Degenerative Cervical Pathology Research Articles

Can Frailty Predict 90-Day Postoperative Outcome in Elderly Patients with Degenerative Cervical Spine Pathology?

Abstract Background: Age and general health status are major points of concern in the decision-making process when it comes to cervical spine surgeries in the elderly. While there have been studies on the various frailty indices in their ability to predict outcomes in spine surgery, there have been few articles that have investigated the utility of the 5-point modified Frailty Index (mFI-5) for this purpose. Our study attempts to have a granular view of the problem of frailty in the elderly and study the correlation between the mFI-5 and American society of anesthesiologists (ASA) classes, and the 90-day surgical outcome of patients of 60 years and above, operated for degenerative cervical spine pathologies. Materials and Methods: This is a single-center retrospective study of prospectively collected data on 41 patients aged 60 years and above who were operated at our institute between January 1, 2017, and December 31, 2022. We studied the correlation of mFI-5, ASA class and the Spinal Surgical Invasiveness Index (SII) with various outcome variables like length of hospital stay, need for ICU stay, complications, severe adverse events (Clavien Dindo grade 4 and above), re-intubation, unplanned re-admission, and need for re-operation. Results: Statistical analysis showed a significant correlation between ASA class and mFI-5 scores (Chi square test, P value: 0.0401) and between ASA scores and the need for an ICU stay (Chi square test, P value: 0.0047). SII was found to correlate with length of hospital stay (Spearman rank test, P value: 0.0037) and with need for ICU care (Mann–Whitney U test, P value 0.0422). However, there was no significant correlation between the mFI-5 scores and the outcome variables. Conclusion: Although there was no significant correlation between mFI-5 and the 90-day surgical outcome, variables like ASA and SII had a bearing on it. Thus, it can be stated that the outcome of cervical spine surgery in the elderly is multifactorial. While frailty should put the healthcare team on alert while dealing with such patients, it should not discourage them from offering a surgical solution when required, as efficient peri-operative management by the surgical, anesthesia, and critical care teams can lead to favorable 90-day outcomes.

Revision Rates After Single-Level Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion: An Observational Study With 5-Year Minimum Follow-Up.

Retrospective Case-Control study. This study aimed to compare rates and risk factors for all-cause 5-year revisions for patients undergoing primary single-level cervical disc arthroplasty (CDA) versus Anterior Cervical Discectomy and Fusion (ACDF). Prospective studies have compared patient reported outcomes, adjacent segment degeneration, and long-term revisions between CDA and ACDF. Despite these high-level evidence studies, well-powered, large investigations have not been adequately reported. A nationwide database was queried for patients undergoing primary single level CDA or ACDF for degenerative cervical spine pathology. Further inclusion criteria consisted of patients having a minimum of 5-year follow-up. Patients undergoing CDA were 1:5 ratio matched to patients undergoing ACDF by age, sex, comorbidities, and overall Elixhauser comorbidity index (ECI). Objectives were to compare the rates and risk factors of all-cause 5-year revisions for those undergoing single level CDA versus ACDF. Multivariate logistic regression models computed odds ratios (OR) of revisions within 5 years. P values less than 0.001 were significant. A total of 32,953 patients underwent single level CDA (N=5,640) or ACDF (N=27,313) with 5-Year minimum follow-up. The incidence of all cause revisions within 5 years were 1.24% for CDA and 9.23% for ACDF (P<0.001). After adjustment, patients undergoing single level ACDF had significantly higher odds of all-cause revisions within 5 years (OR: 8.09; P<0.0001). Additional patient specific factors associated with revisions were a history of reported drug abuse (OR: 1.51; P<0.0001), depression (OR: 1.23; P<0.0001), cardiac arrythmias (OR: 1.21; P=0.0008), hypertension (OR: 1.20; P=0.0006), and tobacco use (OR: 1.18; P=0.0003). In this study of nearly 33,000 single level cervical spine surgeries with minimum 5-year follow-up, all-cause revision rates were significantly lower for patients undergoing CDA. Surgeons may use this data to counsel patients regarding 5-year revisions following single level CDA or ACDF. III.

Anterior cervical hybrid constructs reduce superior adjacent segment burden compared to multilevel anterior cervical discectomy and fusion.

