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Background Stability following multilevel decompressive laminectomy without fusion has been debated using in vitro biomechanical and radiographic models. However, there is a lack of information regarding clinical outcomes for these patients. The aim of the present study was to determine the association between clinical outcomes and number of levels decompressed via laminectomy for treatment of lumbar spinal stenosis. Methods We performed a retrospective cohort analysis of patients who underwent a primary lumbar laminectomy between 2009 and 2015 by senior orthopedic spine surgeons for lumbar spinal stenosis. Patients were divided into 2 groups based on the number of decompression levels: single level or 3 or more levels. Patient-reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, visual analog scale (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey scores, and Veterans Rand 12-Item Health Mental and Physical Survey scores. Results Overall, 138 consecutive patients were assessed, of which 106 underwent a single-level and 32 underwent a 3-or-more-level laminectomy. Average follow-up was 24.2 months. There were no significant differences in the preoperative VAS back, VAS leg, or ODI scores between the single-level laminectomy and 3-or-more-level laminectomy groups. Both groups of patients experienced significant improvements in these clinical outcomes postoperatively with no clinically significant difference in the degree of improvement. Reoperation rates were low and similar between the 2 groups. Conclusions Patients undergoing decompression of 3 or more levels present with similar postoperative outcomes to those who undergo a single-level decompression for lumbar spinal stenosis. Under specific clinical and radiographic criteria, a multilevel decompression of 3 or more levels may be a safe and effective procedure with acceptable outcomes at 2 years after surgery. Level of Evidence 3.

Discharge to acute/intermediate care facilities is a common occurrence after posterior lumbar fusion and can be associated with increased costs and complications after these procedures. This is particularly relevant with the growing popularity of bundled payment plans, creating a need to identify patients at greatest risk.To develop and validate a risk-stratification tool to identify patients at greatest risk for facility discharge after open posterior lumbar fusion.Retrospective cohort study.Patients were queried using separate databases from the institution of study and the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) for all patients undergoing open lumbar fusion between 2011 and 2018.Discharge to intermediate care and/or rehabilitation facilities.Using an 80:20 training and testing NSQIP data split, collected preoperative demographic and operative variables were used in a multivariate logistic regression to identify potential risk factors for postoperative facility discharge, retaining those with a p value.05. A nomogram was generated to develop a scoring system from this model, with probability cutoffs determined for facility discharge. This model was subsequently validated within the NSQIP database, in addition to external validation at the institution of study. Overall model performance and calibration was assessed using the Brier score and calibration plots, respectively.A total of 11,486 patients (10,453 NSQIP, 1,033 local cohort) were deemed eligible for study, of which 16.1% were discharged to facilities (16.7% NSQIP, 9.6% local cohort). Utilizing training data, age (p.001), body mass index (p.001), female sex (p.001), diabetes (p=.043), peripheral vascular disease (p=.001), cancer (p=.010), revision surgery (p.001), number of levels fused (p.001), and spondylolisthesis (p=.049) were identified as significant risk factors for facility discharge. The area under the receiver operating characteristic curve (AUC) indicated a strong predictive model (AUC=0.750), with similar predictive ability in the testing (AUC=0.757) and local data sets (AUC=0.773). Using this tool, patients identified as low- and high-risk had a 7.94% and 33.28% incidence of facility discharge in the testing data set, while rates of 4.44% and 16.33% were observed at the institution of study.Using preoperative variables as predictors, this scoring system demonstrated high efficiency in risk-stratifying patients with an approximate four to fivefold difference in rates of facility discharge after posterior lumbar fusion. This tool may help inform medical decision-making and guide reimbursement under bundled-care repayment plans.

Degenerative spine imaging findings have been extensively studied in the lumbar region and are associated with pain and adverse clinical outcomes after surgery. However, few studies have investigated the significance of these imaging "phenotypes" in the cervical spine. Patients with degenerative cervical spine pathology undergoing anterior cervical discectomy and fusion (ACDF) from 2008 to 2015 were retrospectively and prospectively assessed using preoperative MRI for disc degeneration, narrowing, and displacement, high-intensity zones, endplate abnormalities, Modic changes, and osteophyte formation from C2-T1. Points were assigned for these phenotypes to generate a novel Cervical Phenotype Index (CPI). Demographics were evaluated for association with phenotypes and the CPI using forward stepwise regression. Bootstrap sampling and multiple imputations assessed phenotypes and the CPI in association with patient-reported outcomes (Neck Disability Index [NDI], Visual Analog Scale [VAS]-neck, VAS-arm) and adjacent segment degeneration (ASDeg) and disease (ASDz). Of 861 patients, disc displacement was the most common (99.7%), followed by osteophytes (92.0%) and endplate abnormalities (57.3%). Most findings were associated with age and were identified at similar cervical vertebral levels; at C5-C7. Imaging phenotypes demonstrated both increased and decreased associations with adverse patient-reported outcomes and ASDeg/Dz. However, the CPI consistently predicted worse NDI (P = .012), VAS-neck (P = .007), and VAS-arm (P = .013) scores, in addition to higher odds of ASDeg (P = .002) and ASDz (P = .004). The CPI was significantly predictive of postoperative symptoms of pain/disability and ASDeg/Dz after ACDF, suggesting that the totality of degenerative findings may be more clinically relevant than individual phenotypes and that this tool may help prognosticate outcomes after surgery.

STUDY DESIGN The study is designed as a retrospective cohort study. OBJECTIVE The aim of this study was to identify modifiable and nonmodifiable risk factors of postoperative urinary retention in spine surgery patients. SUMMARY OF BACKGROUND DATA Postoperative urinary retention is a common complication in patients undergoing operative procedures requiring anesthesia. Current studies have shown significant risk factors for postoperative urinary retention, but most are nonmodifiable and subsequently of limited usefulness in preventing this complication. Several new studies have shown possible modifiable risk factors, but current data are inconsistent in terms of their statistical significance. METHODS A total of 814 consecutive patients who underwent open posterior lumbar laminectomy and fusion were included in the retrospective cohort study. Pre, intra-, and postoperative characteristics were collected in all patients to identify risk factors for postoperative urinary retention. RESULTS Glycopyrrolate use (odds ratio [OR] 2.60; P = 0.001), decreased body mass index (OR 0.96; P = 0.018), previous diagnosis of benign prostate hyperplasia (OR 3.34; P ≤ 0.001), and postoperative urinary tract infection (OR 5.60, P = 0.005) were associated with postoperative urinary retention. Previous history of lumbar spine surgery (OR 0.55; P = 0.019) was associated with decreased rates of postoperative urinary retention. CONCLUSION Glycopyrrolate use, benign prostate hyperplasia, and postoperative urinary tract infection were independent risk factors for postoperative urinary retention. The use of glycopyrrolate is a potentially modifiable risk factor for postoperative urinary retention.Level of Evidence: 3.

The purpose of this study was to compare the rates of adjacent segment degeneration (ASD), sagittal alignment parameters, and patient-reported outcomes in patients who underwent multi-level versus single-level anterior cervical discectomy and fusion (ACDF). A retrospective cohort analysis was performed on consecutive patients who underwent an ACDF. Pre- and post-operative radiographic assessment included ASD, change in C2–C7 lordosis, T1 angle, levels fused, sagittal vertical axis (SVA), fusion mass lordosis, proximal and distal adjacent segment lordosis. Patient-reported outcomes were obtained. Of the 404 that underwent an ACDF with a minimum of 6 months of follow-up (average 28 months), there was no significant difference in the rate of radiographic ASD overall (p = 0.479) or in the proximal or distal adjacent segments on multivariate analysis. Secondarily, the multi-level fusions appear to restore significantly greater amounts of lordosis compared to single-level procedures (p

Retrospective cohort study.To compare clinical outcomes after anterior cervical discectomy and fusion (ACDF) based on preoperative duration of radiculopathy symptoms.There is no clear indication of when outcomes after ACDF become less effective in the setting of acute versus chronic symptoms from cervical nerve root compression.A retrospective cohort study of consecutive patients who underwent an ACDF between 2008 and 2015 for radiculopathy was performed. Patients were divided into 3 groups: radicular symptoms lasting for6 months, symptoms lasting for 6-12 months, and those with symptoms for ≥12 months. Neck Disability Index (NDI) and Visual Analog Scale (VAS) scores for both the neck and arms were obtained at preoperative and final postoperative visits. Radiographs were assessed for adjacent segment degeneration, fusion, and subsidence. Bivariate and multivariate regressions were subsequently used to compare outcomes between groups.A total of 379 patients were included. Patients with symptoms lasting for 6-12 months and those with symptoms lasting for ≥12 months had worse preoperative VAS neck pain compared with patients with symptoms lasting for6 months (P=0.000 and P=0.004, respectively). Patients with symptoms lasting for ≥12 months had worse baseline functional status compared with patients with symptoms lasting for6 months (P=0.009). At final follow-up, there were no significant differences in VAS neck, VAS arm, or NDI between symptom duration groups. However, differences in outcomes were noted when considering the type of preoperative symptom. Patients with pain symptoms of ≥12 months had worse preoperative VAS neck (P=0.001), VAS arm (P=0.008), and NDI (P0.001) and had significantly worse final VAS arm (P=0.019) and NDI (P=0.016) compared with patients with preoperative pain symptoms lasting for6 months. The overall reoperation rate was 4.5%. Fusion was achieved in 97.6% of the patients, and subsidence was observed in 5.5%. There were no significant differences in the risk of adjacent segment degeneration, reoperations, fusion rates, or subsidence rates based on preoperative symptom duration.Despite worse preoperative neck pain and functional status in patients with preoperative duration of symptoms6 months, there were no differences in final clinical outcomes across groups.

