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Study Design: Retrospective comparative study. Objectives: To compare the perioperative complications of propensity score-matched cohorts of patients with degenerative cervical myelopathy (DCM), who were treated with anterior cervical discectomy and fusion (ACDF), posterior laminectomy with fusion, or laminoplasty. Methods: The Humana PearlDiver Patient Record Database was queried using the International Classification of Diseases (ICD-9 and ICD-10) and the Current Procedural Terminology (CPT) codes. Propensity score-matched analysis was done using multiple Chi-squared tests with Bonferroni correction of the significance level. Results: Cohorts of 11,790 patients who had ACDF, 2,257 patients who had posterior laminectomy with fusion, and 477 patients who had laminoplasty, were identified. After propensity score matching, all the 3 groups included 464 patients. The incidence of dysphagia increased significantly following ACDF compared to laminoplasty, P < 0.001, and in laminectomy with fusion compared to laminoplasty, P < 0.001. The incidence of new-onset cervicalgia was higher in ACDF compared to laminoplasty, P = 0.005, and in laminectomy with fusion compared to laminoplasty, P = 0.004. The incidence of limb paralysis increased significantly in laminectomy with fusion compared to ACDF, P = 0.002. The revision rate at 1 year increased significantly in laminectomy with fusion compared to laminoplasty, P < 0.001, and in ACDF compared to laminoplasty, P < 0.001. Conclusions: The incidence of dysphagia following laminectomy with fusion was not different compared to ACDF. Postoperative new-onset cervicalgia and revisions were least common in laminoplasty. The highest rate of postoperative limb paralysis was noticed in laminectomy with fusion.

Study Design: Retrospective database study. Objective: Tobacco use is associated with complications after surgical procedures, including poor wound healing, surgical site infections, and cardiovascular events. We used the Nationwide Readmissions Database (NRD) to determine if tobacco use is associated with increased 30- and 90-day readmission among patients undergoing surgery for degenerative spine disorders. Methods: Patients who underwent elective spine surgery were identified in the NRD from 2010 to 2014. The study population included patients with degenerative spine disorders treated with discectomy, fusion, or decompression. Descriptive and multivariate logistic regression analyses were performed to identify patient and hospital factors associated with 30- and 90-day readmission, with significance set at P value Results: Within 30 days, 4.8% of patients were readmitted at a median time of 9 days. The most common reasons for 30-day readmission were postoperative infection (12.5%), septicemia (3.5%), and postoperative pain (3.0%). Within 90 days, 7.3% were readmitted at a median time of 18 days. The most common reasons for 90-day readmission were postoperative infection (9.6%), septicemia (3.5%), and pneumonia (2.3%). After adjustment for patient and hospital characteristics, tobacco use was independently associated with readmission at 90 days (odds ratio 1.05, 95% confidence interval 1.03-1.07, P < .0001) but not 30 days (odds ratio 1.02, 95% confidence interval 1.00-1.05, P = .045). Conclusions: Tobacco use is associated with readmission within 90 days after cervical and thoracolumbar spine surgery for degenerative disease. Tobacco use is a known risk factor for adverse health events and therefore should be considered when selecting patients for spine surgery.

Study Design: Review. Objective: A comparative overview of cost-effectiveness between minimally invasive versus and equivalent open spinal surgeries. Methods: A literature search using PubMed was performed to identify articles of interest. To maximize the capture of studies in our initial search, we combined variants of the terms “cost,” “minimally invasive,” “spine,” “spinal fusion,” “decompression” as either keywords or MeSH terms. PearlDiver database was queried for open and minimally invasive surgery (MIS; endoscopic or percutaneous) reimbursements between Q3 2015 and Q2 2018. Results: In general, MIS techniques appeared to decrease blood loss, shorten hospital lengths of stay, mitigate complications, decrease perioperative pain, and enable quicker return to daily activities when compared to equivalent open surgical techniques. With regard to cost, primarily as a result of these latter benefits, MIS was associated with lower costs of care when compared to equivalent open techniques. However, cost reporting was sparse, and relevant methodology was inconsistent throughout the spine literature. Within the PearlDiver data sets, MIS approaches had lower reimbursements than open approaches for both lumbar posterior fusion and discectomy. Conclusions: Current data suggests that overall cost-savings may be incurred with use of MIS techniques. However, data reporting on costs lacks in uniformity, making it difficult to formulate any firm conclusions regarding any incremental improvements in cost-effectiveness that may be incurred when utilizing MIS techniques when compared to equivalent open techniques.

BACKGROUND CONTEXT The concept of frailty has become increasingly recognized, and while patients with cancer are at increased risk for frailty, its influence on perioperative outcomes in metastatic spine tumors is uncertain. Furthermore, the impact of frailty can be confounded by comorbidities or metastatic disease burden. PURPOSE The purpose of this study was to evaluate the influence of frailty and comorbidities on adverse outcomes in the surgical management of metastatic spine disease. STUDY DESIGN/SETTING Retrospective Cohort Study. PATIENT SAMPLE A total of 7,772 patients underwent spinal fusion with spinal metastasis within the Nationwide Readmissions Database (NRD). OUTCOME MEASURES Mortality, medical complications, surgical complications, increased length of stay (LOS), nonroutine discharge and increased costs. METHODS A validated binary frailty index (Johns Hopkins Adjusted Clinical Groups) was used to identify frail and non-frail groups, and propensity score-matched analysis (including demographics, comorbidities, surgical and tumor characteristics) was performed. Sub- group analysis of levels involved was performed for cervical, thoracic, lumbar and junctional spine. Outcomes analyzed included mortality, complications, length of stay (LOS), nonroutine discharges and costs. Multivariable-regression techniques were used to develop predictive models for outcomes using frailty and the Elixhauser Comorbidity Index (ECI). RESULTS A total of 7,772 patients underwent spinal fusion with spinal metastasis, of which 1,974 (25.4%) patients were identified as frail. Following propensity score matching for frail (n= 1,974) and not-frail (n=1,975) groups, frailty demonstrated significantly greater medical complications (OR=1.58; 95% CI 1.33-1.86), surgical complications (OR=1.46; 95% CI 1.15-1.85), LOS (OR=2.65; 95% CI 2.09-3.37), nonroutine discharges (OR=1.79; 95% CI 1.46-2.20) and costs (OR=1.68; 95% CI 1.32-2.14). Differences in mortality were only observed in subgroup analysis and were greater in frail junctional and lumbar spine subgroups. Models using ECI alone (AUC= 0.636-0.788) demonstrated greater predictive ability compared to those using frailty alone (AUC=0.633-0.752). However, frailty combined with ECI improved the prediction of increased LOS (AUC=0.811), cost (AUC=0.768), medical complications (AUC=0.723) and nonroutine discharges (AUC=0.718). Predictive modeling of frailty in subgroups demonstrated the greatest performance for mortality (AUC=0.750) in the lumbar spine, otherwise performed similarly for LOS, costs, complications, and discharge across subgroups. CONCLUSIONS A high prevalence of frailty existed in the current patient cohort. Frailty contributed to worse short-term adverse outcomes and could be more influential in the lumbar and junctional spine due to higher risk of deconditioning in the postoperative period. Predictions for short-term outcomes can be improved by adding frailty to comorbidity indices, suggesting a more comprehensive preoperative risk stratification should include frailty. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Venous thromboembolism (VTE) is an appreciable burden on health care. The protracted recumbency experienced by many spinal patients juxtaposed with concerns for postoperative hemorrhage from early anticoagulation results in conflicting stances regarding chemoprophylaxis. Identifying risk factors associated with VTE is therefore instrumental in guiding management.To identify VTE risk factors in patients undergoing degenerative spine surgery.The Nationwide Readmissions Database was searched for adults undergoing spine surgery for degenerative diseases between 2010 and 2014. The 30-day and 90-day VTE incidence was estimated from readmissions with new VTE diagnoses. A multivariate survey-adjusted logistic regression model was used to identify variables associated with VTE diagnoses on readmission.Of 838,507 degenerative spine cases queried, 3499 patients (0.42%) were readmitted with a VTE diagnosis within 30 days and 4321 patients (0.62%) were readmitted within 90 days. In multivariate analysis, steroids were independently associated with a higher likelihood of readmission with VTE at both 30 days (odds ratio, 1.58; P0.001) and 90 days (odds ratio, 1.97; P0.001). Significant associations were also identified with thoracolumbar surgery, length of stay, and discharge to institutional care.The incidence of readmission with VTE diagnoses in spine surgery is low. However, their devastating consequences underscore the need to identify those patients deemed high risk. These patients include those having thoracolumbar surgery, of advanced age, with prolonged length of stay, using corticosteroids, and with a disposition to institutional care (e.g., skilled nursing facility or long-term acute care). Given the association between steroids and VTE, clinicians should be judicious about perioperative administration despite their obvious antiinflammatory benefits.

