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Purpose: Intraoperative imaging plays an increased role in support of surgical guidance and quality assurance for interventional approaches. However, image quality sufficient to detect complications and provide quantitative assessment of the surgical product is often confounded by image noise and artifacts. In this work, we translated a three‐dimensional model‐based image reconstruction (referred to as "Known‐Component Reconstruction," KC‐Recon) for the first time to clinical studies with the aim of resolving both limitations. Methods: KC‐Recon builds upon a penalized weighted least‐squares (PWLS) method by incorporating models of surgical instrumentation ("known components") within a joint image registration–reconstruction process to improve image quality. Under IRB approval, a clinical pilot study was conducted with 17 spine surgery patients imaged under informed consent using the O‐arm cone‐beam CT system (Medtronic, Littleton MA) before and after spinal instrumentation. Volumetric images were generated for each patient using KC‐Recon in comparison to conventional filtered backprojection (FBP). Imaging performance prior to instrumentation ("preinstrumentation") was evaluated in terms of soft‐tissue contrast‐to‐noise ratio (CNR) and spatial resolution. The quality of images obtained after the instrumentation ("postinstrumentation") was assessed by quantifying the magnitude of metal artifacts (blooming and streaks) arising from pedicle screws. The potential low‐dose advantages of the algorithm were tested by simulating low‐dose data (down to one‐tenth of the dose of standard protocols) from images acquired at normal dose. Results: Preinstrumentation images (at normal clinical dose and matched resolution) exhibited an average 24.0% increase in soft‐tissue CNR with KC‐Recon compared to FBP (N = 16, P = 0.02), improving visualization of paraspinal muscles, major vessels, and other soft‐tissues about the spine and abdomen. For a total of 72 screws in postinstrumentation images, KC‐Recon yielded a significant reduction in metal artifacts: 66.3% reduction in overestimation of screw shaft width due to blooming (P < 0.0001) and reduction in streaks at the screw tip (65.8% increase in attenuation accuracy, P < 0.0001), enabling clearer depiction of the screw within the pedicle and vertebral body for an assessment of breach. Depending on the imaging task, dose reduction up to an order of magnitude appeared feasible while maintaining soft‐tissue visibility and metal artifact reduction. Conclusions: KC‐Recon offers a promising means to improve visualization in the presence of surgical instrumentation and reduce patient dose in image‐guided procedures. The improved soft‐tissue visibility could facilitate the use of cone‐beam CT to soft‐tissue surgeries, and the ability to precisely quantify and visualize instrument placement could provide a valuable check against complications in the operating room (cf., postoperative CT). [ABSTRACT FROM AUTHOR]

Robotics in spinal surgery has significant potential benefits for both surgeons and patients, including reduced surgeon fatigue, improved screw accuracy, decreased radiation exposure, greater options for minimally invasive surgery, and less time required to train residents on techniques that can have steep learning curves. However, previous robotic systems have several drawbacks, which are addressed by the innovative ExcelsiusGPSTM robotic system. The robot is secured to the operating room floor, not the patient. It has a rigid external arm that facilitates direct transpedicular drilling and screw placement, without requiring K-wires. In addition, the ExcelsisuGPSTM has integrated neuronavigation, not present in other systems. It also has surveillance marker that immediately alerts the surgeon in the event of loss of registration, and a lateral force meter to alert the surgeon in the event of skiving. Here, we present the first spinal surgery performed with the assistance of this newly approved robot. The surgery was performed with excellent screw placement, minimal radiation exposure to the patient and surgeon, and the patient had a favorable outcome. We report the first operative case with the ExcelsisuGPSTM, and the first spine surgery utilizing real-time image-guided robotic assistance. [ABSTRACT FROM AUTHOR]

