Comparison of Clinical and Radiographic Outcomes After Standalone Versus Cage and Plate Constructs for Anterior Cervical Discectomy and Fusion.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) has conventionally been performed using an allograft cage with a plate-and-screw construct. Recently, standalone cages have gained popularity due to theorized decreases in operative time and postoperative dysphagia. Few studies have compared these outcomes. Here, we directly compare the outcomes of plated versus standalone ACDF constructs. METHODS: A single-center retrospective review of patients undergoing ACDF after June 2011 with at least 6 months of follow up was conducted. Clinical outcomes were analyzed and compared between standalone and plated constructs. Multivariate regression analysis of the primary outcome, need for revision surgery, as well as several secondary outcomes, procedure duration, estimated blood loss (EBL), length of hospital stay, disposition, and incidence of dysphagia, hoarseness, or surgical site infection, was completed. RESULTS: A total of 321 patients underwent ACDF and met inclusion-exclusion criteria, with mean follow-up duration of 20 months. Forty-six (14.3%) patients received standalone constructs, while 275 (85.7%) received plated constructs. Fourteen (4.4%) total revisions were necessary, 4 in the standalone group and 10 in the plated group, yielding revision rates of 8.7% and 3.6%, respectively (P = .125). Mean EBL was 98 mL in the standalone group and 63 mL in the plated group (P = .001). Mean procedure duration was 147 minutes in the standalone group and 151 minutes in the plated group (P = .800). Mean hospital stay was 3.6 days in the standalone group and 2.5 days in the plated group (P = .270). There was no significant difference in incidence of dysphagia (P = .700) or hoarseness (P = .700). CONCLUSIONS: Standalone ACDF demonstrates higher, but not statistically significant, revision rates than plate-and-screw constructs, without the hypothesized decreased incidence of dysphagia or hoarseness and without decreased procedure duration or EBL. Surgeons may consider limiting use of these constructs to cases of adjacent segment disease. Larger studies with longer follow up are necessary to make more definitive conclusions. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: This study will help spine surgeons decide between using standalone or cage-and-plate constructs for ACDF.

Intracranial hemorrhage in critically ill patients hospitalized for COVID-19.

In this study, we report three cases of spontaneous intracranial hemorrhage in patients who were initially hospitalized at our tertiary care center in Washington, DC with symptoms of COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed in all three patients, who were critically ill, requiring intubation and ventilatory support. During their protracted hospitalizations, subsequent imaging disclosed intracranial hemorrhages, including intracerebral and subarachnoid hemorrhages, in the context of anticoagulation and coagulopathy. We believe this is related to the tropism of SARS-CoV-2 to the endothelial lining of the cerebral vasculature via their angiotensin-converting enzyme (ACE) II receptors. Given our findings, we advocate heightened vigilance for intracerebral hemorrhage events, and scanning when practicable, in COVID-19 patients which have prolonged ventilatory support and depressed neurologic examinations.

Success and Failure of Percutaneous Minimally Invasive Direct Pars Repair: Analysis of Fracture Morphology.

BACKGROUND: Spondylolysis is a defect in the pars interarticularis that typically presents with axial back pain. Recently, minimally invasive spine techniques have increased in popularity and have been applied to the Buck technique of direct pars repair. CASE DESCRIPTION: In our series, 2 patients underwent minimally invasive direct pars repair by the percutaneous insertion of a cannulated lag screw across the pars defect with compression against the lamina. The defect was then decorticated and packed with bone grafting material through a tubular retractor. The clinical records, including preoperative imaging characteristics and intraoperative variables, were collected. The first patient was a 22-year-old woman with bilateral pars defects, and the second was a 21-year-old woman with a left-sided pars defect. They underwent minimally invasive direct pars repair without complications and were discharged home within 24-48 hours. In the first patient, the fusion was successful; however, the second experienced screw back out and required subsequent revision. The follow-up period was 25 months for patient 1 and 21 months for patient 2. The fracture morphology differed. The successfully repaired fractures were linear with smooth cortical edges and oriented perpendicular to the screw trajectory. The failed repair involved a unilateral, curved defect with comminuted cortical edges. CONCLUSION: Minimally invasive direct pars repair can be performed safely and effectively with shortened hospital stays and reduced morbidity. Fracture morphology and orientation could be important predictors of the success of surgery.