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Although epidural stimulation of the lumbar spinal cord has emerged as a powerful modality for recovery of movement, how it should be targeted to the cervical spinal cord to activate arm and hand muscles is not well understood, particularly in humans. We sought to map muscle responses to posterior epidural cervical spinal cord stimulation in humans. We hypothesized that lateral stimulation over the dorsal root entry zone would be most effective and responses would be strongest in the muscles innervated by the stimulated segment. Twenty-six people undergoing clinically indicated cervical spine surgery consented to mapping of motor responses. During surgery, stimulation was performed in midline and lateral positions at multiple exposed segments; six arm and three leg muscles were recorded on each side of the body. Across all segments and muscles tested, lateral stimulation produced stronger muscle responses than midline despite similar latency and shape of responses. Muscles innervated at a cervical segment had the largest responses from stimulation at that segment, but responses were also observed in muscles innervated at other cervical segments and in leg muscles. The cervical responses were clustered in rostral (C4-C6) and caudal (C7-T1) cervical segments. Strong responses to lateral stimulation are likely due to the proximity of stimulation to afferent axons. Small changes in response sizes to stimulation of adjacent cervical segments argue for local circuit integration, and distant muscle responses suggest activation of long propriospinal connections. This map can help guide cervical stimulation to improve arm and hand function. [ABSTRACT FROM AUTHOR]

CERVICAL SPONDYLOSIS IS THE MOST COMMON NON-TRAUmatic cause of myelopathy in the cervical spine, and cervical spondylotic myelopathy (CSM) is the most frequent cause of spinal cord dysfunction. In 2000, there were 112,400 procedures performed to address degenerative cervical spine disease, a two-fold increase since 1990. The number of patients admitted with CSM doubled between 1993-2002 and 42% of these people underwent spinal fusion, which represents a seven-fold increase over this period. Hospital charges for these procedures exceeded $2 billion in 2000, representing an inflation-adjusted increase of 48%. The incidence of degenerative cervical spine disease increases with age, and as our population ages, so too will surgical treatment and hospital charges. As government and private insurers seek outcomes data and comparative effectiveness studies to use value as the primary measure driving reimbursement, it is of increasing importance to understand which procedures best treat CSM while minimizing complications and cost. Ghogawala et al reported the results of a non-randomized, prospective clinical pilot study comparing ventral and dorsal surgery for treating CSM. Data from such trials is the foundation of evidenced-based practice and guides clinical decision-making. However, study design is challenging and the constraints inherent to these kinds of studies must be understood. In this pilot investigation, 50 patients were enrolled at seven sites over 2 years (2007-09) with clinical assessments obtained pre-operatively and at 3-month, 6-month, and 1-year intervals post-operatively. A panel of 14 surgeons reviewed each patient's imaging and individually confirmed or rejected eligibility for either ventral (anterior cervical discectomy and fusion) or dorsal (laminectomy with posterior instrumentation and fusion) approach. If a majority of panel surgeons agreed, the case was considered eligible for enrollment. The treating surgeon then met with the patient and together they made the final decision regarding surgical approach. There were two significant differences between the groups. First, patients undergoing dorsal surgery had more severe myelopathy as measured by the Japanese Orthopedic Association (mJOA) score (11.6 vs 13.4; P = 0.03). Second, dorsal surgery was performed on more vertebral levels than ventral surgery (3.1 vs 2.6; P < 0.001). These differences prohibit direct comparison between the two groups and indicate that the decision to use one surgical approach vs the other was not random. Although both groups showed improvement in the mJOA scores, there was no difference in the amount of improvement when adjusting for baseline. The 30-day complication rate was not significantly different for dorsal or ventral approaches (13.6% vs 17.9%). However, the length of stay was significantly longer for the dorsal approach compared to ventral approach (4.0 vs 2.6; P < 0.01), and general health-related quality of life at 1 year improved significantly in the ventral group compared to the dorsal group on 1 of 2 measures (SF 36 Physical Component Summary vs EuroQol-5D). Finally, the mean unadjusted costs were lower for the ventral vs dorsal approach ($19,245 vs $29,465, P = 0.005). Given the difference in baseline myelopathy as assessed by the mJOA and the number of levels addressed between the two groups, drawing conclusions from these results is not possible. [ABSTRACT FROM AUTHOR]

Objective We describe our technique and evaluate clinical and radiographic outcomes for patients undergoing L4/5 posterior lumbar interbody fusion with 3D-navigation guided cortical bone trajectory screws (PLIF-CBT) for grade 1 or 2 degenerative spondylolisthesis with a minimum follow-up time of 12 months. Methods A single-institution series of 18 patients was evaluated with data prospectively collected and retrospectively analyzed. Pain and disability scores were collected preoperatively and at a minimum of 12 months postoperatively, including back and bilateral leg pain visual analog scores (VAS) and Oswestry Disability Index (ODI) scores. Radiographic fusion was assessed as complete, partial, or none based on the presence of bridging bones across the disc space, posterior elements, or both. Results Patients demonstrated statistically significant reductions in back pain VAS ( P = 0.0025), leg pain VAS ( P < 0.0001), and ODI ( P < 0.0001) at a minimum of 12 months postoperatively. Radiographic fusion at an average of 14.9 months postoperatively was available for 16/18 patients, with 6 patients demonstrating fusion (4/6 with complete fusion; 2/6 with partial fusion). There were no instances of intraoperative complications or delayed complications requiring subsequent interventions. Conclusions PLIF-CBT can be performed in a safe and reproducible fashion with excellent clinical outcomes at 1 year postoperatively. The outcomes did not correlate with fusion status, which was unexpectedly low at 37.5% without significant hardware abnormalities necessitating reoperations. PLIF-CBT offers several perioperative advantages compared with traditional open PLIF and requires longer-term studies to demonstrate its durability with regard to improvement in clinical pain and radiographic endpoints, including anterior and/or posterior element fusion. [ABSTRACT FROM AUTHOR]

