Early Voice and Swallowing Disturbance Incidence and Risk Factors After Revision Anterior Cervical Discectomy and Fusion Using a Multidisciplinary Surgical Approach: A Retrospective Cohort Evaluation of a Prospective Database.

BACKGROUND AND OBJECTIVES: Dysphagia and vocal cord palsy (VCP) are common otolaryngological complications after revision anterior cervical discectomy and fusion (rACDF) procedures. Our objective was to determine the early incidence and risk factors of VCP and dysphagia after rACDF using a 2-team approach. METHODS: Single-institution, retrospective analysis of a prospectively collected database of patients undergoing rACDF was enrolled from September 2010 to July 2021. Of 222 patients enrolled, 109 patients were included in the final analysis. All patients had prior ACDF surgery with planned revision using a single otolaryngologist and single neurosurgeon. MD Anderson Dysphagia Inventory and fiberoptic endoscopic evaluation of swallowing (FEES) were used to assess dysphagia. VCP was assessed using videolaryngostroboscopy. RESULTS: Seven patients (6.7%) developed new postoperative VCP after rACDF. Most cases of VCP resolved by 3 months postoperatively (mean time-to-resolution 79 ± 17.6 days). One patient maintained a permanent deficit. Forty-one patients (37.6%) reached minimum clinically important difference (MCID) in their MD Anderson Dysphagia Inventory composite scores at the 2-week follow-up (MCID decline of ≥6), indicating new clinically relevant swallowing disturbance. Forty-nine patients (45.0%) had functional FEES Performance Score decline. On univariate analysis, there was an association between new VCPs and the number of cervical levels treated at revision ( P = .020) with long-segment rACDF (≥4 levels) being an independent risk factor ( P = .010). On linear regression, there was an association between the number of levels treated previously and at revision for FEES Performance Score decline ( P = .045 and P = .002, respectively). However, on univariate analysis, sex, age, body mass index, operative time, alcohol use, smoking, and individual levels revised were not risk factors for reaching FEES Performance Score decline nor MCID at 2 weeks postoperatively. CONCLUSION: VCP is more likely to occur in long-segment rACDF but is often temporary. Clinically relevant and functional rates of dysphagia approach 37% and 45%, respectively, at 2 weeks postoperatively after rACDF.

Cerebrospinal Fluid Drainage in Patients with Acute Spinal Cord Injury: A Multi-Center Randomized Controlled Trial.

OBJECTIVE: The secondary phase of spinal cord injury (SCI) is characterized by ischemic injury. Spinal cord perfusion pressure (SCPP), calculated as the difference between mean arterial pressure (MAP) and intrathecal pressure (ITP), has arisen as a therapeutic target for improving outcomes. Cerebrospinal fluid drainage (CSFD) may reduce ITP and thereby increase SCPP. Randomized controlled trial to evaluate the safety and feasibility of CSFD to improve SCPP and outcomes after acute SCI. METHODS: Inclusion criteria included acute cervical SCI within 24 hours of presentation. All patients received lumbar drain placement and appropriate decompressive surgery. Patients randomized to the control group received MAP elevation only. Patients in the experimental group received MAP elevation and CSFD to achieve ITP <10 mmHg for 5 days. ITP and MAP were recorded hourly. Adverse events were documented and patients underwent functional assessments at enrollment, 72 hours, 90 days, and 180 days post-injury. RESULTS: Eleven patients were enrolled; 4 were randomized to receive CSFD. CSFD patients had a mean ITP of 5.3 ± 2.5 mmHg versus. 15 ± 3.0 mmHg in the control group. SCPP improved significantly, from 77 ± 4.5 mmHg in the control group to 101 ± 6.3 mmHg in the CSFD group (P < 0.01). Total motor scores improved by 15 ± 8.4 and 57 ± 24 points in the control and CSFD groups, respectively, over 180 days. No adverse events were attributable to CSFD. CONCLUSIONS: CSFD is a safe, effective mechanism for reducing ITP and improving SCPP in the acute period post-SCI. The favorable safety profile and preliminary efficacy should help drive recruitment in future studies.

