Adjacent Level Disease Research Articles

Late-week Multilevel Anterior Cervical Discectomy and Fusion Associated With Increased Length of Stay.

Retrospective analysis of clinical data from a single institution. To assess the day of surgery during the week as a possible predictor of length of stay (LOS) following anterior cervical discectomy and fusion (ACDF). Surgeries later in the week may result in longer LOS and higher costs for joint arthroplasty, yet this is unclear following spine surgery. Procedures performed later in the week may lead to weekend admissions when there are limited services that may contribute to an extended LOS. We attempt to identify associations between day of surgery and LOS, readmission, and complications following single- and multilevel ACDF. Patients at a single institution undergoing ACDF by 7 primary surgeons in both orthopedic and neurosurgery spine departments between 2015 and 2019 were retrospectively reviewed. Patients were stratified by surgery day at either the beginning (Monday/Tuesday) or end (Thursday/Friday) of the week and by single- or multilevel ACDF. Surgery for trauma, infections, adjacent level disease, or revision were excluded. Patient demographics, Charlson Comorbidity Index (CCI), LOS, postoperative complications, and readmission rates were assessed. Six hundred fifty-two patients underwent ACDF. For single-level ACDF, 222 were reviewed, with 112 having surgery at the beginning and 110 at the end of the week. For multilevel ACDF, 431 were reviewed, with 192 having surgery at the beginning and 239 at the end of the week. No differences in pre- or postoperative variables were determined for single-level ACDF. Despite no differences in pre-operative variables, CCI, operative duration, or number of levels, late-week multilevel ACDF had longer average LOS (2.8±3.0 days) compared to early-week surgery (2.0±2.0 days) ( P =0.018). Late-week multilevel ACDF was associated with an increased LOS, as it may prove beneficial to surgical planning. This conflicts with previous reports that day of week was not associated with LOS following ACDF. III.

REASON(S) FOR REFUSAL OF SURGERY IN PATIENTS WITH ESTABLISHED DEGENERATIVE LUMBAR PATHOLOGY

Low back pain is the single most common cause for disability in individuals aged 45 years or younger, it carries tremendous weight in socioeconomic considerations. Degenerative aging of the structural components of the spine can be associated with genetic aspects, lifetime of tissue exposure to mechanical stress & loads and environmental factors. Mechanical consequences of the disc degenerative include loss of disc height, segment instability and increase the load on facets joints. All these can lead to degenerative changes and osteophytes that can narrow the spinal canal. Surgery is indicated in patients with spinal stenosis who have intractable pain, altered quality of life, substantially diminished functional capacity, failed non-surgical treatment and are not candidates for non-surgical treatment. The aim was to determine the reasons for refusal of surgery in patients with established degenerative lumber spine pathology eligible for surgery.All patients meeting the study criteria, patients older than 18 years, patients with both clinical and radiological established symptomatic degenerative lumbar spine pathology and patients eligible for surgery but refusing it were recruited. Questionnaire used to investigate reasons why they are refusing surgery.Results 59 were recruited, fifty-one (86.4 %) females and eight (13.6 %) males. Twenty (33.8 %) were between the age of 51 and 60 years, followed by nineteen (32.2 %) between 61 and 70 years, and fourteen (23.7 %) between 71 and 80 years. 43 (72 %) patients had lumber spondylosis complicated by lumber spine stenosis, followed by nine (15.2 %) with lumbar spine spondylolisthesis and four (6.7 %) had adjacent level disease. 28 (47.4 %) were scared of surgery, fifteen (25.4 %) claimed that they are too old for surgery and nine (15.2 %) were not ready.Findings from this study outlined that patients lack information about the spinal surgery. Patients education about spine surgery is needed.

Mid-term and Long-term Outcomes After Total Cervical Disk Arthroplasty Compared With Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

A meta-analysis of randomized controlled trials (RCTs). The aim of this study was to compare mid-term to long-term outcomes of cervical disk arthroplasty (CDA) with those of anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic cervical degenerative disk disease. After ACDF to treat symptomatic cervical degenerative disk disease, the loss of motion at the index level due to fusion may accelerate adjacent-level disk degeneration. CDA was developed to preserve motion and reduce the risk of adjacent segment degeneration. Early-term to mid-term clinical outcomes from RCTs suggest noninferiority of CDA compared with ACDF, but it remains unclear whether CDA yields better mid-term to long-term outcomes than ACDF. Two independent reviewers searched PubMed, Embase, and the Cochrane Library for RCTs with at least 60 months of follow-up. The risk ratio or standardized mean difference (and 95% CIs) were calculated for dichotomous or continuous variables, respectively. Eighteen reports of 14 RCTs published in 2014-2023 were included. The pooled analysis demonstrated that the CDA group had a significantly greater improvement in neurological success and Neck Disability Index than the ACDF group. The ACDF group exhibited a significantly better improvement in the Short Form-36 Health Survey Physical Component Summary than the CDA group. Radiographic adjacent segment degeneration was significantly lower in the CDA group at 60- and 84-month follow-ups; at 120-month follow-up, there was no significant difference between the 2 groups. Although the overall rate of secondary surgical procedures was significantly lower in the CDA group, we did not observe any significant difference at 60-month follow-up between the CDA and ACDF group and appreciated statistically significant lower rates of radiographic adjacent segment degeneration, and symptomatic adjacent-level disease requiring surgery at 84-month and 108- to 120-month follow-up. The rate of adverse events and the neck and arm pain scores in the CDA group were not significantly different from those of the ACDF group. In this meta-analysis of 14 RCTs with 5- to 10-year follow-up data, CDA resulted in significantly better neurological success and Neck Disability Index scores and lower rates of radiographic adjacent segment degeneration, secondary surgical procedures, and symptomatic adjacent-level disease requiring surgery than ACDF. ACDF resulted in improved Short Form-36 Health Survey Physical Component Summary scores. However, the CDA and ACDF groups did not exhibit significant differences in overall changes in neck and arm pain scores or rates of adverse events.

