Preventing Unnecessary Surgery in Patients Presenting for Orthopedic Spine Surgery: Literature Review and Case Series.

Introduction: Almost 40% of patients who have been diagnosed with amyotrophic lateral sclerosis (ALS) may have been misdiagnosed. Some of these patients may have undergone surgical procedures to address symptoms that could have actually be early indications of ALS.Up to 40% of patients diagnosed with amyotrophic lateral sclerosis (ALS) have received an incorrect diagnosis, a number undergo surgical treatment for signs and symptoms that can be attributed to early manifestations of ALS. Initial presentation of ALS is elusive and is often mistaken for other disorders originating from the cervical spine such as cervical radiculopathy or myelopathy. Such incorrect diagnoses often display symptoms that fall within the scope of an orthopedic spine surgeon, who can remedy said diagnoses. Given that a diagnosis of ALS is grave, it is crucial to establish a definitive diagnosis quickly, without unnecessary surgery. The objective of this series is to highlight patients who were referred by other physicians for spine surgery to remedy potential side effects of cervical myelopathy but were ultimately diagnosed with ALS. Case Report: Case 1: A 46-year-old Caucasian woman with carpal tunnel syndrome and cervical intervertebral disc degeneration. Case 2: A 77-year-old African American man with a history of arthritis, GERD, a herniated disc, claw hand, hypertension, prostate disease, and general weakness. Case 3: A 74-year-old Caucasian woman with a background history of hypertension, dyslipidemia, hypothyroidism, osteopenia, and foot drop. Conclusion: In orthopedic spine surgery, ALS could be an easily misdiagnosed disease, which can be mistaken for cervical spondylosis, cervical radiculopathy, cervical myelopathy, lumbar radiculopathy, and lumbar myelopathy; it is of note to be aware of how ALS may initially present. It is imperative for the orthopedic spine surgeon to consider ALS with patients presenting with progressive unilateral/bilateral upper extremity weakness.

Sacral Fractures: A Review.

At the cornerstone of the pelvis and spine, the sacrum may be fractured in patients of all ages. Sacral fractures range from high-energy injuries, with mortality rates of up to 18%, to low-energy insufficiency fractures. The intricate geometry of the sacrum, the breadth of morphotypes, and the presence of congenital anomalies all can complicate the treatment of these fractures. Agreement on the surgical indications for these injuries is limited. This narrative review aims to update orthopedic surgeons on the clinical evaluation and the non-surgical and surgical management of these fractures.

Preoperative cross-sectional area of psoas muscle correlates with short-term functional outcomes after posterior lumbar surgery.

PURPOSE: To determine the optimal level for the measurement of psoas cross-sectional area and examine the correlation with short-term functional outcomes of posterior lumbar surgery. METHODS: Patients who underwent minimally invasive posterior lumbar surgery were included in this study. The cross-sectional area of psoas muscle was measured at each intervertebral level on T2-weighted axial images of preoperative MRI. Normalized total psoas area (NTPA) (mm2/m2) was calculated as total psoas area normalized to patient height. Intraclass Correlation Coefficient (ICC) was calculated for the analysis of inter-rater reliability. Patient reported outcome measures including Oswestry disability index (ODI), visual analog scale (VAS), short form health survey (SF-12) and patient-reported outcomes measurement information system were collected. A multivariate analysis was performed to elucidate independent predictors associated with failure to reach minimal clinically important difference (MCID) in each functional outcome at 6 months. RESULTS: The total of 212 patients were included in this study. ICC was highest at L3/4 [0.992 (95% CI: 0.987-0.994)] compared to the other levels [L1/2 0.983 (0.973-0.989), L2/3 0.991 (0.986-0.994), L4/5 0.928 (0.893-0.952)]. Postoperative PROMs were significantly worse in patients with low NTPA. Low NTPA was an independent predictor of failure to reach MCID in ODI (OR = 2.68; 95% CI: 1.26-5.67; p = 0.010) and VAS leg (OR = 2.43; 95% CI: 1.13-5.20; p = 0.022). CONCLUSION: Decreased psoas cross-sectional area on preoperative MRI correlated with functional outcomes after posterior lumbar surgery. NTPA was highly reliable, especially at L3/4.

Airway Complications After Anterior Cervical Spine Surgery: Etiology and Risk Factors.

