Anterior Cervical Discectomy And Fusion Research Articles

Cannabis use is associated with decreased opioid prescription fulfillment following single level anterior cervical discectomy and fusion (ACDF)

Recently, there has been increasing legalization of marijuana within the United States, however data are mixed with respect to its efficacy in treating acute pain. Our goal was to identify a difference in opioid utilization in patients with known cannabis use before anterior cervical discectomy and fusion (ACDF) compared with those that report no cannabis use. This study was a retrospective case-control design using PearlDiver. Patients who underwent a single level ACDF between January 2010 and October 2020, were included. Patients were placed in the study group if they had a previous diagnosis of cannabis use, dependence, or abuse. Patients were excluded if they were under the age of 18 or if they had filled an opioid prescription within 3 months of their procedure. A control group was then created using a propensity score match on age, gender, and Charleston comorbidity index (CCI), and had no diagnosis of cannabis use. The primary outcome was the number of morphine milliequivalents (MME) dispensed per prescription following surgery. A total of 1,339 patients were included in each group. The number of patients filling prescriptions was lower in the cannabis group than in the control group at 3 days postoperatively (p<.001). The average total MME per day as prescribed was lower in the cannabis group than the control group at 60 days post-op (48.5 vs. 59.4, respectively; p=.018). Patients who had a previous diagnosis of cannabis use, dependence or abuse filled fewer opioid prescriptions postoperatively (at 3 days postoperatively) and required lower doses (reduced average daily MME, at 60 days postoperatively) when compared with the control group.

A Novel Classification of Cervical Spine Trauma in Ankylosing Spondylitis and Corresponding Surgical Outcomes

Currently, there are no reports on the specific classification of cervical spine trauma (CST) in ankylosing spondylitis (AS) based on the trauma mechanism. In this study, we aimed to describe a novel classification of CST in AS with more details, and put forward the corresponding surgical outcomes related to different types, hoping to provide a practical reference for clinical decision-making and academic communication. From January 2008 to December 2021, AS patients who experienced CST were retrospectively reviewed and included. Clinical data including gender, age, reason of trauma, time interval between AS diagnosis and trauma were collected. The American Spinal Injury Association (ASIA) grade system was used to describe patients' neurological status. Based on the combination of surgical experience and follow-up observation, the lower cervical spine trauma in AS patients was divided into three main types, namely single level fracture-dislocation (type 1), spinal cord injury without fracture-dislocation (type 2), and Andersson lesion (type 3). Furthermore, we performed detailed subtypes according to whether cervical spine was completely fused and the location of injury. Meanwhile, according to different approaches, surgical methods mainly included Anterior Cervical Discectomy and Fusion (ACDF), Anterior Cervical Corpectomy and Fusion (ACCF), Posterior Expansive Open-door Cervical Laminoplasty (PEOLP), Posterior Cervical Laminectomy Decompression and Fusion (PCLDF), and their combination. Postoperative general and surgery-related complications were also recorded. A total of 102 patients were enrolled, including 91 males and 11 females, with an average age of 51.9 years. Their average interval time between AS diagnosis and injury was 27.8 years. Patients with high-energy and low-energy trauma were 54 and 48 respectively. There were 79 patients suffering spinal cord nerve impairment after trauma. With regard to the distribution of different types, the number of patients in type 1, type 2, and type 3 were 86, 14, and two, respectively. For different types, PCLDF was the most commonly used surgical method, accounting for 55.9%, while ACCF was only applied for one time. In type 1, the frequencies of ACDF, ACCF, PCLDF, and ACDF+PCLDF were 10.5%, 1.2%, 55.8%, and 32.5%. In type 2, the frequencies of ACDF, PCLDF, ACDF+PCLDF, and PEOLP were 7.1%, 50.0%, 7.1%, 35.8%. Postoperatively, 21 patients achieved neurological function improvement. The incidences of general and surgery-related complications were 19.6% and 5.9%, respectively. All patients achieved bone fusion and durable decompression at the last follow-up. Our novel classification could enrich the scope of CST in AS patients and provide valuable references to the corresponding clinical management. Besides, there are strict indications of different surgical methods, factors like patient's physical condition, trauma type, surgical purpose, and expected efficacy were all required to consider before making a clinical decision.

Cervical Discometry: A Useful Technique for an Anterior Cervical Discectomy and Fusion.

