PROM affected by change in focal lordosis was Mental Component Scores (ΔMCS-12) (lordotic = 2.5, neutral = 8.54, and kyphotic = 5.96, P = 0.017) and RR for MCS-12 (lordotic = 0.02, neutral = 0.14, kyphotic 0.10, P = 0.008). Linear regression analysis demonstrated focal lordosis was a predictor of decreased improvement in MCS-12 (ß = -6.45 [-11.03- -1.83], P = 0.007). GAP scores suggested patients who were correctly proportioned had worse MCID compared to moderately disproportioned and severely disproportioned patients (P = 0.024). Conclusions: The change in focal lordosis not a significant predictor of change in PROMs for disability, pain, or physical function. Proportioned patients based on the GAP score had worse MCID for Oswestry Disability Index. Level of Evidence: III.