Level Anterior Cervical Discectomy Research Articles

Predictors of patient satisfaction following 1- or 2-level anterior cervical discectomy and fusion: insights from the Quality Outcomes Database.

Patient satisfaction with treatment outcome is gaining an increasingly important role in assessing the value of surgical spine care delivery. Nationwide data evaluating the predictors of patient satisfaction in elective cervical spine surgery are lacking. The authors sought to decipher the impacts of the patient, surgical practice, and surgeon on satisfaction with outcome following anterior cervical discectomy and fusion (ACDF). The authors queried the Quality Outcomes Database for patients undergoing 1- to 2-level ACDF for degenerative spine disease since 2013. Patient satisfaction with the surgical outcome as measured by the North American Spine Society (NASS) scale comprised the primary outcome. A multivariable proportional odds logistic regression model was constructed with adjustments for baseline patient characteristics and surgical practice and surgeon characteristics as fixed effects. A total of 4148 patients (median age 54 years, 48% males) with complete 12-month NASS satisfaction data were analyzed. Sixty-seven percent of patients answered that "surgery met their expectations" (n = 2803), while 20% reported that they "did not improve as much as they had hoped but they would undergo the same operation for the same results" (n = 836). After adjusting for a multitude of patient-specific as well as hospital- and surgeon-related factors, the authors found baseline Neck Disability Index (NDI) score, US geographic region of hospital, patient race, insurance status, symptom duration, and Workers' compensation status to be the most important predictors of patient satisfaction. The discriminative ability of the model was satisfactory (c-index 0.66, overfitting-corrected estimate 0.64). The authors' results found baseline NDI score, patient race, insurance status, symptom duration, and Workers' compensation status as well as the geographic region of the hospital to be the most important predictors of long-term patient satisfaction after a 1- to 2-level ACDF. The findings of the present analysis further reinforce the role of preoperative discussion with patients on setting treatment goals and realistic expectations.

39. Anterior cervical discectomy and fusions (ACDFs) at physician-owned hospitals: is it time to reconsider the sanctions of the Affordable Care Act (ACA)?

BACKGROUND CONTEXT Due to concerns regarding higher cost and low quality of care provided in physician-owned hospitals, the Affordable Care Act (ACA) imposed sanctions that prevented the formation of new physician-owned hospitals and limited expansion of current facilities. With the demand of spine care growing across the United States, there is a need for re-evaluation and assessment of quality of spine surgical care provided at these physician-owned hospitals. PURPOSE The current study utilizes a national Medicare dataset to assess whether elective 1- to 3-level anterior cervical discectomy and fusions (ACDFs) being performed at physician-owned hospitals are safe and cost-efficacious as compared to non-physician-owned hospitals. STUDY DESIGN/SETTING Retrospective review of 100% Medicare Claims Database. PATIENT SAMPLE The 2005-2014 Medicare 100% Standard Analytical Files (SAF100) was queried using International Classification of Diseases 9th Edition (ICD-9) procedure code for patients undergoing elective 1- to 3-level ACDFs (81.02 and 81.62). The Medicare Hospital Compare database was used to identify provider codes for physician-owned hospitals and were cross-referenced to identify records of patients receiving elective ACDFs at these hospitals from the SAF100 database. OUTCOME MEASURES Ninety-day complications, readmissions, and costs. METHODS Multivariate logistic and linear regression analyses were used to assess significant differences in 90-day complications, readmissions and costs between the two groups, while controlling for age, gender, region, hospital factors (socioeconomic status area, urban vs rural location and volume) and Elixahuser Comorbidity Index. RESULTS After controlling for age, gender, region, hospital factors (socioeconomic status area, urban vs rural location and volume) and ECI, undergoing ACDFs at physician-owned hospital was associated with lower odds of cardiac complications (OR 0.80 [95% CI 0.73-0.86]; p CONCLUSIONS The results of the study suggest that elective 1- to 3-level ACDFs at physician owned hospitals have significant cost-savings (over $1,900/case), while having lower odds of experiencing 90-day medical complications and readmissions. The findings call into the need for revaluation/reconsideration of the ACAs restriction on the expansion of these physician-owned hospitals. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

219. Evaluation of health related quality of life improvement in patients undergoing spine vs adult reconstructive surgery