BACKGROUND CONTEXT Tranexamic acid (TXA) has been increasingly used to decrease blood loss during a large variety of surgical procedures, including joint arthroplasty and spinal deformity procedures. However, TXA is not routinely used in degenerative lumbar spine cases, and the optimal dosing regimen for these cases is not known. PURPOSE The purpose of this study was to explore the clinical utility of TXA in open posterior lumbar fusions (PLF) while comparing intravenous and oral dosing regimens. STUDY DESIGN/SETTING Prospective randomized controlled trial. PATIENT SAMPLE Patients indicated for open posterior lumbar fusion for degenerative pathology by one of three fellowship-trained spine surgeons were recruited for the study. Patients with procedures that included 4 or more levels, or those who had a current/recent history of thromboembolic events, allergy to TXA, and/or pregnancy were excluded. OUTCOME MEASURES Outcome measures assessed were postoperative reduction in hemoglobin and hematocrit, blood transfusion rate, calculated blood loss, and complications. METHODS Patients were randomized to one of four study arms: 1) oral placebo, 2) intravenous TXA at time of incision, 3) 1950mg oral TXA 1 hour before incision, and 4) 1950mg oral TXA 1 hour before incision, and 1950mg oral TXA once per day for three days after surgery. Differences between study arms were assessed using a combination of chi-square & ANOVA for categorical and continuous data, respectively. The threshold for statistical significance was set at p RESULTS A total of 79 patients (44/79; 55.7% female) were enrolled, with a mean age of 64.9±12.2 years, body mass index of 32.3±6.2 kg/m2, and an average of 1.9±1.4 vertebral levels fused. For each treatment group, 21, 19, 20, and 19 patients were assigned to study arms 1-4, respectively. There were no differences in baseline demographic or operative characteristics. Patients across the entire cohort had a mean postoperative reduction in hemoglobin and hematocrit of -3.2±1.4 g/dL and -9.8±4.2 %, respectively, with an associated 1999.2±841.9 ml of calculated blood lost. Four patients experienced postoperative anemia (Group 1: 2/19, 10.5%; Group 4: 2/17, 11.8%) requiring a blood transfusion of 2 units each. No patients experienced other serious hospital complications such as postoperative epidural hematoma formation, pulmonary embolism, deep vein thrombosis, or stroke. There were no significant differences between groups in postoperative reduction in hemoglobin and hematocrit, blood transfusion rate, calculated blood loss, or complications. Similarly, there were no differences in assessed outcomes between patients who received any form of TXA when compared to placebo. CONCLUSIONS TXA can be used safely in PLF, though there was no clear benefit in hemostasis when compared to placebo, and outcomes did not vary based on dosing regimen. These preliminary findings suggest that TXA may not have a clinically meaningful application in short-length open PLF. FDA DEVICE/DRUG STATUS TXA: Investigational.

Work-related injuries are a frequent cause of workplace absence and chronic disability. Worker’s compensation has been developed to protect injured workers and to serve as a method for cost control. In order to adequately assess a patient’s injury, prognosis, and functional status, as well as the injury’s association with the workplace environment, an independent medical examination (IME) is necessary. Several guidelines have been established to assist physicians in performing IMEs in order to ensure thorough medical evaluations. Additionally, the limited relationship that exists between a physician and a patient during an IME is thought to facilitate the objective medical evaluation of a patient. However, this limited relationship has served as a source of controversy due to potential conflicts of interest and questionable physician liability. By appropriately informing and consenting the patient, adhering to established medical guidelines, and utilizing up-to-date evidence-based medicine, a physician can perform an objective and adequate IME.

Objective Current literature has not shown if using either allograft or autograft differentially affects postoperative cervical sagittal parameters. The goal of this study was to compare sagittal alignment and patient-reported outcomes following anterior cervical discectomy and fusion (ACDF) with allograft versus autograft. Methods A retrospective cohort analysis of patients who underwent single-level ACDF was conducted. Preoperative, immediate postoperative, and final follow-up radiographic assessments were conducted and included: change in C2–7 lordosis, T1 slope, levels fused, sagittal vertical axis (SVA), fusion mass lordosis, and proximal and distal adjacent segment degeneration (ASD). Patient-reported outcomes were obtained using the Neck Disability Index and visual analogue scale scores for neck and arm. Results A total of 404 patients were assessed; 353 using allograft and 51 using autograft. No significant differences existed in demographics. Cervical lordosis improved in both groups without significant changes in SVA. Autograft group had a significantly greater amount of lordosis at the proximal segment on immediate postoperative radiographs and less overall cervical lordosis at final follow-up. Sagittal parameters were similar at each time point without significant changes between the 3-time points. No significant differences existed in radiographic ASD or reoperation rates. Fusion rates exceeded 96% in both groups. No significant differences existed between preoperative, postoperative, or change in patient-reported outcomes between the 2 groups. Conclusion Sagittal alignment is maintained following ACDF when using either allograft or autograft. Radiographic evidence of ASD is present in both groups; however, this was not considered clinically significant, given low rates of pseudarthrosis or reoperation. No significant differences exist between groups in terms of patient-reported outcomes.

BACKGROUND CONTEXT Obesity increases complications and cost following spine surgery. However, the impact on sagittal alignment and adjacent segment degeneration (ASD) after anterior cervical decompression and fusion is less understood. PURPOSE To compare clinical and radiographic outcomes after anterior cervical decompression and fusion between obese and nonobese patients. STUDY DESIGN Retrospective cohort study. PATIENT SAMPLE In all, 467 patients that underwent an anterior cervical decompression and fusion procedure from January 2008 through December 2015 were assessed. Surgery indications were radiculopathy, myelopathy, or myeloradiculopathy that had failed nonoperative treatments. Exclusion criteria included patients who had postoperative follow-up less than 6 months. Of 467 patients originally identified, 399 fulfilled the inclusion and exclusion criteria. OUTCOME MEASURES The following patient-reported outcomes were obtained: Neck Disability Index and Visual Analog Scale scores for the neck and arm pain. Radiographic assessments included: C2–C7 lordosis, T1 angle, levels fused, sagittal vertical axis (SVA), fusion mass lordosis, proximal and distal adjacent segment lordosis, ASD, and presence of fusion. METHODS Plain radiographs were performed preoperatively, immediately postoperatively, and final follow-up. Demographic information was collected on all patients. Baseline patient characteristics were compared using chi-squared analysis and independent sample t tests for categorical and continuous data, respectively. For analysis, patients were divided into 4 groups based on obesity stratification as defined by Center for Disease Control: body mass index (BMI) RESULTS Of the 399 patients assessed, 97 were identified as normal weight, 157 as overweight, 81 with Class I obesity, 45 with Class II obesity, and 19 with Class III obesity. On multivariate analysis, despite having similar SVA measurements on preoperative radiographs, increase in BMI was associated with increase in postoperative SVA (p=0.041) along with significantly larger SVA in immediate postoperative (p=0.004) and final follow-up radiographs (p=0.003) for patients with BMI≥30 kg/m2 versus BMI CONCLUSIONS Overall, obese patients who underwent anterior cervical decompression and fusion had similar patient-reported outcomes compared with nonobese patients but had worse radiographic parameters and higher rates of ASD development compared with nonobese patients. This underscores the importance of patient selection and surgical approach for both patient populations.

A retrospective cohort analysis.The aim of this study was to assess whether duration of symptoms (DOS) has an effect on clinical outcomes in patients undergoing lumbar decompression.The success of surgical interventions for lumbar spinal stenosis varies depending on numerous factors, including DOS. However, existing literature does not provide a clear indication of the outcome of lumbar decompression surgery in regard to DOS secondary to nerve root compression.Analysis of patients who underwent primary lumbar laminectomy from 2008 through 2015 by one of two senior orthopedic spine surgeons was conducted. Exclusion criteria were as follows: previous lumbar surgery, patient under 18 years of age at time of surgery, or postoperative follow-up less than 3 months. Patients were divided into groups on the basis of preoperative DOS: less than 1 year and 1 year or greater. Patient-reported outcomes were obtained using Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. Patients were surveyed about expectations and postoperative satisfaction.Two hundred ten patients were assessed; 108 with DOS of less than 1 year and 102 with DOS of 1 year or more. On multivariate analysis, patients with DOS of 1 year or greater presented with significantly lower SF-12 scores (P = 0.043). No significant differences existed in other outcome survey scores. Reoperation rates were not significantly different (P = 0.904). Both groups reported high levels of satisfaction (odds ratio 0.42, P = 0.483) and that surgery met or exceeded their expectations (odds ratio 1.00, P = 0.308).Symptom chronicity did not significantly affect postoperative clinical outcomes, reoperation rates, or patient satisfaction. Nonoperative treatment of lumbar spinal stenosis is often successful but may delay operative intervention. However, results of this study suggest that the delay does not negatively impact surgical outcomes.3.

