Search

Competing Interests: J.M.R.: Alphatec Spine: Paid consultant; Paid presenter or speaker. Biomet: IP royalties. Cervical Spine Research Society: Board or committee member. Medtronic: Paid presenter or speaker. Stryker: IP royalties; Paid presenter or speaker. Wolters Kluwer Health—Lippincott Williams & Wilkins: Publishing royalties, financial or material support. Zimmer: Paid presenter or speaker. K.D.R.: Amedica: Stock or stock options. AOSpine: Board or committee member. AxioMed: Stock or stock options. Benvenue: Stock or stock options. Biomet: IP royalties; Paid presenter or speaker. Clinics in orthopedics: Editorial or governing board. European Spine Journal : Editorial or governing board. Expanding Orthopedics, PSD: Stock or stock options. Global Spine Journal : Editorial or governing board. HAPPE Spine: Unpaid consultant. Medtronic: Paid presenter or speaker. Neurosurgery : Editorial or governing board. North American Spine Society: Board or committee member. Nuvasive: Paid consultant; Paid presenter or speaker. Paradigm Spine: Stock or stock options. Spinal Kinetics: Stock or stock options. Spine : Editorial or governing board. Spine Surgery Today : Editorial or governing board. Spineology: Stock or stock options. Vertiflex: Stock or stock options. A.R.V.: Health Care Entity Relationships and Investments: Medtronics, Receipt of Royalty Payments; Stryker Spine, Receipt of Royalty Payments; Globus, Receipt of Royalty Payments, Stock / Stock Option Ownership Interests; Stout Medical, Stock / Stock Option Ownership Interests; Progressive Spinal Technologies, Stock / Stock Option Ownership Interests; Advanced Spinal Intellectual Properties, Stock / Stock Option Ownership Interests; Flagship Surgical, Stock / Stock Option Ownership Interests; Cytonics, Stock / Stock Option Ownership Interests; Electrocore, Stock / Stock Option Ownership Interests; AVKN Patient Driven Care, Stock / Stock Option Ownership Interests; FlowPharma, Stock / Stock Option Ownership Interests; Rothman Institute and Related Properties, Stock / Stock Option Ownership Interests; AO Spine, Member in good standing// Independent Contractor; Innovative Surgical Design, Stock / Stock Option Ownership Interests; Orthobullets, Stock / Stock Option Ownership Interests; Thieme, Receipt of Royalty Payments; Jaypee, Receipt of Royalty Payments; Elseviere, Receipt of Royalty Payments; Taylor Francis/Hodder and Stoughton, Receipt of Royalty Payments; Expert testimony, Member in good standing// Independent Contractor; Avaz Surgical, Stock/Stock Option Ownership Interests; Dimension Orthotics, LLC, Stock/Stock Option Ownership Interests; SpineWave, Receipt of Royalty Payments; Atlas Spine, Receipt of Royalty Payments, Stock/Stock Option Ownership Interests; Nuvasive, Stock/Stock Option Ownership Interests; Parvizi Surgical Innovation, Stock/Stock Option Ownership Interests; Jushi, Stock/Stock Option Ownership Interests; Deep Health, Stock/Stock Option Ownership Interests; ViewFi Health, Stock/Stock Option Ownership Interests; Sentryx, Service on Scientific Advisory Board/Board of Directors/Service on Committees,Stock/Stock Option Ownership Interests; National Spine Health Foundation (NSHF), Service on Scientific Advisory Board/Board of Directors/Service on Committees; Accellus, Service on Scientific Advisory Board/Board of Directors/Service on Committees, Stock/Stock Option Ownership Interests; Spinal Elements, Consulting/Independent Contractor, Receipt of Royalty Payments; Alphatec (Atec), Receipt of Royalty Payments; Harvard Medtech, Stock/Stock Option Ownership Interests.. T.J.A.: Augmedics: Stock or stock options. Back Story, LLC: Board or committee member. Biomet: IP royalties. Care Equity: Stock or stock options. CytoDyn Inc.: Stock or stock options. DePuy, A Johnson & Johnson Company: IP royalties. Hospital for Special Surgery: Board or committee member. HS2, LLC: Stock or stock options. In ViVo Therapeutics: Stock or stock options. Innovative Surgical Designs, Inc.: Stock or stock options. Journal of Bone and Joint Surgery — American : Editorial or governing board. JP Medical Publishers: Publishing royalties, financial or material support. Morphogenesis: Stock or stock options. Nuvasive: Paid consultant. Orthopedics Today : Board or committee member; Editorial or governing board. Paradigm Spine: Stock or stock options. Parvizi Surgical Innovations: Stock or stock options. Physician Recommended Nutriceuticals: Stock or stock options. Precision Orthopedics: Stock or stock options. Pulse Equity: Stock or stock options. Saunders/Mosby-Elsevier: Publishing royalties, financial or material support. Spine : Editorial or governing board. Spine Deformity Journal : Editorial or governing board. Spine Universe: Board or committee member. Spinicity: Stock or stock options. Springer: Publishing royalties, financial or material support. Strathspey Crown: Stock or stock options. Surg.IO LLC: Stock or stock options. Thieme: Publishing royalties, financial or material support. James S. Harrop, MD, MSHQS: DePuy: Honoraria. Stryker: Honoraria. NuVasive: Honoraria. The remaining authors no conflict of interest.