The differential diagnosis for postoperative back pain is broad, and conventional imaging modalities are not always conclusive. Therefore, we performed a systematic review of the literature and present case studies describing the use of single-photon emission CT (SPECT)/CT or positron emission tomography (PET)/CT in the diagnosis of back pain following spine surgery. A systematic review was conducted according to PRISMA guidelines across 5 databases. Relevant keywords included PET/CT, bone SPECT/CT, and pseudarthrosis. The studies were assessed for diagnostic accuracy of the imaging technologies. A total of 2,444 studies were screened, 91 were selected for full-text review, and 21 were ultimately included. Six retrospective studies investigated the use of SPECT/CT with a total sample size of 309 patients. Two of these studies used SPECT/CT to predict screw loosening in over 50% of patients. Eight studies examined the use of 18-fluoride sodium fluoride (18F-NaF) PET/CT. Among these studies, measures of diagnostic accuracy varied but overall demonstrated the ability of 18F-NaF PET/CT to detect screw loosening and pseudarthrosis. Seven studies examined 18F-fluorodeoxyglucose (FDG) PET/CT and supported its utility in the diagnosis of postoperative infections in the spine. PET/CT and SPECT/CT are useful in the evaluation of postoperative pain of the spine, especially in patients for whom conventional imaging modalities yield inconclusive results. More diagnostic accuracy studies with strong reference standards are needed to compare hybrid imaging to conventional imaging. [ABSTRACT FROM AUTHOR]

The article discusses the history of robotics in spine surgery. It discusses about the first robotic assisted system for spinal surgery, SpineAssist from Mazor Robotics Ltd., Casesarea, Israel that received Food and Drug Administration clearance in 2004 and presented an average error of less than 2mm in 98.3% of pedicle screws inserted. SpineAssist had a greater proportion of non-misplaced screws in comparison to freehand surgery.

Background Context: Awake spine surgery is growing in popularity, and may facilitate earlier postoperative recovery, reduced cost, and fewer complications than spine surgery conducted under general anesthesia (GA). However, trends in the adoption of awake (ie, non-GA) spine surgery have not been previously studied.Purpose: To investigate temporal trends in non-GA spine surgery utilization and outcomes in the United States.Study Design/setting: A retrospective observational study.Patient Sample: Patients undergoing cervical or lumbar decompression or/and fusion from the American College of Surgeons National Surgical Quality Improvement Program database records dated 2005-2019.Outcome Measures: The primary outcome was the adoption trends of awake cervical and lumbar spine operations from 2005 to 2019. The secondary outcomes included the outcomes trends of 30-day complications, readmission rates, and length of stay in cervical and lumbar spine operations from 2005 to 2019.Methods: Patients were stratified into two groups: GA and non-GA (regional, epidural, spinal, monitored anesthesia care/intravenous sedation). Pearson chi-square or Fisher exact test and independent-sample t test were used to compare demographics between groups. Jonckheere-Terpstra test was used to determine whether trends and outcomes of non-GA operations from 2005 to 2019 were statistically significant. No non-GA spine operations were reported in the database from 2005 to 2006.Results: We included 301,521 patients who underwent cervical or lumbar spine operations from 2005 to 2019. GA was used in 294,903 (97.8%) operations; 6,618 (2.2%) operations were non-GA. Patients in the non-GA cohort were more likely to be younger (50.1 vs 57.2 years; p<.001), less likely to have American Society of Anesthesiologists classification ≥3 (39.7% vs 48.3%; p<.001), and to have lower BMI (27.8 vs 31.5 kg/m2; p<.001), outpatient admission status (10.8% vs 4.0%; p<.001), and fewer bleeding disorders (0.0% vs 1.2%; p<.001). The proportion of non-GA spine operations increased from nearly 0% in 2005 to 2.1% in 2019. The increase in non-GA operations was statistically significant in cervical (0.0%-1.1%) and lumbar (0.0%-2.9%) operations. For non-GA lumbar operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (19.1%-5.4%, p<.05; 5.9%-2.8%, p<.05; 30.9 hours-24.9 hours, p<.05, respectively). Similarly, for non-GA cervical operations performed 2007-2019, 30-day complication rates, readmission rates, and mean length of stay all decreased (20.1%-6.1%, p<.05; 6.7%-3.7%, p<.05; 27.0-20.0 hours p<.05, respectively).Conclusions: Our trends analysis revealed increasing utilization and improved outcomes of non-GA spine surgery from 2005 to 2019; however, the proportion of non-GA spine operations remains small. Future research should investigate the barriers to adoption of non-GA spine surgery. [ABSTRACT FROM AUTHOR]

