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Study Design: Anatomic study of the internal carotid artery (ICA) location with respect to C1 based on computed tomography (CT) scans with contrast medium. Objective: To measure the location of the ICA relative to the anterior aspect of C1 to assess the risk of placing C1-C2 transarticular or C1 lateral mass screws. Summary Of Background Data: Vertebral artery injury is a known risk from placement of screws in C1. A previous case report revealed an ideally placed C1-C2 transarticular screw abutting and narrowing the ICA. The risk of ICA injury from C1 screws is unknown. Methods: Fifty random head and neck CT scans with contrast medium were retrospectively analyzed. Measurements were taken bilaterally including the closest distance from the ICA lumen to C1 and the distance from the medial edge of the ICA to a line drawn along the medial border of the foramen transversarium. The risk of inserting bicortical C1-C2 transarticular and C1 lateral mass screws was estimated based on these measurements. Results: The mean distance from the ICA to C1 was 2.88 mm on the left and 2.89 mm on the right. The ICA lumen was medial to the foramen transversarium in 42 (84%) of 50 cases (mean: 2.78 mm on the left and 3.00 mm on the right). The proximity of the ICA to C1 posed moderate risk in 46% of cases and high risk in 12% (on at least one side). Conclusion: Because of the risk of ICA injury from a drill bit or the tip of a bicortical screw, we recommend preoperative CT scan with contrast medium in all cases in which a screw is to be placed into C1. If the ICA is in close proximity to the anterior border of C1, unicortical fixation or a different fusion technique should be considered. [ABSTRACT FROM AUTHOR]

STUDY DESIGN.: Review article. OBJECTIVE.: To review the epidemiology, etiology, risk factors, prevention, and treatment of neurological complications associated with cervical spine surgery. The article focuses on C5 palsy and intraoperative neurophysiological monitoring. SUMMARY OF BACKGROUND DATA.: Neurological problems are the complications most feared by patients and surgeons alike, but, fortunately, spinal cord injury is uncommon. C5 palsy is a less severe but much more common and perplexing problem. Intraoperative monitoring is widely used in cervical spine surgery, but it is unclear how effective it is at preventing spinal cord or nerve root injury. METHODS.: Narrative and review of the literature. RESULTS.: The incidence of new, severe motor weakness in 2 or more extremities occurring within 12 hours of surgery is 0.18%. The rate in the cervical spine is 3 of 1000. The incidence of isolated C5 palsy is much greater; the rate varies between 0% and 30%, depending on how the condition is defined and which patient group is being analyzed. Numerous theories have been postulated to explain the pathogenesis of C5 palsy, and preventative strategies are discussed. Approximately 70% of patients recover completely without treatment. The mean time to full recovery is 4 to 5 months. Recovery is spontaneous; no treatment has been shown to shorten the time to recovery or improve the recovery rate. A systematic review of the literature found a high level of evidence that multimodal intraoperative monitoring is effective at detecting intraoperative neurological injury. The evidence that intraoperative monitoring reduces the rate of new or worsened perioperative neurological deficits is not as strong. Algorithms help surgeons respond to monitoring alerts and manage neurological deficits that are identified postoperatively. CONCLUSION.: The keys to managing neurological complications in cervical spine surgery are prevention through careful planning, appropriate multimodal monitoring, meticulous surgical technique, and decisive action when a problem is identified. [ABSTRACT FROM AUTHOR]

Study Design: En bloc resection of a chordoma of the C5 vertebra with wide surgical margins. Objective: To present the surgical technique of total spondylectomy for a chordoma of the C5 vertebral body. Summary Of Background Data: Malignant bone tumors require wide resection. Wide resection by total en bloc spondylectomy is difficult or not feasible for malignant vertebral tumors of the cervical spine due to the peculiar anatomic complexity of this region, including the vertebral arteries and the neural structures. There are no previous reports of en bloc resection of cervical spine tumors with wide surgical margins. Methods: Using staged posterior and anterior approaches, a total en bloc spondylectomy and spine arthrodesis was performed. En bloc excision of a C5 chordoma was achieved using a threadwire T-saw (Tomita and Kawahara, Kanazawa, Japan) with surgical margins free of tumor. The patient received postoperative adjuvant proton beam radiation therapy. Results: The patient remains disease-free 9 years after the operation. Conclusion: Total en bloc spondylectomy with wide surgical margins is feasible for malignant bone tumors of the cervical spine. [ABSTRACT FROM AUTHOR]

