Vomiting of unclear etiology in an autistic child-multiple possible diagnoses: A case report.

Appendicitis is a common complaint in the emergency department (ED) presenting with abdominal pain or vomiting and is often the foremost etiology the provider must rule out using history and physical examination. However, history and physical examination is limited in children and the developmentally delayed who are often non-cooperative. Less commonly, choledochal cysts are found that also require management, or rarer still, multiple possible radiologic or surgical diagnoses. This case report follows a delayed child presenting with vomiting found to have a large type 1 choledochal cyst, cholecystitis, and appendicitis on advanced imaging prompting surgical management of these etiologies. This report reviews the evaluation of children with vomiting and the need for thorough evaluation with advanced imaging when appropriate.

Evaluation of Lumbar Spine Bracing as a Postoperative Adjunct to Single-level Posterior Lumbar Spine Surgery.

BACKGROUND: Clinical practice in postoperative bracing after posterior single-level lumbar spine fusion (PLF) is inconsistent between providers. This study seeks to assess the effect of bracing on short-term outcomes related to safety, quality of care, and direct costs. METHODS: Retrospective cohort analyses of consecutive patients undergoing single-level PLF with or without bracing at a three-hospital urban academic medical center (2013-2017) were undertaken (n = 906). Patient demographics and comorbidities were analyzed. Test of independence, Mann-Whitney-Wilcoxon test, and logistic regression were used to assess differences in length of stay (LOS), discharge disposition/need for postacute care, quality-adjusted life year (QALY), surgical site infection (SSI), hospital cost, total cost, readmission within 30 days, and emergency room (ER) visits within 30 days. RESULTS: Among the study population, 863 patients were braced and 43 were not braced. No difference was seen between the two groups in short-term outcomes from surgery including LOS (P = 0.836), discharge disposition (P = 0.226), readmission (P = 1.000), ER visits (P = 0.281), SSI (P = 1.000), and QALY gain (P = 0.319). However, the braced group incurred a significantly higher direct hospital cost (median increase of 41.43%, P < 0.001) compared to the unbraced cohort (bracing cost excluded). There was no difference in graft type (P = 0.145) or comorbidities (P = 0.20-1.00) such as obesity (P = 1.000), smoking (P = 1.000), chronic obstructive pulmonary disease (P = 1.000), hypertension (P = 0.805), coronary artery disease (P = 1.000), congestive heart failure (P = 1.000), and total number of comorbidities (P = 0.228). CONCLUSION: Short-term data suggest that removal of bracing from the postoperative regimen for PLF will not result in increased adverse outcomes but will reduce cost.

Proximal junctional kyphosis following T10-pelvis fusion presenting with neurologic compromise: case presentations and review of the literature.

Purpose: Proximal Junctional Kyphosis (PJK) is a well-documented phenomenon following spinal instrumented fusion. Myelopathy associated with proximal junctional failure (PJF) is poorly described in the literature. Adjacent segment disease, fracture above the upper instrumented vertebrae and subluxation may all cause cord compression, ambulatory dysfunction, and/or lower extremity weakness in the postoperative period.Materials and methods: We review the literature on PJK and PJF, and discusses the postoperative management of three patients who experienced myelopathy associated with PJF following T9/10 to pelvis fusion at a single institution.Results and conclusions: PJF with myelopathy must be diagnosed and surgically corrected early on so as to minimize permanent neurologic injury. Patients requiring significant sagittal deformity correction are at greater risk for PJF, and may benefit from constructs terminating in the upper thoracic spine.

Impact of Reduced Preincision Antibiotic Infusion Time on Surgical Site Infection Rates: A Retrospective Cohort Study.

