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Background: Advanced-imaging screening for asymptomatic blunt cerebrovascular injury is controversial. Vertebral artery injury (VAI) is most commonly associated with cervical spine fracture, and many guidelines advocate indiscriminate screening for all cervical spine fractures. The purpose of this study was to determine whether the addition of computed tomographic angiography (CTA) results in a change in management for patients with cervical spine fractures.Methods: Adult patients treated for acute cervical spine fractures after blunt trauma during the period of 2000 to 2015 were retrospectively identified. Patients who sustained a penetrating trauma or who had a history of neoplasm or prior cervical spine surgery were excluded. The following variables were recorded: age, biologic sex, race, medical comorbidities, Injury Severity Score (ISS), mechanism of injury, whether CTA of the neck was obtained in addition to computed tomography (CT), cervical spine fracture characteristics and treatment, and the presence of VAI. Recommendation for a change in management with antithrombotic therapy was the primary outcome measure. Detection of stroke and of VAI were secondary outcomes. Propensity-score matching was performed to negate the significant differences in baseline demographic and clinical characteristics.Results: A total of 3,943 patients were screened for eligibility, and 2,831 patients met the inclusion criteria. Propensity-score matching yielded 1 cohort who underwent CT + CTA and 1 cohort who underwent CT alone, both with 644 patients and equivalent demographic and clinical characteristics. CTA identified definite or indeterminate VAI in 113 patients, and for 62 patients, antithrombotic therapy was recommended. In the CT-alone cohort, VAI was identified in 11 patients incidentally through other imaging, and antithrombotic therapy was recommended for 8 patients. Two patients in the CT + CTA group had major adverse bleeding events as a result of the initiation of antithrombotic therapy. There were no preventable strokes in either group.Conclusions: The addition of CTA increased detection of VAI and the recommendation for antithrombotic therapy. There were no preventable strokes in either cohort and 2 major adverse bleeding events attributable to the recommended pharmacologic antithrombotic therapy. Nonselective screening is not warranted and should be limited to a high-risk subset of patients.Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Study Design: Clinical case series.Objective: To investigate the efficacy of intraoperative neuromonitoring in pediatric cervical spine surgery.Summary Of Background Data: Intraoperative neuromonitoring (IONM) consisting of somatosensory-evoked potentials (SSEP) and transcranial motor-evoked potentials (tcMEP) has been shown to effectively prevent permaneny neurologic injury in deformity surgery. The role of IONM during pediatric cervical spine surgery is not well documented. Advances in cervical spine instrumentation have expanded the surgical options in pediatric populations. The goal of this study is to report the ability of IONM to detect neurologic injury during pediatric cervical spine instrumentation.Methods: A single institution database was queried for pediatric-aged patients who underwent cervical spine instrumentation and fusion between 2011 and 2014. Age, diagnosis, surgical indication, number of instrumented levels, and a complete IONM were extracted. Sensitivity and specificity for the detection of neurologic deficits were calculated with exact 95% confidence intervals. Positive and negative predictive values were calculated with estimated 95% confidence intervals.Results: Sixty-seven patients who underwent cervical spine instrumentation were identified with a mean age of 11.6 years (range 1-18). Diagnoses included instability (27), congenital (11), kyphosis (8), fracture (7), tumor (7), arthritis (4), and basilar invagination (3). Mean number of vertebral levels fused was 4 (range 2-7). All patients underwent cervical instrumentation with SSEP and tcMEP monitoring. A significant change in tcMEP monitoring was observed in 7 subjects (10%). There were no corresponding SSEP changes in these patients. The sensitivity of combined IONM was 75% [95% CI = 24.9, 98.7] and the specificity was 98.5% [92.7, 99.9].Conclusion: tcMEP is a more sensitive indicator to spinal cord injury than SSEP, which is consistent with previous studies. IONM changes in 10% of a patient population are significant enough to warrant intraoperative determination if true SCI has occurred or is underway and intervene accordingly.Level Of Evidence: 4. [ABSTRACT FROM AUTHOR]

