Cervical Spine Surgery Research Articles

Cervical Anatomical Landmarks Indicate the Amount of Vertebra Resection during ACAF Surgery: A Semi-Quantitative Anatomical Parameter Study on Imaging Data.

ObjectiveWith the innovation and development of cervical spine surgical procedures, there is currently a lack of new and reliable data on cervical anatomical landmarks. The purpose of this study is to measure the CT data of the cervical vertebrae of healthy volunteers, so as to make up for the missing part of the measured value of cervical vertebra bone markers, and provide data support for the safety and accuracy of anterior controllable antedisplacement and fusion (ACAF) surgery.MethodsFrom January 2019 to January 2020, the cervical computed tomography (CT) scan image data of volunteers in Changhai Hospital and Zhabei Hospital were randomly selected. The radiological parameters included three parameters were measured in the upper lamina plane. a: the distance from the anterior edge of the vertebral body to the anterior edge of the bilateral uncinate joint; c1: the sagittal diameter of the vertebral body; and d: the distance between the anterior edge of the uncinate joint. Three parameters were measured in the pedicle plane. b: the vertical distance from the anterior edge of the vertebral body to the junction line between the two lateral processes; c2: the sagittal diameter of the vertebral body; e: the transverse diameter of the vertebral body; and f: the sagittal diameter of the vertebral canal. The correlation ratios were calculated: a/c1, b/c2, a/f, b/f, d/e. The data between the two groups were compared by independent sample t‐test.ResultsFinally, 51 patients were included in this study, 18 males and 33 females, with an average age of 47.9 years (21–72 years). The maximum values of seven parameters measured were all at C7. The minimum b value was at C5, and the minimum f value was at C4. The minimum values of the other five parameters were all at C3, and there was an increasing relationship from C3 to C7 (P < 0.05). There was significant difference between male and female with regard to c1, c2, e and d values (P < 0.05). No significant differences were observed between men and women regard to the ratio of related parameters (a/c1, b/c2, a/f, b/f, d/e).ConclusionsAnatomical consideration of this area is useful to estimate amount of vertebral body resection when performing the bony cut made in ACAF surgery; however, pre‐operative examinations with appropriate radiographic analysis are also recommended.

Evaluation of Health-related Quality of Life Improvement in Patients Undergoing Cervical Versus Shoulder Surgery.

Retrospective analysis of outcomes in cervical spine and shoulder arthroscopy patients. The objective of this study is to assess differential improvements in health-related quality of life for cervical spine surgery compared with shoulder surgery. An understanding of outcome differences between different types of orthopedic surgeries is helpful in counseling patients about expected postoperative recovery. This study compares outcomes in patients undergoing cervical spine surgery with arthroscopic shoulder surgery using computer-adaptive Patient-reported Outcome Information System scores. Patients undergoing cervical spine surgery (1-level or 2-level anterior cervical discectomy and fusion, cervical disc replacement) or arthroscopic shoulder surgery (rotator cuff repair±biceps tenodesis) were grouped. Patient-reported Outcome Information System scores of physical function, pain interference, and pain intensity at baseline and at 3, 6, and 12 months were compared using paired t tests. Cervical spine (n=127) and shoulder (n=91) groups were similar in sex (25.8% vs. 41.8% female, P =0.731) but differed in age (51.6±11.6 vs. 58.60±11.2, P <0.05), operative time (148.3±68.6 vs. 75.9±26.9min, P <0.05), American Society of Anesthesiologists (ASAs) (2.3±0.6 vs. 2.0±0.5, P =0.001), smoking status (15.7% vs. 4.4%, P =0.008), and length of stay (1.1±1.0 vs. 0.3±0.1, P =0.000). Spine patients had worse physical function (36.9 ±12.6 vs. 49.4±8.6, P <0.05) and greater pain interference (67.0±13.6 vs. 61.7±4.8, P =0.001) at baseline. Significant improvements were seen in all domains by 3 months for both groups, except for physical function after shoulder surgery. Spine patients had greater physical function improvements at all timepoints (3.33 vs. -0.43, P =0.003; 4.81 vs. 0.08, P =0.001; 6.5 vs. -5.24, P =<0.05). Conversely, shoulder surgery patients showed better 6-month improvement in pain intensity over spine patients (-8.86 vs. -4.46, P =0.001), but this difference resolved by 12 months. Cervical spine patients had greater relative early improvement in physical function compared with shoulder patients, whereas pain interference and intensity did not significantly differ between the 2 groups after surgery. This will help in counseling patients about relative difference in recovery and improvement between the 2 surgery types. III.

