Airway Management for Emergency Spinal Epidural Hematoma Evacuation With Awake Spine Surgery: Case Report and Literature Review.

BACKGROUND: Postoperative spinal epidural hematomas (pSEHs) are a rare complication of microdiscectomy surgery. The hematoma may be unnoticed intraoperatively, but timely treatment may prevent permanent neurologic impairment. Airway management in patients with a full stomach is generally performed with rapid sequence intubation and general anesthesia. Awake spine surgery without intravenous analgesia or sedation may be beneficial in patients with a full stomach who are at higher risk for pulmonary aspiration with general anesthesia due to a loss of non-per-oral (NPO) status. The authors propose that it can also be performed in cases of urgent/emergent postsurgical epidural hematoma evacuation. METHODS: We present the airway management of a 41-year-old man who underwent a minimally invasive microdiscectomy with normal strength immediately after surgery but developed progressive weakness with right foot dorsiflexion, right extensor hallucis longus muscle weakness, and progressive right lower extremity ascending numbness over the course of the first 2 hours after surgery due to an epidural hematoma. RESULTS: The patient underwent urgent awake epidural hematoma evacuation with a spinal anesthetic. Afterward, the patient recovered neurological function and was discharged the following morning. CLINICAL RELEVANCE: pSEHs are a rare complication of microdiscectomy surgery. The purpose of this article is to describe the novel use of awake spine surgery in emergent epidural hematoma evacuation and demonstrate its feasibility. CONCLUSIONS: In emergencies, when a patient is not NPO, awake spine surgery can safely be performed with no sedation, ensuring the patient can protect their airway and avoid the risk of aspiration.

Predictors of Survival After Emergent Surgical Decompression for Acutely Presenting Spinal Metastasis.

BACKGROUND: Metastatic spinal tumors represent 90% of spinal masses and present variably with slow progression and/or rapid symptomatic worsening. Several prognostic scoring systems have been proposed. However, patients presenting acutely and requiring emergent surgery represent a unique subset of patients with different prognostic indicators. METHODS: All cases of symptomatic spinal metastases requiring emergent surgery between 2010 and 2021 at our institution were retrospectively reviewed. Survival time from date of surgery to death or last follow-up was calculated. Patients were stratified on the basis of survival for more or less than 6 months after surgery. Multivariate logistic regression was used to develop a model predicting probability of mortality at 6 months. RESULTS: Forty-four patients satisfied inclusion criteria. Mean age at presentation was 60.4 ± 11.8 years with a median survival time of 6.5 [1.9-19.5 interquartile range] months. On univariate analysis, higher Tokuhashi score, Karnofksy performance scale (KPS), and lower modified McCormick scale were significantly associated with 6-month survival (P = 0.018, P < 0.001, P = 0.002, respectively). Preoperative American Spinal Injury Association grade and Spine Instability Neoplastic Score scores were not associated with survival. Multivariate analysis found KPS significantly correlated with survival (0.91 odds ratio, 0.85-0.98, 95% confidence interval, P = 0.011) at 6 months and that a stepwise regression model derived from KPS and Tokuhashi score demonstrated the highest predictive accuracy for 6-month survival (area under the curve = 0.843, Akaike information criterion = 37.1, P = 0.0039). CONCLUSIONS: KPS and Tokuhashi scores most strongly correlated with 6-month survival in patients presenting with acutely symptomatic spinal metastases. These findings underscore the importance of baseline functional status and overall tumor burden on survival and may be useful in preoperative evaluation and surgical decision making for acutely presenting spinal metastases.

The Adjustable Cranial Plate: A Novel Implant Designed to Eliminate the Need for Cranioplasty Surgery Following a Hemicraniectomy Operation.