BACKGROUND CONTEXT The discussion regarding value based care has evolved in recent years, yet the ability to report Health Related Quality of Life (HRQoL) between different disease states has been limited by lack of validated standardized metrics to compare them. The recent advent of computer adaptive Patient Reported Outcome Information System (PROMIS), which allows for standardized assessment across health conditions, provides the ability to compare differing disease states and procedures. PURPOSE To compare baseline and postoperative PROMIS scores for patients undergoing common single-level spinal surgery procedures, total hip arthroplasty (THA) and total knee arthroplasty (TKA). STUDY DESIGN/SETTING Retrospective clinical cohort study of patients undergoing common single-level spine surgery procedures, THA and TKA at 6-month postoperative follow-up. PATIENT SAMPLE A total of 505 orthopedic surgical patients were included who underwent either: single level anterior cervical discectomy and fusion (ACDF, N=37), lumbar laminectomy (Lami, N=31), microscopic lumbar discectomy (MLD, N=58), transforaminal lumbar interbody fusion (TLIF, N=46), total hip arthroplasty (THA, N=131), or total knee arthroplasty (TKA, N=202) at a single institution. OUTCOME MEASURES Baseline (BL) and 6 month (6M) PROMIS metrics (Physical Function, Pain Interference, Pain Intensity). Patients were compared by T-values, which is age and gender adjusted to give a normal distribution of the general population, as the mean is scored at 50, and each 10 point deviation reflects 1SD of the population in improving or worsening function. METHODS Patients>18 years old who underwent spine surgery (ACDF, Lami, MLD, TLIF) or adult reconstruction surgery (THA or TKA) with BL & 6M PROMIS scores of physical function, pain interference and pain intensity were separately grouped based on surgery type. Paired t-tests compared differences in BL, 6M and the change in PROMIS scores for spine vs adult reconstruction procedures. RESULTS A total of 172 spine surgery patients (age=54.6±15.6; 42.9% female) and 333 adult reconstruction patients were compared (age=65.8±9.5; 59.8% female). Spine surgery patients were significantly younger (p CONCLUSIONS Patients undergoing single level spinal surgery had lower initial and 6 month postoperative PROMIS scores compared to those undergoing total hip and knee arthroplasty. All procedure cohorts demonstrated meaningful improvement after orthopaedic surgical treatment, but spinal surgery patients demonstrated more improvement in physical function and pain interference scores compared to arthroplasty patients. Future study is required to assess the value base of spinal and adult reconstruction surgery, including durability. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Is allograft a more reliable treatment option than autograft in 2-level anterior cervical discectomy and fusion with plate fixation?

This study aimed to assess the efficacy of allograft in 2-level anterior cervical discectomy and fusion (ACDF) with plate fixation by comparing its clinical and radiological outcomes to those of autograft.Thirty five patients with femur cortical allografts and 32 patients with tricortical iliac autografts were evaluated. All surgeries were performed by a single senior surgeon. During routine follow-up (at 3 months, 6 months, and annually after the surgery), the fusion rate, subsidence rate, and fused segmental lordosis angle were assessed by radiologic evaluation. Clinical outcomes were assessed using the visual analog scale (VAS), neck disability index (NDI) scores, and Odom criteria. This study was conducted using the results of the 2-year postoperative follow-up.Among 67 patients, 62 (92.5%) showed successful bone fusion at 2 years postoperatively: 91.4% (32/35) in the allograft group and 93.8% (30/32) in the autograft group. The fusion rate was 37.1% (13/35) in the allograft group and 68.8% (23/32) in the autograft group at 6 months and 68.5% (24/35) in the allograft group and 93.8% (30/32) in autograft group at 1 year. Eight (72.7%) of the remaining 11 patients with allograft achieved bone fusion without any intervention at the 2-year follow-up. The fusion was achieved faster in the autograft group than in the allograft group (P = .003). There was no significant difference in the subsidence rate or change in the fused segmental lordosis angle between the 2 groups; there was also no significant difference in clinical outcomes (NDI scores, VAS scores, Odom criteria) between the 2 groups. However, the intraoperative blood loss was significantly greater in the autograft group, and the operative time was also significantly longer in the autograft group (P < .001). In the autograft group, 6 patients (18.8%) had minor complications at the donor site.In 2-level ACDF with plate fixation, the radiologic and clinical outcomes of autograft and allograft were similar at 2-year follow-up, although fusion was observed earlier in the autograft group.

Rate of Return to Military Active Duty After Single and 2-Level Anterior Cervical Discectomy and Fusion: A 4-Year Retrospective Review.