Objective: Axial neck pain is a prevalent condition that causes significant morbidity and productivity loss. This study aimed to review the current literature and define the impact of surgical intervention on the management of cervical axial neck pain., Methods: A search was conducted of three databases (Ovid MEDLINE, Embase, and Cochrane) for randomized controlled trials and cohort studies written in the English language with a minimum 6-month follow-up. The analysis was limited to patients with axial neck pain/cervical radiculopathy and preoperative/postoperative Neck Disability Index (NDI) and visual analog scale (VAS) scores. Literature reviews, meta-analyses, systematic reviews, surveys, and case studies were excluded. Two patient groups were analyzed: the arm pain predominant (pAP) cohort and the neck pain predominant (pNP) cohort. The pAP cohort had preoperative VAS neck scores that were lower than the arm scores, whereas the pNP cohort was defined as having preoperative VAS neck scores higher than the arm scores. A 30% reduction in patient-reported outcome measure (PROM) scores from the baseline represented the minimal clinically important difference (MCID)., Results: Five studies met the inclusion criteria, involving a total of 5221 patients. Patients with pAP showed a slightly higher percent reduction in PROM scores from baseline than those with pNP. The NDI reduction in patients with pNP was 41.35% (mean change in NDI score 16.3/mean baseline NDI score 39.42) (p < 0.0001), whereas those with pAP had a reduction of 45.12% (15.86/35.15) (p < 0.0001). Surgical improvement was slightly but similarly greater in pNP patients compared with pAP patients (16.3 vs 15.86 points, respectively; p = 0.3193). Regarding VAS scores, patients with pNP had a greater reduction in neck pain, with a change from baseline of 53.4% (3.60/6.74, p < 0.0001), whereas those with pAP had a change from baseline of 50.3% (2.46/4.89, p < 0.0001). The difference in VAS scores for neck pain improvement was significant (3.6 vs 2.46, p < 0.0134). Similarly, patients with pNP had a 43.6% (1.96/4.5) improvement in VAS scores for arm pain (p < 0.0001), whereas those with pAP had 66.12% (4.43/6.7) improvement (p < 0.0001). The VAS scores for arm pain were significantly greater in patients with pAP (4.43 vs 1.96 points, respectively; p < 0.0051)., Conclusions: Overall, despite significant variations in the existing literature, there is mounting evidence that surgical intervention can lead to clinically meaningful improvements in patients with primary axial neck pain. The studies suggest that patients with pNP tend to have better improvement in neck pain than in arm pain. In both groups, the average improvements exceeded the MCID values and reached substantial clinical benefit in all studies. Further research is necessary to identify which patients and underlying pathologies will benefit most from surgical intervention for axial neck pain because it is a multifaceted condition with many causes.

Study Design: The present study design was that of a single center, retrospective cohort study to evaluate the influence of surgeon-specific factors on patient functional outcomes at 6 months following lumbar fusion. Retrospective review of a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis identified the present study population., Objective: This study seeks to evaluate surgeon-specific variable effects on patient-reported outcomes such as Oswestry Disability Index (ODI) and the effect of North American Spine Society (NASS) concordance on outcomes in the setting of variable surgeon characteristics., Summary of Background Data: Lumbar fusion is one of the fastest growing procedures performed in the United States. Although the impact of surgeon-specific factors on patient-reported outcomes has been contested, studies examining these effects are limited., Methods: This is a single center, retrospective cohort study analyzing a prospectively maintained database of patients who underwent neurosurgical lumbar instrumented arthrodesis by 1 of 5 neurosurgery fellowship trained spine surgeons. The primary outcome was improvement of ODI at 6 months postoperative follow-up compared with preoperative ODI., Results: A total of 307 patients were identified for analysis. Overall, 62% of the study population achieved minimum clinically important difference (MCID) in ODI score at 6 months. Years in practice and volume of lumbar fusions were statistically significant independent predictors of MCID ODI on multivariable logistic regression ( P =0.0340 and P =0.0343, respectively). Concordance with evidence-based criteria conferred a 3.16 (95% CI: 1.03, 9.65) times greater odds of achieving MCID., Conclusion: This study demonstrates that traditional surgeon-specific variables predicting surgical morbidity such as experience and procedural volume are also predictors of achieving MCID 6 months postoperatively from lumbar fusion. Independent of surgeon factors, however, adhering to evidence-based guidelines can lead to improved outcomes., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective case-control study., Objective: To compare health-related quality of life outcomes at one-year follow-up between patients who did and did not develop surgical site infection (SSI) after thoracolumbar spinal fusion., Summary of Background Data: SSI is among the most common healthcare-associated complications. As healthcare systems increasingly emphasize the value of delivered care, there is an increased need to understand the clinical impact of SSIs., Materials and Methods: A retrospective 3:1 (control:SSI) propensity-matched case-control study was conducted for adult patients who underwent thoracolumbar fusion from March 2014 to January 2020 at a single academic institution. Exclusion criteria included less than 18 years of age, incomplete preoperative and one-year postoperative patient-reported outcome measures, and revision surgery. Continuous and categorical data were compared via independent t tests and χ 2 tests, respectively. Intragroup analysis was performed using paired t tests. Regression analysis for ∆ patient-reported outcome measures (postoperative minus preoperative scores) controlled for demographics. The α was set at 0.05., Results: A total of 140 patients (105 control, 35 SSI) were included in final analysis. The infections group had a higher rate of readmission (100% vs. 0.95%, P <0.001) and revision surgery (28.6% vs. 12.4%, P =0.048). Both groups improved significantly in Physical Component Score (control: P =0.013, SSI: P =0.039), Oswestry Disability Index (control: P <0.001, SSI: P =0.001), Visual Analog Scale (VAS) Back (both, P <0.001), and VAS Leg (control: P <0.001, SSI: P =0.030). Only the control group improved in Mental Component Score ( P <0.001 vs. SSI: P =0.228), but history of a SSI did not affect one-year improvement in ∆MCS-12 ( P =0.455) on regression analysis. VAS Leg improved significantly less in the infection group (-1.87 vs. -3.59, P =0.039), which was not significant after regression analysis (β=1.75, P =0.050)., Conclusion: Development of SSI after thoracolumbar fusion resulted in increased revision rates but did not influence patient improvement in one-year pain, functional disability, or physical and mental health status., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Patient factors (increased body mass index [BMI], smoking, and diabetes) may impact outcomes after spine surgery. There is a lack of consensus regarding which factors should be screened for and potentially modified preoperatively to optimize outcome., Objective: The purpose of this evidence-based clinical practice guideline is to determine if preoperative patient factors of diabetes, smoking, and increased BMI impact surgical outcomes., Methods: A systematic review of the literature for studies relevant to spine surgery was performed using the National Library of Medicine PubMed database and the Cochrane Library. Clinical studies evaluating the impact of diabetes or increased BMI with reoperation and/or surgical site infection (SSI) were selected for review. In addition, the impact of preoperative smoking on patients undergoing spinal fusion was reviewed., Results: A total of 699 articles met inclusion criteria and 64 were included in the systematic review. In patients with diabetes, a preoperative hemoglobin A1c (HbA1c) >7.5 mg/dL is associated with an increased risk of reoperation or infection after spine surgery. The review noted conflicting studies regarding the relationship between increased BMI and SSI or reoperation. Preoperative smoking is associated with increased risk of reoperation (Grade B). There is insufficient evidence that cessation of smoking before spine surgery decreases the risk of reoperation., Conclusion: This evidence-based guideline provides a Grade B recommendation that diabetic individuals undergoing spine surgery should have a preoperative HbA1c test before surgery and should be counseled regarding the increased risk of reoperation or infection if the level is >7.5 mg/dL. There is conflicting evidence that BMI correlates with greater SSI rate or reoperation rate (Grade I). Smoking is associated with increased risk of reoperation (Grade B) in patients undergoing spinal fusion.The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/2-preoperative-surgical-risk-assessement., (© Congress of Neurological Surgeons 2021.)

