Current surgical practice for multi-level degenerative cervical myelopathy: Findings from an international survey of spinal surgeons.

Degenerative cervical myelopathy (DCM) results from compression of the cervical spine cord as a result of age related changes in the cervical spine, and affects up to 2% of adults, leading to progressive disability. Surgical decompression is the mainstay of treatment, but there remains significant variation in surgical approaches used. This survey was conducted in order to define current practice amongst spine surgeons worldwide, as a possible prelude to further studies comparing surgical approaches. METHODS: An electronic survey was developed and piloted by the investigators using SurveyMonkey. Collected data was categorical and is presented using summary statistics. Where applicable, statistical comparisons were made using a Chi-Squared test. The level of significance for all statistical analyses was defined as p < 0.05. All analysis, including graphs was performed using R (R Studio). RESULTS: 127 surgeons, from 30 countries completed the survey; principally UK (66, 52%) and North America (15, 12%). Respondents were predominantly Neurosurgeons by training (108, 85%) of whom 84 (75%) reported Spinal Surgery as the principal part of their practice. The majority indicated they selected their surgical procedure for multi-level DCM on a case by case basis (62, 49%). Overall, a posterior approach was more popular for multi-level DCM (74, 58%). Region, speciality or annual multi-level case load did not influence this significantly. However, there was a trend for North American surgeons to be more likely to favour a posterior approach. CONCLUSIONS: A posterior approach was favoured and more commonly used to treat multi-level DCM, in an international cohort of surgeons. Posterior techniques including laminectomy, laminectomy and fusion or laminoplasty appeared to be equally popular.

In-hospital Course and Complications of Laminectomy Alone Versus Laminectomy Plus Instrumented Posterolateral Fusion for Lumbar Degenerative Spondylolisthesis: A Retrospective Analysis of 1804 Patients from the NSQIP Database.

STUDY DESIGN: Retrospective analysis of data from the National Surgical Quality Improvement Program (NSQIP). OBJECTIVE: We sought to compare the short-term outcomes of laminectomy with/without fusion for single-level lumbar degenerative spondylolisthesis (DS). SUMMARY OF BACKGROUND DATA: Lumbar DS is a common cause of low back and radicular pain. Controversy remains over the safety and efficacy of fusion in addition to standard decompressive surgery. METHODS: Patients with lumbar DS who underwent laminectomy alone or laminectomy plus posterolateral fusion at a single level were identified from the 2012-2017 NSQIP database. Outcomes included 30-day mortality, major complication, reoperation, readmission, as well as operative duration, need for blood transfusion, length of stay (LOS), and discharge destination. Outcomes were compared between treatment groups by multivariable regression, adjusting for age, sex, and comorbidities (modified Frailty Index). Effect sizes were reported by adjusted odds ratio (aOR) or mean difference (aMD). RESULTS: The study cohort consisted of 1804 patients; of these, 802 underwent laminectomy alone and 1002 laminectomy plus fusion. On both unadjusted and adjusted analyses, there was no difference in 30-day mortality, major complications, reoperation, or readmission. However, laminectomy plus fusion was associated with longer operative time (170.0 vs. 152.7 minutes; aMD 16.00 minutes, P < 0.001), longer hospital LOS (3.2 vs. 2.5 days; aMD 0.68, P < 0.001), more frequent need for intra- or postoperative blood transfusion (6.8% vs. 3.1%; aOR 2.24, P = 0.001), and less frequent discharge home (80.7% vs. 89.2%; aOR 0.46, P < 0.001). CONCLUSION: We found single-level laminectomy plus fusion for lumbar DS to have a comparable short-term safety profile to laminectomy alone. However, fusion was associated with longer operative time and LOS, higher risk of blood transfusion, and greater need for inpatient rehabilitation. These factors should be recognized by clinicians and discussed with patients in the context of their values when weighing surgical treatment of lumbar DS.Level of Evidence: 3.

Use of hypnosis preoperatively for surgery of the spine: Pilot study.

INTRODUCTION: Hypnosis is a technique requiring no drugs that acts during the three phases of surgery, reducing stress at the pre-surgical phase and the adminstration of anesthetic drugs during the intraoperative phase, as well as leading to improved management of postoperative pain and quality of life management. MATERIAL ET METHOD: We carried out a retrospective study of 46 patients operated on for herniated disc or one or two-level laminectomy without arthrodesis. All patients benefited from a preoperative hypnosis session and completed a questionnaire about their possible concerns. The day after surgery, patients completed a second questionnaire on their postoperative experience following hypnosis. RESULTATS: Our results indicate that this technique had a positive impact on the management of preoperative stress (80% of patients) and on postoperative quality of life (48% of patients). Pain measured by decreased from 4.8/10 preoperatively to 0.9/10 postoperatively. CONCLUSION: Our results are consistent with previous findings in the literature as to the positive contribution of this technique in the management of preoperative stress and patient quality of life. Further studies are however required involving considerably larger cohorts and more extensive surgeries to confirm the effect of this technique on management of anesthesia and pain in spine surgery.