Patients with single-ventricle congenital heart disease may present for scoliosis correction. These patients undergo a series of cardiac operations that create a novel circulation that has a significant impact on the management of their spinal surgery. A 21-year-old man with severe scoliosis presented for posterior T4-L3 spinal fusion. He was born with complex congenital heart disease that resulted in his having a single functioning ventricle. He underwent a series of operations culminating in a Fontan procedure to palliate his heart disease. Both the surgical procedure and the anesthetic plan were modified based on his abnormal physiology, which led to a successful correction with no complications. Patients who have undergone a Fontan procedure can successfully undergo a lengthy scoliosis correction, but it requires multidisciplinary planning. [ABSTRACT FROM AUTHOR]

It remains unclear how type of insurance coverage affects long-term, spine-specific patient-reported outcomes (PROs). This study sought to elucidate the impact of insurance on clinical outcomes after lumbar spondylolisthesis surgery. The prospective Quality Outcomes Database registry was queried for patients with grade 1 degenerative lumbar spondylolisthesis who underwent single-segment surgery. Twenty-four-month PROs were compared and included Oswestry Disability Index, Numeric Rating Scale (NRS) back pain, NRS leg pain, EuroQol-5D, and North American Spine Society Satisfaction. A total of 608 patients undergoing surgery for grade 1 degenerative lumbar spondylolisthesis (mean age, 62.5 ± 11.5 years and 59.2% women) were selected. Insurance types included private insurance (n = 319; 52.5%), Medicare (n = 235; 38.7%), Medicaid (n = 36; 5.9%), and Veterans Affairs (VA)/government (n = 17; 2.8%). One patient (0.2%) was uninsured and was removed from the analyses. Regardless of insurance status, compared to baseline, all 4 cohorts improved significantly regarding ODI, NRS-BP, NRS-LP, and EQ-5D scores (P < 0.001). In adjusted multivariable analyses, compared with patients with private insurance, Medicaid was associated with worse 24-month postoperative Oswestry Disability Index (β = 10.2; 95% confidence interval [CI], 3.9–16.5; P = 0.002) and NRS leg pain (β =1.3; 95% CI, 0.3–2.4; P = 0.02). Medicaid was associated with worse EuroQol-5D scores compared with private insurance (β = −0.07; 95% CI −0.01 to −0.14; P = 0.03), but not compared with Medicare and VA/government insurance (P > 0.05). Medicaid was associated with lower odds of reaching ODI minimal clinically important difference (odds ratio, 0.2; 95% CI, 0.03–0.7; P = 0.02) compared with VA/government insurance. NRS back pain and North American Spine Society satisfaction did not differ by insurance coverage (P > 0.05). Despite adjusting for potential confounding variables, Medicaid coverage was independently associated with worse 24-month PROs after lumbar spondylolisthesis surgery compared with other payer types. Although all improved postoperatively, those with Medicaid coverage had relatively inferior improvements. [ABSTRACT FROM AUTHOR]

Regional differences in outcomes after spine surgery are poorly understood. We assessed disability and quality-of-life outcomes by geographic region in the United States using the NeuroPoint Alliance Quality Outcomes Database. We queried the prospective Quality Outcomes Database patient registry to identify patients who underwent elective 1- or 2-level lumbar surgery for grade I degenerative spondylolisthesis from July 2014 through June 2016. Primary outcome measures included Oswestry Disability Index (ODI) and EuroQOL-5D (EQ-5D) reported at 24 months postoperatively. Differences in EQ-5D and ODI were compared across geographic regions of the United States (Northeast, Midwest, South, West). We identified 608 patients from 12 centers who underwent surgery. Of these, 517 (85.0%) had ODI data and 492 (80.9%) had EQ-5D data at 24 months. Southern states had the largest representation (304 patients; 5 centers), followed by Northeastern (114 patients; 3 centers), Midwestern (96 patients; 2 centers), and Western (94 patients; 2 centers) states. Baseline ODI scores were significantly different among regions, with the South having the greatest baseline disability burden (Northeast: 40.9 ± 16.9, South: 51.2 ± 15.8, Midwest: 40.9 ± 17.8, West: 45.0 ± 17.1, P < 0.001). The change in ODI at 24 months postoperatively was significantly different among regions, with the South showing the greatest ODI improvement (Northeast: −21.1 ± 18.2, South: −26.5 ± 20.2, Midwest: −18.2 ± 22.9, West: −21.7 ± 19.6, P < 0.001). All regions had ≥60% achievement of the minimum clinically important difference in ODI at 24 months postoperatively. No regional differences were observed for EQ-5D. Significant regional variation exists for disability outcomes, but not quality of life, at 24 months after spinal surgery for grade I degenerative spondylolisthesis. [ABSTRACT FROM AUTHOR]