OBJECTIVE: Our objective was to determine the impact of total preincision infusion time on surgical site infections (SSIs) and establish an optimal time threshold for subsequent prospective study. BACKGROUND: SSIs remain a major cause of morbidity. Although regulated, the total time of infusion of preincision antibiotics varies widely. Impact of infusion time on SSI risk is poorly understood. METHODS: All consecutive patients (n = 46,791) undergoing inpatient surgical intervention were retrospectively enrolled (2014-2015) and monitored for 1 year. Primary outcomes: the presence of SSI infection as predicted by reduced preoperative antibiotic infusion time. SECONDARY OUTCOMES: preintervention compliance, the impact of a quality improvement algorithm to optimize infusion time compliance. Multivariate logistic regression of the retrospective cohort demonstrated predictors of infection. Receiver-operating characteristic analysis demonstrated the timing threshold predictive of infection. Cost impact of avoidable infections was analyzed. RESULTS: Only 36.1% of patients received preincision infusion of vancomycin in compliance with national and institutional standards (60-120 min). Cephalosporin infusion times were 53 times more likely to be compliant [odds ratio (OR) 53.33, P < 0.001]. Vancomycin infusion times that were not compliant with national standards (less than standard 60-120 min) did not predict infection. However, significantly noncompliant, reduced preincision infusion time, significantly predicted SSI (<24.6 min infusion, AUC = 0.762). Vancomycin infusion, initiated too close to surgical incision, predicted increased SSI (OR = 4.281, P < 0.001). Implementation of an algorithm to improve infusion time, but not powered to demonstrate infection /reduction, improved vancomycin infusion start time (257% improvement, P < 0.001) and eliminated high-risk infusions (sub-24.6 min). CONCLUSIONS: Initially, vancomycin infusion rarely met national guidelines; however, minimal compliance breach was not associated with SSI implications. The retrospective data here suggest a critical infusion time for infection reduction (24.6 min before incision). Prospective implementation of an algorithm led to 100% compliance. These data suggest that vancomycin administration timing should be studied prospectively.

Surgical Outcomes in Post-Traumatic Epilepsy: A Single Institutional Experience.

BACKGROUND: Post-traumatic epilepsy (PTE) is a debilitating sequela of traumatic brain injury (TBI), occurring in up to 20% of severe cases. This entity is generally thought to be more difficult to treat with surgical intervention. OBJECTIVE: To detail our experience with the surgical treatment of PTE. METHODS: Patients with a history of head injury undergoing surgical treatment for epilepsy were retrospectively enrolled. Engel classification at the last follow-up was used to assess outcome of patients that underwent surgical resection of an epileptic focus. Reduction in seizure frequency was assessed for patients who underwent vagal nerve stimulator (VNS) or responsive neurostimulator (RNS) implantation. RESULTS: A total of 23 patients met inclusion criteria. Nineteen (82.6%) had mesial temporal sclerosis, 3 had lesional neocortical epilepsy (13.0%), and 1 had nonlesional neocortical epilepsy (4.3%). Fourteen patients (60.9%) underwent temporal lobectomy (TL), 2 underwent resection of a cortical focus (8.7%), and 7 underwent VNS implantation (30.4%). Three patients underwent RNS implantation after VNS failed to reduce seizure frequency more than 50%. In the patients treated with resection, 11 (68.8%) were Engel I, 3 (18.8%) were Engel II, and 2 (12.5%) were Engel III at follow-up. Average seizure frequency reduction in the VNS group was 30.6% ± 25.6%. RNS patients had reduction of seizure severity but seizure frequency was only reduced 9.6% ± 13.6%. CONCLUSION: Surgical outcomes of PTE patients treated with TL were similar to reported surgical outcomes of patients with nontraumatic epilepsy treated with TL. Patients who were not candidates for resection demonstrated variable response rates to VNS or RNS implantation.

The Risk Assessment and Prediction Tool (RAPT) for Discharge Planning in a Posterior Lumbar Fusion Population.

BACKGROUND: As the use of bundled care payment models has become widespread in neurosurgery, there is a distinct need for improved preoperative predictive tools to identify patients who will not benefit from prolonged hospitalization, thus facilitating earlier discharge to rehabilitation or nursing facilities. OBJECTIVE: To validate the use of Risk Assessment and Prediction Tool (RAPT) in patients undergoing posterior lumbar fusion for predicting discharge disposition. METHODS: Patients undergoing elective posterior lumbar fusion from June 2016 to February 2017 were prospectively enrolled. RAPT scores and discharge outcomes were recorded for patients aged 50 yr or more (n = 432). Logistic regression analysis was used to assess the ability of RAPT score to predict discharge disposition. Multivariate regression was performed in a backwards stepwise logistic fashion to create a binomial model. RESULTS: Escalating RAPT score predicts disposition to home (P < .0001). Every unit increase in RAPT score increases the chance of home disposition by 55.8% and 38.6% than rehab and skilled nursing facility, respectively. Further, RAPT score was significant in predicting length of stay (P = .0239), total surgical cost (P = .0007), and 30-d readmission (P < .0001). Amongst RAPT score subcomponents, walk, gait, and postoperative care availability were all predictive of disposition location (P < .0001) for both models. In a generalized multiple logistic regression model, the 3 top predictive factors for disposition were the RAPT score, length of stay, and age (P < .0001, P < .0001 and P = .0001, respectively). CONCLUSION: Preoperative RAPT score is a highly predictive tool in lumbar fusion patients for discharge disposition.

