Cervical Spine Fusion Research Articles

234. Does nasal screening for methicillin resistant Staphylococcus aureus (MRSA) prevent deep surgical site infections for elective cervical spinal fusion?

<h3>BACKGROUND CONTEXT</h3> Preoperative MRSA screening and decolonization has demonstrated success for some orthopaedic subspecialties in prevention of surgical site infections (SSIs). Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. <h3>PURPOSE</h3> The purpose of this study was to determine the relationship between nasal MRSA testing and SSI rates specifically in the setting of primary posterior cervical instrumented spine surgery. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort study. <h3>PATIENT SAMPLE</h3> Adult patients undergoing primary instrumented posterior cervical procedures from January 2015-December 2019 at two tertiary academic referral centers in an urban setting <h3>OUTCOME MEASURES</h3> Physiologic measures: subfascial presumed infected collection or abscess within 90 days of the index operation. <h3>METHODS</h3> Adult patients undergoing primary instrumented posterior cervical procedures from January 2015-December 2019 were reviewed for MRSA testing < 90-days before surgery, preoperative mupirocin, perioperative antibiotics and SSI defined as operative incision and drainage (I&D) < 90-days after surgery. Trauma, tumor and infection cases were excluded. Logistic regression modeling was used with SSI the primary outcome and MRSA screening the primary predictor with clinical and demographic factors as covariates. <h3>RESULTS</h3> This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, six patients (50%) grew MSSA from intraoperative cultures, with no cases of MRSA. <h3>CONCLUSIONS</h3> There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram-positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Fusion Revision Surgery With Reamer-Irrigator-Aspirator to Harvest Autograft After Spinal Pseudarthrosis.

Background and purposeSpinal pseudarthrosis (SPA) is a common complication after attempted cervical or lumbosacral spinal fusion surgery. Revision surgeries usually necessitate bone graft implementation as an adjunct to hardware revision. Iliac crest bone graft is the gold standard but availability can be limited and usage often leads to persistent postoperative pain at the donor site. There is scant literature regarding the use of reamer-irrigator-aspirator (RIA)-harvested bone graft in lumbar spinal fusion. This is a collaborative study between orthopedic surgery and neurosurgery departments to utilize femur intramedullary autograft harvested using the RIA system as an adjunct graft in SPA revision surgeries.Materials and methodsA retrospective review was conducted at a single center between August 2014 and December 2017 of patients aged ≥ 18 years and diagnosed with cervical, thoracic, or lumbar SPA who underwent revision fusion surgery using femur intramedullary autograft harvested using the RIA system. Plain radiographs and CT scans were utilized to confirm successful fusion.ResultsEleven patients underwent 12 SPA revision surgeries using the RIA system as a source for bone graft in addition to bone morphogenetic protein 2 (BMP-2) and allograft. The mean amount of graft harvested was 51.3 mL (range: 20-70 mL). Nine patients achieved successful fusion (81.8%). The average time to fusion was 9.1 months. Four patients (36.4%) had postoperative knee pain. Regarding patient position and approach for harvesting, 66.7% (n = 8) of cases were positioned prone and a retrograde approach was utilized in 91.7% (n = 11) of cases.InterpretationThis is the first case series in known literature to report the RIA system as a reliably considerable source of autologous bone graft for SPA revision surgeries. It provides a useful adjunct to the known types of bone grafts. Patient positioning and the approach choice for graft harvesting can be adjusted according to the fusion approach and the surgeon’s preference.

Severe dysphagia after a posterior cervical spine fusion at the C1–C3 level and its improvement after correction surgery for malalignment: a case report

BackgroundThe development of dysphagia and trismus following posterior C1–C3 fusion is rare compared to occipitocervical fusion, and there are very few reports in the literature.Case presentationA 75-year-old Thai man who had an extradural tumor at the C1/C2 level developed severe dysphagia and trismus immediately after tumor resection and C1–C3 fusion. During the surgery for malalignment correction, the C1–C2 screws were re-aligned into an increased lordotic position. The symptoms resolved immediately post-surgery.ConclusionsShort upper cervical fusion can produce trismus and dysphagia in a relatively flexed position. Preoperative planning should be individualized based on the patient’s resting neutral alignment to prevent complications.

Cervical Spine Research Society-Cervical Stiffness Disability Index (CSRS-CSDI): Validation of a Novel Scoring System Quantifying the Effect of Postarthrodesis Cervical Stiffness on Patient Quality of Life.