Anterior cervical discectomy and fusion (ACDF), which is widely used in the treatment of cervical spondylosis, may cause complications such as adjacent segment degeneration (ASD). However, such studies on complications are limited, and quantitative evidence is still lacking. To evaluate the clinical value of cervical discometry combined with adjacent intraoperative intradiscal pressure in cervical vertebral surgery through clinical explorations. In this retrospective study, 100 patients who were treated with anterior decompression, reconstruction, and internal fixation, were enrolled. Among them, 50 patients received ACDF combined with perioperative pressure adjustment of the adjacent segments to ensure that the pressure difference was less than 5 mmHg. The other 50 patients who had only simple ACDF were considered as the control group. Patient information, radiographic changes, axial symptoms (AS), and the occurrence of ASD were recorded in the study. The degree of lordosis (D values) at postoperative of all cases were positive. The D value of the two groups of patients immediately after the operation and at the last follow-up were significantly higher than that before the operation (P < 0.05). The incidence of AS was significantly lower in the experimental group than that in the control group (P < 0.05). Besides, there were only 10 patients in the experimental group during the five-year follow-up period, which was significantly lower than the 19 patients in the control group (P < 0.05). The intraoperative intervertebral disc pressure measurement could effectively monitor the vertebral body distraction strength and reduce the incidence of postoperative AS and ASD.

Relative Efficacy of Cervical Total Disc Arthroplasty Devices and Anterior Cervical Discectomy and Fusion for Cervical Pathology: A Network Meta-Analysis.

Systematic Review and Meta Analysis. This study sought to compare patient-reported outcomes, success, complications, and radiographic outcomes directly and indirectly between different cervical total disc arthroplasty (TDA) devices and anterior cervical discectomy and fusion (ACDF). Patients of prospective randomized controlled trials of 1-level cervical TDA with a minimum of 2years follow up were identified in the literature. A frequentist network meta-analysis model was used to compare each outcome across the different TDA devices included and ACDF using the mixed effect sizes. 15 studies were included for quantitative analysis, reporting the outcomes of 2643 patients with an average follow-up was 67.3months (range: 24-120months), 1417 of whom underwent TDA and 1226 of whom underwent ACDF. Nine TDA devices were compared to ACDF, including the Bryan, Discover, Kineflex, M6, Mobi-C, PCM, Prestige ST, ProDisc-C, and Secure-C cervical prostheses. Several devices outperformed ACDF for certain outcomes, including Visual Analog Scale (VAS) Arm, Physical Component Score of the Short-Form Health Survey (SF PCS), neurological success, satisfaction, index-level secondary surgical interventions (SSI), and adjacent level surgeries. Cumulative ranking of each intervention assessed demonstrated the highest performance with the M6 prosthesis (P = .70), followed by Secure-C (P = .67), PCM (P = .57), Prestige ST (P = .57), ProDisc-C (P = .54), Mobi-C (P = .53), Bryan (P = .49), Kineflex (P = .49), Discover (P = .39), and ACDF (P = .14). Cervical TDA was found to be superior on most outcomes assessed in the literature of high-quality clinical trials. While most devices demonstrated similar outcomes, certain prostheses such as the M6 were found to outperform others across several outcomes assessed. These findings suggest that the restoration of near-normal cervical kinematics may lead to improved outcomes.

Predicting surgical outcome and sagittal alignment change in patients with cervical spondylosis and degenerative kyphosis after anterior cervical discectomy and fusion

The aim of this study was to forecast the risk factors of poor outcomes and postoperative loss of lordosis or recurrence of kyphosis. In this retrospective study, 101 patients with cervical spondylosis and preoperative kyphosis who underwent anterior cervical discectomy and fusion (ACDF) were enrolled, between June 2015 and June 2019. Patients were grouped according to the recovery rate of Japanese Orthopaedic Association (JOA) score whether more than 50%, and the change of postoperative cervical Cobb angle. There were 22 cases with less than 50% of recovery rate and 35 cases with the worsening of postoperative sagittal alignment (WPSA). Multivariate linear-regression analysis was conducted with the data. Advanced age (p = 0.019), longer duration of symptoms (p = 0.003) and loss of local Cobb angle (LCA) after surgery (p = 0.031) was significantly associated with a poor clinical outcome. A whole kyphosis (p = 0.009), aggravated neck pain after surgery (p = 0.012), preoperative lower thoracic 1 (T1) (p < 0.001), bigger change of C2-7 sagittal vertical axis (SVA) (p = 0.008) and adjacent segment degeneration (ASD) (p = 0.024) was significantly associated with the WPSA. Preoperative health education, nutritional support and early postoperative rehabilitation intervention, in perioperative period, were recommended for patients with advance age, longer duration of symptoms, whole cervical kyphosis and lower T1. Postoperative sagittal malalignment was related to neck pain and ASD after surgery.

Thermal Generation in Spinal Surgery: Does Rate of Irrigation Matter During Anterior Cervical Discectomy?