Background: Instrumented fusion procedures are essential in the treatment of degenerative lumbar spine disease to alleviate pain and improve neurological function, but they are being performed with increasing incidence and variability. We implemented a training module for neurosurgery residents that is based on evidence-based criteria for lumbar fusion surgery and measured its effectiveness in residents' decision making regarding whether patients should or should not undergo instrumented fusion., Methods: The study design was a pretest versus posttest experiment conducted from September 2019 until July 2020 to measure improvement after formalized instruction on evidence-based guidelines. Neurosurgery residents of all training levels at our institution participated. A test was administered at the beginning of each academic year. The highest possible score was 18 points in each pretest and posttest., Results: There was a general trend of test score improvement across all levels of training with a greater degree of change for participants with lower compared with higher pretest scores, indicating a possible ceiling effect. Paired t test demonstrated an overall mean score increase of 2 points (P < 0.0001), equivalent to an 11.11% increase (P < 0.0001). Stratified by training group, mean absolute change in test score was 2 (P = 0.0217), 1.67 (P = 0.0108), and 2.25 (P = 0.0173) points for junior, midlevel, and senior training groups, respectively., Conclusions: Incorporating a targeted evidence-based learning module for lumbar spine fusion surgery can improve neurosurgery residents' clinical decision making toward a more uniform practice supported by published data., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background Context: High quality evidence is difficult to generate, leaving substantial knowledge gaps in the treatment of spinal conditions. Appropriate use criteria (AUC) are a means of determining appropriate recommendations when high quality evidence is lacking., Purpose: Define appropriate use criteria (AUC) of cervical fusion for treatment of degenerative conditions of the cervical spine., Study Design/setting: Appropriate use criteria for cervical fusion were developed using the RAND/UCLA appropriateness methodology. Following development of clinical guidelines and scenario writing, a one-day workshop was held with a multidisciplinary group of 14 raters, all considered thought leaders in their respective fields, to determine final ratings for cervical fusion appropriateness for various clinical situations., Outcome Measures: Final rating for cervical fusion recommendation as either "Appropriate," "Uncertain" or "Rarely Appropriate" based on the median final rating among the raters., Methods: Inclusion criteria for scenarios included patients aged 18 to 80 with degenerative conditions of the cervical spine. Key modifiers were defined and combined to develop a matrix of clinical scenarios. The median score among the raters was used to determine the final rating for each scenario. The final rating was compared between modifier levels. Spearman's rank correlation between each modifier and the final rating was determined. A multivariable ordinal regression model was fit to determine the adjusted odds of an "Appropriate" final rating while adjusting for radiographic diagnosis, number of levels and symptom type. Three decision trees were developed using decision tree classification models and variable importance for each tree was computed., Results: Of the 263 scenarios, 47 (17.9 %) were rated as rarely appropriate, 66 (25%) as uncertain and 150 (57%) were rated as appropriate. Symptom type was the modifier most strongly correlated with the final rating (adjusted ρ2 = 0.58, p<.01). A multivariable ordinal regression adjusting for symptom type, diagnosis, and number of levels and showed high discriminative ability (C statistic = 0.90) and the adjusted odds ratio (aOR) of receiving a final rating of "Appropriate" was highest for myelopathy (aOR, 7.1) and radiculopathy (aOR, 4.8). Three decision tree models showed that symptom type and radiographic diagnosis had the highest variable importance., Conclusions: Appropriate use criteria for cervical fusion in the setting of cervical degenerative disorders were developed. Symptom type was most strongly correlated with final rating. Myelopathy or radiculopathy were most strongly associated with an "Appropriate" rating, while axial pain without stenosis was most associated with "Rarely Appropriate.", (Copyright © 2021 Elsevier Inc. All rights reserved.)