Surgical Outcomes Following Laminectomy With Fusion Versus Laminectomy Alone in Patients With Degenerative Cervical Myelopathy.

STUDY DESIGN: .: Post-hoc analysis of a prospective observational cohort study. OBJECTIVE: .: To compare clinical outcomes following laminectomy and fusion versus laminectomy alone in an international series of individuals suffering from degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA: .: Significant controversy exists regarding the role of instrumented fusion in the context of posterior surgical decompression for DCM. A previous study comparing laminectomy and fusion with laminoplasty showed no differences in outcomes between groups after adjusting for preoperative characteristics. METHODS: .: Based on the operation they received, 208 of the 757 patients prospectively enrolled in the AO Spine North America or International studies at 26 global sites were included in the present study. Twenty-two patients were treated with laminectomy alone and 186 received a laminectomy with fusion. Patients were evaluated using the modified Japanese Orthopedic Association scale (mJOA), Nurick score, Neck Disability Index, and SF36 quality of life measure. Baseline and surgical characteristics were compared using a t test for continuous variables and a chi-square test for categorical variables. A mixed model analytic approach was used to evaluate differences in outcomes at 24 months between patients undergoing laminectomy and fusion versus laminectomy alone. RESULTS: .: Surgical cohorts were comparable in terms of preoperative patient characteristics. Patients undergoing laminectomy with instrumented fusion had a significantly longer operative duration (P < 0.0001, 231.44 vs. 107.10 min) but a comparable length of hospital stay. In terms of outcomes, patients treated with laminectomy with fusion exhibited clinically meaningful improvements (in functional impairmentΔmJOA = 2.48, ΔNurick = 1.19), whereas those who underwent a laminectomy without fusion did not (ΔmJOA = 0.78; ΔNurick = 0.29). There were significant differences between surgical cohorts in the change in mJOA and Nurick scores from preoperative to 24-months postoperative (mJOA: -1.70, P = 0.0266; Nurick: -0.90, P = 0.0241). The rate of perioperative complications was comparable (P = 0.879). CONCLUSION: .: Our findings suggest that cervical laminectomy with instrumented fusion is more effective than laminectomy alone at improving functional impairment in patients with DCM. These results warrant confirmation in larger prospective comparative studies. LEVEL OF EVIDENCE: 2.

Evaluation of Health-related Quality of Life Improvement in Patients Undergoing Spine Versus Adult Reconstructive Surgery.

STUDY DESIGN: Retrospective analysis of outcomes in single-level spine and primary hip and knee arthroplasty patients. OBJECTIVE: The aim of this study was to compare baseline and postoperative outcomes in patients undergoing spine surgery procedures with total hip arthroplasty (THA) and total knee arthroplasty (TKA) to further define outcomes in orthopedic surgery. SUMMARY OF BACKGROUND DATA: Computer-adaptive Patient Reported Outcome Information System (PROMIS) allows for standardized assessment of the health-related quality of life across different disease states. METHODS: Patients who underwent spine surgery (anterior cervical discectomy and fusion, cervical disc replacement, lumbar laminectomy, microscopic lumbar discectomy, transforaminal lumbar interbody fusion or adult reconstruction surgery [THA, TKA]) were grouped. Mean Charlson Comorbidity Index (CCI), Baseline (BL), and 6-month PROMIS scores of physical function, pain interference, and pain intensity were determined. Paired t tests compared differences in CCI, BL, 6 months, and change in PROMIS scores for spine and adult reconstruction procedures. RESULTS: A total of 304 spine surgery patients (age = 58.1 ±â€Š15.6; 42.9% female) and 347 adult reconstruction patients (age = 62.9 ±â€Š11.8; 54.1% Female) were compared. Spine surgery groups had more disability and pain at baseline than adult reconstruction patients according to physical function ([21.0, 22.2, 9.07, 12.6, 10.4] vs. [35.8, 35.0], respectively, P < 0.01), pain interference ([80.1, 74.1, 89.6, 92.5, 90.6] vs. [64.0, 63.9], respectively, P < 0.01), and pain intensity ([53.0, 53.1, 58.3, 58.5, 56.1] vs. [53.4, 53.8], respectively, P < 0.01). At 6 months, spine surgery patients remained more disabled and had more pain compared to adult reconstruction patients. Over the 6-month timespan, spine patients experienced greater improvements than adult reconstruction patients in terms of physical function ([+8.7, +22.2, +9.7, +12.9, +12.1] vs. [+5.3, +3.9], respectively, P < 0.01) and pain interference scores ([-15.4,-28.1, -14.7, -13.1, -12.3] vs. [-8.3, -6.0], respectively, P < 0.01). CONCLUSION: Spinal surgery patients had lower BL and 6-month PROMIS scores, but greater relative improvement in PROMIS scores compared to adult reconstruction patients. LEVEL OF EVIDENCE: 3.