BACKGROUND CONTEXT Anterior cervical discectomy and fusion (ACDF) is an effective surgical option for the treatment of cervical stenosis. However, the adequacy of decompression and stabilization for patients with central stenosis versus foraminal stenosis has been debated. Many advocate for the use or addition of a posterior cervical approach to the neural foramen to ensure adequacy of decompression. However, this may be associated with a number of adverse effects, including inadequacy of central or anterior decompression, when indicated, and persistent postoperative neck pain. PURPOSE The aim of this study was to assess the effectiveness of ACDF alone across a number of postoperative clinical outcome measures for patients with central stenosis, foraminal stenosis or both. STUDY DESIGN/SETTING Retrospective cohort analysis. PATIENT SAMPLE Analysis was conducted of patients who underwent ACDF for cervical radiculopathy or myelopathy between 2008 and 2015 by one of two senior spine surgeons at our institution. Patients were excluded from analysis if they were under 18 years of age, had a previous operation to the cervical spine, or did not meet a minimum of six months follow-up. OUTCOME MEASURES Preoperative magnetic resonance imaging (MRI) was assessed to determine the location of neural stenosis and compression. Stenosis that occurred medial to the facet or uncovertebral joint in the axial plane was identified as central, whereas stenosis that occurred at, or lateral to, the facet and uncovertebral joints was identified as foraminal. Sagittal measures on plain films were also measured and analyzed, including cervical lordosis, sagittal vertical axis, fusion and T1 angles. Patient reported outcome measures included visual analogue scale (VAS) neck, VAS-arm and neck disability index (NDI). Objective outcome measures included the incidence of adjacent segment disease (ASD), fusion, subsidence and reoperation rate. METHODS Anteroposterior (AP) and lateral cervical radiographs were obtained during the preoperative, immediate postoperative (2-week postoperative follow-up appointment), and final follow-up period along with patient reported outcomes. Bivariate and multivariate analyses were performed to account for baseline differences in patient factors. RESULTS In total, 381 patients met our inclusion criteria. Of these, 126 had central stenosis, 96 had foraminal stenosis, and 159 had both. Average length of follow-up was 28.2 (range 6-101) months. The central stenosis-only and foraminal stenosis-only cohorts had a significantly greater percentage of females compared to the cohort with both central and foraminal stenosis (56.35% and 54.74% versus 40.25%, respectively), with no additional baseline differences between groups. There were no significant differences in the amount of change in the sagittal plane from preoperative to postoperative between cohorts on multivariate analysis. Each cohort experienced considerable improvements in patient reported outcome measures, however, there were no significant differences in preoperative or postoperative VAS-neck, VAS-arm, or NDI scores between groups. Similarly, there were no significant differences in the incidence of ASD, fusion, subsidence, or reoperation rate between groups. CONCLUSIONS Our findings suggest that ACDF offers adequate decompression and stabilization for patients with cervical stenosis, regardless of the location of neural compression as central, foraminal or a combination of both. These data may help to better guide preoperative planning and consideration of surgical approach to the affected level(s). FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Changes in the cervical alignment from preoperative to postoperative may alter cervical spine mechanics, and increase the rate of early adjacent segment pathology. Correction and restoration of cervical sagittal alignment is crucial in achieving a successful result after an ACDF and potentially decreasing the risk of developing ASD. PURPOSE We sought to evaluate the relationship between cervical spine sagittal alignment and adjacent segment disease (ASD) following anterior cervical discectomy and fusion (ACDF) as determined by radiographic and clinical outcomes. STUDY DESIGN/SETTING Retrospective Cohort Series. PATIENT SAMPLE Patients undergoing ACDF from 2008 to 2015 who developed radiographic signs of ASD(+) were identified and compared to a matched group of ACDF patients who did not develop radiographic evidence of ASD(−) for a period of at least 1 year. Patients were excluded from analysis if they were under 18 years of age at the time of surgery, had postoperative follow up less than 12 months or had an ACDF for cervical spine fracture or infection. OUTCOME MEASURES The number or location of levels fused was recorded and radiographs were reviewed preoperatively, immediately postoperative, and at final follow up. The sagittal parameters measured included change in C2-C7 lordosis, T1 angle, levels fused, sagittal vertical axis (SVA), fusion mass lordosis, proximal and distal adjacent segment lordosis. Patient reported outcomes were obtained in the form of Neck Disability Index (NDI) scores and Visual Analog Scales (VAS) scores for the neck and arm. Radiographic diagnosis of ASD was determined by the presence of new or enlarged osteophytes, endplate sclerosis, disc space narrowing g50%, and/or increased calcification of the anterior longitudinal ligament (ALL) as presented by previous published studies. METHODS Radiographic diagnosis of ASD was determined by the presence of new or enlarged osteophytes, endplate sclerosis, disc space narrowing g50%, and/or increased calcification of the anterior longitudinal ligament (ALL) as presented by previous published studies. Baseline patient characteristics were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS A total of 101 ASD(+) patients were identified having underwent ACDF from 2008 to 2015 and compared to 131 ASD(−). The ASD(−) were free of ASD for a period of at least 1 year. The groups were similar with regard to demographic and surgical variables, but with a predominance of males in the ASD group 61.2% (p=.001). Rigid plates were used in 42% of all constructs and were more represented in the ASD(−) than ASD(+) group (48% vs. 33%, respectively, p=.017). The most common levels included in the fusion were C5-7 (28%). For all patients, preoperative lordosis was increased from 4.8p11.4° to 7.9p10.2° postoperatively and improved to 9.4p9.9° at final followup. Patients with greater kyphosis throughout the cervical spine at final followup had increased odds of developing ASD (OR 0.97 per degree, p=.040). Patients with greater preoperative kyphosis through the planned fusion segment had increased odds of ASD (OR 0.93 per degree, p=.003). Patients who lost lordosis through the fusion from initial postop to final followup had greater odds of developing ASD (OR 0.85 per degree, pl0.001). Patients who had greater change in preoperative to postoperative fusion segment lordosis were found to exhibit a greater risk of ASD (OR 1.06 per degree, p=0.019). The SVA and T1 slope angles did not change substantially from preoperative to postoperative and there were no differences between ASD groups. The mean postoperative and final proximal and distal segment lordosis was also not different between groups except for significantly less proximal adjacent segment lordosis in ASD patients at final follow-up (0.2p5.0 vs. 1.4p4.4; p=.026). There were no significant differences between preoperative, postoperative, or change in patient reported outcome surveys in patients with or without signs of radiographic ASD. CONCLUSIONS Patients with a greater preoperative cervical kyphosis and kyphosis through the proposed fusion segment may have greater odds of develeoping radiographic adjacent segment degeneration. Similarly, those that had a greater greater correction of cervical lordosis postoperatively, and those who loss lordosis at the fusion segment also presented with increased odds of developing adjacent segment degeneration. Our results suggest that preoperative and postoperative measures of cervical spine alignment, specifically related to C2-C7 and fusion segment lordosis, may predict the development of radiographic signs of adjacent level pathology following an ACDF.

BACKGROUND CONTEXT A far lateral herniated nucleus pulposus (HNP) consists of 7%-12% of all disc herniations. 'Far lateral' is often used to describe a lumbar disc herniation that compresses the exiting nerve root at the same level, lateral to the neural foramen. The far lateral disc herniations have been described to elicit radicular leg pain that is more severe than a central or paracentral lumbar disc herniation due to direct compression of dorsal root ganglion, and are said to have a more acute onset in their clinical symptoms. However, literature does not provide much description of the comparative postoperative outcomes between those presenting with a far lateral HNP and those with a central or paracentral herniation. PURPOSE The goal of this study is to examine the pre- and postoperative outcomes between patients presenting with a central or paracentral versus a far lateral HNP. STUDY DESIGN/SETTING Retrospective cohort series. PATIENT SAMPLE We performed a retrospective cohort analysis of patients who underwent a primary lumbar microdiscectomy between 2009 and 2015 by one of two senior orthopaedic spine surgeons for lumbar spinal stenosis. Patients were excluded from analysis if they had any previous lumbar surgery, an unstable spondylolisthesis, were under 18 years of age at the time of surgery, or had postoperative follow up less than 3 months. Patients were divided into two groups based on the location of the HNP (central or paracentral versus far-lateral). OUTCOME MEASURES Patient reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 212 consecutive patients who fulfilled our inclusion criteria were assessed. Average follow-up was 24.14 months (range 3–78 months). There were 191 patients who presented with a central or paracentral HNP, while 21 patients presented with a far-lateral HNP. There were no significant differences in the demographic variables between these two groups. Patients with a far lateral disc herniation presented with a trend towards a shorter duration of symptoms prior to surgery (24.5 vs. 31.5 months; p=.052). On multivariate analysis, patients with a far lateral disc herniation presented with significantly lower SF-12 mental (52.14±13.49 vs. 55.1±6.55; p=.034) and physical scores (24.76±7.5 vs. 36.9±11.1; p=.008). Similarly, the far-lateral disc herniation patients also presented with significantly lower VR-12 mental (47.2±12.8 vs. 56.9±7.0; p=.024) and physical scores (25.8±8.7 vs.39.38±11.8; p=.005). However, postoperatively, all patients have similar SF-12 and CR-12 survey scores. The improvement in ODI score was significantly lower in the patients presenting with a far lateral disc herniation (7.8±15.1 vs. 28.3±21.5; p=.002). No significant difference in re-operation rates was found (p=.236). CONCLUSIONS Patients presenting with far lateral disc herniations present with significantly lower SF-12 mental and physical scores as well as lower VR-12 mental and physical scores. However, at approximately 2 years following a lumbar microdecompression surgery, both groups of patients express similar successful outcomes, including SF-12 and VR-12 survey scores. Re-operation rates are similar between the two groups. Despite compression at the site of the dorsal root ganglion and the reported greater difficulty in addressing far lateral disc herniations, patients presenting with these far lateral disc herniations can expect similar outcomes to those patients present with herniations in the central or paracentral region.