Cervical sagittal alignment (CSA) parameters are helpful in determining the surgical technique used to treat cervical spondylotic myelopathy. Upright lateral radiographs are routinely used to measure CSA parameters, but obtaining adequate imaging is difficult. Utilizing magnetic resonance imaging (MRI) to evaluate sagittal parameters has been explored; however, the impact of positional changes on these parameters has not been elucidated. To evaluate CSA parameter measurement reliability and correlation between XR and MRI modalities in patients undergoing posterior decompressive procedures for cervical spondylotic myelopathy. Retrospective cohort study. We evaluated adult patients who had undergone laminoplasty or laminectomy and fusion for cervical spondylotic myelopathy between 2017 and 2019 and who had cervical spine XR and MRI within a 6-month timespan of one another. Outcomes of interest included intra- and interobserver reliability assessment of C2-C7 sagittal angle, C2-C7 sagittal vertical axis (SVA), and T1 tilt measurements as well as correlations in these parameters between imaging modalities. Two clinicians completed two independent rounds of C2-C7 sagittal angle, C2-C7 sagittal vertical axis (SVA), and T1 tilt measurements; intra- and interobserver reliability were assessed by intraclass correlation coefficient (ICC). Correlations between imaging modalities were analyzed using parametric and nonparametric statistical tests. Intra- and interobserver reliabilities were highly correlated with correlations greater than 0.85 across all permutations; ICCs were highest with MRI measurements. The C2-C7 sagittal angle was highly correlated between XR and MRI at 0.76 with no significant difference (p = 0.46). Weaker correlations existed for C2-C7 SVA (0.48) and T1 tilt (0.62) measurements with significant differences observed in the mean values between the two imaging modalities (p < 0.01). The C2-C7 sagittal angle is highly correlated and not significantly different between upright XR and supine MR images. However, cervical SVA and T1 tilt change with patient position. As MRI does not accurately reflect the CSA in the upright position, upright lateral radiographs should be obtained to assess global sagittal alignment when planning posterior based cervical fusions. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Background Content: Cervical laminoplasty (LP) and laminectomy and fusion (LF) are commonly used surgical techniques for cervical spondylotic myelopathy (CSM). Several recent studies have demonstrated superior perioperative metrics and decreased overall costs with LP, yet LF is performed far more often in the United States.Purpose: To determine the percentage of patients with CSM who are radiographically candidates for LP.Study Design: Retrospective comparative cohort study.Patient Sample: Patients >18 years old who underwent LF or LP for CSM at 2 large academic institutions from 2017 to 2019.Outcome Measures: Candidacy for LP based on radiographic criteria.Methods: Radiographs were assessed by 2 spine surgeons not involved in the care of the patients to determine the C2-C7 Cobb angle and the presence and extent of cervical instability. Patients with kyphosis >13°, > 3.5 mm of listhesis on static imaging, or > 2.5 mm of motion on flexion-extension or standing-supine films were not considered candidates for LP. Intraclass coefficient (ICC) was calculated to assess the interobserver reliability of angular measurements and the presence of instability. The percentage of patients for whom LP was contraindicated was calculated.Results: One hundred eight patients underwent LF while 142 underwent LP. Of the 108 patients who underwent LF, 79.6% were radiographically deemed candidates for LP, as were all 142 patients who underwent LP. The ICC for C2-C7 alignment was 0.90; there was 97% agreement with respect to the presence of instability.Conclusions: In 250 patients with CSM, 228 (91.2%) were radiographically candidates for LP. These data suggest that LP may be an underutilized procedure for the treatment for CSM. [ABSTRACT FROM AUTHOR]