BACKGROUND: Decompressive hemicraniectomy (DHC) is performed to relieve life-threatening intracranial pressure elevations. After swelling abates, a cranioplasty is performed for mechanical integrity and cosmesis. Cranioplasty is costly with high complication rates. Prior attempts to obviate second-stage cranioplasty have been unsuccessful. The Adjustable Cranial Plate (ACP) is designed for implantation during DHC to afford maximal volumetric expansion with later repositioning without requiring a second major operation. METHODS: The ACP has a mobile section held by a tripod fixation mechanism. Centrally located gears adjust the implant between the up and down positions. Cadaveric ACP implantation was performed. Virtual DHC and ACP placement were done using imaging data from 94 patients who had previously undergone DHC to corroborate our cadaveric results. Imaging analysis methods were used to calculate volumes of cranial expansion. RESULTS: The ACP implantation and adjustment procedures are feasible in cadaveric testing without wound closure difficulties. Results of the cadaveric study showed total volumetric expansion achieved was 222 cm3. Results of the virtual DHC procedure showed the volume of cranial expansion achieved by removing a standardized bone flap was 132 cm3 (range, 89-171 cm3). Applied to virtual craniectomy patients, the total volume of expansion achieved with the ACP implantation operation was 222 cm3 (range, 181-263 cm3). CONCLUSIONS: ACP implantation during DHC is technically feasible. It achieves a volume of cranial expansion that will accommodate that observed following survivable hemicraniectomy operations. Moving the implant from the up to the down position can easily be performed as a simple outpatient or inpatient bedside procedure, thus potentially eliminating second-stage cranioplasty procedures.

Surgeon-Specific Treatment Selection Bias and Heterogeneous Perioperative Practices in an Observational Spine Surgery Study. A Statistical Tutorial with Implications for Analysis of Observational Studies of Perioperative Interventions.

BACKGROUND: It is essential that treatment effects reported from retrospective observational studies are as reliable as possible. In a retrospective analysis of spine surgery patients, we obtained a spurious result: tranexamic acid (TXA) had no effect on intraoperative blood loss. This statistical tutorial explains how this result occurred and why statistical analyses of observational studies must consider the effects of individual surgeons. METHODS: We used an observational database of 580 elective adult spine surgery patients, supplemented with a review of perioperative medication records. We tested whether common statistical methods (multivariable regression or propensity score-based methods) could adjust for surgeons' selection bias in TXA administration. RESULTS: Because TXA administration (frequency, timing, and dose) and surgeon were linked (collinear), estimating and testing the independent effect of TXA on outcome using multivariable regression without including surgeon as a variable would provide biased (spurious) results. Likewise, because of surgeon/TXA linkage, assumptions of propensity score-based analysis were violated, statistical methods to improve comparability between groups failed, and spurious blood loss results were worsened. Others numerous differences among surgeons existed in intraoperative and postoperative practices and outcomes. CONCLUSIONS: In observational studies in which individual surgeons determine whether their patients receive the treatment of interest, consideration must be given to inclusion of surgeon as an independent variable in all analyses. Failure to include the surgeon in an analysis of observational data carries a substantial risk of obtaining spurious results, either creating a spurious treatment effect or failing to detect a true treatment effect.

Postoperative Use of the Muscle Relaxants Baclofen and/or Cyclobenzaprine Associated With an Increased Risk of Delirium Following Lumbar Fusion.