Exoscopes were recently developed as an alternative to the operative microscope (OM) and endoscope for intraoperative visualization during neurosurgery. Prior reviews studying mixed cranial and spinal surgical cohorts reported advantages with exoscope use, including improved ergonomics and teaching. In recent years, there has been an increase in exoscope research, with no updated systematic review focused exclusively on the benefits and limitations of exoscope use in spine surgery. Thus, we sought to systematically synthesize the literature related to exoscope-assisted spine surgery. A literature search was conducted using the PubMed, Embase, Scopus, Cochrane, and Web of Science databases to identify relevant studies reported between 2010 and September 2023. Data, such as the exoscope model used, procedure types performed, and user observations, were then collected. A total of 31 studies met our inclusion criteria, including 481 patients with spine pathologies who underwent a surgical procedure using 1 of 9 exoscope models. The lumbar region was the most frequently operated area (n = 234; 48.6%), and discectomies comprised the most overall procedures (n = 273; 56.8%). All patients benefited clinically. The reported advantages of exoscopes compared with OMs or endoscopes were improved focal distance, surgeon posture, trainee education, compactness, and assistant participation. Other aspects such as stereopsis, illumination, and cost had various observations. Exoscopes have advantages compared with OMs or endoscopes during spine surgery. The user learning curve is minimal, and no negative patient outcomes have been reported. However, some aspects of exoscope use necessitate longer term prospective research before exoscopes can be considered a standard tool in the armamentarium of intraoperative visualization strategies. [ABSTRACT FROM AUTHOR]

Text message–based interventions have been demonstrated to be a valuable monitoring tool across various conditions. Here, we aimed to describe our early experience using a newly developed text message–based platform designed to track symptoms in spine surgery patients. We used the Informed Mindset Medical (IMM) platform to automatically send text messages with secure and encrypted hyperlinks to enrolled patients. Patient symptoms were monitored using well-standardized functional assessments. Limited patient data and responses were stored on a Health Insurance Portability and Accountability Act–compliant SQL cloud-based server database. In 3 months, 101 patients scheduled for elective spine surgery accepted participation in our pilot study. Overall, 71.2% of the enrolled patients responded to at least 1 preoperative baseline questionnaire. The response rates were similar across attendings, questionnaire bundles (cervical vs. thoracolumbar), genders, and age groups. The overall preoperative IMM pain scores were found to correlate positively with the preoperative electronic medical record pain rates. Similarly, the overall preoperative IMM and electronic medical record pain scores correlated positively with the IMM-collected Neck Disability Index/Oswestry Disability Index scores. From an initial 71.2%, the response rate decreased to 54.9% for the 6-week follow-up questionnaires. Our preliminary findings support the reliability of this text message–based strategy to monitor symptoms in spine surgery patients. Further studies are warranted to explore strategies to increase the response rate and expand this platform's clinical and research applicability. [ABSTRACT FROM AUTHOR]

To explore the relationship between spinal cord compression and hypertension through analysis of blood pressure (BP) variations in a cervical spondylotic myelopathy (CSM) cohort after surgical decompression, along with a review of the literature. A single-institution retrospective review of patients with CSM who underwent cervical decompression between 2016 and 2017 was conducted. Baseline clinical and imaging characteristics, preoperative and postoperative BP readings, heart rate, functional status, and pain scores were collected. In addition, a PRISMA guidelines–based systematic review was performed. We identified 264 patients with CSM treated surgically; 149 (56.4%) of these had hypertension. The degree of spinal canal compromise and spinal cord compression, preoperative neurologic examination, and the presence of T2-signal hyperintensity on magnetic resonance imaging were associated with hypertension. Overall mean arterial pressure (MAP) decreased significantly at 1 and 12 months after surgery. Patients without T2-signal hyperintensity on imaging showed a MAP reduction at 12 months postoperatively, whereas those with T2-signal hyperintensity showed a transient MAP reduction at 1 month postoperatively before returning to preoperative values. At 12 months after surgery, 24 of 97 patients (24.7%) with initially uncontrolled hypertension had controlled BP values with significant reduction of MAP, systolic BP, and diastolic BP. Including the present study, 5 articles were eligible for systematic review, with all reporting a BP decrease in patients with CSM after decompression. Analysis of our retrospective cohort and a systematic review suggest that cervical surgical decompression reduces BP in some patients with CSM. However, this improvement is less apparent in patients with preoperative spinal cord T2-signal hyperintensity. [ABSTRACT FROM AUTHOR]

