Previous Cervical Spine Surgery Research Articles

20. Long-term results of cervical transforaminal epidural steroid injections for cervical radiculopathy

<h3>BACKGROUND CONTEXT</h3> Cervical radiculopathy can have significant effects on patient's pain and quality of life. Cervical transforaminal epidural steroid injections (TF ESIs) are thought to be high-risk procedures with limited longer-term effectiveness. <h3>PURPOSE</h3> To determine whether cervical TF ESIs improve patient reported quality of life outcomes, offer therapeutic benefit, and whether TF ESIs decrease the need to undergo cervical spine surgery. <h3>STUDY DESIGN/SETTING</h3> Academic hospital medical spine practice. <h3>PATIENT SAMPLE</h3> A total of 223 consecutive patients who underwent unilateral cervical TF ESI between 12/11/2013 and 12/23/2020. Average age was 51.8 (SD = 11.2 years) with 49.8% male, 50.2% female. Of the total, 3.8% were performed at C3-4, 9.5% at C4-5, 41.4% at C5-6, 38.0% at C6-7, and 7.2% at C7-T1. Median duration of symptoms was 9 months; 18.7% had previous cervical spine surgery; 19.8% had a repeat injection at the same level; 86.3% had IV sedation (Versed [midazolam]). Pathology 38.9% had disc herniation, 59.9 had bony foraminal stenosis, 1.1% had psedoarthrosis. Ninety-five percent had physicial therapy prior to cervical TF ESI. 35.5% had CT cervical spine and 40.8% had upper extremity EMG prior to cervical TF ESI. <h3>OUTCOME MEASURES</h3> We evaluated data using validated patient-reported outcomes measures – PHQ9, and PROMIS-GH Physical, and PROMIS-GH Mental. <h3>METHODS</h3> Retrospective review of single practitioner's outcomes after all patient undergoing cervical TF ESI from 2014-2020. <h3>RESULTS</h3> Of the 223 patients, 60 patients went on to have cervical surgery, 26.9%. Of the total patients, 92.8% had diagnostic benefit considered to be at least 80% immediate relief 4 hours after injection. History of spine surgery was the only statistically significant predictor to long-term benefit after cervical TF ESI. Patients who had prior spine surgery had a hazard of post-injection surgery that was 2.03 times larger, compared to patients who did not have prior spine surgery (P = 0.012). Mean PHQ-9 change of -1.53 at 3 months (p=0.016, n=91), -2.14 at 6 months (p= 0.006, n=53), -1.40 at 12 months (p= 0.056, n=61), -2.22 at 24 months (p=0.017, n=34). Mean PROMIS-GH physical change of +2.12 at 3 months (p=0.002, n=80), +2.22 at 6 months (p=0.005, n=55), +3.10 at 12 months (p=0.001, n=65), +3.23 at 24 months (p=0.001, n=38). History of cervical surgery was associated with worse PHQ-9 scores. <h3>CONCLUSIONS</h3> Cervical TF ESI can be done safely with minimal morbidity and significant benefit at 24 months. In more than 2/3 of the patients, surgery was not needed due to diagnostic and therapeutic benefit from cervical TF ESI. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

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.

Laryngoscopic Screening Before Revision Anterior Cervical Spine Surgery: Is Vocal Cord Palsy a Relevant Factor in Deciding the Approach Direction?

Retrospective study. The aim was to evaluate the exact incidence of vocal cord palsy (VCP) caused by previous anterior cervical spine surgery (ACSS) and aid surgeons in deciding the approach direction in revision ACSS. The incidence of VCP detected by preoperative laryngoscopic screening before revision ACSS appeared to be much higher in previous reports than in our experience. We reviewed the data of 64 patients who underwent revision ACSS. Preoperative laryngoscopy was performed in all patients to detect VCP and/or structural abnormalities of the vocal cords. The patients' characteristics, laryngoscopy results, and symptoms before revision surgery that were potentially caused by previous recurrent laryngeal nerve injuries (voice change, foreign body sensation, and chronic aspiration) were recorded. Laryngoscopy demonstrated no complete VCP or decreased vocal cord motility. Eleven patients (17.2%) showed vocal cord-related symptoms and 13 patients (20.3%) showed abnormal laryngoscopic findings without VCP. Four patients (6.2%) showed vocal cord-related symptoms and abnormal laryngoscopic findings simultaneously. At the initial operative level, no significant differences in vocal cord-related symptoms were observed between the upper and lower levels (C3-4-5 vs. C5-6-7). However, the frequency of vocal cord-related symptoms was significantly high at the larger number of levels (≥3 segments) (P=0.010). In contrast to previous reports, this study demonstrated that VCP is rarely detected before revision ACSS. Therefore, deciding the approach direction with only vocal cord motility can be dangerous, and more attention is required in setting the approach direction in patients who show both vocal cord-related symptoms and abnormal laryngoscopic finding. In other cases, a contralateral approach which has a low risk of bilateral VCP could be utilized if necessary.

