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Heterotopic ossification (HO) is defined as the process by which trabecular bone forms outside of the skeletal structure, occupying space in soft tissue where it does not normally exist. The current popular prophylactic treatment modalities include non-steroidal anti-inflammatory drugs (NSAIDs) and radiation therapy, although the literature remains inconclusive as to which is superior. Additionally, both treatments can lead to adverse effects to the patient. Recently there have been several studies attempting to identify new aspects of the etiology of heterotopic bone formation and introduce new prophylactic modalities with increased efficacy and fewer side effects. For this review, we selectively retrieved articles from Medline published from 1958-2008 on the prophylaxis of HO with the aim of assisting readers in quickly grasping the current status of research and clinical aspects of HO prophylaxis. [ABSTRACT FROM AUTHOR]

Background Context: Traditionally, cervical radiculopathy is thought to present with symptoms and signs in a standard, textbook, reproducible pattern as seen in a "Netter diagram." To date, no study has directly examined cervical radicular patterns attributable to single level pathology in patients undergoing ACDF., Purpose: The purpose of this study is to examine cervical radiculopathy patterns in a surgical population and determine how often patients present with the standard textbook (ie, Netter diagram) versus nonstandard patterns., Study Design/setting: A retrospective study., Patient Sample: Patients who had single-level radiculopathy with at least 75% improvement of preoperative symptoms following ACDF were included., Outcome Measures: Epidemiologic variables were collected including age, sex, weight, body mass index, laterality of symptoms, duration of symptoms prior to operative intervention, and the presence of diabetes mellitus. The observed pattern of radiculopathy at presentation, including associated neck, shoulder, upper arm, forearm, and hand pain and/or numbness, was determined from chart review and patient-derived pain diagrams., Methods: We identified all patients with single level cervical radiculopathy operated on between March 2011 and March 2016 by six surgeons. The observed pattern of radiculopathy was compared to a standard textbook pattern of radiculopathy that strictly adheres to a dermatomal map Fisher exact test was used to analyze categorical data and Student t test was used for continuous variables. A one-way ANOVA was used to determine differences in the observed versus expected radicular pattern. A logistic regression model assessed the effect of demographic variables on presentation with a nonstandard radicular pattern., Results: Overall, 239 cervical levels were identified. The observed pattern of pain and numbness followed the standard pattern in only 54% (129 of 239; p=.35). When a nonstandard radicular pattern was present, it differed by 1.68 dermatomal levels from the standard (p<.0001). Neck pain on the radiculopathy side was the most prevalent symptom; it was found in 81% (193 of 239) of patients and did not differ by cervical level (p=.72). In a logistic regression model, none of the demographic variables of interest were found to significantly impact the likelihood of presenting with a nonstandard radicular pattern., Conclusions: Observed patterns of cervical radiculopathy only followed the standard pattern in 54% of patients and did not differ by the cervical level involved. Cervical radiculopathy often presents with a nonstandard pattern. Surgeons should think broadly when identifying causative levels because they frequently may not adhere to textbook descriptions in actual clinical practice. We observed III level of evidence., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Study Design: Prospective randomized control trial., Objective: To investigate the role of cervical collars in postoperative care following 1- and 2-level instrumented anterior cervical discectomy and fusion (ACDF)., Methods: The Cervical Spine Research Society Resident Fellow Grant funded this project. Fifty consecutive patients undergoing 1- or 2-level ACDF surgery were randomized into groups receiving either no brace or a cervical brace for 6 weeks postoperatively. Neck Disability Index scores were recorded preoperatively and at regular follow-up visits up to 1 year. Computed tomography scans were read 1 year postoperatively to determine fusion rates, and subsidence was measured as change in middle vertebral distance between initial postoperative and 6-month follow-up lateral cervical radiographs., Results: Twenty-two patients were in the no-brace group, and 22 patients were in the brace group at final follow-up, with an average age of 50 and 55 years, respectively. The no-brace group had a total of 32 operative levels, whereas the brace group had 38 operative levels. There was no statistically significant difference in 1-year postoperative Neck Disability Index scores between the brace (9.30) and no-brace (6.95) groups ( P = .28), in 6-month subsidence of all operative levels between the brace (0.85 mm) and no-brace (0.79 mm) groups ( P = .72), or in the proportion of fused levels between the brace (89%) and no-brace (97%) groups ( P = .37)., Conclusions: Our results suggest no advantage in wearing a cervical brace following 1- or 2-level ACDF surgery with respect to 1-year outcome scores, 1-year fusion rates, and 6-month subsidence., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: SK has received personal fees from Globus Medical and Zimmer. AH has received personal fees from Medtronic, Stryker, and Zimmer. SQ has received personal fees from Globus Medical, Medtronic, Stryker, Zimmer, and Orthofix Inc. These disclosures presented no conflicts of interest relevant to this research study.