STUDY DESIGN: Retrospective, single-center, cohort study. OBJECTIVE: Investigate whether the incidence of postoperative delirium in older adults undergoing spinal fusion surgery is associated with postoperative muscle relaxant administration. SUMMARY OF BACKGROUND DATA: Baclofen and cyclobenzaprine are muscle relaxants frequently used for pain management following spine surgery. Muscle relaxants are known to cause central nervous system side effects in the outpatient setting and are relatively contraindicated in individuals at high risk for delirium. However, there are no known studies investigating their side effects in the postoperative setting. METHODS: Patients over 65 years of age who underwent elective posterior lumbar fusion for degenerative spine disease were stratified into two treatment groups based on whether postoperative muscle relaxants were administered on postoperative day one as part of a multimodal analgesia regimen. Doubly robust inverse probability weighting with cox regression for time-dependent covariates was used to examine the association between postoperative muscle relaxant use and the risk of delirium while controlling for variation in baseline characteristics. RESULTS: The incidence of delirium was 17.6% in the 250 patients who received postoperative muscle relaxants compared with 7.9% in the 280 patients who did not receive muscle relaxants ( P=0.001 ). Multivariate analysis to control for variation in baseline characteristics between treatment groups found that patients who received muscle relaxants had a 2.00 (95% CI: 1.14-3.49) times higher risk of delirium compared with controls ( P=0.015 ). CONCLUSION: Postoperative use of muscle relaxants as part of a multimodal analgesia regimen was associated with an increased risk of delirium in older adults after lumber fusion surgery. Although muscle relaxants may be beneficial in select patients, they should be used with caution in individuals at high risk for postoperative delirium.

Spinal Nerve Sheath Tumors: Factors Associated with Postoperative Residual and Recurrent Tumors: A Single-Center Experience.

BACKGROUND: Spinal schwannomas (SSs) are usually benign tumors with a good prognosis when treated by surgical excision. However, complete resection can be complicated by factors such as the tumor location and configuration. In the present study, we sought to identify the factors associated with incomplete surgical resection (residual) and the factors associated with tumor recurrence. METHODS: We performed a retrospective review of 113 cases of SSs treated surgically from 2008 to 2021. RESULTS: Of the 113 SSs, 102 were benign and 2 were malignant nerve sheath tumors. Of the 102 benign SSs, gross total resection (GTR) was performed for 87, with 8 displaying residual and 7, recurrent tumor. We found a significantly higher ratio of cervical and sacral tumors (P = 0.008 and P = 0.004, respectively), dumbbell and foraminal configurations (P < 0.0001 and P = 0.0006, respectively), and larger tumor volumes (P = 0.003) in the residual and recurrent cohorts compared with the GTR cohort. A second operation was performed for 2 patients in the residual and 4 patients in the recurrent cohorts. The total complication rate was 6%. CONCLUSIONS: We found that most benign SSs will be amenable to GTR (85% of cases), with an excellent prognosis. The patients with residual or recurrent tumor were more likely to have had a cervical or sacral location, a dumbbell or foraminal configuration, and a larger tumor volume. Except for 1 new SS and 1 recurrent tumor that had necessitated a lateral approach, the remainder had been treated using a posterior approach. At surgery, ultrasonography of the canal is advisable to ensure that the intra- and extraspinal components of dumbbell lesions have both been entirely removed.

Biomechanical assessment of the effect of sublaminar band tensioning on lumbar motion.