BACKGROUND CONTEXT Anterior cervical discectomy and fusion (ACDF) is one of the most common procedures in spine surgery. Both rigid and semi-rigid plates have been used to stabilize the anterior cervical spine after intervertebral graft application. No studies have compared the radiographic outcomes between rigid and semi-rigid cervical plate fixation over multiple level ACDF procedures. There is a lack of consensus regarding which plating modality yields superior clinical results. PURPOSE The goal of this study was to compare the long-term radiographic outcomes of patients treated with either rigid or semi-rigid plating modalities.To our knowledge, this is the largest series of patients comparing these instrumentation techniques, and as such, will help to further our understanding of the relative strengths and weaknesses of these instrumentation techniques. STUDY DESIGN/SETTING Retrospective Cohort Series. PATIENT SAMPLE We performed a retrospective cohort analysis of patients who underwent a single-level or multilevel ACDF for cervical radiculopathy or myelopathy. All of the cases were performed by one of two senior spine surgeons in the department. Patients were excluded from analysis if they were under 18 years of age at the time of surgery, had postoperative follow up less than 1 year or had an ACDF for cervical spine fracture or infection. OUTCOME MEASURES Radiographic assessments included: C2-C7 lordosis, T1 angle, levels fused, sagittal vertical axis (SVA), fusion mass lordosis, proximal and distal adjacent segment lordosis, adjacent segment degeneration (ASD), and fusion.Radiographic diagnosis of ASD was determined by the presence of new or enlarged osteophytes, endplate sclerosis, disc space narrowing >50%, and/or increased calcification of the anterior longitudinal ligament (ALL) as presented by previous published studies. Patient reported outcomes were obtained in the form of Neck Disability Index (NDI) scores and Visual Analog Scales (VAS) scores for the neck and arm. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS There were a total of 403 patients who met our inclusion and exclusion criteria. A total of 257 patients underwent semi-rigid plating and 147 patients underwent rigid plating. Regarding demographic variables, there were statistically significantly higher proportions of smokers (24.1% vs. 10.9%; p=.001) in the semi-rigid plating group relative to the rigid group. Both plating systems successfully restore cervical lordosis with an ACDF, without significant changes in the SVA. On multivariate analysis, rigid plate fixation was associated with greater change in preoperative to postoperative overall lordosis compared to semi-rigid plating (4.5±8.6° vs. 2.5±7.6°; p=.046). Similarly, rigid plating was associated with greater change in preoperative to postoperativefusion segmentlordosis compared to semi-rigid plate fixation (8.2 ±7.2° vs. 5.4 ±5.8°; p=.002). Rigid plate fixation also maintained fusion segment lordosis from the immediate postoperative period to final follow-up better than semirigid plating (7.2±7.4° vs. 5.0±6.2; p=.014). There were no significant differences in radiographic ASD (rigid 23.1% vs. semi-rigid 26.9%; p=.525) or reoperation rates (rigid 6.8% vs. semi-rigid 3.5%; p=.134). There was no significant difference in the rate of radiographic ASD overall (semi-rigid 20.3%; rigid 21.8% p=.582). Similarly, there were no significant differences between preoperative, postoperative, or change in patient reported outcome between the two groups. CONCLUSIONS Rigid and semi-rigid plating are appropriate treatment options for patients undergoing ACDF for degenerative cervical pathology. Rigid plate fixation provides greater restoration and maintenance of cervical lordosis and fusion segment lordosis compared semi-rigid plating. Radiographic evidence of ASD is present in approximately a quarter of both groups, however re-operation rates are low. Clinical outcomes are also similar between the two groups.