Preoperative Urinary Tract Infection Increases Postoperative Morbidity in Spine Patients.

STUDY DESIGN: Retrospective review. OBJECTIVE: Compare postoperative infection rates and 30-day outcomes in spine surgery patients with and without a preoperative urinary tract infection (UTI). SUMMARY OF BACKGROUND DATA: There is mixed evidence regarding safety and risks when operating on spine patients with a preoperative UTI. METHODS: Using data from the American College of Surgeons National Surgical Quality Improvement Program, we identified all adult patients undergoing spine surgery between 2012 and 2017 with a preoperative UTI. Patients with other preoperative infections were excluded. Our primary outcome was any postoperative infection (pneumonia, sepsis, surgical site infection, and organ space infection). Our secondary outcomes included surgical site infections, non-infectious complications, return to operating room, and 30-day readmission and mortality. We used univariate, then multivariate Poisson regression models adjusted for demographics, comorbidities, laboratory values, and case details to investigate the association between preoperative UTI status and postoperative outcomes. RESULTS: A total of 270,371 patients who underwent spine surgery were analyzed. The most common procedure was laminectomy (41.9%), followed by spinal fusion (31.7%) and laminectomy/fusion (25.6%). Three hundred fourty one patients had a preoperative UTI (0.14%). Patients with a preoperative UTI were more likely to be older, female, inpatients, emergency cases, with a higher American Society of Anesthesiologists score, and a longer operating time (for all, P < 0.001). Patients with a preoperative UTI had higher rates of infectious and non-infectious complications, return to operating room, and unplanned readmissions (for all, P < 0.001). However, there was no significant difference in mortality (0.6% vs. 0.2%, P = 0.108). Even after controlling for demographics, comorbidities, labs, and case details, preoperative UTI status was significantly associated with more postoperative infectious complications (incidence rate ratio [IRR]: 2.88, 95% confidence interval [CI]: 2.25-3.70, P < 0.001). CONCLUSION: Preoperative UTI status is significantly associated with postoperative infections and worse 30-day outcomes. Spine surgeons should consider delaying or cancelling surgery in patients with a UTI until the infection has cleared to reduce adverse outcomes. LEVEL OF EVIDENCE: 3.

Functional outcome after surgical treatment of spinal meningioma.

OBJECTIVE: Space-occupying spinal meningiomas (SM), commonly diagnosed due to gradual neurological deterioration, are treated surgically by decompression and tumor resection. In this series of patients with surgically treated SM, we determined individual predictors of functional outcome in the context of intraoperative neuromonitoring (IOM). METHODS: This retrospective study included 45 patients (39 women, 6 men; mean age 63 years). We reviewed pre- and postoperative charts, surgical reports, radiographic data for demographics, use of IOM, duration of symptoms, histopathology, co-morbidities, radiographic extension, surgical strategy, neurological performance (Japanese Orthopedic Association Score [JOA score]. Median follow-up was 34 months (12-190 months). RESULTS: Most frequent surgical approaches were laminectomy (71.1%, n = 32) and hemi-laminectomy (28.9%, n = 13). Predominant SM site was the thoracic spine (55.6%, n = 25). Most common symptoms were sensory deficits (77.8%, n = 35), gait disorders (55.6%, n = 25), motor deficits (42.2%, n = 19), and radiating pain (37.8%, n = 17). Simpson grade 1 resection was achieved in 6 patients, most common type of resection was Simpson grade 2 in 36 patients. During follow-up, 80.0% of patients had fully recovered sensory deficits (p < 0.001), 76.0% of patients with preoperative gait disorders had been asymptomatic (p < 0.001), and motor deficits in 12/19 (63.1%). Pain had decreased significantly from admission to follow-up (p = 0.001). IOM was used in 20 (44.4%) patients. Postoperatively, 6(13.3%) patients had developed a new neurological deficit, 4 of them operated without IOM. CONCLUSION: Resection of SM with IOM showed good recovery, excellent functional results with low surgical morbidity.

Does K-line (-) in the Neck-flexed Position Predict Surgical Outcome of Cervical Spondylotic Myelopathy?: Results of a Multivariate Analysis After Muscle-preserving Selective Laminectomy.

