Incidental durotomy resulting in a postoperative lumbosacral nerve root with eventration into the adjacent facet joint: illustrative cases.

BACKGROUND: Radicular pain after lumbar decompression surgery can result from epidural hematoma/seroma, recurrent disc herniation, incomplete decompression, or other rare complications. A less recognized complication is postoperative nerve root herniation, resulting from an initially unrecognized intraoperative or, more commonly, a spontaneous postoperative durotomy. Rarely, this nerve root herniation can become entrapped within local structures, including the facet joint. The aim of this study was to illustrate our experience with three cases of lumbosacral nerve root eventration into an adjacent facet joint and to describe our diagnostic and surgical approach to this rare complication. OBSERVATIONS: Three patients who had undergone lumbar decompression surgery with or without fusion experienced postoperative radiculopathy. Exploratory revision surgery revealed all three had a durotomy with nerve root eventration into the facet joint. Significant symptom improvement was achieved in all patients following liberation of the neural elements from the facet joints. LESSONS: Entrapment of herniated nerve roots into the facet joint may be a previously underappreciated complication and remains quite challenging to diagnose even with the highest-quality advanced imaging. Thus, clinicians must have a high index of suspicion to diagnose this issue and a low threshold for surgical exploration.

Impact of Preoperative Symptom Duration on Patient-Reported Outcomes Following Cervical Disc Replacement for Cervical Radiculopathy.

STUDY DESIGN: Retrospective review of prospectively collected data. OBJECTIVE: To determine the impact of preoperative symptom duration on postoperative functional outcomes following cervical disc replacement (CDR) for radiculopathy. SUMMARY OF BACKGROUND DATA: CDR has emerged as a reliable and efficacious treatment option for degenerative cervical spine pathologies. The relationship between preoperative symptom duration and outcomes following CDR is not well established. METHODS: Patients with radiculopathy without myelopathy who underwent primary 1- or 2-level CDRs were included and divided into shorter (<6 mo) and prolonged (≥6 mo) cohorts based on preoperative symptom duration. Patient-reported outcome measures (PROMs) included Neck Disability Index (NDI), Visual Analog Scale (VAS) Neck and Arm. Change in PROM scores and minimal clinically important difference (MCID) rates were calculated. Analyses were conducted on the early (within 3 mo) and late (6 mo-2 y) postoperative periods. RESULTS: A total of 201 patients (43.6±8.7 y, 33.3% female) were included. In both early and late postoperative periods, the shorter preoperative symptom duration cohort experienced significantly greater change from preoperative PROM scores compared to the prolonged symptom duration cohort for NDI, VAS-Neck, and VAS-Arm. The shorter symptom duration cohort achieved MCID in the early postoperative period at a significantly higher rate for NDI (78.9% vs. 54.9%, P=0.001), VAS-Neck (87.0% vs. 56.0%, P<0.001), and VAS-Arm (90.5% vs. 70.7%, P=0.002). Prolonged preoperative symptom duration (≥6 mo) was identified as an independent risk factor for failure to achieve MCID at the latest timepoint for NDI (OR: 2.9, 95% CI: 1.2-6.9, P=0.016), VAS-Neck (OR: 9.8, 95% CI: 3.7-26.0, P<0.001), and VAS-Arm (OR: 7.5, 95% CI: 2.5-22.5, P<0.001). CONCLUSIONS: Our study demonstrates improved patient-reported outcomes for those with shorter preoperative symptom duration undergoing CDR for radiculopathy, suggesting delayed surgical intervention may result in poorer outcomes and greater postoperative disability. LEVEL OF EVIDENCE: III.

Intravenous Ketorolac Substantially Reduces Opioid Use and Length of Stay After Lumbar Fusion: A Randomized Controlled Trial.

STUDY DESIGN: A randomized, double-blinded, placebo-controlled trial. OBJECTIVE: To examine the effect of intravenous ketorolac (IV-K) on hospital opioid use compared with IV-placebo (IV-P) and IV acetaminophen (IV-A). SUMMARY OF BACKGROUND DATA: Controlling postoperative pain while minimizing opioid use after lumbar spinal fusion is an important area of study. PATIENTS AND METHODS: Patients aged 18 to 75 years undergoing 1 to 2 level lumbar fusions between April 2016 and December 2019 were included. Patients with chronic opioid use, smokers, and those on systemic glucocorticoids or contraindications to study medications were excluded. A block randomization scheme was used, and study personnel, hospital staff, and subjects were blinded to the assignment. Patients were randomized postoperatively. The IV-K group received 15 mg (age > 65) or 30 mg (age < 65) every six hours (q6h) for 48 hours, IV-A received 1000 mg q6h, and IV-P received normal saline q6h for 48 hours. Demographic and surgical details, opioid use in morphine milliequivalents, opioid-related adverse events, and length of stay (LOS) were recorded. The primary outcome was in-hospital opioid use up to 72 hours. RESULTS: A total of 171 patients were included (58 IV-K, 55 IV-A, and 58 IV-P) in the intent-to-treat (ITT) analysis, with a mean age of 57.1 years. The IV-K group had lower opioid use at 72 hours (173 ± 157 mg) versus IV-A (255 ± 179 mg) and IV-P (299 ± 179 mg; P = 0.000). In terms of opiate use, IV-K was superior to IV-A ( P = 0.025) and IV-P ( P = 0.000) on ITT analysis, although on per-protocol analysis, the difference with IV-A did not reach significance ( P = 0.063). When compared with IV-P, IV-K patients reported significantly lower worst ( P = 0.004), best ( P = 0.001), average ( P = 0.001), and current pain ( P = 0.002) on postoperative day 1, and significantly shorter LOS ( P = 0.009) on ITT analysis. There were no differences in opioid-related adverse events, drain output, clinical outcomes, transfusion rates, or fusion rates. CONCLUSIONS: By reducing opioid use, improving pain control on postoperative day 1, and decreasing LOS without increases in complications or pseudarthrosis, IV-K may be an important component of "enhanced recovery after surgery" protocols.