Comparative effectiveness research has a vital role in health reform and policies. Specialty training is one of these provider-side variables, and surgeons performing the same procedure who were trained in different specialties may have different outcomes. The objective of this study was to investigate the impact of spine surgeon specialty (neurosurgery vs. orthopedic surgery) on early perioperative outcome measures of elective anterior/lateral lumbar interbody fusion (ALIF/LLIF) for degenerative disc diseases. In a retrospective, 1:1 propensity score–matched cohort study, 9070 patients were reviewed from the American College of Surgeons National Surgical Quality Improvement Program database. Propensity score matching and subgroup analysis were used. In both groups (single-level and multilevel ALIF/LLIF), patients operated on by neurosurgeons had longer operative time (188 minutes vs. 172 minutes/239 minutes vs. 221 minutes); shorter total hospital stay (71 hours vs. 90 hours/89 hours vs. 96 hours); and lower rates of return to the operating room (2.1% vs. 4.1%/2.4% vs. 4.2%), nonhome discharge (8.7% vs. 11.1%/10.1% vs. 14.9%), discharge after postoperative day 3 (22.0% vs. 30.0%/38.0% vs. 43.9%), and perioperative blood transfusion (2.1% vs. 5.1%/5.0% vs. 9.9%) (P < 0.05). In multilevel ALIF/LLIF, patients operated on by neurosurgeons had lower readmission rates (3.9% vs. 6.9%) (P < 0.05). Other outcome measures and mortality rates were similar between the single-level and multilevel ALIF/LLIF cohorts regardless of surgeon specialty. Our analysis found significant differences in early perioperative outcomes of patients undergoing ALIF/LLIF by neurosurgeons and orthopedic surgeons. These differences have significant clinical and cost implications for patients, physicians, program directors, payers, and health systems. [ABSTRACT FROM AUTHOR]

To investigate the effect of surgical stabilization for patients with metastatic spinal disease on objective mobility metrics. A retrospective chart review identified patients who had mechanical back pain from metastatic spinal disease and underwent spinal stabilization during 2017. Mobility metrics, the Activity Measure for Post-Acute Care (AM-PAC) inpatient mobility short form (IMSF) and the Johns Hopkins Highest Level of Mobility (JH-HLM), were reviewed. A total of 26 patients were included in the analysis with median hospital stay of 8 days. Preoperative JH-HLM scores were available for 17 patients with a mean score of 5.4, increasing to mean score of 6.6 at last follow-up (P = 0.036). Preoperative AM-PAC IMSF scores were available for 14 patients with a mean score of 19.4, decreasing slightly to a mean score of 18.7 at last follow-up (P = 0.367). Last follow-up with mobility metrics occurred a median of 6.5 days postoperatively (range: 3–66 days). Multivariable analysis showed that American Spinal Injury Association and Karnofsky Performance Status scores were significantly associated with both JH-HLM and AM-PAC mobility scores at last follow-up. A higher JH-HLM or AM-PAC score was significantly associated with direct home discharge and a higher AM-PAC score was associated with shorter hospital stay. Surgical stabilization for patients with mechanical back pain secondary to metastatic spinal disease might lead to an objective improvement in JH-HLM score. JH-HLM and AM-PAC scores may be correlated with length of hospital stay and discharge disposition. Future studies are encouraged to further characterize the role of these mobility metrics in the management plan of these patients. [ABSTRACT FROM AUTHOR]

Surgical-site infection (SSI) after spine surgery leads to increased length of stay, reoperation, and worse patient quality of life. We sought to develop a web-based calculator that computes an individual's risk of a wound infection following thoracolumbar spine surgery. We performed a retrospective review of consecutive patients undergoing elective degenerative thoracolumbar spine surgery at a tertiary-care institution between January 2016 and December 2018. Patients who developed SSI requiring reoperation were identified. Regression analysis was performed and model performance was assessed using receiver operating curve analysis to derive an area under the curve. Bootstrapping was performed to check for overfitting, and a Hosmer–Lemeshow test was employed to evaluate goodness-of-fit and model calibration. In total, 1259 patients were identified; 73% were index operations. The overall infection rate was 2.7%, and significant predictors of SSI included female sex (odds ratio [OR] 3.0), greater body mass index (OR 1.1), active smoking (OR 2.8), worse American Society of Anesthesiologists physical status (OR 2.1), and greater surgical invasiveness (OR 1.1). The prediction model had an optimism-corrected area under the curve of 0.81. A web-based calculator was created: https://jhuspine2.shinyapps.io/Wound%5fInfection%5fCalculator/. In this pilot study, we developed a model and simple web-based calculator to predict a patient's individualized risk of SSI after thoracolumbar spine surgery. This tool has a predictive accuracy of 83%. Through further multi-institutional validation studies, this tool has the potential to alert both patients and providers of an individual's SSI risk to improve informed consent, mitigate risk factors, and ultimately drive down rates of SSIs. [ABSTRACT FROM AUTHOR]