Traditional surgical treatment for symptomatic cervical degenerative disc disease is anterior cervical discectomy and fusion (ACDF), yet the increased risk of adjacent segment degeneration (ASD) requiring additional surgery exists and may result in limiting long-term surgical success when it occurs. Disc arthroplasty can preserve or restore physiologic range of motion (ROM), decreasing adjacent level stress and subsequent surgery. For patients with multilevel pathology requiring at least a 1-level fusion, interest is growing in anterior cervical hybrid (ACH) surgery as a partial motion-preserving procedure to decrease the adjacent level burden. This radiographic study compares postoperative superior adjacent segment motion between ACH and ACDF. Secondarily, total global motion, construct motion, inferior adjacent segment motion, and sagittal alignment parameters were compared. This is a single-center, multi-surgeon, retrospective cohort study of 2- and 3-level ACH and ACDF cases between 2013 and 2021. Degrees of motion were analyzed on flexion/extension views using Cobb angles to measure global (C2-C7) construct and adjacent segment lordosis. Neutral lateral X-rays were analyzed for alignment parameters, including global lordosis, cervical sagittal vertical axis (cSVA), and T1 slope (T1S). Differences were determined by independent t-test and Fisher's exact test. Of 100 patients, 38% were 2-level cases (47% ACH, 53% ACDF) and 62% were 3-level cases: (52% ACH, 48% ACDF). Postoperatively, superior adjacent segment motion increased with ACDF and decreased with ACH (-1.3°±5.3° ACH, 1.6°±4.6° ACDF, P=0.005). Postoperatively, the ACH group had greater ROM across the construct (16.3°±8.7° ACH, 4.7°±3.3° ACDF, P<0.001) and total global ROM (38.0°±12.8° ACH, 28.0°±11.1° ACDF, P<0.001). ACH resulted in a significant reduction of motion loss across the construct (-10.0°±11.7° ACH, -18.1°±10.8° ACDF, P<0.001). Postoperative alignment restoration was similar between both cohorts (-2.61°±8.36° ACH, 0.04°±12.24° ACDF, P=0.21). Compared to ACDF, hybrid constructs partially preserved motion across operative levels and had greater postoperative global ROM without increasing superior adjacent segment mobility or sacrificing alignment restoration. This supports the consideration of ACH in patients with multilevel degenerative cervical pathology requiring at least a 1-level fusion and suggests a propensity for long-term success by reducing the superior adjacent segment burden.

Impact of Preoperative Symptom Duration on Patient-Reported Outcomes Following Cervical Disc Replacement for Cervical Radiculopathy.

Retrospective review of prospectively collected data. To determine the impact of preoperative symptom duration on postoperative functional outcomes following cervical disc replacement (CDR) for radiculopathy. CDR has emerged as a reliable and efficacious treatment option for degenerative cervical spine pathologies. The relationship between preoperative symptom duration and outcomes following CDR is not well established. Patients with radiculopathy without myelopathy who underwent primary 1- or 2-level CDRs were included and divided into shorter (<6mo) and prolonged (≥6mo) cohorts based on preoperative symptom duration. Patient-reported outcome measures (PROMs) included Neck Disability Index (NDI), Visual Analog Scale (VAS) Neck and Arm. Change in PROM scores and minimal clinically important difference (MCID) rates were calculated. Analyses were conducted on the early (within 3mo) and late (6mo-2y) postoperative periods. A total of 201 patients (43.6±8.7y, 33.3% female) were included. In both early and late postoperative periods, the shorter preoperative symptom duration cohort experienced significantly greater change from preoperative PROM scores compared to the prolonged symptom duration cohort for NDI, VAS-Neck, and VAS-Arm. The shorter symptom duration cohort achieved MCID in the early postoperative period at a significantly higher rate for NDI (78.9% vs. 54.9%, P=0.001), VAS-Neck (87.0% vs. 56.0%, P<0.001), and VAS-Arm (90.5% vs. 70.7%, P=0.002). Prolonged preoperative symptom duration (≥6mo) was identified as an independent risk factor for failure to achieve MCID at the latest timepoint for NDI (OR: 2.9, 95% CI: 1.2-6.9, P=0.016), VAS-Neck (OR: 9.8, 95% CI: 3.7-26.0, P<0.001), and VAS-Arm (OR: 7.5, 95% CI: 2.5-22.5, P<0.001). Our study demonstrates improved patient-reported outcomes for those with shorter preoperative symptom duration undergoing CDR for radiculopathy, suggesting delayed surgical intervention may result in poorer outcomes and greater postoperative disability. III.

Reoperation Rates According to Surgical Approach After Operation for Degenerative Cervical Pathology in Patients With Athetoid Cerebral Palsy: A Nationwide Cohort Study.