Study Design: In vitro human cadaveric surgical technique study., Objective: To assess the accuracy of percutaneous pedicle screw placement in a human cadaveric model using standard fluoroscopic guidance technique, compared across varying levels of experience., Summary of Background Data: The current literature varies widely in the reported frequency of facet violation during placement of percutaneous pedicle screws. However, as of yet there are no studies examining the effect that training level has on accuracy of placement., Materials and Methods: Four surgeons with differing levels of training (PGY-2, PGY-4, fellow, attending) were evaluated on their accuracy of percutaneous placement of screws in a uniform manner. Each of the 10 cadavers was instrumented from L1 to S1 bilaterally, for a total of 120 screws. Specimens were dissected to evaluate for facet and pedicle wall violations. These were then recorded and analyzed to evaluate for correlation among participating surgeons, laterality, spinal level, and cadaver body mass index., Results: Of 120 screws placed, there were 35 total violations [26 superior articular facet violations (21.7%), 5 intra-articular facet joint violations (4.2%), and 4 pedicle breaches (3.3%)]. Among the trainees there was no difference in the likelihood of causing a violation (P=0.8863) but there was a difference when compared with the attending surgeon (P=0.0175). Laterality (P=0.1598), spinal level (P=0.3536), and body mass index (P=0.8547) did not correlate with the likelihood of a violation., Conclusions: Surgeons of differing training levels are able to safely and accurately place lumbar pedicle screws in a percutaneous manner, with a low likelihood of facet and pedicle wall violations.

Study Design: Retrospective multicenter case series study., Objective: Because cervical dural tears are rare, most surgeons have limited experience with this complication. A multicenter study was performed to better understand the presentation, treatment, and outcomes following cervical dural tears., Methods: Multiple surgeons from 23 institutions retrospectively identified 21 rare complications that occurred between 2005 and 2011, including unintentional cervical dural tears. Demographic data and surgical history were obtained. Clinical outcomes following surgery were assessed, and any reoperations were recorded. Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA), Nurick classification (NuC), and Short-Form 36 (SF36) scores were recorded at baseline and final follow-up at certain centers. All data were collected, collated, and analyzed by a private research organization., Results: There were 109 cases of cervical dural tears among 18 463 surgeries performed. In 101 cases (93%) there was no clinical sequelae following successful dural tear repair. There were statistical improvements ( P < .05) in mJOA and NuC scores, but not NDI or SF36 scores. No specific baseline or operative factors were found to be associated with the occurrence of dural tears. In most cases, no further postoperative treatments of the dural tear were required, while there were 13 patients (12%) that required subsequent treatment of cerebrospinal fluid drainage. Analysis of those requiring further treatments did not identify an optimum treatment strategy for cervical dural tears., Conclusions: In this multicenter study, we report our findings on the largest reported series (n = 109) of cervical dural tears. In a vast majority of cases, no subsequent interventions were required and no clinical sequelae were observed., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Kevin R. O'Neill reports grants from AOSpine North America during the conduct of the study; Michael G. Fehlings reports grants from AOSpine North America during the conduct of the study; Thomas E. Mroz reports other from AOSpine, grants from AOSpine North America, during the conduct of the study, personal fees from Stryker, personal fees from Ceramtec, other from Pearl Diver, outside the submitted work; Zachary A. Smith reports grants from AOSpine North America during the conduct of the study; Wellington K. Hsu reports grants from AOSpine North America during the conduct of the study, personal fees from Medtronic, personal fees from Stryker, personal fees from Bacterin, personal fees from Graftys, personal fees from Ceramtec, personal fees from Relievant, personal fees from Bioventus, personal fees from Globus, personal fees from SpineSmith, outside the submitted work; Michael P. Steinmetz reports grants from AOSpine North America during the conduct of the study; Praveen V. Mummaneni reports grants from AOSpine North America during the conduct of the study, other from Depuy Spine, grants and other from AOSpine, other from Globus, other from Springer Publishers, other from Thieme Publishers, other from Taylor and Francis Publishers, other from Spincity/ISD, outside the submitted work; Dean Chou reports grants from AOSpine North America during the conduct of the study, other from Globus, other from Orthofix, other from Medtronic, outside the submitted work; Ahmad Nassr reports grants from AOSpine North America during the conduct of the study; Sheeraz A. Qureshi reports grants from AOSpine North America during the conduct of the study, and is a consultant and receive royalties from Stryker Spine, Biomet Spine, and RTI; Evan O. Baird reports grants from AOSpine North America during the conduct of the study; Justin S. Smith reports grants from AOSpine North America during the conduct of the study, personal fees from Biomet, personal fees from Nuvasive, personal fees from Cerapedics, personal fees from K2M, personal fees from Globus, personal fees from DePuy, outside the submitted