Revision Anterior Cervical Discectomy And Fusion Research Articles

What Is the Evidence Supporting Osteobiologic Use in Revision Anterior Cervical Discectomy and Fusion?

Systematic literature review. To analyze the literature and describe the evidence supporting osteobiologic use in revision anterior cervical discectomy and fusion (ACDF) surgery. A systematic search of PubMed/MEDLINE, EMBASE, Cochrane library, and ClinicalTrials.gov databases was conducted for literature reporting the use of osteobiologics in revision ACDF. We searched for studies reporting outcomes of using any osteobiologic use in revision ACDF surgeries (independently of the number of levels) in the above databases. There are currently no studies in the literature describing the outcome and comparative efficacy of diverse osteobiologic agents in the context of revision ACDF surgery. A majority of the current evidence is based only upon studies involving primary ACDF surgery. The current study highlights the paucity of literature evidence on the role of diverse osteobiologics in revision ACDF, and foregrounds the need for high-quality evidence on this subject.

Structural Allograft Versus Mechanical Interbody Devices Augmented With Osteobiologics in Anterior Cervical Discectomy and Fusion: A Systematic Review.

Systematic Literature Review. Perform a systematic review evaluating postoperative fusion rates for anterior cervical discectomy and fusion (ACDF) using structural allograft vs various interbody devices augmented with different osteobiologic materials. Comprehensive literature search using PubMed, Embase, The Cochrane Library, and Web of Science was performed. Included studies were those that reported results of 1-4 levels ACDF using pure structural allograft compared with a mechanical interbody device augmented with an osteobiologic. Excluded studies were those that reported on ACDF with cervical corpectomy; anterior and posterior cervical fusions; circumferential (360° or 540°) fusion or revision ACDF for nonunion or other conditions. Risk of bias was determined using the Cochrane review guidelines. 8 articles reporting fusion rates of structural allograft and an interbody device/osteobiologic pair were included. All included studies compared fusion rates following ACDF among structural allograft vs non-allograft interbody device/osteobiologic pairs. Fusion rates were reported between 84% and 100% for structural allograft, while fusion rates for various interbody device/osteobiologic combinations ranged from 26% to 100%. Among non-allograft cage groups fusion rates varied from 73-100%. One study found PEEK cages filled with combinations of autograft, allograft, and demineralized bone matrix (DBM) to have an overall fusion rate of 26%. In one study comparing plate and zero-profile constructs, there was no difference in fusion rates for two-level fusions. There was limited data comparing fusion outcomes of patients undergoing ACDF using structural allograft vs interbody devices augmented with osteobiologic materials to support superiority of one method.

Predictors of Dysphagia After Anterior Cervical Discectomy and Fusion: A Prospective Multicenter Study.

Multicenter prospective study. Our aim was to evaluate the incidence and predictors of postoperative dysphagia in patients undergoing anterior cervical discectomy and fusion (ACDF). Dysphagia is a common complication after ACDF that can have significant effect on patients' quality of life, but the frequency of occurrence and potential risk factors are not known. A multicenter prospective study was undertaken at three academic sites to evaluate patients undergoing ACDF between September 2018 and September 2020. Included patients were aged 18 to 80 years and were undergoing primary or revision ACDF for a degenerative condition. Dysphagia was assessed using the validated Eating Assessment Tool (EAT-10) questionnaire, with dysphagia defined as EAT-10 ≥ 3. A total of 170 patients (53.5% female; mean age at surgery 55.0 yr) were included. At preoperative baseline, 23 patients (13.5%) had dysphagia. Rates of dysphagia increased to 45.3% at 2 weeks postoperatively but gradually decreased to 15.3% at 24weeks. On univariate analysis, patients with dysphagia at 2weeks had longer operations (113.1 ± 58.4 vs. 89.0 ± 39.8 minutes, P = 0.003) and higher baseline dysphagia rates (18.2% vs. 6.2%, P = 0.018) and were more likely to be female (66.2% vs. 45.7%, P = 0.009). Patients with prolonged dysphagia had more levels fused (2.1 ± 1.0 vs. 1.7 ± 0.7, P = 0.020), longer operations (131.8 ± 63.1 vs. 89.3 ± 44.3 min-minutes, P < 0.001), and higher baseline dysphagia rates (32% vs. 7.1%, P < 0.001) and were more likely to be smokers (24% vs. 8%, P = 0.021). On multivariate analysis to determine associations with prolonged dysphagia, only smoking status (OR 6.2, 95% CI 1.57-24.5, P = 0.009) and baseline dysphagia (OR 5.1, 95% CI 1.47-17.6, P = 0.01) remained significant. Dysphagia is common immediately after ACDF, but rates of prolonged dysphagia are similar to preoperative baseline rates. We identified dysphagia rates over time and several patient factors associated with development of short- and long-term postoperative dysphagia.Level of Evidence: 3.