Background Modifiable risk factors (MRFs) represent patient variables associated with increased complication rates that may be prevented. There exists a paucity of studies that comprehensively analyze MRF subgroups and their independent association with postoperative complications in patients undergoing cervical spine surgery. Therefore, the purpose of this study is to compare outcomes between patients receiving cervical spine surgery with reported MRFs. Methods Retrospective analysis of the Nationwide Readmissions Database (NRD) from the years 2016 and 2017, a publicly available and purchasable data source, to include adult patients undergoing cervical fusion. MRF cohorts were separated into three categories: substance abuse (alcohol, tobacco/nicotine, opioid abuse); vascular disease (hypertension, dyslipidemia); and dietary factors (malnutrition, obesity). Three-way nearest-neighbor propensity score matching for demographics, hospital, and surgical characteristics was implemented. Findings We identified 9601 with dietary MRFs (D-MRF), 9654 with substance abuse MRFs (SA-MRF), and 9503 with vascular MRFs (V-MRF). Those with d-MRFs had significantly higher rates of medical complications (9.3%), surgical complications (8.1%), and higher adjusted hospital costs compared to patients with SA-MRFs and V-MRFs. Patients with d-MRFs (16.3%) and V-MRFs (14.0%) were independently non-routinely discharged at a significantly higher rate compared to patients with SA-MRFs (12.6%) (p

Idiopathic spinal cord herniation is a rare cause of progressive myelopathy that can result in severe disability. In the following report, an illustrative case and associated video in the surgical management of ventral thoracic spinal cord herniation is presented and discussed. Spinal cord herniation is most commonly observed in the thoracic spine and is characterized by ventral displacement of the spinal cord through a defect in the dura. Over time ventral herniation of the spinal cord can compromise its vascular perfusion, resulting in further ischemic injury. The etiology is unclear, but suspected to be either acquired or congenital. Multiple surgical techniques have been reported with the goal of detethering the cord and taking adjunctive measures in reducing the risk for re-herniation. Surgical management of thoracic spinal cord herniation carries great risks, although neurological outcomes are generally favorable with improvements reported in the majority of cases.

STUDY DESIGN This was a retrospective database study. OBJECTIVE The objective of this study was to investigate preoperative risk factors and incidence of venous thromboembolic events (VTEs) after cervical spine surgery. SUMMARY OF BACKGROUND DATA VTEs are preventable complications that may occur after spinal procedures. Globally, VTEs account for a major cause of morbidity and mortality. Preoperative risks factors associated with increased VTE incidence after cervical spine surgery have not been well-characterized. MATERIALS AND METHODS Patients undergoing anterior cervical discectomy and fusion (ACDF); posterior cervical fusion (PCF); discectomy; and decompression from 2007 to 2017 were identified using the PearlDiver Database. International Classification of Diseases (ICD) Ninth and 10th Revision codes were used to identify VTEs at 1 week, 1 month, and 3 months postoperative as well as preoperative risk factors. RESULTS Risk factors with the highest incidence of VTE at 3 months were primary coagulation disorder [ACDF=7.82%, odds ratio (OR)=3.96; decompression=11.24%, OR=3.03], central venous line (ACDF=5.68%, OR=2.11; PCF=12.58%, OR=2.27; decompression=10.17%, OR=2.80) and extremity paralysis (ACDF=6.59%, OR=2.73; PCF=18.80%, OR=2.99; decompression=11.86, OR=3.74). VTE incidence at 3 months for populations with these risks was significant for all surgery types (P

Introduction Our goal was to systematically review the current literature on racial/ethnic, insurance, and socioeconomic disparities in adult spine surgery in the United States and analyze potential areas for improvement. Methods We conducted a database search of literature published between January 1990 and July 2020 using PRISMA guidelines for all studies investigating a disparity in any aspect of adult spine surgery care was analyzed based on race/ethnicity, insurance status/payer, or socioeconomic status (SES). Results Out of 2,679 articles identified through database searching, 775 were identified for full-text independent review by 3 authors, from which a final list of 60 included studies were analyzedForty-three studies analyzed disparities based on patient race/ethnicity, 32 based on insurance status, and 8 based on SES. Five studies assessed disparities in access to care, 15 examined surgical treatment, 35 investigated in-hospital outcomes, and 25 explored after-discharge outcomes. Minority patients were less likely to undergo surgery, but more likely to receive surgery from a low-volume provider and experience postoperative complications. White and privately insured patients generally had shorter hospital length of stay, were more likely to undergo favorable/routine discharge, and had lower rates of in-hospital mortality. Post-discharge, white patients reported better outcomes than black patients. Thirty-three papers (55%) reported no disparities within at least one examined metric. Conclusion This comprehensive systematic review underscores ongoing potential for healthcare disparities among adult patients in the field of spinal surgery. We demonstrate a need for continued efforts to promote equity and cultural competency within the field of neurological surgery.

Study Design: Case-control study. Objectives: Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord injury in adults aged over 55 years. However, since the onset is typically insidious, accurately diagnosing CSM can be challenging, often requiring referral to a subspecialist and advanced imaging. To help identify patients at risk for CSM, this case-control study compared responses to a series of 4 questions (DOWN questionnaire) in myelopathic and non-myelopathic patients. Methods: Ninety-two patients, 46 with and 46 without myelopathy, were recruited for the study. Each patient answered 4 questions encompassing common symptoms associated with CSM. Responses between patient groups were compared, and Cohen’s κ was used to assess for agreement between responses and the diagnosis of myelopathy. Results: We found a sensitivity of 91% and a κ of 0.54 to 3 positive responses and a sensitivity of 72% and a κ of 0.61 to 4 positive responses. Conclusions: Positive responses to 3 or more DOWN questions has high sensitivity and moderate agreement with the diagnosis of myelopathy based on history, physical exam, and review of advanced imaging by an orthopedic or neurological surgeon. The DOWN questionnaire is a potentially useful screening tool to identify patients at risk for CSM.

OBJECTIVEFreehand placement of C2 instrumentation is technically challenging and has a learning curve due the unique anatomy of the region. This study evaluated the accuracy of C2 pedicle screws placed via the freehand technique by neurosurgical resident trainees.METHODSThe authors retrospectively reviewed all patients treated at the LAC+USC Medical Center undergoing C2 pedicle screw placement in which the freehand technique was used over a 1-year period, from June 2016 to June 2017; all procedures were performed by neurosurgical residents. Measurements of C2 were obtained from preoperative CT scans, and breach rates were determined from coronal reconstructions on postoperative scans. Severity of breaches reflected the percentage of screw diameter beyond the cortical edge (I = < 25%; II = 26%–50%; III = 51%–75%; IV = 76%–100%).RESULTSNeurosurgical residents placed 40 C2 pedicle screws in 24 consecutively treated patients. All screws were placed by or under the guidance of Pham, who is a postgraduate year 7 (PGY-7) neurosurgical resident with attending staff privileges, with a PGY-2 to PGY-4 resident assistant. The authors found an average axial pedicle diameter of 5.8 mm, axial angle of 43.1°, sagittal angle of 23.0°, spinal canal diameter of 25.1 mm, and axial transverse foramen diameter of 5.9 mm. There were 17 screws placed by PGY-2 residents, 7 screws placed by PGY-4 residents, and 16 screws placed by the PGY-7 resident. The average screw length was 26.0 mm, with a screw diameter of 3.5 mm or 4.0 mm. There were 7 total breaches (17.5%), of which 4 were superior (10.0%) and 3 were lateral (7.5%). There were no medial breaches. The breaches were classified as grade I in 3 cases (42.9%), II in 3 cases (42.9%), III in 1 case (14.3%), and IV in no cases. There were 3 breaches that occurred via placement by a PGY-2 resident, 3 breaches by a PGY-4 resident, and 1 breach by the PGY-7 resident. There were no clinical sequelae due to these breaches.CONCLUSIONSFreehand placement of C2 pedicle screws can be done safely by neurosurgical residents in early training. When breaches occurred, they tended to be superior in location and related to screw length choice, and no breaches were found to be clinically significant. Controlled exposure to this unique anatomy is especially pertinent in the era of work-hour restrictions.