Importance: Cervical spondylotic myelopathy is the most common cause of spinal cord dysfunction worldwide. It remains unknown whether a ventral or dorsal surgical approach provides the best results., Objective: To determine whether a ventral surgical approach compared with a dorsal surgical approach for treatment of cervical spondylotic myelopathy improves patient-reported physical functioning at 1 year., Design, Setting, and Participants: Randomized clinical trial of patients aged 45 to 80 years with multilevel cervical spondylotic myelopathy enrolled at 15 large North American hospitals from April 1, 2014, to March 30, 2018; final follow-up was April 15, 2020., Interventions: Patients were randomized to undergo ventral surgery (n = 63) or dorsal surgery (n = 100). Ventral surgery involved anterior cervical disk removal and instrumented fusion. Dorsal surgery involved laminectomy with instrumented fusion or open-door laminoplasty. Type of dorsal surgery (fusion or laminoplasty) was at surgeon's discretion., Main Outcomes and Measures: The primary outcome was 1-year change in the Short Form 36 physical component summary (SF-36 PCS) score (range, 0 [worst] to 100 [best]; minimum clinically important difference = 5). Secondary outcomes included 1-year change in modified Japanese Orthopaedic Association scale score, complications, work status, sagittal vertical axis, health resource utilization, and 1- and 2-year changes in the Neck Disability Index and the EuroQol 5 Dimensions score., Results: Among 163 patients who were randomized (mean age, 62 years; 80 [49%] women), 155 (95%) completed the trial at 1 year (80% at 2 years). All patients had surgery, but 5 patients did not receive their allocated surgery (ventral: n = 1; dorsal: n = 4). One-year SF-36 PCS mean improvement was not significantly different between ventral surgery (5.9 points) and dorsal surgery (6.2 points) (estimated mean difference, 0.3; 95% CI, -2.6 to 3.1; P = .86). Of 7 prespecified secondary outcomes, 6 showed no significant difference. Rates of complications in the ventral and dorsal surgery groups, respectively, were 48% vs 24% (difference, 24%; 95% CI, 8.7%-38.5%; P = .002) and included dysphagia (41% vs 0%), new neurological deficit (2% vs 9%), reoperations (6% vs 4%), and readmissions within 30 days (0% vs 7%)., Conclusions and Relevance: Among patients with cervical spondylotic myelopathy undergoing cervical spinal surgery, a ventral surgical approach did not significantly improve patient-reported physical functioning at 1 year compared with outcomes after a dorsal surgical approach., Trial Registration: ClinicalTrials.gov Identifier: NCT02076113.

Objective: To explore the clinical efficacy and safety of microscopy-assisted anterior corpectomy and fusion for cervical ossification of the posterior longitudinal ligament (OPLL)., Methods: A retrospective review of 32 cervical OPLL patients who underwent microscopy-assisted anterior corpectomy and fusion from June 2012 to March 2017 was carried out. Patients were evaluated with outcome metrics: Japanese Orthopaedic Association (JOA) scores (17 points method), visual analog scale (VAS), and radiographic parameters of the lordotic angle. The complications during treatment and follow-up were recorded., Results: This study included 32 patients (15 males and 17 females) with a mean age of 58.3 ± 2.9 years (range 42-68 years). The average duration of follow-up was 19.0 ± 3.5 months (range 11-46 months). The scores of postoperative VAS significantly decreased (P < 0.05). The average JOA score at 12 months postoperation significantly improved (p < 0.05). The lordotic angle increased after surgery (P < 0.05). There was no titanium mesh subsidence, no pseudarthrosis or hardware failure at 1‑year follow-up., Complications: One cerebrospinal fluid leakage in the surgery was managed using a gelatine sponge and the patient recovered after 1 week: One patient developed laryngeal nerve injury symptom of hoarseness and recovered spontaneously in 2 weeks without intervention and 1 patient suffered slight postoperative infection. There was no worsening of neurological function., Conclusion: Microscopy-assisted anterior cervical anterior surgery appears to be a safe and effective treatment option for selected cases of cervical posterior longitudinal ligament ossification.

Purpose: Anterior cervical discectomy and fusion has a low but well-established profile of adverse events. The goal of this study was to gauge surgeon opinion regarding the frequency and acceptability of these events., Methods: A 2-page survey was distributed to attendees at the 2015 Cervical Spine Research Society (CSRS) meeting. Respondents were asked to categorize 18 anterior cervical discectomy and fusion-related adverse events as either: "common and acceptable," "uncommon and acceptable," "uncommon and sometimes acceptable," or "uncommon and unacceptable." Results were compiled to generate the relative frequency of these responses for each complication. Responses for each complication event were also compared between respondents based on practice location (US vs. non-US), primary specialty (orthopedics vs. neurosurgery) and years in practice., Results: Of 150 surveys distributed, 115 responses were received (76.7% response rate), with the majority of respondents found to be US-based (71.3%) orthopedic surgeons (82.6%). Wrong level surgery, esophageal injury, retained drain, and spinal cord injury were considered by most to be unacceptable and uncommon complications. Dysphagia and adjacent segment disease occurred most often, but were deemed acceptable complications. Although surgeon experience and primary specialty had little impact on responses, practice location was found to significantly influence responses for 12 of 18 complications, with non-US surgeons found to categorize events more toward the uncommon and unacceptable end of the spectrum as compared with US surgeons., Conclusions: These results serve to aid communication and transparency within the field of spine surgery, and will help to inform future quality improvement and best practice initiatives.

