Lumbar radiculopathy and fracture risk: A Korean nationwide population-based cohort study.

INTRODUCTION: Lumbar radiculopathy is a common disease with a high economic burden, and fractures in adults are a significant public health problem. However, studies of the relationship between lumbar radiculopathy and fractures are scarce. We investigated the fracture risk in patients with lumbar radiculopathy. METHODS: This nationwide retrospective cohort study identified 815,101 patients with lumbar radiculopathy and randomly matched individuals without lumbar radiculopathy (1:1) who were included in the Korean National Health Insurance System in 2012. Cox proportional hazards regression analyses were performed to calculate the hazard ratio (HR) for fracture risk in patients with lumbar radiculopathy. RESULTS: The study included 301,347 patients with lumbar radiculopathy and matched 289,618 individuals without lumbar radiculopathy. Compared to individuals without lumbar radiculopathy, patients with lumbar radiculopathy had a 27 % increased fracture risk (adjusted HR = 1.27, 95 % confidence interval = 1.24-1.31). The Kaplan-Meier plot showed a significantly higher fracture incidence in patients with lumbar radiculopathy than in individuals without lumbar radiculopathy at all times. CONCLUSION: Lumbar radiculopathy is significantly associated with fracture risk.

Prevalence of sleep disturbance in patients with cervical radiculopathy and an analysis of risk factors: a cross-sectional study.

OBJECTIVE: Previous research has shown that many patients with musculoskeletal diseases suffer from sleep disturbances. However, the sleep quality of patients with cervical radiculopathy (CR) has yet to be fully investigated. This study aims to investigate the prevalence and status of sleep disturbances in patients with CR and identify the mechanisms and risk factors associated with this condition. METHODS: We conducted a cross-sectional study of patients diagnosed with CR. The Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) were used to evaluate the sleep quality of patients and determine whether patients experience sleep disturbances. In addition, we analyzed the clinical and radiological risk factors of sleep disturbance and determined the key risk factors related to sleep disturbance by multivariable analysis. RESULTS: According to specific inclusion and exclusion criteria, 186 patients with CR were finally included, with a mean age of 59.1 ± 14.3 years, of which 113 (60.8%) were female. Sleep disturbance was defined as a PSQI score ≥ 6 and was identified in 56.5% of patients (105/186). By performing multivariate analysis, we determined that sleep disturbance was closely related to the female gender, a higher Beck Depression Inventory (BDI) score, a reduction in cervical mobility, an increase in C2-C7 sagittal vertical axis (C2-C7 SVA), and severe asymmetry of the paravertebral muscle at C5 and C6 levels. CONCLUSION: In this study, we identified the high prevalence and potential high-risk factors of sleep disturbance in patients with CR. Clinicians should closely evaluate and monitor such patients and consider appropriate treatment strategies. LEVEL OF EVIDENCE: IV.

Nonorganic (Behavioral) Signs and Their Association With Epidural Corticosteroid Injection Treatment Outcomes and Psychiatric Comorbidity in Cervical Radiculopathy: A Multicenter Study.

OBJECTIVE: To determine the association between cervical nonorganic pain signs and epidural corticosteroid injection outcomes and coexisting pain and psychiatric conditions. PATIENTS AND METHODS: Seventy-eight patients with cervical radiculopathy who received epidural corticosteroid injection were observed to determine the effects that nonorganic signs have on treatment outcome. A positive outcome was a decrease of 2 or more points in average arm pain, coupled with a score of 5 on a 7-point Patient Global Impression of Change scale 4 weeks after treatment. Nine tests in 5 categories (abnormal tenderness, regional disturbances deviating from normal anatomy, overreaction, discrepancies in examination findings with distraction, and pain during sham stimulation) were modified from previous studies and standardized. Other variables examined for their association with nonorganic signs and outcomes included disease burden, psychopathology, coexisting pain conditions, and somatization. RESULTS: Of the 78 patients, 29% (n=23) had no nonorganic signs, 21% (n=16) had signs in 1 category, 10% (n=8) had signs in 2 categories, 21% (n=16) had signs in 3 categories, 10% (n=8) had signs in 4 categories, and 9% (n=7) had signs in 5 categories. The most common nonorganic sign was superficial tenderness (44%; n=34). Mean number of positive nonorganic categories was higher in individuals with negative treatment outcomes (2.5±1.8; 95% CI, 2.0 to 3.1) compared with those with positive outcomes (1.1±1.3; 95% CI, 0.7 to 1.5; P=.0002). Negative treatment outcomes were most strongly associated with regional disturbances and overreaction. Positive associations were noted between nonorganic signs and multiple pain (P=.011) and multiple psychiatric (P=.028) conditions. CONCLUSION: Cervical nonorganic signs correlate with treatment outcome, pain, and psychiatric comorbidities. Screening for these signs and psychiatric symptoms may improve treatment outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04320836.