Study Design: Retrospective, database study. Objectives: The aim of this study was to investigate incidence and risk factors associated with venous thromboembolic events (VTEs) after lumbar spine surgery. Methods: Patients who underwent lumbar surgery between 2007 and 2014 were identified using the Humana within PearlDiver database. ICD-9 (International Classification of Diseases Ninth Revision) diagnosis codes were used to search for the incidence of VTEs among surgery types, patient demographics and comorbidities. Complications including DVT and PE were queried each day from the day of surgery to postoperative day 7 and for periods 0 to 1 week, 0 to 1 month, 0 to 2 months, and 0 to 3 months postoperatively. Results: A total of 64 892 patients within the Humana insurance database received lumbar surgery between 2007 and 2014. Overall VTE rate was 0.9% at 1 week, 1.8% at 1 month, and 2.6% at 3 months postoperatively. Among patients that developed a VTE within 1 week postoperatively, 45.3% had a VTE on the day of surgery. Patients with 1 or more identified risk factors had a VTE incidence of 2.73%, compared with 0.95% for patients without risk factors ( P < .001). Risk factors associated with the highest VTE incidence and odds ratios (ORs) were primary coagulation disorder (10.01%, OR 4.33), extremity paralysis (7.49%, OR 2.96), central venous line (6.70%, OR 2.87), and varicose veins (6.51%, OR 2.58). Conclusions: This study identified several patient comorbidities that were independent predictors of postoperative VTE occurrence after lumbar surgery. Clinical VTE risk assessment may improve with increased focus toward patient comorbidities rather than surgery type or patient demographics.

Study design Retrospective review. Objective To review the feasibility of a posterior-only approach for instrumented reconstruction in lumbar burst fractures. Background Burst fractures of the lumbar spine have been treated through a variety of techniques, including anterior, posterior, or combined approaches. Here we review series of patients undergoing posterior-only transpedicular corpectomy with instrumented fusion for traumatic lumbar burst fracture. Methods All patients treated at the Los Angeles County+University of Southern California (LAC+USC) Medical Center who had sustained traumatic lumbar burst fractures from February 2005 to February 2014 were reviewed. Results A total of 178 traumatic lumbar burst fractures were identified of which 89 required operative intervention. Of those 89 operations, 7 patients underwent posterior-only approach for transpedicular corpectomy. Levels operated on were at L1 (4 patients), L2 (1 patient), and L4 (2 patients). The mean age was 35 years of age (range, 21-56 y), and mechanism of injury was either motor vehicle accident (5 patients) or fall (2 patients). Initial neurological examination was American Spinal Injury Association (ASIA) B in 3 patients, ASIA D in 3 patients, and 1 patient was neurologically intact. Mean thoracolumbar injury classification and severity score on presentation was 6.4 (range, 5-8), whereas the mean load sharing classification score was 7.4 (range, 7-9). Of patients who were not immediately lost to follow-up on hospital discharge, mean clinical follow-up was 45.3 months (range, 18.8-68.6 mo), whereas mean radiographic follow-up was 28.8 months (range, 1.3-63.6 mo). At the last known radiographic follow-up, no patient had gross hardware fracture, pseudoarthrosis, or adjacent segment disease. One patient with the longest radiographic follow-up of 63.6 months was noted to have some minimal subsidence of his cage with no other change in his other hardware. Conclusion A posterior-only approach for transpedicular corpectomy and instrumented fusion is a viable treatment option for lumbar burst fracture which allows for reconstruction of the anterior column while avoiding many of the risks and complications associated with an anterior or combined approach.

Study Design: Retrospective cohort study. Objectives: Lateral interbody fixation is being increasingly used for the correction of segmental sagittal parameters. One factor that affects postoperative correction is the resistance afforded by posterior hypertrophic facet joints in the degenerative lumbar spine. In this article, we describe a novel preoperative motion segment classification system to predict postoperative correction of segmental sagittal alignment after lateral lumbar interbody fusion. Methods: Preoperative computed tomography scans were analyzed for segmental facet osseous anatomy for all patients undergoing lateral lumbar interbody fusion at 3 institutions. Each facet was assigned a facet grade (min = 0, max = 2), and the sum of the bilateral facet grades was the final motion segment grade (MSG; min = 0, max = 4). Preoperative and postoperative segmental lordosis was measured on standing lateral radiographs. Postoperative segmental lordosis was also conveyed as a percentage of the implanted graft lordosis (%GL). Simple linear regression was conducted to predict the postoperative segmental %GL according to MSG. Results: A total of 36 patients with 59 operated levels were identified. There were 19 levels with MSG 0, 14 levels with MSG 1, 13 levels with MSG 2, 8 levels with MSG 3, and 5 levels with MSG 4. Mean %GL was 115%, 90%, 77%, 43%, and 5% for MSG 0 to 4, respectively. MSG significantly predicted postoperative %GL (P < .01). Each increase in MSG was associated with a 28% decrease in %GL. Conclusions: We propose a novel facet-based motion segment classification system that significantly predicted postoperative segmental lordosis after lateral lumbar interbody fusion.

Study DesignRetrospective analysis of a nationwide private insurance database. Chi-square analysis and linear regression models were utilized for outcome measures.PurposeThe purpose of this study was to investigate any relationship between lumbar degenerative disc disease, diabetes, obesity and smoking tobacco.Overview of LiteratureDiabetes, obesity, and smoking tobacco are comorbid conditions known to individually have effect on degenerative disc disease. Most studies have only been on a small populous scale. No study has yet to investigate the combination of these conditions within a large patient cohort nor have they reviewed the combination of these conditions on degenerative disc disease.MethodsA retrospective analysis of insurance billing codes within the nationwide Humana insurance database was performed, using PearlDiver software (PearlDiver, Inc., Fort Wayne, IN, USA), to identify trends among patients diagnosed with lumbar disc degenerative disease with and without the associated comorbidities of obesity, diabetes, and/or smoking tobacco. Patients billed for a comorbidity diagnosis on the same patient record as the lumbar disc degenerative disease diagnosis were compared over time to patients billed for lumbar disc degenerative disease without a comorbidity. There were no sources of funding for this manuscript and no conflicts of interest.ResultsThe total number and prevalence of patients (per 10,000) within the database diagnosed with lumbar disc degenerative disease increased by 241.4% and 130.3%, respectively. The subsets of patients within this population who were concurrently diagnosed with either obesity, diabetes, tobacco use, or a combination thereof, was significantly higher than patients diagnosed with lumbar disc degenerative disease alone (p p p ConclusionsDiabetes, obesity and cigarette smoking each are significantly associated with an increased diagnosis of lumbar degenerative disc disease. The combination of smoking and obesity had a synergistic effect on increased rates of lumbar degenerative disc disease. Patient education and preventative care is a vital goal in prevention of degenerative disc disease within the general population.

This study defined the incidence and trends of surgeries performed for patients with cervical disc degeneration with and without tobacco use disorder (TUD). This study utilized the Humana Inc. database between 2007 and 2013 to identify patients with cervical disc degeneration with or without myelopathy. International Classification of Diseases, ninth revision (ICD-9) and Current Procedural Terminology (CPT) codes determined the initial diagnosis of disc degeneration, myelopathy status and TUD, whether patients received surgery, and TUD status at surgery. The prevalence of disc degeneration with myelopathy increased by 32.8% between 2007 and 2013, while disc disease with myelopathy and TUD increased by 91.6%. For patients without myelopathy, the prevalence of disc degeneration alone increased by 65.4%, and disc degeneration with myelopathy increased by 148.7%. Of myelopathy patients, 1717 (6.4%) had TUD and 1024 (59.6%) received surgery, compared to 6508 patients without TUD (26.1%). For patients without myelopathy, 11,337 (3.5%) had TUD and 787 (6.9%) underwent surgery, compared to 9716 patients (3%) without TUD. Of surgical patients, 781 (76.3%) with myelopathy and TUD still had a TUD diagnosis at surgery, and 542 (68.9%) of patients without myelopathy still had a TUD diagnosis at surgery. The prevalence of degenerative disc disease and TUD has increased more than disc disease alone. Patients with TUD were more likely to get surgery, and to have surgeries earlier than patients without TUD. Patients with TUD at the time of the diagnosis of their disc degeneration likely still had a TUD diagnosis at the time of surgery.

