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Study designAnatomic study.ObjectivesTo determine the relationship of the anatomical footprint of the C1 pedicle relative to the lateral mass (LM).MethodsAnatomic measurements were made on fresh frozen human cadaveric C1 specimens: pedicle width/height, LM width/height (minimum/maximum), LM depth, distance between LM's medial aspect and pedicle's medial border, distance between LM's lateral aspect to pedicle's lateral border, distance between pedicle's inferior aspect and LM's inferior border, distance between arch's midline and pedicle's medial border. The percentage of LM medial to the pedicle and the distance from the center of the LM to the pedicle's medial wall were calculated.ResultsA total of 42 LM were analyzed. The C1 pedicle's lateral aspect was nearly confluent with the LM's lateral border. Average pedicle width was 9.0 ± 1.1 mm, and average pedicle height was 5.0 ± 1.1 mm. Average LM width and depth were 17.0 ± 1.6 and 17.2 ± 1.6 mm, respectively. There was 6.9 ± 1.5 mm of bone medial to the medial C1 pedicle, which constituted 41% ± 9% of the LM's width. The distance from C1 arch's midline to the medial pedicle was 13.5 ± 2.0 mm. The LM's center was 1.6 ± 1 mm lateral to the medial pedicle wall. There was on average 3.5 ± 0.6 mm of the LM inferior to the pedicle inferior border.ConclusionsThe center of the lateral mass is 1.6 ± 1 mm lateral to the medial wall of the C1 pedicle and approximately 15 mm from the midline. There is 6.9 ± 1.5 mm of bone medial to the medial C1 pedicle. Thus, the medial aspect of C1 pedicle may be used as an anatomic reference for locating the center of the C1 LM for screw fixation.

Study Design: Systematic Review. Objective: To review the literature for complications and outcomes after the implantation of cellular bone matrix (CBM) during spine fusion. Methods: The PubMed database was queried from inception to January 31, 2023 for any articles that discussed the role of and identified a specific CBM in spinal fusion procedures. Adverse events, reoperations, methods, and fusion rates were collected from all studies and reported. Results: Six hundred articles were identified, of which 19 were included that reported outcomes of 7 different CBM products. Seven studies evaluated lumbar fusion, 11 evaluated cervical fusion, and 1 study reported adverse events of a single CBM product. Only 4 studies were comparative studies while others were limited to case series. Fusion rates ranged from 68% to 98.7% in the lumbar spine and 87% to 100% in the cervical spine, although criteria for radiographic fusion was variable. While 7 studies reported no adverse events, there was no strict consensus on what constituted a complication. One study reported catastrophic disseminated tuberculosis from donor contaminated CBM. The authors of 14 studies had conflicts of interest with either the manufacturer or distributor for their analyzed CBM. Conclusions: Current evidence regarding the use of cellular bone matrix as an osteobiologic during spine surgery is weak and limited to low-grade non-comparative studies subject to industry funding. While reported fusion rates are high, the risk of severe complications should not be overlooked. Further large clinical trials are required to elucidate whether the CBMs offer any benefits that outweigh the risks. [ABSTRACT FROM AUTHOR]

Study Design: Global Survey Objective: To determine the accuracy, interobserver reliability, and intraobserver reproducibility of the AO Spine Upper Cervical Injury Classification System based on surgeons' AO Spine region of practice (Africa, Asia, Central/South America, Europe, Middle East, and North America). Methods: A total of 275 AO Spine members assessed 25 upper cervical spine injuries and classified them according to the AO Spine Upper Cervical Injury Classification System. Reliability, reproducibility, and accuracy scores were obtained over two assessments administered at three-week intervals. Kappa coefficients (ƙ) determined the interobserver reliability and intraobserver reproducibility. Results: On both assessments, participants from Europe and North America had the highest classification accuracy, while participants from Africa and Central/South America had the lowest accuracy (P <.0001). Participants from Africa (assessment 1 (AS1):ƙ =.487; AS2:0.491), Central/South America (AS1:ƙ =.513; AS2:0.511), and the Middle East (AS1:0.591; AS2:.599) achieved moderate reliability, while participants from North America (AS1:ƙ =.673; AS2:0.648) and Europe (AS1:ƙ =.682; AS2:0.681) achieved substantial reliability. Asian participants obtained substantial reliability on AS1 (ƙ =.632), but moderate reliability on AS2 (ƙ =.566). Although there was a large effect size, the low number of participants in certain regions did not provide adequate certainty that AO regions affected the likelihood of participants having excellent reproducibility (P =.342). Conclusions: The AO Spine Upper Cervical Injury Classification System can be applied with high accuracy, interobserver reliability, and intraobserver reproducibility. However, lower classification accuracy and reliability were found in regions of Africa and Central/South America, especially for severe atlas injuries (IIB and IIC) and atypical hangman's type fractures (IIIB injuries). [ABSTRACT FROM AUTHOR]