Iatrogenic neurologic deficits after lumbar spine surgery are rare complications, but important to recognize and manage. Complications such as radiculopathy, spinal cord compression, motor deficits (i.e. foot drop with L5 radiculopathy), and new onset radiculitis, while uncommon do occur. Attempts at mitigating these complications with the use of neuromonitoring have been successful. Guidance in the literature as to the true rate of iatrogenic neurologic deficit is limited to several case studies and retrospective designed studies describing the management, prevention and treatment of these deficits. The authors review the lumbar spinal surgery literature to examine the incidence of iatrogenic neurologic deficit in the lumbar spinal surgery literature. An advanced MEDLINE search conducted on May 14th, 2015 from January 1, 2004 through May 14, 2015, using the following MeSH search terms "postoperative complications," then subterms "lumbar vertebrae," treatment outcome," "spinal fusion," and "radiculopathy" were included together with "postoperative complications" in a single search. Postoperative complications including radiculopathy, weakness, and spinal cord compression were included. The definition of iatrogenic neurologic complication was limited to post-operative radiculopathy, motor weakness or new onset pain/radiculitis. An advanced MEDLINE search conducted on May 14th, 2015 using all of the above terms together yielded 21 results. After careful evaluation, 11 manuscripts were excluded and 10 were carefully reviewed. The most common indications for surgery were degenerative spondylolisthesis, spondylosis, scoliosis, and lumbar stenosis. In 2783 patients in 12 total studies, there were 56 patients who had reported a postoperative neurologic deficit for a rate of 5.7. The rates of deficits ranged from 0.46% to 17% in the studies used. The average rate of reported neurologic complications within these papers was 9% (range 0.46-24%). Thirty patients of a total of 731 (4.1%) had a new onset neurologic injury after anterior lumber interbody fusion or lateral lumber interbody fusion. Thirty-seven out of 2052 (1.9%) patients had a neurologic injury after posterior decompression and fusion. Screw malposition was responsible for 11 deficits. Spinal surgery for lumbar degenerative disease carries a low but definite rate of neurologic deficits. Despite the introduction of neuromonitoring, these complications still occur. Interpretation of neurologic injury rates for lumbar surgery is limited by the few prospective and cohort-matched controlled studies. Likewise, most injuries were associated with the placement of instrumentation despite the type of approach., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Thoracic kyphosis tends to increase with age. Hyperkyphosis is defined as excessive curvature of the thoracic spine and may be associated with adverse health effects. Hyperkyphosis in isolation or as a component of degenerative kyphoscoliosis has important implications for the surgical management of adult spinal deformity. Our objective was to review the literature on the epidemiology, etiology, natural history, management, and outcomes of thoracic hyperkyphosis. We performed a narrative review of literature on thoracic hyperkyphosis and its implications for adult spinal deformity surgery. Hyperkyphosis has a prevalence of 20% to 40% and is more common in the geriatric population. The cause is multifactorial and involves an interaction between degenerative changes, vertebral compression fractures, muscular weakness, and altered biomechanics. It may be associated with adverse health consequences including impaired physical function, pain and disability, impaired pulmonary function, and increased mortality. Nonoperative management may slow the progression of kyphosis and improve function. Surgery is rarely performed for isolated hyperkyphosis in the elderly due to the associated risk, but is an option when kyphosis occurs in the context of significant deformity. In this scenario, increased thoracic kyphosis influences selection of fusion levels and overall surgical planning. Kyphosis is common in older individuals and is associated with adverse health effects and increased mortality. Current evidence suggests a role for nonoperative therapies in reducing kyphosis and delaying its progression. Isolated hyperkyphosis in the elderly is rarely treated surgically; however, increased thoracic kyphosis as a component of global spinal deformity has important implications for patient selection and operative planning.

Management of spine surgery patients with osteoporosis is challenging because of the difficulty of instrumenting and the potential complications, including nonunion and adjacent level fractures. Treatment of this patient population should involve a multidisciplinary approach including the spine surgeon, primary care physician, endocrinologist, and physical therapist. Indication for preoperative treatment before spinal fusion surgery is unclear. All patients should receive calcium and vitamin D. Hormone replacement therapy, including estrogen or selective estrogen receptor modulators, should be considered for elderly female patients with decreased bone mass. Bisphosphonates or intermittent parathyroid hormone are reserved for those with significant bone loss in the spine. Pretreatment with antiresorption medications affect bone remodeling, which is a vital part of graft incorporation and fusion. Although there have been numerous animal studies, there is limited clinical evidence. Accordingly, surgery should be delayed, if possible, to treat the osteoporosis before the intervention. Treatment may include bisphosphonates, as well as newer agents, such as recombinant parathyroid hormone. Further clinical data are needed to understand the relative advantages/disadvantage of antiresorptive vs anabolic agents, as well as the impact of administration of these medications before vs after fusion surgery. Future clinical studies will enable better understanding of the impact of current therapies on biomechanics and fusion outcomes in this unique and increasingly prevalent patient population.

Background: Surgical simulators are useful in many surgical disciplines to augment residency training. Duty hour restrictions and increasing emphasis on patient safety and attending oversight have changed neurosurgical education from the traditional apprenticeship model. The Congress of Neurological Surgeons Simulation Committee has been developing neurosurgical simulators for the purpose of enhancing resident education and assessing proficiency., Objective: To review the initial experience with an anterior cervical diskectomy and fusion (ACDF) simulator., Methods: The first ACDF training module was implemented at the 2012 Congress of Neurological Surgeons Annual Meeting. The 90-minute curriculum included a written pretest, didactics, a practical pretest on the simulator, hands-on training, a written posttest, a practical posttest, and postcourse feedback. Didactic material covered clinical indications for ACDF, comparison with other cervical procedures, surgical anatomy and approach, principles of arthrodesis and spinal fixation, and complication management. Written pretests and posttests were administered to assess baseline knowledge and evidence of improvement after the module. Qualitative evaluation of individual performance on the practical (simulator) portion was included., Results: Three neurosurgery residents, 2 senior medical students, and 1 attending neurosurgeon participated in the course. The pretest scores were an average 9.2 (range, 6-13). Posttest scores improved to 11.0 (range, 9-13; P = .03)., Conclusion: Initial experience with the ACDF simulator suggests that it may represent a meaningful training module for residents. Simulation will be an important training modality for residents to practice surgical technique and for teachers to assess competency. Further development of an ACDF simulator and didactic curriculum will require additional verification of simulator validity and reliability.