Objective: The aims of this study were to 1) define the incidence of transforaminal lumbar interbody fusion (TLIF) interbody subsidence; 2) determine the relative importance of preoperative and intraoperative patient- and instrumentation-specific risk factors predictive of postoperative subsidence using CT-based assessment; and 3) determine the impact of TLIF subsidence on postoperative complications and fusion rates., Methods: All adult patients who underwent one- or two-level TLIF for lumbar degenerative conditions at a multi-institutional academic center between 2017 and 2019 were retrospectively identified. Patients with traumatic injury, infection, malignancy, previous fusion at the index level, combined anterior-posterior procedures, surgery with greater than two TLIF levels, or incomplete follow-up were excluded. Interbody subsidence at the superior and inferior endplates of each TLIF level was directly measured on the endplate-facing surface of both coronal and sagittal CT scans obtained greater than 6 months postoperatively. Patients were grouped based on the maximum subsidence at each operative level classified as mild, moderate, or severe based on previously documented < 2-mm, 2- to 4-mm, and ≥ 4-mm thresholds, respectively. Univariate and regression analyses compared patient demographics, medical comorbidities, preoperative bone quality, surgical factors including interbody cage parameters, and fusion and complication rates across subsidence groups., Results: A total of 67 patients with 85 unique fusion levels met the inclusion and exclusion criteria. Overall, 28% of levels exhibited moderate subsidence and 35% showed severe subsidence after TLIF with no significant difference in the superior and inferior endplate subsidence. Moderate (≥ 2-mm) and severe (≥ 4-mm) subsidence were significantly associated with decreases in cage surface area and Taillard index as well as interbody cages with polyetheretherketone (PEEK) material and sawtooth surface geometry. Severe subsidence was also significantly associated with taller preoperative disc spaces, decreased vertebral Hounsfield units (HU), the absence of bone morphogenetic protein (BMP) use, and smooth cage surfaces. Regression analysis revealed decreases in Taillard index, cage surface area, and HU, and the absence of BMP use predicted subsidence. Severe subsidence was found to be a predictor of pseudarthrosis but was not significantly associated with revision surgery., Conclusions: Patient-level risk factors for TLIF subsidence included decreased HU and increased preoperative disc height. Intraoperative risk factors for TLIF subsidence were decreased cage surface area, PEEK cage material, bullet cages, posterior cage positioning, smooth cage surfaces, and sawtooth surface designs. Severe subsidence predicted TLIF pseudarthrosis; however, the causality of this relationship remains unclear.

Multiple approaches for instrumentation of the upper cervical spine have evolved to treat atlantoaxial instability which, until the 20th century, was largely considered to be inoperable and managed nonsurgically with immobilization. Surgeons set out to provide safe and effective approaches in a clearly dangerous and technically complex anatomic region. It is important to provide a historical analysis of the evolution of techniques that have shaped C1-C2 instrumentation, and how the diligent efforts of surgeons to improve the biomechanical stability and fusion rates of their constructs eventually led to the prevailing Harms technique. This technique is explored by describing its surgical steps, alternative techniques, and associated outcomes. For successful instrumentation of the atlantoaxial joint, a comprehensive understanding of spinal biomechanics, surgical techniques, and anatomic variations is imperative for surgeons to develop a tailored plan for each patient's individual pathology and anatomy.