The Value of Statistics and Evidence-Based Medicine in the Care of Neurosurgical Patients.

Science and the art of surgery should be anchored on evidence-based medicine. There is no room in the discipline of neurosurgery for "personal anecdotes/experience," and the concept of "hero worship." The construction of evidence-based medicine guidelines is essential in our continued improvement of care for neurosurgical patients.

Chasing the Cup: A Comprehensive Review of Spinal Cord Injuries in Hockey.

Ice hockey is a high-speed sport with a high rate of associated injury, including spinal cord injury (SCI). The incidence of hockey-related SCI has increased significantly in more recent years. A comprehensive literature search was conducted with the PubMed, Medline, Google Scholar, and Web of Science databases using the phrases "hockey AND spinal cord injuries" to identify relevant studies pertaining to hockey-related SCIs, equipment use, anatomy, and biomechanics of SCI, injury recognition, and return-to-play guidelines. Fifty-three abstracts and full texts were reviewed and included, ranging from 1983 to 2021. The proportion of catastrophic SCIs is high when compared to other sports. SCIs in hockey occur most commonly from a collision with the boards due to intentional contact resulting in axial compression, as well as flexion-related teardrop fractures that lead to spinal canal compromise and neurologic injury. Public awareness programs, improvements in equipment, and rule changes can all serve to minimize the risk of SCI. Hockey has a relatively high rate of associated SCIs occurring most commonly due to flexion-distraction injuries from intentional contact. Further investigation into equipment and hockey arena characteristics as well as future research into injury recognition and removal from and return to play is necessary.

Developing Physician Leadership in Hospital Policy Development: A Case Study of Resident-Driven Policy Initiatives in the Department of Neurosurgery at the University of Alabama at Birmingham.

The bulk of a resident's daily work is patient care related; however, other aspects of residency training are vital both to a resident's education and to the advancement of the field. Basic science and clinical research are the more common academic activities in which residents participate after completion of daily patient care objectives. Less frequently, residents participate in a process vital to the delivery of efficient, cost-effective, and safe patient care: hospital policy development. Two policies were identified as outdated or absent: (1) the process for the declaration of brain death and (2) a policy for the use of hypertonic saline in the Neurosciences Intensive Care Unit. The policies were rewritten after review of the existing policy (when applicable), other institutions' examples, national guidelines, and state and federal laws. Once written, proposals were reviewed by department leadership, hospital ethics, legal counsel, ad hoc specialty committees, the Medical Directors Council, and the Medical Executive Committee. After multiple revisions, each proposal was endorsed by the above bodies and ratified as hospital policy. Residents may make a substantial impact on patient care through active participation in the authorship and implementation of hospital policy. The inclusion of residents in policy development has improved the process for declaring brain death and management of patients with devastating neurological pathology. Resident involvement in hospital policy initiatives can be successful, valuable to the institution, and beneficial to patient care. Resident involvement is predicated on faculty and institutional support of such endeavors.

The case for the future role of evidence-based medicine in the management of cervical spine injuries, with or without fractures.