Evaluating the Impact of Modic Changes on Operative Treatment in the Cervical and Lumbar Spine: A Systematic Review and Meta-Analysis.

Modic changes (MCs) are believed to be potential pain generators in the lumbar and cervical spine, but it is currently unclear if their presence affects postsurgical outcomes. We performed a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. All studies evaluating cervical or lumbar spine postsurgical outcomes in patients with documented preoperative MCs were included. A total of 29 studies and 6013 patients with 2688 of those patients having preoperative MCs were included. Eight included studies evaluated cervical spine surgery, eleven evaluated lumbar discectomies, nine studied lumbar fusion surgery, and three assessed lumbar disc replacements. The presence of cervical MCs did not impact the clinical outcomes in the cervical spine procedures. Moreover, most studies found that MCs did not significantly impact the clinical outcomes following lumbar fusion, lumbar discectomy, or lumbar disc replacement. A meta-analysis of the relevant data found no significant association between MCs and VAS back pain or ODI following lumbar discectomy. Similarly, there was no association between MCs and JOA or neck pain following ACDF procedures. Patients with MC experienced statistically significant improvements following lumbar or cervical spine surgery. The postoperative improvements were similar to patients without MCs in the cervical and lumbar spine.

Semispinalis Cervicis Sarcopenia is Associated With Worsening Cervical Sagittal Balance and Junctional Alignment Following Posterior Cervical Fusion for Myelopathy.

This was a retrospective cohort study. The present study is the first to investigate whether cervical paraspinal sarcopenia is associated with cervicothoracic sagittal alignment parameters after posterior cervical fusion (PCF). Few studies have investigated the association between sarcopenia and postoperative outcomes after cervical spine surgery. We retrospectively reviewed patients undergoing PCF from C2-T2 at a single institution between the years 2017-2020. Two independent reviewers utilized axial cuts of T2-weighted magnetic resonance imaging sequences to perform Goutallier classification of the bilateral semispinalis cervicis (SSC) muscles. Cervical sagittal alignment parameters were compared between subgroups based upon severity of SSC sarcopenia. We identified 61 patients for inclusion in this study, including 19 patients with mild SSC sarcopenia and 42 patients with moderate or severe SSC sarcopenia. The moderate-severe sarcopenia subgroup demonstrated a significantly larger change in C2-C7 sagittal vertical axis (+6.8mm) from the 3-month to 1-year postoperative follow-up in comparison to the mild sarcopenia subgroup (-2.0mm; P =0.02). The subgroup of patients with moderate-severe sarcopenia also demonstrated an increase in T1-T4 kyphosis (10.9-14.2, P =0.007), T1 slope (28.2-32.4, P =0.003), and C2 slope (24.1-27.3, P =0.05) from 3-month to 1-year postoperatively and a significant decrease in C1-occiput distance (6.3-4.1, P =0.002) during this same interval. In a uniform cohort of patients undergoing PCF from C2-T2, SSC sarcopenia was associated with worsening cervicothoracic alignment from 3-month to 1-year postoperatively.

Axial Neck-Shoulder Pain After Posterior Correction and Fusion for Adolescent Idiopathic Scoliosis With Structural Thoracic Curve: Does Cranial Fusion Level Affect Neck Symptoms?