National population-based cohort study. The overall complication rate for patients with athetoid cerebral palsy (CP) undergoing cervical surgery is significantly higher than that of patients without CP. The study was conducted to compare the reoperation and complication rates of anterior fusion, posterior fusion, combined fusion, and laminoplasty for degenerative cervical myelopathy/radiculopathy in patients with athetoid cerebral palsy. The Korean Health Insurance Review and Assessment Service national database was used for analysis. Data from patients diagnosed with athetoid CP who underwent cervical spine operations for degenerative causes between 2002 and 2020 were reviewed. Patients were categorized into four groups for comparison: anterior fusion, posterior fusion, combined fusion, and laminoplasty. A total of 672 patients were included in the study. The overall revision rate was 21.0% (141/672). The revision rate was highest in the anterior fusion group (42.7%). The revision rates of combined fusion (11.1%; hazard ratio [HR], .335; P = .002), posterior fusion (13.8%; HR, .533; P = .030) were significantly lower than that of anterior fusion. Revision rate of laminoplasty (13.1%; HR, .541; P = .240) was also lower than anterior fusion although the result did not demonstrate statistical significance. Anterior fusion presented the highest reoperation risk after cervical spine surgery reaching 42.7% in patients with athetoid CP. Therefore, anterior-only fusion in patients with athetoid CP should be avoided or reserved for strictly selected patients. Combined fusion, with the lowest revision risk at 11.1%, could be safely applied to patients with athetoid CP.

Radiographic Risk Factors for Adjacent Segment Disease Following Anterior Cervical Discectomy and Fusion (ACDF): A Systematic Review and Meta-Analysis.

Systematic review and meta-analysis. To assess the radiographic risk factors for adjacent segment disease (ASD) following anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine pathologies. PubMed, Embase and the Cochrane Library databases were searched up to December 2023. The primary inclusion criteria were degenerative spinal conditions treated with ACDF, comparing radiological parameters in patients with and without postoperative ASD. The radiographic parameters included intervertebral disc height, cervical sagittal alignment, sagittal segmental alignment, range of motion, segmental height, T1 slope, sagittal vertical axis (SVA), thoracic inlet angle (TIA), and plate to disc distance (PPD). Risk of bias was assessed for all studies. The Cochrane Review Manager was utilized to perform the meta-analysis. From 7044 articles, 13 retrospective studies were included in the final analysis. Three studies had "not serious" bias and the other 10 studies had serious or very serious bias. The total number of patients in the included studies was 1799 patients. Five studies included single-level ACDF, 2 studies included multi-level ACDF, and 6 studies included single or multi-level ACDF. On meta-analysis, the significant risk factors associated with ASD development were reduced postoperative cervical lordosis (mean difference [MD] = 3.35°, P = .002), reduced last-follow-up cervical lordosis (MD = -3.02°, P = .0003), increased preoperative to postoperative cervical sagittal alignment change (MD = -3.68°, P = .03), and the presence of developmental cervical canal stenosis (Odds ratio [OR] = 4.17, P < .001). Decreased postoperative cervical lordosis, greater change in cervical sagittal alignment and developmental cervical canal stenosis were associated with an increased risk of ASD following ACDF.

Systematic Review and Meta-Analysis of the Effect of Osteoporosis on Fusion Rates and Complications Following Surgery for Degenerative Cervical Spine Pathology.

As the elderly population grows, the increasing prevalence of osteoporosis presents a unique challenge for surgeons. Decreased bone strength and quality are associated with hardware failure and impaired bone healing, which may increase the rate of revision surgery and the development of complications. The purpose of this review is to determine the impact of osteoporosis on postoperative outcomes for patients with cervical degenerative disease or deformity. A systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and Medical Subject Headings terms involving spine surgery for cervical degenerative disease and osteoporosis were performed. This review focused on radiographic outcomes, as well as surgical and medical complications. There were 16 studies included in the degenerative group and 9 in the deformity group. Across degenerative studies, lower bone mineral density was associated with increased rates of cage subsidence in osteoporotic patients undergoing operative treatment for cervical degenerative disease. Most studies reported varied results on the relationship between osteoporosis and other outcomes such as revision and readmission rates, costs, and perioperative complications. Our meta-analysis suggests that osteoporotic patients carry a greater risk of reduced fusion rates at 6 months and 1 year postoperatively. With respect to cervical deformity correction, although individual complication rates were unchanged with osteoporosis, the collective risk of incurring any complication may be increased in patients with poor bone stock. Overall, the literature suggests that outcomes for osteoporotic patients after cervical spine surgery are multifactorial. Osteoporosis seems to be a significant risk factor for developing cage subsidence and pseudarthrosis postoperatively, whereas reports on medical and hospital-related metrics were inconclusive. Our findings highlight the challenges of caring for osteoporotic patients and underline the need for adequately powered studies to understand how osteoporosis changes the risk index of patients undergoing cervical spine surgery. In patients undergoing cervical spine surgery for degenerative disease, osteoporosis is a significant risk factor for long-term postoperative complications-notably cage subsidence and pseudarthrosis. Given the elective nature of these procedures, interdisciplinary collaboration between providers should be routinely implemented to enable medical optimization of patients prior to cervical spine surgery.

Effects of Obesity on Cervical Disc Arthroplasty Complications.