Cervical Steroid Injections Are Not Effective for Prevention of Surgical Treatment of Degenerative Cervical Myelopathy.

Retrospective cohort study. The objective of this study is to determine how often patients with degenerative cervical myelopathy (DCM) and initially treated with cervical steroid injections (CSI) and to determine whether these injections provide any benefit in delaying ultimate surgical treatment. All patients with a new diagnosis of DCM, without previous cervical spine surgery or steroid injections, were identified in PearlDiver, a large insurance database. Steroid injection and surgery timing was identified using Current Procedural Terminology (CPT) codes. Multivariate logistic regression identified associations with surgical treatment. A total of 686 patients with DCM were identified. Pre-surgical cervical spine steroid injections were utilized in 244 patients (35.6%). All patients underwent eventual surgical treatment. Median time from initial DCM diagnosis to surgery was 75.5 days (mean 351.6 days; standard deviation 544.9 days). Cervical steroid injections were associated with higher odds of surgery within 1 year (compared to patients without injections, OR = 1.44, P < .001) and at each examined time point through 5 years (OR = 2.01, P < .001). In multivariate analysis comparing injection types, none of the 3 injection types were associated with decreased odds of surgery within 1 month of diagnosis. While cervical steroid injections continue to be commonly performed in patients with DCM, there is an overall increased odds of surgery after any type of cervical injection. Therefore injections should not be used to prevent surgical management of DCM.

Comorbidities associated with cervical spine degenerative disc disease

Determining important links between medical comorbidities and cervical spine degenerative disc disease (DDD) will help elucidate pathomechanisms of disc degeneration. Electronic medical records and magnetic resonance imaging were retrospectively reviewed to evaluate 799 patients assessed for cervical spine pathology. Bivariate analysis identified older age, diabetes, ASA class, cancer, COPD, depression, hypertension, hypothyroidism, Medicare status, peripheral vascular disease, history of previous cervical spine surgery, smoking, and lower median household income as having strong associations with increased cumulative grade of cervical spine DDD. This study provides evidence suggesting aging and accumulation of medical comorbidities influence severity of cervical spine DDD.

Risk factors for postoperative dysphagia and dysphonia following anterior cervical spine surgery: a comprehensive study utilizing the hospital for special surgery dysphagia and dysphonia inventory (HSS-DDI)

BACKGROUND CONTEXTPostoperative dysphagia and dysphonia (PDD) are prevalent complications after anterior cervical discectomy and fusion (ACDF). Identification of risk factors for these complications is necessary for effective prevention. Recently, patient reported outcome measures (PROM) have been used to determine PDD after ACDF. The Hospital for Special Surgery Dysphagia and Dysphonia Inventory (HSS-DDI) is a validated PROM that specifically assesses dysphagia and dysphonia after anterior cervical spine surgery. PURPOSETo identify the perioperative risk factors for PDD utilizing the HSS-DDI. STUDY DESIGN/SETTINGObservational study of prospectively collected data at a single academic institution. PATIENT SAMPLEPatients undergoing anterior cervical discectomy and fusion from 2015 to 2019 who enrolled in the prospective data collection. OUTCOME MEASUREThe HSS-DDI administered 4 weeks, 8 weeks, and 4-6 months after surgery. METHODSAs potential risk factors, the data on demographic factors, analgesic medications, history of psychiatric illness, preoperative sagittal alignment, surgical factors, preoperative diagnoses, and preoperative Neck Disability Index (NDI) scores were collected. Bivariate and multivariable regression analyses utilizing the Tobit model were conducted. RESULTS291 patients were included in the final analysis. The median HSS-DDI at 4-weeks, 8 weeks, and 4-6 months postoperatively, were 80.7, 92.7, and 98.4, respectively. Multivariable analysis demonstrated that current smoking, previous cervical spine surgery, preoperative C2-7 angle, upper level surgery, multilevel surgery, opioid use, and a high preoperative NDI score, were independent contributing factors to a low HSS-DDI score at 4-weeks follow-up. Intraoperative topical steroid use was an independent protective factor for a low HSS-DDI score. Opioid use and high NDI score remained independent factors at 4-6 months. Sub-domain analysis demonstrated that prior cervical surgery, preoperative C2-7 angle, multilevel surgery, and intraoperative topical steroid use were significant for dysphagia only. Current smoking was significant for dysphonia only. CONCLUSIONSOur results showed that preoperative opioid use and a high preoperative NDI score are novel independent risk factors for postoperative dysphagia and dysphonia in addition to other known factors.