A retrospective cohort study using prospectively collected data. To investigate the incidence and impact of fusion to the upper thoracic spine on neck-shoulder symptoms after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). Axial neck-shoulder pain is established as a sequela of posterior cervical spine surgery and is mainly caused by the dissection of extensor muscles in the cervical and upper thoracic spine. Sixty-three female patients with AIS who underwent PSF using segmental pedicle screw constructs for structural main thoracic curve with a minimum 2-year follow-up were included. Axial neck-shoulder pain was assessed using the visual analog scale and cervical spine function domain score of the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire. The patients were divided into 2 groups, a higher group (underwent fusion up to T3 or above, n=27) and a lower group (underwent fusion up to T4 or below, n=36), and radiologic and clinical outcomes were compared. The incidence of axial neck-shoulder pain (visual analog scale ≥30) preoperatively and at the 2-year follow-up was 29 and 40%, respectively. The pain and mental health domains of the Scoliosis Research Society-22 and cervical spine function domain of the Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire were correlated with the severity of axial neck pain. In the comparison of clinical outcomes between the 2 groups, the pain domain score of the Scoliosis Research Society-22 in the lower group was significantly better than that in the higher group at the 2-year follow-up ( P <0.05). Other parameters showed no significant differences preoperatively or at the 2-year follow-up. Female patients with AIS had a relatively high incidence of axial neck-shoulder pain after PSF, which affected their health-related quality of life. Both groups showed similar clinical outcomes, and the cranial fusion level did not affect axial neck-shoulder pain and cervical spine function. Level 3.

Cerebrospinal fluid pressure dynamics reveal signs of effective spinal canal narrowing in ambiguous spine conditions.

Spinal canal narrowing with consecutive spinal cord compression is considered a key mechanism in degenerative cervical myelopathy (DCM). DCM is a common spine condition associated with progressive neurological disability, and timely decompressive surgery is recommended. However, the clinical and radiological diagnostic workup is often ambiguous, challenging confident proactive treatment recommendations. Cerebrospinal fluid pressure dynamics (CSFP) are altered by spinal canal narrowing. Therefore, we aim to explore the potential value of bedside CSFP assessments for qualitative and quantitative assessment of spinal canal narrowing in DCM. In this prospective case series, seven patients with DCM underwent bedside lumbar puncture with measurement of CSFP dynamics and routine CSF analysis (NCT02170155). The patients were enrolled when standard diagnostic algorithms did not permit a clear treatment decision. Measurements include baseline CSFP, cardiac-driven CSFP peak-to-trough amplitude (CSFPp), and the Queckenstedt's test (firm pressure on jugular veins) in neutral and reclined head position. From the Queckenstedt's test, proxies for craniospinal elastance (i.e., relative pulse pressure coefficient; RPPC-Q) were calculated analogously to infusion testing. CSFP metrics were deemed suspicious of canal narrowing when numbers were lower than the minimum value from a previously tested elderly spine-healthy cohort (N = 14). Mean age was 56 ± 13 years (range, 38–75; 2F); symptom severity was mostly mild to moderate (mean mJOA, 13.5 ± 2.6; range, 9–17). All the patients showed some extent of cervical stenosis in the MRI of unclear significance (5/7 following decompressive cervical spine surgery with an adjacent level or residual stenosis). Baseline CSFP was normal except for one patient (range, 4.7–17.4 mmHg). Normal values were found for CSFPp (0.4–1.3 mmHg) and the Queckenstedt's test in normal head positioning (9.-25.3 mmHg). During reclination, the Queckenstedt's test significantly decreased in one, and CSFPp in another case (>50% compared to normal position). RPPC-Q (0.07–0.19) aligned with lower values from spine-healthy (0.10–0.44). Routine CSF examinations showed mild total protein elevation (mean, 522 ± 108 mg/ml) without further evidence for the disturbed blood brain barrier. Intrathecal CSFP measurements allow discerning disturbed from normal CSFP dynamics in this population. Prospective longitudinal studies should further evaluate the diagnostic utility of CSFP assessments in DCM.

Short-term outcomes after primary reverse total shoulder arthroplasty in patients with cervical spine pathology or previous cervical spine surgery compared to those without