20-year Clinical Outcomes of Cervical Disc Arthroplasty: A Prospective, Randomized, Controlled Trial.

Prospective, Randomized, Controlled Trial. To compare clinical outcomes of anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) at 20 years. Concern for adjacent level disease after ACDF prompted development of CDA. 47 patients with single level cervical radiculopathy were randomized to either BRYAN CDA or ACDF for an FDA IDE trial. At 20 years, patient reported outcomes, including visual analog scales (VAS) for neck and arm pain, neck disability index (NDI), and reoperation rates were analyzed. Follow-up rate was 91.3%. Both groups showed significantly better NDI, VAS arm pain and VAS neck pain scores at 20 years versus preoperative scores. Comparing CDA versus ACDF, there was no difference at 20 years in mean scores for NDI [11.1 (SD 14.1) vs. 19.9 (SD 17.2), P=0.087], mean VAS arm pain [0.9 (SD 2.4) vs. 2.3 (SD 2.8), P=0.095], or mean VAS neck pain [1.2 (SD 2.5) vs. 2.9 (3.3), P=0.073]. There was a significant difference between CDA versus ACDF groups in the change in VAS neck pain score between 10 and 20 years [respectively, -0.4 (SD 2.5) vs. 1.5 (SD 2.5), P=0.030]. Reoperations were reported in 41.7% of ACDF patients and 10.0% of CDA patients (P=0.039). Both CDA and ACDF are effective in treating cervical radiculopathy with sustained improvement in NDI, VAS neck and VAS arm pain at 20 years. CDA demonstrates lower reoperation rates than ACDF. There were no failures of the arthroplasty device requiring reoperation at the index level. Symptomatic non-union rate of ACDF was 4.2% at 20 years. Despite a higher reoperation rate in the CDA group versus ACDF group, there was no difference in the 20-year NDI, VAS Neck and VAS arm pain scores.

The 5-Factor Modified Frailty Index is Associated With Increased Risk of Reoperations and Adjacent Level Disease Following Single-Level Transforaminal Lumbar Interbody Fusion.

Retrospective Cohort Study. To determine the predictive capability between the 5-factor modified frailty index (mFI-5) scores and adverse clinical and radiographic outcomes following single-level transforaminal lumbar interbody fusion (TLIF). All patients over the age of 50 undergoing single-level open or minimally invasive TLIF from 2012 to 2021 with a minimum follow-up of 1year were identified. Deformity, trauma, emergency, and tumor cases were excluded as were patients undergoing revision surgeries. An mFI-5 score was computed for each patient using a set of five factors which included hypertension requiring medication, chronic obstructive pulmonary disease, diabetes mellitus, congestive heart failure, and partially or fully dependent functional status. Univariate and multivariate logistic regression analysis were performed to evaluate the impact of mFI-5 scores on readmissions, reoperations, and postoperative complications. 156 patients were included and grouped according to their level of frailty: no-frailty (mFI = 0, n = 67), mild frailty (mFI = 1, n = 59), and severe frailty (mFI = 2+, n = 30). Multivariate analysis found high levels of frailty (mFI = 2+) to be independent predictors of reoperation (OR: 16.9, CI: 2.7 - 106.9, P = .003) and related readmissions (OR = 16.5, CI: 2.6 - 102.7, P = .003) as compared to the no-frailty group. An mFI-5 score of 2+ was also predictive of any complication (OR = 4.5, CI: 1.4 - 14.3, P = .01) and adjacent segment disease (ASD) (OR = 12.5, CI: 1.2 - 134.0, P = .037). High levels of frailty were predictive of related readmissions, reoperations, any complications, and ASD in older adult patients undergoing single-level TLIF.