High-speed rotational burring is considered the mainstay of modern spinal decompression surgery. However, high-energy burrs generate significant heat due to the friction between the bone and the rotating burr. This study determines the effects of automated irrigation rate on burr tip temperatures either with a serrated steel burr or diamond-coated burr during anterior cervical discectomy and fusion (ACDF). This is an observational study of the routine practice of a single surgeon for 20 patients aged 18 years or older undergoing elective single- or multilevel ACDF. Various continuous irrigation rates of 0, 0.5, 1.0, or 2.0 cc/min were used. Forward-looking infrared thermography was used to measure the burr tip temperatures. The Midas Rex Legend EHS (Medtronic, PLC, Minneapolis, MN) stylus high-speed surgical drill was used with 3-mm burrs (diamond-coated and carbide-serrated steel) paired to the Medtronic Integrated Power Console set at 60,000 rpm. The 0.5-cc/min irrigation rate kept the maximum burr temperatures below 45°C (P < .001). With no irrigation (0 cc/min), the steel burrs reached a maximum of 141°C, and the diamond-coated burrs reached 177°C, which was the only significant difference related to the burr materials (P = 0.0354). With irrigation rates of 0.5 cc/min and above, the maximum recorded temperature for steel burrs was 40.6°C, and the maximum temperature for diamond-coated burrs was 38.9°C. Irrigation rates greater than 0.5 cc/min yielded little additional benefit. This study highlights the importance of adequate irrigation during high-speed burr drilling. Continuous irrigation is recommended even as low as 0.5 cc/min. It is good operative practice to reduce the risk of heat transmission to surrounding tissues, especially considering the proximity of cervical spinal nerve roots during uncoforaminal decompression.

Long-term results comparison after anterior cervical discectomy with BGS-7 spacer (NOVOMAX®-C) and allograft spacer: A prospective observational study.

Introduction: In an anterior cervical discectomy and fusion (ACDF), various types of graft materials including autograft, allograft, and synthetic graft have been used to achieve adequate spinal fusion. Allograft spacer is mainly used in cervical fusion, especially in the anterior approach. The synthetic bone graft material BGS-7(CaO-SiO2-P2O5-B2O3, bioactive Glass-Ceramics) can bind with surrounding bone tissue by forming a hydroxyapatite layer bone bridge, leading to faster graft osseointegration. This study was conducted to compare long-term clinical outcome of BGS-7 spacer and allograft spacer for anterior cervical discectomy and fusion surgery. Materials and Methods: From September 2014 to December 2016, Consecutive anterior cervical discectomy and fusion surgeries using a BGS-7 spacer (N = 18) and Allograft spacer (N = 26) were compared for postoperative clinical outcomes. Radiologic assessments were performed, and Instrumental failure, including breakage, cage migration, subsidence were observed and Fusion status were analyzed. Finite element analysis was performed for simulating mechanical stress between the vertebral body and implant. Clinical outcomes were evaluated using neck VAS, NDI, and JOA on the patient's final follow-up visits. Results: Among the 44 patients who underwent an anterior cervical discectomy and fusion surgery using the BGS-7 spacer and Allograft spacer, there were 30 men and 14 women. The average age at the operation was 47.69 ± 10.49 in allograft spacer and 51.67 ± 11.03 in BGS-7 spacer. The mean follow-up period was 89.18 ± 5.44months. Twenty three (88.46%) patients in allograft spacer and 20(100%) patients in BGS-7 spacer were demonstrated radiologic evidence of interbody fusion in last OPD, which accounts for fusion grade 4 or 5. Peak stresses were 343.85MPa in allograft spacer, and 132.55MPa in BGS-7 spacer. Long-term clinical outcomes including neck VAS, NDI, and JOA didn't show statistical differences between the two groups. There were no adverse events related to the BGS-7 spacer.10.3389/fbioe.2023.110046. Conclusion: The BGS-7 spacer demonstrated reliability as a spacer in anterior cervical discectomy and fusionF surgery without instrumental failure. Early stabilization with a bony bridge formation was observed at the intermediate follow-up period, and the long-term clinical outcome was favorable at more than 60months after surgery without any adverse events. Thus, the BGS-7 spacer is a safe and effective alternative to the allograft spacer in anterior cervical discectomy and fusion surgery.