STUDY DESIGN: Narrative Review. OBJECTIVE: To provide an overview of etiology and risk factors of airway complications after anterior cervical spine surgery (ACSS). METHODS: A search was performed in PubMed and adapted for use in other databases, including Embase, Cochrane Library, Cochrane Register of Controlled Trials, Health Technology Assessment database, and NHS Economic Evaluation Database. RESULTS: 81 full-text studies were reviewed. A total of 53 papers were included were included in the review and an additional four references were extracted from other references. 39 papers were categorized as etiology and 42 as risk factors. CONCLUSIONS: Most of the literature on airway compromise after ACSS is level III or IV evidence. Currently, there are no systems in place to risk-stratify patients undergoing ACSS regarding airway compromise or guidelines on how to manage patients when these complications do occur. This review focused on theory, primarily etiology and risk factors.

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.

Computed Tomography and Magnetic Resonance Imaging Overlay in the Spine for Surgical Planning: A Technical Report.

BACKGROUND: Computed tomography (CT) and magnetic resonance imaging (MRI) studies are used separately for surgical planning of spine surgery. Advanced techniques exist for creating CT-MR fusion images, but at this time these techniques are not easily accessible for large-scale use. TECHNIQUE: We propose a simple graphical technique for CT-MR image overlay, for use in the surgical planning of spinal decompression and guidance of intraoperative resection. The proposed technique involves overlaying a single cross-section from anatomically comparable MRI and CT studies on any software with basic image editing functions. RESULTS: We demonstrate CT-MR fusion images of 8 patients of the senior author in which the technique was used. We found that it can also be referenced intraoperatively for navigation. CONCLUSIONS: Compared to other techniques, our proposed method can be easily implemented by clinicians to create simple CT-MRI fusion images that can be useful for preoperative planning and intraoperative navigation.

The Spine Physical Examination Using Telemedicine: Strategies and Best Practices.

STUDY DESIGN: Technical note. OBJECTIVES: To provide spine surgeons new to telemedicine with a structured physical examination technique based on manual motor testing principles. METHODS: Expert experience describing a series of specific maneuvers for upper and lower extremity strength testing that can be performed using a telemedicine platform. In addition, we offer instruction on "setting up" for these visits and highlight special tests that can be used to diagnose specific cervical and lumbar spine conditions. RESULTS: From our experiences in conducting telemedicine visits, we provide a means of testing and scoring upper and lower extremity strength for interpretation of weakness in the context of traditional manual motor testing. Also, we acknowledge the limitations of a remote examination and discuss maneuvers that cannot be performed remotely. CONCLUSIONS: COVID-19 has drastically altered the delivery of care for patients with spine-related complaints. The need for social distancing has led to the widespread adoption of telemedicine. This technical note provides an urgently needed framework for the standardization of the remote physical exam. Validation of the exam as a diagnostic tool will be a crucial next step in studying the impact of telemedicine.

Alignment Targets, Curve Proportion and Mechanical Loading: Preliminary Analysis of an Ideal Shape Toward Reducing Proximal Junctional Kyphosis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Investigate risk factors for PJK including theoretical kyphosis, mechanical loading at the UIV and age adjusted offset alignment. METHODS: 373 ASD patients (62.7 yrs ± 9.9; 81%F) with 2-year follow up and UIV of at least L1 and LIV of sacrum were included. Images of patients without PJK, with PJK and with PJF were compared using standard spinopelvic parameters before and after the application of the validated virtual alignment method which corrects for the compensatory mechanisms of PJK. Age-adjusted offset, theoretical thoracic kyphosis and mechanical loading at the UIV were then calculated and compared between groups. A subanalysis was performed based on the location of the UIV (upper thoracic (UT) vs. Lower thoracic (LT)). RESULTS: At 2-years 172 (46.1%) had PJK, and 21 (5.6%) developed PJF. As PJK severity increased, the post-operative global alignment became more posterior secondary to increased over-correction of PT, PI-LL, and SVA (all P < 0.005). Also, a larger under correction of the theoretical TK (flattening) and a smaller bending moment at the UIV (underloading of UIV) was found. Multivariate analysis demonstrated that PI-LL and bending moment offsets from normative values were independent predictors of PJK/PJF in UT group; PT and bending moment difference were independent predictors for LT group. CONCLUSIONS: Spinopelvic over correction, under correction of TK (flattening), and under loading of the UIV (decreased bending moment) were associated with PJK and PJF. These differences are often missed when compensation for PJK is not accounted for in post-operative radiographs.

Prevalence of Cannabidiol Use in Patients With Spine Complaints: Results of an Anonymous Survey.