OBJECTIVE: Adjacent-segment disease (ASD) proximal to lumbosacral fusion is assumed to result from increased stress and motion that extends above or below the fusion construct. Sublaminar bands (SBs) have been shown to potentially mitigate stresses in deformity constructs. A similar application of SBs in lumbar fusions is not well described yet may potentially mitigate against ASD. METHODS: Eight fresh-frozen human cadaveric spine specimens were instrumented with transforaminal lumbar interbody fusion (TLIF) cages at L3-4 and L4-5, and pedicle screws from L3 to S1. Bilateral SBs were applied at L2 and tightened around the rods extending above the L3 pedicle screws. After being mounted on a testing frame, the spines were loaded at L1 to 6 Nm in all 3 planes, i.e., flexion/extension, right and left lateral bending, and right and left axial rotation. Motion and intradiscal pressures (IDPs) at L2-3 were measured for 5 conditions: intact, instrumentation (L3-S1), band tension (BT) 30%, BT 50%, and BT 100%. RESULTS: There was significant increase in motion at L2-3 with L3-S1 instrumentation compared with the intact spine in flexion/extension (median 8.78°, range 4.07°-10.81°, vs median 7.27°, range 1.63°-9.66°; p = 0.016). When compared with instrumentation, BT 100% reduced motion at L2-3 in flexion/extension (median 8.78°, range 4.07°-10.81°, vs median 3.61°, range 1.11°-9.39°; p < 0.001) and lateral bending (median 6.58°, range 3.67°-8.59°, vs median 5.62°, range 3.28°-6.74°; p = 0.001). BT 50% reduced motion at L2-3 only in flexion/extension when compared with instrumentation (median 8.78°, range 4.07°-10.81°, vs median 5.91°, range 2.54°-10.59°; p = 0.027). There was no significant increase of motion at L1-2 with banding when compared with instrumentation, although an increase was seen from the intact spine with BT 100% in flexion/extension (median 5.14°, range 2.47°-9.73°, vs median 7.34°, range 4.22°-9.89°; p = 0.005). BT 100% significantly reduced IDP at L2-3 from 25.07 psi (range 2.41-48.08 psi) before tensioning to 19.46 psi (range -2.35 to 29.55 psi) after tensioning (p = 0.016). CONCLUSIONS: In this model, the addition of L2 SBs reduced motion and IDP at L2-3 after the L3-S1 instrumentation. There was no significant increase in motion at L1-2 in response to band tensioning compared with instrumentation alone. The application of SBs may have a clinical application in reducing the incidence of ASD.

Risk factors for delirium in elderly patients after lumbar spinal fusion.

OBJECTIVE: To identify perioperative risk factors for postoperative delirium (POD) in patients aged 65 or older undergoing lumbar spinal fusion procedures. PATIENTS AND METHODS: A retrospective cohort analysis was performed on patients undergoing lumbar spinal fusion over an approximately three-year period at a single institution. Demographic and perioperative data were obtained from electronic medical records. The primary outcome was the presence of postoperative delirium assayed by the Delirium Observation Screening Scale (DOSS) and Confusion Assessment Method for the ICU (CAM-ICU). Univariate and multivariate analyses were performed on the data. RESULTS: Of the 702 patients included in the study, 173 (24.6%) developed POD. Our analysis revealed that older age (p < 0.001), lower preoperative hemoglobin (p < 0.001), and higher ASA status (p < 0.001), were significant preoperative risk factors for developing POD. The only significant intraoperative risk factor was a higher number of spinal levels that were instrumented (p < 0.001). Higher pain scores on postoperative day 1 (p < 0.001), and lower postoperative hemoglobin (p < 0.001) were associated with increased POD; as were ICU admission (p < 0.001) and increased length of ICU stay (p < 0.001). Patients who developed POD had a longer hospital stay (p < 0.001) with lower rates of discharge to home as opposed to an inpatient facility (p < 0.001). CONCLUSION: Risk factors for POD in older adults undergoing lumbar spinal fusion surgery include advanced age, diabetes, lower preoperative and postoperative hemoglobin, higher ASA grade, greater extent of surgery, and higher postoperative pain scores. Patients with delirium had a higher incidence of postoperative ICU admission, increased length of stay, decreased likelihood of discharge to home and increased mortality, all consistent with prior studies. Further studies may determine whether adequate management of anemia and pain lead to a reduction in the incidence of postoperative delirium in these patients.

Spinal Meningioma in Adults: Imaging Characteristics, Surgical Outcomes, and Risk Factors for Recurrence.