High body mass index is a well-established modifiable comorbidity that is known to increase postoperative complications in all types of surgery, including spine surgery. Obesity is increasing in prevalence amongst the general population. As this growing population of obese patients ages, understanding how they faire undergoing cervical disc arthroplasty (CDA) is important for providing safe and effective evidence-based care for cervical degenerative pathology. Our study used the Healthcare Cost and Utilization Project's National Inpatient Sample to assess patients undergoing CDA comparing patient characteristics and outcomes in nonobese patients to obese patients from 2004 to 2014. Our study found a significant increase in the overall utilization of CDA as a treatment modality (p = 0.012) and a statistically significant increase in obese patients undergoing CDA (p < 0.0001) from 2004 to 2014. Obesity was identified as an independent risk factor associated with increased rates of inpatient neurologic complications (odds ratio [OR], 6.99; p = 0.03), pulmonary embolus (OR, 5.41; p = 0.05), and wound infection (OR, 6.97; p < 0.001) in patients undergoing CDA from 2004 to 2014. In patients undergoing CDA, from 2004 to 2014, obesity was identified as an independent risk factor with significantly increased rates of inpatient neurologic complications, pulmonary embolus and wound infection. Large prospective trials are needed to validate these findings.

Utility of Zero-Echo time sequence as an adjunct for MR evaluation of degenerative disease in the cervical spine.

Determine the utility of ZTE as an adjunct to routine MR for assessing degenerative disease in the cervical spine. Retrospective study on 42 patients with cervical MR performed with ZTE from 1/1/2022 to 4/30/22. Fellowship trained radiologists evaluated each cervical disc level for neural foraminal (NF) narrowing, canal stenosis (CS), facet arthritis (FA), and presence of ossification of the posterior longitudinal ligament (OPLL). When NF narrowing and CS were present, the relative contributions of bone and soft disc were determined and a confidence level for doing so was assigned. Comparisons were made between assessments on routine MR without and with ZTE. With ZTE added, bone contribution as a cause of NF narrowing increased in 47% (n = 110) of neural foramina and decreased in 12% (n = 29) (p = < 0.001). Bone contribution as a cause of CS increased in 25% (n = 33) of disc levels and decreased in 10% (n = 13) (p = 0.013). Confidence increased in identifying the cause of NF narrowing (p = < 0.001)) and CS (p = 0.009) with ZTE. The cause of NF narrowing (p = 0.007) and CS (p = 0.041) changed more frequently after ZTE was added when initial confidence in making the determination was low. There was no change in detection of FA or presence of OPLL with ZTE. Addition of ZTE to a routine cervical spine MR changes the assessment of the degree of bone involvement in degenerative cervical spine pathology.

Impact of Frailty and Cervical Radiographic Parameters on Postoperative Dysphagia Following Anterior Cervical Spine Surgery.

Retrospective review of a prospectively collected registry. The purpose of the present study was to investigate the impact of frailty and radiographical parameters on postoperative dysphagia after anterior cervical spine surgery (ACSS). There is a growing body of literature indicating an association between frailty and increased postoperative complications following various surgeries. However, few studies have investigated the relationship between frailty and postoperative dysphagia after anterior cervical spine surgery. Patients who underwent anterior cervical spine surgery for the treatment of degenerative cervical pathology were included. Frailty and dysphagia were assessed by the modified frailty index-11 (mFI-11) and eat assessment tool-10 (EAT-10), respectively. We also collected clinical demographics and cervical alignment parameters previously reported as risk factors for postoperative dysphagia. Multivariable logistic regression was performed to identify the odds ratio (OR) of postoperative dysphagia at early (2-6 weeks) and late postoperative timepoints (1-2 years). Ninety-five patients who underwent ACSS were included in the study. Postoperative dysphagia occurred in 31 patients (32.6%) at the early postoperative timepoint. Multivariable logistic regression identified higher mFI-11 score (OR, 4.03; 95%CI 1.24-13.16; P=0.021), over-correction of TS-CL after surgery (TS-CL, T1 slope minus C2-7 lordosis; OR, 0.86; 95% CI 0.79-0.95; P=0.003), and surgery at C3/4 (OR, 12.38; 95% CI 1.41-108.92; P=0.023) as factors associated with postoperative dysphagia. Frailty, as assessed by the mFI-11, was significantly associated with postoperative dysphagia after ACSS. Additional factors associated with postoperative dysphagia were over-correction of TS-CL and surgery at C3/4. These findings emphasize the importance of assessing frailty and cervical alignment in the decision-making process preceding ACSS.