Disparities in anterior cervical discectomy and fusion provision and outcomes for cervical stenosis

Disparities in neurosurgical care have emerged as an area of interest when considering the impact of social determinants on access to health care. Decompression via anterior cervical discectomy and fusion (ACDF) for cervical stenosis (CS) may prevent progression towards debilitating complications that may severely compromise one's quality of life. This retrospective database analysis aims to elucidate demographic and socioeconomic trends in ACDF provision and outcomes of CS-related pathologies. The Healthcare Cost and Utilization Project National Inpatient Sample database was queried between 2016 and 2019 using International Classification of Diseases 10th edition codes for patients undergoing ACDF as a treatment for spinal cord and nerve root compression. Baseline demographics and inpatient stay measures were analyzed. Patients of White race were significantly less likely to present with manifestations of CS such as myelopathy, plegia, and bowel-bladder dysfunction. Meanwhile, Black patients and Hispanic patients were significantly more likely to experience these impairments representative of the more severe stages of the degenerative spine disease process. White race conferred a lesser risk of complications such as tracheostomy, pneumonia, and acute kidney injury in comparison to non-white race. Insurance by Medicaid and Medicare conferred significant risks in terms of more advanced disease prior to intervention and negative inpatient. Patients in the highest quartile of median income consistently fared better than patients in the lowest quartile across almost every aspect ranging from degree of progression at initial presentation to incidence of complications to healthcare resource utilization. All outcomes for patients age > 65 were worse than patients who were younger at the time of the intervention. Significant disparities exist in the trajectory of CS and the risks associated with ACDF amongst various demographic cohorts. The differences between patient populations may be reflective of a larger additive burden for certain populations, especially when considering patients' intersectionality.

Quantifying the Opportunity Cost of Neurosurgical Resident Education

Education is at the core of neurosurgical residency, but little research in to the cost of neurosurgical education exists. This study aimed to quantify costs of resident education in an academic neurosurgery program using traditional teaching methods and the Surgical Autonomy Program (SAP), a structured training program. SAP assesses autonomy by categorizing cases into zones of proximal development (opening, exposure, key section, and closing). All first-time, 1-level to 4-level anterior cervical discectomy and fusion (ACDF) cases between March 2014 and March 2022 from 1 attending surgeon were divided into 3 groups: independent cases, cases with traditional resident teaching, and cases with SAP teaching. Surgical times for all cases were collected and compared within levels of surgery between groups. The study found 2140 ACDF cases, with 1758 independent, 223 with traditional teaching, and 159 with SAP. For 1-level to 4-level ACDFs, teaching took longer than it did with independent cases, with SAP teaching adding additional time. A 1-level ACDF performed with a resident (100.1 ± 24.3 minutes) took about as long as a 3-level ACDF performed independently (97.1 ± 8.9 minutes). The average time for 2-level cases was 72.0 ± 18.2 minutes independently, 121.7 ± 33.7 minutes traditional, and 143.4 ± 34.9 minutes SAP, with significant differences among all groups. Teaching takes significant time compared with operating independently. There is also a financial cost to educating residents, because operating room time is expensive. Because attending neurosurgeons lose time to perform more surgeries when teaching residents, there is a need to acknowledge surgeons who devote time to training the next generation of neurosurgeons.

Up to 10-year surveillance comparison of survivability in single-level cervical disc replacement versus anterior cervical discectomy and fusion in New York.

Cervical disc replacement (CDR) is an alternative treatment to anterior cervical discectomy and fusion (ACDF), which is the current gold standard, for degenerative cervical diseases such as cervical spondylotic myelopathy and cervical radiculopathy. CDR has several theoretical benefits over ACDF, including preservation of motion, earlier return to unrestricted activity, and potentially a lower risk of adjacent-segment disease. Recent literature has reported positive clinical results for CDR, but few studies have investigated the long-term risk of revision surgery of CDR versus ACDF. The purpose of this study was to identify and analyze the epidemiological, clinical, and operative risk factors that affect revision rates following single-level CDR and ACDF procedures. A retrospective cohort was extracted from the Statewide Planning and Research Cooperative System using ICD-9 and CPT codes. Inclusion criteria were adult patients undergoing primary, subaxial (C3-7), single-level ACDF or CDR for cervical radiculopathy and/or cervical spondylotic myelopathy between 2005 and 2013. Survivability was defined as the time between the index procedure and the presence of a subsequent discharge record for cervical spinal fusion or disc replacement. Statistical analyses were performed using chi-square tests, t-tests, Cox proportional hazards models, and a Kaplan-Meier plot. A total of 7450 patients were included in this study (6615 ACDF and 835 CDR). When adjusted for patient demographics, the hazard ratios showed no significant differences in the incidence of revision risk between the two cohorts. The CDR cohort had a higher incidence of postoperative dysphagia (p < 0.05). Patients undergoing ACDF had a longer average hospital stay (2.8 vs 1.9 days, p < 0.001). There was no significant difference in time to revision surgery (p = 0.486). CDR and ACDF have both been shown to be effective treatments for cervical spine disease. CDR patients had a shorter average inpatient hospital stay compared with ACDF patients but tended to experience dysphagia more frequently. There was a tendency toward increased survivability of CDR; however, this was not found to be statistically significant at any time point. The large size and heterogeneity of each cohort and the availability of > 10 years of surveillance data differentiate this study from other published literature. This investigation has limitations inherent to large data analysis studies, including the implementation and inaccuracy of diagnosis and procedural coding; however, this reflects real-world use of coding by practitioners.