BACKGROUND CONTEXT Disc space collapse often occurs later in the natural course of cervical degenerative disc disease, and during anterior cervical discectomy and fusion (ACDF), restoration of disc space height and lordosis can assist with decompression and restoration of alignment. It is unclear if the amount of preoperative cervical disc space collapse correlates with outcomes following ACDF. PURPOSE The aim of the present study was to characterize preoperative disc space height in a sample of ACDF patients and to determine the association with postoperative clinical and radiographic outcomes following ACDF. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE Analysis of consecutive patients who underwent a single-level ACDF between 2008-2015 for cervical radiculopathy and/or myelopathy, with more than 6 months of clinical and radiographic follow-up was conducted. Exclusion criteria were patients under 18 years of age at the time of surgery, previous cervical fusion or concomitant posterior cervical surgery, had postoperative follow up less than 6 months, or had an ACDF for cervical spine fracture, tumor, or infection. OUTCOME MEASURES Preoperative disc height was measured in terms of preoperative anterior vertebral distance (pAVD), mid-vertebral distance (pMVD), and posterior vertebral distance (pPVD). Sagittal parameters were also measured, and included change in C2-C7 lordosis, T1 angle, levels fused, sagittal vertical axis (SVA), fusion mass lordosis, proximal and distal adjacent segment lordosis. Visual Analog Scale (VAS) neck, VAS arm, and Neck Disability Index (NDI) scores were collected at each postoperative clinical visit. The rates of adjacent segment disease, reoperation, fusion, and subsidence (postoperative disc space collapse >2mm) were determined for the study period. METHODS Radiographs were reviewed preoperatively and immediately postoperatively, and at final follow up along with patient-reported outcomes. Bivariate and multivariate logistic regressions were subsequently used to compare clinical outcomes between disc height. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS A total of 120 patients were included. At final follow-up, pAVD was associated with increased lordosis, SVA and proximal lordosis. Additionally, pMVD was associated with increased postoperative SVA (p=0.025), and final SVA (p=0.011). Preoperative PVD was associated with decreased postoperative distal lordosis (p=0.037) and increased final SVA (p=0.032). Notably, greater pAVD was associated with greater final VAS arm scores (p=0.022), greater pMVD was associated with increased final VAS neck (p=0.037) and final VAS arm scores (p=0.040), and greater pPVD was associated with greater final VAS neck (p=0.031) and arm (p=0.023) scores. Greater AVD, MVD, and PVD were all associated with a decreased preoperative to postoperative difference in VAS neck (p-value range 0.034-0.04). CONCLUSIONS Increased anterior, middle and posterior preoperative disc height were all associated with increased final SVA, among other parameters. Patients with well-maintained preoperative disc heights had greater final VAS neck scores, VAS arm scores, and had less postoperative improvement in VAS neck scores compared to patients with preoperative collapsed discs. These results suggest that patients with preoperative cervical disc space collapse may have superior outcomes compared to patients with maintained cervical disc height, and future studies are needed to further explore these differences. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT While attention to sagittal parameters in the cervical spine is increasing, the relationship between these radiographic measurements and clinical outcomes is less clear. PURPOSE The aim of the present study was to characterize independent associations between cervical spine radiographic parameters and clinical outcomes following anterior cervical discectomy and fusion (ACDF). STUDY DESIGN/SETTING Retrospective cohort analysis. PATIENT SAMPLE Analysis of consecutive patients who underwent a single-level ACDF at an academic institution between 2008 and 2015 for cervical radiculopathy and/or myelopathy, with a minimum of 6 months of clinical and radiographic follow-up. OUTCOME MEASURES Disc height was measured as the anterior vertebral distance (AVD), mid-vertebral distance (MVD), and posterior vertebral distance (PVD) on preoperative and immediate postoperative radiographs. Sagittal parameters were also measured, and included C2-C7 lordosis, T1 angle, fusion segment lordosis, sagittal vertical axis (SVA), proximal and distal adjacent segment lordosis. Preoperative and final visual analog scale (VAS) neck, VAS arm, and Neck Disability Index (NDI) scores were collected. The rates of reoperation, successful fusion, and subsidence (postoperative disc space collapse >2 mm) were determined. METHODS Preoperative, postoperative, and final radiographs were reviewed. Radiographic parameters were tested for association with patient-reported outcomes, reoperation, fusion, and subsidence using multivariate linear regression and multivariate logistic regression for continuous and binary outcomes, respectively. Multivariate regressions controlled for potential confounding variables in order to identify independent risk factors for each outcome. The Sidak-Holm method was used to adjust p-values in order to correct for multiple statistical comparisons. The threshold for statistical significance was set at p RESULTS A total of 381 patients met inclusion criteria. Average follow-up length was 28 months, average age was 50.2 years, average body mass index was 28.7, and 49.2% of patients were female. Of these patients, 93.7% achieved successful fusion, 6.6% had graft subsidence, and 4.99% had a reoperation. Preoperative and postoperative radiographic measurements and patient-reported outcomes were collected. Preoperative radiographic measurements poorly predicted clinical outcomes. Increased preoperative lordosis at the adjacent unfused segment proximal to the eventual fusion mass was found to be associated with increased final NDI (corrected p=0.018), and increased final proximal lordosis was associated with increased final NDI (corrected p=0.049). However, no other radiographic parameters were associated with any patient-reported clinical outcomes. Subsidence rates were increased with greater change in proximal lordosis from preoperative to postoperative (OR 1.30, corrected p=0.007) and from preoperative to final follow-up (OR 1.17, corrected p=0.044). Subsidence was negatively associated with increased change in lordosis across the fused segments from preoperative to postoperative (OR 0.88, corrected p=0.032) and from preoperative to final follow-up (OR 0.86, corrected p=0.017). CONCLUSIONS The present study found that sagittal parameters were poorly predictive of clinical outcomes. Increased preoperative lordosis at the adjacent segment proximal to the fusion mass was associated with worse final NDI scores, and was the only preoperative radiographic parameter associated with clinical outcomes. Further research should attempt to identify other preoperative factors or radiographic parameters that are more closely associated with clinical outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT During anterior cervical discectomy and fusion (ACDF), distraction of the disc space is used to assist with decompression and graft insertion. In patients with significant preoperative disc space collapse, there may be a large increase in disc space height postoperatively after graft insertion. There are concerns that this acute increase may increase the stresses across the graft-endplate interface and may lead to subsidence or affect other radiographic or clinical outcomes. PURPOSE The aim of the present study was therefore to characterize the difference in preoperative and postoperative disc space height, and to determine the association of an increased change in disc space height with clinical and radiographic outcomes following ACDF. STUDY DESIGN/SETTING Retrospective cohort analysis. PATIENT SAMPLE Analysis was performed on patients who underwent a single-level ACDF by one of two senior spine surgeons between 2008 and 2015 for cervical radiculopathy and/or myelopathy, with a minimum of 6 months of clinical and radiographic follow-up. OUTCOME MEASURES Radiographs were reviewed preoperatively and immediately postoperatively, and at final follow up. Disc height was measured as the anterior vertebral distance (AVD), mid-vertebral distance (MVD), and posterior vertebral distance (PVD) on preoperative and immediate postoperative radiographs. Sagittal parameters were also measured, and included C2-C7 lordosis, T1 angle, fusion segment lordosis, sagittal vertical axis (SVA), proximal and distal adjacent segment lordosis. Visual Analogue Scale (VAS) neck, VAS arm, and Neck Disability Index (NDI) scores were collected at each postoperative clinical visit. The rates of adjacent segment disease, reoperation, successful fusion and subsidence (postoperative disc space collapse >2mm) were determined. METHODS Radiographs were reviewed preoperatively and immediately postoperatively, and at final follow-up, along with patient reported outcomes. Multivariate regressions were used to control for baseline patient characteristics. RESULTS A total of 120 patients met inclusion criteria. Mean follow-up length was 29 months, and mean age was 46.9 years, mean BMI was 28.4, and 45.4% of patients were female. Increased preoperative to postoperative disc height change in all regions was associated with development of distal adjacent segment disease (AVD OR 1.89, p=0.013; MVD OR 1.75, p=0.043; PVD OR 2.07, p=0.014), but not proximal adjacent segment disease. increased change in AVD was associated with a greater change in preoperative to postoperative C2-C7 lordosis, fusion segment lordosis and proximal segment lordosis. Increased change in AVD was also associated with increased preoperative to final change in lordosis. No other associations were found between preoperative to postoperative difference in AVD, MVD or PVD and preoperative, immediate postoperative or final sagittal parameters. Additionally, no associations were found between preoperative to postoperative disc height change and any clinical outcomes. Rates of reoperation, fusion, and subsidence did not vary based on preoperative to postoperative disc height change. CONCLUSIONS This study found that a greater difference in preoperative to postoperative disc space height following ACDF was associated with the development of distal adjacent segment degeneration; however, it was not associated with most radiographic outcomes, or any patient-reported outcomes. Large changes in disc space height may not be benign, and further study is needed to characterize the etiology of ASD associated with these changes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background context The excellent clinical re.sults of five US Federal Drug Administration (FDA) trials approved for cervical total disc replacement (TDR) (Prestige [Medtronic Sofamor Danek, Memphis, TN, USA], Bryan [Medtronic Sofamor Danek], ProDisc-C [Synthes, West Chester, PA, USA], Kineflex|C [SpinalMotion, Mountain View, CA, USA], and Mobi-C [LDR Spine, Austin, TX, USA]) have recently been published. In these prospective randomized studies, superiority or equivalency of TDR was claimed, citing an 8.7% (23/265), 9.5% (21/221), 8.5% (9/106), 12.2% (14/115), and 6.2% (5/81) (mean=9.02%) rate of additional related cervical surgical procedures within 2 years in control anterior cervical discectomy and fusion (ACDF) patients, respectively, compared with 1.8% (5/276), 5.8% (14/242), 1.9% (2/103), 11% (15/136), and 1.2% (2/164) (mean=4.34%) in patients receiving the cervical TDR. The rate of reoperation within 2 years after ACDF seems unusually high. Purpose To assess the rate of and specific indications for early reoperation after ACDF in a cohort of patients receiving the ACDF as part of their customary care. These results are contrasted with similar patients receiving ACDF as the control arm of five FDA investigational device exemption (IDE) studies. Study design Multisurgeon retrospective clinical series from a single institution. Patient sample One hundred seventy-six patients with spondylotic radiculopathy or myelopathy underwent ACDF by three surgeons between 2001 and 2005 as part of their clinical practices. All patients had at least 2 years of follow-up with final follow-up within 6 months of completion of this study. Outcome measures Cervical reoperation rates at 2-year follow-up and at 3.5-year follow-up. Methods Review of medical records and telephone conversations were completed to determine the number of patients who had undergone a revision cervical procedure. Results At final follow-up, complete data were available for 159 ACDF patients. Of the 48 patients who underwent single-level ACDF and met criteria for inclusion in the IDE studies, one patient (2.1%) required additional surgery (adjacent-segment degeneration) within 2 years, the duration of follow-up of the five published IDE studies. Of the 159 patients who received single or multilevel ACDF at a mean follow-up of 3.5 years, 12 patients (7.6%) had undergone revision cervical surgery, with three patients (1.9%) undergoing same-level revisions (posterior fusion) and nine patients (5.7%) undergoing adjacent anterior level fusions. Patients who underwent revision same-level surgery typically had the intervention within the first year (mean, 11 months), whereas those requiring adjacent-level fusions typically had surgery later (mean, 29 months). Conclusions The present study identifies a 2.1% rate of repeat surgery within 2 years of a single-level ACDF performed during routine clinical practice, which is lower than that reported in the control arm of the Prestige, ProDisc-C, Bryan, Kineflex|C, and Mobi-C FDA trials (mean=9%). Even with longer follow-up including multilevel cases, our reoperation rate (7.6%) compared favorably with the IDE rates. This discrepancy may reflect different thresholds for reoperation in the control arm of a device IDE study compared with routine clinical practice. Additionally, patients enrolled in the single-level-only IDE trial may have received multilevel procedures outside of the study. This factor could result in a higher rate of subsequent surgeries at adjacent levels not addressed at the index procedure. These data suggest that we need to better understand factors driving treatment and, in particular, decisions to reoperate both in and outside of a device trial.

BACKGROUND CONTEXT The success of surgical interventions for lumbar spinal stenosis can vary significantly depending on various factors, one of which is the duration of symptoms. Literature does not provide a clear indication of when lumbar decompression surgery become less effective in the setting of acute versus chronic symptoms from nerve root compression. PURPOSE The main objective of this study was to assess whether the duration of symptoms has an effect on clinical outcomes, especially resolution of radicular symptoms due to pathology compressing the lumbar nerve roots in patients undergoing lumbar decompression-only procedures. STUDY DESIGN/SETTING Retrospective cohort series. PATIENT SAMPLE We performed a retrospective cohort analysis of patients who underwent a primary lumbar laminectomy, discectomy or a combination of the two between 2009 and 2015 by one of two senior orthopedic spine surgeons. Patients were excluded from analysis if they had any previous lumbar surgery were under 18years of age at the time of surgery or had postoperative follow-up less than 3 months. Patients were divided into two groups: those with lumbar radicular symptoms for less than one year prior to surgery, and those who experienced symptoms for one year or greater before undergoing surgery. OUTCOME MEASURES Patient reported outcomes were obtained in the form of Oswestry Disability Index scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. Patients were also surveyed about their expectations and satisfactions following surgery. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t-tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 210 consecutive patients who fulfilled our inclusion criteria were assessed. Average follow-up was 24.14 months (range 3–78 months). There were 108 patients that experienced radicular symptoms for less than one year, while 102 patients experienced radicular symptoms for one year or more. Patients who experienced radicular symptoms for less than one year had a significantly higher rate of a herniated nucleus pulposus present (75.9% vs. 49.0%; p 1 year 7.9%; p=.904). Patients presented with high levels of satisfaction (pain 1 year 82.4%; OR1.06, p=.904) and expressed that the surgery met or exceeded their expectations (pain 1 year 96.1%; OR1.06, p=.904). CONCLUSIONS Overall, patients present with similar clinical outcome scores, despite the differences in the duration of their lumbar radicular symptoms prior to surgery. At approximately 2years following lumbar decompression-only surgery, all patients, despite their symptom chronicity, appear to show similar improvement in their clinical outcome scores. Re-operation rates were low and similar between the two groups of patients. Most patients report being satisfied with their outcome and with their expectations being met or exceeded to similar degrees. Given the various options available for nonoperative management of lumbar spinal stenosis and/or a lumbar herniated nucleus pulposus, the extended effort of these conservative treatments or delay of operative intervention do not appear to negatively impact the eventual outcome of surgery. Patients report significant improvement in their symptoms, based on clinical outcome surveys, regardless of their symptom chronicity.