Risk factors for failure to achieve minimal clinically important difference following cervical disc replacement

BACKGROUND CONTEXTWhile cervical disc replacement (CDR) has been emerging as a reliable and efficacious treatment option for degenerative cervical spine pathology, not all patients undergoing CDR will achieve minimal clinically important difference (MCID) in patient-reported outcome measures (PROMs) postoperatively—risk factors for failure to achieve MCID in PROMs following CDR have not been established. PURPOSETo identify risk factors for failure to achieve MCID in Neck Disability Index (NDI, Visual Analog Scale (VAS) neck and arm following primary 1- or 2-level CDRs in the early and late postoperative periods. STUDY DESIGNRetrospective review of prospectively collected data. PATIENT SAMPLEPatients who had undergone primary 1- or 2-level CDR for the treatment of degenerative cervical pathology at a single institution with a minimum follow-up of 6 weeks between 2017 and 2022. OUTCOME MEASURESPatient-reported outcomes: Neck disability index (NDI), Visual analog scale (VAS) neck and arm, MCID. METHODSMinimal clinically important difference achievement rates for NDI, VAS-Neck, and VAS-Arm within early (within 3 months) and late (6 months to 2 years) postoperative periods were assessed based on previously established thresholds. Multivariate logistic regressions were performed for each PROM and evaluation period, with failure to achieve MCID assigned as the outcome variable, to establish models to identify risk factors for failure to achieve MCID and predictors for achievement of MCID. Predictor variables included in the analyses featured demographics, comorbidities, diagnoses/symptoms, and perioperative characteristics. RESULTSA total of 154 patients met the inclusion criteria. The majority of patients achieved MCID for NDI, VAS-Neck, and VAS-Arm for both early and late postoperative periods—79% achieved MCID for at least one of the PROMs in the early postoperative period, while 80% achieved MCID for at least one of the PROMs in the late postoperative period. Predominant neck pain was identified as a risk factor for failure to achieve MCID for NDI in the early (OR: 3.13 [1.10–8.87], p-value: .032) and late (OR: 5.01 [1.31–19.12], p-value: .018) postoperative periods, and VAS-Arm for the late postoperative period (OR: 36.63 [3.78–354.56], p-value: .002). Myelopathy was identified as a risk factor for failure to achieve MCID for VAS-Neck in the early postoperative period (OR: 3.40 [1.08–10.66], p-value: .036). Anxiety was identified as a risk factor for failure to achieve MCID for VAS-Neck in the late postoperative period (OR: 6.51 [1.91–22.18], p-value: .003). CDR at levels C5C7 was identified as a risk factor for failure to achieve MCID in NDI for the late postoperative period (OR: 9.74 [1.43–66.34], p-value: .020). CONCLUSIONSOur study identified several risk factors for failure to achieve MCID in common PROMs following CDR including predominant neck pain, myelopathy, anxiety, and CDR at levels C5−C7. These findings may help inform the approach to counseling patients on outcomes of CDR as the evidence suggests that those with the risk factors above may not improve as reliably after CDR.

The Statistical Fragility of Trials Comparing Cervical Disc Arthroplasty and Anterior Cervical Discectomy and Fusion: A Meta Analysis.

Meta-analysis. To assess the robustness of randomized controlled trials (RCTs) that compared cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic degenerative cervical pathology by using fragility indices. RCTs comparing these surgical approaches have shown that CDA may be equivalent or even superior to ACDF due to better preservation of normal spinal kinematics. RCTs reporting clinical outcomes after CDA versus ACDF for degenerative cervical disc disease were evaluated. Data for outcome measures were classified as continuous or dichotomous. Continuous outcomes included: Neck Disability Index, overall pain, neck pain, radicular arm pain, and modified Japanese Orthopedic Association scores. Dichotomous outcomes included: any adjacent segment disease (ASD), superior-level ASD, and inferior-level ASD. The fragility index (FI) and continuous FI (CFI) were determined for dichotomous and continuous outcomes, respectively. The corresponding fragility quotient (FQ) and continuous FQ were calculated by dividing FI/CFI by sample size. Twenty-five studies (78 outcome events) were included. Thirteen dichotomous events had a median FI of 7 [interquartile range (IQR): 3-10], and the median FQ was 0.043 (IQR: 0.035-0.066). Sixty-five continuous events had a median CFI of 14 (IQR: 9-22) and a median continuous FQ of 0.145 (IQR: 0.074-0.188). This indicates that, on average, altering the outcome of 4.3 patients out of 100 for the dichotomous outcomes and 14.5 out of 100 for continuous outcomes would reverse trial significance. Of the 13 dichotomous events that included a loss to follow-up data, 8 (61.5%) represented ≥7 patients lost. Of the 65 continuous events reporting the loss to follow-up data, 22 (33.8%) represented ≥14 patients lost. RCTs comparing ACDF and CDA have fair to moderate statistical robustness and do not suffer from statistical fragility.