Study Design: Retrospective Cohort Objectives: To (1) quantify the risk opioids impart on pseudarthrosis development, (2) analyze the effect of pseudarthrosis on clinical outcomes, and (3) identify if the amount of opioids prescribed are predictive of pseudarthrosis revision. Methods: Patients who underwent ACDF at a single institution between 2017-2019 were retrospectively identified. Postoperative dynamic cervical spine radiographs were reviewed to assess fusion status. Logistic regression models measured the effect of morphine milligram equivalents (MME) prescribed on the likelihood of pseudarthrosis development. Receiver operating characteristic (ROC) curves were generated to predict the probability of surgical revision based on MME prescribed. Results: Of 298 included patients, an average of 2.01 ± 0.82 levels were included in the construct and 121 (40.9%) patients were diagnosed with a pseudarthrosis. However, only 14 (4.7%) required a pseudarthrosis revision. Patients requiring pseudarthrosis revision had worse one-year postoperative Δ PCS-12 (−1.70 vs. 7.58, P = 0.004), Δ NDI (3.33 vs. −15.26, P = 0.002), and Δ VAS Arm (2.33 vs. −2.48, P =.047). Multivariate logistic regression analyses found the three-month postoperative (OR=1.00, P =.010), one-year postoperative (OR=1.001, P = 0.025), and combined pre- and postoperative MME (OR=1.000, P =.035) increased the risk of pseudarthrosis. ROC analysis identified cutoff values to predict pseudarthrosis revision at 90.00 (area under the curve (AUC): 0.693, confidence interval (CI): 0.554-0.832), 132.86 (0.710, CI: 0.589-0.840), 224.76 (0.687, CI: 0.558-0.817) and 285.00 (0.711, CI: 0.585-0.837) MME in the preoperative, three-month postoperative, one-year postoperative, and combined pre-and postoperative period. Conclusion: Increased prescription of opioid medications following ACDF procedures may increase the risk of pseudarthrosis development and revision surgery. Level of Evidence: Therapeutic Level III [ABSTRACT FROM AUTHOR]

Study Design: Retrospective Cohort Study. Objectives: To (1) investigate the effect of marijuana use on surgical outcomes following lumbar fusion, (2) determine how marijuana use affects patient-reported outcomes measures (PROMs), and (3) determine if marijuana use impacts the quantity of opioids prescribed. Methods: Patients > 18 years of age who underwent primary one- or two-level lumbar fusion with preoperative marijuana use at our institution were identified. A 3:1 propensity match incorporating patient demographics and procedure type was conducted to compare preoperative marijuana users to non-marijuana users. Patient demographics, surgical characteristics, surgical outcomes (90-day all-cause and 90-day surgical readmissions, reoperations, and revision surgeries), pre- and postoperative narcotic usage, and PROMs were compared between groups. Multivariate regression models were created to determine the effect of marijuana on surgical reoperations patient-reported outcomes (PROMs) 1-year postoperatively. Results: Of the 259 included patients, 65 used marijuana preoperatively. Multivariate logistic regression analysis demonstrated that marijuana use (OR = 2.28, P =.041) significantly increased the likelihood of having a spine reoperation. No other surgical outcome was found to be significantly different between groups. Multivariate linear regression analysis showed that marijuana use was not significantly associated with changes in 1-year postoperative PROMs (all, P >.05). The quantity of pre- and postoperative opioids prescriptions was not significantly different between groups (all, P >.05). Conclusions: Preoperative marijuana use increased the likelihood of a spine reoperation for any indication following lumbar fusion, but it was not associated with 90-day all cause readmission, surgical readmission, the magnitude of improvement in PROMs, or differences in opioid consumption. Level of Evidence: III [ABSTRACT FROM AUTHOR]