Background: C5 palsy affects approximately 5% to 10% of patients undergoing cervical spine surgery. It has a significant negative impact on patient quality-of-life outcomes and healthcare costs. Although >80% of patients improve, some are left with persistent, debilitating deficits. Our objective was to examine if electrodiagnostic testing could be used to successfully identify patients likely to experience complete, partial, and no recovery.Methods: Patients undergoing posterior cervical decompression and fusion at a single institution over a 10-year period were identified. Those experiencing postoperative C5 palsy were included. Outcomes examined included motor recovery of the affected deltoid as a function of time, and changes in electrodiagnostic testing as a function of time since injury. Electrodiagnostic testing included electromyography and was sub-analyzed by time of acquisition postinjury. Deltoid strength was graded on manual motor testing using the 5-point medical research council grading system.Results: Of 77 patients experiencing C5 palsy, 29 had postoperative electrodiagnostic testing. Patients experiencing complete recovery on average achieved functional (4/5) strength by 6-weeks post injury and 4+ per 5 strength by 6-months. Those experiencing partial recovery only achieved antigravity strength (3/5) by 6-weeks and low-function (4-/5) strength by 6-months. Electrodiagnostic testing performed 6-weeks to 6-months postinjury demonstrated that those experiencing complete recovery were more likely to have normal motor unit (MU) recruitment than those experiencing partial (p<.001) or no recovery (p=.008). The presence of ≥2+ fibrillation on tests acquired ≤6-weeks of injury identified patients unlikely to experience any recovery with a positive predictive value (PPV) of 88.9%. The presence of normal MU recruitment on tests acquired 6-weeks to 6-months postinjury identified patients likely to experience complete recovery with a PPV of 87.5%.Conclusions: Electrodiagnostic testing may be a valuable means of differentiating between patients with C5 palsy likely to experience complete, partial, or no recovery. Testing between 6-weeks and 6-months post onset may aid in identifying those least likely to have a complete recovery. No MUs at 4 to 6-months, or reduced units with strength that is not improving, portends a poor long-term outcome. In this population, peripheral nerve transfers may be considered sooner. [ABSTRACT FROM AUTHOR]

As of May 4, 2020, the coronavirus disease 2019 (COVID-19) pandemic has affected >3.5 million people and touched every inhabited continent. Accordingly, it has stressed health systems worldwide, leading to the cancellation of elective surgical cases and discussions regarding health care resource rationing. It is expected that rationing of surgical resources will continue even after the pandemic peak and may recur with future pandemics, creating a need for a means of triaging patients for emergent and elective spine surgery. Using a modified Delphi technique, a cohort of 16 fellowship-trained spine surgeons from 10 academic medical centers constructed a scoring system for the triage and prioritization of emergent and elective spine surgeries. Three separate rounds of videoconferencing and written correspondence were used to reach a final scoring system. Sixteen test cases were used to optimize the scoring system so that it could categorize cases as requiring emergent, urgent, high-priority elective, or low-priority elective scheduling. The devised scoring system included 8 independent components: neurologic status, underlying spine stability, presentation of a high-risk postoperative complication, patient medical comorbidities, expected hospital course, expected discharge disposition, facility resource limitations, and local disease burden. The resultant calculator was deployed as a freely available Web-based calculator (https://jhuspine3.shinyapps.io/SpineUrgencyCalculator/). We present the first quantitative urgency scoring system for the triage and prioritizing of spine surgery cases in resource-limited settings. We believe that our scoring system, although not all encompassing, has potential value as a guide for triaging spine surgical cases during the COVID pandemic and post-COVID period. [ABSTRACT FROM AUTHOR]