Assessing variability in surgical decision making among attending neurosurgeons at an academic center.

OBJECTIVE: Although it is known that intersurgeon variability in offering elective surgery can have major consequences for patient morbidity and healthcare spending, data addressing variability within neurosurgery are scarce. The authors performed a prospective peer review study of randomly selected neurosurgery cases in order to assess the extent of consensus regarding the decision to offer elective surgery among attending neurosurgeons across one large academic institution. METHODS: All consecutive patients who had undergone standard inpatient surgical interventions of 1 of 4 types (craniotomy for tumor [CFT], nonacute redo CFT, first-time spine surgery with/without instrumentation, and nonacute redo spine surgery with/without instrumentation) during the period 2015-2017 were retrospectively enrolled (n = 9156 patient surgeries, n = 80 randomly selected individual cases, n = 20 index cases of each type randomly selected for review). The selected cases were scored by attending neurosurgeons using a need for surgery (NFS) score based on clinical data (patient demographics, preoperative notes, radiology reports, and operative notes; n = 616 independent case reviews). Attending neurosurgeon reviewers were blinded as to performing provider and surgical outcome. Aggregate NFS scores across various categories were measured. The authors employed a repeated-measures mixed ANOVA model with autoregressive variance structure to compute omnibus statistical tests across the various surgery types. Interrater reliability (IRR) was measured using Cohen's kappa based on binary NFS scores. RESULTS: Overall, the authors found that most of the neurosurgical procedures studied were rated as "indicated" by blinded attending neurosurgeons (mean NFS = 88.3, all p values < 0.001) with greater agreement among neurosurgeon raters than expected by chance (IRR = 81.78%, p = 0.016). Redo surgery had lower NFS scores and IRR scores than first-time surgery, both for craniotomy and spine surgery (ANOVA, all p values < 0.01). Spine surgeries with fusion had lower NFS scores than spine surgeries without fusion procedures (p < 0.01). CONCLUSIONS: There was general agreement among neurosurgeons in terms of indication for surgery; however, revision surgery of all types and spine surgery with fusion procedures had the lowest amount of decision consensus. These results should guide efforts aimed at reducing unnecessary variability in surgical practice with the goal of effective allocation of healthcare resources to advance the value paradigm in neurosurgery.

The Utility of Cervical Spine Bracing as a Postoperative Adjunct to Single-level Anterior Cervical Spine Surgery.

BACKGROUND CONTEXT: Use of cervical bracing/collar subsequent to anterior cervical spine discectomy and fusion (ACDF) is variable. Outcomes data regarding bracing after ACDF are limited. PURPOSE: The purpose of the study is to study the impact of bracing on short-term outcomes related to safety, quality of care, and direct costs in single-level ACDF. STUDY DESIGN/SETTING: This retrospective cohort analysis of all consecutive patients (n = 578) undergoing single-level ACDF with or without bracing from 2013 to 2017 was undertaken. METHODS: Patient demographics and comorbidities were analyzed. Tests of independence (Chi-square, Fisher's exact, and Cochran-Mantel-Haenszel test), Mann-Whitney-Wilcoxon tests, and logistic regressions were used to assess differences in length of stay (LOS), discharge disposition (home, assisted rehabilitation facility-assisted rehabilitation facility, or skilled nursing facility), quality-adjusted life year (QALY), surgical site infection (SSI), direct cost, readmission within 30 days, and emergency room (ER) visits within 30 days. RESULTS: Among the study population, 511 were braced and 67 were not braced. There was no difference in graft type (P = 1.00) or comorbidities (P = 0.06-0.73) such as obesity (P = 0.504), smoking (0.103), chronic obstructive pulmonary disease hypertension (P = 0.543), coronary artery disease (P = 0.442), congestive heart failure (P = 0.207), and problem list number (P = 0.661). LOS was extended for the unbraced group (median 34.00 + 112.15 vs. 77.00 + 209.31 h, P < 0.001). There was no difference in readmission (P = 1.000), ER visits (P = 1.000), SSI (P = 1.000), QALY gain (P = 0.437), and direct costs (P = 0.732). CONCLUSIONS: Bracing following single-level cervical fixation does not alter short-term postoperative course or reduce the risk for early adverse outcomes in a significant manner. The absence of bracing is associated with increased LOS, but cost analyses show no difference in direct costs between the two treatment approaches. Further evaluation of long-term outcomes and fusion rates will be necessary before definitive recommendations regarding bracing utility following single-level ACDF.