Differences in imaging and clinical characteristics are associated with higher rates of decompression-fusion versus decompression-alone in women compared to men for lumbar degenerative spondylolisthesis.

PURPOSE: The goals were to ascertain if differences in imaging/clinical characteristics between women and men were associated with differences in fusion for lumbar degenerative spondylolisthesis. METHODS: Patients had preoperative standing radiographs, CT scans, and intraoperative fluoroscopic images. Symptoms and comorbidity were obtained from patients; procedure (fusion-surgery or decompression-alone) was obtained from intraoperative records. With fusion surgery as the dependent variable, men and women were compared in multivariable logistic regression models with clinical/imaging characteristics as independent variables. The sample was dichotomized, and analyses were repeated with separate models for men and women. RESULTS: For 380 patients (mean age 67, 61% women), women had greater translation, listhesis angle, lordosis, and pelvic incidence, and less diastasis and disc height (all p ≤ 0.03). The rate of fusion was higher for women (78% vs. 65%; OR 1.9, p = 0.008). Clinical/imaging variables were associated with fusion in separate models for men and women. Among women, in the final multivariable model, less comorbidity (OR 0.5, p = 0.05), greater diastasis (OR 1.6, p = 0.03), and less anterior disc height (OR 0.8, p = 0.0007) were associated with fusion. Among men, in the final multivariable model, opioid use (OR 4.1, p = 0.02), greater translation (OR 1.4, p = 0.0003), and greater diastasis (OR 2.4, p = 0.0002) were associated with fusion. CONCLUSIONS: There were differences in imaging characteristics between men and women, and women were more likely to undergo fusion. Differences in fusion within groups indicate that decisions for fusion were based on composite assessments of clinical and imaging characteristics that varied between men and women.

Recovery Kinetics After Cervical Spine Surgery.

STUDY DESIGN: Retrospective review of a prospectively maintained multisurgeon registry. OBJECTIVE: To study recovery kinetics and associated factors after cervical spine surgery. SUMMARY OF BACKGROUND DATA: Few studies have described return to activities cervical spine surgery. This is a big gap in the literature, as preoperative counseling and expectations before surgery are important. MATERIALS AND METHODS: Patients who underwent either anterior cervical discectomy and fusion (ACDF) or cervical disk replacement (CDR) were included. Data collected included preoperative patient-reported outcome measures, return to driving, return to working, and discontinuation of opioids data. A multivariable regression was conducted to identify the factors associated with return to driving by 15 days, return to working by 15 days, and discontinuing opioids by 30 days. RESULTS: Seventy ACDF patients and 70 CDR patients were included. Overall, 98.2% of ACDF patients and 98% of CDR patients returned to driving in 16 and 12 days, respectively; 85.7% of ACDF patients and 90.9% of CDR patients returned to work in 16 and 14 days; and 98.3% of ACDF patients and 98.3% of CDR patients discontinued opioids in a median of seven and six days. Though not significant, minimal (odds ratio (OR)=1.65) and moderate (OR=1.79) disability was associated with greater odds of returning to driving by 15 days. Sedentary work (OR=0.8) and preoperative narcotics (OR=0.86) were associated with decreased odds of returning to driving by 15 days. Medium (OR=0.81) and heavy (OR=0.78) intensity occupations were associated with decreased odds of returning to work by 15 days. High school education (OR=0.75), sedentary work (OR=0.79), and retired/not working (OR=0.69) were all associated with decreased odds of discontinuing opioids by 30 days. CONCLUSIONS: Recovery kinetics for ACDF and CDR are comparable. Most patients return to all activities after ACDF and CDR within 16 days. These findings serve as an important compass for preoperative counseling.

Risk factors for failure to achieve minimal clinically important difference following cervical disc replacement.