Background Context: Following spine surgery, delays in referral to rehabilitation facilities leads to increased length of hospital stay (LOS), increases costs, more risk of hospital acquired complications, and decreased patient satisfaction.Purpose: We sought to create a prediction calculator to determine the expected LOS after spine surgery and identify patients most likely to need postoperative nonhome discharge. The goal would be to facilitate earlier referral to rehabilitation and thereby ultimately shorten LOS, reduce costs, and improve patient satisfaction.Study Design: Retrospective.Patient Sample: We retrospectively reviewed all adult patients who underwent spine surgery for all indications between January and June 2018.Outcome Measures: Length of stay and discharge disposition.Methods: Demographic variables, insurance status, baseline comorbidities, narcotic use, operative characteristics, as well as postoperative length of stay and discharge disposition data were collected. Univariable and multivariable analyses were performed to identify independent predictors of LOS and discharge disposition.Results: Two hundred fifty-seven patients were included. Mean age was 59 years, 46% were females, and 52% had private insurance vs 7% with Medicaid and 41% with Medicare. The most commonly performed procedure was lumbar fusion (31.9%). Mean LOS after surgery was 4.8 days and 18% had prolonged LOS >7 days. Age, insurance type, marriage status, and surgical procedure were significantly associated with LOS and discharge disposition. The final model had an area under the curve of 89% with good discrimination. A web based calculator was developed: https://jhuspine1.shinyapps.io/RehabLOS/ CONCLUSIONS: This study established a novel pilot calculator to identify those patients most likely to be discharged to rehabilitation facilities and to predict LOS after spine surgery. Our calculator had a high predictive accuracy of 89% compared to others in the literature. With validation this tool may ultimately facilitate streamlining of the postoperative period to shorten LOS, optimize resource utilization, and improve patient care. [ABSTRACT FROM AUTHOR]

Increasing patient demand for minimally invasive surgery and increased payer emphasis on quality-based payment schema have created a need for technologies that provide consistent, high-quality outcomes for patients undergoing spine surgery. Robotic assistance is one such technology. We report our early experience with a novel real-time, image-guided robot system for use in short-segment lumbar fusion in patients diagnosed with degenerative disease. A consecutive series of patients undergoing robot-assisted 1-level or 2-level lumbar fusion procedures were compared with matched controls who underwent freehand surgery. Screw accuracy, intraoperative outcomes, and 30-day outcomes were compared. We identified 56 patients who underwent 1-level or 2-level lumbar fusion during the study period: 28 who underwent robot-assisted procedures and 28 matched controls who underwent freehand instrumentation placement. No significant differences were found between the robot-assisted surgery cohort and the freehand surgery cohort with respect to matched variables. Patients who underwent robot-assisted surgery had less intraoperative blood loss (266.1 ± 236.8 mL vs. 598.8 ± 360.2 mL; P < 0.001) and shorter hospitalizations (3.5 ± 1.8 days vs. 4.5 ± 2.0 days; P = 0.01). No differences were noted in complication rates, 30-day outcomes, or screw accuracy. Profiling of our initial series showed an average reduction in operation duration of 4.6 minutes with each additional case. Patients undergoing robot-assisted fusion experienced less intraoperative blood loss and shorter hospitalizations. The results of this initial experience suggest that an image-guided robotic system may provide similar short-term outcomes compared with freehand instrumentation placement. [ABSTRACT FROM AUTHOR]

Objective: To report five patients who underwent cervical decompressive surgeries and developed persistent postoperative neurologic deficits compatible with spinal cord infarctions and evaluate causes for these rare complications. Methods: The clinical courses and imaging studies of five patients were retrospectively analyzed. Imaging findings, types of surgeries, vascular compromise or risk factors, hypotensive episodes, intraoperative somatosensory evoked potentials, concomitant brain infarctions, and clinical degree and radiographic extent of spinal cord infarction were studied. The presence of spinal cord infarction was determined by clinical course and imaging evaluation. Results: All five patients had antecedent cervical cord region vascular compromise or generalized vascular risk factors. Four patients developed hypotensive episodes, two intraoperatively and two postoperatively. None of the four patients with hypotensive episodes had imaging or clinical evidence of concomitant brain infarctions. Conclusions: Neuroimaging evaluation of spinal cord infarction after decompressive surgery is done to exclude spinal cord compression, to ensure adequate surgical decompression, and to confirm infarction by imaging. Antecedent, unrecognized preoperative vascular compromise may be a significant contributor to spinal cord infarction by itself or in combination with hypotension. [Copyright &y& Elsevier]