24. Cervical spine steroid injections for delay of surgery for cervical spondylotic myelopathy

BACKGROUND CONTEXT Cervical spine steroid injections are increasingly being used for diagnosis and treatment of degenerative pathology. For cervical spondylotic myelopathy traditionally treated with surgery, there has been little investigation of the possible therapeutic or preventive effects of targeted injections. As injections may be targeted to the epidural space, the transforaminal region, or the zygapophyseal joints, differing injection modalities may also have variable therapeutic effects. PURPOSE To determine the potential for cervical spine steroid injections to delay surgical treatment for cervical spondylotic myelopathy. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 39,590 patients with a new diagnosis of cervical spondylotic myelopathy, without previous cervical spine surgery. OUTCOME MEASURES Timing of surgical treatment (cervical decompression, fusion, or arthroplasty, from anterior or posterior approaches). METHODS Administration of cervical epidural, transforaminal, or zygapophyseal steroid injections was determined based on Current Procedural Terminology (CPT) codes. Timing of surgical treatment (cervical decompression, fusion, or arthroplasty, from anterior or posterior approaches) was also determined based on CPT codes. Multivariate logistic regression was used to determine the association of steroid injection administration with surgical treatment at various time points after initial diagnosis (1, 3, 6 months, and 1, 2, 5 years). RESULTS A total of 39,590 patients with a new diagnosis of cervical spondylotic myelopathy were identified. A total of 6,405 patients (16.2%) underwent cervical epidural steroid injections, 1,426 (3.6%) underwent transforaminal steroid injections, and 647 (1.6%) underwent zygapophyseal injections. Mean time from initial diagnosis to surgery was 180.2 days (standard deviation=345.9 days). In multivariate analysis epidural injections were associated with decreased odds of surgery within 1 month of diagnosis (odds ratio [OR]=0.69, P CONCLUSIONS Epidural steroid injections do not prevent surgical treatment of cervical spondylotic myelopathy in the long run. There may be some short-term symptomatic benefits that lead to delayed surgical treatment, although the clinical benefits have yet to be demonstrated. No significant benefit is seen with transforaminal or zygapophyseal injections for treatment of cervical myelopathy. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Laminoplasty versus laminectomy and fusion for cervical spondylotic myelopathy: a cost analysis

Background ContextLaminectomy with fusion (LF) and laminoplasty (LP) are commonly used to treat cervical spondylotic myelopathy (CSM). The decision regarding which procedure to perform is largely a matter of surgeon's preference, while financial implications are rarely considered. PurposeWe aimed to better understand the financial considerations of LF compared to LP in the treatment of CSM. Study DesignRetrospective comparative study. Patient SampleAdult patients, 18 years of age or older, who had undergone LF or LP for CSM from 2017 to 2019 at 2 large academic centers were included. Patients who had undergone previous cervical spine surgery or procedures that extended above C2 or below T2 were excluded. Outcome MeasuresThe primary outcome was defined as the total cost of the procedure, which was calculated as the sum of the implant and non-implant supply costs. MethodsPatient demographics, surgical parameters, including estimated blood loss and operative time, and length of stay were collected. Operating room material – both implant and non-implant – cost data was also obtained. Variables were analyzed individually as well as after adjustment based on the number of operative levels involved. Statistical analysis was performed using either Student t test with unequal variance or Wilcoxon rank sum test for continuous variables and chi-squared analysis for categorical variables. ResultsTwo hundred fifty patients were identified who met inclusion criteria. There was no statistical difference in the mean age at time of surgery (p=.25), gender distribution (p=.33), or re-operation rate between the LF and LP groups (p=.39). Overall, operative time was similar between the LF (165.7 ± 61.9 min) and LP (173.8 ± 58.2 min) groups (p=.29), but the LP cohort had a shorter length of stay at 3.8 ± 2.7 days compared to the LF cohort at 4.8 ± 3.7 days. Implant costs in the LF group were significantly more at $6,204.94 ± $1426.41 compared to LP implant costs at $1994.39 ± $643.09. Mean total costs of LP were significantly less at $2,859.08 ± $784.19 compared to LF total costs of $6,983.16 ± $1,589.17. Furthermore, when adjusted for the number of operative levels, LP remained significantly less costly at $766.12 ± $213.64 per level while LF cost $1,789.05 ± $486.66 per operative level. Additional subgroup analysis limiting the cohorts to patients with either three or four involved vertebral levels demonstrated nearly identical cost savings with LP as compared to LF. ConclusionsThis study demonstrates that LF is on average at least 2.4 times the total operative supply cost of LP and at least 2.3 times the operative supply cost of LP when adjusted for the number of operative levels. In patients deemed appropriate for either LP or LF, these data may be incorporated into decision-making for the treatment of CSM.

Anatomical Variations That Can Lead to Spine Surgery at the Wrong Level: Part I, Cervical Spine.