Neuropathic Pain Component in Patients with Cervical Radicular Pain: A Single-Center Retrospective Study.

Background and Objectives: Evidence regarding the prevalence of neuropathic pain in patients with cervical radicular pain is limited. This study aimed to investigate the prevalence of neuropathic pain components in patients with cervical radicular pain using established screening tools and identify the relationship between neuropathic pain components and clinical factors. Materials and Methods: Data from 103 patients (aged ≥ 20 years) with cervical radicular pain who visited our pain clinic were analyzed retrospectively. Demographic characteristics, history of neck surgery, pain intensity using numeric rating score, dominant pain site, duration of symptoms, and neck disability index were assessed. The prevalence of neuropathic pain components was defined according to the Douleur Neuropathique 4 questions and painDETECT questionnaire tools. Patient characteristics were compared using the chi-square test or Fisher's exact test for categorical variables and the independent t-test or Mann−Whitney U test for continuous variables. The correlation between neck disability index and other variables was analyzed using Pearson's correlation coefficient. Results: Of the 103 patients, 29 (28.1%) had neuropathic pain components. The neck disability index was significantly higher (p < 0.001) for patients in the neuropathic pain group (23.79 ± 6.35) than that in the non- neuropathic pain group (18.43 ± 7.68). The Douleur Neuropathique 4 questions (r = 0.221, p < 0.025) and painDETECT questionnaire (r = 0.368, p < 0.001) scores positively correlated with the neck disability index score. Conclusions: The prevalence of neuropathic pain components in patients with cervical radicular pain was low. The patients in our study showed a strong correlation between functional deterioration and their neuropathic pain screening score. This study may be useful in understanding the characteristics of cervical radicular pain.

Detailed features and prognostic factors of twenty-three patients with drop finger caused by cervical radiculopathy: a retrospective multicentre study.

PURPOSE: It has been reported that C7 and C8 nerve root impairment can cause drop finger; however, the clinical characteristics of each injured nerve root and post-operative outcomes remain unclear. This study aimed to investigate the detailed features and surgery-related prognostic factors of drop finger caused by cervical radiculopathy. METHODS: We retrospectively investigated the clinical characteristics, paralysis patterns and surgery-related prognostic factors of 23 patients with drop finger caused by cervical radiculopathy who underwent posterior cervical foraminotomy. We classified paralysis into three patterns based on the fingers predominantly exhibiting extensor digitorum communis (EDC) muscle weakness: index finger side-dominant, middle and ring fingers-dominant and little finger side-dominant. RESULTS: The aetiologies were cervical disc hernia (CDH) in ten patients, cervical spondylotic radiculopathy (CSR) in eight and both CDH and CSR in five. The levels of the decompressed root were C7 in one patient, C8 in 11 and both C7 and C8 in 11. Scapular pain was frequently observed as the initial symptom (78%), especially in patients with only C8 nerve root disorder (91%). Drop finger recovered to a score of ≥ 3 on manual muscle testing in 17 patients; patients with the little finger side-dominant pattern tended to have poor recoveries. Patients with CDH improved significantly than those with CSR or both CDH and CSR (p < 0.05). CONCLUSIONS: Good surgical recovery of drop finger can be expected in patients with CDH and in those with index fingers-dominant and middle and ring fingers-dominant patterns.

Comparative Effectiveness of Parasagittal Interlaminar and Transforaminal Cervical Epidural Steroid Injection in Patients with Cervical Radicular Pain: A Randomized Clinical Trial.