64. Impact of depression on patient reported outcomes following primary vs revision ACDF

<h3>BACKGROUND CONTEXT</h3> Depression has been associated with poorer outcomes following anterior cervical discectomy and fusion (ACDF). However, research examining the relationship between depression and patient reported outcome measures (PROMs) in revision ACDF procedures is limited. <h3>PURPOSE</h3> To assess the relationship of depressive symptoms with PROMs in patients undergoing either primary or revision ACDF procedures. <h3>STUDY DESIGN/SETTING</h3> Retrospective cohort. <h3>PATIENT SAMPLE</h3> 143 patients undergoing primary or revision, single- or multilevel ACDF procedures. <h3>OUTCOME MEASURES</h3> Demographic and perioperative characteristics, Patient Health Questionnaire-9 (PHQ-9), visual analog scale (VAS), Neck Disability Index (NDI). <h3>METHODS</h3> A prospective database was retrospectively reviewed for primary or revision, single- or multi-level ACDF procedures from 2016 to 2020. Patients lacking preoperative PHQ-9 surveys were excluded. Demographic and perioperative characteristics were recorded and analyzed using Fisher's exact test or t-test. Patient-reported outcome measures were collected preoperatively and postoperatively. Postoperative improvement from baseline scores (ΔPROM) was calculated at all postoperative timepoints. Differences in mean PROM and ΔPROM between groups and changes from baseline PROM scores within groups were assessed using student's t-test. Linear regression analyzed the impact of preoperative PHQ-9 on ΔPROM among primary and revision patients. <h3>RESULTS</h3> A total of 143 patients (121 primary and 22 revision) were included. Significant differences between groups were demonstrated at the preoperative timepoint for NDI (p=0.022). ΔPROM values did not significantly differ between groups. Regression analysis revealed significant relationships between preoperative PHQ-9 and ΔPHQ-9 at all timepoints, ΔVAS neck at 6-weeks and 6-months, ΔVAS arm at 6-months, and ΔNDI at 6-weeks and 6-months for the primary group (all p<0.05). Regression analysis revealed no significant associations for the revision group. <h3>CONCLUSIONS</h3> Primary or revision ACDF procedures did not significantly differ in depressive symptoms through 1-year. Primary ACDF patients significantly improved in all PROMs through all timepoints, while revision patients had limited improvement in PROMs. Preoperative depression may have a stronger association on postoperative outcomes for primary procedures. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Hospital use following anterior cervical discectomy and fusion

Most existing anterior cervical discectomy and fusion (ACDF) outcome studies omit emergency department (ED) use. To our knowledge, this study on ED use following ACDF surgery is the first to use a direct patient chart review and the first to include revision patients, 1–5 levels of ACDFs, and performance of corpectomy in the analysis. This study examines the frequency and basis of hospital service use within 30 days of ACDF surgery, specifically ED visits, hospital readmissions, and returns to the operating room. A retrospective chart review was performed for 1273 consecutive patients who underwent ACDF surgery at one institution from July 2013 to June 2016. Of the 1273 patients with ACDF, 97 (7.6%) presented to the ED within 30 days after surgery. Of 43 patients with revision ACDF, 9 (20.9%) returned to the ED, compared with 88 (7.2%) of 1230 patients with primary ACDF (P = 0.001). Of the 111 ED visits by 97 patients, 40 (36%) were for cervicalgia, 13 (12%) were for dysphagia, 8 (7%) were for trauma, 7 (6%) were for nausea, 4 (4%) were for medication refill, 3 (3%) were for dehiscence, 3 (3%) were for pneumonia, and 3 (3%) were for urinary tract infection. Of the ED presentations, 8 (7%) occurred during the first 2 days after surgery, and 46 (41%) occurred within the first postoperative week.

Primary and Revision Anterior Cervical Discectomy and Fusion: A Study of Otolaryngologic Outcomes in a Large Cohort.