STUDY DESIGN: A retrospective single-center study. OBJECTIVE: The aim of this study was to investigate the influence of the K-line in the neck-flexed position (flexion K-line) on the surgical outcome after muscle-preserving selective laminectomy (SL) for cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Development of CSM is associated with dynamic factors and cervical alignment. The flexion K-line, which reflects both dynamic and alignment factors, provides an indicator of surgical outcome after posterior decompression surgery for patients with ossification of the posterior longitudinal ligament. However, the value of the flexion K-line for patients with CSM has not been evaluated. METHODS: Our study group included 159 patients treated with SL for CSM. Patients were divided into a flexion K-line (+) group and a flexion K-line (-) group. The influence of the flexion K-line on radiological and surgical outcomes was analyzed, with multivariate analysis conducted to identify factors affecting the surgical outcome. RESULTS: Patients in the flexion K-line (-) group were younger (P = 0.003), had a less lordotic cervical alignment (pre-and postoperatively, P < 0.001), a smaller C7 slope (pre-and postoperatively, P < 0.001), and a greater mismatch between the C7 slope and the C2-C7 angle (preoperatively, P = 0.047; postoperatively, P = 0.001). The postoperative increase in Japanese Orthopedic Association (JOA) score and the JOA score recovery rate (RR) were lower for the flexion K-line (-) than for the K-line (+) group (P < 0.001 and P < 0.001, respectively). On multivariate regression analysis, the flexion K-line (-) (ß = -0.282, P < 0.001), high signal intensity (SI) changes on T2-weighted image (WI) combined with low SI changes on T1-WI in the spinal cord (ß = -0.266, P < 0.001), and older age (ß= -0.248, P = 0.001) were predictive of a lower JOA score RR. CONCLUSION: The flexion K-line may be a useful predictor of surgical outcomes after SL in patients with CSM. LEVEL OF EVIDENCE: 4.

American Society of Anesthesiologists' Status Association With Cost and Length of Stay in Lumbar Laminectomy and Fusion: Results From an Institutional Database.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The objective of this study was to characterize the costs associated with American Society of Anesthesiologists (ASA) class, and to determine the extent to which ASA status is a predictor of increased cost and LOS following lumbar laminectomy and fusion (LLF). SUMMARY OF BACKGROUND DATA: Spinal fusion accounts for the highest hospital costs of any surgical procedure performed in the United States, and ASA (American Society of Anesthesiologists) status is a known risk factor for cost and length of stay (LOS) in the orthopedic literature. There is a paucity of literature that directly addresses the influence of ASA status on cost and LOS following LLF. METHODS: This is a retrospective cohort study of an institutional database of patients undergoing single-level LLF at an academic tertiary care facility from 2006 to 2016. Univariate comparisons were made using χ tests for categorical variables and t tests for continuous variables. Multivariate linear regression was utilized to estimate regression coefficients, and to determine whether ASA status is an independent risk factor for cost and LOS. RESULTS: A total of 1849 patients met inclusion criteria. For every one-point increase in ASA score, intensive care unit (ICU) LOS increased by 0.518 days (P < 0.001), and hospital length of stay increased by 1.93 days (P < 0.001). For every one-point increase in ASA score, direct cost increased by $7474.62 (P < 0.001). CONCLUSION: ASA status is a predictor of hospital LOS, ICU LOS, and direct cost. Consideration of the ways in which ASA status contributes to increased cost and prolonged LOS can allow for more accurate reimbursement adjustment and more precise targeting of efficiency and cost effectiveness initiatives. LEVEL OF EVIDENCE: 3.

Preoperative Predictors of Better Long-term Functional Ability and Decreased Pain Following LSS Surgery: A Prospective Observational Study with a 10-year Follow-up Period.

STUDY DESIGN: A prospective observational 10-year follow-up study. OBJECTIVE: This study aimed to examine preoperative predictors for better surgical outcomes in patients with lumbar spinal stenosis (LSS) 10 years after surgery. SUMMARY OF BACKGROUND DATA: LSS is a leading cause of low back surgery in patients older than 65 years. Limited data are available for predictors of long-term surgical outcomes in patients with LSS. METHODS: At the baseline, 102 patients with LSS underwent decompressive surgery, and 72 of the original study sample participated in a 10-year follow-up study. Study patients filled out a questionnaire preoperatively, and follow-up data were collected at 3 months, 6 months, 1 year, 2 years, 5 years, and 10 years postoperatively. Surgical outcomes were evaluated in terms of disability with the Oswestry Disability Index (ODI) and pain with the visual analog scale (VAS). Predictors in the models were nonsmoking status, absence of previous lumbar surgery, self-rated health, regular use of painkillers for symptom alleviation, and BMI. Statistical analyses included longitudinal associations, subgroup analyses, and cross-sectional analyses. RESULTS: Using multivariate analysis, statistically significant predictors for lower ODI and VAS scores at 10 years were nonsmoking status, absence of previous lumbar surgery, better self-rated health, and regular use of painkillers for <12 months. Patients who smoked preoperatively or had previous lumbar surgery experienced more pain and disability at the 10-year follow-up. CONCLUSION: These study results can enhance informed decision-making processes for patients considering surgical treatment for LSS by showing preoperative predictors for surgical outcomes up to 10 years after surgery. Smokers and patients with previous lumbar surgery showed a decline in surgical benefits after 5 years. LEVEL OF EVIDENCE: 3.