work; Christopher Shaffrey reports grants from AOSpine North America during the conduct of the study, personal fees from Biomet, personal fees from Medtronic, from Nuvasive, personal fees from K2M, personal fees from Stryker, outside the submitted work, and Editorial Board Spine, Spinal Deformity and Neurosurgery; Chadi A. Tannoury reports grants from AOSpine North America during the conduct of the study; Tony Tannoury reports grants from AOSpine North America during the conduct of the study; Ziya L. Gokaslan reports grants from AOSpine North America during the conduct of the study, grants from AOSpine North America, personal fees from AO Foundation, grants from AOSpine, outside the submitted work; Jeffrey L. Gum reports grants from AOSpine North America during the conduct of the study, personal fees from Medtronic, Alphatec, Stryker, LifeSpine, Acuity, Pacira, PAKmed, Gerson Lehrman Group, personal fees from OREF, AOSpine, personal fees from Acuity, other from Medtronic, personal fees from MiMedx, Pacira Pharmaceuticals, Alphatec, grants from Fischer Owen Fund, nonfinancial support from American Journal of Orthopaedics, nonfinancial support from American Journal of Orthopaedics, The Spine Journal, outside the submitted work; Robert A. Hart reports grants from AOSpine North America during the conduct of the study, other from CSRS Board, other from ISSLS, other from ISSG Executive Commitee, personal fees from DepuySynthes, personal fees from Globus, personal fees from Medtronic, other from Evans, Craven & Lackie, other from Benson, Bertoldo, Baker, & Carter, grants from Medtronic, grants from ISSGF, personal fees from Seaspine, personal fees from DepuySynthes, other from Spine Connect, personal fees from DepuySynthes, outside the submitted work; Robert E. Isaacs reports grants from AOSpine North America during the conduct of the study, grants and personal fees from NuVasive, Inc., personal fees from Association for Collaborative Spine research, outside the submitted work; David B. Bumpass reports grants from AOSpine North America during the conduct of the study, grants from North American Spine Society, personal fees from Doximity, personal fees from Gerson Lehrman Group, outside the submitted work; Adeeb Derakhshan reports grants from AOSpine North America during the conduct of the study; Eric M. Massicotte reports grants from AOSpine North America during the conduct of the study, grants from Medtronic, Depuy-Synthes Spine Canada, personal fees from Watermark Consulting, grants from AOSpine North America, nonfinancial support from AOSpine North America, outside the submitted work; Jonathan R. Pace reports grants from AOSpine North America during the conduct of the study; Gabriel A. Smith reports grants from AOSpine North America during the conduct of the study; Khoi D. Than reports grants from AOSpine North America during the conduct of the study; K. Daniel Riew reports personal fees from AOSpine International, other from Global Spine Journal, other from Spine Journal, other from Neurosurgery, personal fees from Multiple Entities for defense, plantiff, grants from AOSpine, grants from Cerapedics, grants from Medtronic, personal fees from AOSpine, personal fees from NASS, personal fees from Biomet, personal fees from Medtronic, non-financial support from Broadwater, outside the submitted work.

Study Design: A multicenter, retrospective review of C5 palsy after cervical spine surgery., Objective: Postoperative C5 palsy is a known complication of cervical decompressive spinal surgery. The goal of this study was to review the incidence, patient characteristics, and outcome of C5 palsy in patients undergoing cervical spine surgery., Methods: We conducted a multicenter, retrospective review of 13 946 patients across 21 centers who received cervical spine surgery (levels C2 to C7) between January 1, 2005, and December 31, 2011, inclusive. P values were calculated using 2-sample t test for continuous variables and χ 2 tests or Fisher exact tests for categorical variables., Results: Of the 13 946 cases reviewed, 59 patients experienced a postoperative C5 palsy. The incidence rate across the 21 sites ranged from 0% to 2.5%. At most recent follow-up, 32 patients reported complete resolution of symptoms (54.2%), 15 had symptoms resolve with residual effects (25.4%), 10 patients did not recover (17.0%), and 2 were lost to follow-up (3.4%)., Conclusion: C5 palsy occurred in all surgical approaches and across a variety of diagnoses. The majority of patients had full recovery or recovery with residual effects. This study represents the largest series of North American patients reviewed to date., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Sara E. Thompson reports grants from AOSpine North America during the conduct of the study; Zachary A. Smith reports grants from AOSpine North America during the conduct of the study; Wellington K. Hsu reports grants from AOSpine North America during the conduct of the study, personal fees from Medtronic, personal fees from Stryker, personal fees from Bacterin, personal fees from Graftys, personal fees from Ceramtec, personal fees from Relievant, personal fees from Bioventus, personal fees from Globus, personal fees from SpineSmith, outside the submitted work; Ahmad Nassr reports grants from AOSpine North America during the conduct of the study; Thomas E. Mroz reports other from AOSpine, grants from AOSpine North America during the conduct of the study, personal fees from Stryker, personal fees from Ceramtec, other from Pearl Diver, outside the submitted work; David E. Fish reports grants from AOSpine North America during the conduct of the study; Jeffrey C. Wang reports grants from AOSpine North