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Purpose: To describe the incidence of complications associated with cervical spine surgery and post-operative physical therapy (PT), and to identify if the timing of initiation of post-operative PT impacts the incidence rates., Methods: MOrtho PearlDiver database was queried using billing codes to identify patients who had undergone Anterior Cervical Discectomy and Fusion (ACDF), Posterior Cervical Fusion (PCF), or Cervical Foraminotomy and post-operative PT from 2010-2019. For each surgical procedure, patients were divided into three 12-week increments for post-operative PT (starting at post-operative weeks 2, 8, 12) and then matched based upon age, gender, and Charlson Comorbidity Index score. Each group was queried to determine complication rates and chi-square analysis with adjusted odds ratios, 95% confidence intervals, and p-values were used., Results: Following matching, 3,609 patients who underwent cervical spine surgery at one or more levels and had post-operative PT (ACDF:1784, PCF:1593, and cervical foraminotomy:232). The most frequent complications were new onset cervicalgia (2-14 weeks, 8-20 weeks, 12-24 weeks): ACDF (15.0%, 14.0%, 13.0%), PCF (18.8%, 18.0%, 19.9%), cervical foraminotomy (16.8%, 16.4%, 19.4%); revision: ADCF (7.9%, 8.2%, 7.4%), PCF (9.3%, 10.6%, 10.2%), cervical foraminotomy (11.6%, 10.8% and 13.4%); wound infection: ACDF (3.3%, 3.4%, 3.1%), PCF (8.3%, 8.0%,7.7%), cervical foraminotomy (5.2%, 6.5%, < 4.7%). None of the comparisons were statistically significant., Conclusion: The most common post-operative complications included new onset cervicalgia, revision and wound infection. Complications rates were not impacted by the timing of initiation of PT whether at 2, 8, or 12 weeks post-operatively., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The aim of this study was to characterize if the use of surgical drains or length of drain placement following spine surgery increases the risk of post-operative infection., Methods: Records of patients undergoing elective spinal surgery at a tertiary care center were collected between May 5, 2016 and August 16, 2018. Pre-operative baseline characteristics were recorded including patient's demographics and comorbidities. Intraoperative procedure information was documented related to procedure type, blood loss, and antibiotics used. Following surgery, patients were then further subdivided into two groups: patients who were discharged with a spinal surgical site drain and patients who did not receive a drain. Post-operative surgical variables included length of stay (LOS), drain length, number of antibiotics given, and type of post-operative infection. Univariate and multivariate statistical analysis was conducted., Results: A total of 671 patients were included in the current study, 386 (57.5%) with and 285 (42.5%) without the drain. The overall infection rate was 5.7% with 6.22% among patients with the drain compared to 4.91% in patients without drain. The univariate analysis identified the following variables to be significantly associated with the infection: total number of surgical levels, spinal region, blood loss, redosing of antibiotics, length of stay, length of drain placement, and number of antibiotics (P < 0.05). However, the multivariate analysis none of the predictors was significant., Conclusions: The current study shows that the placement of drain does not increase rate of infection, irrespective of levels, length of surgery, or approach., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To elucidate the effects of bisphosphonates on complications following posterior lumbar fusion (PLF) with a large database study., Methods: The PearlDiver Patient Record Database was queried to identify adult patients who had undergone posterior lumbar fusion (PLF). Those patient cohorts were divided based on a diagnosis of osteoporosis prior to surgery and bisphosphonate usage. This yielded three groups: Osteo+Bisph+, Osteo+Bisph-, and Osteo-Bisph-. The primary outcome of the present study was revision rates at 6 months and 1 year following surgery. Incidence of postoperative complications was analyzed, and statistical analysis was conducted using Pearson chi-square analysis., Results: Patients taking bisphosphonates did not have significantly different rates of revision surgery at 6 months and 1 year, instrumentation complications, or post-vertebral fractures than patients not taking bisphosphonates. Additionally, osteoporotic patients did not have significantly different rates of these complications than patients without osteoporosis., Conclusion: Bisphosphonate usage did not significantly affect the rates of postoperative complications following posterior lumbar fusion. Further research is required to fully elucidate the effects of bisphosphonates on outcomes and complications following spine surgery.