BACKGROUND CONTEXT: While cervical disc replacement (CDR) has been emerging as a reliable and efficacious treatment option for degenerative cervical spine pathology, not all patients undergoing CDR will achieve minimal clinically important difference (MCID) in patient-reported outcome measures (PROMs) postoperatively-risk factors for failure to achieve MCID in PROMs following CDR have not been established. PURPOSE: To identify risk factors for failure to achieve MCID in Neck Disability Index (NDI, Visual Analog Scale (VAS) neck and arm following primary 1- or 2-level CDRs in the early and late postoperative periods. STUDY DESIGN: Retrospective review of prospectively collected data. PATIENT SAMPLE: Patients who had undergone primary 1- or 2-level CDR for the treatment of degenerative cervical pathology at a single institution with a minimum follow-up of 6 weeks between 2017 and 2022. OUTCOME MEASURES: Patient-reported outcomes: Neck disability index (NDI), Visual analog scale (VAS) neck and arm, MCID. METHODS: Minimal clinically important difference achievement rates for NDI, VAS-Neck, and VAS-Arm within early (within 3 months) and late (6 months to 2 years) postoperative periods were assessed based on previously established thresholds. Multivariate logistic regressions were performed for each PROM and evaluation period, with failure to achieve MCID assigned as the outcome variable, to establish models to identify risk factors for failure to achieve MCID and predictors for achievement of MCID. Predictor variables included in the analyses featured demographics, comorbidities, diagnoses/symptoms, and perioperative characteristics. RESULTS: A total of 154 patients met the inclusion criteria. The majority of patients achieved MCID for NDI, VAS-Neck, and VAS-Arm for both early and late postoperative periods-79% achieved MCID for at least one of the PROMs in the early postoperative period, while 80% achieved MCID for at least one of the PROMs in the late postoperative period. Predominant neck pain was identified as a risk factor for failure to achieve MCID for NDI in the early (OR: 3.13 [1.10-8.87], p-value: .032) and late (OR: 5.01 [1.31-19.12], p-value: .018) postoperative periods, and VAS-Arm for the late postoperative period (OR: 36.63 [3.78-354.56], p-value: .002). Myelopathy was identified as a risk factor for failure to achieve MCID for VAS-Neck in the early postoperative period (OR: 3.40 [1.08-10.66], p-value: .036). Anxiety was identified as a risk factor for failure to achieve MCID for VAS-Neck in the late postoperative period (OR: 6.51 [1.91-22.18], p-value: .003). CDR at levels C5C7 was identified as a risk factor for failure to achieve MCID in NDI for the late postoperative period (OR: 9.74 [1.43-66.34], p-value: .020). CONCLUSIONS: Our study identified several risk factors for failure to achieve MCID in common PROMs following CDR including predominant neck pain, myelopathy, anxiety, and CDR at levels C5-C7. These findings may help inform the approach to counseling patients on outcomes of CDR as the evidence suggests that those with the risk factors above may not improve as reliably after CDR.

Emerging Need for PROMs to Measure the Impact of Spine Disorders on Overall Health and Well-being: Measuring Expectations as an Example for Lumbar Degenerative Spondylolisthesis.

Background: Assessing the impact of spine disorders such as lumbar degenerative spondylolisthesis (LDS) on overall health is a component of quality of care that may not be comprehensively captured by spine-specific and single-attribute patient-reported outcome measures (PROMs). Purpose: We sought to compare PROMs to the Lumbar Surgery Expectations Survey ("Expectations Survey"), which addresses multiple aspects of health and well-being, and to compare the relevance of surgeon-selected versus survey-selected Patient-Reported Outcomes Measurement Information System (PROMIS) items to LDS. Methods: In a cross-sectional study, 379 patients with LDS preoperatively completed the Expectations Survey, Numerical Rating Pain Scales, Oswestry Disability Index (ODI), and PROMIS computer-adaptive physical function, pain, and mental health surveys. Expectations Survey scores were compared to PROMs with correlation coefficients (indicating strengths of relationships) and probability values (indicating associations by chance). Surgeons reviewed physical function questions to identify those particularly relevant to LDS. Results: Patients' mean age was 67 years, 64% were women, and 83% had single-level and 17% had multiple-level LDS. Probability values between the Expectations Survey and PROMs were reliable, but strengths of relationships were only mild to moderate, indicating PROMs did not comprehensively capture the impact of LDS. None of the surgeon-selected PROMIS physical function questions were posed to patients. Conclusion: This cross-sectional study found PROMs to be reliably associated but not strongly correlated with the Expectations Survey, which addresses the whole-patient impact of LDS. New measures that complement PROMIS and ODI should be developed to capture the whole-person effects of LDS and permit attribution of LDS treatments to overall health.

Instability Missed by Flexion-Extension Radiographs Subsequently Identified by Alternate Imaging in L4-L5 Lumbar Degenerative Spondylolisthesis.