Cervical Disc Arthroplasty vs Anterior Cervical Discectomy and Fusion at 10 Years: Results From a Prospective, Randomized Clinical Trial at 3 Sites

Over the past 20 years, multiple randomized controlled trials have shown cervical disc arthroplasty (CDA) to be safe and effective for treating 1- and 2-level degenerative disc disease (DDD). The purpose of this postmarket study is to compare 10-year outcomes between CDA and anterior cervical discectomy and fusion (ACDF) from a randomized study at 3 centers. This study was a continuation of a randomized, prospective, multicenter clinical trial comparing CDA with the Mobi-C cervical disc (Zimmer Biomet) vs ACDF. Following completion of the 7-year US Food and Drug Administration study, 10-year follow-up was obtained from consenting patients at 3 high-enrolling centers. The clinical and radiographic endpoints collected at 10 years included composite success, Neck Disability Index, neck and arm pain, short form-12, patient satisfaction, adjacent-segment pathology, major complications, and subsequent surgery. A total of 155 patients were enrolled (105 CDA; 50 ACDF). Follow-up was obtained from 78.1% of patients eligible after 7 years. At 10 years, CDA demonstrated superiority to ACDF. Composite success was 62.4% in CDA and 22.2% in ACDF (P < 0.0001). The cumulative risk of subsequent surgery at 10 years was 7.2% vs 25.5% (P = .001), and the risk of adjacent-level surgery was 3.1% vs 20.5% (P = .0005) in CDA vs ACDF, respectively. The progression to radiographically significant adjacent-segment pathology at 10 years was lower in CDA vs ACDF (12.9% vs 39.3%; P = 0.006). At 10 years, patient-reported outcomes and change from baseline were generally better in CDA patients. A higher percentage of CDA patients reported they were "very satisfied" at 10 years (98.7% vs 88.9%; P = 0.05). In this postmarket study, CDA was superior to ACDF for treating symptomatic cervical DDD. CDA was statistically superior to ACDF for clinical success, subsequent surgery, and neurologic success. Results through 10 years demonstrate that CDA continues to be a safe and effective surgical alternative to fusion. The results of this study support the long-term safety and effectiveness of cervical disc arthroplasty with the Mobi-C.

407 Anterior Cervical Discectomy and Fusion in Ambulatory Surgery Center Versus Hospital Setting: One-Year Cost Utility and Cost Benefit Analysis

INTRODUCTION: Outpatient anterior cervical discectomy and fusion (ACDF) has recently gained popularity due to improved care and reduced costs. Cost-utility studies for ambulatory vs. inpatient ACDF are largely limited to small series, precluding an accurate assessment of cost-effectiveness. METHODS: A 6,504, ASA 1-3, patient sample (520 ASC, 5,984 inpatient) was used to propensity-match 748 patients (374/cohort) undergoing 1-2-level ACDF. Data was queried from the National Quality Outcomes Database (QOD). Medical resource utilization, missed work, and quality adjusted life years (QALYs) were assessed. Direct cost (one-year resource use x unit costs based on Medicare national allowable payment amounts) and indirect cost (missed workdays x average US daily wage) were recorded and incremental cost-effectiveness ratio was calculated. RESULTS: Estimated blood loss, length of surgery, and hospitalization were less for ASC vs. inpatient ACDF (p &lt; 0.001). ASC vs. inpatient ACDF demonstrated similar improvement in patient reported outcomes. ASC vs. inpatient ACDF was associated with lower total one-year cost of $5,879.46 for Medicare patients and $12,873.97 for private payers (p &lt; 0.001), with similar QALYs gained. Hospital vs ASC had a highly cost ineffective ICER of $3,674,662.50/QALY-gained and $8,046,231.25/QALY for Medicare and private payer patients, respectively. CONCLUSIONS: 1-2-level ACDF in the hospital vs ASC is associated with increased mean costs, without a QALY, safety, or outcome benefit. Hence, health economics strongly favor the ASC setting to the hospital for ACDF.