Radiological parameters after LLIF for adjacent-level disease treatment

OBJECTIVE: To analyze the radiological outcomes of using the LLIF technique to treat adjacent-level disease. METHODS: Patients undergoing LLIF surgery for treatment of adjacent level disease, with preoperative radiography and postoperative radiography at 3 months to 1 year of follow-up, who had completed the informed consent form were included. Patients whose radiographs did not allow the measurements proposed in the study to be performed were excluded. The following outcomes were analyzed: pelvic incidence, pelvic version, sacral tilt, lumbar lordosis, and adjacent-level segmental lordosis on preoperative and postoperative radiographs. RESULTS: 37 patients were included in the study (16 women and 21 men) were included in this study. The most frequently addressed levels were L3L4 (20) and L2L3 (14). Patients had an average of 4.9° (±4.2°) segmental lordosis gain at the addressed level, whereas they had an average of 6.7° (±7.3°) lumbar lordosis correction (p<0.05). CONCLUSION: The use of the LLIF technique for the treatment of adjacent-level disease can significantly improve several spinopelvic parameters and segmental lordosis.

A Bibliometric and Visual Analysis of the Most Cited Articles on Disc Arthroplasty.

Bibliometric literature review. Total disc arthroplasty (TDA) is an evolving technique used by surgeons to preserve neural elements and range of motion in patients with degenerative disc disease, spondylosis and more. In comparison to discectomy, disc arthroplasty has been shown to decrease morbidity, reduce adjacent-level disease, and preserve pre-operative range of motion. The objective of this manuscript is to provide a bibliometric analysis of the use of disc arthroplasty in scientific literature and highlight the main contributing authors and their publication characteristics. The Scopus database was used to perform a title-specific, keyword-based search for all publications until June 2022. The keyword "total disc arthroplasty" was used. The most-cited 100 articles were selected for analysis. Parameters included the following: title, citation count, citations per year, authors, specialty first author, institution, country of origin, publishing journal, Source Normalized, Impact Per Paper (SNIP), and Hirsch index. Our search on disc arthroplasty yielded 580 articles that were published, with the first publication on the topic found in 1966. The most cited 100 articles received a total of 8694 citations, with an average of 86.94 citations per article. After assessing countries with the greatest contributions, United States, China, and Germany were top 3 with 54, 14, and 7 articles, respectively. The bibliometric analysis provides an overview of how medical research is analyzed in academic medicine. In the present study, we evaluated the global trends in disc arthroplasty for the treatment of degenerative disc disease.

Comparison of Surgical Outcomes Between Anterior and Posterior Cervical Fusions Stratified by Levels Decompressed.

Retrospective database study. To compare outcomes between 1-, 2-, 3-, and 4- level anterior cervical discectomy and fusions (ACDF) and posterior cervical fusions (PCF) procedures using a national database. Surgical outcomes involving 3- or 4-level ACDF and PCF cases are not well-described. As there are situations where both ACDF and PCF can be employed, it is important to compare the risks and benefits of both procedures. Patients who underwent ACDF or PCF between 2010 and 2020 were identified in PearlDiver using current procedural terminology codes. Surgeries done for infectious, traumatic, or neoplastic etiologies were excluded. 2-year reoperations and 90-day readmissions were queried. Surgical complications and transfusions were compiled using ICD-9/10 billing codes. ACDF and PCF procedures were then matched by age, sex, Charlson Comorbidity Index, and a number of levels fused, and the above outcomes were compared. In all, 31,301 PCFs and 110,526 ACDFs were identified. After matching for age, sex, and Charlson Comorbidity Index, a total of 30,353 ACDF and PCF procedures were compared. Three-level and 4-level PCFs had higher rates of 90-day postoperative surgical complications compared with ACDF (OR=2.4 and 2.87, respectively; P <0.001). In addition, higher rates of 90-day readmissions were noted in 3-level PCF compared with 3-level ACDF (OR=1.24, P <0.001). Ninety-day postoperative transfusions were higher in both 3- and 4-level PCFs (OR=2.44 and 18.27, respectively; P <0.001). Two-year reoperations rates were higher for 3-level PCF procedures than 3-level ACDF (OR=1.22; P =0.01). Patients who underwent 3-4-level ACDF had lower rates of readmission, blood transfusions, and postoperative complications compared with 3-4-level PCF. This data suggests that in cases of 3-4-level pathology with clinical equipoise regarding approach, ACDF may be associated with less short-term morbidity, however, data on fusion rates and adjacent level disease are needed.

Long-term results of the NECK trial—implanting a disc prosthesis after cervical anterior discectomy cannot prevent adjacent segment disease: five-year clinical follow-up of a double-blinded randomised controlled trial