OBJECTIVE: Although spinal meningiomas (SMs) are associated with overall long tumor-free survival, SMs can recur. This study analyzed factors associated with complications, misdiagnosis, and recurrence of SMs. METHODS: We reviewed patient demographics; radiographic characteristics of patients with SMs, including level, location within the canal, and size; surgical resection; pathology; and recurrence. RESULTS: The study included 64 women and 10 men (74 SMs). Of patients, 64 showed no recurrence after surgery with a median (range) follow-up of 17 (1-99) months. Recurrence was identified in 10 patients (13.5%) during a median (range) follow-up of 66 (25-230) months. There was no significant difference in sex between the recurrence and no recurrence cohorts. Patients in the recurrence cohort were significantly younger (median [range] age 58 [35-70] years) than patients in the no recurrence cohort (median [range] age 69 [18-93] years; P = 0.0091). There was significant predilection for foraminal locations in the recurrence cohort (P < 0.001) compared with the no recurrence cohort. SM was correctly identified on preoperative magnetic resonance imaging or computed tomography myelography in 62 of 64 tumors (96.9%) in the no recurrence cohort, but in only 6 of 10 tumors (60%) in the recurrence cohort (P < 0.001). CONCLUSIONS: In 74 patients with SMs, a preponderance of female patients and a predilection of tumors for the thoracic spine were shown. Recurrence was significantly more common in younger than older patients. Risk factors for recurrence included larger tumors, foraminal location, and en plaque lesions. Patients who developed recurrence were significantly more likely to have been misdiagnosed on preoperative imaging with nerve sheath tumors or lymphoma.

Use of a Smartphone Leveling Application to Optimize Cervical Thoracic Alignment Before Posterior Instrumentation.

OBJECTIVE: Posterior cervical decompression and instrumentation (PCDI) often is associated with increase in sagittal balance and loss of lordosis. Here, we propose a simple method of surgical positioning using a readily available smartphone application to optimize cervical thoracic alignment in PCDI. The intent of this optimization is to minimize losses in lordosis and increases in sagittal balance. METHODS: For patients since 2019, the position of the head was adjusted so that the occiput to thoracic spine was aligned and the chin brow angle was parallel to the rails of the surgical table using a leveling smart application (RIDGID level). Patients before 2019 who were not optimized were compared. RESULTS: There were 13 patients in the nonoptimized cohort (NOC) and 20 in the optimized cohort (OC). In the NOC, the change in lordosis was -7° (P = 0.016) and change in C2-sagittal vertical axis was 7 mm (P < 0.001) from preoperative to postoperative values. In the OC, the change in lordosis was 2° (P = 0.104) and change in C2-SVA was 2 mm (P = 0.592) from preoperative to postoperative values. Between the NOC and OC cohorts, the changes in lordosis and sagittal balance between cohorts were significant (P = 0.002 and P = 0.001, respectively). There was no significant difference in clinical outcomes as measured by Japanese Orthopaedic Association or complication rates. CONCLUSIONS: Positioning of the patient in preparation for PCDI can influence postoperative lordosis and sagittal balance. Using the leveling application on the smartphone (RIDGID level), is a rapid and free alternative for the maintenance of lordosis and sagittal balance during instrumentation in the operating room.

Cervical alignment in the obese population following posterior cervical fusion for cervical myelopathy.