Objective: Malignant melanotic nerve sheath tumors are rare tumors characterized by neoplastic melanin-producing Schwann cells. In this study, the authors report their institution's experience in treating spinal and peripheral malignant melanotic nerve sheath tumors and compare their results with the literature., Methods: Data were collected from 8 patients who underwent surgical treatment for malignant melanotic nerve sheath tumors between 1996 and 2023 at Mayo Clinic and 63 patients from the literature. Time-to-event analyses were performed for the combined group of 71 cases to evaluate the risk of recurrence, metastasis, and death based on tumor location and type of treatment received. Unpaired 2-sample t-tests and Fisher's exact tests were used to determine statistical significance between groups., Results: Between 1996 and 2023, 8 patients with malignant melanotic nerve sheath tumors underwent surgery at the authors' institution, while 63 patients were identified in the literature. The authors' patients and those in the literature had the same mean age at diagnosis (43 years). At the authors' institution, 5 patients (63%) experienced metastasis, 6 patients (75%) experienced long-term recurrence, and 5 patients (62.5%) died. In the literature, most patients (60.3%) were males, with a peak incidence between the 4th and 5th decades of life. Nineteen patients (31.1%) were diagnosed with Carney complex. Nerve root tumors accounted for most presentations (n = 39, 61.9%). Moreover, 24 patients (38.1%) had intradural lesions, with 54.2% (n = 13) being intramedullary and 45.8% (n = 11) extramedullary. Most patients underwent gross-total resection (GTR) (n = 41, 66.1%), followed by subtotal resection (STR) (n = 12, 19.4%), STR with radiation therapy (9.7%), and GTR with radiation therapy (4.8%). Sixteen patients (27.6%) experienced metastasis, 23 (39.7%) experienced recurrence, and 13 (22%) died. Kaplan-Meier analyses showed no significant differences among treatment approaches in terms of recurrence-free, metastasis-free, and overall survival (p > 0.05). Similar results were obtained when looking at the differences with respect to intradural versus nerve root location of the tumor (p > 0.05)., Conclusions: Malignant melanotic nerve sheath tumors are rare tumors with a high potential for malignancy. They carry a dismal prognosis, with a pooled local recurrence rate of 42%, distant metastasis rate of 27%, and mortality rate of 26%. The findings from this study suggest a trend favoring the use of GTR alone or STR with radiation therapy over STR alone. Mortality was similar regardless, which highlights the need for the development of effective treatment options to improve survival in patients with melanotic schwannomas.

Study Design: This was a retrospective cohort study., Objective: The present study is the first to investigate whether cervical paraspinal sarcopenia is associated with cervicothoracic sagittal alignment parameters after posterior cervical fusion (PCF)., Summary of Background Data: Few studies have investigated the association between sarcopenia and postoperative outcomes after cervical spine surgery., Methods: We retrospectively reviewed patients undergoing PCF from C2-T2 at a single institution between the years 2017-2020. Two independent reviewers utilized axial cuts of T2-weighted magnetic resonance imaging sequences to perform Goutallier classification of the bilateral semispinalis cervicis (SSC) muscles. Cervical sagittal alignment parameters were compared between subgroups based upon severity of SSC sarcopenia., Results: We identified 61 patients for inclusion in this study, including 19 patients with mild SSC sarcopenia and 42 patients with moderate or severe SSC sarcopenia. The moderate-severe sarcopenia subgroup demonstrated a significantly larger change in C2-C7 sagittal vertical axis (+6.8 mm) from the 3-month to 1-year postoperative follow-up in comparison to the mild sarcopenia subgroup (-2.0 mm; P =0.02). The subgroup of patients with moderate-severe sarcopenia also demonstrated an increase in T1-T4 kyphosis (10.9-14.2, P =0.007), T1 slope (28.2-32.4, P =0.003), and C2 slope (24.1-27.3, P =0.05) from 3-month to 1-year postoperatively and a significant decrease in C1-occiput distance (6.3-4.1, P =0.002) during this same interval., Conclusions: In a uniform cohort of patients undergoing PCF from C2-T2, SSC sarcopenia was associated with worsening cervicothoracic alignment from 3-month to 1-year postoperatively., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective cohort study., Objective: The present study is the first to assess the impact of paraspinal sarcopenia on patient-reported outcome measures (PROMs) following cervical laminoplasty., Background: While the impact of sarcopenia on PROMs following lumbar spine surgery is well-established, the impact of sarcopenia on PROMs following laminoplasty has not been investigated., Methods: We performed a retrospective review of patients undergoing laminoplasty from C4-6 at a single institution between 2010 and 2021. Two independent reviewers utilized axial cuts of T2-weighted magnetic resonance imaging sequences to assess fatty infiltration of the bilateral transversospinales muscle group at the C5-6 level and classify patients according to