America during the conduct of the study; Michael G. Fehlings reports grants from AOSpine North America during the conduct of the study; Chadi A. Tannoury reports grants from AOSpine North America during the conduct of the study; Tony Tannoury reports grants from AOSpine North America during the conduct of the study; P. Justin Tortolani reports grants from AOSpine North America during the conduct of the study, other from Globus Medical, grants from Spineology, other from Innovasis, outside the submitted work, and in addition, Dr. Tortolani has a patent Globus with royalties paid; Vincent C. Traynelis reports grants from AOSpine North America during the conduct of the study, and Medtronic – Royalties, Consultant Globus – Institutional Fellowship Support; Ziya Gokaslan reports grants from AOSpine North America during the conduct of the study, grants from AOSpine North America, personal fees from AO Foundation, grants from AOSpine, outside the submitted work; Alan S. Hilibrand reports grants from AOSpine North America during the conduct of the study, other from Amedica, Vertiflex, Benvenue, Lifespine, Paradigm Spine, PSD, Spinal Ventures, outside the submitted work, and in addition, Dr. Hilibrand has a patent Aesculap, Amedica, Biomet, Stryker, Alphatec, with royalties paid; Robert E. Isaacs reports grants from AOSpine North America during the conduct of the study, grants and personal fees from NuVasive, Inc., personal fees from Association for Collaborative Spine research, outside the submitted work; Praveen V. Mummaneni reports grants from AOSpine North America during the conduct of the study, other from Deputy Spine, grants and other from AOSpine, other from Globus, other from Springer Publishers, other from Thieme Publishers, other from Taylor and Francis Publishers, other from Spincity/ISD, outside the submitted work; Dean Chou reports grants from AOSpine North America during the conduct of the study, other from Globus, other from Medtronic, other from Orthofix, outside the submitted work; Sheeraz A. Qureshi reports grants from AOSpine North America during the conduct of the study, and is a consultant and receives royalties from Stryker Spine, Biomet Spine, and RTI; Evan O. Baird reports grants from AOSpine North America during the conduct of the study; Zorica Buser reports grants from AOSpine North America during the conduct of the study; Michelle J. Clarke reports grants from AOSpine North America during the conduct of the study; Adeeb Derakhshan reports grants from AOSpine North America during the conduct of the study; Elizabeth L. Lord reports grants from AOSpine North America during the conduct of the study; Eric M. Massicotte reports grants from AOSpine North America during the conduct of the study, grants from Medtronic, Depuy-Synthes Spine Canada, personal fees from Watermark consulting, grants from AOSpine North America, nonfinancial support from AOSpine North America, outside the submitted work; Michael P. Steinmetz reports grants from AOSpine North America during the conduct of the study; Jonathan Pace reports grants from AOSpine North America during the conduct of the study; Peter I. Cha reports grants from AOSpine North America during the conduct of the study; Erica L. Gee reports grants from AOSpine North America during the conduct of the study; D. Alex Stroh reports grants from AOSpine North America during the conduct of the study; Khoi D. Than reports grants from AOSpine North America during the conduct of the study; and K. Daniel Riew reports personal fees from AOSpine International, other from Global Spine Journal, other from Spine Journal, other from Neurosurgery, personal fees from Multiple Entities for defense, plantiff, grants from AOSpine, grants from Cerapedics, grants from Medtronic, personal fees from AOSpine, personal fees from NASS, personal fees from Biomet, personal fees from Medtronic, nonfinancial support from Broadwater, outside the submitted work; Samuel K. Cho reports grants from AOSpine North America during the conduct of the study; grants from OREF, personal fees from Stryker, from Medtronic, personal fees from DePuy Synthes, outside the submitted work; Rick C. Sasso reports grants from AOSpine North America during the conduct of the study; personal fees from medtronic, grants from medtronic, grants from K2, outside the submitted work; Paul M. Arnold reports grants from AOSpine North America during the conduct of the study; other from Z-Plasty, other from Medtronic Sofamore Danek, other from Stryker Spine, other from FzioMed, other from AOSpine North America, other from Life Spine, other from Integra Life, other from Spine Wave, other from MIEMS, other from Cerapedics, other from AOSpine North America, outside the submitted work; Mohamad Bydon reports grants from AOSpine North America during the conduct of the study; Anthony F. De Giacomo reports grants from AOSpine North America during the conduct of the study; Bruce Jobse reports grants from AOSpine North America during the conduct of the study; Daniel Lubelski reports grants from AOSpine North America during the conduct of the study; Mark Corriveau reports grants from AOSNA during the conduct of the study; Sungho Lee reports grants from AOSpine North America during the conduct of the study; Dhananjay Chatterjee reports grants from AOSpine North America during the conduct of the study; Erik N. Mayer reports grants from AOSpine North America during the conduct of the study; Owen J. McBride reports grants from AOSpine North America during the conduct of the study; Allison K. Roe reports grants from AOSpine North America during the conduct of the study; Marisa Y. Yanez reports grants from AOSpine North America during the conduct of the study.