Cross-sectional study. The aim was to create and validate a novel patient-reported outcome measure (PROM) focusing on stiffness-related patient functional limitations after cervical spine fusion. Cervical arthrodesis is a common treatment for myelopathy/radiculopathy, however, results in increased neck stiffness as a collateral outcome. No current PROM exists quantifying the impact of postoperative stiffness on patient function. The Cervical Spine Research Society-Cervical Stiffness Disability Index (CSRS-CSDI) was created through a modified Delphi process. The resultant 10-item questionnaire yields a score out of 100 with higher scores indicating increased functional difficulty related to neck stiffness. Cross-sectional study of control and postoperative patients was completed for CSRS-CSDI validation. Retest reliability (intraclass correlation coefficient), internal consistency (Cronbach alpha), responsiveness (levels fused vs. CSRS-CSDI scores), and discriminatory validation (CSRS-CSDI vs. neck disability index) scores) were completed. Fifty-seven surgical and 24 control patients completed the questionnaire. Surgical patients underwent a variety of procedures: 11 (19%) motion preserving operations, nine (16%) subaxial 1-2 level fusions, seven (12%) subaxial 3-5 level fusions, five (9%) C1-subaxial cervical spine fusions, 20 (35%) C2-upper thoracic spine fusions, five (9%) occiput-subaxial or thoracic spine fusions. The questionnaire demonstrated high internal consistency (Cronbach alpha=0.92) and retest reliability (intraclass correlation coefficient=0.95, P <0.001). Good responsiveness validity with a significant difference between fusion cohorts was found ( P <0.001, rs =0.63). Patient CSRS-CSDI scores also correlated with neck disability index scores recorded ( P <0.001, r =0.70). This is the first study to create a PROM addressing the functional impact of cervical stiffness following surgical arthrodesis. The CSRS-CSDI was a reliable and valid measure of postoperative stiffness impact on patient function. This may prove useful in counseling patients regarding their expected outcomes with further investigation demonstrating its value in a prospective fashion.

Opioid-free shoulder arthroplasty is safe, effective, and predictable compared with a traditional perioperative opiate regimen: a randomized controlled trial of a new clinical care pathway.

Opiate-based regimens have been used as a foundation of postoperative analgesia in orthopedic surgery for decades, and the vast majority of orthopedic patients in the United States receive postoperative opioid prescriptions. Both the safety and efficacy of opioid use in orthopedic patients have been questioned because of mounting evidence that postoperative opioid use can be detrimental to outcomes and patient satisfaction. The purpose of this study is to compare a new, opioid-free pain management pathway with a traditional opioid-containing, multimodal pathway in patients undergoing shoulder arthroplasty. This is a single-center randomized clinical trial in which 67 patients who underwent shoulder arthroplasty were allocated into 2 treatment arms: either a completely opioid-free, multimodal perioperative pain management pathway (OF), or a traditional opioid-containing perioperative pain management pathway (OC). Pain was measured on a numeric rating scale from 0 to 10 at 6-, 12-, 24-hour, 2-week, and 6-week time points. Deviations from the OF pathway, morphine milligram equivalents, readmissions, and opioid-related side effects were analyzed. Pain levels were significantly lower in the OF group at 12 hours, 24 hours, and 2 weeks. At 12 hours, the median pain rating was 0 compared with a median pain rating of 3 in the OC group (P=.003). At 24 hours, the OF group reported a median pain rating of 1 and the OC group reported a median pain rating of 4 (P<.001). The median pain rating at the 2-week time point in the OF group was 2 compared with 4 in the OC group (P=.006). Median pain ratings were similar between the OF group and the OC group at the 6-week time point. The median pain rating in the OF group at 6 weeks was 1, compared with 1.5 in the OC group. Of the 35 patients in the OF pathway, 1 required a rescue opioid medication for left cervical radiculopathy that ultimately necessitated cervical spine fusion after recovery from right shoulder arthroplasty, and 1 was noted to have taken an opioid medication, diverted from a prior prescription, at the 2-week visit. The morphine milliequivalents received in the OF group was 20 compared with 4936.25 in the OC group. There were no readmissions in the OF pathway, and no differences between the groups with regard to constipation, falls, or delirium. A multimodal, opioid-free perioperative pain management pathway is safe and effective in patients undergoing total shoulder arthroplasty and offers superior pain relief to that of a traditional opioid-containing pain management pathway at 12 hours, 24 hours, and 2 weeks postoperatively.