the Fuchs Modification of the Goutalier grading system. PROMs were then compared between subgroups., Results: We identified 114 patients for inclusion in this study, including 35 patients with mild sarcopenia, 49 patients with moderate sarcopenia, and 30 patients with severe sarcopenia. There were no differences in preoperative PROMs between subgroups. Mean postoperative neck disability index scores were lower in the mild and moderate sarcopenia subgroups (6.2 and 9.1, respectively) than in the severe sarcopenia subgroup (12.9, P =0.01). Patients with mild sarcopenia were nearly twice as likely to achieve minimal clinically important difference (88.6 vs. 53.5%; P <0.001) and six times as likely to achieve SCB (82.9 vs. 13.3%; P =0.006) compared with patients with severe sarcopenia. A higher percentage of patients with severe sarcopenia reported postoperative worsening of their neck disability index (13 patients, 43.3%; P =0.002) and Visual Analog Scale Arm scores (10 patients, 33.3%; P =0.03)., Conclusion: Patients with severe paraspinal sarcopenia demonstrate less improvement in neck disability and pain postoperatively and are more likely to report worsening PROMs following laminoplasty., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Wide excision of chordoma provides better local control than intralesional resection or definitive radiotherapy. The en bloc excision of high cervical chordomas is a challenging endeavor because of the complex anatomy of this region and limited reconstructive options., Observations: This is the first case report to describe reconstruction with a free vascularized fibular graft following the en bloc excision of a chordoma involving C1-3., Lessons: This report demonstrates the durability of this construct at 10-year follow-up and is the first case report demonstrating satisfactory long-term oncological outcomes after a true margin-negative resection of a high cervical chordoma.

Study Design: Retrospective cohort study., Objective: The present study is the first to assess the impact of paraspinal sarcopenia on patient-reported outcome measures (PROMs) following posterior cervical decompression and fusion (PCDF)., Summary of Background Data: While the impact of sarcopenia on PROMs following lumbar spine surgery is well-established, the impact of sarcopenia on PROMs following PCDF has not been investigated., Materials and Methods: We performed a retrospective review of patients undergoing PCDF from C2 to T2 at a single institution between the years 2017 and 2020. Two independent reviewers who were blinded to the clinical outcome scores utilized axial cuts of T2-weighted magnetic resonance imaging sequences to assess fatty infiltration of the bilateral multifidus muscles at the C5-C6 level and classify patients according to the Fuchs Modification of the Goutalier grading system. PROMs were then compared between subgroups., Results: We identified 99 patients for inclusion in this study, including 28 patients with mild sarcopenia, 45 patients with moderate sarcopenia, and 26 patients with severe sarcopenia. There was no difference in any preoperative PROM between the subgroups. Mean postoperative Neck Disability Index scores were lower in the mild and moderate sarcopenia subgroups (12.8 and 13.4, respectively) than in the severe sarcopenia subgroup (21.0, P <0.001). A higher percentage of patients with severe multifidus sarcopenia reported postoperative worsening of their Neck Disability Index (10 patients, 38.5%; P =0.003), Visual Analog Scale Neck scores (7 patients, 26.9%; P =0.02), Patient-Reported Outcome Measurement Information System Physical Component Scores (10 patients, 38.5%; P =0.02), and Patient-Reported Outcome Measurement Information System Mental Component Scores (14 patients, 53.8%; P =0.02)., Conclusion: Patients with more severe paraspinal sarcopenia demonstrate less improvement in neck disability and physical function postoperatively and are substantially more likely to report worsening PROMs postoperatively., Level of Evidence: 3., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Patients with adolescent idiopathic scoliosis (AIS) often have reduced sagittal thoracic kyphosis (hypokyphosis) and cervical lordosis causing an uneven distribution of physiologic load. However, the long-term consequences of hypokyphosis in AIS patients have not been previously documented. To evaluate whether uneven load distribution leads to future complications in patients with AIS, we conducted a retrospective chart review and subsequently surveyed 180 patients treated for idiopathic scoliosis between 1975 and 1992. These patients all had a minimum follow-up time of 20 years since their treatment. We observed a ten-fold increase in the incidence of anterior cervical discectomy and fusion (ACDF) compared to reported rates in the non-pathologic population. Out of the 180 patients, 33 patients met the criteria and returned for follow-up radiographs. This population demonstrated a statistically significant increased rate of cervical osteoarthritis and disc degeneration. Overall, our study suggests that hypokyphosis in patients with AIS presents with increased rates of cervical spine degeneration and dysfunction, suggesting that these patients may require additional follow-up and treatment.