Spine surgery at the wrong level is an adversity that many spine surgeons will encounter in their career, and it falls under the wrong-site surgery sentinel events reporting system. The cervical spine is the second most common location in the spine at which surgery is performed at the wrong level. Anatomical variations of the cervical spine are one of the most important incriminating risk factors. These anomalies include craniocervical junction abnormalities, cervical ribs, hemivertebrae, and block/fused vertebrae. In addition, patient characteristics, such as tumors, infection, previous cervical spine surgery, obesity, and osteoporosis, play an important role in the development of cervical surgery at the wrong level. These were described, and several effective techniques to prevent this error were provided. A thorough review of the English-language literature was performed in the database PubMed between 1981 and 2019 to review and summarize these risk factors. Compulsive attention to these factors is essential to ensure patient safety. Therefore, the surgeon must carefully review the patient’s anatomy and characteristics through imaging and collaborate with radiologists to reduce the likelihood of performing cervical spine surgery at the wrong level.

Improvements in Neck Pain and Disability Following C1-C2 Posterior Cervical Instrumentation and Fusion for Atlanto-Axial Osteoarthritis

Symptomatic Atlanto-axial (C1-2) osteoarthritis (AAOA) is a common phenomenon in elderly patients; however, there is a paucity of data on the effectiveness of posterior atlanto-axial fusion (PAAF) for this condition. To this end, here we assess changes in patient-reported outcomes and neck-related disability in adult patients undergoing PAAF for symptomatic C1-2 AAOA. In this retrospective study, the clinical records of consecutive patients with symptomatic AAOA who underwent PAAF between 2004 and 2017 were reviewed. Patient demographics, comorbidities, intraoperative and postoperative variables, and complication rates were collected. Neck Disability Index (NDI) scores were recorded at baseline and 6 weeks, 6 months, 1 year, and 2 years postoperatively. Forty-two patients (average age, 72.04 ± 8.56 years; 26.19% males) met the study's inclusion criteria. In this cohort, 19.04% had previous subaxial cervical spine surgery, 35.71% had a history of smoking (all had stopped smoking before surgery), and 11.90% had type II diabetes. At baseline, the majority of patients had a normal neurologic exam. The average preoperative NDI score was 26.88 ± 24.85, which improved to 10.59 ± 14.88 at the 1-year follow-up and 13.20 ± 14.96 at the 2-year follow-up (P=0.004). At baseline, 18% of the patients reported severe disability based on NDI score; this percentage decreased to 2% at 1 year and 0 at 2 years (P= 0.01). Importantly, a high percentage (11.90%) of patients had undergone previous subaxial cervical fusion for their pain due to a mistaken diagnosis for this condition, without symptom relief. In appropriately selected patients, PAAF may decrease neck pain and improve functional disability in patients with AAOA. Future prospective longitudinal studies are needed to corroborate these findings.

Does Smoking Status Influence Health-Related Quality of Life Outcome Measures in Patients Undergoing ACDF?

Study design:Retrospective comparative study.Objective:Whereas smoking has been shown to affect the fusion rates for patients undergoing an anterior cervical discectomy and fusion (ACDF), the relationship between smoking and health-related quality of life outcome measurements after an ACDF is less clear. The purpose of this study was to evaluate whether smoking negatively affects patient outcomes after an ACDF for cervical degenerative pathology.Methods:Patients with tumor, trauma, infection, and previous cervical spine surgery and those with less than a year of follow-up were excluded. Smoking status was assessed by self-reported smoking history. Patient outcomes, including Neck Disability Index, Short Form 12 Mental Component Score, Short Form 12 Physical Component Score (PCS-12), Visual Analogue Scale (VAS) arm pain, VAS neck pain, and pseudarthrosis rates were evaluated. Outcomes were compared between smoking groups using multiple linear and logistic regression, controlling for age, sex, and body mass index (BMI), among other factors. A P value <.05 was considered significant.Results:A total of 264 patients were included, with a mean follow-up of 19.8 months, age of 53.1 years, and BMI of 29.6 kg/m2. There were 43 current, 69 former, and 152 nonsmokers in the cohort. At baseline, nonsmokers had higher PCS-12 scores than current smokers (P = .010), lower VAS neck pain than current (P = .035) and former (P = .014) smokers, as well as lower VAS arm pain than former smokers (P = .006). Postoperatively, nonsmokers had higher PCS-12 scores than both current (P = .030) and former smokers (P = .035). Smoking status was not a significant predictor of change in patient outcome in multivariate analysis.Conclusions:Whereas nonsmokers had higher function and lower pain than former or current smokers preoperatively, smoking status overall was not found to be an independent predictor of outcome scores after ACDF. This supports the notion that smoking status alone should not deter patients from undergoing ACDF for cervical degenerative pathology.