BACKGROUND CONTEXT There has been debate on the stability, and thus clinical outcomes, of multilevel lumbar decompression-only surgeries compared to those undergoing a single-level procedure. In patients with single-level stenosis, laminectomy has long been considered the standard of surgical care, with generally favorable outcomes. However, there has been considerable debate regarding the optimal surgical approach for patients with multi-level spinal stenosis. While the addition of a posterior lumbar fusion has been supported for a number of patient populations (degenerative spondylolisthesis, degenerative scoliosis, pars defects with disc disease, symptomatic baseline instability), the merits of fusion in patients with only multi-level stenosis is still debated. PURPOSE The goal of this study was to compare patient outcomes following a multi-level versus a single-level stability-preserving decompression-only surgery for lumbar spinal stenosis. STUDY DESIGN/SETTING Retrospective cohort series. PATIENT SAMPLE We performed a retrospective cohort analysis of patients who underwent a primary lumbar laminectomy between 2009 and 2015 by one of two senior orthopedic spine surgeons for lumbar spinal stenosis. Patients were excluded from analysis if they had any previous lumbar surgery, an unstable spondylolisthesis, were under 18 years of age at the time of surgery, or had postoperative follow-up less than 3 months. Patients were divided into three groups based on the number of decompression levels: single-level, two-level, or three or more levels. OUTCOME MEASURES Patient reported outcomes were obtained in the form of Oswestry Disability Index (ODI) scores, Visual Analog Scales (VAS) scores for the back and leg, 12-Item Short Form Mental and Physical Survey (SF-12) scores, and the Veterans Rand 12-Item Health Mental and Physical Survey (VR-12) scores. METHODS Baseline patient characteristics were compared using chi-squared analysis and independent sample t tests for categorical and continuous data, respectively. Bivariate and multivariate regressions were subsequently used to compare clinical outcomes between procedure groups. Multivariate analyses controlled for differences in baseline patient characteristics. RESULTS Overall, 212 consecutive patients who fulfilled our inclusion criteria were assessed. Average follow-up was 24.14 months (range 3-78 months). There were 106 patients who underwent a single-level, 74 patients underwent a two-level, and 32 patients underwent a three- or more level laminectomy. The multi-level decompression patients were significantly older (3+ levels 67.9±8.7 years, 2-level 56.4±14.7 years, single-level 48.7±16.4 years; p CONCLUSIONS Patients undergoing decompression of three or more levels present with similar postoperative outcomes to those who undergo a single-level decompression for lumbar spinal stenosis. Despite concerns for instability following a multi-level decompression, re-operation rates are low and not significantly different when comparing the number of levels that underwent a stability-preserving lumbar decompression. Under specific clinical and radiographic criteria, a multi-level decompression of three or more levels appears to be a safe and effective procedure with acceptable outcomes at 2 years after surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Background context Anterior cervical discectomy and fusion (ACDF) is an established procedure for the operative treatment of cervical disc disease in patients with radiculopathy resulting from impingement from uncovertebral joint osteophytes. Studies demonstrate that direct decompression of the lesion provides good result. However, known complications include vertebral artery injury, dural tears, nerve root injury, loss of biomechanical stability and increased operative time. Other studies suggest that disc space distraction may play an important role by indirectly decompressing neural elements. Therefore, if equivalent functional outcomes can be achieved without sacrificing the uncovertebral joint, then potential morbidity and mortality could be decreased. Purpose To assess and compare clinical and radiographic outcomes of patients with neck pain and cervical radiculopathy who underwent instrumented ACDF with or without direct uncovertebral joint decompression. Study design/setting Retrospective clinical chart and radiographic review to assess clinical outcome and graft fusion in 109 patients who underwent one- or two-level ACDF with rigid anterior plate fixation. Patient sample Radiographs and clinical charts for 109 patients (mean, 46 years; range, 27 to 83) who underwent ACDF with rigid anterior plate fixation were retrospectively reviewed at a single institution. Patients with radiculopathy resulting from herniated disc, spondylosis or a combination of both refractory to conservative treatment underwent surgery using a standard Smith-Robinson left-sided approach. Seventy-one patients who received direct uncovertebral joint decompression (Group 1) were compared with 38 patients without direct decompression but indirect decompression by disc space distraction (Group 2). In Group 1, 37 one-level and 34 two-level ACDFs were performed. In Group 2, 11 and 27 were one-level and two-level ACDFs, respectively. Smoking and work-related injuries involved 26.7% and 38.0% of Group 1 and 28.9% and 28.9% of Group 2, respectively. Autologous iliac crest grafts were used in 51 patients, whereas 58 patients received allograft. Outcome measures Independent blinded analyses of plain lateral neutral, flexion and extension radiographs were conducted to assess fusion, evaluate graft and plate and screw integrity (mean, 12 months). Clinical outcomes were reported as excellent, good, fair or poor (mean, 23 months) based on Odom's criteria. Methods Postoperative clinical outcome and radiographic studies of graft and instrument integrity were assessed in 71 patients undergoing ACDF with uncovertebral joint decompression and 38 patients without uncovertebral joint decompression, but with indirect decompression through disc space distraction. Results Fusion occurred in 95.8% of Group 1 and 100% of Group 2. In Group 1, 26.8% of the patients reported excellent results, 57.7% reported good results, 12.7% reported fair results and 2.8% reported poor results. In Group 2, 23.7% of the patients reported excellent results, 60.5% reported good results and 15.8% reported fair results. All nonunions reported good outcomes. Postoperative respiratory distress developed in one patient and dysphagia developed in another both from Group 1. No other complications were noted. The presence or absence of direct uncovertebral joint decompression and clinical outcome was not statistically significant (p>.05). The use of graft-type, operative level, presence of smoking and work-related injury in relation to clinical outcome was not found to be significant (p>.05). Conclusion Good to excellent results were obtained in 84.5% and 84.2% of patients for Groups 1 and 2, respectively. Indirect foraminal decompression through distraction remains somewhat controversial during ACDF. However, sacrificing the uncovertebral joint can increase operative time and potentially increase complication rates. This study demonstrates that ACDF with or without direct uncovertebral joint decompression can provide good clinical results for neck pain with cervical radiculopathy. Therefore, routine direct uncovertebral joint decompression should not be undertaken during ACDF.

This study addressed radiographically the evaluation, presence, location, and degree of subsidence with secondary focus on the various clinical parameters and outcomes in 32 patients who underwent anterior cervical discectomy and fusion (ACDF) with tricortical iliac crest bone grafts and rigid anterior plate fixation. Postoperative follow-up plain radiographs were evaluated to determine subsidence on lateral neutral images by measuring the change in height of interscrew distance (ISD) and anterior (AVD), mid (MVD), and posterior (PVD) vertebral endplate-to-endplate vertical distances. Clinical functional outcome and various risk factors were also addressed. A 100% fusion rate was achieved, no instrumentation-related complications were noted, and mild graft subsidence occurred in each patient after the initial 2 months of surgery. Mean AVD, MVD, and PVD were 1.2 mm, 0.4 mm and 0.6 mm, respectively. Mean ISD was 0.6 mm. Percent change for AVD, MVD, PVD, and ISD was 2.3%, 0.8%, 1.2%, and 1.2%, respectively. Subsidence was more pronounced at the anterior vertebral graft-endplate interface (P.05). Satisfactory clinical results were reported in 90.9% of the patients. With such a sample size, age, sex, smoking status, plate design, graft type, and operative or number of fused levels did not demonstrate statistically significant differences to the degree of subsidence. This paper has shown that ACDF with tricortical bone grafts and rigid plating is associated with slight subsidence, graft load-sharing, high fusion rate, and excellent clinical outcome.

Sexual dimorphism is evident during formation, growth, and development of the spine. Pregnancy alters spine physiology and is a risk factor for back pain. The processes of aging and spinal degeneration adversely affect men and women slightly differently. Although degenerative changes are observed at similar rates in both sexes, women seem to be more susceptible to degenerative changes leading to instability and malalignment, structural deterioration, such a stenosis or disc degeneration. Surgical satisfaction is greater in men, which has been attributed to poorer preoperative function secondary to more advanced disease at time of surgery and lower patient expectations for clinical improvement, both observed in women.