BACKGROUND: Cervical epidural steroid injections (ESI) are performed either by interlaminar (IL) or transforaminal (TF) approaches; however, there is controversy over which is better for safety and efficacy. OBJECTIVES: This clinical trial aimed to compare the effectiveness of the parasagittal IL and TF approaches for cervical ESI in patients who were suffering from cervical radicular pain. STUDY DESIGN: A prospective randomized assessor-blind study. SETTING: The study took place at a single pain clinic within a tertiary medical center in Seoul, Republic of Korea. METHODS: This prospective randomized, assessor-blind trial included 80 patients with cervical radicular pain. We randomly assigned patients to the TF or parasagittal IL approach for cervical ESI. The effectiveness of the 2 groups was compared based on pain intensity using the Numeric Rating Scale (NRS-11) at 1 and 3 months. The Neck Disability Index (NDI), Medication Quantification Scale (MQS), and responders at 1 and 3 months between the 2 groups were compared. RESULTS: The pain intensity of both groups significantly reduced after 1 and 3 months after each procedure (P < 0.001). Two-way repeated measures of analysis of variance showed no significant interaction between group and time for cervical radicular pain (P = 0.266), although NRS-11 pain score was lower in the TF group than the parasagittal IL group after 1 month (P = 0.010). NDI, MQS, and successful responders were not different between the 2 groups at 1 and 3 months after the procedure. We observed 7 cases (18.4%) of vascular visualization in the TF group, although no serious complications were found in either group. LIMITATIONS: This study had no placebo control group and limited follow-up time. CONCLUSIONS: Parasagittal IL ESI may be recommended over the TF ESI in reducing cervical radicular pain, considering both clinical effectiveness and safety.

Lumbosacral Radiculoplexus Neuropathy: Neurologic Outcomes and Survival in a Population-Based Study.

OBJECTIVE: To determine whether patients in the community with lumbosacral radiculoplexus neuropathy (LRPN) have milder neuropathy than referral patients, we characterized the outcomes and survival of population-based compared to referral-based LRPN cohorts. BACKGROUND: Previously, we found that the incidence of LRPN is 4.16/100,000/y, a frequency greater than other inflammatory neuropathies. The survival of patients with LRPN is uncharacterized. METHODS: Sixty-two episodes in 59 patients with LRPN were identified over 16 years (2000-2015). Clinical findings were compared to previous referral-based LRPN cohorts. Survival data were compared to those of age- and sex-matched controls. RESULTS: At LRPN diagnosis, median age was 70 years, median Neuropathy Impairment Score (NIS) 22 points, 92% had pain, 95% had weakness, 23% were wheelchair-bound, and median modified Rankin Scale score (mRS) was 3 (range 1-4). At last follow-up, median NIS improved to 17 points (p < 0.001) with 56% having ≥4 points improvement, 16% were wheelchair-bound, and median mRS was 2. Compared to referral-based LRPN cohorts, community patients with LRPN had less impairment, less bilateral disease (37% vs 92%), and less wheelchair usage (23% vs 49%). LRPN survival was 86% at 5 years and 55% at 10 years. Compared to age- and sex-matched controls, patients with LRPN had 76% increased risk of death (p = 0.016). In multivariate analysis, diabetes, age, stroke, chronic kidney disease, peripheral artery disease, and coronary artery disease were significant mortality risk factors but LRPN was not. CONCLUSION: LRPN is a painful, paralytic, asymmetric, monophasic, sometimes bilateral pan-plexopathy that improves over time but leaves patients with impairment. Although having LRPN increases mortality, this increase is probably due to comorbidities (diabetes) rather than LRPN itself.

Lumbar disc herniation with contralateral radiculopathy: a systematic review on pathophysiology and surgical strategies.

Lumbar disc herniation (LDH) is a relatively common pathology usually presenting with unilateral radiculopathy ipsilateral to the disc herniation. Some patients can present with contralateral radicular symptoms. The objective of this article is to review the current literature on lumbar disc herniations with contralateral radiculopathy regarding its pathophysiology and surgical strategies. A systematic review of the literature on LDH with contralateral radiculopathy was performed using MEDLINE (via PubMed) using MeSH terms. This review was done following recommendations of PRISMA statement and PICOT strategy of search. Initial electronic search identified 126 papers. Finally, 18 articles were reviewed. None of the included papers was described as comparative. Pathophysiological processes underlying contralateral pain may include prominent spondylotic changes and the accompanying stenosis; hypertrophic yellow ligament; dural attachments along the posterior longitudinal ligament; nerve root traction forces; and friction radiculitis, migrated epidural fat, nerve root anomaly, and venous congestion inside the vertebral canal. In our pooled analysis, 11 patients reported were treated by bilateral approach with 100% of clinical success and no complications. Eight patients were treated by unilateral approach ipsilateral to pain with 100% of clinical success and no complications. Forty-eight patients were treated by unilateral approach ipsilateral to herniation with 100% of clinical success and no complications. Pathophysiology underlying contralateral pain in LDH is probably multifactorial. There is not enough scientific evidence to define the best surgical approach for patients with LDH and contralateral pain.