Over the years of rigorous of military service, military personnel may experience cervical spondylosis and radiculopathy. Given the frequency of this occurrence, the capacity to return to unrestricted full duty in the military after anterior cervical discectomy and fusion (ACDF) is worthy of analysis. To identify the rate of return to full, unrestricted active duty after single and 2-level anterior cervical discectomy, and fusion surgery in military personnel. A retrospective chart review was performed at a tertiary care military treatment facility for all active duty personnel who underwent a single or 2-level ACDF over a 4-yr period. Patient and procedural data were collected to include single or 2-level fusion, indication for surgery, fusion level, tobacco use, age, and military rank. Fischer's Exact and Wilcoxon Rank Sum tests were used to identify statistically significant differences in the rate of return to active duty. A total of 132 anterior cervical discectomy and fusions were analyzed. One hundred sixteen patients (88%) were able to return to unrestricted full active duty, while the remaining 16 required separation from the military for continued pain or disability. The return to active duty rate was significantly higher in service members with a rank of E7 or above (99%) than those E6 and below (73%). There was a strong association between the presence of a pseudoarthrosis and the capacity to return to full duty (P=.013). Both single and 2-level ACDFs have high overall success with an 88% rate of return to full duty.

Outpatient and inpatient readmission rates of 3- and 4-level anterior cervical discectomy and fusion surgeries.

With the costs related to the United States medical system constantly rising, efforts are being made to turn traditional inpatient procedures into outpatient same-day surgeries. In this study the authors looked at the various comorbidities and perioperative complications and their impact on readmission rates of patients undergoing outpatient versus inpatient 3- and 4-level anterior cervical discectomy and fusion (ACDF). This was a retrospective study of 337 3- and 4- level ACDF procedures in 332 patients (5 patients had both primary and revision surgeries that were included in this total of 337 procedures) between May 2012 and June 2017. In total, 331 procedures were analyzed, as 6 patients were lost to follow-up. Outpatient surgery was performed for 299 procedures (102 4-level procedures and 197 3-level procedures), and inpatient surgery was performed for 32 procedures (11 4-level procedures and 21 3-level procedures). Age, sex, comorbidities, number of fusion levels, pain level, and perioperative complications were compared between both cohorts. Analysis was performed for 331 3- and 4-level ACDF procedures done at 6 different hospitals. The overall 30-day readmission rate was 1.2% (outpatient 3 [1.0%] vs inpatient 1 [3.1%], p = 0.847). Outpatients had increased readmission risk, with comorbidities of coronary artery disease (OR 1.058, p = 0.039), autoimmune disease (OR 1.142, p = 0.006), diabetes (OR 1.056, p = 0.001), and chronic kidney disease (OR 0.933, p = 0.035). Perioperative complications of delirium (OR 2.709, p < 0.001) and surgical site infection (OR 2.709, p < 0.001) were associated with increased risk of 30-day hospital readmission in outpatients compared to inpatients. This study demonstrates the safety and effectiveness of 3- and 4-level ACDF surgery, although various comorbidities and perioperative complications may lead to higher readmission rates. Patient selection for outpatient 3- and 4-level ACDF cases might play a role in the safety of performing these procedures in the ambulatory setting, but further studies are needed to accurately identify which factors are most pertinent for appropriate selection.

A Comparison of 30-Day Hospital Readmission and Complication Rates After Outpatient Versus Inpatient 1 and 2 Level Anterior Cervical Discectomy and Fusion Surgery: An Analysis of a Medicare Patient Sample

Same-day surgery has been demonstrated to be a safe and cost-effective alternative to traditional inpatient surgery. Several studies have demonstrated no differences in the postoperative complication profile or 30-day hospital readmission rates with outpatient versus inpatient anterior cervical discectomy and fusion (ACDF). However, none of these studies compared the outcomes in elderly patients (aged >65 years) undergoing ACDF. Whether the results from previous studies can be applied to this subgroup pf patients remains unknown. The aim of the present study was to compare the 30-day hospital readmission rates for Medicare patients (aged >65 years) undergoing outpatient versus inpatient ACDF. We performed a retrospective analysis of a Medicare database, including data from 17,421 patients. Of the 17,421 patients, 16,386 had undergone inpatient ACDF and 1035, outpatient ACDF. Age, sex, comorbidities, postoperative complications, readmission rates, and overall financial costs were compared between the 2 cohorts. In a Medicare sample (aged >65 years), inpatient ACDF was associated with a greater incidence of postoperative complications compared with outpatient ACDF. Outpatient surgery was associated with significantly lower rates of postoperative complications (urinary tract infection, surgical site infection, deep vein thrombosis, pulmonary embolism, and myocardial infarction) and significantly lower treatment costs (P ≤ 0.001). All-cause 30-day hospital readmission rates were also greater for inpatients (10.1% vs. 4%; P= 0.17). The results from the present study suggest that outpatient ACDF appears to be safe and effective with low complication and readmission rates in a Medicare patient sample.