Study Design: A multicenter retrospective case series., Objective: Horner's syndrome is a known complication of anterior cervical spinal surgery, but it is rarely encountered in clinical practice. To better understand the incidence, risks, and neurologic outcomes associated with Horner's syndrome, a multicenter study was performed to review a large collective experience with this rare complication., Methods: We conducted a retrospective multicenter case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network. Medical records for 17 625 patients who received subaxial cervical spine surgery from 2005 to 2011 were reviewed to identify occurrence of 21 predefined treatment complications. Descriptive statistics were provided for baseline patient characteristics. Paired t test was used to analyze changes in clinical outcomes at follow-up compared to preoperative status., Results: In total, 8887 patients who underwent anterior cervical spine surgery at the participating institutions were screened. Postoperative Horner's syndrome was identified in 5 (0.06%) patients. All patients experienced the complication following anterior cervical discectomy and fusion. The sympathetic trunk appeared to be more vulnerable when operating on midcervical levels (C5, C6), and most patients experienced at least a partial recovery without further treatment., Conclusions: This collective experience suggests that Horner's syndrome is an exceedingly rare complication following anterior cervical spine surgery. Injury to the sympathetic trunk may be limited by maintaining a midline surgical trajectory when possible, and performing careful dissection and retraction of the longus colli muscle when lateral exposure is necessary, especially at caudal cervical levels., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Vincent C. Traynelis reports grants from AOSpine North America during the conduct of the study, and Medtronic - Royalties, Consultant Globus - Institutional Fellowship Support; Zachary A. Smith reports grants from AOSpine North America during the conduct of the study; Wellington K. Hsu reports grants from AOSpine North America during the conduct of the study, personal fees from Medtronic, personal fees from Stryker, personal fees from Bacterin, personal fees from Graftys, personal fees from Ceramtec, personal fees from Relievant, personal fees from Bioventus, personal fees from Globus, personal fees from SpineSmith, outside the submitted work; Sheeraz A. Qureshi reports grants from AOSpine North America during the conduct of the study, and is a consultant and receives royalties from Stryker Spine, Biomet Spine, and RTI; Evan O. Baird reports grants from AOSpine North America during the conduct of the study; Robert E. Isaacs reports grants from AOSpine North America during the conduct of the study, grants and personal fees from NuVasive, Inc., personal fees from Association for Collaborative Spine research, outside the submitted work; Galina Polevaya reports grants from AOSpine North America during the conduct of the study; Justin S. Smith reports grants from AOSpine North America during the conduct of the study, personal fees from Biomet, personal fees from Nuvasive, personal fees from Cerapedics, personal fees from K2M, personal fees and other from DePuy, personal fees from Medtronic, outside the submitted work; Christopher Shaffrey reports grants from AOSpine North America during the conduct of the study, personal fees from Biomet, personal fees from Medtronic, from Nuvasive, personal fees from K2M, personal fees from Stryker, outside the submitted work, and Editorial Board Spine, Spinal Deformity and Neurosurgery; P. Justin Tortolani reports grants from AOSpine North America during the conduct of the study, other from Globus Medical, grants from Spineology, other from Innovasis, outside the submitted work, and in addition, Dr. Tortolani has a patent Globus with royalties paid; D. Alex Stroh reports grants from AOSpine North America during the conduct of the study; Michael G. Fehlings reports grants from AOSpine North America during the conduct of the study; Thomas E. Mroz reports other from AOSpine, grants from AOSpine North America, during the conduct of the study, personal fees from Stryker, personal fees from Ceramtec, other from Pearl Diver, outside the submitted work; and K. Daniel Riew reports personal fees from AOSpine International, other from Global Spine Journal, other from Spine Journal, other from Neurosurgery, personal fees from Multiple Entities for defense, plantiff , grants from AOSpine, grants from Cerapedics, grants from Medtronic, personal fees from AOSpine, personal fees from NASS, personal fees from Biomet, personal fees from Medtronic, nonfinancial support from Broadwater, outside the submitted work; Hani R. Malone reports grants from AOSpine North America during the conduct of the study; Adam S. Kanter reports grants from AOSpine North America during the conduct of the study; Samuel K. Cho reports grants from AOSpine North America during the conduct of the study; grants from OREF, personal fees from Stryker, personal fees from Medtronic, personal fees from DePuy Synthes, outside the submitted work; Ra'Kerry K. Rahman reports grants from AOSpine North America during the conduct of the study; in addition, Dr. Rahman has a patent Deformity System & Pedicle Screws pending. Paul M. Arnold reports grants from AOSpine North America during the conduct of the study; other from Z-Plasty, other from Medtronic Sofamore Danek, other from Stryker Spine, other from FzioMed, other from AOSpine North America, other from Life Spine, other from Integra Life, other from Spine Wave, other from MIEMS, other from Cerapedics, other from AOSpine North America, outside the submitted work.