Study Design: Review. Objectives: Cervical spondylotic myelopathy (CSM) is a major cause of disability, particular in elderly patients. Awareness and understanding of CSM is imperative to facilitate early diagnosis and management. This review article addresses CSM with regard to its epidemiology, anatomical considerations, pathophysiology, clinical manifestations, imaging characteristics, treatment approaches and outcomes, and the cost-effectiveness of surgical options. Methods: The authors performed an extensive review of the peer-reviewed literature addressing the aforementioned objectives. Results: The clinical presentation and natural history of CSM is variable, alternating between quiescent and insidious to stepwise decline or rapid neurological deterioration. For mild CSM, conservative options could be employed with careful observation. However, surgical intervention has shown to be superior for moderate to severe CSM. The success of operative or conservative management of CSM is multifactorial and high-quality studies are lacking. The optimal surgical approach is still under debate, and can vary depending on the number of levels involved, location of the pathology and baseline cervical sagittal alignment. Conclusions: Early recognition and treatment of CSM, before the onset of spinal cord damage, is essential for optimal outcomes. The goal of surgery is to decompress the cord with expansion of the spinal canal, while restoring cervical lordosis, and stabilizing when the risk of cervical kyphosis is high. Further high-quality randomized clinical studies with long-term follow up are still needed to further define the natural history and help predict the ideal surgical strategy.

BACKGROUND In an attempt to improve patient care, a perioperative complex spine surgery management protocol was developed through collaboration between spine surgeons and neuroanesthesiologists. The aim of this study was to investigate whether implementation of the protocol in 2015 decreased total hospital and intensive care unit (ICU) length of stay (LOS) and complication rates after elective complex spine surgery. MATERIALS AND METHODS A retrospective cohort study was conducted by review of the medical charts of patients who underwent elective complex spine surgery at an academic medical center between 2012 and 2017. Patients were divided into 2 groups based on the date of their spine surgery in relation to implementation of the spine surgery protocol; before-protocol (January 2012 to March 2015) and protocol (April 2015 to March 2017) groups. Outcomes in the 2 groups were compared, focusing on hospital and ICU LOS, and complication rates. RESULTS A total of 201 patients were included in the study; 107 and 94 in the before-protocol and protocol groups, respectively. Mean (SD) hospital LOS was 14.8±10.8 days in the before-protocol group compared with 10±10.7 days in the protocol group (P

In conjunction with neurofibromas, schwannomas are the second most commonly occurring intradural extramedullary tumor. They are a benign encapsulated nerve sheath tumor that are typically slow growing. They occur equally as frequently in the cervical and lumbar spine. If symptomatic, surgical resection may be warranted. In this surgical technique video, we present a case of a 70-year-old woman who presented with worsening symptoms consistent with cauda equina syndrome secondary to intradural masses at the L1-2 level. A minimally invasive resection of the intradural lesions was performed without any complication. Final pathology of the resected masses revealed schwannoma.

OBJECTIVE The objective of this study was to determine factors associated with admission to the hospital through the emergency room (ER) for patients with a primary diagnosis of low-back pain (LBP). The authors further evaluated the impact of ER admission and patient characteristics on mortality, discharge disposition, and hospital length of stay. METHODS The authors conducted a retrospective analysis of patients with LBP discharged from hospitals according to the Nationwide Inpatient Sample (NIS) between 1998 and 2007. Univariate comparisons of patient characteristics according to the type of admission (ER versus non-ER) were conducted. Multivariate analysis evaluated factors associated with an ER admission, risk of mortality, and nonroutine discharge. RESULTS According to the NIS, approximately 183,151 patients with a primary diagnosis of LBP were discharged from US hospitals between 1998 and 2007. During this period, an average of 65% of these patients were admitted through the ER, with a significant increase from 1998 (54%) to 2005 (71%). Multivariate analysis revealed that uninsured patients (OR 2.1, 95% CI 1.7–2.6, p < 0.0001) and African American patients (OR 1.5, 95% CI 1.2–1.7, p < 0.0001) were significantly more likely to be admitted through the ER than private insurance patients or Caucasian patients, respectively. Additionally, a moderate but statistically significant increase in the likelihood of ER admission was noted for patients with more preexisting comorbidities (OR 1.1, 95% CI 1.0–1.2, p < 0.001). An 11% incremental increase in the odds of admission through the ER was observed with each year increment (OR 1.1, 95% CI 1.0–1.2, p < 0.001). Highest income patients ($45,000+) were more likely to be admitted through the ER (OR 1.3, 95% CI 1.1–1.6, p = 0.007) than the lowest income cohort. While ER admission did not impact the risk of mortality (OR 0.95, 95% CI 0.60–1.51, p = 0.84), it increased the odds of a nonroutine discharge (OR 1.39, 95% CI 1.26–1.53, p < 0.0001). CONCLUSIONS A significant majority of patients discharged from hospitals in the US from 1998 to 2007 with a primary diagnosis of LBP were admitted through the ER, with more patients being admitted via this route each year. These patients were less likely to be discharged directly home compared with patients with LBP who were not admitted through the ER. Uninsured and African American patients with LBP were more likely to be admitted through the ER than their counterparts, as were patients with more preexisting health problems. Interestingly, patients with LBP at the highest income levels were more likely to be admitted through hospital ERs. The findings suggest that socioeconomic factors may play a role in the utilization of ER resources by patients with LBP, which in turn appears to impact at least the short-term outcome of these patients.

OBJECT The objective of this study was to compare the incidence of degeneration and need for subsequent fusion surgery between patients who were treated nonsurgically and patients treated with fusion after a diagnosis of thoracic-or lumbar-level fracture without degenerative disease. METHODS The authors performed a retrospective study of Orthopedic United Healthcare patients diagnosed with thoracic or lumbar fracture. Patients were filtered into thoracic and lumbar fracture groups using diagnostic codes and then assigned to one of 2 treatment subgroups (fusion surgery or no surgery) on the basis of procedural codes. Disc degeneration and follow-up surgery were recorded. Chi-square statistical analysis was used. RESULTS Of 3699 patients diagnosed with a thoracic fracture, 117 (3.2%) underwent thoracic fusion and 3215 (86.9%) were treated nonsurgically. Within 3 years, 147 (4.6%) patients from the nonsurgical subgroup and fewer than 11 (0.9%–8.5%) from the fusion subgroup were diagnosed with thoracic disc degeneration. From the nonsurgical subgroup, 11 (0.3%) patients underwent a thoracic surgery related to disc degeneration compared with zero from the fusion group (p > 0.05). Of 5016 patients diagnosed with lumbar fracture, 150 (3.0%) underwent fusion and 4371 (87.1%) had no surgery. Within 3 years, 503 patients (11.5%) from the nonsurgical subgroup and 35 (23.3%) from the fusion subgroup were diagnosed with lumbar disc degeneration (p < 0.05). From the nonsurgical subgroup, 42 (1.0%) went on to have surgery related to disc degeneration, compared with fewer than 11 (0.7%–6.7%) from the fusion subgroup (values not precise due to privacy limitations). CONCLUSIONS Fusion surgery for thoracic fracture does not appear to increase the likelihood of undergoing future surgery. In the lumbar region, initial fusion surgery appears to increase the incidence of disc degeneration and could potentially necessitate future surgeries.