Retrospective chart review. To determine risk factors for postoperative otolaryngologic complications among patients who undergo primary and revision anterior cervical discectomy and fusion (ACDF). Swallowing and voice dysfunction are frequent postoperative complaints after ACDF surgery with a published incidence varying between 1.2% and 60%. A thorough understanding of the incidence and risk factors for these complications is needed. Electronic medical records of adults who underwent ACDF with predicted difficult surgical site exposure performed by two-surgeon approach between 2008 and 2018 were reviewed. Patients were categorized by primary or revision ACDF status and by the number of levels addressed during the operation. Associations with postoperative otolaryngologic symptoms were assessed using simple and multivariable logistic regression. Participants included 718 adults with an average age of 55.8 years and 45% female sex. One hundred seventy-five patients (27%) underwent revision ACDF; ACDF status was unidentifiable for 74 patients. Seventy-nine cases (12%) involved one spinal level. New postoperative otolaryngologic symptoms among those who underwent primary and revision ACDF were 12.6% and 10.9% respectively. No evidence was found of an association between postoperative otolaryngologic symptoms and revision ACDF (OR, 0.84 [95% CI, 0.48-1.49]; P = 0.55), but evidence was found of an association with prior thyroidectomy (aOR, 3.8 [95% CI, 1.53-8.94], P = 0.0003). Significant evidence was found of increased odds for new postoperative dysphagia with increasing number of surgical levels (aOR, 1.5 [95% CI, 1.09-2.07]; P = 0.01). Prior thyroidectomy and number of spinal levels addressed during ACDF were identified as risk factors for postoperative otolaryngologic complications including dysphagia. Revision ACDF was not associated with increased odds of postoperative otolaryngologic symptoms or dysphagia.Level of Evidence: 4.

Impact of Depression on Patient Reported Outcomes Following Primary Versus Revision ACDF.

Retrospective cohort. To assess the relationship of depressive symptoms with patient reported outcome measures (PROMs) in patients undergoing either primary or revision anterior cervical discectomy and fusion (ACDF) procedures. Depression has been associated with poorer outcomes following ACDF. However, research examining the relationship between depression and PROMs in revision ACDF procedures is limited. A prospective database was retrospectively reviewed for primary or revision, single- or multilevel ACDF procedures from 2016 to 2019. Patients lacking preoperative Patient Health Questionnaire-9 (PHQ-9) surveys were excluded. Demographic and perioperative characteristics were recorded and analyzed using Fisher's exact test or t test. Patient-reported outcome measures were collected preoperatively and postoperatively. Postoperative improvement from baseline scores (ΔPROM) was calculated at all postoperative timepoints. Differences in mean PROM and ΔPROM between groups and changes from baseline PROM scores within groups were assessed using Student's t test. Linear regression analyzed the impact of preoperative PHQ-9 on ΔPROM. A total of 143 patients (121 primary and 22 revision) were included. Significant differences between groups were demonstrated at the preoperative timepoint for Neck Disability Index (NDI) (P = 0.022). ΔPROM values did not significantly differ between groups. Regression analysis revealed significant relationships between preoperative PHQ-9 and ΔPHQ-9 at all timepoints, ΔVAS neck at 6-weeks and 6-months, ΔVAS arm at 6-months, and ΔNDI at 6-weeks and 6-months for the primary group (all P < 0.05). Regression analysis revealed no significant associations for the revision group. Primary or revision ACDF procedures did not significantly differ in depressive symptoms through 1-year. Primary ACDF patients significantly improved in all PROMs through all timepoints, while revision patients had limited improvement in PROMs. Preoperative depression may have a stronger association on postoperative outcomes for primary procedures.Level of Evidence: 3.

Revision Anterior Cervical Discectomy and Fusion and Revision Cervical Arthroplasty Are Associated with Similar Outcomes: Real-World Analysis from a National Quality Registry.

To utilize a national surgical quality registry to compare 30-day quality outcomes between repeat anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA). The National Surgical Quality Improvement Project (NSQIP) Participant User Files (PUF) for the years 2005-2018 were queried for patients undergoing repeat ACDF and CDA using current procedural terminology (CPT) and International Classification of Disease (ICD)-9th version codes. We compared demographic and baseline clinical characteristics, operative characteristics, 30-day readmissions, reoperations, and complications between the two groups. We also performed multivariable analyses to assess the impact of the type of repeat procedure on outcomes of interest. A total of 3,957 patients were identified, of which 182 underwent revision/removal of arthroplasty, while 3,775 underwent revision or removal of fusion. Up to 4.6% of patients (n=179) in the repeat ACDF group had a complication, compared to 0.5% (n=1) in the CDA group. The 30-day readmission rate was found to be similar between the two groups (repeat-ACDF, 3.8% (n=145), vs. repeat-CDA, 2.2% (n=4); p=0.23). Similarly, 30-day reoperation rate was also not found to be different between the two groups (repeat-ACDF, 3.9% (n=149) vs. repeat-CDA, 2.7% (n=5); p=0.39). On multivariable analysis, removal or revision ACDF was found to be only significantly associated with an increased risk of 30-day complications (OR, 8.00; 95% CI, 1.07-59.79; p=0.04). Repeat ACDF or repeat CDA can be performed safely and are associated with optimal 30-day outcomes, comparable to those of index procedures. However, patients undergoing revision ACDF may be slightly more likely to have complications than those undergoing revision CDA.

Structural Allograft Versus Synthetic Interbody Cage for Anterior Cervical Discectomy and Fusion: A Comparison of 1-Year Outcomes From a National Database.