Less Use of the Bipolar Cautery can Prevent Postlaminectomy Epidural Fibrosis: An Experimental Study in Rats.

AIM: To investigate the role of bipolar electrocautery in the occurrence of epidural fibrosis following lumbar spine laminectomy in a rat model. MATERIAL AND METHODS: Fourteen male Sprague-Dawley rats (age: 4-6 months, weight: 250-300 g) were randomly divided into two groups, a bipolar group (Group I) and a control group (Group II). Laminectomy was performed between the L1 and L3 levels. In Group I (n=7), a laminectomy was carried out and soft tissue around the spinal cord was coagulated by using a bipolar electrocautery. In the control group (n=7), only laminectomy was performed. The animals were sacrificed 4 weeks after surgery, and post-laminectomy epidural fibrosis (PLEF) was evaluated. Macropathological, qualitative and quantitative histological evaluations as well as immunohistochemical staining including transforming growth factor-ß (TGF-ß), collagen I and collagen III were performed. RESULTS: The numbers of TGF-ß positive cells staining (PCS) were 3.00 ± 0.46 for Group I and 1.00 ± 0.52 for Group II. The numbers of collagen I PCS were 2.00 ± 0.93 for Group I and 1.25 ± 0.46 for Group II. The numbers of collagen III PCS were 2.25 ± 0.76 for Group I, 1.25 ± 0.46 for Group II, and TGF-ß PCS than Group II (p≤0.05). Compared with the control group, Group I's formation of epidural fibrosis was significantly increased. CONCLUSION: Our study clearly demonstrated that the use of bipolar cauterisation is associated with increased PLEF in the experimental animal model. Thus, limiting the use of bipolar cauterisation may be effective in reducing this complication.

The Impact of Preoperative Chronic Opioid Therapy in Patients Undergoing Decompression Laminectomy of the Lumbar Spine.

STUDY DESIGN: Retrospective review of electronic medical records (EMR). OBJECTIVE: This study aims to (1) characterize the pattern of opioid utilization in patients undergoing spine surgery and (2) compare the postoperative course between patients with and without chronic preoperative opioid prescriptions. SUMMARY OF BACKGROUND DATA: Postoperative pain management for patients with a history of opioid usage remains a challenge for spine surgeons. Opioids are controversial in this setting due to side effects and potential for abuse and addiction. Given the increasing rate of opioid prescriptions for spine-related pain, more studies are needed to evaluate patterns and risks of preoperative opioid usage in surgical patients. METHODS: EMR were reviewed for patients (age > 18) with lumbar spinal stenosis undergoing lumbar laminectomy in 2011 at our institution. Data regarding patient demographics, levels operated, pre/postoperative medications, and in-hospital length of stay were collected. Primary outcomes were length of stay and duration of postoperative opioid usage. RESULTS: One hundred patients were reviewed. Fifty-five patients had a chronic opioid prescription documented at least 3 months before surgery. Forty-five patients were not on chronic opioid therapy preoperatively. The preoperative opioid group compared with the non-opioid group had a greater proportion of females (53% vs. 40%), younger mean age (63 yrs vs. 65 yrs), higher frequency of preoperative benzodiazepine prescription (20% vs. 11%), longer average in-hospital length of stay (3.7 d vs. 3.2 d), and longer duration on postoperative opioids (211 d vs. 79 d). CONCLUSION: Patients on chronic opioids prior to spine surgery are more likely to have a longer hospital stay and continue on opioids for a longer time after surgery, compared with patients not on chronic opioid therapy. Spine surgeons and pain specialists should seek to identify patients on chronic opioids before surgery and evaluate strategies to optimize pain management in the pre- and postoperative course. LEVEL OF EVIDENCE: 3.

National Trends in the Surgical Management of Lumbar Spinal Stenosis in Adult Spinal Deformity Patients.