Evaluation of the Risk Assessment and Prediction Tool for Postoperative Disposition Needs After Cervical Spine Surgery.

BACKGROUND: Bundled care payment models are becoming more prevalent in neurosurgery. Such systems place the cost of postsurgical facilities in the hands of the discharging health system. Opportunity exists to leverage prediction tools for discharge disposition by identifying patients who will not benefit from prolonged hospitalization and facilitating discharge to post-acute care facilities. OBJECTIVE: To validate the use of the Risk Assessment and Predictive Tool (RAPT) along with other clinical variables to predict discharge disposition in a cervical spine surgery population. METHODS: Patients undergoing cervical spine surgery at our institution from June 2016 to February 2017 and over 50 yr old had demographic, surgical, and RAPT variables collected. Multivariable regression analyzed each variable's ability to predict discharge disposition. Backward selection was used to create a binomial model to predict discharge disposition. RESULTS: A total of 263 patients were included in the study. Lower RAPT score, RAPT walk subcomponent, older age, and a posterior approach predicted discharge to a post-acute care facility compared to home. Lower RAPT also predicted an increased risk of readmission. RAPT score combined with age increased the predictive capability of discharge disposition to home vs skilled nursing facility or acute rehabilitation compared to RAPT alone (P < .001). CONCLUSION: RAPT score combined with age is a useful tool in the cervical spine surgery population to predict postdischarge needs. This tool may be used to start early discharge planning in patients who are predicted to require post-acute care facilities. Such strategies may reduce postoperative utilization of inpatient resources.

Aneurysm Dome Excision and Picket Fence Clip Reconstruction of a Previously Coiled Recurrent Giant Middle Cerebral Artery Aneurysm: Technical Nuances.

This video case illustrates key surgical steps required in safe management of a giant recurrent previously coiled middle cerebral artery (MCA) aneurysm (Video 1). The patient described in this case was a 68-year-old man who presented with sudden-onset severe headache and dizziness. The patient had a history of a prior coil embolization of a 12-mm left middle cerebral artery aneurysm at an outside hospital. Imaging demonstrated recurrence now of a giant left middle cerebral artery aneurysm with coil compaction and left temporal lobe edema. Magnetic resonance imaging further demonstrated thrombus in the aneurysm and aneurysm wall enhancement concerning for impending rupture. Given the aneurysm size, imaging features, and mass effect, the aneurysm was treated with microsurgical clipping. This case is valuable to the literature with a clear video case illustration of aneurysm dome excision, aneurysm endarterectomy, and picket fence aneurysm neck reconstruction. Aneurysm dome excision is critical for treatment of giant aneurysms causing mass effect and was only used in this case because thrombus and coil mass did not allow for direct clipping across the neck without compromise of the MCA M2 branch. Hence, this video highlights key technical tenets, such as safe thrombus removal and adequate cleaning of the endoluminal surface and preparedness for bypass in challenging cases.

Quality of Life in Patients Undergoing Spine Surgery: Systematic Review and Meta-Analysis.

STUDY DESIGN: Meta-analysis. OBJECTIVE: Despite the increasing importance of tracking clinical outcomes using valid patient-reported outcome measures, most providers do not routinely obtain baseline preoperative health-related quality of life (HRQoL) data in patients undergoing spine surgery, precluding objective outcomes analysis in individual practices. We conducted a meta-analysis of pre- and postoperative HRQoL data obtained from the most commonly published instruments to use as reference values. METHODS: We searched PubMed, EMBASE, and an institutional registry for studies reporting EQ-5D, SF-6D, and Short Form-36 Physical Component Summary scores in patients undergoing surgery for degenerative cervical and lumbar spinal conditions published between 2000 and 2014. Observational data was pooled meta-analytically using an inverse variance-weighted, random-effects model, and statistical comparisons were performed. RESULTS: Ninety-nine articles were included in the final analysis. Baseline HRQoL scores varied by diagnosis for each of the 3 instruments. On average, postoperative HRQoL scores significantly improved following surgical intervention for each diagnosis using each instrument. There were statistically significant differences in baseline utility values between the EQ-5D and SF-6D instruments for all lumbar diagnoses. CONCLUSIONS: The pooled HRQoL values presented in this study may be used by practitioners who would otherwise be precluded from quantifying their surgical outcomes due to a lack of baseline data. The results highlight differences in HRQoL between different degenerative spinal diagnoses, as well as the discrepancy between 2 common utility-based instruments. These findings emphasize the need to be cognizant of the specific instruments used when comparing the results of outcome studies.