264. Economic impact of revision operations for adjacent segment disease of the cervical spine

BACKGROUND CONTEXT Adjacent-segment disease (ASD) of the cervical spine is a common disabling phenomenon that often requires operative intervention. PURPOSE To evaluate the economic impact of revision operations for cervical ASD after previous cervical spine surgery. STUDY DESIGN/SETTING Single-center retrospective cohort analysis. PATIENT SAMPLE Adults who underwent revision cervical spine surgery for ASD. OUTCOME MEASURES Total and direct costs. METHODS Consecutive adults who underwent revision cervical spine surgery for ASD at a single institution between 2007 and 2013 were retrospectively reviewed. Direct costs (surgical supplies/implants, room/care, pharmacy, services) were identified from medical billing data and calculated for each revision surgery for ASD. Not included in direct cost data were charges, surgeon fees, or revision operations for indications other than ASD (ie, pseudarthrosis). No cost data was obtained for the index operations. Incomplete cost data for revision operations was used as criteria for exclusion. Total costs were calculated from the sum of indirect and direct costs. Costs data were stratified based on the approach of the index and revision operations. RESULTS Eighty-five patients (average age 57±10 years; range 23-80 years) underwent revision surgery for cervical ASD. For all revisions, direct costs summed to $2 million (average $23,702) and total cost summed to $3.2 million (average $37,983). Revisions consisted of 45 anterior operations (anterior cervical discectomy and fusions [ACDF]-34; corpectomy-10, cervical disc replacement-1), 32 posterior operations (posterior cervical fusion [PCF]-14; foraminotomy-14; laminoplasty-4), and 8 circumferential operations. Revisions that entailed a circumferential approach had significantly higher average costs (direct: $57,376 ± 31,258; total: $91,409) than revisions performed via a single approach ([anterior: direct costs - $20,084; total costs - $32,141]; [posterior: direct costs - $20,371; total costs - $32,841]). Of the posterior revisions, foraminotomies had the lowest average costs (direct: $5,389; total: $8,972), while PCF was associated with the greatest average costs (direct: $35,950; total: $57,749). Of the anterior revisions, corpectomies (direct: $30,265; total: $48,419) had significantly greater average costs than ACDFs (direct: $17,514; total: $28,033). CONCLUSIONS Revision operations forASD in the cervical spine are highly heterogeneous and were associated with an average direct cost of $27,702 and an average total cost of $37,983. Over a 6-year period at a single tertiary referral center, operative care for 85 patients with cervical ASD represented a significant economic expense (greater than $2.0 million). FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. Adjacent-segment disease (ASD) of the cervical spine is a common disabling phenomenon that often requires operative intervention. To evaluate the economic impact of revision operations for cervical ASD after previous cervical spine surgery. Single-center retrospective cohort analysis. Adults who underwent revision cervical spine surgery for ASD. Total and direct costs. Consecutive adults who underwent revision cervical spine surgery for ASD at a single institution between 2007 and 2013 were retrospectively reviewed. Direct costs (surgical supplies/implants, room/care, pharmacy, services) were identified from medical billing data and calculated for each revision surgery for ASD. Not included in direct cost data were charges, surgeon fees, or revision operations for indications other than ASD (ie, pseudarthrosis). No cost data was obtained for the index operations. Incomplete cost data for revision operations was used as criteria for exclusion. Total costs were calculated from the sum of indirect and direct costs. Costs data were stratified based on the approach of the index and revision operations. Eighty-five patients (average age 57±10 years; range 23-80 years) underwent revision surgery for cervical ASD. For all revisions, direct costs summed to $2 million (average $23,702) and total cost summed to $3.2 million (average $37,983). Revisions consisted of 45 anterior operations (anterior cervical discectomy and fusions [ACDF]-34; corpectomy-10, cervical disc replacement-1), 32 posterior operations (posterior cervical fusion [PCF]-14; foraminotomy-14; laminoplasty-4), and 8 circumferential operations. Revisions that entailed a circumferential approach had significantly higher average costs (direct: $57,376 ± 31,258; total: $91,409) than revisions performed via a single approach ([anterior: direct costs - $20,084; total costs - $32,141]; [posterior: direct costs - $20,371; total costs - $32,841]). Of the posterior revisions, foraminotomies had the lowest average costs (direct: $5,389; total: $8,972), while PCF was associated with the greatest average costs (direct: $35,950; total: $57,749). Of the anterior revisions, corpectomies (direct: $30,265; total: $48,419) had significantly greater average costs than ACDFs (direct: $17,514; total: $28,033). Revision operations forASD in the cervical spine are highly heterogeneous and were associated with an average direct cost of $27,702 and an average total cost of $37,983. Over a 6-year period at a single tertiary referral center, operative care for 85 patients with cervical ASD represented a significant economic expense (greater than $2.0 million).

Treatment of Adhesive Capsulitis of the Shoulder.