Smoking is Associated With 1-year Suboptimal Patient-reported Outcomes After 2-level Anterior Cervical Fusion.

Retrospective cohort study. To study the impact of smoking on patient-reported outcomes after primary 2-level anterior cervical discectomy and fusion (ACDF). Previous studies have found suboptimal outcomes after multilevel ACDF in smoking patients. There is contrasting evidence on the negative effects of smoking in single-level ACDF, while there are no specific reports in 2-level ACDF. Adding knowledge of smoking's impact on patient-reported outcomes (PRO) will help in tailored patient counseling and preoperative education. Patients 18 years of age or older at a single academic institution who underwent 2-level ACDF to treat cervical radiculopathy and/or myelopathy between September 2013 and September 2015 were included. PRO was studied using the neck disability index (NDI) preoperatively, and at 3, 6, 12 months. χ test for qualitative variables, and one-way analysis of variance (ANOVA) and unpaired t test for quantitative variables were used for statistical analysis. A total of 61 patients, of which 23 (37.7%) were classified as smokers were included. Demographic and clinical profile of patients was similar both groups. Preoperatively, smokers had a mean NDI of 62.8±12.7 with a 17.5%, 18.7%, and 27.7% decrease at 3, 6, and 12-months, respectively. Nonsmokers had a mean preoperative NDI of 45.9±15.3, with a 36.4%, 61.2% and 65.4% decrease at 3, 6, and 12-months, respectively. Despite higher baseline NDI in smokers, improvement in NDI reached significance at 3-months in nonsmokers. In smokers, the improvement in NDI was slower and reached significance at 12-months. The radiographic fusion status at latest follow-up was similar in smokers and nonsmokers (P=0.67). Smokers had lower improvements in NDI scores compared to nonsmokers after a 2-level ACDF. Preoperative counseling before 2-level ACDF should include education about risks of inferior clinical outcomes in smokers independent of fusion status.

Rigid-Plating and Cortico-Cancellous Allograft Are Effective for 3-Level Anterior Cervical Discectomy and Fusion: Radiographic and Clinical Outcomes

ObjectiveTo determine the risk factors associated with radiographic changes and clinical outcomes following 3-level anterior cervical discectomy and fusion (ACDF) using rigidplate constructs and cortico-cancellous allograft. ACDF has demonstrated efficacy for treatment of multilevel degenerative cervical conditions, but current data exists in small heterogeneous forms. MethodsA retrospective review included 98 patients with primary 3-level ACDF surgery at one institution from 2008 to 2013 with minimum 1-year follow-up. Cervical sagittal vertical axis (SVA), segmental height, fusion, and lordosis radiographs were measured preoperatively and at 2 postoperative periods. ResultsRates of asymptomatic pseudarthroses and total reoperations were 18% and 4%, respectively. Results demonstrated immediate improvements in cervical lordosis (5.5°, p < 0.01) and segmental height (5.0-mm increase, p < 0.01) with little changes in the cervical SVA (3.2-mm increase, p < 0.01). The segmental height decreased from immediate postoperative period to final follow-up (1.7-mm decrease, p < 0.01). Older age was protective against radiolucent lines (p < 0.05). Patient-reported outcomes significantly improved following surgery (p < 0.01). Current smoking status and diagnosis of diabetes mellitus had no impact on radiographic or clinical outcomes. Risk factors were not identified for the 5 reoperations (4%). ConclusionThree-level ACDF with rigid-plating and cortico-cancellous allograft is an effective procedure for degenerative diseases of the cervical spine without the application of additional adjuncts or combined anteriorposterior cervical surgeries. Significant improvements in cervical lordosis, segmental height, and segmental alignment can be achieved with little change in cervical SVA and a low rate of reoperations over short-term follow-up. Similarly, patient-reported outcomes show significant improvements.

Safety of 2-level Anterior Cervical Discectomy and Fusion (ACDF) Performed in an Ambulatory Surgery Setting With Same-day Discharge.