STUDY DESIGN: Cross-sectional preoperative and intraoperative imaging study of L4-L5 lumbar degenerative spondylolisthesis (LDS). OBJECTIVE: To determine if alternate imaging modalities would identify LDS instability that did not meet the criteria for instability based on comparison of flexion and extension radiographs. SUMMARY OF BACKGROUND DATA: Pain may limit full flexion and extension maneuvers and thereby lead to underreporting of true dynamic translation and angulation in LDS. Alternate imaging pairs may identify instability missed by flexion-extension. MATERIALS AND METHODS: Consecutive patients scheduled for surgery for single-level L4-L5 LDS had preoperative standing radiographs in the lateral, flexion, and extension positions, supine computed tomography (CT) scans, and intraoperative fluoroscopic images in the supine and prone positions after anesthesia but before incision. Instability was defined as translation ≥3.5 mm or angulation ≥11° between the following pairs of images: (1) flexion-extension; (2) CT-lateral; (3) lateral-intraoperative supine; (4) lateral-intraoperative prone; and (5) intraoperative supine-prone. RESULTS: Of 240 patients (mean age 68 y, 54% women) 15 (6%) met the criteria for instability by flexion-extension, and 225 were classified as stable. Of these 225, another 84 patients (35% of total enrollment) were reclassified as unstable by comparison of CT-lateral images (21 patients) and by lateral-intraoperative images (63 patients). Nine of the 15 patients diagnosed with instability by flexion-extension had fusion (60%), and 68 of the 84 patients reclassified as unstable by other imaging pairs had fusion (81%) ( P =0.07). The 84 reclassified patients were more likely to undergo fusion compared with the 141 patients who persistently remained classified as stable (odds ratio=2.6, 95% CI: 1.4-4.9, P =0.004). CONCLUSIONS: Our study provides evidence that flexion and extension radiographs underreport the dynamic extent of LDS and therefore should not be solely relied upon to ascertain instability. These findings have implications for how instability should be established and the extent of surgery that is indicated.

Quantitative CT for Preoperative Assessment of Lumbar Degenerative Spondylolisthesis: The Unique Impact of L4 Bone Mineral Density on Single-Level Disease.

Background: Quantitative computed tomography (qCT) efficiently measures 3-dimensional vertebral bone mineral density (BMD), but its utility in measuring BMD at various vertebral levels in patients with lumbar degenerative spondylolisthesis (LDS) is unclear. Purpose: We sought to determine whether qCT could differentiate BMD at different levels of LDS, particularly at L4-L5, the most common single level for LDS. In addition, we sought to describe patterns of BMD for single-level and multiple-level LDS. Methods: We conducted a study of patients undergoing surgery for LDS who were part of a larger longitudinal study comparing preoperative and intraoperative images. Preoperative patients were grouped as single-level or multiple-level LDS, and qCT BMD was obtained for L1-S1 vertebrae. Mean BMD was compared with literature reports; in multivariable analyses, BMD of each vertebra was assessed according to the level of LDS, controlling for covariates and for BMD of other vertebrae. Results: Of 250 patients (mean age: 67 years, 64% women), 22 had LDS at L3-L4 only, 170 at L4-L5 only, 13 at L5-S1 only, and 45 at multiple levels. Compared with other disorders reported in the literature, BMD in our sample similarly decreased from L1 to L3 then increased from L4 to S1, but mean BMD per vertebra in our sample was lower. Nearly half of our sample met criteria for osteopenia. In multivariable analysis controlling for BMD at other vertebrae, lower L4 BMD was associated with LDS at L4-L5, greater pelvic incidence minus lumbar lordosis, and not having diabetes. In contrast, in similar multivariable analysis, greater L4 BMD was associated with LDS at L3-L4. Bone mineral density of L3 and L5 was not associated with LDS levels. Conclusion: In our sample of preoperative patients with LDS, we observed lower BMD for LDS than for other lumbar disorders. L4 BMD varied according to the level of LDS after controlling for covariates and BMD of other vertebrae. Given that BMD can be obtained from routine imaging, our findings suggest that qCT data may be useful in the comprehensive assessment of and strategy for LDS surgery. More research is needed to elucidate the cause-effect relationships among spinopelvic alignment, LDS, and BMD.

Telemedicine Visits Can Generate Highly Accurate Diagnoses and Surgical Plans for Spine Patients.

STUDY DESIGN: A Retrospective cohort study. OBJECTIVE: To (1) assess whether diagnoses and surgical plans established during a new patient telemedicine visit changed following an in-person evaluation and (2) determine any differences in perioperative outcomes between patients who only had a telemedicine visit before surgery versus those who had a telemedicine visit followed by an in-person evaluation before surgery. SUMMARY OF BACKGROUND DATA: Data on capability of telemedicine to deliver high-quality preoperative assessment without a traditional in-person interaction and physical examination is lacking. MATERIALS AND METHODS: Records of patients who had a new patient telemedicine visit and indicated for surgery with documented specific diagnosis as well as surgical plans from a spine department at an urban tertiary center from April 2020 to April 2021 were reviewed. For a subset of patients that had a follow-up in-person evaluation before surgery, these diagnoses and plans were compared. Perioperative outcomes were compared between patients who only had a telemedicine visit before surgery versus those who had a telemedicine visit followed by an in-person evaluation before surgery. RESULTS: A total of 166 patients were included. Of these, 101 patients (61%) only had a new patient telemedicine visit before surgery while 65 (39%) had a telemedicine visit followed by an in-person evaluation. There were no differences in the rate of case cancellations before surgery and patient-reported outcome measures between these two groups ( P >0.05). Of 65 patients who had both a telemedicine followed by an in-person visit, the diagnosis was unchanged for 61 patients (94%) and the surgical plan did not change for 52 patients (80%). The main reason for surgical plan change was due to updated findings on new imaging, 10 patients, (77%). CONCLUSIONS: The current study suggests that telemedicine evaluations can provide an effective means of preoperative assessment for spine patients. LEVEL OF EVIDENCE: Level 3.

Classification system for cervical spine deformity morphology: a validation study.