BACKGROUND: Cannabidiol (CBD) is a cannabis derivative that has been popularized as a medicinal product with analgesic and anti-inflammatory effects. Given the anecdotal observations that several patients have reported use of CBD for spine-related pain, this study was designed to characterize CBD consumption patterns and perceived effects in patients with spine-related complaints. METHODS: The study design was a cross-sectional survey. Over a 4-week period, an anonymous paper survey was administered to all patients presenting for evaluation by 1 of 9 spine surgeons at a single institution. Surveys were given upon registration for the office visit and collected by the office manager or nurse before evaluation by the surgeon. Patients were included regardless of surgical status (ie, preoperative, postoperative, or nonoperative) or region of pathology (lumbar, thoracic, or cervical). The survey consisted of multiple-choice questions on patient patterns of CBD use. RESULTS: Out of 300 surveys, 214 (71%) were completed. CBD use for spine-related pain was reported by 54 (25.2%) patients. CBD was initially used for potential relief of back pain (66.7%), neck pain (37.0%), leg pain (35.2%), and/or arm pain (9.3%). Users also sought improvements in insomnia (25.9%) and mood (18.5%). Oil was the most popular formulation (64.8%). CBD was most often consumed 2-5 times (40.7%) or 6-10 times (31.5%) per week. The most common source of initial recommendation for CBD was friends or family (75.9%). Reported benefits were pain relief (46.3%), improved sleep (33.3%), and reduced anxiety (20.4%); however, 24.1% of patients reported no benefit from CBD use. The most reported side effect was fatigue (7.4%). Most users (63.0%) would recommend CBD to a friend for pain relief. CONCLUSION: CBD is already used by many patients, and further high-quality research on this supplement is essential. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: CBD is a commonly used by spine patients as an off label treatment.

A Primer on the Use of Artificial Intelligence in Spine Surgery.

DESIGN: This was a narrative review. PURPOSE: Summarize artificial intelligence (AI) fundamentals as well as current and potential future uses in spine surgery. SUMMARY OF BACKGROUND DATA: Although considered futuristic, the field of AI has already had a profound impact on many industries, including health care. Its ability to recognize patterns and self-correct to improve over time mimics human cognitive function, but on a much larger scale. METHODS: Review of literature on AI fundamentals and uses in spine pathology. RESULTS: Machine learning (ML), a subset of AI, increases in hierarchy of complexity from classic ML to unsupervised ML to deep leaning, where Language Processing and Computer Vision are possible. AI-based tools have been developed to segment spinal structures, acquire basic spinal measurements, and even identify pathology such as tumor or degeneration. AI algorithms could have use in guiding clinical management through treatment selection, patient-specific prognostication, and even has the potential to power neuroprosthetic devices after spinal cord injury. CONCLUSION: While the use of AI has pitfalls and should be adopted with caution, future use is promising in the field of spine surgery and medicine as a whole. LEVEL OF EVIDENCE: Level IV.

Early Failures After Lumbar Discectomy Surgery: An Analysis of 62 690 Patients.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine the rate of early failures (readmission or reoperation for new or recurrent pain/neurological symptoms) within 30 days after lumbar discectomy and identify associated risk factors. METHODS: A retrospective cohort study was conducted of patients undergoing lumbar discectomy in the National Surgical Quality Improvement Program database between 2013 and 2017. Rates of readmission for new or recurrent symptoms or reoperation for revision discectomy or fusion within 30 days postoperatively were measured and correlated with risk factors. RESULTS: In total 62 690 patients were identified; overall rate of readmission within 30 days was 3.3%, including 1.2% for pain or neurological symptoms. Populations at increased risk of readmission were those with 3 or more levels of treatment (2.0%, odds ratio [OR] 2.8%, P < .01), age >70 years (1.8%, OR 1.6, P < .01), class 3 obesity (1.5%, OR 1.4, P = .04), and female gender (1.4%, OR 1.2, P = .02). The overall rate of reoperation within 30 days was 2.2%, including 1.2% for revision decompression or lumbar fusion surgery. Populations at increased risk of reoperation were revision discectomies (1.4%, OR 1.7, P < .01) and females (1.1%, OR 1.4, P < 0.01). Extraforaminal discectomies were associated with lower rates of readmission (0.7%, OR 0.6, P = 0.02) and reoperation (0.4%, OR 0.4, P = .01). CONCLUSIONS: Early failures after lumbar discectomy surgery are rare. However, certain subpopulations are associated with increased rates of early failure: obesity, multilevel surgery, females, and revision discectomies.

Morphometric analysis of cervical interlaminar space for posterior surgical approach and decompression.