BackgroundCervical spine (c-spine) and shoulder pathology have been known to cause similar symptoms and often co-exist, making an accurate diagnosis difficult, especially in an elderly population. Reverse total shoulder arthroplasty (rTSA) has been shown to decrease pain and improve quality of life when shoulder pathology is the source of pain and disability. The purpose of this study was to identify the prevalence of c-spine pathology in a cohort of patients who underwent rTSA and to compare postoperative outcome scores to a cohort without c-spine pathology. MethodsA retrospective review was performed utilizing a single institution's operative records of primary rTSAs. Radiology reports, imaging, and operative reports were reviewed, and presence of any c-spine pathology or previous surgery were recorded. Additionally, postoperative outcome scores (American Shoulder and Elbow Surgeons [ASES], Constant Score, University of California, Los Angeles [UCLA], and Simple Shoulder Test [SST]) were evaluated at >2 years post-rTSA. ResultsA total of 438 primary rTSA cases were evaluated. Of these, 143 (32.6%) had documentation of prior c-spine pathology and/or history of previous c-spine surgery. After applying further exclusion criteria, a total of 50 patients with c-spine pathology and 108 patients without c-spine pathology were found to have complete medical records and postoperative outcome scores to allow comparison between groups. Patients without c-spine pathology were found to have statistically higher postoperative UCLA, ASES, and SST scores when compared to patients with c-spine pathology. Patients without c-spine pathology also demonstrated a significant improvement in the difference between their postoperative and preoperative UCLA and ASES scores. ConclusionThis study demonstrated a high prevalence of c-spine pathology (32.6%) in a cohort of patients who underwent primary rTSA. Additionally, short-term outcome scores of patients undergoing rTSA with concomitant c-spine pathology are significantly lower than those of patients without a history of c-spine pathology.

Factors Affecting the Waiting Time from Injury to Surgery in Elderly Patients with a Cervical Spine Injury: A Japanese Multicenter Survey

The management of cervical spine injuries in the elderly is often complicated by the presence of multiple medical comorbidities, and it is not uncommon for preoperative testing to reveal other conditions that require the postponement of surgery. However, the factors that affect the waiting time from injury to surgery have not been clarified. The purpose of this multicenter database study was to analyze the clinical features and identify the factors affecting the number of days waited between injury and surgery in elderly patients with a cervical spine injury. We retrospectively reviewed the case histories of 1512 Japanese patients with a cervical spinal injury, who were seen at 33 institutions. After excluding patients who were not initially receiving a surgery for cervical spinal injury, 694 patients were ultimately analyzed. Based on a multivariate mixed model, we determined the factors related to the number of days from injury to surgery. The mean time from injury to surgery was 12.3days. Multivariate analysis revealed delays of 10.7days for a renal disorder, 7.3days for anticoagulant use, and 15.2days for non-surgical thoracolumbar fracture as factors prolonging wait time. In contrast, a C3 or lower spine injury was significantly associated with a shortening of 9.5days to surgery. This multicenter database study identified several factors influencing the time between injury and cervical spine surgery in elderly patients. While renal impairment, anticoagulant use, and non-surgical thoracolumbar fracture may increase the number of days to surgery, trauma to C3 or lower may expedite surgical treatment.

Longus Colli and Vertebral Artery Guide Safety of Cervical Spine Surgery

Objective: To improve the safety of the anterior cervical vertebral surgical approach, MRI and CT have been used and the distances between the medial borders of the longus colli (LC) to expose the uncinated process (UP) have been reported. The anatomic parameters of the LC and vertebral artery (VA) were considered here in relation to the UP to minimize complications.Materials and Methods: Data were obtained from 60 Thai adult skeletons and 20 embalmed cadavers. Direct measurements of the dry cervical vertebrae were performed using digital Vernier calipers, while computer imaging analysis was used for the cadaveric measurements after capturing the images.Results: No significant difference was noted in the inter-UP distance between the dry and cadaveric cervical measurements. The average UP width was 6.7 ± 0.2 mm. The average distance from the tip of the UP to the VA was 2.6 ± 0.1 mm. The calculated distance from the LC to the UP which derived from the inter-UP distance and the distance between the LC increased from C2 to C7 with an average distance of 11.9 ± 0.3 mm.Conclusion: Within a distance of 11.9 ± 0.3 mm from the medial border of the LC, UP can be identified. Dissecting at a distance less than 10 mm posterior, 5–6 mm lateral and superior to the base of the UP can avoid VA injury and optimize the safety of the anterior cervical vertebral surgical approach.

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.