Background contextMotion preserving anterior cervical disc arthroplasty (ACDA) in patients with cervical radiculopathy was introduced to prevent symptomatic adjacent segment disease as compared to anterior cervical discectomy and fusion (ACDF). PurposeTo evaluate the long-term outcome in patients with cervical radiculopathy due to a herniated disc undergoing ACDA, ACDF or ACD (no cage, no plate) in terms of clinical outcome measured by the Neck Disability Index (NDI). Likewise, clinically relevant adjacent segment disease is assessed as a long-term result. Study designDouble-blinded randomized controlled trial. Patient sampleA total of 109 patients with one level herniated disc were randomized to one of the following treatments: ACDA, ACDF with intervertebral cage, ACD without cage. Outcome measuresClinical outcome was measured by patients’ self-reported NDI, Visual Analogue Scale (VAS) neck pain, VAS arm pain, SF36, EQ-5D, perceived recovery and reoperation rate. Radiological outcome was assessed by radiographic cervical curvature and adjacent segment degeneration (ASD) parameters at baseline and up until five years after surgery. MethodsTo account for the correlation between repeated measurements of the same individual Generalized Estimated Equations (GEE) were used to calculate treatment effects, expressed in difference in marginal mean values for NDI per treatment group. ResultsClinical outcome parameters were comparable in the ACDA and ACDF group, but significantly worse in the ACD group, though not reaching clinical relevance. Annual reoperation rate was 3.6% in the first two years after surgery, declined to 1.9% in the years thereafter. The number of reoperations for ASD was not lower in the ACDA group, while the number of reoperations at the index level was higher after ACD, when compared to ACDF and ACDA. ConclusionsA persisting absence of clinical superiority was demonstrated for the cervical disc prosthesis five years after surgery. Specifically, clinically relevant adjacent level disease was not prevented by implanting a prosthesis. Single level ACD without implanting an intervertebral device provided worse clinical outcome, which was hypothesized to be caused by delayed fusion. This stresses the need for focusing on timely fusion in future research.

172. Seven-year progression and 10-year prediction of adjacent level degeneration and disease after lumbar total disc replacement: A post hoc analysis of a prospective clinical trial with 7-year follow-up

<h3>PURPOSE</h3> To understand the progression of radiographic adjacent-level degeneration (ALDeg) seven years after lumbar total disc replacement (TDR) and the relationship of these changes with range of motion (ROM) and symptomatic adjacent-level disease (ALDis) using the seven-year follow-up data from a prospective, multicenter activL Food and Drugs Administration (FDA) Investigational Device Exemption (IDE) randomized controlled trial. <h3>METHODS</h3> Patients with single-level, symptomatic lumbar disc degeneration who were unresponsive to 6 months of nonoperative care, received activL or ProDisc-L, and had radiographs available were analyzed for the incidence for ALDeg and progression of ALDeg (ΔALDeg). ALDeg presence was determined using a modified, four-point, Kellgren-Lawrence scale. Incidence of ALDis was identified in patients who received activL or ProDisc-L with or without available radiographs. ALDis was defined as the need for reoperation at the segment adjacent to the index segment. The possible relationship between ROM and ΔALDeg was also investigated. Logistic regression modeling was used to predict ALDeg and ALDis outcomes to 10 years. <h3>RESULTS</h3> At baseline, 25% of patients had ALDeg. By seven-year follow-up, 33% of patients had ALDeg and 80% of these patients showed no ΔALDeg. Only a small percentage (3.4%) of patients had severe ΔALDeg by seven-year follow-up; the majority of patients had mild (75.9%) or moderate (20.7%) ΔALDeg by seven years. Incidence of ALDis was identified in 4 patients through seven-year follow-up (2.4%). Three patients received fusion at an adjacent level and one patient underwent fusion at the index and adjacent levels to treat stenosis at both levels along with symptomatic disc degeneration at the adjacent level. Improvement in ROM from baseline ranged from 0°to 16.4° at seven-year follow-up. For each degree in ROM gained at the TDR level, there was a consistent decrease in the percent of patients with ΔALDeg. Of patients having any improvement in ROM from baseline at the TDR level, only 16.9% had ΔALDeg; of patients having a 10°improvement in ROM, 0% of patients had ΔALDeg. The predicted probability of ALDeg after lumbar TDR was 53.9% by 10 years. In contrast, the predicted probability of clinical ALDis was only 2.8% by 10 years. <h3>CONCLUSIONS</h3> Post hoc analysis of seven-year data from a prospective trial confirm relatively low rates of ALDeg, ALDeg progression, and clinical ALDis after TDR over the long-term, with predicted rates being low through to 10 years. Improvement in ROM may be associated with reduced ΔALDeg. <h3>FDA DEVICE/DRUG STATUS</h3> activL total disc replacement (Approved for this indication), prodisc-L total disc replacement (Approved for this indication).

59. Long-term survival and clinical outcomes in patients managed with emergent surgery for a spinal epidural abscess with associated sepsis and neurologic decline