OBJECTIVE: The objective of this study was to initially validate a recent morphological classification of cervical spine deformity pathology. METHODS: The records of 10 patients for each of the 3 classification subgroups (flat neck, focal deformity, and cervicothoracic), as well as for 8 patients with coronal deformity only, were extracted from a prospective multicenter database of patients with cervical deformity (CD). A panel of 15 physicians of various training and professional levels (i.e., residents, fellows, and surgeons) categorized each patient into one of the 4 groups. The Fleiss kappa coefficient was utilized to evaluate intra- and interrater reliability. Accuracy, defined as properly selecting the main driver of deformity, was reported overall, by morphotype, and by reviewer experience. RESULTS: The overall classification demonstrated a moderate to substantial agreement (round 1: interrater Fleiss kappa = 0.563, 95% CI 0.559-0.568; round 2: interrater Fleiss kappa = 0.612, 95% CI 0.606-0.619). Stratification by level of training demonstrated similar mean interrater coefficients (residents 0.547, fellows 0.600, surgeons 0.524). The mean intrarater score was 0.686 (range 0.531-0.823). A substantial agreement between rounds 1 and 2 was demonstrated in 81.8% of the raters, with a kappa score > 0.61. Stratification by level of training demonstrated similar mean intrarater coefficients (residents 0.715, fellows 0.640, surgeons 0.682). Of 570 possible questions, reviewers provided 419 correct answers (73.5%). When considering the true answer as being selected by at least one of the two main drivers of deformity, the overall accuracy increased to 86.0%. CONCLUSIONS: This initial validation of a CD morphological classification system reiterates the importance of dynamic plain radiographs for the evaluation of patients with CD. The overall reliability of this CD morphological classification has been demonstrated. The overall accuracy of the classification system was not impacted by rater experience, demonstrating its simplicity.

Cervical Disc Replacement for Radiculopathy Versus Myeloradiculopathy: An MCID Analysis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVES: The aim was to compare the minimally clinically important difference (MCID) across multiple patient-reported outcomes (PROs) in patients undergoing cervical disc replacement (CDR) for cervical spondylotic radiculopathy versus myeloradiculopathy. SUMMARY OF BACKGROUND DATA: To date, a limited number of studies have demonstrated mostly similar results in patients with cervical spondylotic radiculopathy or myeloradiculopathy undergoing CDR. However, each of these previous studies have focused on statistically significant differences, which may not correlate with patient perceived improvements in outcomes or success. METHODS: Patients who underwent 1 or 2-level CDR with radiculopathy versus myeloradiculopathy were identified, and prospectively collected data was retrospectively reviewed. Demographic variables, preoperative diagnosis, and operative variables were collected for each patient. The following PROs were prospectively collected: Neck Disability Index (NDI), visual analog scale (VAS)-Neck, VAS-Arm, Short Form-12 Health Survey (SF-12) Physical Component Score (PCS), SF-12 Mental Component Score (MCS), PROMIS Physical Function (PF). An MCID analysis of PROs for each diagnosis group was performed and the percentage of patients achieving the MCID was compared between the two diagnosis groups. RESULTS: Eight-five patients, of which 56% had radiculopathy and 44% had myeloradiculopathy. MCID analysis demonstrated that at 6-week, 12-week, and final postoperative follow-up there was no significant difference in the percentage of patients with radiculopathy or myeloradiculopathy achieving the MCID for each PRO assessed. In both diagnosis groups the percentage of patients achieving the MCID for each PRO continued to increase from the 6-week to final postoperative follow-up except for the SF-12 MCS in patients with myeloradiculopathy. CONCLUSIONS: The percentage of patients achieving the MCID was not significantly different at each postoperative period assessed in the radiculopathy and myeloradiculopathy groups treated with CDR. In addition, the percentage of patients achieving the MCID continued to increase from 6 weeks to final follow-up in both groups for almost all PROs assessed.

Anterior Cervical Discectomy and Fusion Versus Cervical Disc Replacement in Patients With Significant Cervical Spondylosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The aim was to compare clinical outcomes in patients with significant cervical spondylosis treated with cervical disc replacement (CDR) compared with anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA: As CDR utilization has increased over the past decade, recent studies have investigated the outcomes of CDR in patients with more significant spondylotic changes and demonstrated improved postoperative patient-reported outcomes (PROs). However, no prior study has investigated clinical outcomes of patients with significant spondylotic changes treated with CDR in comparison to ACDF. METHODS: Patients who underwent 1-level or 2-level CDR or ACDF with significant cervical spondylosis, quantified using a validated grading scale, were identified, and prospectively collected data was retrospectively reviewed. The following PROs were analyzed: Neck Disability Index (NDI), visual analog scale-Neck, visual analog scale-Arm, and PROMIS Physical Function (PROMIS-PF) Computer Adaptive Test Score. Demographic, operative, and radiographic variables, and achievement of minimum clinically important difference (MCID) for each PRO were compared between the 2 groups. RESULTS: A total of 66 patients were included in the present study, of which 35 (53%) were treated with CDR and 31 (47%) with ACDF. The preoperative cervical spondylotic grade was similar between the 2 groups (1.8 vs. 2.2, P=0.27). At final follow-up, there was no significant difference in the absolute value for each PRO between the 2 groups (P>0.19) and both groups demonstrated significant improvement in each PRO compared with preoperative values (P<0.01). There was no significant difference in the percentage of patients achieving the MCID for each PRO when comparing CDR to ACDF (P>0.09). CONCLUSIONS: A similar percentage of patients with significant degenerative cervical spondylosis achieved the MCID across multiple PROs when treated with CDR or ACDF. Patients in both treatment groups demonstrated significant improvement in all PROs assessed when compared with preoperative values. LEVEL OF EVIDENCE: Level III.

