Is neck pain treatable with surgery?

INTRODUCTION: Neck pain is one of the most common complaints in clinical practice and can be caused by a wide variety of conditions. While cervical spine surgery is a well-accepted option for radicular pain and myelopathy, surgery for isolated neck pain is controversial. The identification of the source of pain is challenging and subtle, and misdiagnosis can lead to inappropriate treatment. MATERIALS AND METHODS AND RESULTS: We conducted a thorough literature review to discuss and compare different causes of neck pain. We then supplemented the literature with our senior author's expert analysis of treating cervical spine pathology. CONCLUSIONS: This study provides an in-depth discussion of neck pain and its various presentations, as well as providing insight into treatment strategies and diagnostic pearls that may prevent mistreatment of cervical spine pathology.

Think and Talk Like You Went to Business School.

Most orthopaedic surgeons do not have formal training in business education. We have learned that success comes to those who study hard, choose the correct answer on multiple-choice tests, and focus on patient care and operating. In contrast, business school graduates learned that success comes to those who apply interpersonal skills to build relationships and trust, in addition to taking risks. Medical school and business school teach one to confront the "real world" with quite a different perspective. In this manuscript, we will touch on a few things that we can learn from business school graduates.

Revision of Harrington rod constructs: a single-center's experience with this homogenous adult spinal deformity population at a minimum 2-year follow-up.

PURPOSE: To evaluate radiographic and clinical outcomes following revision surgery after HRC fusions. METHODS: Single-institution, retrospective study of patients revised following HRC with minimum 2-year follow-up post-revision. Demographics, perioperative information, radiographic parameters, complications, and Oswestry disability index (ODI) scores were collected. Radiographic parameters included global alignment, coronal and sagittal measurements pre and postoperatively, as well as final follow-up time points. RESULTS: 26 patients were included with a mean follow-up of 3.3 ± 1.1 years. Mean age was 55.5 ± 7.8 years, BMI 25.2 ± 5.8, and 22 (85%) were females. Instrumented levels increased from 9.7 ± 2.8 to 16.0 ± 2.2. Five (19.2%) patients underwent lumbar pedicle subtraction osteotomies, and 23 (88.4%) had interbody fusions. Patients significantly improved in all radiographic parameters at immediate and final follow-up (p < 0.005), except for thoracic kyphosis and pelvic incidence (p > 0.05). Correction was maintained from immediate postop to final follow-up (p > 0.05). 20 (76.9%) of patients experienced a complication at some point within the follow-up period with the most common being a lumbar nerve root deficit (n = 7). However, only one patient had a nerve root deficit at final follow-up, that being a 4/5 unilateral anterior tibialis function. 5 (19.2%) patients required further revision within a mean of 1.8 ± 1.1 years. On average, patients had an improvement in ODI score by final follow-up (35.6 ± 16.8 vs 25.4 ± 19.8, p = 0.035). CONCLUSION: Patients revised for HRCs significantly improve, both clinically and radiographically by final follow-up. This group did have a propensity for distal lumbar root neurological issues, which were common but all patients except for one, recovered to full strength by two-year follow-up.

Outcomes and reoperation rates of adult spinal deformity patients with baseline sagittal malalignment based on the cranial axis to the hip at 2 years postoperatively.