Making Meaningful Use of Price Transparency Data: Describing Price Variation of Spine Surgery and Imaging in a Single System.

Price transparency is an increasingly popular solution for high healthcare expenditures in the United States, but little is known about its potential to facilitate patient price shopping. Our objective was to analyze interhospital and interpayer price variability in spine surgery and spine imaging using newly public payer-specific negotiated charges (PNCs). We selected a subset of billing codes for spine surgery and spine imaging at 12 hospitals within a Saint Louis metropolitan area healthcare system. We then compared PNCs for these procedures and tested for significant differences in interhospital and interinsurer IQR using the Mann-Whitney U Test. We found significantly greater IQRs of PNCs as a factor of the insurance plan than as a factor of the hospital for cervical spinal fusions (interinsurer IQR $8256; interhospital IQR $533; P < .0001), noncervical spinal fusions (interinsurer IQR $28 423; interhospital IQR $5512; P < .001), computed tomographies of the lower spine (interinsurer IQR $595; interhospital IQR $113; P < .0001), and MRIs lower spinal canal (interinsurer IQR $1010; interhospital IQR $158; P < .0001). There was no significant difference between the interinsurer IQR and the interhospital IQR for lower spine x-rays (interinsurer IQR $107; interhospital IQR $67; P = .0543). Despite some between-hospital heterogeneity, we show significantly higher price variability between insurers than between hospitals. Our single system analysis limits our ability to generalize, but our results suggest that savings depend more on hospital and provider negotiations than patient price shopping, given the difficulty of switching insurers.

Pragmatic Prediction of Excessive Length of Stay After Cervical Spine Surgery With Machine Learning and Validation on a National Scale.

Extended postoperative hospital stays are associated with numerous clinical risks and increased economic cost. Accurate preoperative prediction of extended length of stay (LOS) can facilitate targeted interventions to mitigate clinical harm and resource utilization. To develop a machine learning algorithm aimed at predicting extended LOS after cervical spine surgery on a national level and elucidate drivers of prediction. Electronic medical records from a large, urban academic medical center were retrospectively examined to identify patients who underwent cervical spine fusion surgeries between 2008 and 2019 for machine learning algorithm development and in-sample validation. The National Inpatient Sample database was queried to identify cervical spine fusion surgeries between 2009 and 2017 for out-of-sample validation of algorithm performance. Gradient-boosted trees predicted LOS and efficacy was assessed using the area under the receiver operating characteristic curve (AUROC). Shapley values were calculated to characterize preoperative risk factors for extended LOS and explain algorithm predictions. Gradient-boosted trees accurately predicted extended LOS across cohorts, achieving an AUROC of 0.87 (SD = 0.01) on the single-center validation set and an AUROC of 0.84 (SD = 0.00) on the nationwide National Inpatient Sample data set. Anterior approach only, elective admission status, age, and total number of Elixhauser comorbidities were important predictors that affected the likelihood of prolonged LOS. Machine learning algorithms accurately predict extended LOS across single-center and national patient cohorts and characterize key preoperative drivers of increased LOS after cervical spine surgery.

Does Nasal Screening for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevent Deep Surgical Site Infections for Elective Cervical Spinal Fusion?

Retrospective cohort study. The objective of this study was to determine the relationship between nasal methicillin-resistant Staphylococcus aureus (MRSA) testing and surgical site infection (SSI) rates in the setting of primary posterior cervical instrumented spine surgery. Preoperative MRSA screening and decolonization has demonstrated success for some orthopedic subspecialties in prevention of SSIs. Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. Adult patients undergoing primary instrumented posterior cervical procedures from January 2015 to December 2019 were reviewed for MRSA testing <90 days before surgery, preoperative mupirocin, perioperative antibiotics, and SSI defined as operative incision and drainage (I&D) <90 days after surgery. Logistic regression modeling used SSI as the primary outcome, MRSA screening as primary predictor, and clinical and demographic factors as covariates. This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, 6 patients (50%) grew methicillin sensitive Staphylococcus aureus from intraoperative cultures, with no cases of MRSA. There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing.