Objective: The purpose of this study was to identify risk factors for pseudarthrosis in patients undergoing anterior cervical discectomy and fusion (ACDF) with a focus on the role of bone mineral density (BMD) on arthrodesis., Methods: We retrospectively reviewed a prospectively collected database of patients undergoing 1- to 4-level ACDF for degenerative indications between 2012 and 2018 at a single institution. All patients were required to have undergone a preoperative dual-energy x-ray absorptiometry (DEXA) scan. Fusion status was assessed on computed tomography (CT) scans obtained 1 year postoperatively. Patients were divided into subgroups based on fusion status and compared on the basis of demographic, BMD, and surgical variables to determine risk factors for pseudarthrosis., Results: We identified 79 patients for inclusion in this study. Fusion was achieved in 65 patients (82%), while 14 patients (18%) developed pseudarthrosis. The pseudarthrosis subgroup demonstrated significantly lower BMD than their counterparts who achieved successful fusion in both mean hip (-1.4 ± 1.2 vs. -0.2 ± 1.2, respectively; P = 0.002) and spine T-scores (-0.8 ± 1.8 vs. 0.6 ± 1.9, respectively; P = 0.02). The pseudarthrosis group had a substantially higher proportion of patients with osteopenia (57.1% vs. 20.0%) and osteoporosis (21.5% vs. 6.2%; P < 0.001) than the fusion group. Multivariate analysis demonstrated osteopenia (odds ratio [OR] 8.76, P = 0.04), osteoporosis (OR 9.97, P = 0.03), and low BMD (OR 11.01, P = 0.002) to be associated with an increased likelihood of developing pseudarthrosis., Conclusions: The results of this study suggest that both osteopenia and osteoporosis are associated with increased rates of pseudarthrosis in patients undergoing elective ACDF., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Study Design: Retrospective Study., Objective: To compare methods of assessing pre-operative bone density to predict risk for osteoporosis related complications (ORC), defined as proximal junctional kyphosis, pseudarthrosis, accelerated adjacent segment disease, reoperation, compression fracture, and instrument failure following spine fusions., Methods: Chart review of primary posterior thoracolumbar or lumbar fusion patients during a 7 year period. Inclusion criteria: preoperative dual-energy x-ray absorptiometry (DXA) test within 1 year and lumbar CT scan within 6 months prior to surgery with minimum of 1 year follow-up. Exclusion criteria: <18 years at time of index procedure, infection, trauma, malignancy, skeletal dysplasia, neuromuscular disorders, or anterior-posterior procedures., Results: 140 patients were included. The average age was 67.9 years, 83 (59.3%) were female, and 45 (32%) had an ORC. There were no significant differences in patient characteristics between those with and without an ORC. Multilevel fusions were associated with ORCs (46.7% vs 26.3%, p = 0.02). Patients with ORCs had lower DXA t-scores (-1.62 vs -1.10, p = 0.003) and average Hounsfield units (HU) (112.1 vs 148.1, p ≤ 0.001). Multivariable binary logistic regression analysis showed lower average HU (Adj. OR 0.00 595% CI 0.0001-0.1713, p = 0.001) was an independent predictor of an ORC. The odds of an ORC increased by 1.7-fold for every 25 point decrease in average HU., Conclusions: The gold standard for assessing bone mineral density has been DXA t-scores, but the best predictor of ORC remains unclear. While both lower t-scores and average HU were associated with ORC, only HU was an independent predictor of ORC.

Introduction: Klippel-Feil Syndrome is the congenital fusion of at least two cervical vertebrae. Often asymptomatic, though in rare cases it may lead to severe cervical spine deformity and neurologic injury., Case Presentation: We report a case of a 48-year-old woman with a history of Klippel-Feil Syndrome and congenital scoliosis who developed progressive cervical myelopathy. She was surgically treated with anterior C5 corpectomy and arthrodesis. Pre-operative evaluation was facilitated by 3D printed models. The surgical decompression and spinal reconstruction was completed with the use of a patient-specific, custom-made cervical spine locking plate., Discussion: Pre-operative evaluation with 3D printing technology was useful in understanding the patient's complex curve pattern and in designing a patient specific implant. Custom designed implant is a reasonable option to treat cervical myelopathy associated with complex cervical deformity., (© 2022. The Author(s), under exclusive licence to International Spinal Cord Society.)