Double crush syndrome: Epidemiology, diagnosis, and treatment results.

BACKGROUND: Double Crush Syndrome (DCS) is a clinical condition that involves multiple compression sites along a single peripheral nerve. The present study aims to describe the epidemiology of DCS and surgical results. METHODS: A retrospective observational analytic study included patients with clinical diagnosis of cervical radiculopathy and carpal tunnel syndrome who underwent surgery between January 2009 and January 2019. General demographic characteristics were noted, and 3 groups were distinguished: spinal surgery, carpal tunnel release, and bimodal decompression (BD); statistical differences were analyzed between them. RESULTS: The sample comprised 32 patients. DCS prevalence was 10.29%. Mean age at presentation was 59.25±10.98 years. There was female predominance (75%). Paresthesia was the main symptom (65.6%). Post-surgical results of BD showed significant improvement in sensory nerve conduction velocity, motor nerve conduction velocity (both P=0.008), and disability on Douleur Neuropathique 4 questions, Neck Disability Index, and Boston Carpal Tunnel Questionnaire (P=0.001, 0.004, 0.008, respectively). CONCLUSIONS: Diagnosis and management of DCS are a challenge. It is necessary to determine the site with maximal compression and risk of complications to decide on treatment. If first-line surgery is adequate, proximal and distal symptomatology can be improved. To maximize success, we recommend BD, according to the present results.

Frequency of cervical radiculopathy among patients with chronic cervical pain in Lahore, Pakistan.

OBJECTIVE: To determine the frequency of cervical radiculopathy in cases of non-traumatic chronic neck pain. METHODS: The descriptive cross-sectional study was conducted from September 2015 to February 2016 at the Department of Physiotherapy, Azra Naheed Medical College, Superior University, Lahore and comprised patients of either gender aged 20-50 years with chronic neck pain lasting more than 6 months. Data was collected using a 14-point self-administered questionnaire. Spurling test was applied to find out the occurrence of radiculopathy in chronic neck pain and the intensity of pain was rated using visual analogue scale. Data was analysed using SPSS 21. RESULTS: Of the 196 patients, 135(68.9%) were females and 61(31.1%) were males. The largest age group was 20-30 years with 75(38.3%) patients. Also, 46(23.5%) patients had no neck pain, 144(73.5%) had moderate pain and 6(3.1%) had unbearable pain. Radiculopathy was negative in 84(42.9%) patients and positive in 112(57.1%). CONCLUSIONS: Cervical radiculopathy was found to be associated with chronic neck pain.

Clinical features as predictors of histologically confirmed inflammation in patients with lumbar disc herniation with associated radiculopathy.

BACKGROUND: An understanding of the clinical features of inflammation in low back pain with or without leg symptoms may allow targeted evaluations of anti-inflammatory treatment in randomised-controlled-trials and clinical practice. PURPOSE: This study evaluated the diagnostic accuracy of clinical features to predict the presence/absence of histologically confirmed inflammation in herniated disc specimens removed at surgery in patients with lumbar disc herniation and associated radiculopathy (DHR). STUDY DESIGN: Cohort Study. METHODS: Disc material from patients with DHR undergoing lumbar discectomy was sampled and underwent histological/immunohistochemistry analyses. Control discs were sampled from patients undergoing surgical correction for scoliosis. Baseline assessment comprising sociodemographic factors, subjective examination, physical examination and psychosocial screening was conducted and a range of potential clinical predictors of inflammation developed based on the existing literature. Multi-variate analysis was undertaken to determine diagnostic accuracy. RESULTS: Forty patients with DHR and three control patients were recruited. None of the control discs had evidence of inflammation compared to 28% of patients with DHR. Predictors of the presence of histologically confirmed inflammation included back pain < 5/10, symptoms worse the next day after injury, lumbar flexion range between 0 and 30° and a positive clinical inflammation score (at least 3 of: constant symptoms, morning pain/stiffness greater than 60-min, short walking not easing symptoms and significant night symptoms). The model achieved a sensitivity of 90.9%, a specificity of 92.9%, and a predictive accuracy of 92.3%. CONCLUSION: In a sample of patients with lumbar DHR a combination of clinical features predicted the presence or absence of histologically confirmed inflammation. CLINICAL RELEVANCE: These clinical features may enable targeted anti-inflammatory treatment in future RCTs and in clinical practice.