OBJECTIVE: The aim of this study was to discern whether patients with a cranial sagittal vertical axis to the hip (CrSVA-H) > 2 cm at 2 years postoperatively exhibit significantly worse patient-reported outcomes (PROs) and clinical outcomes compared with patients with CrSVA-H < 2 cm. METHODS: This was a retrospective, 1:1 propensity score-matched (PSM) study of patients who underwent posterior spinal fusion for adult spinal deformity. All patients had a baseline sagittal imbalance of CrSVA-H > 30 mm. Two-year patient-reported and clinical outcomes were assessed in unmatched and PSM cohorts, including Scoliosis Research Society-22r (SRS-22r) and Oswestry Disability Index scores as well as reoperation rates. The study compared two cohorts based on 2-year alignment: CrSVA-H < 20 mm (aligned cohort) vs CrSVA-H > 20 mm (malaligned cohort). For the matched cohorts, binary outcome comparisons were carried out using the McNemar test, while continuous outcomes used the Wilcoxon rank-sum test. For unmatched cohorts, categorical variables were compared using chi-square/Fisher's tests, while continuous outcomes were compared using Welch's t-test. RESULTS: A total of 156 patients with mean age of 63.7 (SEM 1.09) years underwent posterior spinal fusion spanning a mean of 13.5 (0.32) levels. At baseline, the mean pelvic incidence minus lumbar lordosis mismatch was 19.1° (2.01°), the T1 pelvic angle was 26.6° (1.20°), and the CrSVA-H was 74.9 (4.33) mm. The mean CrSVA-H improved from 74.9 mm to 29.2 mm (p < 0.0001). At the 2-year follow-up, 129 (78%) of 164 patients achieved CrSVA-H < 2 cm (aligned cohort). Patients who had CrSVA-H > 2 cm (malaligned cohort) at the 2-year follow-up had worse preoperative CrSVA-H (p < 0.0001). After performing PSM, 27 matched pairs were generated. In the PSM cohort, the aligned and malaligned cohorts demonstrated comparable preoperative patient-reported outcomes (PROs). However, at the 2-year postoperative follow-up, the malaligned cohort reported worse outcomes in SRS-22r function (p = 0.0275), pain (p = 0.0012), and mean total score (p = 0.0109). Moreover, when patients were stratified based on their magnitude of improvement in CrSVA-H (< 50% vs > 50%), patients with > 50% improvement in CrSVA-H had superior outcomes in SRS-22r function (p = 0.0336), pain (p = 0.0446), and mean total score (p = 0.0416). Finally, patients in the malaligned cohort had a higher 2-year reoperation rate (22% vs 7%; p = 0.0412) compared with patients in the aligned cohort. CONCLUSIONS: Among patients who present with forward sagittal imbalance (CrSVA-H > 30 mm), patients with CrSVA-H exceeding 20 mm at the 2-year postoperative follow-up have inferior PROs and higher reoperation rates.

Chronic Warfarin Anticoagulation in Hip Fracture Patients Delays Surgery and Is Associated With Increased Risk of Postoperative Complications: A Multicenter Propensity-Score-Matched Analysis.

OBJECTIVE: To evaluate the effect of warfarin on blood transfusion and postoperative complications in a low-energy hip fracture population compared with a non-anticoagulated comparison group. DESIGN: Multicenter Retrospective Cohort. SETTING: Three Urban Level I Academic Trauma Centers. PATIENTS: Acute, low-energy, native hip fractures in patients 55 years of age or older on chronic warfarin anticoagulation, propensity score matched 1:2 to non-anticoagulated hip fracture patients meeting all other inclusion criteria. MAIN OUTCOME MEASUREMENTS: Transfusion and postoperative complication rates. RESULTS: Two hundred ten anticoagulated hip fracture patients were matched to 420 nonanticoagulated patients. A higher proportion of patients required blood transfusion in the warfarin cohort (52.4% vs. 43.3%, P < 0.001), attributable mostly to the subgroup of patients undergoing arthroplasty. Warfarin patients had higher incidence of overall 90-day complications (47% vs. 38%, P = 0.039) and readmissions (31.4% vs. 8.9%, P < 0.001). Day of surgery international normalized ratio (INR) did not influence transfusions or complications among warfarin patients. Warfarin patients undergoing surgery within 24 hours had no difference in transfusions and had fewer complications compared with those undergoing surgery after 24 hours. On multivariable logistic regression analysis, warfarin use and day of surgery INR were not predictors of transfusion or complications. CONCLUSIONS: Patients on warfarin experienced longer time to surgery and higher incidence of overall transfusion and postoperative complications within 90 days of surgery. However, warfarin use and day of surgery INR was not independently associated with transfusions or complications. The reason for poorer outcomes in warfarin patients remains a topic of further investigation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Stem Cells and Spinal Fusion.

BACKGROUND: This manuscript is a review of the literature investigating the use of mesenchymal stem cells (MSCs) being applied in the setting of spinal fusion surgery. We mention the rates of pseudarthrosis, discuss current bone grafting options, and examine the preclinical and clinical outcomes of utilizing MSCs to assist in successfully fusing the spine. METHODS: A thorough literature review was conducted to look at current and previous preclinical and clinical studies using stem cells for spinal fusion augmentation. Searches for PubMed/MEDLINE and ClinicalTrials.gov through January 2021 were conducted for literature mentioning stem cells and spinal fusion. RESULTS: All preclinical and clinical studies investigating MSC use in spinal fusion were examined. We found 19 preclinical and 17 clinical studies. The majority of studies, both preclinical and clinical, were heterogeneous in design due to different osteoconductive scaffolds, cells, and techniques used. Preclinical studies showed promising outcomes in animal models when using appropriate osteoconductive scaffolds and factors for osteogenic differentiation. Similarly, clinical studies have promising outcomes but differ in their methodologies, surgical techniques, and materials used, making it difficult to adequately compare between the studies. CONCLUSION: MSCs may be a promising option to use to augment grafting for spinal fusion surgery. MSCs must be used with appropriate osteoconductive scaffolds. Cell-based allografts and the optimization of their use have yet to be fully elucidated. Further studies are necessary to determine the efficacy of MSCs with different osteoconductive scaffolds and growth/osteogenic differentiation factors. LEVEL OF EVIDENCE: 3.