Adhesive capsulitis presents clinically as limited, active and passive range of motion caused by the formation of adhesions of the glenohumeral joint capsule. Radiographically, it is thickening of the capsule and rotator interval. The pathology of the disease, and its classification, relates to inflammation and formation of extensive scar tissue. Risk factors include diabetes, hyperthyroidism, and previous cervical spine surgery. Nonsurgical management includes physical therapy, corticosteroid injections, extracorporeal shock wave therapy, calcitonin, ultrasonography-guided hydrodissection, and hyaluronic acid injections. Most patients will see complete resolution of symptoms with nonsurgical management, and there appears to be a role of early corticosteroid injection in shortening the overall duration of symptoms. Surgical intervention, including manipulation under anesthesia, arthroscopic capsular release both limited and circumferential, and the authors' technique are described in this article. Complications include fracture, glenoid and labral injuries, neurapraxia, and rotator cuff pathology. Postoperative care should always include early physical therapy.

Cervical Discogenic Pain Treatment with Percutaneous Jellified Ethanol: Preliminary Experience

Background Percutaneous DiscoGel® (Gelscom SAS, France), introduced in 2007 as a promising new minimal invasive technique, showed efficacy and safety in lumbar spine surgery, with limited use and scientific reports with regard to the cervical spine. Since the first publication of its use on the cervical spine (2010), less than 100 cases have been published. We introduce an initial experience with this relatively new procedure. We hypothesized that percutaneous DiscoGel® is a safe and effective option for chronic neck pain of cervical discogenic origin. Method This was a clinical study on 10 patients with chronic discogenic pain operated on for 18 cervical discs with percutaneous DiscoGel®. Inclusion criteria were patients with chronic axial or referred neck pain with MRI showing a cervical disc that is consistent with patient symptoms and failed conservative treatment. Exclusion criteria were clinical myelopathy, motor deficit, severe stenosis or reduced disc height by more than 50%, or previous cervical spine surgery. Results A total of 10 cases consisting of 6 females and 4 males underwent treatment with percutaneous DiscoGel® for 18 cervical discs. C5/C6 was the most affected level. The mean preoperative VAS score was 8; the postoperative VAS scores at 6 weeks and 3 months were 2.2 and 2.9, respectively. There were no postoperative complications or neurological deficits. Conclusion The present study has the limitation of the small number of cases; however, with the limited number of studies and less than 100 published cases in the literature, this initial work shows that cervical percutaneous DiscoGel® is an effective minimally invasive bridging option between conservative and open surgical treatment for cervical discogenic pain, with a high success rate. The differentiation of pain types (nociceptive, referred, radicular, and trapezius myalgia) that can coexist is crucial for procedure selection and improving treatment outcome.

Wednesday, September 26, 2018 3:35 PM – 5:05 PM Preserving Spinal Motion: 87. Posterior cervical foraminotomy for cervical radiculopathy: should cervical sagittal alignment be considered?

BACKGROUND CONTEXT Despite an increasing trend for anterior approach, microsurgical and endoscopic advances have enabled excellent outcomes by minimally invasive posterior cervical foraminotomy with motion preservation, for managing cervical radiculopathy. On the other hand, the poserior approach inherently compromises posterior column integrity, where roughly two-thirds of cervical load is transmitted. Hence, surgeons often avoid posterior cervical foraminotomy in patients presenting with imaging evidence of kyphosis or straightening to prevent postoperative kyphotic deformity. PURPOSE To determine interval changes in cervical segmental angles after postrior cervical foraminotomy and analyzing factors affecting cervical sagittal re-alignment in the postoperative period. STUDY DESIGN/SETTING In this retrospective study, we reviewed interval change in cervical segmental angles after posterior cervical foraminotomy. analyzing factors affecting cervical sagittal re-alignment in the immediate postoperative period and at 6-months follow-up. PATIENT SAMPLE Between January, 2007 and January, 2013, a total of 289 consecutive patients underwent key-hole post cervical foraminotomy at single center for unilateral radiculopathy due to degenerative cervical disease. Patients with myelopathy, neoplasm, congenital deformity, fracture, or history of previous cervical spine surgery were excluded, as were patients with focal instability at affected levels. Pathology predisposing to radiculopathy was softened disc (n=157), foraminal stenosis (n=116), or both (n=16). OUTCOME MEASURES On admission, prior to postoperative radiographs and 6 months after operation follow-up in outpatient, patients were routinely asked to gauge levels of pain they feeling at that point in time by VAS and it was recorded in medical chart. METHODS Within 2 days and 6 months after posterior cervical foraminotomy, postoperative plain radiographs were obtained to compare the cervical sagittal alignment with preoperative alignment in 289 consecutive patients. Sagittal alignment was evaluated using Cobb's angle between C2 and C7 formed by lines drawn at the base of axis and the superior endplate of the C7 vertebral body on the lateral radiograph. To evaluate the clinical outcomes, patients were routinely asked to gauge levels of pain they experienced by VAS on admission, prior to postoperative radiographs and 6 months after operation follow-up in outpatient. RESULTS More than two-third of the patients presenting with kyphotic or straight curvature improved short-term following operation. On follow-up plain radiographs after 6 months, the improvement of sagittal alignment was well maintained, but rather more prominent. Improvement in sagittal alignment was dominant when radiculopathy was due to softened discs, rather than stenosis, and with shorter symptom duration. Patient age had no significant impact on outcomes. In patients with higher preoperative VAS score, Cobb's angle was significantly lower, and as perioperative VAS score declined, sagittal alignment improved significantly. CONCLUSIONS Overall, our data suggest that loss of preoperative cervical lordotic curvature may be a distorted reflection due to pain. Particularly in acute-onset radiculopathies from softened discs, posterior cervical foraminotomy is thus a valid surgical option, despite preoperative loss of normal lordotic sagittal alignment. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Cervical sagittal balance parameters after single-level anterior cervical discectomy and fusion: Correlations with clinical and functional outcomes.