Initial Assessment of the Risk Assessment and Prediction Tool in a Heterogeneous Neurosurgical Patient Population.

BACKGROUND: Bundled care payments are increasingly being explored for neurosurgical interventions. In this setting, skilled nursing facility (SNF) is less desirable from a cost perspective than discharge to home, underscoring the need for better preoperative prediction of postoperative disposition. OBJECTIVE: To assess the capability of the Risk Assessment and Prediction Tool (RAPT) and other preoperative variables to determine expected disposition prior to surgery in a heterogeneous neurosurgical cohort, through observational study. METHODS: Patients aged 50 yr or more undergoing elective neurosurgery were enrolled from June 2016 to February 2017 (n = 623). Logistic regression was used to identify preoperative characteristics predictive of discharge disposition. Results from multivariate analysis were used to create novel grading scales for the prediction of discharge disposition that were subsequently compared to the RAPT Score using Receiver Operating Characteristic analysis. RESULTS: Higher RAPT Score significantly predicted home disposition (P < .001). Age 65 and greater, dichotomized RAPT walk score, and spinal surgery below L2 were independent predictors of SNF discharge in multivariate analysis. A grading scale utilizing these variables had superior discriminatory power between SNF and home/rehab discharge when compared with RAPT score alone (P = .004). CONCLUSION: Our analysis identified age, lower lumbar/lumbosacral surgery, and RAPT walk score as independent predictors of discharge to SNF, and demonstrated superior predictive power compared with the total RAPT Score when combined in a novel grading scale. These tools may identify patients who may benefit from expedited discharge to subacute care facilities and decrease inpatient hospital resource utilization following surgery.

Technical nuances of percutaneous sacroiliac joint fixation: A cadaveric study.

Sacroiliac (SI) joint can produce debilitating lower back pain with radiation to groin, buttocks, and lower extremities. SI joint dysfunction poses a clinical challenge to the spine surgeons. Studies entailing surgical arthrodesis utilizing Titanium implants have been reported with reputedly high level of patient satisfaction. Authors have described technical aspects of surgical technique with use of titanium screw implants. The transarticular technique is used to places SI joint screw implants across the articular portion of SI joint. Cadaveric SI joint instrumentation is performed under fluoroscopic guidance. Moreover, Medline literature search is conducted to study surgical outcome, and patient satisfaction. 4 cadavers are prepped prone for the percutaneous approach. Bilaterally 6 screws are placed using transarticular placement technique under fluoroscopic guidance. The posterior technique utilizes alignment guide to place the screws inline on the inlet view, parallel in the outlet view, and parallel to the dorsal aspect of the sacral body in the lateral view. One C-arm is used in the entire technique. The technical aspects of surgical technique have been described in a stepwise fashion for easy reproducibility in the operating room. Each screw track is checked with tactile feel of a blunt K-wire before final deployment. All bilateral screws were checked on a set of fluoroscopic views. A detail clinical examination, diagnostic joint injection, with the radiological imaging must be considered before surgical consideration. SI Joint fusion utilizing 3 transarticular sacral screws is equally effective and safe procedure to treat chronic lower back pain ensuing from SI joint dysfunction.

Implications of anesthetic approach, spinal versus general, for the treatment of spinal disc herniation.