Background and importance In an era of curtailed work hours and concerns over achieving technical proficiency in the repertoire of procedures necessary for independent practice, many residencies have turned to model simulation as an educational adjunct. Cerebrospinal fluid (CSF) leak repair after inadvertent durotomy in spine surgery is a fundamental skillset for any spine surgeon. While primary closure with suture is not always necessary for small durotomies, larger defects, on the other hand, must be repaired. However, the dire consequences of inadequate repair dictate that it is generally performed by the most experienced surgeon. Few intraoperative opportunities, therefore, exist for CSF leak repair by trainees. Objective To simulate dural repair in spine surgery using minimal-access techniques. Methods A cohort of 8 neurosurgery residents was evaluated on their durotomy repair efforts in a perfusion-based cadaveric model. Results Study participants demonstrated consistent improvement across trials, with a significant reduction in closure times between their initial (12 min, 7 sec ± 4 min, 43 sec) and final attempts (7 min, 4 sec ± 2 min, 6 sec; P = .02). Moreover, all trainees-irrespective of postgraduate year-were able to accomplish robust dural closures resistant to simulated Valsalva maneuvers. Participants reported high degrees of model realism and exhibited significant increases in postprocedure confidence scores. Conclusion Our results support use of perfusion-based simulation models as a complement to neurosurgery training, as it affords unrestricted opportunities for honing psychomotor skillsets when resident learning is increasingly being challenged by work-hour limitations and stricter oversight in the context of value-based healthcare.

Study Design Biomechanical cadaveric study. Objective Clinical studies indicate that using less-rigid fixation techniques in place of the standard all-pedicle screw construct when correcting for scoliosis may reduce the incidence of proximal junctional kyphosis and improve patient outcomes. The purpose of this study is to investigate whether there is a biomechanical advantage to using supralaminar hooks in place of pedicle screws at the upper-instrumented vertebrae in a multilevel thoracic construct. Methods T7–T12 spines were biomechanically tested: (1) intact; (2) following a two-level pedicles screw fusion from T9 to T11; and after proximal extension of the fusion to T8–T9 with (3) bilateral supra-laminar hooks, (4) a unilateral hook + unilateral screw hybrid, or (5) bilateral pedicle screws. Specimens were nondestructively loaded while three-dimensional kinematics and intradiscal pressure at the supra-adjacent level were recorded. Results Supra-adjacent hypermobility was reduced when bilateral hooks were used in place of pedicle screws at the upper-instrumented level, with statistically significant differences in lateral bending and torsion ( p < 0.05 and p < 0.001, respectively). Disk pressures in the supra-adjacent segment were not statistically different among top-off techniques. Conclusions The use of supralaminar hooks at the top of a multilevel posterior fusion construct reduces the stress at the proximal uninstrumented motion segment. Although further data is needed to provide a definitive link to the clinical occurrence of PJK, this in vitro study demonstrates the potential benefit of “easing” the transition between the stiff instrumented spine and the flexible native spine and is the first to demonstrate these results with laminar hooks.

OBJECT Transforaminal lumbar interbody fusion (TLIF) has become one of the preferred procedures for circumferential fusion in the lumbar spine. Over the last decade, advances in surgical techniques have enabled surgeons to perform the TLIF procedure through a minimally invasive approach (MI-TLIF). There are a few studies reported in the medical literature in which perioperative complication rates of MI-TLIF were evaluated; here, the authors present the largest cohort series to date. They analyzed intraoperative and perioperative complications in 513 consecutive MI-TLIF–treated patients with lumbar degenerative disc disease. METHODS The authors performed a retrospective review of prospectively collected data on 513 consecutive patients treated over a 10-year period for lumbar degenerative disc disease using MI-TLIF. All patients undergoing either a first-time or revision 1- or 2-level MI-TLIF procedure were included in the study. Demographic, intraoperative, and perioperative data were collected and analyzed using bivariate analyses (Student t-test, analysis of variance, odds ratio, chi-square test) and multivariate analyses (logistic regression). RESULTS A total of 513 patients underwent an MI-TLIF procedure, and the perioperative complication rate was 15.6%. The incidence of durotomy was 5.1%, and the medical and surgical infection rates were 1.4% and 0.2%, respectively. A statistically significant increase in the infection rate was seen in revision MI-TLIF cases, and the same was found for the perioperative complication rate in multilevel MI-TLIF cases. Instrumentation failure occurred in 2.3% of the cases. After analysis, no statistically significant difference was seen in the rates of durotomy during revision and multilevel surgeries. There was no significant difference between the complication rates when stratified according to presenting diagnosis. CONCLUSIONS To the authors' knowledge, this is the largest study of perioperative complications in MI-TLIF in the literature. A total of 513 patients underwent MI-TLIF (perioperative complication rate 15.6%). The most common complication was a durotomy (5.1%), and there was only 1 surgical wound infection (0.2%). There were significantly more perioperative infections in revision MI-TLIF cases and more perioperative complications in multilevel MI-TLIF cases. The results of this study suggest that MI-TLIF has a similar or better perioperative complication profile than those documented in the literature for open-TLIF treatment of degenerative lumbar spine disease.

Object Access to the intervertebral discs from L2–S1 in one surgical position can be challenging. The transpsoas minimally invasive surgical (MIS) approach is preferred by many surgeons, but this approach poses potential risk to neural structures of the lumbar plexus as they course through the psoas. The lumbar plexus and iliac crest often restrict the L4–5 disc access, and the L5–S1 level has not been a viable option from a direct lateral approach. The purpose of the present study was to investigate an MIS oblique corridor to the L2–S1 intervertebral disc space in cadaveric specimens while keeping the specimens in a lateral decubitus position with minimal disruption of the psoas and lumbar plexus. Methods Twenty fresh-frozen full-torso cadaveric specimens were dissected, and an oblique anatomical corridor to access the L2–S1 discs was examined. Measurements were taken in a static state and with mild retraction of the psoas. The access corridor was defined at L2–5 as the left lateral border of the aorta (or iliac artery) and the anterior medial border of the psoas. The L5–S1 corridor of access was defined transversely from the midsagittal line of the inferior endplate of L-5 to the medial border of the left common iliac vessel and vertically to the first vascular structure that crosses midline. Results The mean access corridor diameters in the static state and with mild psoas retraction, respectively, were as follows: at L2–3, 18.60 mm and 25.50 mm; at L3–4, 19.25 mm and 27.05 mm; and at L4–5, 15.00 mm and 24.45 mm. The L5–S1 corridor mean values were 14.75 mm transversely, from midline to the left common iliac vessel and 23.85 mm from the inferior endplate of L-5 cephalad to the first midline vessel. Conclusions The oblique corridor allows access to the L2–S1 discs while keeping the patient in a lateral decubitus position without a break in the table. Minimal psoas retraction without significant tendon disruption allowed for a generous corridor to the disc space. The L5–S1 disc space can be accessed from an oblique angle consistently with gentle retraction of the iliac vessels. This study supports the potential of an MIS oblique retroperitoneal approach to the L2–S1 discs.

Objective To review spine surgery management strategies for patients with chronic low back pain (CLBP) that has failed to respond to all nonsurgical treatment options. Materials and Methods Literature review was conducted for spine surgery in the treatment of CLBP without compressive anatomical disease. The main diagnosis identified was degenerated disc disease, and surgical options targeted for the treatment of CLBP were reviewed. Results The history of current spine intervention for CLBP was reviewed, including various surgical options. Surgical treatment options for patients with CLBP include lumbar fusion, lumbar disc arthroplasty, and dynamic stabilization. Lumbar fusion remains the most frequent spine surgery performed for CLBP, but questions still exist regarding its efficacy in comparison with conservative care or interventional pain management. Lumbar disc arthroplasty and dynamic stabilization can both be considered only for select patients with CLBP, and their uses are currently limited. Conclusion Despite the number of spine surgeries that have been performed for CLBP, the surgical outcome still remains questionable. Until a precise identification of the cause of CLBP in any given patient can be precisely determined, surgical solutions will continue to be less than optimal.

The lateral transpsoas approach to the lumbar spine has become an increasingly popular method to achieve fusion. Although this approach requires less tissue dissection, a smaller incision, decreased operative time, reduced blood loss and postoperative pain, and shorter hospital stay, it carries the potential for serious neurologic and visceral complications. This article reviews these complications in detail and proposes mechanisms for their avoidance.