Are Modic Changes Associated With Health-related Quality of Life After Discectomy: A Study on 620 Patients With Two-year Follow-up.

STUDY DESIGN: A registry-based comparative cohort study with 2-year follow-up. OBJECTIVE: To assess whether Modic changes (MCs) are associated with health-related quality of life, long-term physical disability, back- or leg pain after discectomy. SUMMARY OF BACKGROUND DATA: Previous studies have failed to show a clinically significant association between MCs and patient-reported outcomes (PROs) after discectomy. METHODS: Data from the Danish National Spine Registry on patients undergoing first-time lumbar discectomy at a single institution from 2014 to 2017 with an accessible preoperative lumbar magnetic resonance imaging, complete preoperative, and 2-year follow-up questionnaires were obtained. PROs including Oswestry disability index (ODI), European Quality of Life-Five Dimensions (EQ-5D), visual analogue scale (VAS) back and leg pain, and patient satisfaction were collected. Patients were stratified based on the presence (+MC) or absence (-MC) of MCs on the preoperative MRI. RESULTS: Of 620 patients included, MCs were present in 290 patients (47%). Of these, MC type 1 (MC-1) was present in 73 (25%) and MC type 2 (MC-2) in 217 (75%) patients. Preoperative data for ODI, EQ-5D, VAS-BP, and VAS-LP were comparable for the +MC and -MC groups. Both groups had a statistically significant improvement in PROs from baseline compared with 2-year follow-up (P < 0.001). At 2-year follow-up, both groups had improved with no significant difference between them in regards to ODI (15.5 vs. 17.2, P = 0.208); EQ-5D (0.75 vs. 0.72, P = 0.167); VAS-BP (27.1 vs. 28.3, P = 0.617); VAS-LP (26.8 vs. 25.0, P = 0.446); and patient satisfaction (74% vs. 76%, P = 0.878). CONCLUSION: MCs were not found to be associated with health-related quality of life, disability, back- or leg pain, or patient satisfaction 2 years after discectomy. LEVEL OF EVIDENCE: 2.

Cervical spine radiculopathy epidemiology: A systematic review.

BACKGROUND AND OBJECTIVE: Cervical spine radiculopathy (CSR) is a disabling condition that has significant negative impacts on a person's mental health, physical functioning and social participation. Research has reported variable CSR incidence and prevalence among different populations. To date, no systematic review has been completed investigating the prevalence or incidence of CSR; therefore, our objective was to determine the incidence and/or prevalence of CSR in adults. DESIGN AND METHOD: A systematic review was conducted including searches of PubMed (MEDLINE), EMBASE and CINAHL from inception to February 25, 2020. Studies including data on incidence and/or prevalence of CSR were included. Methodological quality was assessed using a modified Hayden, Cote and Bombardier appraisal checklist. Data were analysed narratively. RESULTS: Nine low- to high-quality studies were included in the final review. Incidence ranged between 0.832 and 1.79 per 1,000 person-years from two high-quality and one low-quality study. Prevalence values ranged from 1.21 to 5.8 per 1,000 from four medium- to high-quality studies. Prevalence values of 1.14% [95% confidence interval (CI): 0.45-1.82] and 1.31% (95% CI: 0.66-1.96) for males and females, respectively, were reported from one medium-quality study. One medium-quality study reported an unadjusted prevalence value of 6.3% for males and females. CONCLUSIONS: This is the first systematic review investigating the epidemiology of CSR in an adult population. This review reports a variable incidence rate and prevalence of CSR among specific populations; however, this was based on nine studies. There is a priority to investigate CSR epidemiology across other populations globally and standardising CSR diagnostic criteria.

Radiculopathy Following Vertebral Body Compression Fracture: The Role of Percutaneous Cement Augmentation.