Study design A review of 66 consecutive patients at a single institution who underwent one-level anterior cervical discectomy and fusion (ACDF) with rigid anterior plate fixation with allograft or autograft. Objectives To address the efficacy of allograft to autograft with primary respect to fusion rate and secondary attention to risk factors and clinical outcome in patients undergoing one-level ACDF with rigid anterior plate fixation. Summary of background data Although autograft is considered the gold standard in achieving optimal fusion, when compared with allograft in noninstrumented one-level ACDF and in plated and nonplated multilevel ACDF, the efficacy of allograft to autograft in one-level ACDF with rigid anterior plate fixation is not thoroughly understood. Methods Sixty-six consecutive patients (mean age, 45 years) at a single institution who underwent one-level ACDF with rigid anterior plate fixation with allograft (n = 35) or autograft (n = 31) were reviewed for radiographic fusion (mean, 12 months), risk factors, and clinical outcome (mean, 17 months). Smokers entailed 33.3% of the patients, and 45.5% of all patients presented with a work-related injury. An independent blinded observer reviewed at last follow-up lateral neutral and flexion/extension plain radiographs for radiographic fusion and instrumentation integrity. Clinical outcome was assessed on last follow-up and rated according to the Odom criteria. The threshold for statistical significance was established at P Results Solid fusion was achieved in 63 patients (95.5%). Fusion was noted in 100% of the allograft patients, whereas 90.3% of the autograft cases achieved fusion. No statistically significant difference was noted between allograft to autograft with regard to fusion rate (P > 0.05). Three patients developed nonunions (1 smoker; 2 nonsmokers) and entailed Orion instrumentation. In the one patient who was a nonsmoker with a nonunion, slight screw penetration into the involved and uninvolved interbody spaces was noted. No other intraoperative, postoperative, or radiographic complication was noted. All of the nonunions occurred early in the series. Postoperatively, excellent results were reported in 19.7%, good results in 71.2%, and fair results in 9.1% of the patients. Satisfactory clinical outcome was noted in all nonunion patients. A nonstatistically significant difference was noted with regard to clinical outcome of fused and nonfused patients, demographics, and the presence of a work-related injury (P > 0.05). The impact of smoking was not a factor influencing fusion or clinical outcome in this series (P > 0.05). A statistically significant difference was noted in plate-type on fusion rate (P Conclusion A 100% and 90.3% radiographic fusion rate was obtained for allograft and autograft in one-level ACDF procedures with rigid anterior plate fixation, respectively. Although autograft achieved a higher incidence of nonunion than allograft, this may be attributed to the use of autograft early in the experience of plate application and fixation in this series. The effects of smoking were not found to be a significant factor influencing fusion in these plated patients. In 90.9% of the patients, excellent and good clinical outcome results were reported. The use of allograft in one-level ACDF with rigid plate fixation yields similar and high fusion rates as autograft. The use of allograft bone eliminates complications and pitfalls associated with autologous donor site harvesting. However, the use of autograft is a viable alternative to avoid the risk of infection, disease transmission, and histocompatibility differences associated with allograft. The use of allograft or autograft bone in properly selected patients for one-level ACDF with rigid anterior plate fixation can result in high fusion rates with excellent and good clinical outcomes.

Degenerative lumbar spinal stenosis manifests primarily after the sixth decade of life as a result of facet hypertrophy and degenerative disc disease. Congenital stenosis, on the other hand, presents earlier in age with similar clinical findings but with multilevel involvement and fewer degenerative changes. These patients may have subtle anatomic variations of the lumbar spine that may increase the likelihood of thecal sac compression. However, to the authors' knowledge, no quantitative studies have addressed various radiographic parameters of symptomatic, congenitally stenotic individuals to normal subjects.To radiographically quantify and compare the anatomy of the lumbar spine in symptomatic, congenitally stenotic individuals to age- and sex-matched, asymptomatic, nonstenotic controlled individuals.A prospective, control-matched, cohort radiographic analysis.Axial and sagittal magnetic resonance imaging (MRI) and lateral, lumbar, plain radiographs of 20 surgically treated patients who were given a clinical diagnosis of congenital lumbar stenosis by the senior author were randomized with images of 20, asymptomatic age- and sex-matched subjects.MRIs and lateral, lumbar, plain radiographs were independently quantitatively assessed by two individuals. Measurements obtained from the axial MRIs included: midline anterior-posterior (AP) vertebral body diameter, vertebral body width, midline AP canal diameter, canal width, spinal canal cross-sectional area, pedicle length, and pedicle width. From the sagittal MRIs, the following measurements were calculated: AP vertebral body diameter, vertebral body height, and AP canal diameter at the mid-vertebral level. On the lateral, lumbar, plain radiograph (L3 level), the AP diameters of the vertebral body spinal canal were measured.The images of these 40 individuals were then randomized and distributed in a blinded fashion to five separate spine surgeons who graded the presence and severity of congenital stenosis utilizing a five-tier scale. Images consisting of 15 symptomatic individuals, graded definitely congenitally stenotic (mean age, 51.7 years; range, 43-65 years), and 15 asymptomatic individuals, graded definitely not stenotic (mean age, 50.7 years; range, 41-55 years), were age- and sex-matched and included for further review. From these 30 patients, a lateral, lumbar, plain radiograph and axial and sagittal MRIs (T1/T2 weighted) from L2-L5 were quantitatively analyzed. Rater reliability was assessed by Kappa coefficient testing.The cross-sectional area of the canal was significantly smaller in the congenitally stenotic patients at all lumbar levels measured (L2: 176 mm(2) vs. 259 mm(2), L3: 177 mm(2) vs. 275 mm(2), L4: 183 mm(2) vs. 283 mm(2), L5: 213 mm(2) vs. 323 mm(2), p.05). Pedicle length was markedly shorter in the stenosis group at each lumbar level (L2: 5.9 mm vs. 8.9 mm, L3: 6.0 mm vs. 8.8 mm, L4: 6.5 mm vs. 9.2 mm, L5: 5.8 mm vs. 9.1 mm, p.05). Furthermore, midline, axial AP canal diameter, vertebral body width, and sagittal AP canal diameter were all significantly smaller than the control patients (p.05). A ratio of the AP diameter of the pedicle length to the vertebral body was also noted to be statistically significant on both the lateral plain radiographs (L3: 0.426 vs. 0.704) and sagittal MRI (L2: 0.343 vs. 0.461, L3: 0.361 vs. 0.461, L4: 0.362 vs. 0.481, L5: 0.354 vs. 0.452, p.05). No difference was noted comparing the AP diameter of the vertebral body (axial and sagittal images), vertebral body height, canal width, and pedicle width. Kappa testing coefficient indicated a strong rater reliability (k=0.81, 95% confidence interval: 0.62-0.94).Congenital lumbar stenosis has not been clearly defined radiographically. Clinically, congenitally stenotic patients present at a younger age with fewer degenerative changes and multiple levels of involvement. Radiographically, these patients have a shorter pedicular length and as a result a smaller cross-sectional spinal canal area (mean critical values of 6.5 mm and 213 mm(2) were observed, respectively). The mean critical ratios were 0.43 (2:1 AP vertebral body: pedicle length) on the lateral lumbar radiograph and 0.36 on the sagittal MRI. The altered canal anatomy resulting from a decreased pedicle length may anatomically predispose these patients to earlier complaints of symptomatic neurogenic claudication. Identification of the presence of congenital stenosis should increase the treating surgeon's awareness of the potential need for multilevel treatment.

Background context A relatively high pseudarthrosis rate is associated with multilevel anterior cervical discectomy and fusion (ACDF). Anterior plate fixation increases fusion rate in multilevel ACDF. A debate still exists between the effectiveness of allograft versus autograft in plated multilevel ACDF. Purpose To determine the efficacy of allograft versus autograft in fusion rate and clinical outcome in patients undergoing two- and three-level ACDFs with rigid anterior plate fixation. Study design A retrospective radiographic and clinical review to assess fusion, risk factors and clinical outcome of 80 consecutive patients who underwent ACDF with rigid anterior plate fixation involving two and three levels with either allograft or autograft. Patient sample There were 45 patients (56%) who had autogenous iliac crest tricortical grafts and 35 patients (44%) who received tricortical allograft with an average age of 49 years who were treated by multilevel ACDF with rigid anterior plate fixation at a single institution. Thirty-three Peak polyaxial (Depuy-Acromed, Rayham, MA), 26 Orion (Sofamor-Danek, Memphis, TN), 16 Atlantis (Sofamor-Danek, Memphis, TN) and 5 Synthes (Paoli, PA) anterior cervical plating systems were used. All patients underwent ACDF (61 two-level, 19 three-level) by a Smith Robinson technique. All patients had burring of the end plates, 2-mm distraction of the motion segment and graft countersunk 2 mm from the anterior vertebral border. Anterior cervical plate with unicortical screw purchase was used in all cases. Segmental screw fixation was performed in 46 patients. Soft collars were worn postoperatively for 3 to 4 weeks. Outcome measures Follow-up lateral neutral, flexion and extension radiographs were used to assess fusion. The radiographs were reviewed by an independent blinded observer in assessing fusion grades between autograft versus allograft. Clinical outcomes were rated excellent, good, fair and poor based on Odom's criteria. Methods Fusion rate and postoperative clinical outcome were assessed in 80 patients who underwent two- or three-level ACDF with rigid anterior plate fixation. Additional risk factors were also analyzed. Results Radiographic fusion was assessed in all patients (mean, 16 months). Seventy-eight patients (97.5%) achieved solid arthrodesis. Pseudarthrosis occurred in two patients who had allograft for two-level and three-level fusions. Nonsegmental screws were used in the two-level nonunion case. Postoperative dysphagia developed in one two-level nonunion patient, and revision surgery was performed in the other nonunion three-level patient. Twenty-three patients were smokers, and 26 patients had work-related injuries. Clinical outcome (mean, 20 months) was excellent in 23, good in 48 and fair in 9 patients. No statistical significance was noted between demographics, history of tobacco use, graft-type, end plate preparation technique, intermediate segmental screws, plate-type, clinical outcome of fused and nonfused patients and presence of work-related injuries (p > .05). Conclusions A high fusion rate of 97.5% was obtained for multilevel ACDF with rigid plating with either autograft or allograft. In this study, nonunion occurred in patients with allograft but this difference was not statistically significant. Fusion was obtained in 97.8% of patients with segmental screw fixation and 97.1% with nonsegmental screw fixation. Nonsegmental screw fixation may contribute to less than adequate stability and contribute to a higher rate of nonunion, but such effects could not be discerned from this study. Excellent and good clinical outcome was noted in 88.8% of the patients. Proper patient selection and meticulous operative technique is essential to obtain high fusion rates and optimal clinical outcome, which is more important than graft type.