Esophageal Perforation in a 76-Year-Old Man After C5-C7 Anterior Discectomy and Anterior Plate Fusion

Anterior cervical discectomy and fusion (ACDF) is indicated for the treatment of various cervical pathologies, including myelopathy, cervical disc degeneration, and radiculopathy. Esophageal perforation is a rare postsurgical complication of ACDF, although it poses serious and potentially fatal outcomes. Esophageal perforation has been described as the most fatal complication of the gastrointestinal tract as delayed diagnosis can lead to sepsis and death. Diagnosis of this complication is often difficult because it can be masked by various symptoms such as recurrent aspiration pneumonia, fever, dysphagia, and neck pain. While this complication usually occurs within the first 24 h post-surgery, it can also develop later and persist chronically in rare cases. Awareness and early recognition of this complication may improve outcomes and reduce mortality and morbidity. A 76-year-old man underwent C5-C7 ACDF in October 2017. A thorough review of the patient's postoperative condition included computed tomography (CT) and esophagogram, which were negative for signs of acute complications. The postoperative recovery was uneventful until several months post-procedure when he began to develop vague dysphagia and weight loss of unknown etiology. A CT scan was obtained 6 months postoperatively and was negative for perforation. He then underwent a battery of inconclusive procedures and scans at multiple institutions. After several months of persistent dysphagia and weight loss without a diagnosis, the patient presented to our network for further workup and treatment recommendations. Upper endoscopy was performed and showed fistulization between the esophagus and the metal hardware in the cervical spine. Esophagram demonstrated no obstruction but decreased peristalsis of the lower esophagus and lateral rightward deviation of the left upper cervical esophagus with minimal mucosal irregularities. These findings were secondary to mass effect of the cervical plate. The patient was successfully treated with a surgical approach using esophagogastroduodenoscopy (EGD) guided repair in layers and a sternocleidomastoid muscle flap. This report demonstrates a rare case of delayed esophageal perforation after ACDF and successful treatment of the perforation by surgical repair using the dual technique.

Anterior Cervical Discectomy and Fusion Versus Microendoscopic Posterior Cervical Foraminotomy for Unilateral Cervical Radiculopathy: A 1-Year Cost-Utility Analysis.

Anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy (PCF) are the most common surgical approaches for medically refractory cervical radiculopathy. Rigorous cost-effectiveness studies comparing ACDF and PCF are lacking. To assess the cost-utility of ACDF vs PCF performed in the ambulatory surgery center setting for Medicare and privately insured patients at 1-year follow-up. A total of 323 patients who underwent 1-level ACDF (201) or PCF (122) at a single ambulatory surgery center were compared. Propensity matching generated 110 pairs (220 patients) for analysis. Demographic data, resource utilization, patient-reported outcome measures, and quality-adjusted life-years were assessed. Direct costs (1-year resource use × unit costs based on Medicare national allowable payment amounts) and indirect costs (missed workdays × average US daily wage) were recorded. Incremental cost-effectiveness ratios were calculated. Perioperative safety, 90-day readmission, and 1-year reoperation rates were similar between groups. Both groups experienced significant improvements in all patient-reported outcome measures at 3 months that was maintained at 12 months. The ACDF cohort had a significantly higher preoperative Neck Disability Index and a significantly greater improvement in health-state utility (ie, quality-adjusted life-years gained) at 12 months. ACDF was associated with significantly higher total costs at 1 year for both Medicare ($11 744) and privately insured ($21 228) patients. The incremental cost-effectiveness ratio for ACDF was $184 654 and $333 774 for Medicare and privately insured patients, respectively, reflecting poor cost-utility. Single-level ACDF may not be cost-effective in comparison with PCF for surgical management of unilateral cervical radiculopathy.

Removal of a Floating and Migrated Plate Screw in a Patient with a Failed Anterior Cervical Discectomy and Fusion

Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure for degenerative cervical spine disease. Rare complications of ACDF surgery include hardware failure, in the form of screw loosening and migration, or rod breakage. We present a case in which we removed a migrated screw lodged in the esophagus from a patient with a failed anterior cervical fusion. To present a surgical technique and considerations to remove a migrated screw. The previous ACDF incision was reopened and exposure was gained under the guidance of a head and neck surgeon. Longus coli were mobilized off the spine bilaterally with electrocautery. After dissection, the screw was found lodged in the longitudinal muscle of the esophageal wall and excised with the use of a 15-blade. The integrity of the esophageal mucosa and submucosa was maintained and subsequently checked with rigid esophagoscopy. Fluoroscopy was used to confirm that all hardware was removed, with the exception of the anterior cages. The dislodged screw, which was embedded in the esophagus, was successfully removed. Failure of an ACDF carries a risk of screw migration, which may be asymptomatic even if the screw is lodged in the esophagus. Additional considerations are required with potential violations of the adjacent viscera.