STUDY DESIGN: This is a retrospective analysis of national administrative hospital data. OBJECTIVE: This study examines national trends in the surgical management of lumbar spinal stenosis (LSS) in patients with and without coexisting scoliosis between 2010 and 2014. The study also examines revision rates for LSS procedures. SUMMARY OF BACKGROUND DATA: There is wide variability in the surgical management of patients with LSS, with and without coexisting spinal deformity. METHODS: Data were obtained from the Healthcare Cost and Utilization Project's National Inpatient Sample Database. International Classification of Diseases 9th revision- Clinical Modification codes were used to identify all patients with a primary diagnosis of lumbar spinal stenosis. These patients were divided into two groups: 1) LSS alone and 2) LSS with coexisting scoliosis. The two groups were examined for one of three surgical outcomes: 1) decompression alone (discectomy, laminectomy), 2) simple fusion, and 3) complex fusion (>three vertebrae or 360° fusion). The groups were then further examined for revision operations. National Inpatient Sample discharge weights were applied where relevant. RESULTS: In 2014 national estimates of discharged patients indicated 76,275 patients with a primary diagnosis of LSS (population rate, 23.9; in the elderly (65+) the age-adjusted population rate was 95.4). Of these patients, 88.5% were managed through primary surgery (34.6% decompression, 47.2% simple fusion, 5.7% complex fusion). Between 2010 and 2014, the percentage of decompression decreased from 47.5% to 34.6%, the percent of simple fusion increased from 35.3% to 47.2%, and the percent of complex fusion increased from 5.7% to 7.1% (P < 0.01). In patients with coexisting scoliosis, lumbar spinal stenosis was predominantly managed by simple fusion and complex fusion (15.5% decompression, 51.9% simple fusion, 27.3% complex fusion, in 2014). Revision rates were highest among patients without scoliosis managed with complex fusion (15.8% in 2014) compared with patients with scoliosis (8.8% in 2014). Patients with scoliosis who underwent decompression only had revision rates of 1.7% and 0.62% in 2010 and 2014, respectively. CONCLUSION: We observed a leveling-off of the rate of operation for patients with a primary diagnosis of LSS at around 88%. There was an increase in the rate of fusion and a decrease in the rate of decompression across all patient groups. We report no difference in revision rates between patients with and without scoliosis, except in those undergoing a complex fusion. LEVEL OF EVIDENCE: 3.

Effect of Curcumin on the Formation of Epidural Fibrosis in an Experimental Laminectomy Model in Rats.

AIM: To clarify the effects of topical application of curcumin on the prevention of epidural fibrosis. MATERIAL AND METHODS: Twenty-one rats were randomly divided into three equal groups (control, spongostan, local curcumin) and a laminectomy procedure was performed between T11 and L1 in all rats. Subsequently, spongostan soaked with curcumin (100 mg/kg) was applied topically. After four weeks, the vertebral column from T9 to L3, which included the paraspinal muscles and epidural scar tissue, was removed as a single piece and the epidural fibrosis and arachnoidal scarring were graded and histopathological analysis carried out accordingly. Kruskal-Wallis and Pearson Chi-Square tests were used for statistical analysis. A p-value of less than 0.05 was considered to be significant. RESULTS: The grading of epidural fibrosis was far lower in the experimental group with curcumin compared to the control and spongostan groups, but the difference was not statistically significant. CONCLUSION: The findings of this study show that local curcumin decreases the formation of epidural fibrosis and this effect of curcumin is thought to be mediated by reducing the functions of inflammatory cells such as macrophages, neutrophils and fibroblasts, and the anti-inflammatory and antioxidant effects.

Management of Chiari I malformations: a paradigm in evolution.

PURPOSE: Despite decades of experience and research, the etiology and management of Chiari I malformations (CM-I) continue to raise more questions than answers. Controversy abounds in every aspect of management, including the indications, timing, and type of surgery, as well as clinical and radiographic outcomes. This review aims to outline past experiences, consolidate current evidence, and recommend directions for the future management of the Chiari I malformation. METHODS: A review of recent literature on the management of CM-I in pediatric patients is presented, along with our experience in managing 1073 patients who were diagnosed with CM-I over the past two decades (1998-2018) at Children's National Medical Center (CNMC) in Washington DC. RESULTS: The general trend reveals an increase in the diagnosis of CM-I at younger ages with a significant proportion of these being incidental findings (0.5-3.6%) in asymptomatic patients as well as a rise in the number of patients undergoing Chiari posterior fossa decompression surgery (PFD). The type of surgical intervention varies widely. At our institution, 104 (37%) Chiari surgeries were bone-only PFD with/without outer leaf durectomy, whereas 177 (63%) were PFD with duraplasty. We did not find a significant difference in outcomes between the PFD and PFDD groups (p = 0.59). An analysis of failures revealed a significant difference between patients who underwent tonsillar coagulation versus those whose tonsils were not manipulated (p = 0.02). CONCLUSION: While the optimal surgical intervention continues to remain elusive, there is a shift away from intradural techniques in favor of a simple, extradural approach (including dural delamination) in pediatric patients due to high rates of clinical and radiographic success, along with a lower complication rate. The efficacy, safety, and necessity of tonsillar manipulation continue to be heavily contested, as evidence increasingly supports the efficacy and safety of less tonsillar manipulation, including our own experience.