STUDY DESIGN: Retrospective cohort study OBJECTIVE: The aim of this study was to investigate the effect of body mass index (BMI) on the reoperation rate and cervical sagittal alignment of patients who underwent posterior cervical decompression and fusion for cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Cervical sagittal balance has been correlated with postoperative clinical outcomes. Previous studies have shown worse postoperative sagittal alignment and higher reoperation rates in patients with high BMI undergoing anterior decompression and fusion. Similar evidence for the impact of obesity in postoperative sagittal alignment for patients with (CSM) undergoing posterior cervical decompression and fusion (PCF) is lacking. METHODS: A retrospective analysis of 198 patients who underwent PCF for cervical myelopathy due to degenerative spine disease was performed. Demographics, need for reoperation, and perioperative radiographic parameters were collected. Cervical lordosis (CL), C2-7 sagittal vertical axis (SVA), and T1 slope (T1S) was measured on standing lateral radiographs. Comparative analysis of the patient cohort was performed by stratifying the sample population into three BMI categories (<25, 25-30, ≥30). RESULT: Of the 198 patients that met inclusion criteria, 53 had BMI normal (<25), 65 were overweight (25-30), and 80 were obese (≥30). Mean SVA increased postoperatively in all groups, 4 mm in the normal group, 13 mm in the overweight group, and 13 mm in the obese group (p = 0.003). There was no significant difference in the postoperative change of cervical lordosis or T1 slope between the groups. Multivariate analysis demonstrated fusions involving the cervicothoracic junction and those involving 5 or more levels significantly affected alignment parameters. There were 27 complications requiring reoperation (14%) with no significant differences among the groups stratified by BMI (p = 0.386). CONCLUSIONS: Overweight patients (BMI>25) with CSM undergoing PCF had a greater increase in SVA than normal weight patients while reoperation rates were similar. In addition, preoperative CL increased with increasing BMI, although this trend was not Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation significant and there was not found to be a significant difference between the change in CL from baseline to post-fusion between BMI cohorts. This study further highlights the importance of considering BMI when attempting to optimize sagittal alignment in patients undergoing PCF.

What is the most accurate substitute for an invisible T1 slope in cervical radiographs? A comparative study of a novel method with previously reported substitutes.

OBJECTIVE: The ability to utilize the T1 slope is often limited by poor visibility on cervical radiographs. The C7 slope has been proposed as a reliable substitute but may have similar limitations of visibility. Herein, the authors propose a novel method that takes advantage of the superior visibility on CT to accurately substitute for the radiographic T1 slope and compare the accuracy of this method with previously reported substitutes. METHODS: Lateral neutral standing cervical radiographs and cervical CT scans were examined. When the T1 slope was clearly visible on radiographs, the C3-7 slopes and T1 slope were measured. In CT method 1, a direct method, the T1 slope was measured from the upper endplate of T1 to the bottom edge of the CT image, assuming the edge was parallel to the horizontal plane. In CT method 2, an overlaying method, the T1 slope was calculated by superimposing the C7 slope angle measured on a radiograph onto the CT scan and measuring the angle formed by the upper endplate of T1 and the superimposed horizontal line of the C7 slope. A Pearson correlation with linear regression modeling was performed for potential substitutes for the actual T1 slope. RESULTS: Among 160 patients with available noninstrumented lateral neutral cervical radiographs, the T1 slope was visible in only 54 patients (33.8%). A total of 52 patients met the inclusion criteria for final analysis. The Pearson correlation coefficients between the T1 slope and the C3-7 slopes, CT method 1, and CT method 2 were 0.243 (p = 0.083), 0.292 (p = 0.035), 0.609 (p < 0.001), 0.806 (p < 0.001), 0.898 (p < 0.001), 0.426 (p = 0.002), and 0.942 (p < 0.001), respectively. Linear regression modeling showed R2 = 0.807 for the correlation between C7 slope and T1 slope and R2 = 0.888 for the correlation between T1 slope with the CT method 2 and actual T1 slope. CONCLUSIONS: The C7 slope can be a reliable predictor of the T1 slope and is more accurate than more rostral cervical slopes. However, this study disclosed that the novel CT method 2, an overlaying method, was the most reliable estimate of true T1 slope with a greater positive correlation than C7 slope. When CT studies are available in patients with an invisible T1 slope on cervical radiographs, CT method 2 should be used as a substitute for the T1 slope.

Bone flap management strategies for postcraniotomy surgical site infection.