Study Design: Global cross-sectional survey Objective: To develop and refine the techniques for web-based international validation of fracture classification systems. Methods: A live webinar was organized in 2018 for validation of the AO Spine Subaxial Injury Classification System, consisting of 35 unique computed tomography (CT) scans and key images with subaxial spine injuries. Interobserver reliability and intraobserver reproducibility was calculated for injury morphology, subtype, and facet injury according to the classification system. Based on the experiences from this webinar and incorporating rater feedback, adjustments were made in the organization and techniques used and in 2020 a repeat validation webinar was performed, evaluating images of 41 unique subaxial spine injuries. Results: In the 2018 session, the AO Spine Subaxial Injury Classification System demonstrated fair interobserver reliability for fracture subtype (κ = 0.35) and moderate reliability for fracture morphology and facet injury (κ=0.45, 0.43, respectively). However, in 2020, the interobserver reliability for fracture morphology (κ = 0.87) and fracture subtype (κ = 0.80) was excellent, while facet injury was substantial (κ = 0.74). Intraobserver reproducibility for injury morphology (κ =0.49) and injury subtype/facet injury were moderate (κ = 0.42) in 2018. In 2020, fracture morphology and subtype reproducibility were excellent (κ =0.85, 0.88, respectively) while reproducibility for facet injuries was substantial (κ = 0.76). Conclusion: With optimized webinar-based validation techniques, the AO Spine Subaxial Injury Classification System demonstrated vast improvements in intraobserver reproducibility and interobserver reliability. Stringent fracture classification methodology is integral in obtaining accurate classification results. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective Cohort Study Objectives: To determine if decreased preoperative symptom duration is associated with greater clinical improvement in function and myelopathic symptoms after posterior cervical decompression and fusion (PCDF). Methods: All patients over age 18 who underwent primary PCDF for cervical myelopathy or myeloradiculopathy at a single institution between 2014 and 2020 were retrospectively identified. Patient demographics, surgical characteristics, duration of symptoms, and preoperative and postoperative patient reported outcomes measures (PROMs) including modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI), Visual Analogue Scale (VAS) Neck, VAS Arm, and SF-12 were collected. Univariate and multivariate analyses were performed to compare change in PROMs and minimum clinically important difference achievement (%MCID) between symptom duration groups (< 6 months, 6 months–2 years, > 2 years). Results: Preoperative symptom duration groups differed significantly by sex and smoking status. Patients with < 6 months of preoperative symptoms improved significantly in all PROMs. Patients with 6 months–2 years of preoperative symptoms did not improve significantly in mJOA, Physical Component Scores (PCS), or NDI. Patients with > 2 years of symptoms failed to demonstrate significant improvement in mJOA, NDI, or Mental Component Scores (MCS). Univariate analysis demonstrated significantly decreased improvement in mJOA with longer symptom durations. Increased preoperative symptom duration trended toward decreased %MCID for mJOA and MCS. Regression analysis demonstrated that preoperative symptom duration of > 2 years relative to < 6 months predicted decreased improvement in mJOA and NDI and decreased MCID achievement for mJOA and MCS. Conclusion: Increased duration of preoperative symptoms (> 2 years) before undergoing PCDF was associated with decreased postoperative improvement in myelopathic symptoms. [ABSTRACT FROM AUTHOR]

Study Design: Global cross-sectional survey. Objective: To explore the influence of geographic region on the AO Spine Sacral Classification System. Methods: A total of 158 AO Spine and AO Trauma members from 6 AO world regions (Africa, Asia, Europe, Latin and South America, Middle East, and North America) participated in a live webinar to assess the reliability, reproducibility, and accuracy of classifying sacral fractures using the AO Spine Sacral Classification System. This evaluation was performed with 26 cases presented in randomized order on 2 occasions 3 weeks apart. Results: A total of 8320 case assessments were performed. All regions demonstrated excellent intraobserver reproducibility for fracture morphology. Respondents from Europe (k =.80) and North America (k =.86) achieved excellent reproducibility for fracture subtype while respondents from all other regions displayed substantial reproducibility. All regions demonstrated at minimum substantial interobserver reliability for fracture morphology and subtype. Each region demonstrated >90% accuracy in classifying fracture morphology and >80% accuracy in fracture subtype compared to the gold standard. Type C morphology (p2 =.0000) and A3 (p1 =.0280), B2 (p1 =.0015), C0 (p1 =.0085), and C2 (p1 =.0016, p2 =.0000) subtypes showed significant regional disparity in classification accuracy (p1 = Assessment 1, p2 = Assessment 2). Respondents from Asia (except in A3) and the combined group of North, Latin, and South America had accuracy percentages below the combined mean, whereas respondents from Europe consistently scored above the mean. Conclusions: In a global validation study of the AO Spine Sacral Classification System, substantial reliability of both fracture morphology and subtype classification was found across all geographic regions. [ABSTRACT FROM AUTHOR]