Study Design: This was a research methodology study., Objective: This review discusses the most commonly utilized consensus group methodologies for formulating clinical practice guidelines and current methods for accessing rigorous up-to-date clinical practice guidelines., Summary of Background Data: In recent years, clinical practice guidelines for the management of several conditions of the spine have emerged to provide clinicians with evidence-based best-practices. Many of these guidelines are used routinely by administrators, payers, and providers to determine the high-quality and cost-effective surgical practices. Most of these guidelines are formulated by consensus groups, which employ methodologies that are unfamiliar to most clinicians., Methods: An extensive literature review was performed. The literature was then summarized in accordance with the authors' clinical experience., Results: The Nominal Group Technique, Delphi method, and RAND-UCLA Appropriateness Model are 3 commonly utilized consensus group methodologies employed in the creation of clinical practice guidelines. Each of these methodologies has inherent advantages and disadvantages, is dependent on rigorously performed systematic reviews and meta-analyses to inform the panel of experts, and can be used to answer challenging clinical questions that remain unanswered due to a paucity of class I evidence., Conclusions: This review highlights the most commonly utilized consensus group methodologies and informs spine surgeons regarding options to access current clinical practice guidelines., Level of Evidence: Level V., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: This was a retrospective chart review., Objective: The objective of this study was to compare the effect of teriparatide on Hounsfield Units (HU) in the cervical spine, thoracic spine, lumbar spine, sacrum, and pelvis. Second, to correlate HU changes at each spinal level with bone mineral density (BMD) on dual-energy x-ray absorptiometry (DXA)., Summary of Background Data: HU represent a method to estimate BMD and can be used either separately or in conjunction with BMD from DXA., Materials and Methods: A retrospective chart review included patients who had been treated with at least 6 months of teriparatide. HU were measured in the vertebral bodies of the cervical, thoracic, and lumbosacral spine and iliac crests. Lumbar and femoral neck BMD as measured on DXA was collected when available., Results: One hundred twenty-five patients were identified for analysis with an average age of 67 years who underwent a mean (±SD) of 22±8 months of teriparatide therapy. HU improvement in the cervical spine was 11% (P=0.19), 25% in the thoracic spine (P=0.002), 23% in the lumbar spine (P=0.027), 17% in the sacrum (P=0.11), and 29% in the iliac crests (P=0.09). Lumbar HU correlated better than cervical HU with BMD as measured on DXA., Conclusions: Teriparatide increased average HU in the thoracolumbar spine to a proportionally greater extent than the cervical spine. The cervical spine had a higher baseline starting HU than the thoracolumbar spine. Lumbar HU correlated better than cervical and thoracic HU with BMD as measured on DXA., Competing Interests: J.L.F. reports being a consultant to Medtronic. A.S.S. reports being a consultant to Johnson & Johnson. B.L.C. reports receiving royalties from DePuy Synthes, Zimmer Biomet, and Wolters Kluwer, and receiving institutional support for a spine fellowship from AOSNA. B.D.E. is a consultant for Johnson & Johnson, reports receiving the support of non–study-related clinical or research effort from SI Bone and being on the scientific advisory board of Injectsense. The remaining authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: This was a retrospective cohort study., Objectives: When anterior cervical osteophytes become large enough, they may cause dysphagia. There is a paucity of work examining outcomes and complications of anterior cervical osteophyte resection for dysphagia., Methods: Retrospective review identified 19 patients who underwent anterior cervical osteophyte resection for a diagnosis of dysphagia. The mean age was 71 years and follow-up, 4.7 years. The most common level operated on was C3-C4 (13, 69%)., Results: Following anterior cervical osteophyte resection, 79% of patients had improvement in dysphagia. Five patients underwent cervical fusion; there were no episodes of delayed or iatrogenic instability requiring fusion. Fusion patients were younger (64 vs 71 years, P = .05) and had longer operative times (315 vs 121 minutes, P = .01). Age of 75 years or less trended toward improvement in dysphagia ( P = .09; OR = 18.8; 95% CI 0.7-478.0), whereas severe dysphagia trended toward increased complications ( P = .07; OR = 11.3; 95% CI = 0.8-158.5). Body mass index, use of an exposure surgeon, diffuse idiopathic skeletal hyperostosis diagnosis, surgery at 3 or more levels, prior neck surgery, and fusion were not predictive of improvement or complication., Conclusions: Anterior cervical osteophyte resection improves swallowing function in the majority of patients with symptomatic osteophytes. Spinal fusion can be added to address stenosis and other underlying cervical disease and help prevent osteophyte recurrence, whereas intraoperative navigation can be used to ensure complete osteophyte resection without breaching the cortex or entering the disc space. Because of the relatively high complication rate, patients should undergo thorough multidisciplinary workup with swallow evaluation to confirm that anterior cervical osteophytes are the primary cause of dysphagia prior to surgery.