Background: Pulmonary embolism (PE) is a rare but serious event that may occur after spinal surgery., Objective: To correlate PE incidence after spinal arthrodesis with surgical approach, region of spine operated, and primary spinal pathology. To identify PE incidence trends in this population., Methods: The Nationwide Inpatient Sample was queried using ICD-9 codes (81.01-81.08) for spinal fusion procedures over a 21-year period (1988-2008). Other data points included PE occurrence, surgical approach, spinal region, surgical indication, and mortality. Multivariate and relational analyses were performed., Results: 4,505,556 patients were identified and 9530 had PE (incidence=0.2%). PE patients had higher odds of combined A/P surgical approaches than posterior approaches (OR=1.97; 95% CI=1.66-2.33), and PE incidence was higher in thoracic versus cervical or lumbar fusions (OR=2.54; 95% CI=2.14-3.02). PE was more likely with vertebral fracture (OR=1.85; 95% CI=1.53-2.23) and SCI with vertebral fracture (OR=4.59; 95% CI=3.72-5.70) than without trauma. Between 1988 and 2008, the PE incidence remained stable for patients with intervertebral disk degeneration and scoliosis, but increased for patients with vertebral fracture, and SCI with vertebral fracture. There was greater inpatient mortality with occurrence of a PE (OR=12.92; 95% CI=10.55-14.41)., Conclusion: Although the incidence of PE in spinal arthrodesis patients is only 0.2%, there is a higher incidence after combined A/P approaches, thoracic procedures, and trauma surgical procedures. Despite the overall PE incidence remaining stable since 1988, incidence steadily increased among trauma patients. Further research is needed to explain these trends, given the context of changing patient populations and improving surgical techniques and prophylaxis measures. Greater caution and prophylaxis among trauma patients may be warranted., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Object: Prospective examination of perioperative complications in spine surgery is limited in the literature. The authors prospectively collected data on patients who underwent spinal fusion at a tertiary care center and evaluated the effect of spinal fusion and comorbidities on perioperative complications., Methods: Between May and December 2008 data were collected prospectively in 248 patients admitted to the authors' institution for spine surgery. The 202 patients undergoing spine surgery with instrumentation were further analyzed in this report. Perioperative complications occurring within the initial 30 days after surgery were included. All adverse occurrences, whether directly related to surgery, were included in the analysis., Results: Overall, 114 (56.4%) of 202 patients experienced at least one perioperative complication. Instrumented fusions were associated with more minor complications (p = 0.001) and more overall complications (0.0024). Furthermore, in the thoracic and lumbar spine, complications increased based on the number of levels fused. Advanced patient age and certain comorbidities such as diabetes, cardiac disease, or a history of malignancy were also associated with an increased incidence of complications., Conclusions: Using a prospective methodology with a broad definition of complications, the authors report a significantly higher perioperative incidence of complications than previously indicated after spinal fusion procedures. Given the increased application of instrumentation, especially for degenerative disease, a better estimate of clinically relevant surgical complications could aid spine surgeons and patients in an individualized complication index to facilitate a more thorough risk-benefit analysis prior to surgery.

Study Design: Clinically based systematic review., Objective: To define optimal clinical care for elderly patients with Type II and III odontoid fractures using a systematic review with expert opinion., Summary of Background Data: Numerous manuscripts have been written about treatment strategies of odontoid fractures in the elderly. However, these articles are of low quality and optimal treatment algorithms do not exist., Methods: Focused questions on the treatment of elderly patients with Type II and III odontoid fractures were refined by a panel of spine traumologists surgeons, consisting of fellowship trained neurologic and orthopedic surgeons. MeSH keywords were searched through MEDLINE, EMBASE, and the Cochrane Database of Systematic reviews, and pertinent abstracts and manuscripts obtained. The quality of literature was rated as high, moderate, low, or very low. Using the GRADE evidence-based review system, the proposed questions were answered using the literature review and expert opinion. These treatment recommendations were then rated as either strong or weak based on the quality of evidence and clinical expertise., Results: The literature searches revealed low and very low quality evidence with no prospective or randomized studies. The MEDLINE search engine returned 1759 articles, which were further limited to "all aged (65 and over)," human subjects and the English language. The subsequent search resulted in a return of 377 manuscripts. These abstracts where then reviewed in detail and 117 manuscripts were selected, which were obtained and supplemented with additional manuscripts to form an evidentiary table., Conclusion: Odontoid fractures have a significant morbidity in the elderly (>65 years) population. Type II fractures in this population are recommended to be treated operatively with a weak recommendation, and if treated nonoperatively using a hard collar immobilization device. Type III odontoid fractures in the elderly optimal treatment with a strong recommendation is immobilization in a hard collar.

Commentary on: Cunningham BW, Dawson JM, Hu N, et al. Preclinical evaluation of the Dynesys posterior spinal stabilization system: a nonhuman primate model. Spine J 2010;10:775-83 (in this issue)., (Published by Elsevier Inc.)

Study Design: An illustrative technique display and discussions., Objectives: Review of traditional and new "anatomic" techniques for placement of iliac-spinal fixation., Summary of Background Data: Placement of iliac fixation traditionally has been performed using offset connectors, devascularizing the iliac muscles, in addition to the posterior iliac spine. The technique reviewed provides for the screw heads to be placed in a more anatomic position, allowing rods to be laid parallel without the detachment of the erector spinous muscles., Methods: Utilization of anatomic models and discussion of present surgical technique for iliac bolt fixation (traditional) compared and contrasted to newer technique using the anatomic landmarks and structures of the iliac crest., Results: The anatomic models illustrate and support the utilization of an anatomic technique for fixation due to the lessening of muscle trauma, alignment of the rod systems, and preservation of the cortical surfaces., Conclusions: The anatomic placement of iliac bolts provides for improved alignment of constructs while addressing spinal deformities. It may also increase screw pullout and construct strength.

Background: Femoral nerve palsy is not a common adverse effect of lumbar spinal surgery., Objective: To report 3 unique cases of femoral nerve neuropathy due to instrumentation and positioning during complex anterior and posterior spinal surgery., Methods: Case series, Results: All 3 patients demonstrated femoral nerve neuropathy. The first patient presented postoperatively but after 6 months, the palsy resolved. Femoral nerve malfunctioning was documented in the second and third patients intraoperatively; however, with rapid patient repositioning and removal of offending instrumentation, postoperative palsy was avoided., Conclusions: Use of motor evoked potential monitoring of the femoral nerve during surgery is vital for the prevention of future neuropathies, an avoidable complication of spinal surgery.