Objective: To evaluate risk factors for the development of dysphagia after anterior cervical surgery. Methods: The records of 249 patients who underwent anterior cervical surgery were reviewed. The presence and severity of dysphagia were assessed with the Dysphagia Disability Index 6 weeks and 3, 6, and 12 months after surgery. Age; sex; ethnicity; cigarette smoking; previous cervical surgeries; reoperation for same pathology; type of procedure, incision, and instrumentation; number and levels involved; side of procedure, length of surgery; and use of postoperative bracing were analyzed. Results: During the first 6 months after surgery, 27 (10.8%) patients developed dysphagia. From these patients the presence of dysphagia at 6 weeks and at 3 and 6 months was 88.8%, 29.6%, and 7.4%, respectively. By 12 months, dysphagia had resolved in all cases. The mean age of patients with dysphagia was 55 years (SD 12.98) and 50 years (SD 12.07) in patients without dysphagia (P = 0.05). Dysphagic patients had an average of 2.2 (SD 1.15) levels operated compared with 1.84 (SD 0.950) in nondysphagic patients (P = 0.05). Patients who developed dysphagia were most often treated at C4-5 (67%) and C5-6 (81%: P < 0.001). Although mean operative time was slightly longer in patients with dysphagia (186 minutes) compared with those without (169 minutes), the difference was not significant. Conclusions: In our patients, the incidence of dysphagia was low, and it had completely resolved at 12 months in all cases. Risk factors for dysphagia were multilevel procedures, involvement of C4-5 and C5-6, and age. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT With the overall advancement in management of patients with human immunodeficiency virus (HIV) infection/AIDS, especially antiretroviral therapy regimens, HIV infection is now considered as a chronic disease and the longevity of these patients has significantly improved for the last two decades. As such, an increasing number of patients with HIV-infection are now potential candidates for elective surgical procedures such as spine surgery. In 2015, an estimated 1.1million adults and adolescents were living with HIV and 39,782 patients were newly diagnosed with HIV infection annually in 2016 (CDC data). Despite this increasing prevalence and incidence of the disease, the literature regarding clinical outcomes of spine surgery in patients with HIV is surprisingly scarce. As is the same as patients with other concurrent immunocompromising co-morbidities such as steroid use, diabetes mellitus, organ recipients, and/or chemo or radiation therapy, postoperative infection is one of the most concerning complications. Furthermore, bone mineral densities of HIV-infected patients are reported to be lower than noninfected controls, which could have some potential indications for worse long-term outcomes such as pseudoarthrosis. Thus, we aimed to characterize clinical outcomes of spine surgery in patients with HIV infection in order to facilitate judicious patient selection and comprehensive informed consent, which are of paramount importance in surgical decision-making processes for this high-risk cohort. PURPOSE Summarize clinical outcomes of spine surgery in patients with HIV, such as readmission rate, infectious complications, fusion rate, and mortality to address surgical indications for this specific cohort. STUDY DESIGN/SETTING Retrospective, single-center, propensity-matched cohort. PATIENT SAMPLE Patients who underwent spine surgery with HIV infection were included and compared with a matched-cohort without HIV infection OUTCOME MEASURES CD4 absolute count/uL, HIV-1 RNA copy numbers/mL, 30-day readmission rate, 90-day medical complication rate, one-year surgical site infectious complication rate, one-year fusion rate, and one-year mortality METHODS Single-center, retrospective data review from 2010 to 2016 yielded a total of 4,968 patients of spine surgery. Amongst those, 45 patients had HIV infection. Patients from the database were propensity-matched for age, sex, diagnoses, procedures, co-morbidities other than HIV at a 1:2 ratio, which yielded 90 matched-patients. Clinical outcomes of (A) 45 patients with HIV infection and (B) 90 matched-patients were compared and statistically analyzed. Intergroup comparison of binary variables was performed via Fisher's exact test. Intergroup comparison of continuous variables was achieved using unpaired t -tests. All reported p values are 2-sided and p values <.05 were regarded as statistically significant. RESULTS No statistically significant differences were noted for baseline characteristics including age, sex, diagnoses, procedures, and co-morbidities. There were no statistically significant intergroup differences in operative data such as operative time and operated levels. the HIV-infected patient group had higher rates of 30-day readmission (11.1% vs. 2.2%, P=.04), one-year surgical site infectious complication (13.3% vs. 3.3%, P=.06), and one-year pseudoarthrosis (17.8% vs. 4.4%, P=.02) as well as longer hospital stay (6.8days vs. 4.6days, p<.01) when compared with the control matched-cohort. Our post-hoc analysis only on 45 HIV-infected patients revealed that while HIV-1 RNA copy number with any cut-off values failed to predict 90-day medical complication rates, the cut-off value of CD4 absolute count <200/uL at the most recent preoperative encounter allowed us to stratify them into the two groups with regards to 90-day medical complication rates with statistical significance (44.4% (CD4<200) vs. 11.4% (CD4≥200), P=.04). CONCLUSIONS Spinal surgery in HIV-infected patients was associated with worse short- and long-term clinical outcomes, including higher rates of 30-day readmission, one-year infectious complication rate, and one-year pseudoarthrosis rate. Furthermore, CD4 absolute count may have some role in preoperative risk stratification. These results warrant further investigation of this cohort on multicenter, prospective basis, which should facilitate better patient selection for spine surgery and detailed informed consent, thereby potentially benefitting patients with HIV infection in the future. [ABSTRACT FROM AUTHOR]