Posterior approaches for decompression in minimally invasive spine surgery are increasingly used for a wide range of pathology. Surgeons and patients must understand these risks in order to identify, manage, and ideally prevent complications. Technical intraoperative complications, recurrences and reoperations, infections, and medical complications associated with the surgery are considered for common posterior minimally invasive decompression procedures of the cervical and lumbar spine. Methods of possibly avoiding these complications are also discussed. This article then aggregates the relevant data to allow concise understanding of the complications associated with these procedures.

Lateral interbody fusion techniques are heavily reliant on fluoroscopy for retractor docking and graft placement, which expose both the patient and surgeon to high doses of radiation. Use of image-guided technologies with CT-based images, however, can eliminate this radiation exposure for the surgeon. We describe the surgical technique of performing lateral lumbar interbody fusion using CT navigation.

Varicella-zoster virus and herpes simplex virus types 1 and 2 are neurotropic viruses that can be reactivated after a surgical or stressful intervention. Although such cases are uncommon, consequences can be debilitating, and variable treatment responses merit consideration. We describe a 41-year-old male with a history of varicella-mediated skin eruptions, who presented with continuing right arm pain, burning, and numbness in a C6 dermatomal distribution following a C5-6 anterior cervical discectomy and fusion and epidural steroid injections. The operative course was uncomplicated and he was discharged home on postoperative day 1. Approximately ten days after surgery, the patient presented to the emergency department complaining of severe pain in his right upper extremity and a vesicular rash from his elbow to his second digit. He was started on Acyclovir and discharged home. On outpatient follow-up, his rash had resolved though his pain continued. The patient was started on a neuromodulating agent for chronic pain. This case adds to the limited literature regarding this rare complication, brings attention to the symptoms for proper diagnosis and treatment, and emphasizes the importance of prompt antiviral therapy. We suggest adding a neuromodulating agent to prevent long-term sequelae and resolve acute symptoms.

Modern imaging has revealed that thoracic disc herniation (TDH) has a prevalence of 11–37% in asymptomatic patients. Pain, sensory disturbances, myelopathy, and lower extremity weakness are the most common presenting symptoms, but other atypical extraspinal complaints, such as gastrointestinal or cardiopulmonary discomfort, may be reported. Our objective is to make providers familiar with TDH’s atypical symptoms to help avoid potential serious consequences created by a delay in diagnosis. We report the cases of two patients who each presented with atypical extraspinal symptoms secondary to a TDH. One patient presented with a chronic history of nausea, emesis, and chest tightness and MRI showed a large right paramedian disc herniation at T7-8. A second patient reported chronic constipation, buttock and leg burning pain, gait instability, and urinary frequency; an MRI of his thoracic spine demonstrated a central disc herniation at T10-11. TDH can present with vague extraspinal symptoms and unfamiliarity with these symptoms can lead to misdiagnosis with progression of the disease and unnecessary diagnostic tests and medical procedures. Therefore, TDH should be included in the differential diagnosis of patients with negative gastrointestinal, genitourinary, and cardiopulmonary system basic studies.

There has been a conscious effort to address osteoporosis in the aging population. As bisphosphonate and intermittent parathyroid hormone (PTH) therapy become more widely prescribed to treat osteoporosis, it is important to understand their effects on other physiologic processes, particularly the impact on spinal fusion. Despite early animal model studies and more recent clinical studies, the impact of these medications on spinal fusion is not fully understood. Previous animal studies suggest that bisphosphonate therapy resulted in inhibition of fusion mass with impeded maturity and an unknown effect on biomechanical strength. Prior animal studies demonstrate an improved fusion rate and fusion mass microstructure with the use of intermittent PTH. The purpose of this study was to determine if bisphosphonates and intermittent PTH treatment have impact on human spinal fusion. A systematic review of the literature published between 1980 and 2015 was conducted using major electronic databases. Studies reporting outcomes of human subjects undergoing 1, 2, or 3-level spinal fusion while receiving bisphosphonates and/or intermittent PTH treatment were included. The results of relevant human studies were analyzed for consensus on the effects of these medications in regards to spinal fusion. There were nine human studies evaluating the impact of these medications on spinal fusion. Improved fusion rates were noted in patients receiving bisphosphonates compared to control groups, and greater fusion rates in patients receiving PTH compared to control groups. Prior studies involving animal models found an improved fusion rate and fusion mass microstructure with the use of intermittent PTH. No significant complications were demonstrated in any study included in the analysis. Bisphosphonate use in humans may not be a deterrent to spinal fusion. Intermittent parathyroid use has shown early promise to increase fusion mass in both animal and human studies but further studies are needed to support routine use.

Watertight dural repair is crucial for both incidental durotomy and closure after intradural surgery.The study aimed to describe a perfusion-based cadaveric simulation model with cerebrospinal fluid (CSF) reconstitution and to compare spine dural repair techniques.The study is set in a fresh tissue dissection laboratory.The sample includes eight fresh human cadavers.A watertight closure was achieved when pressurized saline up to 40 mm Hg did not cause further CSF leakage beyond the suture lines.Fresh human cadaveric specimens underwent cannulation of the intradural cervical spine for intrathecal reconstitution of the CSF system. The cervicothoracic dura was then exposed from C7-T12 via laminectomy. The entire dura was then opened in six cadavers (ALLSPINE) and closed with 6-0 Prolene (n=3) or 4-0 Nurolon (n=3), and pressurized with saline via a perfusion system to 60 mm Hg to check for leakage. In two cadavers (INCISION), six separate 2-cm incisions were made and closed with either 6-0 Prolene or 4-0 Nurolon, and then pressurized. A hydrogel sealant was then added and the closure was pressurized again to check for further leakage.Spinal laminectomy with repair of intentional durotomy was successfully performed in eight cadavers. The operative microscope was used in all cases, and the model provided a realistic experience of spinal durotomy repair. For ALLSPINE cadavers (mean: 240 mm dura/cadaver repaired), the mean pressure threshold for CSF leakage was observed at 66.7 (±2.9) mm Hg in the 6-0 Prolene group and at 43.3 (±14.4) mm Hg in the 4-0 Nurolon group (p.05). For INCISION cadavers, the mean pressure threshold for CSF leakage without hydrogel sealant was significantly higher in 6-0 Prolene group than in the 4-0 Nurolon group (6-0 Prolene: 80.0±4.5 mm Hg vs. 4-0 Nurolon: 32.5±2.7 mm Hg; p.01). The mean pressure threshold for CSF leakage with the hydrogel sealants was not significantly different (6-0 Prolene: 100.0±0.0 mm Hg vs. 4-0 Nurolon: 70.0±33.1 mm Hg). The use of a hydrogel sealant significantly increased the pressure thresholds for possible CSF leakage in both the 6-0 Prolene group (p=.01) and the 4-0 Nurolon group (p.01) when compared with mean pressures without the hydrogel sealant.We described the feasibility of using a novel cadaveric model for both the study and training of watertight dural closure techniques. 6-0 Prolene was observed to be superior to 4-0 Nurolon for watertight dural closure without a hydrogel sealant. The use of a hydrogel sealant significantly improved watertight dural closures for both 6-0 Prolene and 4-0 Nurolon groups in the cadaveric model.

Surgical treatment of symptomatic adjacent segment disease (ASD) typically involves extension of previous instrumentation to include the newly affected level(s). Disruption of the incision site can present challenges and increases the risk of complication. Lateral-based interbody fusion techniques may provide a viable surgical alternative that avoids these risks. This study is the first to analyze the biomechanical effect of adding a lateral-based construct to an existing fusion.The study aimed to determine whether a minimally invasive lateral interbody device, with and without supplemental instrumentation, can effectively stabilize the rostral segment adjacent to a two-level fusion when compared with a traditional posterior revision approach.This is a cadaveric biomechanical study of lateral-based interbody strategies as add-on techniques to an existing fusion for the treatment of ASD.Twelve lumbosacral specimens were non-destructively loaded in flexion, extension, lateral bending, and torsion. Sequentially, the tested conditions were intact, two-level transforaminal lumbar interbody fusion (TLIF) (L3-L5), followed by lateral lumbar interbody fusion procedures at L2-L3 including interbody alone, a supplemental lateral plate, a supplemental spinous process plate, and then either cortical screw or pedicle screw fixation. A three-level TLIF was the final instrumented condition. In all conditions, three-dimensional kinematics were tracked and range of motion (ROM) was calculated for comparisons. Institutional funds ($50,000) in support of this work were provided by Medtronic Spine.The addition of a lateral interbody device superadjacent to a two-level fusion significantly reduced motion in flexion, extension, and lateral bending (p.05). Supplementing with a lateral plate further reduced ROM during lateral bending and torsion, whereas a spinous process plate further reduced ROM during flexion and extension. The addition of posterior cortical screws provided the most stable lateral lumbar interbody fusion construct, demonstrating ROM comparable with a traditional three-level TLIF.The data presented suggest that a lateral-based interbody fusion supplemented with additional minimally invasive instrumentation may provide comparable stability with a traditional posterior revision approach without removal of the existing two-level rod in an ASD revision scenario.