OBJECTIVEHealthcare costs continue to escalate. Approaches to care that have comparable outcomes and complications are increasingly assessed for quality improvement and, when possible, cost containment. Efforts to identify components of care to reduce length of stay (LOS) have been ongoing. Spinal anesthesia (SA), for select lumbar spine procedures, has garnered interest as an alternative to general anesthesia (GA) that might reduce cost and in-hospital LOS and accelerate recovery. While clinical outcomes with SA or GA have been studied extensively, few authors have looked at the cost-analysis in relation to clinical outcomes. The authors' objectives were to compare the clinical perioperative outcomes of patients who received SA and GA, as well as the direct costs associated with each modality of care, and to determine which, in a retrospective analysis, can serve as a dominant procedural approach.METHODSThe authors retrospectively analyzed a homogeneous surgical population of 550 patients who underwent hemilaminotomy for disc herniation and who received either SA (n = 91) or GA (n = 459). All clinical and billing data were obtained via each patient's chart and the hospital's billing database, respectively. Additionally, the authors prospectively assessed patient-reported outcome measures for a subgroup of consecutively treated patients (n = 75) and compared quality-adjusted life year (QALY) gains between the two cohorts. Furthermore, the authors performed a propensity score-matching analysis to compare the two cohorts (n = 180).RESULTSDirect hospital costs for patients receiving SA were 40% higher, in the hundreds of dollars, than for patients who received GA (p < 0.0001). Furthermore, there was a significant difference with regard to LOS (p < 0.0001), where patients receiving SA had a considerably longer hospital LOS (27.6% increase in hours). Patients undergoing SA had more comorbidities (p = 0.0053), specifically diabetes and hypertension. However, metrics of complications, including readmission (p = 0.3038) and emergency department (ED) visits at 30 days (p = 1.0), were no different. Furthermore, in a small pilot group, QALY gains were statistically no different (n = 75, p = 0.6708). Propensity score-matching analysis demonstrated similar results as the univariate analysis: there was no difference between the cohorts regarding 30-day readmission (p = 1.0000); ED within 30 days could not be analyzed as there were no patients in the SA group; and total direct costs and LOS were significantly different between the two cohorts (p < 0.0001 and p = 0.0126, respectively).CONCLUSIONSBoth SA and GA exhibit the qualities of a good anesthetic, and the utilization of these modalities for lumbar spine surgery is safe and effective. However, this work suggests that SA is associated with increased LOS and higher direct costs, although these differences may not be clinically or fiscally meaningful.

Quantitative MRI correlates with histological grade in a percutaneous needle injury mouse model of disc degeneration.

Low back pain due to disc degeneration is a major cause of morbidity and health care expenditures worldwide. While stem cell-based therapies hold promise for disc regeneration, there is an urgent need to develop improved in vivo animal models to further develop and validate these potential treatments. The objectives of this study were to characterize a percutaneous needle injury model of intervertebral disc degeneration in the mouse caudal spine, and compare two non-invasive quantitative imaging techniques, microcomputed tomography and magnetic resonance imaging (MRI), as effective measures of disc degeneration in this model. Percutaneous needle injury of mouse caudal discs was undertaken using different needle sizes and injury types (unilateral or bilateral annulus fibrosus (AF) puncture). Mice were euthanized 4 weeks post-injury, and MRI and microcomputed tomography were used to determine T2 relaxation time of the NP and disc height index, respectively. Disc condition was then further assessed using semi-quantitative histological grading. Bilateral AF puncture with either 27 or 29G needles resulted in significantly lower T2 relaxation times compared to uninjured controls, while disc height index was not significantly affected by any injury type. There was a strong, inverse linear relationship between histological grade and NP T2 relaxation time. In this study, we demonstrated that quantitative MRI can detect disc degeneration in the mouse caudal spine 4 weeks following percutaneous needle injury, and may therefore serve as a surrogate for histology in longitudinal studies of both disc degeneration and cell-based therapies for disc regeneration using this model. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2771-2779, 2018.

Surgical Approaches for the Treatment of Multilevel Cervical Ossification of the Posterior Longitudinal Ligament: Results of a Decision Analysis.