BACKGROUND CONTEXT Solid organ transplant is the mainstay of treatment for a wide variety of several end-stage organ diseases. The number of patients who will benefit from it is expected to increase due to improvement in distribution system for organs from donors, the discovery of novel immunosuppressive treatment/regimens, and better per- and post-operative management of these patients in general. Hence, an increasing number of these patients are becoming reasonable candidates for subsequent, elective surgeries such as spine surgery. Even though these patients are considered to be a high-risk group for surgery generally, clinical outcomes of spine surgery in patients with solid organ transplantation are not well-documented in the current literature partly due to its substantially rare incidence. Furthermore, prolonged use of steroids as well as immunosuppressant such as cyclosporine is associated with a decrease in bone mineral density. Thus, these outcome data might be of particular importance to consider surgical options for this high-risk cohort and inform them of specific risks and complications associated with spinal surgery after organ transplantation. PURPOSE Summarize clinical outcomes of spine surgery in solid organ recipients, such as readmission rate, infectious complications, and mortality, to facilitate clinical decision-making processes for this specific cohort. STUDY DESIGN/SETTING Retrospective, single-center, propensity-matched cohort. PATIENT SAMPLE Patients who underwent spine surgery at a single institution with previous history of solid organ transplantation were included and compared with a matched-cohort without solid organ transplantation. OUTCOME MEASURES Thirty-day readmission rate, 90-day medical complication rate, one-year infectious complication rate, one-year mortality, and functional outcomes such as ambulatory status, which was rated on a four-point scale (4, independently ambulatory; 3, requiring a cane; 2, requiring a walker; and 1, wheelchair bound). METHODS Single-center, retrospective data review from 2010 to 2016 yielded a total of 4,968 patients who underwent spine surgery. Amongst those, 28 patients had a previous history of solid organ transplantation. Patients from the database were propensity-matched for age, sex, body mass index (BMI), smoking status, diagnoses, procedures, co-morbidities other than diseases which had prompted organ transplantation at 1:2 ratio, which yielded 56 matched-patients. Clinical outcomes of (A) 28 patients with organ transplantation and (B) 56 matched-patients were compared and statistically analyzed. Intergroup comparison of binary variables was performed via Fisher's exact test. Intergroup comparison of continuous variables was achieved using unpaired t -tests. All reported p values are 2-sided and p values <.05 were regarded as statistically significant. RESULTS Baseline characteristics including age, sex, BMI, smoking, diagnoses, procedures, and co-morbidities (ASA scale) were similar between the two groups with no statistically significant difference, which validated our matching methods. There were no statistically significant intergroup differences in operative data such as operative time, estimated blood loss, operated levels, and use of bone morphogenetic protein-2. In terms of functional outcomes, postoperative improvement in ambulatory status was comparable between the two groups (A) 16.7% vs. (B) 18.1%, p>.99). However, the organ-recipient group resulted in longer hospital stays (A) 7.2days vs. (B) 4.3days, p<.01), higher rates of 30-day readmission (A) 14.3% vs. (B) 7.1%, P=.04), 90-day medical complication (A) 42.8% vs. (B) 17.9%, P=.02), one-year infectious complication (A) 14.3% vs. (B) 3.6%, P=.09), one-year reoperation (A) 14.3% vs. (B) 3.6%, P=.09) as compared with the control matched-cohort. CONCLUSIONS Spinal surgery after solid organ transplantation resulted in substantially increased complication rates when compared with the matched-control group, while other variables such as baseline characteristics, operative data, and functional outcomes were similar between the two groups. Careful patient selection, meticulous perioperative care, and thorough informed consent of potential complications would be imperative when performing spine surgery on this cohort. [ABSTRACT FROM AUTHOR]