Study design Retrospective analysis of national insurance billing database. Objective To examine trends in reoperation after single-level lumbar discectomy. Summary of background data Lumbar discectomy is the most commonly performed procedure for treatment of radiculopathy caused by disc herniation. Randomized clinical trials have demonstrated the advantage of discectomy over nonsurgical treatment options, allowing for a more rapid reduction in symptoms. However, population-level data regarding reoperation after single level discectomy is limited. Methods Data were collected using the commercially available PearlDiver software for patients billed with the Current Procedural Terminology code for our index procedure, hemilaminotomy and removal of disc material, between January 2007 and September 2014. The index group was then followed for up to 4 years for recurrent lumbar surgery, including spinal fusion, laminectomy, and additional discectomy. Results Analysis of data obtained from 13,654 patient records revealed a rate of additional lumbar surgeries after single-level discectomy of 3.95% (539/13654) within 3 months and 12.2% (766/6274) within 4 years of the index procedure. Lumbar spinal fusion was performed on 5.9% (370/6274) of patients within 4 years. Patients who received a re-exploration discectomy within 2 years of the index procedure went on to receive lumbar fusion at a rate of 38.4% (48/125) within the 4 years after the re-exploration discectomy. The average additional cost of lumbar reoperation, as measured by insurance reimbursement, was approximately $11,161 per-patient per year. Conclusion We report an overall 4-year reoperation rate of 12.2% after single-level discectomy. In addition, we report a rate of progression to lumbar fusion following re-exploration discectomy of 38.4% within 4 years of reoperation. Further studies are needed regarding the best treatment algorithm in patients with reherniation or iatrogenic instability after lumbar discectomy. This study should enhance the shared decision making process by providing surgeons and patients with valuable data regarding the frequency and nature of reoperations after discectomy. Level of evidence 3.

The Dynesys dynamic stabilization system is an alternative to rigid instrumentation and fusion for the treatment of lumbar degenerative disease. Although many outcomes studies have shown good results, currently lacking is a comprehensive report on complications associated with this system, especially in terms of how it compares with reported complication rates of fusion. For the present study, the authors reviewed the literature to find all studies involving the Dynesys dynamic stabilization system that reported complications or adverse events. Twenty-one studies were included for a total of 1166 patients with a mean age of 55.5 years (range 39–71 years) and a mean follow-up period of 33.7 months (range 12.0–81.6 months). Analysis of these studies demonstrated a surgical-site infection rate of 4.3%, pedicle screw loosening rate of 11.7%, pedicle screw fracture rate of 1.6%, and adjacent-segment disease (ASD) rate of 7.0%. Of studies reporting revision surgeries, 11.3% of patients underwent a reoperation. Of patients who developed ASD, 40.6% underwent a reoperation for treatment. The Dynesys dynamic stabilization system appears to have a fairly similar complication-rate profile compared with published literature on lumbar fusion, and is associated with a slightly lower incidence of ASD.

Background context Metastatic epidural spinal cord compression from gastrointestinal stromal tumors (GISTs) is a rarely reported phenomenon. Purpose To describe the surgical management of metastatic GIST to two noncontiguous regions of the spinal column. Study design Case report. Methods Review of the medical chart, radiographic studies, and relevant literature. Results The patient underwent direct surgical decompression and stabilization of the cervicothoracic junction and the lumbar region during treatment of two distinct sites of metastatic pathology. Conclusions Treatment of epidural compression from metastatic GIST with direct decompression and stabilization is safe and feasible.

Lumbar discectomy is the most commonly performed spine surgery and in recent years, minimally invasive tubular discectomy has become increasingly popular among surgeons and patients. However, recent reports have raised the question of whether or not patients have shorter hospitalizations following minimally invasive discectomy. From 2005 to 2010, we analyzed 109 patients who underwent elective, single-level lumbar discectomy for central or paracentral disc herniations. A retrospective analysis of medical records was performed for perioperative complications. Tubular discectomy was not associated with increased rates of durotomy, nerve root injury, wound complications, or recurrent disc herniations requiring additional surgery. Minimally invasive tubular discectomy in the lumbar spine results in a small, but statistically significant, advantage in length of stay compared to conventional open microdiscectomy. While small on an individual basis, this difference may translate to substantial economic savings over time when one considers how many discectomies are performed in aggregate.

Background context Superficial siderosis is a rare condition resulting from the presence of chronic bleeding into the subarachnoid space usually causing gait instability and deafness. The surgical management of superficial siderosis depends on localizing the source of hemorrhage. Purpose The surgical treatment of this rare condition has not been well described in the literature. We present a case illustrating the surgical treatment for superficial siderosis. Study design Case report. Patient sample The authors describe the case report of a 70-year-old gentleman with gait instability and deafness found to have an abnormal communication between the spinal epidural venous plexus and the subarachnoid space. Methods The source of hemorrhage into the subarachnoid space was identified to be a fistula in the ventral thoracic dural. A costotransversectomy approach was undertaken at the T4–T5 level to expose the fistula. The abnormal communication was patched and sealed. Results The patient's symptoms remained stable on follow-up at 15 months with no worsening of his symptoms. Conclusions Superficial siderosis is a neurologic disorder that arises from chronic hemosiderin deposition into the subarachnoid space. The progressive nature of the disease can be halted if a source of hemorrhage can be found and treated surgically.

Vertebral artery injury following cervical spine trauma can be associated with stroke. We present a case of a C1 fracture resulting in vertebral artery dissection and neurological decline as a result of basilar artery occlusion treated with chemical and mechanical thrombolysis resulting in basilar artery patency and clinical improvement. The patient is a 43-year-old female who was involved in a motor vehicle collision where she sustained multiple cervical spine injuries including a comminuted fracture of the left lateral mass of C1 resulting in vertebral artery dissection which eventually led to a basilar artery embolus and occlusion. A total of 15 mg of intraarterial tissue plasminogen activator was infused throughout the clot, followed by mechanical clot embolectomy using an FDA-approved device. Her neurological exam improved post-procedurally and she was discharged with a left hemiparesis to a rehabilitation facility 3 weeks after admission. At 15 month follow up, she is neurologically intact with the exception of some subtle difficulty with fine motor movement in the right upper extremity and mild dysmetria on the right. With this case, we report a rare and potentially devastating complication of C1 fracture. To our knowledge there are only two previously reported cases where a C1 fracture has been associated with basilar artery occlusion resulting in death and locked-in syndrome respectively. In this case, chemical thrombolysis and mechanical thrombectomy resulted in recanalization of the basilar artery with excellent long-term neurological outcome.