Oesophageal perforation following cervical spinal surgery with instrumentation: A case report on primary repair with pedicled sternocleidomastoid muscle flap reinforcement and review of the literature

AbstractAnterior cervical spine fusion and stabilisation is an entrenched procedure for managing traumatic spinal fracture. Oesophageal perforation by spinal hardware after cervical spinal fusion surgery is a rare complication that can be life‐threatening. We present a case with a complication of oesophageal perforation following anterior and posterior spinal fusion with instrumentation performed 7 years ago with a review of literature.

Cefazolin prophylaxis in spine surgery: patients are frequently underdosed and at increased risk for infection

BACKGROUND CONTEXTPerioperative antibiotics are critical in reducing the risk of postoperative spine infections. However, the efficacy and optimal weight-based prophylactic cefazolin dosing is unclear. PURPOSETo determine (1) if inadequate weight-based prophylactic dosing of cefazolin affects infection rates after spinal fusions, and (2) identify the optimal dosing of cefazolin. STUDY DESIGN/SETTINGSingle center retrospective cohort PATIENT SAMPLEPatients undergoing posterior cervical or lumbar spinal fusion between January 2000 and October 2020 OUTCOME MEASURESPostoperative surgical site infection status METHODSPatients were grouped based on our institutionally derived dosing adequacy standards, 1 g for <60 kg, 2 g for 60 to 120 kg, and 3 g for >120 kg. Univariate comparisons and multivariate regressions identified the effect of inadequate dosing on infection rate. Patients were subsequently regrouped into cefazolin dose (grams) administered and logistic regression and receiver operating characteristic curves were compiled to determine the probability of infection based on cefazolin dose and patient weight. Alpha was set at 0.05. RESULTSA total of 2,643 patients met inclusion criteria and 95 infections (3.6%) were identified. The infection rate was higher in the inadequate dosing group (5.86% vs. 2.58%, p<.001). Adequate dosing was a predictor of decreased infections after lumbar fusion (OR: 0.43, p<.001), but not posterior cervical fusions (OR: 0.47, p=.065). Patients were subsequently regrouped into 1 g or 2 g of cefazolin administered resulting in a 5.01% and 2.77% infection rate, respectively (p=.005). The area under the curve (AUC) and 95% confidence interval for one (0.850 [0.777–0.924]) and two (0.575 [0.493–0.657]) g of cefazolin demonstrated lower infection rates for patients given 2 g cefazolin. CONCLUSIONSPatients receiving an inadequate weight-based dose of preoperative cefazolin had an increased risk of infection following spinal fusion surgery. Two grams prophylactic cefazolin significantly reduces the likelihood of infection.

Trends in the Charges and Utilization of Computer-Assisted Navigation in Cervical and Thoracolumbar Spinal Surgery.

Retrospective national database study. This study is conducted to assess the trends in the charges and usage of computer-assisted navigation in cervical and thoracolumbar spinal surgery. This study is the first of its kind to use a nationwide dataset to analyze trends of computer-assisted navigation in spinal surgery over a recent time period in terms of use in the field as well as the cost of the technology. Relevant data from the National Readmission Database in 2015-2018 were analyzed, and the computer-assisted procedures of cervical and thoracolumbar spinal surgery were identified using International Classification of Diseases 9th and 10th revision codes. Patient demographics, surgical data, readmissions, and total charges were examined. Comorbidity burden was calculated using the Charlson and Elixhauser comorbidity index. Complication rates were determined on the basis of diagnosis codes. A total of 48,116 cervical cases and 27,093 thoracolumbar cases were identified using computer-assisted navigation. No major differences in sex, age, or comorbidities over time were found. The utilization of computer-assisted navigation for cervical and thoracolumbar spinal fusion cases increased from 2015 to 2018 and normalized to their respective years' total cases (Pearson correlation coefficient=0.756, p =0.049; Pearson correlation coefficient=0.9895, p =0.010). Total charges for cervical and thoracolumbar cases increased over time (Pearson correlation coefficient=0.758, p =0.242; Pearson correlation coefficient=0.766, p =0.234). The use of computer-assisted navigation in spinal surgery increased significantly from 2015 to 2018. The average cost grossly increased from 2015 to 2018, and it was higher than the average cost of nonnavigated spinal surgery. With the increased utilization and standardization of computer-assisted navigation in spinal surgeries, the cost of care of more patients might potentially increase. As a result, further studies should be conducted to determine whether the use of computer-assisted navigation is efficient in terms of cost and improvement of care.