The authors believe that the standardized and systematic study of immobilization techniques, diagnostic modalities, medical and surgical treatment strategies, and ultimately outcomes and outcome measurement after cervical spinal trauma and cervical spinal fracture injuries, if performed using well-designed medical evidence-based comparative investigations with meaningful follow-up, has both merit and the remarkable potential to identify optimal strategies for assessment, characterization, and clinical management. However, they recognize that there is inherent difficulty in attempting to apply evidence-based medicine (EBM) to identify ideal treatment strategies for individual cervical fracture injuries. First, there is almost no medical evidence reported in the literature for the management of specific isolated cervical fracture subtypes; specific treatment strategies for specific fracture injuries have not been routinely studied in a rigorous, comparative way. One of the vulnerabilities of an evidenced-based scientific review in spinal cord injury (SCI) is the lack of studies in comparative populations and scientific evidence on a given topic or fracture pattern providing level II evidence or higher. Second, many modest fracture injuries are not associated with vascular or neural injury or spinal instability. The application of the science of EBM to the care of patients with traumatic cervical spine injuries and SCIs is invaluable and necessary. The dedicated multispecialty author groups involved in the production and publication of the two iterations of evidence-based guidelines on the management of acute cervical spine and spinal cord injuries have provided strategic guidance in the care of patients with SCIs. This dedicated service to the specialty has been carried out to provide neurosurgical colleagues with a qualitative review of the evidence supporting various aspects of care of these patients. It is important to state and essential to understand that the science of EBM and its rigorous application is important to medicine and to the specialty of neurosurgery. It should be embraced and used to drive and shape investigations of the management and treatment strategies offered patients. It should not be abandoned because it is not convenient or it does not support popular practice bias or patterns. It is the authors' view that the science of EBM is essential and necessary and, furthermore, that it has great potential as clinician scientists treat and study the many variations and complexities of patients who sustain acute cervical spine fracture injuries.

Assessment of the Reliability of the Fiberoptic Endoscopic Evaluation of Swallowing as an Outcome Measure in Patients Undergoing Revision Anterior Cervical Discectomy and Fusion.

BACKGROUND: Dysphagia is one of the most common complications of anterior cervical spine surgery, and there is a need to establish that the means of testing for it are reliable and valid. The objective of this study was to measure observer variability of the fiberoptic endoscopic evaluation of swallowing (FEES) test, specifically when used for evaluation of dysphagia in patients undergoing revisionary anterior cervical decompression and fusion (ACDF). METHODS: Images from patients undergoing revision ACDF at a single institution were collected from May 1, 2010, through July 1, 2014. Two senior certified speech pathologists independently evaluated the swallowing function of patients preoperatively and at 2 weeks postoperatively. Their numeric evaluations of the Rosenbeck Penetration-Aspiration Scale and the Swallowing Performance Scale during the FEES were then compared for interrater reliability. RESULTS: Positive agreement between raters was 94% for the preoperative Penetration-Aspiration Scale (prevalence-adjusted bias-adjusted κ, 0.77). The postoperative Penetration-Aspiration Scale showed reliability coefficients for κ, Kendall's W, and intraclass correlation coefficient (ICC) of 0.34 (fair agreement), 0.70 (extremely strong agreement), and 0.35 (poor agreement), respectively. The preoperative Swallowing Performance Scale showed strong agreement, with a Kendall's W coefficient of 0.68, and fair reliability, with an ICC of 0.40. The postoperative Swallowing Performance Scale indicated extremely strong agreement between raters, with a Kendall's W of 0.82, and good agreement, with an ICC of 0.53. CONCLUSIONS: The FEES test appears to be a reliable assessor of dysphagia in patients undergoing ACDF and may be a useful measure for exploring outcomes in this population.

Current Topics in the Management of Acute Traumatic Spinal Cord Injury.

Acute traumatic spinal cord injury (SCI) affects more than 250,000 people in the USA, with approximately 17,000 new cases each year. It continues to be one of the most significant causes of trauma-related morbidity and mortality. Despite the introduction of primary injury prevention education and vehicle safety devices, such as airbags and passive restraint systems, traumatic SCI continues to have a substantial impact on the healthcare system. Over the last three decades, there have been considerable advancements in the management of patients with traumatic SCI. The advent of spinal instrumentation has improved the surgical treatment of spinal fractures and the ability to manage SCI patients with spinal mechanical instability. There has been a concomitant improvement in the nonsurgical care of these patients with particular focus on care delivered in the pre-hospital, emergency room, and intensive care unit (ICU) settings. This article represents an overview of the critical aspects of contemporary traumatic SCI care and notes areas where further research inquiries are needed. We review the pre-hospital management of a patient with an acute SCI, including triage, immobilization, and transportation. Upon arrival to the definitive treatment facility, we review initial evaluation and management steps, including initial neurological assessment, radiographic assessment, cervical collar clearance protocols, and closed reduction of cervical fracture/dislocation injuries. Finally, we review ICU issues including airway, hemodynamic, and pharmacological management, as well as future directions of care.