Study Design: Cadaver study. Objectives: Assess the feasibility of robot-assisted cervical pedicle screw (RA-CPS) placement and understand the anatomical considerations of this technique. Methods: Four cadaver specimens free from bony pathology were acquired. Anatomical considerations, such as pedicle width (PW) and height (PH), transverse pedicle angle (TPA), and maximal screw length (MSL), were recorded from preoperative computational tomography (CT) scans. Intraoperative cone-beam CT was acquired and registered to the robotic system. After cervical levels were segmented, screw sizes and trajectories were planned, and RA-CPS were placed. Accuracy was assessed using Gertzbein and Robbin's classification on postoperative CT scans. Results: Thirty-five RA-CPS were placed. Major breaches (≥Grade C) occurred in 28.57% screws. Grade A or B accuracy was found in 71.43% of screws, with the most common direction of breach being medial (81.3%). The greatest proportion of breach per level occurred in the upper subaxial levels, (C3:71.4%, C4 66.6%, C5:50%) which had the smallest PW (C3: 4.34 ±.96 mm, C4: 4.48 ±.60, C5: 5.76 ± 1.11). PH was greatest at C2 (8.14 ± 1.89 mm) and ranged subaxial from 6.36 mm (C3) to 7.48 mm (C7). The mean PW was 5.37 mm and increased caudally from 4.34 mm (C3) to 6.31 mm (C7). The mean TPA was 39.9° and decreased moving caudally 46.9°) to C7 (34.4°). The MSL was 37.1 mm and increased from C2 (26.3 mm) to C7 (41.0 mm). Conclusion: RA-CPS has the potential to be feasible, but technological and instrument modifications are necessary to increase the accuracy in the cervical region. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study Objectives: The purpose of this study is to compare patient-reported outcome measures (PROMs) for patients undergoing one-to three-level lumbar fusion using robotically assisted vs freehand pedicle screw placement. Methods: Patients who underwent either robotically assisted or freehand pedicle screw placement for one-to three-level lumbar fusion surgery from January 1, 2014 to August 31, 2020 at a single academic institution were identified. Propensity score matching was performed based on demographic variables. Clinical and surgical outcomes were compared between groups. Recovery Ratios (RR) and the proportion of patients achieving the minimally clinically important difference (%MCID) were calculated for Oswestry Disability Index, PCS-12, MCS-12, VAS Back, and VAS Leg at 1 year. Surgical outcomes included complication and revision rates. Results: A total of 262 patients were included in the study (85 robotic and 177 freehand). No significant differences were found in ΔPROM scores, RR, or MCID between patients who underwent robotically assisted vs freehand screw placement. The rates of revision (1.70% freehand vs 1.18% robotic, P = 1.000) and complications (.57% freehand vs 1.18% robotic, P =.546) were not found to be statically different between the 2 groups. Controlling for demographic factors, procedure type (robotic vs freehand) did not emerge as a significant predictor of ΔPROM scores on multivariate linear regression analysis. Conclusions: Robotically assisted pedicle screw placement did not result in significantly improved clinical or surgical outcomes compared to conventional freehand screw placement for patients undergoing one-to three-level lumbar fusion. [ABSTRACT FROM AUTHOR]