Generalized Arterial Calcification of Infancy (GACI): Optimizing Care with a Multidisciplinary Approach.

It is very unusual to see evidence of arterial calcification in infants and children, and when detected, genetic disorders of calcium metabolism should be suspected. Generalized arterial calcification of infancy (GACI) is a hereditary disease, which is characterized by severe arterial calcification of medium sized arteries, mostly involving the media with marked intimal proliferation and ectopic mineralization of the extravascular tissues. It is caused by inactivating variants in genes encoding either ENPP1, in a majority of cases (70–75%), or ABCC6, in a minority (9–10%). Despite similar histologic appearances between ENPP1 and ABCC6 deficiencies, including arterial calcification, organ calcification, and cardiovascular calcification, mortality is higher in subjects carrying the ENPP1 versus ABCC6 variants (40% vs 10%, respectively). Overall mortality in individuals with GACI is high (55%) before the age of 6 months, with 24.4% dying in utero or being stillborn. Rare cases show spontaneous regression with age, while others who survive into adulthood often manifest musculoskeletal complications (osteoarthritis and interosseous membrane ossification), enthesis mineralization, and cervical spine fusion. Despite recent advances in the understanding of the genetic mechanisms underlying this disease, there is still no ideal therapy for the resolution of vascular calcification in GACI. Although bisphosphonates with anti-calcification properties have been commonly used for the treatment of CAGI, their benefit is controversial, with favorable results reported at one year and questionable benefit with delayed initiation of treatment. Enzyme replacement therapy with administration of recombinant form of ENPP1 prevents calcification and mortality, improves hypertension and cardiac function, and prevents intimal proliferation and osteomalacia in mouse models of ENPP1 deficiency. Therefore, newer treatments targeting genes are on the horizon. In this article, we review up to date knowledge of the understanding of GACI, its clinical, pathologic, and etiologic understanding and treatment in support of more comprehensive care of GACI patients.

Change in the Alignment and Distal Junctional Kyphosis Development after Posterior Cervical Spinal Fusion Surgery for Cervical Spondylotic Myelopathy - Risk Factor Analysis.

ObjectiveThis study analyzed the risk factors in patients who developed distal junctional kyphosis (DJK) after posterior cervical fusion. MethodsWe retrospectively analyzed the clinical and radiographic outcomes of 64 patients, aged ≥18 years (51 and 13 male and female patients, respectively), who underwent single-staged multilevel (3–6 levels) posterior cervical fusion surgery due to multiple cervical spondylotic myelopathy. The surgeries were performed by a single spinal surgeon between January 2012 and December 2017. Demographic data, clinical outcomes, and radiological results were collected. We divided the patients into a DJK group and a non-DJK group according to the presence of DJK and investigated the risk factors by comparing the differences between the two groups. ResultsOf the 64 patients, 13 developed DJK. No significant differences in clinical results were observed between the two groups before and immediately after the surgery. At the final follow-up, a higher visual analog score for neck pain was observed in the DJK group compared to the non-DJK group (p<0.01). The DJK group had a significantly lower T1 slope and a significantly higher C2-7 sagittal vertical axis (SVA) before surgery compared to the non-DJK group (p=0.03 and p<0.01, respectively). Immediately after surgery, the difference between the two groups decreased and no significant difference was observed. However, at the last followup, a significantly higher C2-7 SVA was observed in the DJK group (p<0.01). At the last follow up, there is no discrepancy in T1S-CL. In multiple logistic regression analysis, preoperative higher C2-7 SVA and preoperative lower T1 slope were identified as independent risk factors (p=0.03 and p<0.01, respectively). As a result, it was confirmed that DJK occurred along the process of returning to preoperative values. ConclusionDJK can be considered to be caused by cervical misalignment due to excessive change in the surgical site in patients with low T1 slope and high C2-7 SVA before surgery. This also affects the clinical outcome after surgery. It is recommended to refrain from excessive segmental lordosis changes during multilevel cervical post fusion surgery, especially in patients with a small preoperative T1 slope and a large SVA value.