Primary and Revision Cervical Disc Arthroplasty from 2010–2020: Patient Demographics, Utilization Trends, and Health Care Reimbursements

Despite lack of nationwide Medicare Coverage by the Centers for Medicare and Medicaid Services, the utilization of cervical disc arthroplasty (CDA) has risen in popularity. The purpose was to compare primary and revision cervical disc arthroplasty (CDA) from 2010 to 2020 with respect to: 1) utilization trends, 2) patient demographics; and 3) healthcare reimbursements. Using the PearlDiver database, we studied patients undergoing primary and revision CDA for degenerative cervical disc pathology from 2010 to 2020. Endpoints of the study were to compare patient demographics (including Elixhauser Comorbidity Index (ECI)), annual utilization trends, lengths of stay (LOS), and reimbursements. Chi-square analyses compared patient demographics. T-tests compared LOS and reimbursements. A linear regression was used to evaluate for trends in procedural volume over time. P values <0.05 were statistically significant. In total, 15,306 patients underwent primary (n= 14,711) or revision CDA (n= 595). Patients undergoing revisions had a greater comorbidity burden (mean ECI= 4.16 vs 2.91; p<0.0001). From 2010 to 2020, primary CDA utilization increased by 413% (447 vs 2297 procedures; p<0.001); comparatively revision CDA utilization increased by 141% (32 vs 77 procedures; p<0.001). Mean LOS were greater for revision cases (1.37 vs 3.30 days, p<0.001). Reimbursements for revisions were higher on the day of surgery ($5,585 vs $13,692) and within 90 days of surgery ($7,031 vs $19,340), all p<0.0001. There is a high rate of annual growth in CDA utilization and revision CDA in the United States. Reimbursements for revision CDA were more than double primary cases.

Posterior Cervical Fusion for Fracture Is Not the Same as Fusion for Degenerative Cervical Spine Disease: Implications for a Bundled Payment Model.

Retrospective. To understand differences in 30-day outcomes between patients undergoing posterior cervical fusion (PCF) for fracture versus degenerative cervical spine disease. Current bundled payment models for cervical fusions, such as the Bundled Payments for Care Improvement revolve around the use of diagnosis-related groups to categorize patients for reimbursement purposes. Though a PCF performed for a fracture may have a different postoperative course of care as compared with a fusion being done for degenerative cervical spine pathology, the current DRG system does not differentiate payments based on the indication/cause of surgery. The 2012-2017 American College of Surgeons-National Surgical Quality Improvement Program was queried using Current Procedural Terminology code 22600 to identify patients receiving elective PCFs. Multivariate analyses were used to compare rates of 30-day severe adverse events, minor adverse events, readmissions, length of stay, and nonhome discharges between the 2 groups. A total 2546 (91.4%) PCFs were performed for degenerative cervical spine pathology and 240 (8.6%) for fracture. After adjustment for differences in baseline clinical characteristics, patients undergoing a PCF for a fracture versus degenerative pathology had higher odds of severe adverse events [18.8% vs. 10.6%, odds ratio (OR): 1.65 (95% CI, 1.10-2.46); P =0.015], prolonged length of stay >3 days [54.2% vs. 40.5%, OR: 1.93 (95% CI, 1.44-2.59); P <0.001], and nonhome discharges [34.2% vs. 27.6%, OR: 1.54 (95% CI, 1.10-2.17); P =0.012]. Patients undergoing PCFs for fracture have significant higher rates of postoperative adverse events and greater resource utilization as compared with individuals undergoing elective PCF for degenerative spine pathology. The study calls into question the need of risk adjustment of bundled prices based on indication/cause of the surgery to prevent the creation of a financial disincentive when taking care/performing surgery in spinal trauma patients.

A comparison of in-hospital outcomes after elective anterior cervical discectomy and fusion in cases with and without Parkinson's Disease

BackgroundFollowing orthopedic surgery, patients with Parkinson's disease (PD) have been shown to have high rates of surgical complications, and some studies suggest that PD may be associated with greater risk for postoperative medical complications. As complication rates are critical to consider for elective surgery planning, the current study aimed to describe the association of PD with medical complications following anterior cervical discectomy and fusion (ACDF), the most commonly performed procedure to treat cervical degenerative pathology. MethodsThe 2008-2018 National Inpatient Sample database was queried for cases involving elective ACDF. Demographics and comorbidities were extracted using ICD codes. Cases were propensity matched based on demographic and comorbidity burden, and logistic regression was used to compare in-hospital complications between patients with and without PD. ResultsAfter weighting, a total of 1,273,437 elective ACDF cases were identified, of which 3948 (0.31%) involved cases with PD. After 1:1 propensity score matching by demographic and comorbidity variables, there were no differences between the PD and non-PD cohorts. Logistic regression models constructed for the matched and unmatched populations showed that PD cases have greater odds of in-hospital minor adverse events with no differences in odds of serious adverse events or mortality. ConclusionsAfter matching for demographics and comorbidity burden, PD cases undergoing elective ACDF had slightly longer length of stay and greater risk for minor adverse events but had similar rates of serious adverse events and mortality. These findings are important for surgeons and patients to consider when making decisions about surgical intervention.