Study Design: Multicenter retrospective study., Objectives: To investigate the risk of symptomatic recurrent laryngeal nerve palsy (RLNP) following cervical spine surgery, to examine risk factors for its development, and to report its treatment and outcomes., Methods: A multicenter study from 21 high-volume surgical centers from the AOSpine North America Clinical Research Network was performed. Each center screened for rare complications following cervical spine surgery, including RLNP. Patients were included if they underwent cervical spine surgery (levels from C2 to C7) between January 1, 2005 and December 31, 2011. Data were analyzed with regard to complication treatment and outcome. Cases were compared to a control group from the AOSpine CSM and CSM-I studies., Results: Three centers reported 19 cases of RLNP from a cohort of 1345 patients. The reported incidence of RLNP ranged from 0.6% to 2.9% between these 3 centers. Fifteen patients (79%) in the RLNP group were approached from the left side. Ten patients (52.6%) required treatment for RLNP-6 required medical therapy (steroids), 1 interventional treatment (injection laryngoplasty), and 3 conservative therapy (speech therapy). When examining outcomes, 73.7% (14/19) of cases resolved completely, 15.8% (3/19) resolved with residual effects, and in 10.5% (2/19) of cases this could not be determined., Conclusions: In this multicenter study examining rare complications following cervical spine surgery, the risk of RLNP after cervical spine surgery ranged from 0.6% to 2.9% between centers. Though rare, it was found that 16% of patients may experience partial resolution with residual effects, and 74% resolve completely., Competing Interests: Declaration of Conflicting Interests: The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Ziya L. Gokaslan reports grants from AOSpine North America, personal fees from AO Foundation, grants from AOSpine, outside the submitted work; Zachary A. Smith reports grants from AOSpine North America during the conduct of the study; Wellington K. Hsu reports grants from AOSpine North America during the conduct of the study, personal fees from Medtronic, personal fees from Stryker, personal fees from Bacterin, personal fees from Graftys, personal fees from Ceramtec, personal fees from Relievant, personal fees from Bioventus, personal fees from Globus, personal fees from SpineSmith, outside the submitted work; Sheeraz A. Qureshi reports grants from AOSpine North America during the conduct of the study, and is a consultant and receive royalties from Stryker Spine, Biomet Spine, and RTI; Thomas E. Mroz reports other from AOSpine, during the conduct of the study, personal fees from Stryker, personal fees from Ceramtec, other from Pearl Diver, outside the submitted work; Michael Fehlings reports grants from AOSpine North America during the conduct of the study; and K. Daniel Riew reports personal fees from AOSpine International, other from Global Spine Journal, other from Spine Journal, other from Neurosurgery, personal fees from Multiple Entities for defense, plantiff, grants from AOSpine, grants from Cerapedics, grants from Medtronic, personal fees from AOSpine, personal fees from NASS, personal fees from Biomet, personal fees from Medtronic, nonfinancial support from Broadwater, outside the submitted work; Mohamad Bydon reports grants from AOSpine North America during the conduct of the study; Rafael De la Garza-Ramos reports grants from AOSpine North America during the conduct of the study; Samuel K. Cho Dr. Cho reports grants from AOSpine North America during the conduct of the study; grants from OREF, personal fees from Stryker, personal fees from Medtronic, personal fees from DePuy Synthes, outside the submitted work; Evan O. Baird reports grants from AOSpine North America during the conduct of the study; Paul M. Arnold Paul M. Arnold reports grants from AOSpine North America, during the conduct of the study; other from Z-Plasty, other from Medtronic Sofamore Danek, other from Stryker Spine, other from FzioMed, other from AOSpine North America, other from Life Spine, other from Integra Life, other from Spine Wave, other from MIEMS, other from Cerapedics, other from AOSpine North America, outside the submitted work.

Study Design: Systematic literature review and meta-analysis., Objective: This study is a meta-analysis assessing the clinical outcomes of degenerative lumbar spondylolisthesis treated with either a posterolateral fusion (PLF) or interbody fusion (IBF) SUMMARY OF BACKGROUND DATA.: Degenerative spondylolisthesis remains one of the most common reasons for which lumbar fusion is performed in the United States. Both PLF and IBF have been advanced as adequate surgical techniques that result in successful fusion and improved clinical outcomes., Methods: A systematic review of PubMed, Cochrane, and Embase was performed. The pooled results were performed by calculating the effect size based on the Hedges g standardized difference in means or odds ratio. Studies were weighted by the inverse of the variance. Heterogeneity was assessed using the Q statistic and I. Sensitivity analysis was performed through single elimination of studies. Publication bias was assessed by funnel plot assessment and the Egger-Harbord test., Results: The systematic review resulted in 865 articles. After two-reviewer assessment, five articles were found to match all of the inclusion criteria and were included in the meta-analysis. The combined effect size was found to be in favor of PLF for length of stay (P = 0.002); however, there were no differences in fusion rate, operative time, Estimated blood loss, Oswestry Disability Index, Short Form 36, Visual Analog Scale, or complication rate between PLF and IBF. All of the variables demonstrated relative homogeneity, with I < 25. The sensitivity analysis validated the results of the model and there was no publication bias detected., Conclusion: Patients with degenerative spondylolisthesis can be effectively managed with either a PLF or IBF with no significant differences in clinical outcomes or fusion rate between the two groups. Length of stay was the only variable that was found to be in favor of either group, with the PLF group demonstrating a shortened hospitalization., Level of Evidence: 3.