Towards Evidence-Based Guidelines in Neurological Surgery.

Neurological surgery practice is based on the science of balancing probabilities. A variety of clinical guidance documents have influenced how we collectively practice our art since the early 20th century. The quality of the science within these guidelines varies widely, as does their utility in positively shaping our practice. The guidelines development process in neurological surgery has evolved significantly over the last 30 yr. Historically based in expert opinion, as a specialty we have increasingly relied on objective medical evidence to guide our clinical practice. We assessed the changing practice guidelines development process and the impact of scientifically robust guidelines on patient care. The evolution of the guidelines development process in neurological surgery was chronicled. Several subspecialty guidelines were extracted and reviewed in detail. Their impact on practice patterns was evaluated. The importance of evidence-based research and practice guidelines development was discussed. Evidence-based practice guidelines serve to chronicle multiple acceptable treatment options and help us move towards more standardized care for specific disease processes. They help refute false "standards of care." Guidelines-based care supported by solid medical evidence has the potential to streamline patient care and improve patient outcomes. The guidelines development process identifies areas, issues, and strategies for which little medical evidence exists, as well as topics that need focused scientific investigation and future study. The production of evidence-based practice recommendations is a vital part of furthering our specialty. Guidelines development advances our science, augments the resident education process, and protects our practice from undue external influence.

Education level as a prognostic indicator at 12 months following decompression surgery for symptomatic lumbar spinal stenosis.

OBJECTIVEThe goal of this study was to analyze the effect of patient education level on functional outcomes following decompression surgery for symptomatic lumbar spinal stenosis.METHODSPatients with surgically decompressed symptomatic lumbar stenosis were collected in a prospective observational registry at a single institution between 2012 and 2014. Patient education level was compared to surgical outcomes to elucidate any relationships. Outcomes were defined using the Oswestry Disability Index score, back and leg pain visual analog scale (VAS) score, and the EuroQol-5 Dimensions questionnaire score.RESULTSOf 101 patients with symptomatic lumbar spinal stenosis, 27 had no college education and 74 had a college education (i.e., 2-year, 4-year, or postgraduate degree). Preoperatively, patients with no college education had statistically significantly greater back and leg pain VAS scores when compared to patients with a college education. However, there was no statistically significant difference in quality of life or disability between those with no college education and those with a college education. Postoperatively, patients in both cohorts improved in all 4 patient-reported outcomes at 3 and 12 months after treatment for symptomatic lumbar spinal stenosis.CONCLUSIONSDespite their education level, both cohorts showed improvement in their functional outcomes at 3 and 12 months after decompression surgery for symptomatic lumbar spinal stenosis.

Association between payer status and patient-reported outcomes in adult patients with lumbar spinal stenosis treated with decompression surgery.

OBJECTIVE: Insurance disparities can have relevant effects on outcomes after elective lumbar spinal surgery. The aim of this study was to evaluate the association between private/public payer status and patient-reported outcomes in adult patients who underwent decompression surgery for lumbar spinal stenosis. METHODS: A sample of 100 patients who underwent surgery for lumbar spinal stenosis from 2012 to 2014 was evaluated as part of the prospectively collected Quality Outcomes Database at a single institution. Outcome measures were evaluated at 3 months and 12 months, analyzed in regard to payer status (private insurance vs Medicare/Veterans Affairs insurance), and adjusted for potential confounders. RESULTS: At baseline, patients had similar visual analog scale back and leg pain, Oswestry Disability Index, and EQ-5D scores. At 3 months postintervention, patients with government-funded insurance reported significantly worse quality of life (mean difference 0.11, p < 0.001) and more leg pain (mean difference 1.26, p = 0.05). At 12 months, patients with government-funded insurance reported significantly worse quality of life (mean difference 0.14, p < 0.001). There were no significant differences at 3 months or 12 months between groups for back pain (p = 0.14 and 0.43) or disability (p = 0.19 and 0.15). Across time points, patients in both groups showed improvement at 3 months and 12 months in all 4 functional outcomes compared with baseline (p < 0.001). CONCLUSIONS: Both private and public insurance patients had significant improvement after elective lumbar spinal surgery. Patients with public insurance had slightly less improvement in quality of life after surgery than those with private insurance but still benefited greatly from surgical intervention, particularly with respect to functional status.