PURPOSE: The purpose of this study is to provide a morphometric description of the bony margins of the interlaminar spaces by level in the cervical spine for guidance of safe posterior cervical surgical dissection and decompression. We also aim to describe the impact of increasing static cervical lordosis on the overlap between the lamina. METHODS: Morphometric measurements of the interlaminar space were performed on 100 consecutive cervical spine CT scans of patients ranging in age from 18 to 50 years were selected. Three raters performed measurements of the interlaminar height measured using two techniques (true interlaminar height and surgical interlaminar height), and interlaminar width from C2-C3 to C7-T1. RESULTS: In total, 100 patients were included. The true interlaminar height was greatest at C2-3, C3-4, C4-5 (5.2 ± 1.4-1.8 mm) and smallest at C6-7 (4.4 ± 1.3 mm). Surgical interlaminar height was greatest at C3-4 (4.2 ± 1.7) and smallest at C6-7 (3.0 ± 1.3 mm). The widest interlaminar space was observed at C3-4 (27.1 ± 2.1 mm) and most narrow at C7-T1 (20.9 ± 2.4 mm). Following multivariate regression, male gender was associated with greater interlaminar widths at each cervical level between C4 and T1 (Table 2). While greater patient height was associated with larger interlaminar height (true and surgical) and width at C2-3 and C4-5, weight was not independently associated with the interlaminar measurements. Increasing C2-C7 lordosis was significantly associated with decreasing true and surgical interlaminar heights at all levels except C7-T1, but was not associated with differences between interlaminar width. CONCLUSION: The study provides a morphometric analysis of interlaminar anatomy in the cervical spine. Surgeons can apply this information in their pre-operative plan to safely approach the posterior cervical spine.

Shoulder Double Crush Syndrome: A Retrospective Study of Patients With Concomitant Suprascapular Neuropathy and Cervical Radiculopathy.

PURPOSE: While the double crush phenomena (compression along two points on a nerve) has been established between median neuropathy and cervical radiculopathy, combined suprascapular neuropathy (SSN) and cervical C5/C6 radiculopathy-so-called shoulder double crush syndrome-has not been well examined. We aim to identify the incidence of shoulder double crush syndrome in patients undergoing arthroscopic suprascapular nerve release for SSN. METHODS: One hundred consecutive patients >18 years of age who were positive for SSN on electromyography and motor nerve conduction studies (EMG/NCS) and underwent a suprascapular nerve release were included. Patients with evidence of shoulder double crush syndrome were identified based on x ray, cervical spine magnetic resonance imaging (MRI) and examination findings. Demographics, electrodiagnostics results, treatment courses, and clinical outcomes (visual analog scores and rotator cuff strength) following arthroscopic suprascapular nerve release were compared between patients with double crush syndrome versus isolated SSN. RESULTS: Thirty one percent of patients had evidence of shoulder crush syndrome. Two significant electrophysiologic differences were noted in shoulder double crush patients compared to isolated SSN patients. Patients with double crush had an increased incidence of median neuropathy (51% vs 30%, P = .04). Double crush patients had less supraspinatus motor amplitude difference between the affected side and non-affected side compared to isolated SSN patients (2.62 mV vs 3.44 mV, P = .03). In general, most double crush patients were treated conservatively with regard to their cervical spine pathology. CONCLUSION: A significant percentage of patients with SSN have evidence of shoulder double crush syndrome. Patients with SSN and concomitant median neuropathy should have a detailed neck examination performed.

Hypoglossal Nerve Palsy After Anterior Cervical Spine Surgery: A Case Report and Literature Review.

CASE: A 37-year-old man was found to have hypoglossal nerve palsy after undergoing anterior cervical spine surgery at C3-C5, an injury that would cause him severe disability and further complications. CONCLUSION: Knowledge of the hypoglossal nerve is crucial for cervical spine surgery even at lower levels (C4-C7), including variations in its course and potential displacement during the induction of anesthesia.

New Strategies in Enhancing Spinal Fusion.

The biologic steps involved in creating a bony fusion between adjacent segments of the spine are a complex and highly coordinated series of events. There have been significant advancements in bone grafts and bone graft substitutes in order to augment spinal fusion. While autologous bone grafting remains the gold standard, allograft bone grafting, synthetic bone graft substitutes, and bone graft enhancers are appropriate in certain clinical situations. This article provides an overview of the basic biology of spinal fusion and strategies for enhancing fusion through innovations in bone graft material.

The necessity and risk factors of subsequent fusion after decompression alone for lumbar spinal stenosis with lumbar spondylolisthesis: 5 years follow-up in two different large populations.