This was a retrospective review of prospectively collected data. To evaluate differences in patient factors, procedural factors, outcomes and safety in 2-level anterior cervical discectomy and fusion (ACDF) performed in ambulatory surgery centers (ASCs) versus the hospital setting. Emphasis on reducing health care costs has led to numerous surgeries across specialties being performed in ASCs. Because of short operative times and moderate postoperative pain, 1-level ACDF is one of the most common spine surgeries successfully performed in ASCs. Despite the success of single-level ACDF, concerns over postoperative complications, including respiratory compromise have curtailed the performance of 2-level ACDF in ASCs. Patient demographics, operative factors and outcomes [blood loss, operative time, length of stay, complications and patient-reported outcomes (PROs)] of patients undergoing 2-level ACDF in an ASC and a hospital were compared using the Fisher exact test for categorical and the Student t test for continuous variables. Of the 83 patients included, 25 underwent 2-level ACDF in an ASC, and 58 in a hospital. Mean age for the ASC group was 51.7±7.6 and 53.2±7.9 years for the hospital group (P=0.44). Body mass index was lower in the ASC group, at 27.3 kg/m versus 30.4 in the hospital group (P=0.03). Likewise, the ASC group had a lower ASA grade, favoring ASA 1 and 2 (P<0.001). There were no differences in blood loss (P=0.72) or complication rates, (P=0.16) with urinary retention being most common, and only 1 patient in the hospital setting requiring reintubation. In addition, no patients in the ASC setting required hospitalization. There were no differences in preoperative, 6-week and 6-month PROs. The results of our study suggest that 2-level ACDF can be performed safely in the ASC setting without increased risk of complications compared with the hospital setting in an appropriately selected patient. Specifically, body mass index, and ASA class should be taken into consideration. Importantly, the setting of the surgery does not impact early PROs. Level 3.

Predictive Factors of Postoperative Dysphagia in Single-Level Anterior Cervical Discectomy and Fusion.

Retrospective review of prospectively collected data. To investigate if zero profile devices offer an advantage over traditional plate/cage constructs for dysphagia rates in single level anterior cervical discectomy and fusion (ACDF). Dysphagia rates following ACDF have been reported to be as high as 83%, most cases are self-limiting, but chronic dysphagia can continue in up to 35% of patients. Zero profile devices were developed to limit dysphagia, and other plate specific complications, however the literature is currently divided regarding their efficacy. Dysphagia was assessed by swallowing quality of life (SWAL-QOL) scores preoperatively, at 6 weeks and 12 weeks. Patient reported outcome measures (PROMs) including visual analog scale (VAS) and Neck Disability Index (NDI) were collected preoperatively, at 6 weeks and at 6 months. Univariate and multivariate regression analysis was conducted with SWAL-QOL score as the dependent variable. Sixty-four patients were included, 41 received a zero profile device, and 23 received plate-graft construct. Both groups were similar regarding patient demographics, except operative time, with the zero-profile group having a shorter procedure time than the cage-plate group (44.88 ± 6.54 vs. 54.43 ± 14.71 min, P = 0.001). At all timepoints dysphagia rates were similar between the groups. Regression analysis confirmed preoperative SWAL-QOL and operative time were the only significant variables. PROMs were also similar between groups at all time points, except VAS neck at 6 months, which was lower in the plate-graft group (1.05 ± 1.48 vs. 3.43 ± 3.21, P = 0.007). Operative time and preoperative SWAL-QOL scores are predictive of dysphagia in single level ACDF. Zero profile devices had a significantly shorter operative time, and may provide a benefit in dysphagia rates in this regard. 3.

Outpatient and Inpatient Readmission Rates of 1- and 2-Level Anterior Cervical Discectomy and Fusion Surgeries

This study looks at the various comorbidities and postoperative complications and their impact on readmission rates of patients undergoing outpatient versus inpatient 1- and 2-level anterior cervical discectomy and fusion (ACDF). With increasing costs within the United States medical system, one emerging cost-saving strategy is to evolve traditional inpatient procedures into outpatient same-day surgeries. However, patient safety remains a crucial priority. A total of 28,427 patients were analyzed, with 26,368 undergoing inpatient ACDF surgery and 2059 undergoing outpatient ACDF surgery. Age, sex, comorbidities, postoperative complications, readmission rates, and overall financial cost were compared between both cohorts. Data from 28,427 one- and two-level ACDF procedures that were split between inpatient and outpatient were collected. Thirty-day readmission rates were significantly lower in outpatients than inpatients (4% vs. 10.1%, P < 0.001). Inpatients had higher rates of urinary tract infection (2.4% vs. 1.4%), deep vein thrombosis (0.6% vs. 0%), and myocardial infarction (0.2% vs. 0%), whereas outpatients had higher rates of pulmonary embolism (7.7% vs. 0.4%). Outpatients had increased readmission risk with comorbidities of diabetes (odds ratio [OR], 48.93; P < 0.001), smoking (OR, 4.6; P < 0.001), body mass index ≥30 (OR, 2392; P < 0.001). The average cost of outpatient surgery was less than that of inpatient surgery ($7774.8 vs. $7956.75, P=0.0444). This study suggests that in the appropriately selected patients, ACDF can safely be performed in an outpatient setting.