Study Design: This study is a retrospective case control. Objectives: This study aims to determine whether cervical degenerative spondylolisthesis (DS) is associated with increased baseline neck/arm pain and inferior health quality states compared to a similar population without DS. Methods: Patient demographics, pre-operative radiographs, and baseline PROMs were reviewed for 315 patients undergoing anterior cervical decompression and fusion (ACDF) with at least 1 year of follow-up. Patients were categorized based on the presence (S) or absence of a spondylolisthesis (NS). Statistically significant variables were further explored using multiple linear regression analysis. Results: 49/242 (20%) patients were diagnosed with DS, most commonly at the C4–5 level (27/49). The S group was significantly older than the NS group (58.0 ± 10.7 vs 51.9 ± 9.81, P =.001), but otherwise, no demographic differences were identified. Although a higher degree of C2 slope was found among the S cohort (22.5 ± 8.63 vs 19.8 ± 7.78, P =.044), no differences were identified in terms of preoperative visual analogue scale (VAS) neck pain or NDI. In the univariate analysis, the NS group had significantly increased VAS arm pain relative to the S group (4.93 ± 3.16 vs 3.86 ± 3.30, P =.045), which was no longer significant in the multivariate analysis. Conclusions: Although previous reports have suggested an association between cervical DS and neck pain, we could not associate the presence of DS with increased baseline neck or arm pain. Instead, DS appears to be a relatively frequent (20% in this series) age-related condition reflecting radiographic, rather than necessarily clinical, disease. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective case series. Objective: To determine risk factors associated with prolonged opioid use after lumbar fusion and to elucidate the effect of opioid use on patient-reported outcome measures (PROMs) after surgery. Methods: Patients who underwent 1–3 level lumbar decompression and fusion with at least one-year follow-up were identified. Opioid data were collected through the Pennsylvania Prescription Drug Monitoring Program. Preoperative "chronic use" was defined as consumption of >90 days in the one-year before surgery. Postoperative "prolonged use" was defined as a filled prescription 90-days after surgery. PROMs included the following: Short Form-12 Health Survey PCS-12 and MCS-12, ODI, and VAS-Back and Leg scores. Logistic regression was performed to determine independent predictors for prolonged opioid use. Results: The final analysis included 260 patients. BMI >35 (OR:.44 [.20,.90], P =.03) and current smoking status (OR: 2.73 [1.14, 6.96], P =.03) significantly predicted postoperative opioid usage. Chronic opioid use before surgery was associated with greater improvements in MCS-12 (β= 5.26 [1.01, 9.56], P =.02). Patients with prolonged opioid use self-reported worse VAS-Back (3.4 vs 2.1, P =.003) and VAS-Leg (2.6 vs 1.2, P =.03) scores after surgery. Prolonged opioid use was associated with decreased improvement in VAS-Leg over time (β =.14 [.15, 1.85], P =.02). Conclusions: Current smoking status and lower BMI were significantly predictive of prolonged opioid use. Excess opioid use before and after surgery significantly affected PROMs after lumbar fusion. [ABSTRACT FROM AUTHOR]

Study Design: Systematic Review. Objectives: To systematically review the current literature and perform a meta-analysis on patients with cervical or lumbar spine Modic changes to determine if their baseline axial back pain and disability are comparable to patients without Modic changes. Methods: A systematic review of the PubMed database was conducted in accordance with PRISMA guidelines. A meta-analysis was performed to compare the mean differences in back pain, leg pain, and disability based on the presence of cervical or lumbar spine Modic changes. A subgroup analysis of the different types of Modic changes was conducted to determine if Modic type affected back pain or disability. Results: – After review of 259 articles, 17 studies were included for meta-analysis and ten studies were included for qualitative synthesis. In the lumbar spine, 10 high-quality studies analyzed Visual Analog Scale (VAS) back pain, 10 evaluated VAS leg pain, and 8 analyzed Oswestry Disability Index. VAS back pain (mean difference (MD), −.38; 95% CI, -.61 –.16) and Oswestry disability index (MD −2.52; 95% CI, −3.93 – −1.12) were significantly lower in patients without Modic changes. Modic change subtype was not associated with differences in patient-reported outcomes. Patients with cervical spine Modic changes did not experience more severe pain than those without MC. Conclusions: Modic changes in the lumbar spine are not associated with clinically significant axial low back pain severity or patient disability. Similar to the lumbar spine, Modic changes in the cervical spine are not associated with symptom severity, but they are associated with pain duration. [ABSTRACT FROM AUTHOR]