BACKGROUND: Vertebral cement augmentation is a commonly used procedure in patients with vertebral body compression fractures from primary or secondary osteoporosis, metastatic disease, or trauma. Many of these patients present with radiculopathy as a presenting symptom, and can experience symptomatic relief following the procedure. OBJECTIVES: To determine the incidence of preprocedural radiculopathy in patients with vertebral body compression fractures presenting for cement augmentation, and present their postoperative outcomes. STUDY DESIGN: Retrospective cohort study. SETTING: Interventional pain practice in a tertiary care university hospital. METHODS: In this cohort study, all patients who underwent kyphoplasty (KP) or vertebroplasty (VP) procedures in a 7-year period within our practice were evaluated through a search of the electronic medical records. The primary endpoint was to evaluate the prevalence of noncompressive preprocedural radiculopathy in our patients. Evaluation of each patient's relative improvement following the procedure, respective to the initial presence or absence of radicular symptoms (including and above T10, above and below T10, and below T10) was included as a secondary endpoint. Additional subanalysis was performed with respect to patients demographics, fracture location, and primary indication for the procedure (osteoporosis, trauma, etc.). RESULTS: A total of 302 procedures were performed during this time period, encompassing 544 total vertebral body levels. After exclusion criteria were applied to this cohort, 31.6% of patients demonstrated radiculopathy prior to the procedure that could not be explained by nerve impingement. Nearly half of patients demonstrated an optimal clinical outcome (48.5% nearly complete/complete resolution of symptoms, 40.1% partial resolution of symptoms, 11.4% little to no resolution of symptoms). Patients with fractures above T10 were more likely to see complete resolution, whereas patients with fractures above and below T10 were likely to not see any resolution. Men and women without initial radiculopathy symptoms were more likely to see little to no resolution, regardless of fracture location. LIMITATIONS: This retrospective study used an electronic chart review of clinicians' notes to determine the presence of radiculopathy and their relative improvement following the procedure. CONCLUSIONS: Preprocedural radiculopathy is a common symptom of patients presenting for the evaluation of VP or KP. The presence of radiculopathy in the absence of nerve impingement may be an important marker for those patients who may experience greater benefit from the procedure. KEY WORDS: Radiculopathy, kyphoplasty, vertebroplasty, osteoporosis, compression fracture, spine, cement augmentation.

Cervical epidural steroid injections: incidence and determinants of subsequent surgery.

BACKGROUND CONTEXT: Cervical epidural steroid injections (CESIs) are sometimes used in the management of cervical radicular pain in order to delay or avoid surgery. However, the rate and determinants of surgery following CESIs remain uncertain. PURPOSE: This study sought to determine: (1) the proportion of patients having surgery following CESI, and (2) the timing of and factors associated with subsequent surgery. STUDY DESIGN: Retrospective analysis of a large, national administrative claims database. PATIENT SAMPLE: The study included 192,777 CESI patients (age 50.9±11.3 years, 55.2% female) who underwent CESI for imaging-based diagnoses of cervical disc herniation or stenosis, a clinical diagnosis of radiculopathy, or a combination thereof. OUTCOME MEASURES: The primary outcome was the time from index CESI to surgery. METHODS: Inclusion criteria were CESI for cervical disc herniation, stenosis, or radiculopathy, age ≥18, and active enrollment for 1 year before CESI to screen for exclusions. Patients were followed until they underwent cervical surgery, or their enrollment lapsed. Rates of surgery were assessed with Kaplan-Meier survival curves and 99% confidence intervals. Factors associated with subsequent surgery were assessed with multivariable Cox proportional hazard models. RESULTS: Within 6 months of CESI, 11.2% of patients underwent surgery, increasing to 14.5% by 1 year and 22.3% by 5 years. Male patients and those aged 35 to 54 had an increased likelihood of subsequent surgery. Patients with radiculopathy were less likely to undergo surgery following CESI than those with stenosis or herniation, while patients with multiple diagnoses were more likely. Patients with comorbidities including CHF, other cardiac comorbidities or chronic pain were less likely to undergo surgery, as were patients in the northeast US region. Some 33.5% of patients underwent >1 CESI, with 84.6% of these occurring within 1 year. Additional injections were associated with reduced rates of subsequent surgery. CONCLUSIONS: Following CESI, over one in five patients underwent surgery within 5 years. Multiple patient-specific risk factors for subsequent surgery were identified, and patients undergoing repeated injections were at lower risk. Determining which patients may progress to surgery can be used to improve resource utilization and to inform shared decision-making.

40% reoperation rate in adolescents with spondylolisthesis.