Fixation of multiple level anterior cervical disc using cages versus cages and plating

BackgroundCervical disc herniation is a common cause of neck, upper limb, and upper back pain. In severe cases, neurological deficit might occur. It is surgically treated anteriorly or posteriorly, anteriorly through both cervical discectomy and fusion (ACDF) using cages alone or using cages plus plating.ObjectivesWe aimed to evaluate the fusion rate and the clinical outcome of multiple level anterior cervical discectomy followed by cage fusion alone and cage fusion with plate insertion.Materials and methodsIn this prospective comparative study, 33 patients were included. Patients were divided into 2 groups: group A: 19 cases received ACDF and group B: 14 patients had ACDF plus plate fixation. Fusion rate was assessed by radiographs. Clinical outcome was assessed by the visual analog scale (VAS). Overall patients’ satisfaction postoperatively was graded according to Odom’s criteria.ResultsThe rate of fusion was 78.9% of patients in group A and 85.7% of patients in group B. Clinical outcomes were similar in both groups. Patient satisfaction according to Odom’s criteria of outcome grading showed 36.8% of patients had excellent recovery and 31.6% had good recovery in group A. While in group B, 42.9% of patients had excellent recovery and 21.4% had good recovery. The differences between both groups were not statistically significant (P = 0.19).ConclusionsACDF with or without plate fixation in more than two-level cervical discectomies achieves good stability and functional outcome. Addition of anterior cervical plate fixation resulted in a higher fusion rate and reduced cage subsidence than that of cage alone.

Fusion rate following three- and four-level ACDF using allograft and segmental instrumentation: A radiographic study

Cervical spine degenerative pathologies remain one of the most common spinal conditions treated by spine surgeons worldwide. Surgery is recommended in all patients with symptomatic cervical spinal stenosis with either moderate to severe myelopathy, degeneration, or refractory radiculopathy. As the number of levels increases the potential for complications associated with anterior surgery can be significant, especially dysphagia and pseudarthrosis. The objective of this study was to analyze the fusion rate following three- or more level anterior cervical discectomy and fusion (ACDF). A retrospective review was performed analyzing patients who underwent three or more level ACDF. Fusion was evaluated using post-operative dynamic upright radiographs Relevant post-operative complications especially dysphagia requiring dietary modifications or placement of feeding tube was also noted. A total of 72 patients were included in the study. Of the 232 levels fused, pseudarthrosis occurred at 47 (14%) levels. Overall 45.8% of patients (33/72) had a pseudarthrosis. The incidence of pseudarthrosis was higher in patients with 4 level ACDF as compared to those with 3 level ACDF [56% (9/16) versus 42% (24/56)]. At last follow up, the number of patients that were symptomatic from their pseudarthrosis and required posterior spinal instrumentation was 8/72 (11.1%). Fusion rates in a large cohort of patients with three- and four-level ACDF performed utilizing allograft and segmental instrumentation is reported. The study demonstrates that 3–4 level, stand-alone anterior cervical arthrodeses result in at least one level of pseudarthrosis in almost half of patients, especially at the caudal level of the construct.

Can Self-Locking Cages Offer the Same Clinical Outcomes as Anterior Cage-with-Plate Fixation for 3-Level Anterior Cervical Discectomy and Fusion (ACDF) in Mid-Term Follow-Up?

BackgroundSelf-locking stand-alone cages (MC+) and cage-with-pate fixation system are 2 different surgical methods used in anterior cervical discectomy and fusion (ACDF), but few systematic comparative studies comparing the 2 methods in treating multilevel cervical spondylotic myelopathy (MCSM) have been published.Material/MethodsSixty-two patients with MCSM who underwent multilevel ACDF were enrolled and completed at least a 3-year postoperative follow-up. The operative time, intra-operative blood loss, and clinical and radiological results were compared between the MC+ self-locking cages group and the cage-with-plate fixation group. Clinical parameters, including VAS for neck pain, Japanese Orthopedic Association (JOA) score, and neck disabled index (NDI), were evaluated. Surgical results according to Odom’s criteria and postoperative dysphagia status, C5 nerve root palsy, and loosening of the instrumentation were recorded. Postoperative radiological results, including fusion rates, fusion segmental Cobb’s angle (FSC), cervical lordosis, fusion segmental height (FSH), cage subsidence, and adjacent segment degeneration, were assessed.ResultsThe VAS score, JOA score, and NDI score were significantly improved in both groups. However, the patients in the cage-with-plate group were more likely to have neck pain at the last follow-up. The cervical lordosis, FSC, and FSH showed significant correction immediately after surgery. The loss of the cervical lordosis and FSH were higher in the MC+ group.ConclusionsWe found that use of MC+ cages is safe and effective in treating MCSM, but for patients who require strong postoperative stabilization and maintaining the cervical alignment better, the cage-with-plate fixation may best.