Study Design: A multi-disciplinary review. Objectives: To provide a roadmap for implementing time-driven activity-based costing (TDABC) for spine surgery. This is achieved by organizing and scrutinizing publications in the spine, neurosurgical, and orthopedic literature which utilize TDABC and related methodologies. Methods: PubMed and Google Scholar were searched for relevant articles. The articles were selected by two independent researchers. After article selection, data was extracted and summarized into research domains. Preferred reporting items for systematic reviews and meta-analyses (PRISMA) systematic review process was followed. Results: Of the 524 articles screened, thirty-five articles met the inclusion criteria. Each included article was examined and reviewed to define the primary research question and objective. Comparing different procedures was the most common primary objective. Direct observation along with one other strategy (surveys, interviews, surgical database, or EMR) was most commonly employed during process map development. Across all surgical subspecialties (spine, neurologic, and orthopedic surgery), costs were divided into direct cost, indirect cost, cost to patient, and total costs. The most commonly calculated direct costs included personnel and supply costs. Facility costs, hospital overhead costs, and utilities were the most commonly calculated indirect costs. Transportation costs and parental lost wages were considered when calculating cost to patient. The total cost was a sum of direct costs, indirect costs, and costs to the patient. Conclusion: TDABC provides a common platform to accurately estimate costs of care delivery. Institutions embarking on TDABC for spine surgery should consider the breadth of methodologies highlighted in this review to determine which type of calculations are appropriate for their practice. [ABSTRACT FROM AUTHOR]

Study Design: Systematic Literature Review. Objective: To propose a systematic imaging algorithm for diagnosing posterior ligamentous complex (PLC) injury in computed tomography (CT) and magnetic resonance imaging (MRI) to improve the reliability of PLC assessment. Methods: A systematic review was conducted following PRISMA guidelines. The Scopus database was searched from its inception until July 21, 2022, for studies evaluating CT or MRI assessment of the PLC injury following thoracolumbar trauma. The studies extracted key findings, objectives, injury definitions, and radiographic modalities. Results: Twenty-three studies were included in this systematic review, encompassing 2021 patients. Five studies evaluated the accuracy of MRI in detecting thoracolumbar PLC injury using intraoperative findings as a reference. These studies indicate that black stripe discontinuity due to supraspinous or ligamentum flavum rupture is a more specific criterion of PLC injury than high-signal intensity. Thirteen papers evaluated the accuracy or reliability of CT in detecting thoracolumbar PLC injury using MRI or intraoperative findings as a reference. The overall accuracy rate of CT in detecting PLC injury was 68-90%. Two studies evaluate the accuracy of combined CT findings, showing that ≥2 CT findings are associated with a positive predictive value of 88-91 %. Vertebral translation, facet joint malalignment, spinous process fracture, horizontal laminar fracture, and interspinous widening were independent predictors of PLC injury. Conclusion: We provided a comprehensive imaging algorithm for diagnosing PLC in CT and MRI based on available literature and our experience. The algorithm will potentially improve the accuracy and reliability of PLC assessment, however it needs multicentre prospective validation. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective cohort study Objective: The aim of this study is to determine if there is a correlation between the amount of facet distraction and postoperative patient-reported outcomes after ACDF. Methods: A retrospective cohort analysis of patients undergoing 1 to 3 level ACDF for degenerative pathologies at a single academic center was performed. Each patient received upright, lateral cervical spine x-rays at the immediate postoperative time point from which interfacet distance (facet distraction) was measured. Patient-reported outcome measures including NDI, PCS-12, MCS-12, VAS Neck, and VAS Arm pain scores were obtained preoperatively and at short-term (<3 months) and long-term (>1 year) follow-up. Receiver operating curves were generated to evaluate the possibility of a critical interfacet distraction distance. Univariate and multivariate analysis were performed to compare outcomes between groups based on the degree of facet distraction. Results: A total of 229 patients met the inclusion criteria. Receiver operating curves failed to yield a critical interfacet distraction distance associated with worse post-operative outcomes. Patients were instead grouped based on facet distraction distance below and above the third quartile (0.8mm-2.0 mm, 2.0mm-3.7 mm), with 173 and 56 patients in each respective group. Univariate analysis did not detect any statistically significant differences in outcome measures, recovery ratio, or % MCID achievement at short- and long-term follow-up between groups. Multivariate analysis also failed to demonstrate any significant differences between the facet distraction groups. Conclusion: Increased interfacet distance did not correlate with increased neck pain or disability after an ACDF. [ABSTRACT FROM AUTHOR]