BACKGROUND: Surgical site infection (SSI) after a craniotomy is traditionally treated with wound debridement and disposal of the bone flap, followed by intravenous antibiotics. The goal of this study is to evaluate the safety of replacing the bone flap or performing immediate titanium cranioplasty. METHODS: All craniotomies at single center between 2008 and 2020 were examined to identify 35 patients with postoperative SSI. Patients were grouped by bone flap management: craniectomy (22 patients), bone flap replacement (seven patients), and titanium cranioplasty (six patients). Retrospective chart review was performed to identify patient age, gender, index surgery indication and duration, diffusion restriction on MRI, presence of gross purulence, bacteria cultured, sinus involvement, implants used during surgery, and antibiotic prophylaxis/ treatment. These variables were compared to future infection recurrence and wound breakdown. RESULTS: There was no significant difference in infection recurrence or future wound breakdown among the three bone flap management groups (P = 0.21, P = 0.25). None of the variables investigated had any significant relation to infection recurrence when all patients were included in the analysis. However, when only the bone flap replacement group was analyzed, there was significantly higher infection recurrence when there was frank purulence present (P = 0.048). CONCLUSION: Replacing the bone flap or performing an immediate titanium cranioplasty is safe alternatives to discarding the bone flap after postoperative craniotomy SSI. When there is gross purulence present, caution should be used in replacing the bone flap, as infection recurrence is significantly higher in this subgroup of patients.

Outcomes and complications of surgical treatment of anterior osteophytes causing dysphagia: Single center experience.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To better understand the functional swallow outcomes, cervical balance, and surgical complications, we examined patients with anterior osteophytes and dysphagia who were treated operatively. SUMMARY OF BACKGROUND DATA: Anterior osteophytes from diffuse idiopathic skeletal hyperostosis (DISH) or degenerative etiology of the cervical spine can cause dysphagia from mechanical compression of the esophagus. Osteophytectomy is generally accepted as a safe surgical treatment, but the risk of instability is unclear. The potential for associated complications must be considered. METHODS: Patients who had anterior osteophytes and dysphagia from 2005 to 2020 were reviewed retrospectively. Demographics, radiographic parameters, functional swallow outcome, and complications were examined. RESULTS: There were 15 patients identified treated surgically. Increased osteophyte height positively correlated with severity of dysphagia with Pearson coefficient of 0.53 (p = 0.042). Functional Outcome Swallowing Scale (FOSS) scores improved after surgical treatment from median of 2 to 0 (p = 0.002). C2-7 SVA did increase by 8 mm (p = 0.007) but was generally well tolerated. There was a 27% complication rate including a case of C5 lateral mass fracture with central cord syndrome after a fall 4 days following osteophytectomy. There was one patient who was preoperatively dependent on gastrostomy tube who required a tracheostomy and had continued reliance on the gastrostomy tube. CONCLUSION: Surgical treatment of anterior osteophytes causing dysphagia with osteophytectomy can lead to overall improved FOSS scores for most patients. However, a high preoperative FOSS score may be a prognostic indicator of poor postoperative functional swallow outcome. It is important to consider the potential for instability when osteophytectomy is performed at 3 or more spinal segments.

Relationship between odontoid fracture angle and cervical sagittal balance.

BACKGROUND: Fractures can occur in various locations within the odontoid process with differing orientations. However, little is known about what factors contribute to the anterior versus posterior angles/orientation of these fractures. METHODS: We evaluated 74 patients with odontoid fractures (2013-2018) from a single-institution. Patients' fracture angles/orientations were measured on computed tomography studies, and were grouped into oblique posterior (OP) or oblique anterior (OA) groups. We also took into account cervical sagittal balance utilizing upright x-rays. Other variables studied included patients' ages, sagittal balance measurements, and the mechanisms of injury. RESULTS: Fracture angles were significantly steeper in the OP group. OP fractures had larger C2-C7 sagittal vertical axis, occiput-C2 angles, and occiput-C7 angles versus anteriorly oriented fractures. In our linear regression model, advanced age and large occiput-C2 angles were predictive of the odontoid fracture angle. Patients who sustained ground-level falls also had significantly steeper fracture angles versus those involved in motor vehicle accidents. CONCLUSION: The odontoid tends to fracture at a steep, posterior angle in elderly patients who demonstrate a large positive sagittal balance when the head is extended following a ground-level falls.