Comparison of Single-Level Posterior Cervical Foraminotomy to Anterior Cervical Discectomy and Fusion for Radiculopathy.

Posterior cervical foraminotomy (PCF) and anterior cervical discectomy and fusion (ACDF) are 2 commonly used surgical approaches to address cervical radiculopathy. Demonstrating superiority in clinical outcomes and durability of one of the approaches could change clinical practice on a large scale. This is the largest reported single-institutional retrospective cohort of single-level PCFs compared with single-level ACDFs for cervical radiculopathy. Patients undergoing either ACDF or PCF between 2014 and 2021 were identified using Current Procedural Terminology codes. Medical records were reviewed for demographics, surgical characteristics, and reoperations. Statistical analysis included t tests for continuous characteristics and c2 testing for categorical characteristics. In total, 236 single-level ACDFs and 138 single-level PCFs were included. There was no significant difference in age (51.0 vs 51.3 years), body mass index (BMI; 28.6 vs 28.1), or Charlson Comorbidity Index (1.89 vs 1.68) between patients who underwent ACDF and those who underwent PCF. There was no difference in the rate of reoperation (5.1% vs 5.1%), time to reoperation (247 vs 319 days), or reoperation for recurrent symptoms (1.7% vs 2.9%) for ACDF vs PCF. Hospital length of stay (LOS) was longer for ACDF compared with PCF (1.65 vs 1.35 days, P = 0.041), and the overall readmission rate after ACDF was 20.8% vs 10.9% after PCF (P = 0.014). Overall reoperation rates or reoperation for recurrent symptoms between ACDF and PCF were not significantly different, demonstrating that either procedure effectively addresses the indication for surgery. There was a significantly longer LOS after ACDF than PCF, and readmission rates at 90 days and 1 year were higher after ACDF.

Surgical Management of Hangman's Fracture: A Systematic Review.

Hangman's fractures are bilateral fractures of the C2 pars interarticularis produced during hyperextension injuries. The Levine-Edwards classification divides these fractures into 4 categories determined by injury stability. While stable fracture patterns are typically managed conservatively, prolonged traction required in unstable fractures may be superseded by surgery in its practicality. Surgical approaches can be divided into anterior and posterior: the anterior approach allows access to the disc and is used for anterior cervical discectomy and fusion (ACDF); the posterior approach includes C2 direct pedicle screw (DPS), which preserves motion segments and may be done with a minimally invasive surgery (MIS) approach. Multilevel rod and screw fusion provide the strongest biomechanical fixation. This systematic review compares indications, complications, and functional outcomes of different approaches. A search of multiple databases with keywords "hangman fracture," "hangman's fracture," "axis fracture," and "C2 fracture" was conducted; articles were included if they described the surgical technique and included at least one of the primary outcomes: functional outcomes, complication rates, operation time, and blood loss. A total of 1889 abstracts were screened, 137 full text articles were analyzed, and 36 articles were included, yielding a combined total of 627 patients. ACDF was preferred in unstable fracture patterns. Pre- and postoperative visual analog scale (VAS) scores fell in all groups, with MIS DPS producing the lowest VAS scores. Approaches had excellent neurological improvement and fusion rates. Reported complication rates were generally low; self-limiting dysphagia was most common in the anterior approach and higher volumes of blood loss occured with the posterior approach (255.9 mL in open posterior approach, 75.8 mL in MIS, and 64.3 mL in ACDF). All surgical methods of hangman's fracture fixation have their indications and advantages; surgeons should be equipped to perform all options. Anterior approaches may be preferred for their lower blood loss and access to the disc; however, MIS may improve outcomes in posterior approach. This systematic review can assist spinal surgeons in the selection of the most appropriate surgical option for hangman's fracture and allow surgeons to inform patients of the risks and benefits.

Complications and Reoperation Following Surgery for Concurrent Carpal Tunnel and Cervical Spine Compression.