Background:Normal sagittal cervical alignment has been associated with improved outcome after anterior cervical discectomy and fusion (ACDF).Objective:The aim of this study is to identify alterations of cervical sagittal balance parameters after single-level ACDF and assess correlations with postoperative functionality.Methods:A retrospective chart review was performed between January 2010 and January 2014 to identify adult patients with no previous cervical spine surgery who underwent ACDF at any one level between C2 and C7 for the single-level degenerative disease. Tumor, infection, and trauma cases were excluded from the study. For the included cases, the following data were recorded preoperatively and 6 months–1 year after surgery: sagittal balance-marker measurements of the C1–C2 angle, C2–C7 angle, C7 slope, segmental angle at the operated level, and sagittal vertical axis (SVA) distance between C2 and C7, as well as the neck disability index and visual analog scale of pain.Results:The present study included 47 patients (average age: 51.2 years; range: 28–86 years). A moderate negative correlation between a smaller C2–C7 angle and the presence of right arm pain before treatment was found (P = 0.0281). Postoperatively, functionality scores significantly improved in all patients. C1–C2 angle increased with statistical significance (P = 0.0255). C2–C7 angle, segmental angle, C7 slope, and SVA C2–C7 distance did not change with statistical significance after surgery. C7 slope significantly correlated with overall cervical sagittal balance (P < 0.05).Conclusions:Single-level ACDF significantly increases upper cervical lordosis (C1–C2) without significantly changing lower cervical lordosis (C2–C7). The C7 slope is a significant marker of overall cervical sagittal alignment (P < 0.05).

Two-Year Results of the Prospective Spine Treatment Outcomes Study: An Analysis of Complication Rates, Predictors of Their Development, and Effect on Patient Derived Outcomes at 2 Years for Surgical Management of Cervical Spondylotic Myelopathy.

To investigate the baseline patient characteristics, nonoperative modalities, surgical procedures, and complications rates of surgical cervical spondylotic myelopathy (CSM) patients. To evaluate risk factors for developing complications and compare the changes in health-related quality of life (HRQOL) from baseline to 2 years postoperatively. A retrospective review was performed on a prospectively collected database of CSM patients. Baseline patient demographic data, comorbidities, clinical information, nonoperative treatment modalities, surgical procedures, and complication rates were collected. HRQOL outcomes were assessed using the Short Form 36 (SF-36) Physical Score Component (PCS) and Mental Score Component (MCS) and the Neck Disability Index (NDI) at baseline and 2 years postoperatively. Statistical analyses included paired-sample t tests and multivariate logistic regression controlling for age, sex, and body mass index (BMI). A total of 203 surgical CSM patients were identified (43% female). Average age was 57.7 years and average BMI was 29.6 kg/m2. Before surgical intervention, patients underwent various nonoperative treatment modalities, most commonly nonsteroidal anti-inflammatory drugs (34%), analgesics (32%), and physical therapy (26%). The overall rate of complications was 7.4%. Complications included cerebrospinal fluid leak (2.5%), postoperative radiculopathy (1.0%), and excessive bleeding (1.0%). A previous history of cervical spine surgery was the sole significant risk factor for developing a complication (odds ratio, 9.22; P= 0.034). Average HRQOL scores improved significantly from baseline to 2 years postsurgery. The overall complication rate was 7.4% for the cohort. Baseline clinical information, comorbidities, use of nonoperative treatment modalities, and procedure type were not significantly associated with an increased risk of complications. Previous cervical spine surgery increased the risk of complications by 9-fold. The patients showed significantly improved SF-36 PCS, SF-36 MCS, and NDI scores at 2 years after surgery.

Multilevel cervical arthroplasty: current evidence. A systematic review.