Surgical Site Infection Following Neuromuscular Posterior Spinal Fusion Fell 72% After Adopting the 2013 Best Practice Guidelines.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study is to investigate the incidence of surgical site infection in neuromuscular scoliosis (NMS) patients at a tertiary children's hospital before and after the implementation of strategies mentioned in the 2013 Best Practice Guideline. SUMMARY OF BACKGROUND DATA: Patients with NMS are at high risk for surgical site infection following spine surgery. In 2013, a Best Practice Guideline for surgical site infection prevention in high-risk pediatric spine surgery patients reported strategies to decrease incidence. To date, no studies have looked at the efficacy of these strategies. METHODS: A retrospective review of surgical site infection in NMS patients was performed. NMS patients undergoing primary posterior spinal fusion from January 2008 to December 2012 (Group 1) and January 2014 to December 2018 (Group 2) were included, with 2013 excluded as a transition year. The primary outcome was incidence of surgical site infection within 1 year of surgery, as defined by the Centers for Disease Control and National Healthcare Safety Network. All patients had at least 1 year of documented follow-up. RESULTS: One hundred ninety eight patients were included, 62 in Group 1 and 136 in Group 2. Age, BMI, sex, fusion to pelvis, preoperative Cobb angle, incontinence, drain use, blood loss, surgical time, and other perioperative values were similar (P > 0.05). Deep surgical site infection occurred in 10 (16.1%) patients in Group 1 and six (4.4%) patients in Group 2 (P = 0.005). Thirteen (59.1%) identified organisms were gram-negative, with 11 (84.6%) isolated from Group 1 (P = 0.047). Polymicrobial infections accounted for six (37.5%) infections overall. CONCLUSION: The incidence of surgical site infection in NMS patients decreased significantly (16.1% vs. 4.4%) after the implementation of the strategies mentioned in the 2013 Best Practice Guideline. Further studies are required to continue to decrease the incidence in this high-risk population.Level of Evidence: 3.

C1-C2 Distraction Ligamentous Injury Treated with Halo-Vest Application: A Case Report.

CASE: There is a paucity of literature regarding pediatric upper cervical spine traumatic instability, atlanto-occipital dislocations, and fractures, with no clear treatment algorithm. We present a 12-year-old girl with significant posterior C1-C2 distraction and resultant ligamentous injury after a motor vehicle collision who was treated with a halo vest for 3 months. At 8-month follow-up, follow-up magnetic resonance imaging demonstrated complete ligamentous healing without instability on dynamic radiographs, and at 18-month follow-up, the patient made a full recovery. CONCLUSION: In some pediatric patients with isolated posterior ligamentous injury, as long as anatomic alignment can be achieved with halo-vest application, a fusion may be avoided.

Severe Chin-on-Chest Cervical Spine Deformity in the Setting of Stiff-Person Syndrome: A Case Report.

CASE: Stiff-person syndrome (SPS) presents with progressive muscle rigidity, postural instability, and periodic debilitating spasms. Reports of axial hyperextension exist, but kyphotic deformities have not been described. We surgically treated a patient with debilitating SPS and severe cervicothoracic hyperkyphosis with posterior spinal fusion and instrumentation. At 1-year follow-up, the patient displayed better upright gait and forward gaze, 18° cervical lordosis, and improved patient-reported outcome scores. CONCLUSION: SPS can lead to extreme spinal deformity and disease, including hyperkyphosis of the cervicothoracic spine, and can successfully be managed with a multidisciplinary team and a posterior-only correction with spinal instrumentation and fusion.

Fascia Iliaca Regional Anesthesia in Hip Fracture Patients Revisited: Which Fractures and Surgical Procedures Benefit Most?