The Effect of the Coronavirus Disease 2019 (COVID-19) Pandemic on Elective Cervical Spine Surgery Utilization and Complications in the United States: A Nationwide Temporal Trends Analysis

ObjectivesAs a result of the coronavirus disease 2019 (COVID-19) pandemic, elective surgeries nationwide were suspended. The objective was to compare temporal trends in patient demographics, case volumes, and postoperative complications of patients undergoing elective cervical spine surgery from pre-COVID-19 (2019–2020 Q1) to post-COVID-19 (2020 Q2–Q4).MethodsThe 2019 to 2020 American College of Surgeon's National Surgery Quality Improvement Program database was queried for common elective cervical spine surgeries. Patients pre-COVID-19 (2019–2020 Q1) were compared with those undergoing surgery during post-COVID-19 (2020 Q2–Q4) protocols. Procedural use, patient demographics, and complications were compared. Linear regression was used to evaluate case volume changes over time. P values less than 0.05 were significant.ResultsIn total, 31,013 patients underwent elective cervical spine surgery in 2019 (N = 16,316) and 2020 (N = 14,697); an overall 10% decline. Compared with the calendar year 2019 through 2020 Q1 mean, elective surgery volume decreased by 21.6% in 2020 Q2 and never returned to prepandemic baseline. The percentage decline in case volume from 2019 to 2020 Q1 to 2020 Q2 was greatest for anterior cervical discectomy and fusion (23.3%), followed by cervical decompression (23.4%), posterior cervical fusion (15.0%), and cervical disc arthroplasty and vertebral corpectomy (13.7%). Patients undergoing surgery in 2020 Q2–Q4 had overall greater comorbidity burden (American Society of Anesthesiologists grade 3 and 4) (P < 0.001). From 2019–2020 Q1 versus 2020 Q2–Q4, there was a significant increase in total complication (5.5% vs. 6.8%, P < 0.001), reoperation (1.9% vs. 2.2%, P = 0.048), and mortality (0.25% vs. 0.37%, P = 0.049) rates.ConclusionsElective surgery declined drastically during the second quarter of 2020. Patients undergoing surgery during the pandemic had an overall greater comorbidity burden, resulting in increased total complication and mortality rates over the study period.

A nationwide study of patients operated for cervical degenerative disorders in public and private hospitals

During the last decades, there has been an increase in the rate of surgery for degenerative disorders of the cervical spine and in the use of supplementary private health insurance. Still, there is limited knowledge about the differences in characteristics of patients operated in public and private hospitals. Therefore, we aimed at comparing sociodemographic-, clinical- and patient management data on patients operated for degenerative cervical radiculopathy and degenerative cervical myelopathy in public and private hospitals in Norway. This was a cross-sectional study on patients in the Norwegian Registry for Spine Surgery operated for degenerative cervical radiculopathy and degenerative cervical myelopathy between January 2012 and December 2020. At admission for surgery, we assessed disability by the following patient reported outcome measures (PROMs): neck disability index (NDI), EuroQol-5D (EQ-5D) and numerical rating scales for neck pain (NRS-NP) and arm pain (NRS-AP). Among 9161 patients, 7344 (80.2%) procedures were performed in public hospitals and 1817 (19.8%) in private hospitals. Mean age was 52.1 years in public hospitals and 49.7 years in private hospitals (P < 0.001). More women were operated in public hospitals (47.9%) than in private hospitals (31.6%) (P < 0.001). A larger proportion of patients in private hospitals had high education (≥ 4 years of college or university) (42.9% vs 35.6%, P < 0.001). Patients in public hospitals had worse disease-specific health problems than those in private hospitals: unadjusted NDI mean difference was 5.2 (95% CI 4.4 – 6.0; P < 0.001) and adjusted NDI mean difference was 3.4 (95% CI 2.5 – 4.2; P < 0.001), and they also had longer duration of symptoms (P < 0.001). Duration of surgery (mean difference 29 minutes, 95% CI 27.1 – 30.7; P < 0.001) and length of hospital stay (mean difference 2 days, 95% CI 2.3 – 2.4; P < 0.001) were longer in public hospitals. In conclusion, patients operated for degenerative cervical spine in private hospitals were healthier, younger, better educated and more often men. They also had less and shorter duration of symptoms and seemed to be managed more efficiently. Our findings indicate that access to cervical spine surgery in private hospitals could be skewed in favour of patients with higher socioeconomic status.

The Role of Intraoperative Neuromonitoring Modalities in Anterior Cervical Spine Surgery.