Study Design: Systematic review of published incidence of radiographic adjacent segment degeneration (ASDeg) and symptomatic adjacent segment disease (ASDis) after arthrodesis or total disc replacement., Objective: Assess impact of surgery method and other factors on the incidence of ASDeg and ASDis., Summary of Background Data: Twenty-seven articles, none of which were class I or II, met the inclusion criteria. Twenty involved arthrodesis (1732 patients) and 7 involved arthroplasty (758 patients). Nineteen detailed ASDeg and 16 detailed ASDis., Methods: Data were established for number of patients, gender, average patient age, incidence of ASDeg and ASDis, average time to follow-up, and level and type of surgery. Multivariate logistic regression was used to identify which parameters had a significant effect on the incidence of ASDeg and ASDis., Results: Three hundred fourteen of 926 patients in the arthrodesis group (34%) and 31 out of 313 patients in the total disc replacement group (9%) developed ASDeg. (P < 0.0001) Multivariate logistic regression indicated that higher odds of ASDeg were associated with: older patients (P < 0.001); arthodesis (P = 0.0008); and longer follow-up (P = 0.0025). For ASDis, 173/1216 (14%) arthrodesis patients developed ASDis compared to 7/595 (1%) of arthroplasty patients (P < 0.0001). Using multivariate logistic regression, higher odds of ASDis were seen in studies with fusion (P < 0.0001), higher percentages of male patients (P = 0.0019), and shorter follow-up (P < 0.05)., Conclusion: Analysis of the literature suggests a correlation between fusion and the development of ASDeg compared to arthroplasty, but this association is dampened by the influence of patient age. There is a stronger correlation between fusion and ASDis compared to arthroplasty. The data supports only a class C recommendation (lowest tier) for the use of arthroplasty to reduce ASDis and disc degeneration compared to arthrodesis.

Study Design: A retrospective magnetic resonance imaging (MRI) review of a series of patients who underwent a single-level anterior cervical discectomy and fusion followed by anterior plate stabilization using an anterior cervical resorbable mesh plate and screw system., Objective: MRI evaluation of the long-term implant resorption properties of a bioresorbable anterior cervical plate and the adjacent peri-implant soft tissue environment., Summary of Background Data: The use of bioresorbable anterior cervical plates for immediate cervical stabilization following an anterior cervical discectomy and fusion presents several distinct advantages over metallic instrumentation. Bioresorbable polymers may diminish, by their resorbability, implant-related complications such as loosening, migration, and failure of instrumentation, as well as stress shielding of the underlying fusion. Information on the intermediate and long-term bony and soft tissue reaction to the resorption byproducts of these biomaterials is limited., Methods: There were 9 consecutive patients who underwent single-level anterior cervical decompression and fusion using allograft cortical bone, followed by bioresorbable polylactide anterior mesh plate and screw fixation. Following institutional review board approval, 5 of the 9 patients agreed to postoperative MRI assessment of the peri-implant area. An independent radiologist then characterized implant degradation, and the presence of soft tissue inflammation and swelling during the resorption phase of the bioresorbable plate., Results: At an average follow-up of 32 months, MRI assessment showed no evidence of soft tissue swelling or inflammation related to the resorption of a bioresorbable anterior plate in any of the 5 patients. In addition, none of the patients complained of any dysphagia or phonation difficulties., Conclusions: Based on MRI assessment, these devices, at more than 2-year follow-up, did not indicate any local chronic inflammation or swelling resulting from their degradation. Clinical symptoms of dysphagia or dysarthria, a common reported problem following anterior cervical spine procedures, were not observed in any patient.

Introduction: Prevertebral soft tissue swelling (PSTS) has been evaluated in the setting of traumatic cervical spine injuries. However, no study to date has quantified the PSTS following elective anterior cervical decompression and fusion or the time course to resolution of that swelling., Methods: From May 2002 to May 2005 the senior author performed 193 elective 1- or 2-level anterior cervical decompression and fusions. Patients who underwent corpectomies and anterior cervical fusions for trauma or tumor were excluded. Preoperative, 2-week postoperative and 6-week postoperative radiographs were available on 100 patients. The prevertebral soft tissue stripe was measured on the neutral lateral radiographs for the 3 time points. The mean swelling (mm) for each time point was calculated and stratified by cervical level. Repeated measures analysis of variance with the Tukey-Kramer multiple comparisons test was used to compare the measured swelling at the various time points., Results: The average PSTS was calculated for each cervical level, for each of the 3 time points, preoperative, 2- and 6-week postoperative. There was a significant increase in PSTS between the preoperative and 2-week postoperative measurements at all levels. There is a significant decrease in PSTS between 2- and 6-week postoperatively at all cervical levels. There is no significant change in PSTS at C2, C3, and C5, when comparing the preoperative and 6-week postoperative measurements. There is significant PSTS at C4, C6, and C7, when comparing preoperative and 6-week postoperative measurements., Conclusions: The "normal" range for PSTS at 2 weeks and at 6 weeks after elective 1- and 2- level anterior cervical decompression and fusions is described. Our data demonstrates that edema persists at the 2-week follow-up. By 6 weeks postoperative, the increased PSTS has greatly dissipated.

Study Design: A case of remarkable instability adjacent to an L5-S1 fusion is reported., Objectives: The objective of this study was to review a case of marked instability adjacent to a prior fusion. Diagnostic workup and surgical management options are discussed., Summary of Background Data: Junctional degeneration above or below the levels of a spinal fusion may be associated with instability. We present an unusual case of instability whose severity was only apparent when the patient was under general anesthesia., Materials and Methods: A 52-year-old man with a history of prior L5-S1 fusion presented with severe back pain and lower extremity weakness. Workup including multiple imaging methods revealed junctional degeneration and a Grade I spondylolisthesis at L4-L5 with minimal translation on dynamic imaging. Operative intervention was planned., Results: Intraoperative imaging revealed marked distraction at the L4-L5 disc space not apparent on preoperative dynamic films. The surgical approach was modified accordingly., Conclusions: Adjacent segment degeneration next to a prior lumbar fusion may be associated with extreme instability. Treatment may require complex stabilization.