Study Design:Observational cohort study.Objective:To compare 1-year perioperative complications between structural allograft (SA) and synthetic cage (SC) for anterior cervical discectomy and fusion (ACDF) using a national database.Methods:The TriNetX Research Network was retrospectively queried. Patients undergoing initial single or multilevel ACDF surgery between October 1, 2015 and April 30, 2019 were propensity score matched based on age and comorbidities. The rates of 1-year revision ACDF surgery and reported diagnoses of pseudoarthrosis, surgical site infection (SSI), and dysphagia were compared between structural allograft and synthetic cage techniques.Results:A comparison of 1-year outcomes between propensity score matched cohorts was conducted on 3056 patients undergoing single-level ACDF and 3510 patients undergoing multilevel ACDF. In single-level ACDF patients, there was no difference in 1-year revision ACDF surgery (P = .573), reported diagnoses of pseudoarthrosis (P = .413), SSI (P = .620), or dysphagia (P = .529) between SA and SC groups. In multilevel ACDF patients, there was a higher rate of revision surgery (SA 3.8% vs SC 7.3%, odds ratio = 1.982, P < .001) in the SC group, and a higher rate of dysphagia in the SA group (SA 15.9% vs SC 12.9%).Conclusion:While the overall revision and complication rate for single-level ACDF remains low despite interbody graft selection, SC implant selection may result in higher rates of revision surgery in multilevel procedures despite yielding lower rates of dysphagia. Further prospective study is warranted.

Immediate Voice and Swallowing Complaints Following Revision Anterior Cervical Spine Surgery.

To report on the incidence of dysphagia, dysphonia, and acute vocal fold motion impairment (VFMI) following revision anterior cervical spine surgery, as well as to identify risk factors associated with acute VFMI in the immediate postoperative period. Retrospective cohort study. Tertiary care center. All patients who underwent 2-team reoperative anterior cervical discectomy and fusion (ACDF) were retrospectively reviewed. Incidence of dysphonia, dysphagia, and acute VFMI was noted. Patient and operative factors were evaluated for association with risk of acute VFMI. The incidence of postoperative dysphonia and dysphagia was 25% (18/72) and 52% (37/72), respectively. The incidence of immediate VFMI was 21% (15/72). Subjective postoperative dysphonia (odds ratio, [OR] 8; 95% CI, 2.2-28; P = .001) and dysphagia (OR, 22; 95% CI, 2.5-168; P = .005) were significantly associated with increased risk of VFMI. Three patients with VFMI required temporary injection medialization for voice complaints and/or aspiration. Infection (OR, 14; 95% CI, 1.4-147, P = .025) and level C7/T1 (OR, 5.5; 95% CI, 1.3-23, P = .02) were significantly associated with an increased risk of acute VFMI on multivariate logistic regression analysis. Number of prior surgeries, laterality of approach, side of approach relative to prior operations, and number of levels exposed were not significant. Early involvement of an otolaryngologist in the care of a patient undergoing revision ACDF can be helpful to the patient in anticipation of voice and swallowing changes in the postoperative period. This may be particularly important in those being treated at C7/T1 or those with spinal infections.

Solid Organ Transplant Is Associated With Increased Morbidity and Mortality in Patients Undergoing One or Two-level Anterior Cervical Decompression and Fusion

Retrospective database review OBJECTIVE.: The aim of this study was to analyze the implications of solid organ transplant (SOT) on postoperative outcomes following elective one or two-level anterior cervical discectomy and fusion (ACDF). Although SOTs have been associated with increased morbidity, postoperative outcomes in SOT recipients undergoing cervical spinal surgery are not well studied. A retrospective database review of Medicare patients younger than 85 years who underwent an elective one to two-level ACDF from 2006-2013 was conducted. Following our exclusion criteria, patients were then divided into the following groups: those with a prior history of kidney, liver, heart or lung transplant (SOT group) and non-SOT patients. Both groups were compared for hospital length of stay, 90-day major medical complications, 90-day hospital readmission, 1-year surgical site infection (SSI), 1-year revision ACDF, and 1-year mortality. A total of 992 (0.5%) SOT recipients (1,144 organs) were identified out of 199,288 ACDF patients. SOT recipients had a significantly longer length of stay (2.32 vs. 5.22 days, p<0.001), higher rate of major medical complications (8.2% vs. 4.5%; OR 1.85, 95% CI 1.45-2.33, p<0.001) and hospital readmission (19.5% vs. 7.5%, OR 2.05, 95% CI 1.74-2.41, p<0.001). In addition, SOT patients had increased mortality within one year of surgery (5.8% vs. 1.3%; OR 3.01, 95% CI 2.26-3.94, p<0.001) compared to non-SOT patients. SOT was not independently associated with SSI (OR 1.25, 95% CI 0.85-1.75, p=0.230), and there was no significant difference in revision rate (0.9% vs. 0.5%; OR 1.54, 95% CI 0.73-2.82, p=0.202) between both groups. SOT is independently associated with longer hospital stay, increased rate of major medical complications, hospital readmission and mortality. Spine surgeons should be aware of the higher rates of morbidity and mortality in these patients and take it into consideration when developing patient-specific treatment plans. 3.