Background: Intraoperative neuromonitoring (IONM) is frequently used during spine surgery to mitigate the risk of neurological injuries. Yet, its role in anterior cervical spine surgery remains controversial. Without consensus on which anterior cervical spine surgeries would benefit the most from IONM, there is a lack of standardized guidelines for its use in such procedures. Purpose: We sought to assess the alerts generated by each IONM modality for 4 commonly performed anterior cervical spinal surgeries: anterior cervical diskectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), cervical disk replacement (CDR), or anterior diskectomy. In doing so, we sought to determine which IONM modalities (electromyography [EMG], motor evoked potentials [MEP], and somatosensory evoked potentials [SSEP]) are associated with alert status when accounting for procedure characteristics (number of levels, operative level). Methods: We conducted a retrospective review of IONM data collected by Accurate Neuromonitoring, LLC, a company that supports spine surgeries conducted by 400 surgeons in 8 states, in an internally managed database from December 2009 to September 2018. The database was queried for patients who underwent ACCF, ACDF, anterior CDR, or anterior diskectomy in which at least 1 IONM modality was used. The IONM modalities and incidence of alerts were collected for each procedure. The search identified 8854 patients (average age, 50.6 years) who underwent ACCF (n = 209), ACDF (n = 8006), CDR (n = 423), and anterior diskectomy (n = 216) with at least 1 IONM modality. Results: Electromyography was used in 81.3% (n = 7203) of cases, MEP in 64.8% (n = 5735) of cases, and SSEP in 99.9% (n = 8844) of cases. Alerts were seen in 9.3% (n = 671), 0.5% (n = 30), and 2.7% (n = 241) of cases using EMG, MEP and SSEP, respectively. In ACDF, a significant difference was seen in EMG alerts based on the number of spinal levels involved, with 1-level ACDF (6.9%, n = 202) having a lower rate of alerts than 2-level (10.0%, n = 272), 3-level (15.2%, n = 104), and 4-level (23.4%, n = 15). Likewise, 2-level ACDF had a lower rate of alerts than 3-level and 4-level ACDF. A significant difference by operative level was noted in EMG use for single-level ACDF, with C2-C3 having a lower rate of use than other levels. Conclusions: This retrospective review of anterior cervical spinal surgeries performed with at least 1 IONM modality found that SSEP had the highest rate of use across procedure types, whereas MEP had the highest rate of nonuse. Future studies should focus on determining the most useful IONM modalities by procedure type and further explore the benefit of multimodal IONM in spine surgery.

Success Rate and Complications Associated with the Surgical Treatment of Cervical Spondylosis Myelopathy in Albania.

Background: Patients suffering from cervical spondylotic myelopathy (SCM) and that do not respond to conservative treatment could benefit from anterior cervical spine surgery. However, surgical intervention is associated with increased risk of complications and therefore the decision to operate should be weighed against benefits. The purpose of this study was to describe the effectiveness and the rate of complications of anterior cervical spine surgery among CSM who do not respond to conservative treatment in Albania. &#x0D; Material and Methods: A total of 100 CSM patients who did not respond to conservative treatment and who showed up at our Service during 2014-2019 were subjected to anterior cervical spine surgery to resolve the CSM related signs and symptoms. The success rate as well as short-term and long-term complication of surgery were evaluated and reported. &#x0D; Results: The mean age of CSM patients (59% males) in the study was 51.5 years. One surgical procedure was employed in 90% of CSM patients whereas two procedures were necessary in the remaining 10%. The overall success rate of anterior cervical spine surgery was 70% (excellent in 40% of CSM patients and good in 30% of patients) whereas in 30% of CSM patients’ surgery did not bring any benefit or there were no changes compared to before the surgery. The overall rate of complications was 16%; no patients died following surgery. Specific complications were rare and varying from 1% of patients (Brown-Sequard syndrome, vocal cord paresis, wound infection) to 3% (subcutaneous hematoma).&#x0D; Conclusion: Anterior cervical spine surgery is associated with a relatively high success rate and a low level of post-operative complications and it might be regarded as a safe treatment among these CSM patients who do not respond to conservative treatment.

Cost analysis comparison between anterior and posterior cervical spine approaches.