STUDY DESIGN: Multicenter retrospective. OBJECTIVE: To determine the long-term complication rate associated with surgical treatment of spondylolisthesis in adolescents. There is limited information on the complication rate associated with posterior spinal fusion (PSF) of spondylolisthesis in the pediatric and adolescent population. METHODS: Patients who underwent PSF for spondylolisthesis between 2004 and 2015 at four spine centers, < 21 years of age, were included. Exclusion criteria were < 2 years of follow-up or anterior approach. Charts and radiographs were reviewed. RESULTS: 50 patients had PSF for spondylolisthesis, 26 had PSF alone, while 24 had PSF with trans-foraminal lumbar interbody fusion (TLIF). Mean age was 13.9 years (range 9.6-18.4). Mean follow-up was 5.5 years (range 2-15). Mean preoperative slip was 61.2%. 20/50 patients (40%) experienced 23 complications requiring reoperation at a mean of 2.1 years (range 0-9.3) for the following: implant failure (12), persistent radiculopathy (3), infection (3), persistent back pain (2), extension of fusion (2), and hematoma (1). In addition, there were 22 cases of radiculopathy (44%) that were transient. Rate of implant failure was related to preoperative slip angle (p = 0.02). Reoperation rate and rates of implant failure were not associated with preoperative % slip (reoperation: p = 0.42, implant failure: p = 0.15), postoperative % slip (reoperation: p = 0.42, implant failure: p = 0.99), postoperative kyphosis of the lumbosacral angle (reoperation: p = 0.81, implant failure: p = 0.48), change in % slip (reoperation: p = 0.30, implant failure: p = 0.12), change in slip angle (reoperation: p = 0.42, implant failure: p = 0.40), graft used (reoperation: p = 0.22, implant failure: p = 0.81), or addition of a TLIF (reoperation: p = 0.55, implant failure: p = 0.76). CONCLUSION: PSF of spondylolisthesis in the adolescent population was associated with a 40% reoperation rate and high rate of post-operative radiculopathy. Addition of a TLIF did not impact reoperation rate or rate of radiculopathy.

Occupation-related Cervical Spine Disease in Orthopaedic Surgeons.

INTRODUCTION: Musculoskeletal injury can substantially affect orthopaedic surgeons and productivity. The objective of this study was to assess occupation-related neck pain and cervical radiculopathy/myelopathy among orthopaedic surgeons and to identify the potential risk factors for injury. METHODS: An online survey was sent to orthopaedic surgeons via their state orthopaedic society. The survey consisted of items related to orthopaedic practices, such as the number of arthroscopic procedures done and the use of microscopes/loupes. The prevalence, potential causes, and reporting practices of neck pain and cervical radiculopathy/myelopathy among orthopaedic surgeons were also assessed. RESULTS: There were 685 responses from surgeons representing 27 states. A total of 59.3% of respondents reported neck pain and 22.8% reported cervical radiculopathy. After adjusting for age and sex, surgeons performing arthroscopy had an odds ratio of 3.3 (95% confidence interval: 1.4 to 8.3, P = 0.007) for neck pain. Only five of the surgeons with neck pain and one of the surgeons with cervical radiculopathy/myelopathy had ergonomic evaluations. CONCLUSION: Neck pain and cervical radiculopathy/myelopathy are common among orthopaedic surgeons. Associated factors included older age, higher stress levels, and performing arthroscopy. Cervical injuries are rarely reported, and ergonomic workplace evaluations are infrequent.

Risk Factors for Symptomatic Contralateral Foraminal Stenosis After Unilateral Transforaminal Lumbar Interbody Fusion.

OBJECTIVE: The most common cause of contralateral symptoms after unilateral transforaminal lumbar interbody fusion (TLIF) is contralateral foraminal stenosis (FS). This retrospective cohort study aimed to investigate the cause of and risk factors for contralateral FS after unilateral TLIF with a single cage. METHODS: Patients with degenerative lumbar spinal disorders who underwent unilateral TLIF at L4-5 were divided into 2 groups: those without contralateral radicular symptoms after surgery (group A; n = 340) and those with contralateral radicular symptoms after surgery (group B; n = 16). We investigated the influence of various radiological and cage-related factors on postoperative contralateral FS with radicular symptoms. The cage location indicates whether the cage's anterior tip crosses the disc midline-exceeding 50%-and in such a case, how far. RESULTS: Group B showed significantly increased postoperative coronal angle and sagittal angle and decreased contralateral foraminal height and foraminal area. Statistically significant (P < 0.01) factors according to the multivariate logistic regression analysis were the preoperative sagittal range of motion (odds ratio [OR]: 1.562, P = 0.004) and cage location (OR: 2.047, P = 0.015). The cutoff values for the sagittal range of motion and the cage location were 9.0° and 50.5%, respectively. The preoperative and postoperative 6-month visual analog scale scores and Oswestry disability index values were not significantly different between the groups. CONCLUSIONS: The 2 most meaningful risk factors were the preoperative sagittal range of motion and cage location. Inserting the cage beyond the disc midline, especially in patients with a high preoperative sagittal range of motion (≥9.0°), would help reduce postoperative complications.