Patients with carpal tunnel syndrome (CTS) may also have cervical radiculopathy (CR) or vice versa, potentially requiring carpal tunnel release (CTR) and anterior cervical discectomy and fusion (ACDF). This study evaluates whether there is an increased risk of complications following CTR or ACDF in patients with concurrent CTS and CR (CTS-CR) compared with those with only CTS or CR. A multipayer database was used to identify patients with CTS-CR. From this cohort, patients who underwent CTR and/or ACDF were identified. Patients with CTS-CR undergoing surgery were compared with those undergoing surgery with only CTS or CR. Multivariable logistic regression was used to compare matched populations to assess postoperative complications and risk of undergoing both procedures. A total of 110 379 patients with CTS-CR were identified. Carpal tunnel release was performed in 21 152 patients (19.2%) with CTS-CR, from which 835 (0.76%) underwent ACDF. Anterior cervical discectomy and fusion was performed in 6960 patients (6.31%) with CTS-CR followed by CTR in 1098 patients (0.99%). Patients with CTS-CR were at greater risk of reoperation and complex regional pain syndrome following CTR. In ACDF, patients with CTS-CR were at greater risk of reoperation. Obesity and tobacco use were significant risk factors in patients with CTS-CR who underwent both CTR and ACDF rather than a single surgery. Examination of more than 100 000 patients with CTS-CR found a greater likelihood of reoperation and perioperative complications following surgery than those without concurrent diagnoses. Obesity and smoking increased the risk for patients undergoing both procedures. Patients presenting with CTS-CR are high risk and should be counseled on risk of complication and reoperation and optimized to reduce risk of undergoing both CTR and ACDF.

Early postoperative MRI findings following anterior cervical discectomy and fusion: What to expect when the unexpected happens

BackgroundMagnetic resonance imaging (MRI) is not routinely ordered following spinal fusion. Some literature suggests MRIs are unhelpful due to postoperative changes that obscure interpretation. We aim to describe findings of acute postoperative MRI following anterior cervical discectomy and fusion (ACDF). MethodsThe authors retrospectively analyzed adult MRIs completed within 30 days of ACDF (from 2005–2022). T1 and T2 signal intensity in the interbody space dorsal to the graft, mass effect on the dura/spinal cord, intrinsic spinal cord T2 signal, and interpretability were reviewed. ResultsIn 38 patients there were 58 ACDF levels (1, 2, and 3 levels; 23, 10, and 5, respectively). MRIs were completed on mean postoperative day 8.37 (range; 0–30 days). T1-weighted imaging was described as isointense, hyperintense, heterogenous, and hypointense in 48 (82.8%), 5 (8.6%), 3 (5.2%), and 2 levels (3.4%), respectively. T2-weighted imaging was described as hyperintense, heterogenous, isointense, and hypointense in 41 (70.7%), 12 (20.7%), 3 (5.2%), and 2 levels (3.4%), respectively. There was no mass effect in 27 levels (46.6%), 14 (24.1%) had thecal sac compression, and 17 (29.3%) had cord compression. ConclusionsThe majority of MRIs exhibited readily compression and intrinsic spinal cord signal even with various types of fusion constructs. Early MRI after lumbar surgery can be difficult to interpret. However, our results support the use of early MRI to investigate neurological complaints following ACDF. Our findings do not support the idea that epidural blood products and mass effect on the cord are seen in most postoperative MRIs after ACDF.

Using Machine Learning and Deep Learning Algorithms to Predict Postoperative Outcomes Following Anterior Cervical Discectomy and Fusion.

A retrospective cohort study from a multisite academic medical center. To construct, evaluate, and interpret a series of machine learning models to predict outcomes related to inpatient health care resource utilization for patients undergoing anterior cervical discectomy and fusion (ACDF). Reducing postoperative health care utilization is an important goal for improving the delivery of surgical care and serves as a metric for quality assessment. Recent data has shown marked hospital resource utilization after ACDF surgery, including readmissions, and ED visits. The burden of postoperative health care use presents a potential application of machine learning techniques, which may be capable of accurately identifying at-risk patients using patient-specific predictors. Patients 18-88 years old who underwent ACDF from 2011 to 2021 at a multisite academic center and had preoperative lab values within 3 months of surgery were included. Outcomes analyzed included 90-day readmissions, postoperative length of stay, and nonhome discharge. Four machine learning models-Extreme Gradient Boosted Trees, Balanced Random Forest, Elastic-Net Penalized Logistic Regression, and a Neural Network-were trained and evaluated through the Area Under the Curve estimates. Feature importance scores were computed for the highest-performing model per outcome through model-specific metrics. A total of 1026 cases were included in the analysis cohort. All machine learning models were predictive for outcomes of interest, with the Random Forest algorithm consistently demonstrating the strongest average area under the curve performance, with a peak performance of 0.84 for nonhome discharge. Important features varied per outcome, though age, body mass index, American Society of Anesthesiologists classification >2, and medical comorbidities were highly weighted in the studied outcomes. Machine learning models were successfully applied and predictive of postoperative health utilization after ACDF. Deployment of these tools can assist clinicians in determining high-risk patients. III.