Background: The costs of cervical spine surgery have steadily increased. We performed a 5-year propensity scoring-matched analysis of 276 patients undergoing anterior versus posterior cervical surgery at one institution.Methods: We performed propensity score matching on financial data from 276 patients undergoing 1–3 level anterior versus posterior cervical fusions for degenerative disease (2015–2019).Results: We found no significant difference between anterior versus posterior approaches for hospital costs ($42,529.63 vs. $45,110.52), net revenue ($40,877.25 vs. $34,036.01), or contribution margins ($14,230.19 vs. $6,312.54). Multivariate regression analysis showed variables significantly associated with the lower contribution margins included age (β = −392.3) and length of stay (LOS; β = −1151). Removing age/LOS from the analysis, contribution margins were significantly higher for the anterior versus posterior approach ($17,824.16 vs. $6,312.54, P = 0.01).Conclusion: Anterior cervical surgery produced higher contribution margins compared to posterior approaches, most likely because posterior surgery was typically performed in older patients requiring longer LOS.

The Difference of Sagittal Correction of Adult Subaxial Cervical Spine Surgery According to Age: A Retrospective Study.

ObjectiveAt present, the true sagittal alignment of the cervical spine is uncertain, resulting in no standard reference for subaxial cervical surgery. So, we aimed to explore the age difference of normal cervical sagittal alignment and to further investigate the mid‐and long‐term changes of sagittal alignment after subaxial cervical spine surgery.Materials and MethodsThis was a retrospective study and 1223 asymptomatic volunteers and 79 patients undergoing subaxial cervical spine surgery were retrospectively reviewed in total. Asymptomatic volunteers and patients were divided into six subgroups: 20–29, 30–39, 40–49, 50–59, 60–69 and ≥70 groups. The age difference and trend with age of cervical sagittal parameters of asymptomatic volunteers were assessed by cervical lateral radiography and analyzed by ANOVA test, and the regression equation of C2‐7 Cobb was established via multiple linear regression. Based on the C2‐7 Cobb regression equations of different ages, the theoretical value, deviation value, loss value of the C2‐7 Cobb, and JOA recovery rate of patients were calculated, and the correlation among the loss value, deviation value of the C2‐7 Cobb, and JOA recovery rate of the 79 patients was evaluated by Pearson correlation analysis.ResultsFor the asymptomatic volunteers, the C0‐2 Cobb decreased gradually with increasing age. The C2‐7 Cobb, C2‐7 SVA, T1S, NT, and TIA increased gradually with increasing age. The CBVA fluctuated with increasing age. T1S demonstrated a moderate correlation with C2‐7 Cobb (r = 0.60, p < 0.01); C0‐2 Cobb, C2‐7 SVA, CBVA, and TIA demonstrated a fair correlation with C2‐7 Cobb (r = −0.30, −0.33, 0.41, 0.40, p < 0.01); age demonstrated a poor correlation with C2‐7 Cobb (r = 0.19, p < 0.01). The regression equations of C2‐7 Cobb were established using C0‐2 Cobb, C2‐7 SVA, CBVA, and T1S. For the patients with subaxial cervical spine surgery, the loss of C2‐7 Cobb was moderately correlated with the deviation of C2‐7 Cobb (r = 0.33, p < 0.01).ConclusionThe age difference of cervical sagittal alignment was obvious, and the C2‐7 Cobb increased with age especially. The closer the postoperative C2‐7 Cobb was to the theoretical value of corresponding age, the smaller the loss of correction angle was, and the better the mid‐ and long‐term outcomes. The personalized sagittal reconstruction should be performed according to age difference for subaxial cervical spine surgery.

Management of postoperative cervical pseudomeningocele with percutaneous aspiration and epidural blood patch.

While epidural blood patch can be an effective management option in lumbar pseudomeningoceles in certain clinical settings, its utility in the cervical spine is unclear. The aim of this study was to evaluate the safety and effectiveness of percutaneous aspiration and autologous blood patch for post-operative durotomy related pseudomeningoceles within the cervical spine. A single institution retrospective review detailing 3 patients with durotomy related pseudomeningocele following posterior cervical spine surgery was completed. In all three cases, aspiration with subsequent injection of autologous epidural blood patch successfully treated each pseudomeningocele. One patient required more than one intervention, while the other two were successfully treated after one procedure. All three patients improved clinically without need for additional surgery. Percutaneous aspiration and epidural blood patch can be used to safely manage post-operative pseudomeningoceles within the posterior cervical spine.

Incidence and risk factors of postoperative symptomatic spinal epidural hematoma in cervical spine surgery: a single center, retrospective study of 18,220 patients.