OBJECTIVES: Perioperative fascia iliaca regional anesthesia (FIRA) decreases pain in hip fracture patients. The purpose of this study is to determine which hip fracture types and surgical procedures benefit most. DESIGN: Prospective observational study compared with a retrospective historical control. PATIENTS/PARTICIPANTS: Patients older than 60 years who received perioperative FIRA were compared with a historical cohort not receiving FIRA. SETTING: This study was conducted at a Level 1 trauma center. MAIN OUTCOME MEASUREMENTS: The primary outcome was morphine milliequivalents (MME) consumed during the index hospitalization. Fracture pattern-specific preoperative and postoperative MME consumption and surgical procedure-specific postoperative MME consumption was compared between the FIRA and non-FIRA groups. RESULTS: A total of 949 patients were included in this study, with 194 (20.4%) patients in the prospective protocol group. There were no baseline differences between cohorts. Preoperatively, only femoral neck fracture patients receiving FIRA used fewer MME (P < 0.001). Postoperatively, femoral neck fracture patients receiving FIRA used fewer MME on postoperative day (POD) 1 (P = 0.027) and intertrochanteric fracture patients used fewer MME on POD1 and POD2 (P = 0.013; P = 0.002). Cephalomedullary nail patients receiving FIRA used fewer MME on POD1 and POD2 (P = 0.004; P = 0.003). Hip arthroplasty patients receiving FIRA used fewer MME on POD1 (P = 0.037). Percutaneous pinning and sliding hip screw patients had no significant MME reduction from FIRA. CONCLUSIONS: Preoperatively, patients with femoral neck fractures benefit most from FIRA. Postoperatively, both patients with femoral neck fractures and intertrochanteric fractures benefit from FIRA. Patients undergoing cephalomedullary nail fixation or hip arthroplasty benefit most from FIRA postoperatively. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Comparison in Outcomes of Preoperative Single-shot versus Continuous Catheter Fascia Iliaca Regional Anesthesia in Geriatric Hip Fracture Patients.

BACKGROUND: Fascia iliaca nerve blocks relieve pain in geriatric hip fracture patients and can be administered via a single-shot or continuous catheter. We compared perioperative opioid consumption and pain scores between these two blocks. METHODS: We performed a prospective, observational cohort study, including geriatric hip fracture patients who received a preoperative block. We compared morphine milligram equivalent (MME) consumption and visual analog scale (VAS) pain scores between single-shot and continuous fascia iliaca blocks at multiple time points: preoperative and on postoperative (POD) day 0, 1, and 2. We compared the change in preoperative total and hourly opioid consumption before and after block placement within and between groups. Secondary outcomes included opioid related adverse events, length of stay, and readmission rates. RESULTS: 107 patients were analyzed, 66 received a single-shot and 41 a continuous block. No significant differences were found between both blocks at any time point for median MME consumption or pain scores. MME [IQR]: preoperative 20.5 [6.0,48.8] vs. 24.0 [8.8,48.0], p=0.95; POD0 6.0 [0.0,18.6] vs. 10.0 [0.0,14.0], p=0.52; POD1 12.0 [0.0,30.0] vs. 18.0 [5.0,24.0], p=0.69; POD2 6.0 [0.0,21.2] vs. 12.0 [0.0,24.0], p=0.54. VAS [IQR]: preoperative 4.0 [2.2,5.3] vs. 4.6 [3.2,5.3], p=0.34; POD0 1.3 [0.0,3.7] vs. 2.5 [0.0,3.6], p=0.73; POD1 2.9 [1.7,4.4] vs. 3.7 [1.5,4.7], p=0.59; POD2 2.4 [1.0,4.4] vs. 3.3 [1.9,4.2], p=0.18. Preoperative MME/hr significantly decreased after the block for both groups: 1.05 [0.0,2.2] to 0.0 [0.0,0.0], p < 0.001; 1.4 [0.6,3.1] to 0.0 [0.0,0.1], p < 0.001. The reduction in MME/hr between groups was not significantly different: 0.9 [0.0,1.9] vs. 1.4 [0.6,3.1], p = 0.067. We found no significant differences in secondary outcomes between groups. CONCLUSIONS: We report no differences in opioid use and pain scores between single-shot and continuous catheter fascia iliaca nerve blocks. Both blocks similarly reduce preoperative opioid consumption.

Time to Block: Early Regional Anesthesia Improves Pain Control in Geriatric Hip Fractures.