Case: A 71-year-old woman sustained C1 lateral mass and type 2 odontoid fractures 3 years after C2-T2 anterior-posterior fusion. She was treated with C1-C4 instrumentation without fusion for 9 months followed by instrumentation removal to restore atlantoaxial motion. After instrumentation removal, she maintained clinically relevant cervical lateral bending, rotation, and flexion and extension., Conclusion: The loss of upper cervical motion after C1-C2 instrumented fusion may be debilitating for patients in the setting of previous subaxial cervical fusion. Temporary instrumentation without fusion may allow for preservation of upper cervical motion in patients with concomitant C1 and C2 fractures above a previous cervical fusion., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B441)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Introduction: This case report details the surgical treatment of an RA patient who presented with concomitant AAI and subaxial spondylotic stenosis and was subsequently treated via a C1-2 screw-rod construct, semispinalis cervicis sparing C3 laminectomy, and C4-C7 laminoplasty. Our case report is the first to describe a surgical approach for treatment of concomitant AAI and subaxial spondylotic stenosis in a patient with RA., Case Presentation: A 66-year-old male with a history of rheumatoid arthritis and atlantoaxial instability presented to an outpatient spine clinic with complaints of neck pain and worsening gait imbalance. A flexion-extension MRI revealed compression of the posterior aspect of the C1 ring on the back of the spinal cord during flexion, resulting in cord deformation; subaxial spondylosis with moderate associated stenosis and congenital narrowing from C3-7; and central cord compression with T2 signal change at C5-6. A C1-2 arthrodesis was performed and the subaxial spinal cord was then decompressed by performing a seminspinalis-sparing C3 laminectomy, C4-6 laminoplasties, and C7 dome laminectomy. Follow-up flexion-extension radiographs demonstrated satisfactory hardware position at C1-2 and full range of motion at C3-7., Discussion: This is the first study to describe the surgical management of an RA patient with concomitant AAS and subaxial spondylotic stenosis. Patients with these simultaneous pathologies can be considered for decompression caudal to the C1-2 arthrodesis, though they should be adequately counseled regarding the risk of developing SAS requiring subsequent fusion.

Objective: Pelvic incidence (PI) is a commonly utilized spinopelvic parameter in the evaluation and treatment of patients with spinal deformity and is believed to be a fixed parameter. However, a fixed PI assumes that there is no motion across the sacroiliac (SI) joint, which has been disputed in recent literature. The objective of this study was to determine if patients with SI joint vacuum sign have a change in PI between the supine and standing positions., Methods: A retrospective chart review identified patients with a standing radiograph, supine radiograph, and CT scan encompassing the SI joints within a 6-month period. Patients were grouped according to their SI joints having either no vacuum sign, unilateral vacuum sign, or bilateral vacuum sign. PI was measured by two independent reviewers., Results: Seventy-three patients were identified with an average age of 66 years and a BMI of 30 kg/m2. Patients with bilateral SI joint vacuum sign (n = 27) had an average absolute change in PI of 7.2° (p < 0.0001) between the standing and supine positions compared to patients with unilateral SI joint vacuum sign (n = 20) who had a change of 5.2° (p = 0.0008), and patients without an SI joint vacuum sign (n = 26) who experienced a change of 4.1° (p = 0.74). ANOVA with post hoc Tukey test showed a statistically significant difference in the change in PI between patients with the bilateral SI joint vacuum sign and those without an SI joint vacuum sign (p = 0.023). The intraclass correlation coefficient between the two reviewers was 0.97 for standing PI and 0.96 for supine PI (p < 0.0001)., Conclusions: Patients with bilateral SI joint vacuum signs had a change in PI between the standing and supine positions, suggesting there may be increasing motion across the SI joint with significant joint degeneration.