Outcomes of cervical disc replacement in patients with neck pain greater than arm pain

BACKGROUND CONTEXTAlthough anterior cervical discectomy and fusion is believed to positively impact a patient's radicular symptoms as well as axial neck pain, the outcomes of cervical disc replacement (CDR) with regards to neck pain specifically have not been established. PURPOSEPrimary: to assess clinical improvement following CDR in patients with neck pain greater than arm pain. Secondary: to compare the clinical outcomes between patients undergoing CDR for predominant neck pain (pNP), predominant arm pain (pAP), and equal neck and arm pain (ENAP). STUDY DESIGNRetrospective review of prospectively collected data. PATIENT SAMPLEPatients who had undergone one- or two-level CDR for the treatment of degenerative cervical pathology and had a minimum of 6-month follow-up were included and stratified into three cohorts based on their predominant location of pain: pNP, pAP, and ENAP. OUTCOME MEASURESPatient-reported outcomes: Neck Disability Index (NDI), Visual Analog Scale (VAS) neck and arm, Short Form 12-Item Physical Health Score (SF12-PHS), Short Form 12-Item Mental Health Score (SF12-MHS), minimal clinically important difference (MCID). METHODSChanges in Patient-reported outcomes from preoperative values to early (<6 months) and late (≥6 months) postoperative timepoints were analyzed within each of the three groups. The percentage of patients achieving MCID was also evaluated. RESULTSOne hundred twenty-five patients (52 pNP, 30 pAP, 43 ENAP) were included. The pNP cohort demonstrated significant improvements in early and late NDI and VAS-Neck, early SF-12 MCS, and late SF-12 PCS. The pAP and ENAP cohorts demonstrated significant improvements in all PROMs, including NDI, VAS-Neck, VAS-Arm, SF-12 PCS, and SF-12 MCS, at both the early and late timepoints. No statistically significant differences were found in the MCID achievement rates for NDI, VAS-Neck, SF-12 PCS, and SF-12 MCS at the late timepoint amongst the three groups. CONCLUSIONSCDR leads to comparable improvement in neck pain and disability in patients presenting with neck pain greater than arm pain and meeting specific clinical and radiographic criteria.

Possibilies of multi–level cervical fusion in degenerative cervical pathology

The aim of this study was to improve the results of surgical treatment of patients with cervical hernias who underwent cervical fusion using improved cylindrical cages from the left anterior parapharyngeal access. The study included 12 patients with degenerative disease of cervical spine who were implanted 16 titanium cages after microdiscectomy. The assessment of the results was performed by neurologic examination, neurovisualization data, and visual analogue pain scale. Mean duration of surgery was 45–90 min, blood loss — 30–60 ml, length of hospital stay — 4–6 days. Substantial decrease of frequency and intensity of neck and arm pain was observed in 89 % of patients after surgery. When properly performed, anterior cervical interbody fusion applying cylindrical cage is a simple and effective method.

Preliminary 12-Month Safety and Efficacy Outcomes for the Treatment of Cervical Radiculopathy and Myelopathy with the Stalif-C Integrated Interbody Fusion Device

Anterior cervical discectomy and fusion (ACDF) has been widely utilized as the workhorse approach for the surgical treatment of cervical degenerative pathology. Minimal high-level evidence data exists on the efficacy and safety of integrated cage-screw implants. A prospective, non-randomized clinical study utilizing STALIF C-Ti® integrated cage-screw implants was performed in 145 patients. 12-month outcome scores demonstrated significant improvements in all patient reported outcome scores collected (p&lt;0.05 for all), including NDI, VAS neck, VAS left arm, and VAS right arm. Patients receiving STALIF C-Ti integrated cage-screw implants demonstrated significant improvements in clinical outcome scores with minimal overall complication rate

P24. Dysphagia and Odynophagia following zero profile ACDF: Incidence, severity and resolution