Objective: To evaluate the use of guidelines for lumbar spine fusions among spine surgeons in North America. Methods: An anonymous survey was electronically sent to all AO Spine North America members. Survey respondents were asked to indicate their opinion surrounding the suitability of instrumented fusion in a variety of clinical scenarios. Fusion indications in accordance with North America Spine Society (NASS) guidelines for lumbar fusion were considered NASS-concordant answers. Respondents were considered to have a NASS-concordant approach if ≥ 70% (13 of 18) of their answers were NASS-concordant answers. Comparisons were performed using bivariable statistics. Results: A total of 105 responses were entered with complete data available on 70. Sixty percent of the respondents (n = 42) were considered compliant with NASS guidelines. NASS-discordant responses did not differ between surgeons who stated that they include the NASS guidelines in their decision-making algorithm (5.10 ± 1.96) and those that did not (4.68 ± 2.09) (p = 0.395). The greatest number of NASS-discordant answers in the United States. was in the South (5.75 ± 2.09), with the lowest number in the Northeast (3.84 ± 1.70) (p < 0.01). For 5 survey items, rates of NASS-discordant answers were ≥ 40%, with the greatest number of NASS-discordant responses observed in relation to indications for fusion in spinal deformity (80%). Spine surgeons utilizing a NASS-concordant approach had a significant lower number of NASS-discordant answers for synovial cysts (p = 0.03), axial low back pain (p < 0.01), adjacent level disease (p < 0.01), recurrent stenosis (p < 0.01), recurrent disc herniation (p = 0.01), and foraminal stenosis (p < 0.01). Conclusion: This study serves an important role in clarifying the rates of uptake of clinical practice guidelines in spine surgery as well as to identify barriers to their implementation. [ABSTRACT FROM AUTHOR]

Recent published RCTs have created uncertainty around the appropriate utilization of lumbar fusion when performing a laminectomy for symptomatic lumbar degenerative spondylolisthesis. SLIP II is an RCT that aims to determine if spinal expert review might help to optimize patient experience and outcome for patients with degenerative lumbar spondylolisthesis. To determine if use of a surgical expert review panel might improve surgical outcome for patients with symptomatic degenerative lumbar spondylolisthesis. Multicenter prospective RCT at 14 sites. A total of 273 patients with Grade I degenerative lumbar spondylolisthesis enrolled in an RCT (SLIP II) and with 1-year follow-up. EuroQol 5-D Owestery Disability Index NASS patient satisfaction index We performed a multicenter prospective RCT at 14 sites. Patients (ages 18-85) with symptomatic lumbar stenosis with degenerative spondylolisthesis were enrolled. Patients were randomized to either receive an expert panel review of their case or not. Spinal expert review consisted of 10-15 surgeons' review of patient imagines and history regarding appropriateness of fusion that was shared with both treating surgeon and patient. Patients had surgical treatment at the discretion of the treating surgeon. Analysis focused upon whether outcomes differed when surgery aligned with the majority of the panel experts or not. Analysis also focused on whether super majority consensus on treatment was associated with superior outcomes or not. Outcome assessments (EQ-5D and ODI) were assessed preoperatively, 3 months, 6 months, and 1 year. NASS patient satisfaction was also assessed at 1 year. Fourteen sites randomized 575 patients. Analysis was performed on 273 patients who had one-year follow-up available. Of these, 146 underwent review and 127 no review. Mean age was 66 years (57% female). Baseline characteristics were comparable. Fusion was performed on 210 (77%) of patients. For patients randomized to an expert review – fusion was recommended in 112/146 (77%) cases. Fusion was associated with significantly improved outcomes regardless of panel recommendation. ODI and EQ-5D outcomes for patients treated with decompression alone versus decompression and fusion were not different at one-year; ODI (20-point change vs 22-point change, respectively [p=0.594]) and EQ-5D (0.25 change vs 0.23 change, respectively [p=0.799]). A super majority (>80% consensus among experts) recommended fusion 54% of the time and decompression alone 15% of the time. Super majority recommendation for fusion aligned with actual surgery performed in 92% of cases. NASS patient satisfaction was graded at 1 (treatment met my expectations) in 83% of patients who had super majority review favoring fusion as compared to 65% of other cases (P=0.12). Supermajority recommendation for fusion was associated with 24.7-point ODI change vs 17.3-point ODI change (p= 0.024) and 0.28 change in Eq5D vs 0.19 change in Eq5D (p=0.026). Expert panel review does not reduce the number of fusion operations performed but is associated with a trend toward improved patient satisfaction at one year after surgery. Super majority vote for fusion was associated with superior patient reported outcomes. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]

Surgical site infections (SSIs) pose a significant burden to both patients and the health care system with recent focus on the identification and modification of applicable risk factors in spine surgery. However, there is a paucity of literature evaluating the clinical outcomes of patients treated for infection after spine surgery. To compare the clinical outcomes of patients who developed SSI after thoracolumbar spine surgery to an aseptic control cohort. Retrospective propensity matched case-control study. Adult patients who underwent thoracolumbar spinal fusion between March 2014 and January 2020. Oswestry Disability Index (ODI), Visual Analog Scale (VAS) Back and Leg, Physical Component (PCS) and Mental Component (MCS) of the SF-12. Structured query language query (SQL) was used to identify patients and extract patient-reported outcome measures (PROMs). Demographic data was extracted through chart review. Patients who developed an SSI were matched to a control cohort based on age, sex, body mass index (BMI), diabetes status, smoking status and race through propensity score matching. A total of 176 patients (132 Control, 44 SSI) with a mean age of 66 years, body-mass index of 34, ASA of 2.76 were included in final analysis. Both groups demonstrated significant improvements in ODI (Control: p<0.001, SSI: p=0.006), VAS Back (Control: p<0.001, SSI: p=0.002), VAS Leg (Control and SSI:p<0.001), and PCS-12 (Control:p<0.009, SSI:p=0.01) after surgery. Despite comparable preoperative and ∆ODI scores, patients who had an SSI had significantly worse postoperative ODI scores (Control:28.5, SSI: 37.5, p=0.024). ∆VAS Leg, ∆VAS Back, ∆PCS-12, and ∆MCS-12 did not differ significantly between groups with no difference in the proportion of individuals meeting MCID for VAS Leg (60.6% vs 57.1%, p=0.899), VAS Back (Control: 63.6%, SSI: 57.1%, p=0.667), PCS-12 (Control: 22.1%, SSI: 26.1%, p=0.868) or MCS-12 (Control: 20.5%, SSI: 30.4%, p=0.427). Despite the associated morbidity of infection after spine surgery, the results of this study demonstrate that patients who sustain SSI after lumbar fusion can ultimately expect similar clinical outcomes as those without postoperative complications and can be used by surgeons to help counsel patients. This abstract does not discuss or include any applicable devices or drugs. [ABSTRACT FROM AUTHOR]