Radiographic Evaluation of Cervical Disk Replacement: The Impact of Preoperative Arthrosis and Implant Positioning on Patient-report Outcomes.

STUDY DESIGN: This was a retrospective review. OBJECTIVE: Provide a validated method of radiographic evaluation of cervical disk replacement (CDR) patients linked to outcomes. SUMMARY OF BACKGROUND DATA: Preoperative radiographic criteria for CDRs and the impact of intraoperative positioning remain without formalized guidelines. The association between preexisting degenerative changes, optimal implant positioning, and patient-reported outcome measures (PROMs) are not well understood. Our study establishes a systematic radiographic evaluation of preoperative spondylosis, implant placement, and associated clinical outcomes. METHODS: Preoperative radiographs for CDR patients were evaluated for disk height, facet arthrosis, and uncovertebral joint degeneration. Postoperative radiographs were scored based on the position of the CDR implant on anterior-posterior (AP) and lateral radiographs. PROMs including Visual Analogue Scale (VAS) arm pain, VAS neck pain, Neck Disability Index (NDI), Short Form 12 physical health (SF12-PCS) and mental health (SF12-M) were collected preoperatively, at early follow, and at late follow-up. RESULTS: A total of 115 patients were included. Preoperative disk height had the highest reliability, intraclass correlation coefficient of 0.798). Facet arthrosis had the lowest intraclass correlation coefficient at 0.563. Preoperative disk height scores showed a significant correlation with AP radiographs and implant positioning score. Patients with more advanced uncovertebral degenerative changes showed less improvement 6 months postoperatively, based on SF-12 PCS scores (R=0.446, P=0.025). Postoperative implant position on lateral radiograph showed a significant correlation with SF-12 MCS scores at follow-up beyond 6 months (R=0.385, P=0.011). Overall postoperative implant position scores demonstrated significant correlation with SF-12 PCS (R=0.350, P=0.046) scores. CONCLUSION: This study provides a systematic method of evaluation of preoperative and intraoperative radiographs that can optimize outcomes. On the basis of our study, spine surgeons performing cervical disk replacement surgery should consider: (a) the presence of preexisting uncovertebral joint degeneration can negatively impact outcomes, (b) achieving optimal implant positioning can be increasingly difficult with more severe loss of disk height, and (c) overall implant position as judged on AP and lateral fluoroscopy can impact outcomes.

Early Peri-operative Outcomes Were Unchanged in Patients Undergoing Spine Surgery During the COVID-19 Pandemic in New York City.

BACKGROUND: Healthcare resources have been greatly limited by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic halting non-essential surgical cases without clear service expansion protocols. QUESTIONS/PURPOSES: We sought to compare the peri-operative outcomes of patients undergoing spine surgery during the SARS-CoV-2 pandemic to a matched cohort prior to the pandemic. METHODS: We identified a consecutive sample of 127 adult patients undergoing spine surgery between March 9, 2020, and April 10, 2020, corresponding with the state of emergency declared in New York and the latest possible time for 1-month surgical follow-up. The study group was matched one-to-one based on age, gender, and body mass index with eligible control patients who underwent similar spine procedures prior to the SARS-CoV-2 outbreak. Surgeries performed for infectious or oncologic indications were excluded. Intra- and post-operative complication rates, re-operations, hospital length of stay, re-admissions, post-operative visit format, development of post-operative fever and/or respiratory symptoms, and SAR-CoV2 testing. RESULTS: A total of 254 patients (127 SARS-CoV-2 pandemic, 127 matched controls) were included. One hundred fifty-eight were male (62%), and 96 were female (38%). The mean age in the pandemic group was 59.8 ± 13.4 years; that of the matched controls was 60.3 ± 12.3. All patients underwent general anesthesia and did not require re-intubation. There were no significant differences in 1-month post-operative complication rates (16.5% pandemic vs. 12.6% control). There was one death in the pandemic group. No patients tested positive for the virus. CONCLUSION: This study represents the first report of post-operative outcomes in a large group of spine surgical patients in an area heavily affected by the SARS-CoV-2 pandemic.

Enhanced Recovery after Lumbar Spine Fusion: A Randomized Controlled Trial to Assess the Quality of Patient Recovery.