What Factors Influence Reimbursement for 1 to 2 Level Anterior Cervical Discectomy and Fusion Procedures?

Retrospective review. To determine reimbursement associated with an anterior cervical discectomy and fusion (ACDF) and the demographic factors influencing reimbursement for an ACDF. ACDF has been shown to be a cost-effective procedure. However, there has been minimal analysis of factors influencing reimbursement for this procedure. Clinical and financial data were retrospectively reviewed for 176 patients undergoing an ACDF procedure in 2013 and 2014. Patients were included if they had primary ACDF and excluded if they were treated for a traumatic cervical spine fracture, infection, failed primary procedure, front/back procedure, or total disc replacement procedure. Clinical factors analyzed included number of levels fused, surgical time, length of stay in the hospital, estimated blood loss, implant type, Charleson Comorbidity Index (CCI), and preoperative diagnosis. Payer type and reimbursement associated with physician and hospital fees were collected for each patient. A multiple linear regression model determined the factors influencing reimbursement data using a backward conditional stepwise methodology. Variables were only included in multivariate analysis if there was a significant (P < 0.05) impact on reimbursement within univariate analysis. One hundred and twenty-eight patients met inclusion criteria. The average reimbursement per patient was $24,622 (+/- standard deviation of 14,616). The only significant factors influencing reimbursement was payer type (P < 0.001) and length of hospital stay (P < 0.001). These two independent multivariate determinants of reimbursement only accounted for 18.6% of reimbursement variability. There is substantial variability in reimbursement for ACDF procedures. Multivariate analysis indicates that payer type and length of hospital stay significantly influence reimbursement. Our model, however, only explained a small proportion of reimbursement variability indicating that factors outside our analysis may significantly affect hospital reimbursement. 3.

Utilization of Time-driven Activity-based Costing to Determine the True Cost of a Single or 2-level Anterior Cervical Discectomy and Fusion.

This is a prospective case series. To determine the actual cost of performing 1- or 2-level anterior cervical discectomy and fusion (ACDF) using actual patient data and the time-driven activity-based cost methodology. As health care shifts to use value-based reimbursement, it is imperative to determine the true cost of surgical procedures. Time-driven activity-based costing determines the cost of care by determining the actual resources used in each step of the care cycle. In total, 30 patients who underwent a 1- or 2-level ACDF by 3 surgeons at a specialty hospital were prospectively enrolled. To build an accurate process map, a research assistant accompanied the patient to every step in the care cycle including the preoperative visit, the preadmission testing, the surgery, and the postoperative visits for the first 90 days. All resources utilized and the time spent with every member of the care team was recorded. In total, 27 patients were analyzed. Eleven patients underwent a single-level ACDF and 16 underwent a 2-level fusion. The total cost for the episode of care was $29,299±$5048. The overwhelming cost driver was the hospital disposable costs ($13,920±$6325) which includes every item used during the hospital stay. Intraoperative personnel costs including fees for the surgeon, resident/fellow, anesthesia, nursing, surgical technician, neuromonitoring, radiology technician and orderlies, accounted for the second largest cost at $6066±$1540. The total cost excluding hospital overhead and disposables was $9071±$1939. Reimbursement for a bundle of care surrounding a 1- or 2-level ACDF should be no less than $29,299 to cover the true costs of the care for the entire care cycle. However, this cost may not include the true cost of all capital expenditures, and therefore may underestimate the cost.

Stand-Alone Cervical Cages in 2-Level Anterior Interbody Fusion in Cervical Spondylotic Myelopathy: Results from a Minimum 2-Year Follow-up.