BACKGROUND/CONTEXT: Although decompression without fusion is a reasonable surgical treatment option for some patients with lumbar spinal stenosis (LSS) secondary to spondylolisthesis, some of these patients will require secondary surgery for subsequent fusion. Long-term outcome and need for subsequent fusion in patients treated with decompression alone in the setting of lumbar spondylolisthesis remains controversial. PURPOSE: The aim of this study was to examine the rate, timing, and risk factors of subsequent fusion for patients after decompression alone for LSS with spondylolisthesis. STUDY DESIGN/SETTING: A retrospective cohort study. PATIENT SAMPLE: Patients who had LSS with spondylolisthesis and underwent decompression alone at 1 or 2 levels as a primary lumbar surgery with more than 5 year follow-up. OUTCOME MEASURES: The rate, timing, and risk factors for subsequent fusion. METHODS: Subjects were extracted from both public and private insurance resources in a nationwide insurer database. Risk factors for subsequent fusion were evaluated by multivariate cox proportion-hazard regression controlling for age, gender, comorbidities and the presence or absence of claudication. RESULTS: Five thousand eight hundred and seventy-five patients in the public insurance population (PI population) and 1,456 patients in the private insurance population (PrI population) were included in this study. The rates of patients who needed subsequent fusion were 1.9% at 1 year, 3.5% at 2 years, and 6.7% at 5 years in the PI population, whereas they were 4.3% at 1 year, 8.9% at 2 years, 14.6% at 5 years in the PrI population. The time to subsequent fusion was 730 (365-1234) days in the PI population and 588 (300-998) days in the PrI population. Age less than 70 years, presence of neurogenic claudication and rheumatoid arthritis (RA)/collagen vascular diseases (CVD) were independent risk factors for subsequent fusion in both populations. CONCLUSIONS: Decompression surgery alone can demonstrate good outcomes in some patients with LSS with spondylolisthesis. It is important for surgeons to recognize, however, that patient age less than 70 years, symptomatic neurogenic claudication, and presence of RA and/or CVD are significant independent factors associated with greater likelihood of needing secondary fusion surgery.

Overlapping, Masquerading, and Causative Cervical Spine and Shoulder Pathology: A Systematic Review.

STUDY DESIGN: Systematic review. OBJECTIVE: To assess the current literature regarding the relationship between the shoulder and the spine with regard to (1) overlapping pain pathways; (2) differentiating history, exam findings, and diagnostic findings; (3) concomitant pathology and optimal treatments; and (4) cervical spine-based etiology for shoulder problems. METHODS: A systematic literature search was performed according to the guidelines set forth by the Cochrane Collaboration. Studies were included if they examined the clinical, anatomical, or physiological overlap between the shoulder and cervical spine. Two reviewers screened and selected full texts for inclusion according to the objectives of the study. Quality of evidence was graded using OCEBM (Oxford Center for Evidence Based Medicine) and MINORS (Methodological Index for Nonrandomized Studies) scores. RESULTS: Out of 477 references screened, 76 articles were included for review and grouped into 4 main sections (overlapping pain pathways, differentiating exam findings, concomitant/masquerading pathology, and cervical spine-based etiology of shoulder pathology). There is evidence to suggest cervical spine pathology may cause shoulder pain and that shoulder pathology may cause neck pain. Specific examination tests used to differentiate shoulder and spine pathology are critical as imaging studies may be misleading. Diagnostic injections can be useful to confirm sources of pain as well as predicting the success of surgery in both the shoulder and the spine. There is limited evidence to suggest alterations in the relationship between the spine and the scapula may predispose to shoulder impingement or rotator cuff tears. Moreover, cervical neurological lesions may predispose patients to developing rotator cuff tears. The decision to proceed with shoulder or spine surgery first should be delineated with careful examination and the use of shoulder and spine diagnostic injections. CONCLUSION: Shoulder and spine pathology commonly overlap. Knowledge of anatomy, pain referral patterns, shoulder kinematics, and examination techniques are invaluable to the clinician in making an appropriate diagnosis and guiding treatment. In this review, we present an algorithm for the identification and treatment of shoulder and cervical spine pathology.

A retrospective review of 112 patients undergoing arthroscopic suprascapular nerve decompression.

BACKGROUND: Arthroscopic suprascapular nerve release has yielded good results previously. However, comprehensive literature is still lacking. PURPOSE: This study assessed results of suprascapular nerve release in patients with intractable shoulder pain with confirmed suprascapular neuropathy. METHODS: Retrospectively reviewed patients undergoing suprascapular nerve release. Patients were evaluated with VAS scores and supraspinatus/infraspinatus strength. RESULTS: 112 patients were included showing reduction in VAS pain scores from the initial visit to final follow up. Additionally, improvement in both supra/infraspinatus strength occurred. There were no major complications. CONCLUSION: This series demonstrates improvement in pain and strength following suprascapular nerve release with limited risk. LEVEL OF EVIDENCE: IV.