BACKGROUND: Ossification of the posterior longitudinal ligament (OPLL) often leads to cervical myelopathy. Although multiple procedures have been shown to be effective in the treatment of OPLL, outcomes are less predictable than in degenerative cervical myelopathy, and surgery is associated with high rates of complications and reoperation, which affect quality of life. In this study, we performed a decision analysis using postoperative complication data and health-related quality of life (HRQoL) utility scores to assess the average expected health utility and 5-year quality-adjusted life years (QALYs) associated with the most common surgical approaches for multilevel cervical OPLL. METHODS: We searched Medline, EMBASE, and the Cochrane Library for relevant articles published between 1990 and October 2017. Meta-analytically pooled complication data and HRQoL utility scores associated with each complication were evaluated in a long-term model. RESULTS: The overall incidence of perioperative complications ranged from 6.2% for laminectomy alone to 11.0% for anterior decompression and fusion. Revision surgery for hardware/fusion failure or progression was highest for laminectomy alone (3.0%) and lowest for laminectomy and fusion (1.6%). Laminoplasty resulted in the highest 5-year QALYs gained, compared with laminectomy and anterior approaches (P < 0.001). There was no significant difference in QALY gained between laminectomy-fusion and laminoplasty. CONCLUSION: The results suggest that owing to the higher rates of complications associated with anterior cervical approaches, laminoplasty may result in improved long-term outcomes from an HRQoL standpoint. These findings may guide surgeons in cases where either procedure is a reasonable option.

Posterior Cervical Laminectomy Results in Better Radiographic Decompression of Spinal Cord Compared with Anterior Cervical Discectomy and Fusion.

BACKGROUND: Cervical spondylitic myelopathy is a degenerative condition resulting from chronic spinal cord compression and a leading cause of nontraumatic spinal cord dysfunction. The chief surgical goal in the management of cervical spondylitic myelopathy is adequate spinal cord decompression with or without fusion to slow or prevent further neurologic decline. We conducted a radiographic analysis of canal parameters preoperatively and postoperatively for patients undergoing either anterior or posterior cervical decompression. METHODS: Preoperative and postoperative radiographic analysis was performed using midsagittal and axial magnetic resonance imaging at the level of the disc space for 37 patients who underwent anterior or posterior cervical decompression. Statistical comparisons between anterior and posterior groups were performed using independent t test and Mann-Whitney U test where appropriate. RESULTS: Both postoperative anteroposterior canal diameter and posterior cerebrospinal fluid (CSF) space were greater in patients undergoing posterior decompression (P = 0.011 and P < 0.001, respectively), although postoperative anterior CSF space was comparable between both groups. Both anterior and posterior approaches to decompression resulted in a statistically significant improvement in anteroposterior diameter, anterior CSF space, and posterior CSF space (P < 0.001). Posterior decompression yielded significantly greater change in anteroposterior diameter and posterior CSF space compared with the anterior approach (P < 0.001). CONCLUSIONS: In this quantitative radiographic study, we found that although both posterior cervical laminectomy and anterior cervical discectomy yielded significant decompression, laminectomy yielded a greater degree of decompression of the posterior CSF space.

Post-operative bracing after pedicle screw fixation for thoracolumbar burst fractures: A cost-effectiveness study.

PURPOSE: While frequently prescribed to patients following fixation for spine trauma, the utility of spinal orthoses during the post-operative period is poorly described in the literature. In this study, we calculated rates of reoperation and performed a decision analysis to determine the utility of bracing following pedicle screw fixation for thoracic and lumbar burst fractures. METHODS: Pubmed was searched for articles published between 2005 and 2015 for terms related to pedicle screw fixation of thoracolumbar fractures. Additionally, a database of neurosurgical patients operated on within the authors institution was also used in the analysis. Incidences of significant adverse events (wound revision for either dehiscence or infection or re-operation for non-union or instability due to hardware failure) were determined. Pooled means and variances of reported parameters were obtained using a random-effects, inverse variance meta-analytic model for observational data. Utilities for surgical outcome and complications were assigned using previously published values. RESULTS: Of the 225 abstracts reviewed, 48 articles were included in the study, yielding a total of 1957 patients. After including patients from the institutional registry, together a total of 2081 patients were included in the final analysis, 1328 of whom were braced. Non-braced patients were older then braced patients, although this only approached significance (p=0.051). Braced patients had significantly lower rates of re-operation for non-union or clinically significant hardware failure (1.3% vs. 1.8%, p<0.001) although the groups had comparable rates of operative wound dehiscence and infection (p=1.000). These two approaches yielded comparable utility scores (p=0.120). Costs between braced and non-braced patients were comparable excluding the cost of the brace (p=0.256); hence, the added cost of the brace suggests that bracing post-operatively is not a cost effective measure. CONCLUSIONS: Bracing following operative stabilization of thoracolumbar fracture does not significantly improve stability, nor does it increase wound complications. Moreover, our data suggests that post-operative bracing may not be a cost-effective measure.