Unilateral laminectomy for bilateral decompression improves low back pain while standing equally on both sides in patients with lumbar canal stenosis: analysis using a detailed visual analogue scale.

BACKGROUND: Unilateral laminectomy for bilateral decompression (ULBD) for lumbar spinal stenosis (LSS) is a less invasive technique compared to conventional laminectomy. Recently, several authors have reported favorable results of low back pain (LBP) in patients of LSS treated with ULBD. However, the detailed changes and localization of LBP before and after ULBD for LSS remain unclear. Furthermore, unsymmetrical invasion to para-spinal muscle and facet joint may result in the residual unsymmetrical symptoms. To clarify these points, we conducted an observational study and used detailed visual analog scale (VAS) scores to evaluate the characteristics and bilateral changes of LBP and lower extremity symptoms. METHODS: We included 50 patients with LSS treated with ULBD. A detailed visual analogue scale (VAS; 100 mm) score of LBP in three different postural positions: motion, standing, and sitting, and bilateral VAS score (approached side versus opposite side) of LBP, lower extremity pain (LEP), and lower extremity numbness (LEN) were measured. Oswestry Disability Index (ODI) was used to quantify the clinical improvement. RESULTS: Detailed LBP VAS score before surgery was 51.5 ± 32.5 in motion, 63.0 ± 30.1 while standing, and 37.8 ± 31.8 while sitting; and showed LBP while standing was significantly greater than LBP while sitting (p < 0.01). After surgery, LBP while standing was significantly improved relative to that while sitting (p < 0.05), and levels of LBP in the three postures became almost the same with ODI improvement. Bilateral VAS scores showed significant improvement equally on both sides (p < 0.01). CONCLUSIONS: ULBD improves LBP while standing equally on both sides in patients with LCS. The improvement of LBP by the ULBD surgery suggests radicular LBP improved because of decompression surgery. Furthermore, the symmetric improvement of LBP by the ULBD surgery suggests unsymmetrical invasion of the paraspinal muscles and facet joints is unrelated to residual LBP.

Changes in sagittal alignment after surgical excision of thoracic spinal cord tumors in adults.

STUDY DESIGN: Retrospective chart audit. OBJECTIVES: This study investigated changes in sagittal alignment in adults after excision of thoracic spinal cord tumors without spinal fixation. SETTING: Single-center study at an academic orthopedic department in Japan. METHODS: We retrospectively reviewed records for 32 adults who underwent excision of thoracic spinal cord tumors by multilevel laminectomies without fixation. The participants were divided according to whether the tumor was in the upper (T1-4), middle (T5-8), or lower (T9-12) thoracic spine. We analyzed parameters such as age, sex, time in surgery and estimated blood loss, follow-up period, and preoperative and follow-up the Japanese Orthopaedic Association (JOA) scores and radiographs. RESULTS: Postoperative T1-12 kyphotic changes did not correlate with age, the number of resected laminae, or preoperative T1-12 kyphosis. JOA recovery rates were similar regardless of the tumor location. Participants with tumors in the upper thoracic spine had significant postoperative increases in T1-4 kyphosis, T1 slope (p < .05, respectively). In contrast, there were no significant changes in alignment in participants with tumors in the middle or lower thoracic spine. CONCLUSION: Even without fixation, sagittal alignment did not change after surgery to excise tumors in the middle and lower thoracic spine, indicating that fixation may not be necessary when excising spinal cord tumors in this region. In contrast, postoperative kyphosis may increase when the tumor is in the upper thoracic spine.

Complications of Poor Cervical Alignment in Patients Undergoing Posterior Cervicothoracic Laminectomy and Fusion.