Study Design Systematic literature review and meta-analysis of studies published in English. Objective This study evaluated differences in outcome variables between percutaneous and open pedicle screws for traumatic thoracolumbar fractures. Methods A systematic review of PubMed, Cochrane, and Embase was performed. The variables of interest included postoperative visual analog scale (VAS) pain score, kyphosis angle, and vertebral body height, as well as intraoperative blood loss and operative time. The results were pooled by calculating the effect size based on the standardized difference in means. The studies were weighted by the inverse of the variance, which included both within- and between-study error. Confidence intervals were reported at 95%. Heterogeneity was assessed using the Q statistic and I (2). Results After two-reviewer assessment, 38 studies were eliminated. Six studies were found to meet inclusion criteria and were included in the meta-analysis. The combined effect size was found to be in favor of percutaneous fixation for blood loss and operative time (p < 0.05); however, there were no differences in vertebral body height (VBH), kyphosis angle, or VAS scores between open and percutaneous fixation. All of the studies demonstrated relative homogeneity, with I (2) < 25. Conclusions Patients with thoracolumbar fractures can be effectively managed with percutaneous or open pedicle screw placement. There are no differences in VBH, kyphosis angle, or VAS between the two groups. Blood loss and operative time were decreased in the percutaneous group, which may represent a potential benefit, particularly in the polytraumatized patient. All variables in this study demonstrated near-perfect homogeneity, and the effect is likely close to the true effect.

Background Context: The posterior cervical foraminotomy (PCF) may be performed using an open or minimally-invasive (MIS) approach using a tubular retractor. Although there are theoretical advantages such as less blood loss and shorter hospitalizations, there is no consensus in the literature regarding the best approach for treatment., Purpose: To assess clinical outcomes of PCF treated with either an open or an MIS approach using a tubular retractor., Study Design: Systematic literature review and meta-analysis of English language studies for the treatment of cervical radiculopathy treated with foraminotomy., Patient Sample: Pooled patient results from Level I studies and Level IV retrospective studies., Outcome Measures: Meta-analysis for clinical success as determined by Odom and Prolo criteria, and visual analog scale scores for arm and neck pain., Methods: A literature search of three databases was performed to identify investigations performed in the treatment of PCF with an open or MIS approach. The pooled results were performed by calculating the effect size based on the logit event rate. Studies were weighted by the inverse of the variance, which included both within and between-study errors. Confidence intervals (CIs) were reported at 95%. Heterogeneity was assessed using the Q statistic and I-squared, where I-squared is the estimate of the percentage of error due to between-study variation., Results: The initial literature search resulted in 195 articles, of which, 20 were determined as relevant on abstract review. An open foraminotomy approach was performed in six; similarly, an MIS approach was performed in three studies. The pooled clinical success rate was 92.7% (CI: 88.9, 95.3) for open foraminotomy and 94.9% (CI: 90.5, 97.4) for MIS foraminotomy, which was not statistically significant (p=.418). The open group demonstrated relative homogeneity with Q value of 7.6 and I(2) value of 34.3%; similarly, the MIS group demonstrated moderate study heterogeneity with Q value of 4.44 and I(2) value of 54.94%., Conclusions: Patients with symptomatic cervical radiculopathy from foraminal stenosis can be effectively managed with either a traditional open or an MIS foraminotomy. There is no significant difference in the pooled outcomes between the two groups., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Study Design Systematic literature review and meta-analysis. Objective This study is a meta-analysis assessing the fusion rate and the clinical outcomes of cervical pseudarthrosis treated with either a posterior or a revision anterior approach. Methods A literature search of PubMed, Cochrane, and Embase was performed. Variables of interest included fusion rate and clinical success. The effect size based on logit event rate was calculated from the pooled results. The studies were weighted by the inverse of the variance, which included both within- and between-study error. The confidence intervals were reported at 95%. Heterogeneity was assessed using the Q statistic and I (2), where I (2) is the estimate of the percentage of error due to between-study variation. Results Sixteen studies reported fusion outcomes; 10 studies reported anterior and/or posterior results. The pooled fusion success was 86.4% in the anterior group and 97.1% in the posterior group (p = 0.028). The anterior group demonstrated significant heterogeneity with Q value of 34.2 and I (2) value of 73.7%; no heterogeneity was seen in the posterior group. The clinical outcomes were reported in 10 studies, with eight reporting results of anterior and posterior approaches. The pooled clinical success rate was 77.0% for anterior and 71.7% for posterior (p = 0.55) approaches. There was significant heterogeneity in both groups (I (2) 16.1; 19.2). Conclusions Symptomatic cervical pseudarthrosis can be effectively managed with either an anterior or a posterior approach. The posterior approach demonstrates a significantly greater fusion rate compared with the anterior approach, though the clinical outcome does not differ between the two groups.