BACKGROUND: Prospective trials of enhanced recovery after spine surgery are lacking. We tested the hypothesis that an enhanced recovery pathway improves quality of recovery after one- to two-level lumbar fusion. METHODS: A patient- and assessor-blinded trial of 56 patients randomized to enhanced recovery (17 evidence-based pre-, intra-, and postoperative care elements) or usual care was performed. The primary outcome was Quality of Recovery-40 score (40 to 200 points) at postoperative day 3. Twelve points defined the clinically important difference. Secondary outcomes included Quality of Recovery-40 at days 0 to 2, 14, and 56; time to oral intake and discharge from physical therapy; length of stay; numeric pain scores (0 to 10); opioid consumption (morphine equivalents); duration of intravenous patient-controlled analgesia use; complications; and markers of surgical stress (interleukin 6, cortisol, and C-reactive protein). RESULTS: The analysis included 25 enhanced recovery patients and 26 usual care patients. Significantly higher Quality of Recovery-40 scores were found in the enhanced recovery group at postoperative day 3 (179 ± 14 vs. 170 ± 16; P = 0.041) without reaching the clinically important difference. There were no significant differences in recovery scores at days 0 (175 ± 16 vs. 162 ± 22; P = 0.059), 1 (174 ± 18 vs. 164 ± 15; P = 0.050), 2 (174 ± 18 vs. 167 ± 17; P = 0.289), 14 (184 ± 13 vs. 180 ± 12; P = 0.500), and 56 (187 ± 14 vs. 190 ± 8; P = 0.801). In the enhanced recovery group, subscores on the Quality of Recovery-40 comfort dimension were higher (longitudinal mean score difference, 4; 95% CI, 1, 7; P = 0.008); time to oral intake (-3 h; 95% CI, -6, -0.5; P = 0.010); and duration of intravenous patient-controlled analgesia (-11 h; 95% CI, -19, -6; P < 0.001) were shorter; opioid consumption was lower at day 1 (-57 mg; 95% CI, -130, -5; P = 0.030) without adversely affecting pain scores (-2; 95% CI, -3, 0; P = 0.005); and C-reactive protein was lower at day 3 (6.1; 95% CI, 3.8, 15.7 vs. 15.9; 95% CI, 6.6, 19.7; P = 0.037). CONCLUSIONS: Statistically significant gains in early recovery were achieved by an enhanced recovery pathway. However, significant clinical impact was not demonstrated.

Postoperative pain following posterior iliac crest bone graft harvesting in spine surgery: a prospective, randomized trial.

BACKGROUND CONTEXT: Postoperative pain at the site of bone graft harvest for posterior spine fusion is reported to occur in 6%-39% of cases. However, the area around the posterior, superior iliac spine is a frequent site of referred pain for many structures. Therefore, many postoperative spine patients may have pain in the vicinity of the posterior iliac crest that may not in fact be caused by bone graft harvesting. The literature may then overestimate the true incidence of postoperative iliac crest pain. PURPOSE: We performed a prospective study testing the hypothesis that patients will not report significantly higher visual analog scores over the graft harvest site when compared with the contralateral, non-harvested side. STUDY DESIGN/SETTING: This is a prospective, randomized cohort study. PATIENT SAMPLE: Patients aged 18-75 years undergoing elective spinal fusion of one to two levels between L4 and S1 for spinal stenosis and spondylolisthesis were randomized to left-sided or right-sided iliac crest bone graft (ICBG) donor sites and blinded to the side of harvest. OUTCOME MEASURES: Primary outcome was a 10-point visual analog scale (VAS) for pain over the left and right posterior superior iliac spine. METHODS: Bone graft was harvested via spinal access incisions without making a separate skin incision over the crest. Each patient's non-harvested side served as an internal control. Data points were recorded by patients on their study visit sheets preoperatively and at 6 weeks, 3 months, 6 months, and 1 year postoperatively. RESULTS: Forty patients were enrolled in the study (23 females) with an average follow-up of 8.1 months (1.5-12 months). Mean age was 51.7 years (23-77 years). Left- and right-side ICBG harvesting was performed equally between the 40 patients. The average volume of graft harvested from the left was 35.3 mL (15-70 mL) and 36.1 mL (15-60 mL) from the right. There was no statistical difference between preoperative VAS score on the harvested side compared with the non-harvested side (p=.415). Postoperatively, there were consistently higher VAS scores on the operative side; however, these differences were not statistically significant at 6 weeks (p=.111), 3 months (p=.440), 6 months (p=.887), or 12 months (p=.240). Both groups did, however, show statistically significant improvements in VAS scores over time within the operative and nonoperative sides (p<.05). Graft volume had no effect on the VAS scores (p=.382). CONCLUSIONS: The current literature does not adequately illuminate the incidence of postoperative pain at the site of harvest and the relative magnitude of this pain in comparison with the patient's residual low back pain. This is the first study to blind the patient to the laterality of bone graft harvesting. Our randomized investigation showed that although pain on the surgical side was slightly higher, it was neither clinically nor statistically different from the nonsurgical side. Our conclusion supports surgeons' use of autologous bone graft, which offers a cost-effective, efficacious spinal fusion supplement.

Lateral lumbar interbody fusion with unilateral pedicle screw fixation for the treatment of adjacent segment disease: a preliminary report.