Association between preoperative activity level and functional outcome at 12 months following surgical decompression for lumbar spinal stenosis.

OBJECTIVE: This study defines the association of preoperative physical activity level with functional outcomes at 3 and 12 months following surgical decompression for lumbar spinal stenosis. METHODS: Data were collected as a prospective observational registry at a single institution from 2012 through 2015, and then analyzed with a retrospective cohort design. Patients who were able to participate in activities outside the home preoperatively were compared to patients who did not participate in such activities, with respect to 3-month and 12-month functional outcomes postintervention, adjusted for relevant confounders. RESULTS: Ninety-nine patients were included. At baseline, sedentary/inactive patients (n = 55) reported greater back pain, lower quality of life, and higher disability than similarly treated patients who were active preoperatively. Both cohorts experienced significant improvement from baseline in back pain, leg pain, disability, and quality of life at both 3 and 12 months after lumbar decompression surgery. At 3 months postintervention, sedentary/inactive patients reported more leg pain and worse disability than patients who performed activities outside the home preoperatively. However, at 12 months postintervention, there were no statistically significant differences between the two cohorts in back pain, leg pain, quality of life, or disability. Multivariate analysis revealed that sedentary/inactive patients had improved disability and higher quality of life after surgery compared to baseline. Active patients experienced greater overall improvement in disability compared to inactive patients. CONCLUSIONS: Sedentary/inactive patients have a more protracted recovery after lumbar decompression surgery for spinal stenosis, but at 12 months postintervention can expect to reach similar long-term outcomes as patients who are active/perform activities outside the home preoperatively.

Voice and swallowing outcomes following reoperative anterior cervical discectomy and fusion with a 2-team surgical approach.

OBJECTIVE Dysphagia and vocal cord palsy (VCP) are common complications after anterior cervical discectomy and fusion (ACDF). The reported incidence rates for dysphagia and VCP are variable. When videolaryngostroboscopy (VLS) is performed to assess vocal cord function after ACDF procedures, the incidence of VCP is reported to be as high as 22%. The incidence of dysphagia ranges widely, with estimates up to 71%. However, to the authors' knowledge, there are no prospective studies that demonstrate the rates of VCP and dysphagia for reoperative ACDF. This study aimed to investigate the incidence of voice and swallowing disturbances before and after reoperative ACDF using a 2-team operative approach with comprehensive pre- and postoperative assessment of swallowing, direct vocal cord visualization, and clinical neurosurgical outcomes. METHODS A convenience sample of sequential patients who were identified as requiring reoperative ACDF by the senior spinal neurosurgeon at the University of Alabama at Birmingham were enrolled in a prospective, nonrandomized study during the period from May 2010 until July 2014. Sixty-seven patients undergoing revision ACDF were enrolled using a 2-team approach with neurosurgery and otolaryngology. Dysphagia was assessed both preoperatively and postoperatively using the MD Anderson Dysphagia Inventory (MDADI) and fiberoptic endoscopic evaluation of swallowing (FEES), whereas VCP was assessed using direct visualization with VLS. RESULTS Five patients (7.5%) developed a new postoperative temporary VCP after reoperative ACDF. All of these cases resolved by 2 months postoperatively. There were no new instances of permanent VCP. Twenty-five patients had a new swallowing disturbance detected on FEES compared with their baseline assessment, with most being mild and requiring no intervention. Nearly 60% of patients showed a decrease in their postoperative MDADI scores, particularly within the physical subset. CONCLUSIONS A 2-team approach to reoperative ACDF was safe and effective, with no new cases of VCP on postoperative VLS. Dysphagia rates as assessed through the MDADI scale and FEES were consistent with other published reports.