<h3>BACKGROUND CONTEXT</h3> Patients with a spinal epidural abscess (SEA) and associated sepsis and neurologic deterioration require immediate evaluation and prompt surgical intervention. The goals of surgery are life preservation, eradication of the infectious nidus, and restoration of neurologic function. The focus of treatment in these critically ill patients is to achieve these immediate goals. There has been limited attention given to the long-term status of patients who have survived this life threatening condition. <h3>PURPOSE</h3> To identify the survivability and long-term outcome of patients who underwent emergent surgical management for a SEA with associated sepsis and neurologic decline. <h3>STUDY DESIGN/SETTING</h3> A retrospective review of all consecutive patients with a SEA, sepsis and neurologic decline treated at a single, tertiary referral medical center from 2000-2010. <h3>PATIENT SAMPLE</h3> Fifty-four patients. <h3>OUTCOME MEASURES</h3> Survival/mortality, neurologic improvement (ASIA Grade), need for further spine surgery. <h3>METHODS</h3> All patients were clinically septic and had documented neurologic deterioration directly related to a spinal epidural abscess. Surgery was performed emergently from the time of notification of the spine service. Surgical approach was determined by the location of the abscess in relation to the thecal sac; 8 occurred in the cervical spine (all anterior), 20 in the thoracic spine (7 anterior, 13 posterior) and 26 in the lumbar spine (9 anterior, 17 posterior). All cervical SEA underwent an anterior decompression and fusion with structural grafting and plating, while anterior SEA within the thoracic or lumbar spines underwent anterior decompression and fusion with structural grafting followed by a staged, posterior instrumented fusion. Posterior SEA in the thoracic or lumbar spine underwent decompression and abscess evacuation only. Preoperative neurologic status was ASIA B in 20 patients, C in 20, and D in 10. The mean time of neurologic deterioration documented in the medical record was 24 hours (range: 6 hours-5 days). Stepwise multiple regression analysis was performed to identify risk factors for survival and neurologic improvement. Long-term survival was assessed using the institution's electronic medical record and subsequently confirmed by direct patient contact. <h3>RESULTS</h3> All patients survived the surgery, although 6 (11%) died within one month. Significant risk factors for early mortality included age >70 (p=.01), hospitalization >5 days prior to surgery (p=.02), ASIA D (p=.02), diabetes (p=.02), end stage renal disease (p=.02), and MRSA sepsis (p=.02). Of the surviving patients, the mean neurologic improvement was 2.4 ASIA grades. Of surviving patients, 92% (44/48) regained the ability to ambulate. Significant factors for neurologic improvement included age <70 (p=.01), documented neurologic decline <24 hours (p=.01), non-diabetic (p=.02), a cervical abscess (p=.01), a thoracic or lumbar abscess not requiring fusion (p=.02), and preoperative ASIA D (p=.01). At the 10-year follow-up, 88% (42/48) of the patients who survived their perioperative course were still alive. The six non-surviving patients had died of causes unrelated to their spine infections. At the 10-year follow-up, all 42 patients were noted to have maintained their level of neurologic recovery, with none having evidence of recurrent neurologic deficits or loss of ambulatory ability. Ten percent (4/42) of the long-term surviving patients had undergone additional spine surgery, 2 for removal of painful segmental instrumentation and 2 for extension of fusions for symptomatic adjacent level disease. None of the long-term survivors required additional surgery for a recurrent spine infection. Advanced imaging (MRI or CT scan) was available for 30 of the surviving patients. Aside from the 2 patients requiring surgery for adjacent level stenosis, there were no instances of residual infectious spinal column involvement, segmental instability or sagittal plane deformity in any patient. <h3>CONCLUSIONS</h3> Spinal epidural abscesses in patients with sepsis and neurologic deterioration can be effectively managed when diagnosed promptly and treated with emergent surgery. In this series, the majority of patients survived, had neurologic recovery and regained independent ambulation. However, there was a notable early mortality rate (11%), with older, diabetic patients with prolonged neurologic deficits most susceptible. Long-term survival occurred in 88% of patients, with evidence of sustained neurologic improvement, permanent eradication of the spine infection, and relatively uncommon need for additional surgery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Commentary: Hounsfield Unit as a Predictor of Adjacent-Level Disease in Lumbar Interbody Fusion Surgery.

Commentary: Hounsfield Unit as a Predictor of Adjacent-Level Disease in Lumbar Interbody Fusion Surgery.

Hounsfield Unit as a Predictor of Adjacent-Level Disease in Lumbar Interbody Fusion Surgery.

Bone density has been associated with a successful fusion rate in spine surgery. Hounsfield units (HUs) have more recently been evaluated as an indirect representation of bone density. Low preoperative HUs may be an early indicator of global disease and chronic process and, therefore, indicative of the need for future reoperation. To assess preoperative HUs and their association with future adjacent segment disease requiring surgical intervention through retrospective study. Patients who underwent lumbar interbody fusion at a single institution between 2007 and 2016 were retrospectively reviewed. Hounsfield unit values were measured from preoperative computed tomography (CT) using sagittal images, encircling cancellous portion of the vertebral body. Patient charts were reviewed for follow-up data and adjacent-level disease development. A total of 793 patients (age: 56.1 ± 13.7 years, 54.4% female) were included in this study. Twenty-two patients required surgical intervention for adjacent segment disease. Patients who underwent lumbar interbody fusion and did not subsequently require surgical intervention for adjacent-level disease were found to have a higher mean preoperative HU than patients who did require reoperation (180.7 ± 70.0 vs 148.4 ± 8.1, P = .032). Preoperative CT HU was a significant independent predictor for the requirement of adjacent-level surgery after spinal arthrodesis (odds ratio = 0.891 [0.883-0.899], P = .029). Patients who underwent lumbar interbody fusion that did not require reoperation for adjacent-level degeneration were found to have a higher mean preoperative HU than patients who did require surgical intervention. Lower preoperative CT HU was a significant independent predictor for the requirement of adjacent-level surgery after spinal arthrodesis.