Purpose: To evaluate the effect of cervical sagittal alignment on craniocervical junction kinematic., Methods: We retrospectively reviewed 359 patients (119 cervical lordosis, 38 cervical sagittal imbalances, 111 cervical straight, and 91 cervical kyphosis) who underwent cervical spine multi-positional magnetic resonance imaging (mMRI). The C2-7 angle, disc degeneration grading and cSVA were analyzed in neutral position. The C3-5 OCI, O-C2 angle, and OCD were analyzed in neutral, flexion, and extension position. The Kruskal-Wallis test was used to detect difference among four groups. The post hoc analysis was performed by Mann-Whitney U test., Results: The cervical sagittal imbalance, cervical straight, and cervical kyphosis groups had significantly more lordosis angle in C3 and C4 OCI and O-C2 angle than the cervical lordosis group (p < 0.0125). Head motion in relation to C2, C3, and C4 (O-C2 angle, C3-4 OCI) in the kyphosis group was significantly greater than in the cervical lordosis group (p < 0.0125). The cervical sagittal imbalance group showed significantly increased O-C2 angle than the cervical lordosis group (p = 0.008). Regression analysis showed that an increase in O-C2 angle by one unit had a relative risk of 4.3% and 3.5% for a patient to be in the cervical sagittal imbalance and cervical kyphosis groups, respectively., Conclusions: Cervical sagittal alignment affected craniocervical junction motion with the head exhibiting greater extension and motion in the cervical sagittal imbalance and cervical kyphosis groups. Motion of the head in relation to C2 can be used to predict the cervical sagittal alignment.

Purpose: To evaluate which cervical level is the most appropriate level to measure occipitocervical inclination (OCI)., Methods: Sixty-two patients with multi-positional MRI: 24 males and 38 females, who had cervical lordosis and had a disk degeneration grade of 3 or less were included. We measured patient's OCI at C3, C4, and C5, occipitocervical angle (OCA), occipitocervical distance (OCD), C2-7 angle, and cervical sagittal vertical axis (cSVA) in neutral, flexion, and extension position. The correlation between OCI and OCA, OCD, C2-7 angle, and cSVA on each cervical level in all three positions was tested using Pearson's correlation coefficient test. The difference between OCIs at each cervical level was tested by Wilcoxon signed-rank test. p value of less than 0.05 was set as a statistically significant level., Results: C5 OCI showed statistically significant correlation with OCA, OCD, C2-7 angle, and cSVA in all three positions (p < 0.05, r = 0.214-0.525). C3 OCI in flexion (p = 0.393, r = 0.081) and C4 OCI in neutral and flexion (neutral p = 0.275, r 0.104; flexion p = 0.987, r = 0.002) did not show significant correlation with C2-7 angle. There was a statistically significant difference between C3, C4, and C5 OCIs in neutral and extension position (p < 0.05). At the same time, OCI showed statistically strong correlation between adjacent cervical levels (p < 0.001, r = 0.627-0.822)., Conclusion: C5 cervical level is the most appropriate level for OCI measurement. OCI should be measured at the same cervical level at all time. C4 OCI can reliably substitute C5 OCI in case C5 which is invisible on radiographic image. These slides can be retrieved under Electronic Supplementary Material.

Purpose: As the population continues to age, the number of lumbar spine surgeries continues to increase. While there are many complications associated with lumbar surgeries, a myocardial infarction (MI) is a particularly devastating one. This complication is of considerable importance with mortality rates of postoperative MI documented between 26.5 and 70%. This study aimed to determine the relationship between lumbar surgeries, preoperative diagnoses (risk factors), and myocardial infarction., Methods: Data from the Humana database (PearlDiver) were analyzed from 2007 to 2016. Patients undergoing lumbar spine surgeries were identified and stratified based on procedural approach, patient demographics, and preoperative risk factors. Each group was analyzed to determine the incidence and relative risk. Chi-square analysis was used to determine the significance., Results: A total of 105,505 patients who fit inclusion criteria were identified in the PearlDiver database between 2007 and 2016. A total of 644 patients (0.63%) experienced a postoperative myocardial infarction within 30 days of surgery. Patients undergoing fusion and non-fusion procedures showed significantly different rates of postoperative myocardial infarction (0.08% vs. 0.05%, p < 0.01). Male patients, older patients, and patients with a Charlson comorbidity index > 3 showed a considerable increase in incidence (p < 0.01). Furthermore, patients with preoperative risk factors (high cholesterol, obesity, depression, congestive heart failure, hypertension, and hypotension) exhibited risk ratios from 0.01 to 1.85 (p < 0.01)., Conclusion: Preoperative risk factors, patient demographics, and procedure type had a significant effect on the incidence of postoperative myocardial infarction. These slides can be retrieved under Electronic Supplementary Material.