OBJECTIVE: This study sought to determine whether a relationship exists between caudal instrumented level and revision rates, neck disability index scores, and cervical alignment in patients undergoing multilevel posterior cervical fusion. METHODS: This study examined a dataset of all patients undergoing posterior cervical decompression and fusion at ≥3 levels, terminating between C4 and T4, between January 2010 and December 2015, with at least 12 months of clinical follow-up. Patients were separated into cohorts based on caudal level of the fusion: C6 (or more cranial), C7, T1, or T2 (or more caudal). Revision rate, neck disability index score, sagittal vertical axis, T1 slope, and cervical lordosis were recorded. Linear regression and multivariate analysis were performed to identify independent predictors of patient outcomes and disparities between ending constructs in the cervical and the thoracic spine. RESULTS: The overall revision rate was 10.8% (n = 24). No statistically significant difference in the revision rate was identified between fusions terminating at C6 or cranial, C7, T1, or T2 and caudal (P = 0.74). Revision correlated strongly with increased sagittal vertical axis (P = 0.002) and T1 slope (P = 0.04). Increased neck disability index score correlated with revision rate (P = 0.01), cervical kyphosis (P < 0.001), and increased sagittal vertical axis (P = 0.04). CONCLUSIONS: This study suggests that constructs terminating in the proximal thoracic spine have similar revision rates, postoperative neck disability index scores, and radiographic measurements as those terminating in the cervical spine. Poor cervical alignment, as evidenced by increased sagittal vertical axis, cervical kyphosis and T1 slope, predicts need for revision and of poorer clinical outcomes.

Synovial Cyst as a Marker for Lumbar Instability: A Systematic Review and Meta-Analysis.

BACKGROUND: The pathogenesis of synovial cysts is largely unknown; however, they have been increasingly thought of as markers of spinal facet instability and typically associated with degenerative spondylosis. We specifically investigated the incidence of concomitant synovial cysts with underlying degenerative spondylolisthesis. METHODS: A literature search was performed using 4 online databases to assess the association between lumbar synovial cysts and degenerative spinal pathological features. Meta-analyses were performed on the prevalence rates of coexisting degenerative spinal pathological entities and treatment modalities. A random effects model was used to calculate the mean and 95% confidence intervals. RESULTS: A total of 17 studies encompassing 824 cases met the inclusion criteria. The pooled prevalence rates of concurrent spondylolisthesis, facet arthropathy, and degenerative disc disease at the same level of the synovial cysts were 42.5% (range, 39.0%-46.1%), 89.3% (range, 79.0%-94.8%), and 48.8% (range, 43.8%-53.9%), respectively. Among these, patients with coexisting spondylolisthesis were more likely to undergo spinal fusion surgery (vs. laminectomy alone) and reoperation than were patients without spondylolisthesis with a pooled odds ratio of 11.5 (95% confidence interval, 4.5-29.1; P < 0.0001) and 2.0 (95% confidence interval, 0.9-4.2; P = 0.088), respectively. CONCLUSIONS: Patients with a combination of synovial cysts and degenerative spondylolisthesis are more likely to undergo spinal fusion surgery than laminectomy alone compared with patients with synovial cysts and no preoperative spondylolisthesis. Furthermore, patients with synovial cysts and spondylolisthesis are more likely to require additional fusion surgery. The results from the present review lend credence to the argument that synovial cyst herniation might be a manifestation of an unstable spinal level.

Is the Posterior-Only Approach Sufficient for Treating Cervical Spine Metastases? The Evidence from a Case Series.

OBJECTIVES: Few studies have evaluated surgical options in the treatment of cervical metastatic disease. The aim of this study is to report the surgical outcomes of patients treated with the posterior-only approach for metastatic cervical disease. METHODS: In this retrospective analysis, all cases treated in our institution from 2009 to 2017 were reviewed. Six (20%) patients had intracompartimental lesions (Tomita 1-3), whereas 24 (80%) patients had extracompartimental lesions (Tomita 4-7), with extensive anterior column involvement. All patients were surgically treated with laminectomy and posterior stabilization. Pain and neurologic function were evaluated before and after surgery. RESULTS: Thirty patients were included (15 female, 15 male), with a mean age of 60.6 ± 11.56 years (range 35-82 years). Lesions were located in 7 patients (23.3%) in the upper cervical spine and in 14 patients (46.6%) and in 9 patients (30,1%) in the mid-cervical and in the cervicothoracic junction, respectively. At a mean follow up of 13.7 ± 14.8 months, 15 (50%) patients died from their disease. Pain decreased in all patients after surgery, (preoperative NRS 5.57 ± 1.81 postoperative Numeric Rating Scale of 2.1 ± 1.0, P < 0.00001). Two patients (6.7%) had significant neurologic worsening after surgery. Two (6.9%) patients had surgical-site infection that required reintervention. No mechanical failures were observed. CONCLUSIONS: In our series, posterior-only fixation provided postoperative pain relief and achieve spinal stability, ultimately improving the quality of life. In conclusion, posterior-approach decompression and stabilization is a safe and feasible procedure in patients with neurologic or mechanical instability for cervical spine metastasis.