Thorough Comparative Analysis of Stand-Alone Cage and Anterior Cervical Plate for Anterior Cervical Discectomy and Fusion in the Treatment of Cervical Degenerative Disease: A Systematic Review and Meta-analysis.

In this systematic review and meta-analysis, we aim to thoroughly describe and objectively compare the efficacy of anterior cervical plate (ACP) and stand-alone cage (SAC). Although recognized as an effective procedure for cervical degenerative disease (CDD), a debate between the methods of anterior cervical discectomy and fusion exists. ACP provides stability to the fusion construct; however, some complications have been reported, such as dysphagia, adjacent disc disease, and soft tissue injury. To overcome these complications, a SAC was later introduced. A systematic search was conducted on the basis of PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines to identify relevant studies through PubMed, Google Scholar, and Cochrane database. A total of 14 studies (960 patients) were included in the meta-analysis. Twenty outcomes were clinically and radiologically compared between the two procedures. ACP and SAC were comparable in terms of dysphasia rate, loss of segmental angle, loss of disc height, the Odom criteria, Robinson's criteria, hospital stay, Japanese Orthopaedic Association score, Neck Disability Index, Visual Analog Scale, and fusion time. However, SAC was superior in terms of shorter operation time, less blood loss, lower dysphagia rate, and lower rate of adjacent level disease, whereas ACP was advantageous in terms of lower subsidence rate, better maintenance of the cervical global and segmental angles and disc height, and higher fusion rate. Both procedures can be used in patients with CDD, although it might be more beneficial to choose ACP in patients with multi-level pathologies, wherein better mechanical stability is provided. However, SAC may be more beneficial to use in patients with comorbidities, anemia, or swelling problems because it offers lower complication rates.

Segmental Motion of Cervical Arthroplasty Leads to Decreased Adjacent-Level Degeneration: Analysis of the 7-Year Postoperative Results of a Multicenter Randomized Controlled Trial.

Cervical artificial disc replacement (C-ADR) has become a common and accepted surgical treatment for many patients with cervical disc degeneration/herniation and radiculopathy who have failed nonoperative treatment. Midterm follow-up studies of the original investigational device exemption trials comparing C-ADR to traditional anterior cervical discectomy and fusion (ACDF) have revealed C-ADR patients have less adjacent-level disease and fewer reoperations at 5 to 7 years. The purpose of this study was to examine the relationship of radiographic adjacent-level disease (R-ALD) with the amount of index-level segmental range of motion (ROM) in C-ADR patients using the long-term follow-up data from the ProDisc-C investigational device exemption trial. This was a post hoc analysis of a 1:1 randomized controlled trial. The initial previously described Food and Drug Administration-approved 2-year study was extended, and consenting patients in the original study were followed at annual intervals up to 7 years. Logistic regression was used to assess any progression in adjacent-level disease (ALD). Ordinal logistic regression was also used to assess the relationship between any progressive R-ALD and final flexion extension (F/E) ROM in C-ADR patients. Spearman's rank-order correlation was used when R-ALD was kept as an ordinal variable to assess the same relationship. At the last follow-up visit, the rate of progressive R-ALD was significantly higher in ACDF patients than in C-ADR patients. When C-ADR patients were divided into 3 groups based on final F/E ROM, those with 0° to 3° (n = 19), 4° to 6° (n = 15), and 7° (n = 42) of segmental motion at the index procedure level, the rate of progressive R-ALD trended significantly with final ROM (P = 0.01). C-ADR leads to a significant decrease in R-ALD compared to ACDF. The difference in R-ALD is related to the preservation of motion at the index level and resultant preservation of kinematics and forces across the adjacent disc space.

Spine Surgery: A Narrative Review About Recent Updates and Future Directions

Background: Advances in case selection, operative methods, and postsurgical care have facilitated spine surgeons to manage complex spine cases with short operative times, decreased hospital stay and improved outcomes. Methods: This is an overview of recent updates and future directions in the field of spine surgery. All the articles were obtained through a literature review on PubMed. Results: Minimally invasive spine procedures like Endoscopic spine surgeries, Oblique Lumbar Interbody Fusion, use of retractor systems, etc. are emerging in rapidly in modern world. Fusion surgeries are associated with adjacent level disease hence, motion preservation surgeries that mimic the natural biomechanics of the spine are being explored as alternatives. In view of risks to vital structures, nerve injury due to mal-positioning, etc.; robotic spine surgery has paved a way to allow surgeons real-time procedural manipulation along with instrument control, real-scale magnification. Many high-impact discoveries in cancer research, stereotactic radiotherapy, newer combinations of chemotherapy, and tumor-specific antibodies have increased our understanding of spine oncology. Past two decades have seen many advancements in treatment of spine deformities right from initial radiographic assessment, surgical planning to postoperative care. Conclusion: All in all, all stakeholders in innovation including the industry, scientists and surgeons must work in an open and honest collaboration to benefit the future patients and continue the evolution in Spine Surgery. Keywords: Spine surgery, Recent updates, Minimally invasive surgery, Artificial disc replacement, Artificial intelligence.