30-Day Postoperative Morbidity and Readmission Following Revision Anterior Cervical Discectomy and Fusion (ACDF).

This was a retrospective cohort study. To analyze risk factors associated with 30-day adverse outcomes and readmissions after revision anterior cervical discectomy and fusion (ACDF). No current literature has evaluated the risk factors associated with adverse outcomes after revision ACDF. The 2012-2016 American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database was queried using Current Procedural Terminology codes for ACDF (22551, 22554, and 63075) combined with Current Procedural Terminology codes 22830 (exploration of spinal fusion) or 22855 (removal of anterior instrumentation) to identify revision cases. Patients undergoing concurrent posterior cervical spine surgery and/or corpectomies were excluded from the analysis. A total of 1140 patients were retrieved for analysis. Out of a total of 1140 patients, 51 (4.5%) experienced at least 1 any adverse event, with 40 (3.5%) experiencing a severe adverse event, and 17 (1.5%) experiencing a minor adverse event. A 30-day readmission rate was 3.4% (N=39) after a revision ACDF. On multivariate analysis, any adverse events were significantly associated with male sex [odds ratio (OR), 1.98], 2-level versus 1-level fusion (OR, 2.05), and a length of stay (LOS)>1 day (OR, 7.70). Severe adverse events were independently associated with male sex (OR, 2.85), smoking (OR, 0.33), 2-level versus 1-level fusion (OR, 2.03), and LOS>1 day (OR, 7.28). LOS>1 day was the only significant factor associated with an minor adverse event (OR, 14.65) and readmission within 30 days (OR, 2.67). Using a national surgical database, the study is the first of its kind to report rates and risk factors associated with adverse outcomes after ACDFs. Providers should understand the need of preoperative risk stratification in these patients to reduce the risk of experiencing adverse outcomes. Level III-retrospective.

P112. 30-day postoperative morbidity and readmissions following revision anterior cervical discectomy and fusion (ACDF)

BACKGROUND CONTEXT Despite a 48% national increase in the incidence of revision anterior cervical fusions from 2007 to 2010, as well as higher inpatient costs and longer hospital length of stay as compared to primary ACDFs, current literature remains limited to with regard to how revision ACDF patients fare in the acute 30-day postoperative period. PURPOSE Utilizing a national surgical database, the current study was designed to understand the incidence and risk factors for adverse outcomes and re-admissions following a revision ACDF. Furthermore, as a secondary objective, the study evaluated the causes of re-admissions and re-operations in these patients. STUDY DESIGN/SETTING Retrospective cohort study performed using the American College of Surgeons - National Surgical Quality Improvement Program (ACS-NSQIP) database. PATIENT SAMPLE The 2012-2016 ACS-NSQIP database files were queried using Current Procedural Terminology codes for ACDF (22551, 22554 and 63075) combined with Current Procedural Terminology codes 22830 (exploration of spinal fusion) or 22855 (removal of anterior instrumentation) to identify revision cases. Patients undergoing concurrent posterior cervical fusion and/or decompression (laminectomies/laminotomies) were excluded from the study. In addition, patients undergoing posterior segmental/non-segmental instrumentation and/or corpectomies were also excluded. OUTCOME MEASURES Thirty-day outcomes were categorized into severe adverse events (SAEs) and minor adverse events (MAEs). SAEs included the following – deep surgical site infection (SSI), organ/space SSI, wound disruption/dehiscence, unplanned intubation, postoperative ventilator use >48 hours, pulmonary embolism, deep venous thrombosis, myocardial infarction, cardiac arrest, stroke, acute renal failure, sepsis, septic shock, re-operation and death. MAEs included the occurrence of urinary tract infections, bleeding requiring transfusions, pneumonia, progressive renal insufficiency and superficial SSI. An additional variable defined as “any adverse event” or “AAE” recorded the presence of at least one SAE or MAE. METHODS Multi-variate logistic regression analyses were used to identify significant risk factors associated with experiencing adverse 30-day outcomes following revision ACDFs. Descriptive analyses were used to report the causes of readmissions and re-operations in these patients. RESULTS Out of a total of 1,140 patients, 51 (4.5%) experienced at least one adverse event (AAE), with 40 (3.5%) experiencing a severe adverse event (SAE) and 17 (1.5%) experiencing a minor adverse event (MAE). On multivariate analysis, AAEs were significantly associated with male gender (OR 1.98; p=0.023), 2-level vs 1-level fusion (OR 2.05; p=0.019) and a LOS>1 day (OR 7.70; p 1 day (OR 7.28; p 1 day was the only significant factor associated with a MAE (OR 14.65; p CONCLUSIONS In conclusion, 4.5 % of patients experience an adverse event following a revision ACDF with up to 3.4% experiencing a re-admission. The study is the also the first of its kind to analyze the risk factors for experiencing an adverse event following a revision ACDF. Providers should utilize these data to enhance the dissemination of knowledge regarding postoperative outcomes following a revision ACDF among hospital staff and/or patients to improve shared decision-making, reduce fragmentation of services and increase the quality of care to improve outcomes and curb costs in these high-risk patients. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Thursday, September 27, 2018 3:35 PM–5:05 PM Section on Motion Technology Abstract Presentations: 132. Subsequent cervical spine surgery after cervical disc arthroplasty and anterior cervical discectomy and fusion