OBJECTIVE Cervical disc arthroplasty (CDA) has been demonstrated to be an effective treatment modality for single-level cervical radiculopathy or myelopathy. Its advantages over an anterior cervical discectomy and fusion (ACDF) include motion preservation and decreased reoperations at the index and adjacent segments up to 7 years postoperatively. Considering the fact that many patients have multilevel cervical disc degeneration (CDD), the authors performed a systematic review of the clinical studies evaluating patients who underwent multilevel CDA (2 or more levels). METHODS A systematic review in the MEDLINE database was performed. Clinical studies including patients who had multilevel CDA were selected and included. Case reports and literature reviews were excluded. Articles were then grouped according to their main study objective: 1) studies comparing multilevel CDA versus ACDF; 2) studies comparing single-level CDA versus multilevel CDA; and 3) multilevel CDA after a previous cervical spine surgery. RESULTS Fourteen articles met all inclusion criteria. The general conclusions were that multilevel CDA was at least as safe and effective as ACDF, with preservation of cervical motion when compared with ACDF and potentially with fewer reoperations expected in most of the studies. Multilevel CDAs are clinically effective as single-level surgeries, with good clinical and radiological outcomes. Some studies reported a higher incidence of heterotopic ossification in multilevel CDA when compared with single-level procedures, but without clinical relevance during the follow-up period. A CDA may be indicated even after a previous cervical surgery in selected cases. CONCLUSIONS The current literature supports the use of multilevel CDA. Caution is necessary regarding the more restrictive indications for CDA when compared with ACDF. Further prospective, controlled, multicenter, and randomized studies not sponsored by the device manufactures are desirable to prove the superiority of CDA surgery over ACDF as the treatment of choice for CDD in selected cases.

Endoscopic Posterior Cervical Foraminotomy as a Treatment for Osseous Foraminal Stenosis

Posterior cervical foraminotomy is a valuable treatment option for cervical radiculopathy. Here the authors present their technique and results in the treatment of a series of patients suffering from osseous foraminal stenosis. Forty-three patients suffering from cervical osseous foraminal stenosis were operated on via a posterior approach with the EasyGO endoscopic system. Decompression was performed in 1 segment in 31 patients, in 2 segments in 11 patients, and in 3 segments in 1 patient. Bilateral decompression was performed in 4 cases. Twenty-four (55.8%) patients had been subjected to previous spine surgery. All procedures were video recorded and afterwards retrospectively analyzed. In addition, particular reference was given to previous cervical spine surgery, postoperative outcome, reoperation rate, and complications. The endoscopic system was easy to handle intraoperatively in all procedures. No emergency stopping was required. Forty-one patients reported improved and/or even no remaining pain postoperatively (95%). Thirty-five patients (81.4%) regained full motor strength. Clinical success rate with respect to Odom's criteria reached 39 patients (90.7%). One reoperation was needed due to postoperative hematoma (2.3%). One patient suffered from transient worsening of his preoperative paresis (2.3%). Neither dural tear nor nerve root injury was observed. Reoperation rate due to degenerative changes was 18.6% (8of 43 patients). This retrospective analysis shows that posterior endoscopic decompression is a successful option in the treatment of osseous cervical foraminal stenosis.

Dropped Head Deformity due to Cervical Myopathy

Case series. Report long-term outcomes, complications, and surgical technique of cervical myopathy (CM) patients treated with posterior instrumented, cervico-thoracic (C-T) fusions. CM is a rare, progressive, debilitating condition where weakness of neck extensor muscles results in a dropped head deformity (DHD), or severe flexible, cervico-thoracic kyphosis. Treatment algorithms are currently based on small case reports and only 1 patient's short-term surgical outcome. Re-examination at follow-up, chart review, and radiographic analysis was carried out for all CM patients with DHD treated by the senior author. Additional outcome measures included Odom criteria, verbal rating scores for pain, and patient satisfaction ratings. Patients with less than 2-years follow-up, previous cervical spine surgery or intrinsic, structural spinal deformities were excluded. Nine CM patients met the study inclusion criteria with average follow-up of 6 years (range, 2-17 years) and average age 67 years. Four primary and 5 secondary myopathies after radiotherapy underwent deformity correction and posterior arthrodesis with instrumentation from the second cervical level to the upper thoracic spine. Patient presentation, deformity correction, and surgical techniques are described. All pain ratings improved, satisfaction was excellent in 7 and fair in 2 patients, and Odom scores were good to excellent in 7 and fair in 2 patients. Shoulder weakness remained equivalent or improved after surgery and all ambulated independently, though 1 continued to use a walker. Eleven postoperative complications are described. Surgical correction with posterior, instrumented C-T spinal fusion is associated with high patient satisfaction rates in CM patients with DHD. Complications are frequent but do not diminish long-term outcomes. New rod and screw instrumentation with bone morphogenic protein may improve arthrodesis and correction.