Background Context: Laminectomy with fusion (LF) and laminoplasty (LP) are commonly used to treat cervical spondylotic myelopathy (CSM). The decision regarding which procedure to perform is largely a matter of surgeon's preference, while financial implications are rarely considered.Purpose: We aimed to better understand the financial considerations of LF compared to LP in the treatment of CSM.Study Design: Retrospective comparative study.Patient Sample: Adult patients, 18 years of age or older, who had undergone LF or LP for CSM from 2017 to 2019 at 2 large academic centers were included. Patients who had undergone previous cervical spine surgery or procedures that extended above C2 or below T2 were excluded.Outcome Measures: The primary outcome was defined as the total cost of the procedure, which was calculated as the sum of the implant and non-implant supply costs.Methods: Patient demographics, surgical parameters, including estimated blood loss and operative time, and length of stay were collected. Operating room material - both implant and non-implant - cost data was also obtained. Variables were analyzed individually as well as after adjustment based on the number of operative levels involved. Statistical analysis was performed using either Student t test with unequal variance or Wilcoxon rank sum test for continuous variables and chi-squared analysis for categorical variables.Results: Two hundred fifty patients were identified who met inclusion criteria. There was no statistical difference in the mean age at time of surgery (p=.25), gender distribution (p=.33), or re-operation rate between the LF and LP groups (p=.39). Overall, operative time was similar between the LF (165.7 ± 61.9 min) and LP (173.8 ± 58.2 min) groups (p=.29), but the LP cohort had a shorter length of stay at 3.8 ± 2.7 days compared to the LF cohort at 4.8 ± 3.7 days. Implant costs in the LF group were significantly more at $6,204.94 ± $1426.41 compared to LP implant costs at $1994.39 ± $643.09. Mean total costs of LP were significantly less at $2,859.08 ± $784.19 compared to LF total costs of $6,983.16 ± $1,589.17. Furthermore, when adjusted for the number of operative levels, LP remained significantly less costly at $766.12 ± $213.64 per level while LF cost $1,789.05 ± $486.66 per operative level. Additional subgroup analysis limiting the cohorts to patients with either three or four involved vertebral levels demonstrated nearly identical cost savings with LP as compared to LF.Conclusions: This study demonstrates that LF is on average at least 2.4 times the total operative supply cost of LP and at least 2.3 times the operative supply cost of LP when adjusted for the number of operative levels. In patients deemed appropriate for either LP or LF, these data may be incorporated into decision-making for the treatment of CSM. [ABSTRACT FROM AUTHOR]

Preoperative MRSA screening and decolonization has demonstrated success for some orthopaedic subspecialties in prevention of surgical site infections (SSIs). Spine surgery, however, has seen varied results, potentially secondary to the anatomic and surgical heterogeneity of the patients included in prior studies. Given that prior research has demonstrated greater propensity for gram positive SSIs in the cervical spine, we sought to investigate if MRSA screening would be more impactful in the cervical spine. The purpose of this study was to determine the relationship between nasal MRSA testing and SSI rates specifically in the setting of primary posterior cervical instrumented spine surgery. Retrospective cohort study. Adult patients undergoing primary instrumented posterior cervical procedures from January 2015-December 2019 at two tertiary academic referral centers in an urban setting Physiologic measures: subfascial presumed infected collection or abscess within 90 days of the index operation. Adult patients undergoing primary instrumented posterior cervical procedures from January 2015-December 2019 were reviewed for MRSA testing < 90-days before surgery, preoperative mupirocin, perioperative antibiotics and SSI defined as operative incision and drainage (I&D) < 90-days after surgery. Trauma, tumor and infection cases were excluded. Logistic regression modeling was used with SSI the primary outcome and MRSA screening the primary predictor with clinical and demographic factors as covariates. This study included 668 patients, of whom MRSA testing was performed in 212 patients (31.7%) and 6 (2.8%) were colonized with MRSA. Twelve patients (1.8%) underwent an I&D. On adjusted analysis, preoperative MRSA testing was not associated with postoperative I&D risk. Perioperative vancomycin similarly had no association with postoperative I&D risk. Notably, six patients (50%) grew MSSA from intraoperative cultures, with no cases of MRSA. There was no association between preoperative nasal MRSA screening and SSIs in primary posterior cervical instrumented procedures, nor was there any association between vancomycin or infection rate. Furthermore, there was a preponderance of gram-positive infections but none caused by MRSA. Given these findings, the considerable cost and effort associated with MRSA testing in the setting of primary posterior cervical instrumentation may not be justified. Further research should investigate if higher-risk scenarios demonstrate greater utility of preoperative testing. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]