The goal of this research is to explore the incidence and risk factors of symptomatic spinal epidural hematoma (SSEH) following cervical spine surgery. Patients with SSEH from January 2009 to February 2019 were identified as hematoma group. Two control subjects without SSEH were randomly selected for each patient in SSEH group as control group. We collected gender, age, body mass index (BMI), ossification of the posterior ligament (OPLL), comorbidities, anti-platelet or anti-coagulate treatment, coagulation function, segments, instrumental fixation, surgical approach, surgical procedure, duration of surgery and estimated blood loss, which might affect the occurrence of symptomatic epidural hematoma. T-test and Chi-square test were used to univariable test. Multifactor logistic regression analysis was used to investigate the correlation with symptomatic epidural hematoma, furthermore its causes were explored. Among 18,220 patients, 43 subjects developed SSEH, the incidence was 0.24%. The median time from the end of index surgery to SSEH was 150 min (25 and 75 percentile: 85 min to 290 min). The neurologic function before evacuation by modified Frankel scale is grade B in 5 patients, C in 32 patients, grade D in 6 patients. All patients' symptoms relieved partially or completely after evacuation. All patients with neurologic deficit worse than grade C pre-evacuation had at least one-grade improvement except for one patient. Multifactor logistic regression revealed OPLL involved segments are significantly correlated to the incidence of postoperative symptomatic epidural hematoma (P < 0.05), with a cut-off value of 1.5 levels. OPLL involved segments are significantly correlated to the incidence of postoperative symptomatic epidural hematoma.

What PROMIS Scores Correlate With Severe Disability in Cervical Spine Surgery?

Institutional Review Board-approved prospective cohort study. To establish a conversion between Neck Disability Index (NDI) and Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (PI). As the National Institutes of Health (NIH) PROMIS is a global outcome measure, it can be difficult to interpret the clinical implications in patients with cervical spine surgery. To determine how a disease-specific legacy instrument (NDI) correlates with PROMIS PI and define levels of substantial and minimal disability, we developed a formula to convert NDI scores to PROMIS PI. Adult patients undergoing cervical spine surgery at a single institution from 2016 to 2018 were prospectively enrolled. Patients undergoing surgery for instability due to trauma were excluded. Preoperative questionnaires, demographic data, presenting complaint (radiculopathy, myelopathy, myeloradiculopathy), and procedural data were recorded. Patients were included if they had completed the NDI and PROMIS PI. Correlation and regression analyses were performed. One hundred ninety-six patients met inclusion criteria. The average age was 56.9±12.9 years. The mean NDI score was 68.6±38 and PROMIS PI was 60.9±7.3. The PROMIS PI was strongly correlated with the NDI ( r =0.76, P <0.001). Linear regression analysis revealed the following formula. We performed a regression analysis allowing for the conversion of PROMIS PI scores with NDI. In keeping with the previous studies, our analysis showed that PROMIS PI was most strongly correlated to NDI. A PROMIS PI score >66 was correlated to substantial disability (NDI=50), whereas a PROMIS PI score <59 was correlated to minimal relative impairment (NDI=28). These results provide important reference, as PROMIS reporting becomes more widespread in the literature.

Impact of local steroid application on dysphagia after anterior cervical spine surgery: a meta-analysis.

Dysphagia is one of the most common complications of anterior cervical spine surgery. Local steroid was widely used to reduce the postoperative swallowing pain. However, the effect of local steroid application on dysphagia after anterior cervical spine surgery was still uncertain. We searched Medline (PubMed), Embase and the Cochrane Library on July 27, 2021 for studies investigating the effect of local steroid application on dysphagia after anterior cervical spine surgery from their date of inception to 2021. The relative risk or weighted mean difference with 95% confidence interval was recorded as a summary statistic consist of postoperative dysphagia, swallowing VAS scores, SWAL-QOL scores, PSTSI, and steroid related complications. This meta-analysis included 7 RCT studies involving 254 patients in the steroid group and 232 patients in the placebo group. Results showed local steroid group had less patients with dysphagia, lower swallowing VAS scores and less severe of prevertebral soft-tissue edema on the fourth day after surgery. No significant difference in non-fusion rate between the two groups was observed. And all included studies had no serious steroid related complications reported. The use of local steroid in anterior cervical spine surgery could reduce the early postoperative dysphagia without serious steroid related complication. However, the safety of local steroid application still need further studies with larger samples.