Background context: Anterior cervical discectomy and fusion (ACDF) is an accepted surgical procedure to treat degenerative conditions, including disc herniations and spinal stenosis. The literature on lumbar spine surgery reports that patients with a workman's compensation claim have less successful clinical results. Regarding the cervical spine, however, different conclusions have been drawn. Purpose: The purpose of this study was to directly compare the functional outcomes of ACDF in patients with and without a workman's compensation claim and to determine whether a compensation claim adversely affected the clinical outcome. Study design: This is a retrospective study examining the long-term results of ACDF in the workman's and non–workman's compensation populations. Patient sample: Eighty consecutive patients undergoing ACDF were retrospectively analyzed. The patients were divided into two groups: 30 patients in Group 1 (workman's compensation) and 50 patients in Group 2 (non–workman's compensation). The average age of Group 1 was 45 years (range, 31 to 57) and Group 2 was 45 years (range, 30 to 79). The patients were followed for an average length of 4 years (range, 2 to 7 years). Outcome measures: We evaluated the surgical results using a functional outcome scoring system (Odom's Criteria), visual analog scale and a radiographic grading scale. The questionnaire was independently administered in a standard question-answer format at the 1-year follow-up. Statistical analyses was performed using a Levene's test. Methods: All surgeries were performed by the same attending physician. A left-sided approach and Smith-Robinson fusion technique with autograft or allograft without instrumentation was used in all cases. A hard cervical orthosis was used postoperatively for 8 weeks. Radiographic examination including lateral flexion and extension views were obtained at a minimum of 12 months postoperatively. Furthermore, radiographic analysis was performed each subsequent postoperative year. The radiographs were analyzed by two independent physicians in a blind fashion for evidence of radiographic fusion. Results: At follow-up no discernible difference was noted for functional outcomes. Eighty-three percent of patients in Group 1 and 90% of patients in Group 2 noted excellent or good results. This was not statistically significant (p=.280). In Group 1, 97% of patients returned to work at an average of 18 weeks, whereas 98% of patients in Group 2 returned to work at an average of 10 weeks postoperatively. Upon radiographic evaluation, 64% of patients in Group 1 were determined to have a solid fusion (Grade 3). The fusion rate in Group 2 was 72%. This was not statistically significant. However, the fusion rate among smokers was 50%, and among nonsmokers it was 80%. This was statistically significant (p=.001). Conclusions: Workman's compensation claims did not adversely affect the functional outcome of ACDF. It should be noted that a significant increase in pseudarthroses was noted with the smoking population. Patient selection is a critical factor in determining functional outcome, with 83% good to excellent results if the pathology, clinical presentation and radiographic findings correlate

Background context Although plate fixation enhances the fusion rate in multilevel anterior cervical discectomy and fusion (ACDF), debate exists regarding the efficacy of nonplating to rigid plate fixation in one-level ACDF. Purpose To determine the efficacy of nonplating to rigid plate fixation in regards to fusion rate and clinical outcome in patients undergoing one-level ACDF with autograft. Study design A review of 69 consecutive patients who underwent one-level ACDF with autograft and with or without rigid anterior cervical plate fixation. Patient sample Sixty-nine patients who underwent one-level ACDF (mean age, 45 years) were evaluated for radiographic evidence of fusion (mean, 14 months) and for clinical outcome. All patients received tricortical iliac crest autografts. Disc space distraction was 2 mm, the grafts were inserted with the cortical surface positioned anteriorly, and each graft was countersunk 2 mm from the anterior vertebral border. Thirty-eight patients underwent nonplated ACDF and 31 patients underwent plated ACDF. Eighteen Orion (Sofamor-Danek, Memphis, TN), eight Atlantis (Sofamor-Danek) and five PEAK polyaxial (Depuy-Acromed, Rayham, MA) anterior cervical plating systems were used. Rigid plate fixation was used in all patients with instrumentation. Postoperatively, hard collars were worn 6 to 8 weeks in nonplated patients and soft collars were worn for 3 to 4 weeks in plated patients. Twenty-four patients were smokers (54.2% nonplating; 45.8% plating) and work-related injuries entailed 23 patients (47.8% nonplating; 52.2% plating). Outcome measures Fusion was assessed based on last follow-up of lateral neutral, flexion and extension radiographs. Radiographs were evaluated blindly to assess fusion and instrumentation integrity between nonplated and plated patients. Clinical outcomes were assessed with the Cervical Spine Outcomes Questionnaire and also assessed on last follow-up as excellent, good, fair or poor based on Odom's criteria. Methods Fusion rate and postoperative clinical outcome were assessed in 69 patients who underwent one-level ACDF with autograft and with or without rigid anterior plate fixation. Additional risk factors were also analyzed. Statistical significance was established at p Results Sixty-six patients (95.7%) achieved a solid fusion (100% nonplated; 90.3% plated). Nonunions occurred in three patients (1 smoker; 2 nonsmokers) with Orion instrumentation. Slight screw penetration into the involved and uninvolved interbody spaces occurred in one patient who was a nonsmoker and did not achieve fusion. One superficial cervical wound infection was noted in a nonplated patient. No other intraoperative or postoperative complications were noted. No statistically significant difference was noted between nonplating to rigid plating upon fusion rate (p>.05). All nonunions occurred at the C5–C6 level. Mean estimated intraoperative blood loss was significantly greater in plated patients (p=.043). Revision surgery involved 9.7% of the plated patients, whereas none of the nonplated patients required reoperation. Postoperative clinical outcome was assessed in all patients (mean, 21 months). Excellent results were noted in 18.8%, good results in 72.5% and fair results in 8.7% of the patients. Nonunion patients reported satisfactory clinical outcome. No statistical significance was noted between clinical outcome of fused and nonfused patients, the presence of a work-related injury and the use of plating (p>.05). Demographics and history of smoking were not factors influencing fusion or clinical outcome in this series (p>.05). The effect on fusion by various plate types could not be discerned from this study. Conclusion A 100% and 90.3% fusion rate was obtained for one-level nonplated and plated ACDF procedures with autograft, respectively. The effects of smoking or level of fusion could not be discerned from these one-level cases. Excellent and good clinical outcome results were obtained for 91.3%. Nonplating or rigid plate fixation for ACDF in properly selected patients to treat radiculopathy with or without myelopathy has a high fusion rate and yields a satisfactory clinical outcome. Although controversy exists as to the efficacy of rigid plate fixation in one-level ACDF, solid bone fusion can be adequately obtained without plate fixation and instrumentation-related complications can be avoided. In line with the literature, plate fixation should be reserved for patients unwilling or unable to wear a hard orthosis postoperatively for an extended period of time or for those patients who seek a quicker return to normal activities. Proper patient selection, meticulous operative technique and postoperative care is essential to promote optimal graft-host incorporation.

This retrospective study reports on the surgical treatment of chronic lateral epicondylitis. Thirty-four elbows were followed for an average of four years after surgery. Only those patients with persistent or recurrent local pain and muscle weakness, nonresponsive to conservative measures for at least six months, were considered for surgery. A complete release of the common extensor tendon permitted about a 1-cm distal muscle slide to a new resting length. The results indicate 73% excellent, 18% good, and 9% failures. Complete pain relief was obtained in 25 of 34 (73%) elbows, and eight of 33 (24%) had minimal residual symptoms that did not impair activity. There was no loss of range of motion in any patient, and 33 of 34 (97%) elbows had improved extremity muscle strength. All but one patient (97%) returned to their regular jobs on the average of five weeks after surgery. The gross and histologic findings were consistent with a degenerative process. This relatively simple outpatient procedure using Bier block anesthesia is recommended for carefully selected patients.