Response of enthesopathy in ENPP1 deficiency to enzyme replacement therapy in murine models and enthesopathy comorbidities and quality of life in ENPP1‐deficient adults

Biallelic ectonucleotide pyrophosphatase/phosphodiesterase 1 (ENPP1) deficiency leads to cardiovascular calcification in infancy, FGF23‐mediated hypophosphatemic rickets in childhood, and osteomalacia in adulthood. Excessive enthesis mineralization and cervical spine fusion have been previously reported in patients with biallelic ENPP1 deficiency, but their effect on quality of life is unknown. We describe additional musculoskeletal complications in patients with ENPP1 deficiency, namely osteoarthritis and interosseous membrane ossification, and for the first time evaluate health‐related quality of life (HRQoL) in patients with this disease, both subjectively via narrative report, and objectively via the Brief Pain Inventory – Short Form, and a Patient Reported Outcome Measurement Information System Physical Function (PROMIS PF) short form. Residual pain, similar in magnitude to that identified in adult patients with X‐linked hypophosphatemia, was experienced by the majority of patients despite use of analgesic medications. Impairment in physical function varied from mild to severe. To assess murine ENPP1 deficiency for the presence of enthesopathy, and for the potential response to enzyme replacement therapy, we maintained Enpp1asj/asj mice on regular chow for 23 weeks and treated cohorts with either vehicle or a long‐acting form of recombinant ENPP1. Enpp1asj/asj mice treated with vehicle exhibited robust calcification throughout their Achilles tendons, whereas two‐thirds of those treated with ENPP1 enzyme replacement exhibited complete or partial suppression of the Achilles tendon calcification. Our combined results document that musculoskeletal complications are a significant source of morbidity in homozygous ENPP1 Deficiency, a phenotype which is closely recapitulated in Enpp1asj/asjmice. Finally, we show that a long‐acting form of recombinant ENPP1 prevents the development of enthesis calcification at the relatively modest dose of 0.3 mg/kg per week, suggesting that suppression of enthesopathy may be attainable upon dose escalation.

C2 translaminar screw fixation in pediatric occipitocervical fusion

PurposeRigid occipitocervical (O-C) instrumentation can reduce the anterior pathology and has a high fusion rate in children with craniovertebral instability. Typically, axis (C2) screw fixation utilizes C1–C2 transarticular screws or C2 pars screws. However, anatomic variation may preclude these screw types due to the size of fixation elements or by placing the vertebral artery at risk for injury. Pediatric C2 translaminar screw fixation has low risk of vertebral artery injury and may be used when the anatomy is otherwise unsuitable for C1–C2 transarticular screws or C2 pars screws.MethodsWe retrospectively reviewed a neurosurgical database at UCSF Benioff Children’s Hospital Oakland for patients who had undergone a cervical spinal fusion that utilized translaminar screws for occipitocervical instrumentation between 2002 and 2020. We then reviewed the operative records to determine the parameters of C2 screw fixations performed. Demographic and all other relevant clinical data were then recorded.ResultsTwenty-five patients ranging from 2 to 18 years of age underwent O-C fusion, with a total of 43 translaminar screws at C2 placed. Twenty-three patients were fused (92%) after initial surgery with a mean follow-up of 43 months. Two patients, both with Down syndrome, had a nonunion. Another 2 patients had a superficial wound dehiscence that required wound revision. One patient died of unknown cause 7 months after surgery. One patient developed an adjacent-level kyphosis.ConclusionWhen performing occipitocervical instrumentation in the pediatric population, C2 translaminar screw fixation is an effective option to other methods of C2 screw fixation dependent on anatomic feasibility.

Clinical and radiological assessment of adjacent segment degenerative changes in cervical spine after instrumentation in indian scenerio

OBJECTIVE: Over the last 50 years many authors have used cervical spine fusion as a treatment for degenerative spondylotic conditions, and it has become the standard of care for numerous pathologic conditions of the spine. However, since over the past two decades spinal fusion has been performed on younger patients and the rates of cervical spine surgery have increased. Here we have studied the incidence of the adjacent segment disease and the radiological changes of cervical cord at the level of previous operation and at the adjacent segment. METHODS: Non randomised, open level study done at territory care centre for a period of three years a total 51 operated cervical spine patients were studied. MRI of cervical spine was done in symptomatic patients. All the patients were followed up clinically and radiologically. RESULTS: Fifty one patients were followed up for minimum of 2 years (average 72.82 months) after cervical spine instrumentation. 23 patients had single or multiple co- morbidities. 29 (56.86%) patients developed adjacent segment degeneration following the primary surgery. Rate of re- surgery for the symptomatic ASD was 9.8% , Development of radiological or clinical ASD 54.9%.