BACKGROUND CONTEXT Cervical disc arthroplasty (CDA) has emerged as an alternative surgical option to anterior cervical discectomy and fusion (ACDF) for cervical disc pathology, with recent trials demonstrating non-inferiority of CDA to ACDF. While short-term trends regarding utilization rates, revision procedures and complications have been explored, longer-term outcomes, specifically involving re-operation rates and type of reoperation are lacking. Therefore, we used the New York Statewide Planning and Research Cooperative Systems (SPARCS) database to characterize subsequent cervical spine surgery in patients undergoing primary elective CDA and ACDF. PURPOSE Characterize subsequent cervical spine surgery in patients undergoing primary elective CDA and ACDF. STUDY DESIGN/SETTING Retrospective state database study. PATIENT SAMPLE Patients who underwent elective inpatient CDA and ACDF in New York State. METHODS We analyzed the SPARCS inpatient database from 2005 to 2013 to identify patients who underwent elective inpatient CDA and ACDF procedures. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to extract the index procedures (CDA: 84.61, 84.62; ACDF: 81.02) and to identify patient demographics and cervical re-operation procedures. Patients were longitudinally followed until September 2015, corresponding to a minimum of two year follow-up, to determine the incidence of subsequent cervical spine reoperation, which included another primary CDA or ACDF, revision CDA or ACDF, and posterior cervical fusion. Logistic regression analysis was used to determine the odds of subsequent cervical spine reoperation. RESULTS Between January 2005 and September 2013, 731 patients underwent an inpatient CDA and 45,204 underwent an inpatient ACDF. Patients undergoing CDA were more likely to be younger (43.6 vs. 50.7, p CONCLUSIONS Compared to patients undergoing ACDF, patients undergoing CDA are more likely to be younger, to have fewer comorbidities and to have a primary diagnosis of cervical disc displacement. While there is no significant difference in subsequent cervical spine re-operation rates between ACDF and CDA, surgeons performing revision procedures at the same cervical level or performing primary procedures at adjacent cervical levels are more likely to utilize ACDF rather than CDA. Further investigation in outpatient primary and revision cervical spine cases is needed to assess these findings. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Trends in resource utilization and rate of cervical disc arthroplasty and anterior cervical discectomy and fusion throughout the United States from 2006 to 2013

Background ContextThe typically accepted surgical procedure for cervical disc pathology has been the anterior cervical discectomy and fusion (ACDF), although recent trials have demonstrated equivalent or improved outcomes with cervical disc arthroplasty (CDA). Trends for these two procedures regarding utilization, revision procedures, and other demographic information have not been sufficiently explored. PurposeThe present study aims to provide data regarding ACDF and CDA from 2006 to 2013 in the United States. DesignThe present study is a retrospective national database analysis. Patient SampleThe present study included 20% sample of discharges from US hospitals, which is weighted to provide national estimates. Outcome MeasuresFunctional measures such as national incidence, hospital costs, length of stay (LOS), routine discharge, revision burden, and patient characteristics were used in the present study. MethodsPatients from the National Inpatient Sample (NIS) database who underwent primary ACDF, revision ACDF, primary CDA, and revision CDA from 2006 to 2013 were included. Demographic and economic data for the procedures' respective International Classification of Diseases, Ninth Revision, Clinical Modification codes were collected. ResultsA total of 1,059,403 ACDF and 13,099 CDA surgeries were performed in the United States from 2006 to 2013. The annual number of ACDF increased by 5.7% nonlinearly from 120,617 in 2006 to 127,500 in 2013 (mean per year 132,425; range 120,617–147,966); CDA increased by 190% nonlinearly from 540 in 2006 to 1,565 in 2013 (mean per year 1,637; range 540–2,381). Cervical disc arthroplasty patients were younger and had more private or “other” insurance, including worker's compensation (p<.0001). Mean LOS was longer for ACDF (ACDF 2.3 days vs. CDA 1.5; p<.0001). Routine discharge was higher in the CDA group (CDA 96% vs. ACDF 89%; p-value<.0001). The mean hospital-related cost was more expensive for ACDF (ACDF $16,178 vs. CDA $13,197; p-value=.0007). Cervical disc arthroplasty mean revision burden, defined as the ratio of revision procedures to the sum of primary and revision procedures, was greater (CDA 5.9% vs. ACDF 2.3%, p-value=.01). ConclusionsNationally approximately 132,000 ACDFs are done each year compared with only 1,600 CDAs. The number of ACDF surgeries performed far outpaces CDA by a ratio of 81:1 in the United States without a clear direction in the trend for utilization given recent fluctuations. Cervical disc arthroplasty revision burden was more than double compared with the ACDF revision burden (5.9% vs. 2.3%), which was not accounted for by patient baseline demographics. The etiologies of these findings are likely multifactorial and require further research.