<h3>BACKGROUND CONTEXT</h3> Stand-alone or zero-profile devices for anterior cervical discectomy and fusion (ACDF) have become popular in the management of degenerative cervical pathology in order to mitigate some of the complications associated with anterior cervical plating. <h3>PURPOSE</h3> To determine the incidence, severity and resolution of dysphagia and odynophagia following zero-profile ACDF. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study of prospectively collected data. <h3>PATIENT SAMPLE</h3> Patients who had undergone zero-profile ACDF between 2017-2020. <h3>OUTCOME MEASURES</h3> Patient-reported Outcome Measure (PROMs) - Patient reported responses on the Dysphagia, Odynophagia and Voice (DOV) Questionnaire. In particular, the "Swallowing" and "Pain with Swallowing" components of the DOV Questionnaire were used for this study. <h3>METHODS</h3> Patients completed the DOV Questionnaire preoperatively and postoperatively (2 weeks, 6 weeks, 12 weeks, 6 months, 1 year and 2 years). Patients selected one of five answer choices (0-4) for dysphagia and one of four choices (0-3) for odynophagia, with zero indicating no symptoms and higher point values indicating worse symptomatology. Scores of 1, 2, 3, and 4 were graded as mild, moderate, severe, and very-severe, respectively. <h3>RESULTS</h3> Forty-eight patients, with a mean age of 58.46 ± 9.74 years, mean BMI of 27.38 ± 4.76 kg/m^2 and comprised of 31 males (64.6%) and 17 females (35.4%) were included. There were 17 single-level (35.4%), 24 two-level (50.0%) and 7 three-level (14.6%) surgeries. Nine (18.8%) patients reported dysphagia preoperatively, all of whom had symptom resolution. Ten (20.8%) patients reported dysphagia at 2 weeks postoperatively, which was mild in all patients. Of these, 5 had resolution during follow-up, with a majority reporting resolution by 6 weeks. Of the 5 patients that did not report resolution, 4 did not have follow-up data available beyond 6 weeks, and 1 reported persistent dysphagia at 2 years. Seven (16.7%) patients reported new-onset dysphagia at 6 weeks, which was mild in all patients. Of these, 5 had resolution, with a majority reporting resolution by 12 weeks. Of the 2 patients that did not report resolution, 1 patient did not have long-term follow-up available, and 1 reported persistent dysphagia at 1 year. Six (12.5%) patients reported odynophagia preoperatively, all of whom had complete symptom resolution. Eleven (22.9%) patients reported odynophagia at 2 weeks postoperatively, which was mild in all patients. Of these, 8 had resolution during the available follow-up, with a majority reporting resolution by 12 weeks. The 3 patients that did not report resolution did not have long-term follow-up data available. In addition, 5 (10.4%) patients reported new-onset, odynophagia after 2 weeks postoperatively, which was mild in all patients. Of these 5 patients, 4 reported resolution while 1 reported persistent symptoms at 1 year. Further, 6/48 (12.5%) patients reported only dysphagia, 4/48 (8.3%) patients reported only odynophagia, and 11/48 (22.9%) patients reported both dysphagia and odynophagia. <h3>CONCLUSIONS</h3> All cases of postoperative dysphagia and odynophagia were mild and a majority resolved by 6-12 weeks postoperatively. Only 2 (4.2%) patients reported persistent dysphagia and only 1 (2.1%) patient reported persistent odynophagia at or after 1 year postoperatively, which was mild in all cases. <h3>FDA DEVICE/DRUG STATUS</h3> Stand-alone ACDF cage (Approved for this indication).

C5 palsy after cervical laminectomy: natural history in a 10-year series

BACKGROUND CONTEXTC5 palsy is a well-known complication following cervical laminectomy, however the cause of this complication remains elusive, with many studies providing conflicting reports on prognosis and the impact of specific risk factors. PURPOSETo describe the natural history of and risk factors for C5 palsy after first time cervical laminectomy involving C4 and/or C5, in a large series with a high rate of postoperative palsy. STUDY DESIGN/SETTINGThis is a retrospective case series. PATIENT SAMPLEPatients undergoing first time cervical laminectomy for degenerative spine pathologies at a single institution between January 2008 and July 2018. Adult patients were included if a complete laminectomy was performed at C4 or C5 for degenerative pathology and pre- and postoperative upright lateral x-rays were performed. OUTCOME MEASURESThe primary outcome measure was postoperative C5 palsy, defined as a decrease in strength of at least one point in deltoid and/or biceps within 30 days of operation. The secondary outcome measure was recovery of function. METHODSA retrospective database of patients who underwent posterior cervical spine surgery was created and further focused by utilizing specific Common Procedural Technology (CPT) codes associated with our desired patient population. Patients were excluded from our study if they had inadequate pre- and postoperative imaging, as well as patients with a history of prior cervical spine surgery, concurrent anterior surgery, intradural pathology, spinal tumor, or spinal trauma. Patient history, surgical specifics, and neurologic function were recorded. RESULTSA total of 190 patients were treated by 13 surgeons. 53 (27.9%) developed C5 palsy postoperatively. Of patients with C5 palsy, 40 (75.5%) recovered to baseline strength, 46 (86.6%) had at least grade 4 strength at last follow up, and 4 (7.5%) had strength worse than baseline and motor grade less than 4. Median time to recovery was 2.0 (IQR: 0.18 to 8.24) months. Age, gender, preoperative motor score, number of levels decompressed, smoking history, and comorbidities were not associated with a significant increase in the odds of C5 palsy. Risk of C5 palsy increased by 35% for every additional level fused below C4. CONCLUSIONThe risk of C5 palsy is increased with instrumentation caudal to C5 in operations addressing degenerative cervical pathology. This should be taken into consideration during operative planning. Overall prognosis of C5 palsy is good; however, incidence of this condition may be greater than previously reported.