458 Pulsed Electromagnetic Fields (PEMF) Used in Cervical Spine Fusion for Patients with Risk Factors for Non-Union

INTRODUCTION: A post market prospective study was conducted to examine the effect of the adjunctive use of a pulsed electromagnetic field (PEMF) device on cervical fusion rate in subjects with risk factors for non-union. PEMF has been shown to stimulate bone healing and can be a valuable tool to help overcome biological deficiencies in patients at risk for non-union. METHODS: Patients undergoing cervical fusion surgery were identified for enrollment from 11 investigator sites based on being classified as having one or more risk factors for non-union. Subjects were those having a multi-level (2 or more) fusion, prior cervical spine fusion, diabetes, osteoporosis, or smokers. Subjects were required to wear the PEMF device for 4 hours/day for 6 months. Compliance was measured based on usage data downloaded from the device. The primary outcome measure was fusion status at 12 month follow-up period as indicated by x-ray and CT. Fusion status was determined by the site investigator using A/P, lateral, and flexion/extension radiographs in addition to CT (without contrast). RESULTS: Out of 152 subjects, 138 (90.8%) were graded as fused (all levels) at the 12 month visit About half of the subjects (49.3%) had 3 or more levels fused. Fusion success for subjects with 2 or more risk factors was 88.5%, and was 94.4% for subjects with a single risk factor. On average, compliance rates (minutes using device/minutes prescribed) were 83.8% and 74.9% for the 3 and 6 month visit, respectively. The followup rate at the 12 month visit was 97%. CONCLUSION: The results of our study suggest that adjunctive use of PEMF is effective in cervical spine fusion patients with factors associated with non-union. Favorable fusion rates were obtained with patients having elevated comorbidity and/or complex surgeries. Further research is planned to include a control group in a real world setting to better assess the impact of the PEMF device in this population.

Titanium Hypersensitivity Diagnosed by Patch Testing After Anterior Cervical Spine Fusion.

Titanium Hypersensitivity Diagnosed by Patch Testing After Anterior Cervical Spine Fusion.

Syndrome Associated with Cervical Vertebrae Anomalies and Orthodontic Relevance

Cervical vertebrae anomalies (such as Dehiscence, fusion of cervical spine, occipitalization) are associated with myelopathy, cause limitation in neck movement, muscular atrophy, and regional sensory loss. These cervical vertebrae anomalies are associated with syndromes such as Klippel-Feil syndrome, Goldenhar syndrome, Pfeiffer syndrome, Crouzon syndrome, Apert syndrome, Larsen syndrome and 22q11.2 micro deletion syndromes. Cervical vertebrae anomalies can be visualized in lateral cephalogram which is routinely advised for orthodontic patients to assess maxillary and mandibular relationship. Assessment of CVA in lateral cephalogram at an early age is essential, not only for treatment of the malformation but because there may be an association with other spinal and non-spinal diseases related to development. Present review discusses about various syndromes and clinical manifestations associated with cervical vertebrae anomalies and its relevance in orthodontics.

Anaesthetic Challenges in a Paediatric Patient with Escobar Syndrome-Difficult Airway and Postoperative Pneumothorax.

Escobar syndrome (ES) is an autosomal recessive disorder characterised by the presence of pterygia in cervical, antecubital and popliteal regions. Anaesthesiologist encounter notable challenges in this syndrome, especially airway management due to associated malformations like cleft lip/palate, micrognathia, syngnathia, ankyloglossia, neck contracture, cervical spine fusion, limited neck extension and craniofacial dysmorphism. In addition to difficult airway, anaesthesiologist may encounter other perioperative challenges. Here, we report a paediatric patient with ES, who required general anaesthesia for laparoscopic inguinal hernia repair and orchidopexy. Initial attempt with video laryngoscope failed due to inability to visualise epiglottis. Subsequent attempt with fibreoptic bronchoscope also failed due to rapid decrease in oxygen saturation. He was finally intubated with fibreoptic bronchoscope along with oxygen insufflation with a 3mm internal diameter polyvinylchloride endotracheal tube inserted nasally and connected to oxygen supply. Further perioperative challenges faced were intraoperative hyperthermia and postoperative pneumothorax with mediastinal shift. To the best of our knowledge, this is the first case reporting pneumothorax with mediastinal shift as a postoperative complication and use of oxygen insufflation through nasal tube during fibreoptic intubation in paediatric patient with ES.