Reoperative Anterior Lumbar Spine Access is Feasible and Safe

During the past two decades, the number of anterior lumbar spine reconstructions has increased significantly, as has the need for revisions and treatment of adjacent levels. We sought to determine the feasibility of reoperative anterior lumbar spine exposure. We performed a retrospective analysis of patients who had undergone repeat anterior extraperitoneal exposure of the lumbar spine from January 2009 to March 2021. Cases were excluded if reoperation had occurred within 1 month of the index procedure or if the reoperation had used a lateral approach. The demographic data and details on the operative procedure were analyzed. During the study period, 6130 procedures for anterior, oblique, or lateral exposure of the lumbar spine were performed. Within this cohort, 137 anterior reoperations were performed on 135 patients (mean age, 55.7 years; range, 19-83 years). The mean body mass index was 25.7 kg/m2 (range, 17-43 kg/m2). Most reoperations were remote from the index disc level (61%). The main indications for reoperation were adjacent level disease (n = 84), failed artificial disk repair (n = 25), and nonunion (n = 16). The approach was via the contralateral retroperitoneal space in 74, ipsilateral in 61, both sides in 1, and retro- and transperitoneal in 1. The median estimated blood loss for the 61 procedures performed without concomitant posterior reconstruction was 150 mL (range, 10-2050 mL). The procedure was aborted in seven cases (5%) because of the intraoperative anatomic findings. The levels successfully treated were L2-L3 in 16, L3-L4 in 26, L4-L5 in 30, L5-S1 in 88, and L6-S1 in 1. Artificial disk repair was performed at 33 levels and fusions at 128 levels. Two minor ureteral injuries occurred. Twenty venous injuries (15%) were primarily repaired. One patient required a venous stent for iatrogenic stenosis. Two internal iliac artery injuries were treated with ligation or repair. No patient died. Reoperative anterior spine exposure was successful in 95% of cases with relatively low morbidity and no mortality. Primary exposure of the L5-S1 level should be performed in the right retroperitoneal space to preserve the left side for adjacent level exposure. Ureteral catheters are recommended to assist in identifying the ureters when ipsilateral retroperitoneal exposure is required.

P130. Comparative safety and efficacy of four surgical techniques in three level Anterior Cervical Discectomy and Fusion (ACDF)

<h3>BACKGROUND CONTEXT</h3> No consensus exists on the ideal surgical technique for multilevel ACDF, the gold standard treatment for cervical disc disease. Anterior plate (AP) fixation has been traditionally utilized for additional stability but associated complications have led to the increased use of stand-alone (SA) PEEK-anchored cages in recent years. There is a paucity of literature on use of these techniques in 3-level ACDF patients. In order to gain insight into the optimal surgical technique for 3-level ACDF, we conducted a retrospective comparative analysis of the safety and efficacy of the AP, SA and two other common surgical techniques. <h3>PURPOSE</h3> To compare the safety and efficacy of four surgical techniques in patients receiving three-level Anterior Cervical Discectomy and Fusion (ACDF). <h3>STUDY DESIGN/SETTING</h3> A retrospective chart review of patients who underwent primary 3-level ACDF by the two senior authors at two hospitals in Westchester County, NY. <h3>PATIENT SAMPLE</h3> A total of 50 patients who received primary 3-level ACDF by the senior authors between August 2015 and February 2020. <h3>OUTCOME MEASURES</h3> The outcomes investigated in this study include the following: Clinical Success (measured using Odom's criteria score), Safety (complication incidence), Operative (OP) Time, Blood Loss (BL) and Hospital Length of Stay (LOS). <h3>METHODS</h3> Surgical and clinical data for 50 patients who received primary 3-level ACDF by the senior authors between August 2015 and February 2020 was retrospectively analyzed. All patients received a combination of autograft and allograft. Four patient groups were compiled based on surgical technique performed; Anterior Plating with no cage at 3 levels (AP, 24%), Stand-Alone PEEK-anchored cages at 3 levels (SA, 30%), Stand-Alone PEEK-anchored cage at the first level and Anterior Plating with PEEK-anchored cages at the 2 subsequent levels (SAAP, 30%), and Anterior Plating with PEEK-anchored cages at three levels (APC, 16%). Patients were assessed at 5 time points: 1-4 weeks, 5-10 weeks, 3-5.5 months, 6-8 months and 9-12 months. At each time point, patients were evaluated for clinical success (using Odom's Criteria scoring) and safety (complication incidence). Other outcomes investigated include Operative (OP) Time, Blood Loss (BL) and Hospital Length of Stay (LOS). Data analysis was conducted in SPSS 20.0 (SPSS, Inc. Chicago, IL) and included one-way ANOVA, two-tailed t-test, and linear regression analyses. <h3>RESULTS</h3> Patients in the AP group had longer mean OP times (220 min) when compared to patients in the SA (170 min, p=0.04), SAAP (175 min, p=0.009), and APC (167 min, p=0.01) groups. The difference in mean OP time between the AP group and each of the other patient groups were statistically significant (p=0.008). A linear regression analysis showed no significant differences in the mean Odom's criteria score between the four groups (1) over time and (2) at each time point. There were four complications recorded, one per group. The complications were as follows (group in parenthesis): pulmonary embolism (AP), hematoma (SA), adjacent level disease (SAAP) and broken hardware (APC). There were no statistically significant differences between any of the patient groups regarding BL (p = 0.378) and LOS (p = 0.174). The following patient factors were controlled for in all analyses: advanced age (age greater than 65), gender, high BMI (BMI greater than 35), diabetes, osteoporosis, cardiac history (hypertension and/or myocardial infarction), sleep apnea and smoking status. None of these factors were found to have a statistically significant effect on the study outcomes. <h3>CONCLUSIONS</h3> Consistent with the literature, the OP times were longer for 3-level ACDF patients who underwent the AP technique compared to patients who underwent the SA technique. We demonstrated that patients in the AP group also had longer OP times than patients in the SAAP and APC groups. In addition, all four surgical techniques appeared to have analogous safety profiles and clinical success rates. Past studies in the literature examining the AP and SA techniques in 2-level ACDF patients have reported comparable clinical outcomes. Future studies should employ a larger sample size and investigate radiological outcomes such as fusion rate and loss of lordosis. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