The incidence of impingement syndrome in cases of cervical radiculopathy: An analysis of 220 cases.

BACKGROUND: We hypothesized that cervical radiculopathy (CR) has a role in subacromial impingement syndrome (SAIS) etiology, which cannot be directly connected to anatomical causes. OBJECTIVE: We aimed to investigate the presence of cervical radiculopathy in patients with SAIS diagnosed clinically and radiologically. METHODS: Patients who had a clinical and radiological SAIS diagnosis between 2014 and 2016 were included in the study. Patients with secondary causes that led to SAIS were excluded. Cervical MRI of all patients with SAIS was examined for cervical radiculopathy. RESULTS: A significant (p< 0.05) relationship was found between SIAS and the presence of root compression on the same side. 35% of the patients with SIAS had root compression on the same side. CONCLUSIONS: Cervical radiculopathy and shoulder impingement syndrome can be easily confused due to the similarity of the symptoms and the anatomical proximity of the lesions. Although both diseases can occur with different mechanisms, we believe that there is a cause and effect relationship between them.

A Prospective, Psychometric Validation of National Institutes of Health Patient-Reported Outcomes Measurement Information System Physical Function, Pain Interference, and Upper Extremity Computer Adaptive Testing in Cervical Spine Patients: Successes and Key Limitations.

STUDY DESIGN: Prospective Cohort Study OBJECTIVE.: The aim of this study was to validate the Patient Reported Outcomes Measurement Information System (PROMIS) against existing patient-reported outcomes in the cervical spine. SUMMARY OF BACKGROUND DATA: Current patient-reported outcomes in cervical spine have substantial limitations. PROMIS offers the potential for improved psychometric properties with reduced questionnaire burden. METHODS: Adult patients undergoing cervical spine surgery at a single institution between 2016 and 2018 were prospectively enrolled. Patients completed questionnaires (36-Item Short Form Health Survey [SF-36], Neck Disability Index (NDI), Visual Analog Scale arm/neck, and PROMIS pain Interference [PI], physical Function [PF], and Upper Extremity [UE]) preoperatively and at 6 months postoperatively. Demographic data, diagnosis, and procedural data were recorded. Validation of the instruments was completed with a Rasch Model as well as measurement of coverage, efficiency, test-retest reliability, responsiveness, and convergent validity. RESULTS: Of 197 patients who completed the preoperative survey, 164 were eligible for 6-month follow-up and 139 completed 6-month postoperative surveys. The most common diagnoses were radiculopathy (37.6%), myeloradiculopathy (30.5%), and myelopathy (28.4%). All studied instruments had acceptable fit to a Rasch model. PROMIS computer adaptive testings (CATs) demonstrated improved average time to completion for PI (39 seconds), PF (47 seconds), and UE (54  seconds), compared to NDI (117 s) and SF-36 PCS (175 seconds). Responsiveness for PROMIS CATs was similar to NDI and SF-36, test-retest reliability was lower for PI (intraclass correlation: 0.68), PF (0.70), and UE (0.59), compared to NDI (0.86) and PCS (0.85). For convergent validity, PI was strongly correlated to NDI and PF to SF-36 PCS. There were no significant floor or ceiling effects for the PROMIS domains, although UE had preoperative clustering (n = 18) at a high score (56.4) and PI had postoperative clustering (n = 27) at a low score (38.7). CONCLUSION: PROMIS CATs demonstrate several advantages, including efficiency and responsiveness, while demonstrating good convergent validity with legacy instruments. Nevertheless, CATs had lower test-retest reliability and had significant clustering at higher levels of function for the PI and UE CATs. These limitations must be considered before broad adoption of CATs in cervical spine patients. LEVEL OF EVIDENCE: 3.