Differences in Short-Term Outcomes Between Primary and Revision Anterior Cervical Discectomy and Fusion.

Retrospective cohort study. To compare short-term morbidity for primary and revision anterior cervical discectomy and fusion (ACDF). Revision ACDF procedures are relatively common, yet their risks are poorly characterized in the literature. There is a need to assess the relative risk of revision ACDF procedures compared with primary surgery. The prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients who underwent primary and revision ACDF from 2005 to 2014. The occurrence of 30-day postoperative complications, readmission, operative time, and postoperative length of stay were compared between primary and revision procedures using multivariate regression to control for patient and operative characteristics. A total of 20,383 ACDF procedures were identified, 1219 (6.0%) of which were revision cases. On multivariate analysis, revision procedures were associated with significantly increased risk of any adverse event (relative risk [RR] 2.3, P < 0.001), any severe adverse event (RR 2.2, P < 0.001), thromboembolic events (RR 3.3, P = 0.001), surgical site infections (RR 3.2, P < 0.001), return to the operating room (RR 1.9, P = 0.001), any minor adverse event (RR 2.5, P < 0.001), and blood transfusion (RR 8.3, P < 0.001). Revision procedures had significantly increased risk of readmission within 30 days (RR = 1.6, P = 0.001). Minor, but statistically significant increases in average operative time and postoperative length of stay were identified for revisions procedures (7 min and half a day, respectively [P < 0.001 for both]). Revision procedures were associated with significantly increased risk of multiple adverse outcomes, including thromboembolic events, surgical site infections, return to the operating room, blood transfusion, and readmission within 30 days. These results are important for patient counseling and risk stratification. 3.

Subsequent Cervical Disc Herniation following Single-Level ACDF

Introduction Subsequent herniated cervical disc (HCD) and revision anterior cervical discectomy and fusion (ACDF) is not an uncommon disease and procedure. And we, as a spinal surgeon, have some difficulties in decision-making, because of the airway, esophagus, and vocal cord problems. Adjacent segment disease is well known as the pathologic process, in which the changes in the other segment may occur at the cranial or caudal segment. In this study, we discuss about the subsequent HCD which requires surgical treatment following single-level ACDF. Materials and Methods From 2006 to 2012, 27 Korean patients, who were operated for subsequent HCD following previous ACDF, were enrolled. The subsequent HCD was detected not only in adjacent segments just around fused spine but also in the skipped segments. A total of 23 patients were approached anteriorly (22 revision ACDF and 1 anterior foraminotomy) and 4 patients were approached posteriorly for posterior keyhole surgery. All 23 patients with anterior approach were evaluated for vocal cord palsy before anterior revision surgery. We retrospectively reviewed and analyzed the pre- and postoperative data. Results The subsequent HCD significantly occurred on the caudal segment in patients with C3–4 and C4–5 fused patients and on the cranial segment in C6–7 and C7–T1 fused patients ( p = 0.045). In C5–6 fused patients, the subsequent HCD occurred similarly, both caudally and cranially (5 cranially, 6 caudally). The use of plate in primary ACDF has no significant effect on either the caudal or the cranial segment ( p = 0.168). The direction of approach in primary ACDF (right vs. left) was mainly on contralateral side to the patient's symptom ( p = 0.007), whereas there was no laterality of approach in the revision ACDF according to the symptom and previous ACDF ( p = 0.767). Vocal cord palsy developed only in one patient with anterior keyhole surgery, who had been approached right in primary ACDF and left in revision surgery and there was right-sided vocal cord damage. Conclusion Revision ACDF was the major surgical method for subsequent HCD. There was no relationship between the laterality of the approach according to the previous operation and development of vocal cord palsy. The vocal cord palsy was detected in a significantly lower incidence (4.3%, 1/23) compared with the results of other studies. The subsequent HCD had a tendency of developing in the caudal segments in C3–4, 4–5 fused patients and in cranial segment in C6–7, C7–T1 fused patients. In C5–6 fused patients, the subsequent HCD occurred both caudally and cranially.