BACKGROUND: To assess the clinical outcomes of 20 patients who underwent single level unilateral pedicle screw fixation following lateral lumbar interbody fusion (LLIF) for treatment of lumbar adjacent segment disease (ASD). METHODS: Demographic, comorbidity, clinical assessment, peri-operative, and complication data were assessed. Visual analog scale (VAS), Oswestry disability index (ODI), and short form-12 (SF-12) were used to assess clinical outcomes. Post-operative radiographs were assessed for subsidence, cage migration, and fusion. RESULTS: Average age of patients was 63.2±13.7 years (range, 41-86 years), with 8 males and 12 females. Recombinant human bone morphogenic protein-2 (rhBMP-2) was utilized in 18 LLIF cages (90%) and 12 posterolateral fusions (60%). Mean operation time was 214.1±47.2 minutes (range, 146-342 minutes), mean estimated blood loss of 187.5±90.1 cc (range, 50-400 cc). No patients received a blood transfusion. There were no intra-operative complications. Mean hospital length of stay was 4.4±1.7 days (range, 2-9 days). At final follow-up (mean: 13.0±12.7 months after surgery), there was significant improvement in post-op VAS (P=0.006) score compared to pre-op, but not ODI (P=0.181), SF-12 PC (P=0.480), and SF-12 MC (P=0.937). Patients with >6 months of post-operative imaging (14/20, 70%) demonstrated successful fusion in 13 out of 14 cases (93%). There was grade 0 subsidence of adjacent cranial vertebra in all cases (100%). There was grade 0 subsidence of the adjacent caudal vertebra in 13 cases (93%) and grade 1 subsidence in 1 case (7%). There was evidence of cage migration in 3 cases (21%). There were 4 patients (20%) who experienced transient neurological deficits that eventually resolved. Two patients required surgery for further ASD. CONCLUSIONS: In conclusion, this pilot study suggests that patients who undergo LLIF with unilateral pedicle screw fixation for treatment of ASD may have significantly reduced pain and favorable radiographic results. Further investigation in techniques for treatment of ASD is warranted.

Early clinical and radiological results of unilateral posterior pedicle instrumentation through a Wiltse approach with lateral lumbar interbody fusion.

BACKGROUND: To assess the clinical outcomes of 44 patients who underwent single-level lateral lumbar interbody fusion (LLIF) with unilateral pedicle screw instrumentation through a paramedian Wiltse approach. METHODS: Demographic, comorbidity, clinical assessment, peri-operative, and complication data were assessed. Visual analog scale (VAS), Oswestry disability index (ODI), and short form-12 (SF-12) were used to assess clinical outcomes. Post-operative plain radiographs were assessed for subsidence, cage migration, and fusion. RESULTS: Average age of patients at surgery was 60.8±10.6 years (range, 32-79 years), with 15 males and 29 females. Recombinant human bone morphogenic protein-2 (rhBMP-2) was used in 32 cases (73%) and 13 posterolateral fusions (30%). Average duration of surgery was 195.2±36.9 minutes (range: 111-295 minutes), with an estimated blood loss of 159.3±90.8 cc (range, 50-500 cc). There were no intra-operative complications. Average length of hospital stay was 4.2±2.5 days (range, 2-13 days). Four patients (9%) experienced neurological deficit, 2 of which resolved by 3-month follow-up and 2 of which improved but did not resolve by final follow-up at 11 and 16 months. There was significant improvement in VAS (P<0.001), ODI (P<0.001), and SF-12 physical component (P<0.001), but not for SF-12 mental component (P=0.053). Patients with minimum 6 months radiographic follow-up demonstrated successful fusion in 90% of cases (35/39), with 2 cases of grade 1 (5%) subsidence of the adjacent cranial vertebra, and no cases higher than grade 0 subsidence of the adjacent caudal vertebra. CONCLUSIONS: Unilateral pedicle screw instrumentation following LLIF was associated with significant improvement in clinical outcomes and favorable radiographic outcomes.

Serotonergic Antidepressants Are Associated with Increased Blood Loss and Risk for Transfusion in Single-Level Lumbar Fusion Surgery.

STUDY DESIGN: Retrospective case-control study. PURPOSE: The purpose of this study was to examine the effect of antidepressants on blood loss and transfusion requirements in spinal surgery patients. OVERVIEW OF LITERATURE: Several studies have shown an increase in perioperative bleeding in orthopedic surgery patients on antidepressant drug therapy, yet no study has examined the impact of these agents on spinal surgery patients. METHODS: Charts of patients who underwent single-level spinal fusion (posterior lumbar interbody fusion with posterior instrumentation) performed by five fellowship-trained surgeons at a tertiary spine center between 2008 and 2013, were retrospectively reviewed. Exclusion criteria included select medical comorbidities, select drug therapy, and Amercian Society of Anesthesiologists Physical Status Classification score of greater than 2. Serotonergic antidepressants were examined in multivariate analysis to assess their predictive value on estimated blood loss and risk of transfusion. RESULTS: A total of 235 patients, of which 52% were female, were included. Allogeneic blood was transfused in 7% of patients. The average estimated blood loss was 682±463 mL. Selective serotonin reuptake inhibitors were taken by 10% of all patients. Multivariable regression analysis showed that intake of selective serotonin reuptake inhibitors was a significant predictor for blood loss (average increase of 34%, p=0.015) and for the need of allogeneic blood transfusion (odds ratio, 4.550; p=0.029). CONCLUSIONS: There was a statistically significant association between selective serotonin reuptake inhibitors and both increased blood loss and risk of allogeneic red blood cell transfusion. Surgeons and perioperative providers should take these findings into account when assessing patients' preoperative risk for blood loss and transfusion.