Study DesignA retrospective review of patients who underwent 2-level anterior cervical discectomy and fusion (ACDF) with standalone polyetheretherketone (PEEK) cages for cervical spondylotic myelopathy (CSM).Purpose To evaluate the efficacy of stand-alone PEEK cage in 2-level cervical interbody fusion for CSM.Overview of LiteratureACDF is a standard surgical procedure to treat degenerative disc disease. However, the use of additional anterior plating for 2-level ACDF remains controversial.MethodsWe reviewed outcomes of patients who underwent 2-level ACDF with stand-alone PEEK cages for CSM over a 7-year period (2007–2015) in a regional hospital. Japanese Orthopaedic Association (JOA) score, fusion rate, subsidence rate, cage migration, and cervical alignment by the C2–7 angle as well as the local segmental angle (LSA) of the cervical spine were assessed.ResultsIn total, 31 patients (mean age, 59 years; range, 36–87 years) underwent 2-level ACDF with a cage-only construct procedure between 2007 and 2015. The minimum follow-up was 24 months; mean follow-up was 51 months. C3–5 fusion was performed in 45%, C4–6 fusion in 32%, and C5–7 fusion in 23%. Mean JOA score improved from 10.1±2.2 to 13.9±2.1 (p<0.01) at the 24-month follow-up. Fusion was achieved in all patients. Subsidence occurred in 22.5% of the cages but was not associated with differences in JOA scores, age, sex, or levels fused. Lordosis of the C2–7 angle and LSA increased after surgery, which were maintained for up to 1 year but subsequently disappeared after 2 years, yet the difference was not statistically significant. No cage migration was noted; two patients developed adjacent segment disease requiring posterior laminoplasty 3 years after ACDF.ConclusionsThe use of a stand-alone PEEK cage in a 2-level cervical interbody fusion achieves satisfactory improvements in both clinical outcomes and fusion.

Anterior Cervical Discectomy with or without Fusion in Non-traumatic Single level Cervical Disc Disorder: Study of 50 Cases

Objectives: The aim of this study is to compare patients undergoing single level anterior cervical discectomy without fusion (ACD) versus anterior cervical discectomy with fusion (ACDF).&#x0D; Methods: A retrospective analysis of 50 patients with degenerative cervical spondylosis of them 25 had undergone ACD without fusion and remaining 25 undergone ACDF at either C4-C5, C5- C6 level or at C6-C7 level.&#x0D; Results: The kinematic analysis included the range of motion, intervertebral angulations, anteroposterior translation and disc height assessed for the cervical functional spinal units at the operated level and adjacent levels. At the operated level of C4-C5, C5-C6 and C6-C7, the range of motion and the translation were minimal in the anterior cervical discectomy without fusion (ACD) group, but absent in the cervical discectomy with fusion (ACDF) group. The superior adjacent levels range of motion and the translation were greater in the ACDF group compared with the ACD group. But both groups had almost similar results in term of hospital stay, mean time for improvement and patient satisfaction.&#x0D; Conclusion: The clinical results of anterior cervical discectomy without fusion (ACD) and anterior cervical discectomy with fusion (ACDF) were comparable. In cervical discectomy without fusion, the elastic fibrous intradiscal scar at the operated level allows a small degree of mobility and the adjacent cervical levels are not overstressed. Fusion is not routinely required in single level cervical disc herniation until it is associated with instability, loss of cervical lordosis, hard disc, osteophytic bar and multi-segmental disease. So ACD is a better option in single level cervical disc disorder than ACDF.&#x0D; J Dhaka Medical College, Vol. 27, No.1, April, 2018, Page 29-35

Chronic Obstructive Pulmonary Disease Is an Independent Predictor for 30-Day Complications and Readmissions Following 1- to 2-Level Anterior Cervical Discectomy and Fusion.

Study Design:Retrospective cohort.Objectives:To study evidence to assess the impact of chronic obstructive pulmonary disease (COPD) on 30-day outcomes following 1- to 2-level anterior cervical discectomy and fusion (ACDF).Methods:The 2015-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using Current Procedural Terminology (CPT) codes 22 551 (single-level) and 22 552 (additional level). Patients undergoing disc arthroplasty, multilevel (>2) fusion, posterior cervical spine surgery, and patients with fracture, tumor, and/or infection were excluded.Results:Out of 14 835 patients undergoing an elective 1- to 2-level ACDF, 649 (4.4%) had a diagnosis of COPD at the time of the surgery. Following adjusted logistic regression analysis, prior history of COPD was significantly associated with a longer length of stay (odds ratio [OR] 1.25 [95% confidence interval (CI0 1.04-1.52]; P = .019), superficial surgical site infection (OR 2.68 [95% CI 1.06-6.80]; P = .038), discharge destination other than home (OR 1.49 [95% CI 1.05-2.12]; P = .026), pneumonia (OR 4.37 [95% CI 2.42-7.88]; P < .001), ventilator use >48 hours (OR 5.34 [95% CI 1.88-15.15]; P = .002), unplanned reintubation (OR 3.36 [1.48-7.62]; P = .004), and 30-day readmissions (OR 1.69 [95% CI 1.20-2.38]; P = .003).Conclusions:The findings of this study show that COPD patients are more likely to have postoperative complications and 30-day readmissions, despite elective ACDF itself being a low-risk surgery in general. Results show that majority of the complications were pulmonary in nature, further stressing the need for accurate medical optimization following surgery in these patients.