Study design A retrospective clinical study. Objective To investigate clinical and radiographic outcomes following the surgical treatment of fixed cervical kyphosis with myelopathy. Summary of background data To our knowledge, a study specifically addressing the surgical treatment of fixed cervical sagittal deformity has never before been published. Methods Sixteen patients treated surgically for fixed cervical kyphosis and myelopathy were followed for a mean of 4.5 years (range, 25-112 months). The study group consisted of 9 males and 7 females, with an average age of 52 years (range, 31-78 years). The principal etiologies of cervical deformity were prior laminectomy (63%), advanced spondylosis (19%), infection (6%), neuromuscular disease (6%), and metabolic disease (renal osteodystrophy) (6%). All patients were clinically evaluated by the Nurick classification and Odom criteria both before surgery and at the time of most recent follow-up. Radiographic analysis was performed using thin-cut CT scans, dynamic radiographs, and 14 x 36-inch scoliosis films. Results The mean preoperative cervical Cobb angle as measured from the C2-C7 was +38 degrees and improved to -10 degrees at final follow-up, yielding an average correction of 48 degrees . The mean number of anterior and posterior segments fused was 4.8 (range, 2-6) and 7.2 (range, 3-14), respectively. The mean Nurick score improved from 2.4 before surgery to 1.5 at the time of follow-up. According to Odom criteria, outcomes were as follows: excellent (38%), good (50%), fair (6%), and poor (6%). At the time of most recent follow-up, solid bony arthrodesis and maintenance of correction occurred in all patients; however, revision was required in one patient. Conclusion The treatment of fixed cervical kyphosis with myelopathy using circumferential spinal osteotomies and instrumented reconstruction is technically demanding; however, restoration and maintenance of a neutral or lordotic cervical profile and excellent clinical outcomes are achievable.

STUDY DESIGN A retrospective clinical study. OBJECTIVE To evaluate the safety and efficacy of using an omental flap in complex spine reconstruction in patients at high-risk for wound dehiscence. SUMMARY OF BACKGROUND DATA Postoperative wound dehiscence represents a major cause of morbidity in patients undergoing instrumented spinal reconstruction. A variety of approaches for the prevention and treatment of this problem have been previously described in the literature; however, the use of omental flaps has received little attention. METHODS In this retrospective analysis, 5 patients were studied both clinically and radiographically. The study population included 4 women and 1 man, with a mean age of 49 years (range, 31-67 years). All patients underwent an omental flap procedure at the time of spinal reconstruction because of significant soft tissue defects or active spinal infection. Mean clinicoradiographic follow-up was 53 months (range, 36-115 months). RESULTS At the time of follow-up, all patients had well-healed surgical wounds with an acceptable structural and esthetic result. One patient in the study group experienced minor supra-fascial wound dehiscence. In terms of spinal outcome, all patients achieved successful bony arthrodesis; 1 patient, however, developed symptomatic adjacent segment degeneration and was treated by extension of the fusion construct. CONCLUSION In patients undergoing thoracolumbar surgery who are at high risk of spinal wound dehiscence, closure using a pedicled omental flap is a viable procedure that may limit the risk of dehiscence and improve outcome.

OBJECT The lateral jack-knife position is often used during transpsoas surgery to improve access to the spine. Postoperative neurological signs and symptoms are very common after such procedures, and the mechanism is not adequately understood. The objective of this study is to assess if the lateral jack-knife position alone can cause neurapraxia. This study compares neurological status at baseline and after positioning in the 25° right lateral jack-knife (RLJK) and the right lateral decubitus (RLD) position. METHODS Fifty healthy volunteers, ages 21 to 35, were randomly assigned to one of 2 groups: Group A (RLD) and Group B (RLJK). Motor and sensory testing was performed prior to positioning. Subjects were placed in the RLD or RLJK position, according to group assignment, for 60 minutes. Motor testing was performed immediately after this 60-minute period and again 60 minutes thereafter. Sensory testing was performed immediately after the 60-minute period and every 15 minutes thereafter, for a total of 5 times. Motor testing was performed by a physical therapist who was blinded to group assignment. A follow-up call was made 7 days after the positioning sessions. RESULTS Motor deficits were observed in the nondependent lower limb in 100% of the subjects in Group B, and no motor deficits were seen in Group A. Statistically significant differences (p < 0.05) were found between the 2 groups with respect to the performance on the 10-repetition maximum test immediately immediately and 60 minutes after positioning. Subjects in Group B had a 10%–70% (average 34.8%) decrease in knee extension strength and 20%–80% (average 43%) decrease in hip flexion strength in the nondependent limb. Sensory abnormalities were observed in the nondependent lower limb in 98% of the subjects in Group B. Thirty-six percent of the Group B subjects still exhibited sensory deficits after the 60-minute recovery period. No symptoms were reported by any subject during the follow-up calls 7 days after positioning. CONCLUSIONS Twenty-five degrees of right lateral jack-knife positioning for 60 minutes results in neurapraxia of the nondependent lower extremity. Our results support the hypothesis that jack-knife positioning alone can cause postoperative neurological symptoms.

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has been scrutinized for having a complex learning curve. Careful assessment of MI-TLIF complications and critical analyses of prevention may aid a safe adoption of this technique. The current report focuses on the incidence of interbody cage extrusions following MI-TLIF in a series of 513 patients. The authors discuss their experience with graft extrusions and provide methods to minimize this complication. This study retrospectively reviewed 513 prospectively followed patients who underwent MI-TLIF over a 10 year period. The inclusion criteria consisted of all patients who underwent one to three level MI-TLIF, from whom the incidence of cage extrusion was analyzed. Cage extrusion was defined as an interbody graft migrating outside the cephalad and caudal vertebral body posterior margin. Cage extrusions were diagnosed by comparing the intraoperative radiographs to the postoperative radiographs. Patients with >10° coronal curves, significant sagittal malalignment, infection, and preoperative instrumentation failure were excluded. Of 513 patients undergoing MI-TLIF, five patients (0.97%) were diagnosed with cage migrations. The mean follow-up duration was 13.6 ± standard deviation of 8.8 months. Complications included asymptomatic cage migration alone (two patients) neurological decline (two patients) and epidural hematoma (one patient). On average, cage migrations cost a university hospital an additional $US17,217 for revision treatment. While the incidence of cage migrations is low (0.97%), it can lead to postoperative complications that require revision surgery and increased hospital costs. The risk for this significant complication can be minimized with proper technique and patient selection.

Study design A retrospective clinical study. Objectives To evaluate the safety and efficacy of using an integrated titanium mesh cage and pedicled rib flap for thoracic spine reconstruction in patients at high risk of pseudarthrosis. Summary of background data A variety of materials are available for interbody thoracic reconstruction; however, the optimal treatment of patients at high risk of pseudarthrosis remains a challenging problem. Free or pedicled bone flaps have been shown to be highly effective in terms of promoting fusion and titanium mesh cages provide excellent structural support. Methods Eleven patients who underwent anterior thoracic corpectomy and spinal reconstruction using an integrated titanium mesh cage and pedicled rib flap were analyzed with a mean follow-up of 37 months (range, 25-55 months). The etiology of spinal disease was infection in 7 (64%) patients and tumor in the remaining 4 (36%) patients. Seven (64%) patients were treated with only an anterior approach while the remaining 4 (36%) patients underwent circumferential spinal reconstruction. Results All patients demonstrated clinical and radiographic evidence of spinal fusion at the time of follow-up. All patients had stable or improved Frankel grades after surgery. There was a mean kyphosis correction of 7 degrees for both the focal and regional thoracic kyphosis. There were three significant postoperative complications: bilateral pleural effusion, gram-negative bacteremia, and transient right lower extremity weakness requiring reoperation and pedicle screw revision. Two patients died after surgery: one from aneurysmal subarachnoid hemorrhage and the other from complications of breast cancer. Conclusions The use of an integrated rib flap and titanium mesh cage construct appears to be a safe and effective means of providing immediate and substantial anterior column support as well as achieving arthrodesis in challenging fusion candidates.

OBJECTIVE Laparoscopic anterior lumbar interbody fusion (LALIF) has been demonstrated to be safe and effective. Its use as a standard surgical technique has been recommended for arthrodesis in the lumbosacral region. We reviewed our experience with LALIF for safety, effectiveness, and usefulness. METHODS Retrospective review of 14 patients who underwent LALIF was performed. All patients had a diagnosis of degenerative disc disease with medically retractable mechanical back pain. RESULTS No intraoperative vascular or neurological injury was encountered. An average operating time of 300 minutes with blood loss of 60 ml was found. The average hospital stay was 3.4 days. At 3 to 6 months after surgery, 80% fusion rates were achieved. CONCLUSION Although LALIF is a safe and effective procedure, it has many disadvantages, which make it a less than optimal procedure for routine use. Other minimally invasive approaches to the anterior lumbar spine result in similar beneficial results without the drawbacks associated with LALIF.