Comparison of revision surgeries for one- to two-level cervical TDR and ACDF from 2002 to 2011

Background contextCervical total disc replacement (TDR) and anterior cervical discectomy and fusion (ACDF) provide comparable outcomes for degenerative cervical pathology. However, revisions of these procedures are not well characterized. PurposeThe purpose of this study is to examine the rates, epidemiology, perioperative complications, and costs between the revision procedures and to compare these outcomes with those of primary cases. Study designThis study is a retrospective database analysis. Patient sampleA total of 3,792 revision and 183,430 primary cases from the Nationwide Inpatient Sample (NIS) database from 2002 to 2011 were included. Outcome measuresIncidence of revision cases, patient demographics, length of stay (LOS), in-hospital costs, mortality, and perioperative complications. MethodsPatients who underwent revision for either one- to two-level cervical TDR or ACDF were identified. SPSS v.20 was used for statistical analysis with χ2 test for categorical data and independent sample t test for continuous data. The relative risk for perioperative complications with revisions was calculated in comparison with primary cases using a 95% confidence interval. An alpha level of less than 0.05 denoted statistical significance. ResultsThere were 3,536 revision one- to two-level ACDFs and 256 revision cervical TDRs recorded in the NIS database from 2002 to 2011. The revision cervical TDR cohort demonstrated a significantly greater LOS (3.18 vs. 2.25, p<.001), cost ($16,998 vs. $15,222, p=.03), and incidence of perioperative wound infections (13.6 vs. 5.3 per 1,000, p<.001) compared with the ACDF revision cohort (p<.001). There were no differences in mortality between the revision surgical cohorts. Compared with primary cases, both revision cohorts demonstrated a significantly greater LOS and cost. Furthermore, patients who underwent revision demonstrated a greater incidence and risk for perioperative wound infections, hematomas, dysphagia, and neurologic complications relative to the primary procedures. ConclusionsThis study demonstrated a significantly greater incidence of perioperative wound infection, LOS, and costs associated with a TDR revision compared with a revision ACDF. We propose that these differences are by virtue of the inherently more invasive nature of revising TDRs. In addition, compared with primary cases, revision procedures are associated with greater costs, LOS, and complications including wound infections, dysphagia, hematomas, and neurologic events. These additional risks must be considered before opting for a revision procedure.

Preoperative laryngoscopic examination in patients undergoing repeat anterior cervical discectomy and fusion

Study BackgroundPatients who experience a recurrent laryngeal nerve injury (RLI) after undergoing an Anterior Cervical Discectomy and Fusion (ACDF) procedure may eventually become asymptomatic. If patients with an asymptomatic vocal cord abnormality undergo a subsequent ACDF they may be at risk for developing bilateral vocal cord paralysis (VCP). Bilateral VCP is a potentially life threatening problem, requiring emergent tracheotomy in some cases. A program of referring patients for preoperative laryngoscopic examinations (PLE) who were being considered for a revision ACDF was instituted. This study reviews the results of these examinations and determines if the information gained impacted management. MethodsPatients who were referred for PLE prior to revision ACDF were identified from a prospectively maintained database during the period 2004 – 2010. All patients underwent examinations by an Otorhinolaryngologist specialist (ENT) using a nasopharyngoscope in combination with video stroboscopic examination. Results23 patients were identified as having a PLE and subsequent revision ACDF. 18 patients underwent a single level ACDF and 5 patients underwent a previous 2 level surgery. Significant findings were found in 4 patients. 2 patients presented with asymptomatic VCP and 2 patients with chronic hoarseness. One was found with VCP and the other with a vocal cord mass. The revision procedures were performed on the same side as the previous ACDF. Conclusions17.3% of patients undergoing PLE exhibited abnormalities, affecting decision-making regarding side of approach for revision ACDF. PLE is a simple and effective way of screening patients for abnormalities prior to revision ACDF surgery.

Patient Satisfaction After Revision Anterior Cervical Discectomy and Fusion (ACDF) for Adjacent Segment Disease: Relationship to Clinical Outcomes, Patient Characteristics and Cost-Effectiveness

Adjacent segment disease (ASD) has been found to occur in up to 26% of patients at 10 years following index anterior cervical discectomy and fusion (ACDF) surgery. Revision ACDF surgery is effective and durable in treating ASD, however information is scarce regarding patient reported satisfaction following the operation. Gathering patient satisfaction data can be valuable for clinicians and directly relevant to treatment effectiveness.