Study Design: A Markov state-transition model was developed to evaluate the cost-effectiveness of anterior cervical discectomy and fusion (ACDF) and cervical disc replacement (CDR) at 5 years., Objective: To determine the cost-effectiveness of ACDF and CDR at 5 years., Summary of Background Data: ACDF and CDR are surgical options for the treatment of an acute cervical disc herniation with associated myelopathy/radiculopathy. Cost-effectiveness analysis provides valuable information regarding which intervention will lead to a more efficient utilization of health care resources., Methods: Outcome and complication probabilities were obtained from existing literature. Physician costs were based on a fixed percentage of 140% of 2010 Medicare reimbursement. Hospital costs were determined from the Nationwide Inpatient Sample. Utilities were derived from responses to health state surveys (Short Form 36) at baseline and at 5 years from the treatment arms of the ProDisc-C trial. Incremental cost-effectiveness ratios were used to compare treatments. One-way sensitivity analyses were performed on all parameters within the model., Results: CDR generated a total 5-year cost of $102,274, whereas ACDF resulted in a 5-year cost of $119,814. CDR resulted in a generation of 2.84 quality-adjusted life years, whereas ACDF resulted in 2.81. The incremental cost-effectiveness ratio was -$557,849 per quality-adjusted life year gained. CDR remained the dominant strategy below a cost of $20,486. ACDF was found to be a cost-effective strategy below a cost of $18,607. CDR was the dominant strategy when the utility value was above 0.713. CDR remained the dominant strategy assuming an annual complication rate less than 4.37%., Conclusion: ACDF and CDR were both shown to be cost-effective strategies at 5 years. CDR was found to be the dominant treatment strategy in our model. Further long-term studies evaluating the clinical and quality-of-life outcomes of these 2 treatments are needed to further validate the model., Level of Evidence: 5.

Study Design Cross-sectional study. Objective To assess the current practices of spine surgeons performing ambulatory surgery in the United States. Methods An electronic survey was distributed to members of the International Society for the Advancement of Spine Surgery. Data were initially examined in a univariate manner; variables with a p value < 0.25 were entered into a multiple logistic regression model. All statistical analyses were performed using the SAS System software Version 9.2 (SAS Institute, Inc., Cary, North Carolina, United States). Results Overall, 84.2% of respondents performed some manner of ambulatory spine surgery, and 49.1% were investors in an ambulatory surgery center. Surgeon investors in ambulatory surgery centers were more likely to perform procedures of increased complexity than noninvestors, though limited data precluded a statistical correlation. Surgeons in private practice were more likely to perform ambulatory surgery (94.3%; p = 0.0176), and nonacademic surgeons were both more likely to invest in ambulatory surgery centers (p = 0.0024) and perform surgery at least part of the time in a surgery center (p = 0.0039). Conclusions Though the numbers were too few to calculate statistical significance, there was a trend toward the performance of high-risk procedures on an ambulatory basis being undertaken by those with investment status in an ambulatory center. It is possible that this plays a role in the decision to perform these procedures in this setting versus that of a hospital, where a patient may have better access to care should a complication arise requiring emergent assessment and treatment by a physician. This decision should divest itself of financial incentives and focus entirely on patient safety.

Study Design Retrospective population-based observational study. Objective To assess the growth of cervical spine surgery performed in an outpatient setting. Methods A retrospective study was conducted using the United States Healthcare Cost and Utilization Project's State Inpatient and Ambulatory Surgery Databases for California, New York, Florida, and Maryland from 2005 to 2009. Current Procedural Terminology, fourth revision (CPT-4) and International Classification of Diseases, ninth revision Clinical Modification (ICD-9-CM) codes were used to identify operations for degenerative cervical spine diseases in adults (age > 20 years). Disposition and complication rates were examined. Results There was an increase in cervical spine surgeries performed in an ambulatory setting during the study period. Anterior cervical diskectomy and fusion accounted for 68% of outpatient procedures; posterior decompression made up 21%. Younger patients predominantly underwent anterior fusion procedures, and patients in the eighth and ninth decades of life had more posterior decompressions. Charlson comorbidity index and complication rates were substantially lower for ambulatory cases when compared with inpatients. The majority (>99%) of patients were discharged home following ambulatory surgery. Conclusions Recently, the number of cervical spine surgeries has increased in general, and more of these procedures are being performed in an ambulatory setting. The majority (>99%) of patients are discharged home but the nature of analyzing administrative data limits accurate assessment of postoperative complications and thus patient safety. This increase in outpatient cervical spine surgery necessitates further discussion of its safety.

C5 nerve root palsy is a rare and potentially debilitating complication of cervical spine surgery. Currently, however, there are no guidelines to help surgeons to prevent or treat this complication. We carried out a systematic review of the literature to identify the causes of this complication and options for its prevention and treatment. Searches of PubMed, Embase and Medline yielded 60 articles for inclusion, most of which addressed C5 palsy as a complication of surgery. Although many possible causes were given, most authors supported posterior migration of the spinal cord with tethering of the nerve root as being the most likely. Early detection and prevention of a C5 nerve root palsy using neurophysiological monitoring and variations in surgical technique show promise by allowing surgeons to minimise or prevent the incidence of C5 palsy. Conservative treatment is the current treatment of choice; most patients make a full recovery within two years., (©2014 The British Editorial Society of Bone & Joint Surgery.)