The Role of Cervical Muscles Morphology in the Surgical Treatment of Degenerative Disc Disease: Clinical Correlations Based on Magnetic Resonance Imaging Studies.

Cervical spine musculature still remains a less studied component of the cervical spine anatomical compartments, although it plays a significant role in the mobility of the head and the preservation of cervical spine alignment. The goal of this study was to extract any significant information from the literature regarding the role of cervical spine muscles morphology in the outcome of surgically treated patients for degenerative disc disease (DDD) based on preoperative magnetic resonance imaging (MRI) studies. Eleven clinical case series were found, from which four were prospective and seven were retrospective. Six studies were concentrated on anterior approaches and five studies on posterior approaches in the cervical spine. In posterior approaches aiming at the preservation of muscles attachments and overall less surgical manipulations, results on cervical lordosis, axial pain and patient’s functionality were found superior to traditional laminectomies. The study of cross-sectional areas (CSAs) of deep paraspinal muscles in the cervical spine could add significant information for the spine surgeon such as the prediction of adjacent level disease (ALD), fusion failure, axial pain persistence, postoperative cervical alignment and patient’s postoperative functionality. It seems that MRI studies focusing on muscle layers of the cervical spine could add significant information for the spinal surgeon regarding the final surgical outcome in terms of pain and function expression. Larger multicenter clinical studies are a necessity in defining the role of the muscle component of the cervical spine in the surgical treatment of DDD.

Are Lumbar Fusion Guidelines Followed? A Survey of North American Spine Surgeons.

ObjectiveTo evaluate the use of guidelines for lumbar spine fusions among spine surgeons in North America. MethodsAn anonymous survey was electronically sent to all AO Spine North America members. Survey respondents were asked to indicate their opinion surrounding the suitability of instrumented fusion in a variety of clinical scenarios. Fusion indications in accordance with North America Spine Society (NASS) guidelines for lumbar fusion were considered NASS-concordant answers. Respondents were considered to have a NASS-concordant approach if ≥ 70% (13 of 18) of their answers were NASS-concordant answers. Comparisons were performed using bivariable statistics. ResultsA total of 105 responses were entered with complete data available on 70. Sixty percent of the respondents (n = 42) were considered compliant with NASS guidelines. NASS-discordant responses did not differ between surgeons who stated that they include the NASS guidelines in their decision-making algorithm (5.10 ± 1.96) and those that did not (4.68 ± 2.09) (p = 0.395). The greatest number of NASS-discordant answers in the United States. was in the South (5.75 ± 2.09), with the lowest number in the Northeast (3.84 ± 1.70) (p < 0.01). For 5 survey items, rates of NASS-discordant answers were ≥ 40%, with the greatest number of NASS-discordant responses observed in relation to indications for fusion in spinal deformity (80%). Spine surgeons utilizing a NASS-concordant approach had a significant lower number of NASS-discordant answers for synovial cysts (p = 0.03), axial low back pain (p < 0.01), adjacent level disease (p < 0.01), recurrent stenosis (p < 0.01), recurrent disc herniation (p = 0.01), and foraminal stenosis (p < 0.01). ConclusionThis study serves an important role in clarifying the rates of uptake of clinical practice guidelines in spine surgery as well as to identify barriers to their implementation.