BACKGROUND: Fascia iliaca nerve blocks (FIBs) anesthetize the thigh and provide opioid-sparing analgesia for geriatric patients with hip fracture awaiting a surgical procedure. FIBs are recommended for preoperative pain management; yet, block administration is often delayed for hours after admission, and delays in pain management lead to worse outcomes. Our objective was to determine whether opioid consumption and pain following a hip fracture are affected by the time to block (TTB). We also examined length of stay and opioid-related adverse events. METHODS: This prospective cohort study included patients who were ≥60 years of age, presented with a hip fracture, and received a preoperative FIB from March 2017 to December 2017. Individualized care timelines, including the date and time of admission, block placement, and surgical procedure, were created to evaluate the effect that TTB and time to surgery (TTS) had on outcomes. Patterns among TTB, TTS, and morphine milligram equivalents (MME) were investigated using the Spearman rho correlation. For descriptive purposes, we divided patients into 2 groups based on the median TTB. Multivariable regression for preoperative MME and length of stay was performed to assess the effect of TTB. RESULTS: There were 107 patients, with a mean age of 83.3 years, who received a preoperative FIB. The median TTB was 8.5 hours. Seventy-two percent of preoperative MME consumption occurred before block placement (pre-block MME). A longer TTB was most strongly correlated with pre-block MME (rho = 0.54; p < 0.001), and TTS was not correlated. Patients with a faster TTB consumed fewer opioids preoperatively (12.0 compared with 33.1 MME; p = 0.015), had lower visual analog scale scores for pain on postoperative day 1 (2.8 compared with 3.5 points; p = 0.046), and were discharged earlier (4.0 compared with 5.5 days; p = 0.039). There were no differences in preoperative pain scores, postoperative opioid consumption, delirium, or opioid-related adverse events. Multivariate regression showed that every hour of delay in TTB was associated with a 2.8% increase in preoperative MME and a 1.0% increase in the length of stay. CONCLUSIONS: Faster TTB in geriatric patients with hip fracture may reduce opioid use, pain, and length of stay. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The Utility of Pulmonary Function Testing in Patients Presenting With Dysphonia.

OBJECTIVE: We aimed to evaluate the utility of pulmonary function testing (PFT), particularly forced expiratory flow (FEF) 25-75%, in patients presenting with dysphonia. STUDY DESIGN: A retrospective chart review was carried out. METHODS: Records of 199 patients who presented with dysphonia were reviewed to determine whether in-office PFTs, which we perform routinely, lead to new pulmonary diagnoses or the need for additional pulmonary medications, after assessment by a pulmonologist. Of particular interest was evaluating if FEF25-75% of predicted values less than 80% can be used as a marker for occult pulmonary disease in patients presenting with dysphonia. RESULTS: Of the 199 patient charts reviewed, 129 were female and 70 were male. The age of patients ranged from 18 to 88 years, with a mean of 46.8 years. The body mass index ranged from 17.5 to 53.4 kg/m2. One hundred five (52.8%) patients had FEF25-75% values less than 80% of predicted (poor midflow values). Of these patients, 76 (72.4%) were referred to a pulmonologist, 22 of 76 (28.9%) completed the referral, and 17 of 22 (77.3%) received a new pulmonary diagnosis or change in medications. Of the 155 patients without a history of pulmonary disease, 76 had poor midflow values, 57 (75%) of these patients were referred, and 12 of 57 (21%) completed the referral. Eight (67%) of these 12 patients were diagnosed with a previously unrecognized pulmonary disorder. Of the 44 patients with a prior history of pulmonary disease, 29 (65.9%) had poor midflow values. Nineteen (65.5%) of these patients were referred, and 9 (47%) received a new pulmonary diagnosis or a change in their medications. There were 51 classically trained singers and 148 nonclassically trained singers or nonsingers. There was no significant difference in average midflow values between the two groups (80.96 ± 24.7 and 80.73 ± 28.4, respectively) or in the percentage of classically trained singers with poor midflow values compared with nonsingers (53.5% vs. 49%, respectively). CONCLUSION: This study suggests that patients with dysphonia may have unrecognized underlying pulmonary disease, and PFT should be considered as part of the routine initial voice evaluation for patients presenting with dysphonia.

Pigmented Villonodular Synovitis: A Comprehensive Review and Proposed Treatment Algorithm.

Evidence now exists suggesting a neoplastic origin for pigmented villonodular synovitis, including a thorough description of the translocations involved. Arthroscopic excision for localized pigmented villonodular synovitis allows for both minimal recurrence and morbidity when compared with open excision; however, open excision still plays an important role in treating posterior compartment nodules. The optimal surgical treatment for diffuse pigmented villonodular synovitis is still a matter for debate, with combined anterior arthroscopic and open posterior excision being considered the preferred method. Radiation therapy has re-emerged as an additional treatment method for pigmented villonodular synovitis; however, the potential for serious toxicity makes it a questionable option, especially for such a benign condition. Small molecule and monoclonal antibody targeted therapies are being investigated as novel treatment methods for pigmented villonodular synovitis, with promising results.