Case: A 41-year-old man sustained occipitocervical dislocation (OCD) and atlantoaxial dislocation (AAD) injuries in a motor vehicle collision. These injuries were treated nonoperatively with a hard cervical collar and activity restrictions with an excellent result at 4-year follow-up., Conclusion: OCD and AAD injuries require prompt diagnosis and immobilization. Standard of care for coexisting injuries is occipitocervical fusion; however, some patients have coexisting injuries which may prevent operative treatment. These polytrauma patients require a creative nonoperative approach with close follow-up to avoid neurologic decline., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B352)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Objective: Opportunistic Hounsfield unit (HU) determination from CT imaging has been increasingly used to estimate bone mineral density (BMD) in conjunction with assessments from dual energy x-ray absorptiometry (DXA). The authors sought to compare the effect of teriparatide on HUs across different regions in the pelvis, sacrum, and lumbar spine, as a surrogate measure for the effects of teriparatide on lumbosacropelvic instrumentation., Methods: A single-institution retrospective review of patients who had been treated with at least 6 months of teriparatide was performed. All patients had at least baseline DXA as well as pre- and post-teriparatide CT imaging. HUs were measured in the pedicle, lamina, and vertebral body of the lumbar spine, in the sciatic notch, and at the S1 and S2 levels at three different points (ilium, sacral body, and sacral ala)., Results: Forty patients with an average age of 67 years underwent a mean of 20 months of teriparatide therapy. Mean HUs of the lumbar lamina, pedicles, and vertebral body were significantly different from each other before teriparatide treatment: 343 ± 114, 219 ± 89.2, and 111 ± 48.1, respectively (p < 0.001). Mean HUs at the S1 level for the ilium, sacral ala, and sacral body were also significantly different from each other: 124 ± 90.1, -10.7 ± 61.9, and 99.1 ± 72.1, respectively (p < 0.001). The mean HUs at the S2 level for the ilium and sacral body were not significantly different from each other, although the mean HU at the sacral ala (-11.9 ± 52.6) was significantly lower than those at the ilium and sacral body (p = 0.003 and 0.006, respectively). HU improvement occurred in most regions following teriparatide treatment. In the lumbar spine, the mean lamina HU increased from 343 to 400 (p < 0.001), the mean pedicle HU increased from 219 to 242 (p = 0.04), and the mean vertebral body HU increased from 111 to 134 (p < 0.001). There were also significant increases in the S1 sacral body (99.1 to 130, p < 0.05), S1 ilium (124 vs 165, p = 0.01), S1 sacral ala (-10.7 vs 3.68, p = 0.04), and S2 sacral body (168 vs 189, p < 0.05)., Conclusions: There was significant regional variation in lumbar and sacropelvic HUs, with most regions significantly increasing following teriparatide treatment. The sacropelvic area had lower HU values than the lumbar spine, more regional variation, and a higher degree of correlation with BMD as measured on DXA. While teriparatide treatment resulted in HUs > 110 in the majority of the lumbosacral spine, the HUs in the sacral ala remained suggestive of severe osteoporosis, which may limit the effectiveness of fixation in this region.

Objective: The goal of this study was to compare different recognized definitions of osteoporosis in patients with degenerative lumbar spine pathology undergoing elective spinal fusion surgery to determine which patient population should be considered for preoperative optimization., Methods: A retrospective review of patients in whom lumbar spine surgery was planned at 2 academic medical centers was performed, and the rate of osteoporosis was compared based on different recognized definitions. Assessments were made based on dual-energy x-ray absorptiometry (DXA), CT Hounsfield units (HU), trabecular bone score (TBS), and fracture risk assessment tool (FRAX). The rate of osteoporosis was compared based on different definitions: 1) the WHO definition (T-score ≤ -2.5) at total hip or spine; 2) CT HU of < 110; 3) National Bone Health Alliance (NBHA) guidelines; and 4) "expanded spine" criteria, which includes patients meeting NBHA criteria and/or HU < 110, and/or "degraded" TBS in the setting of an osteopenic T-score. Inclusion criteria were adult patients with a DXA scan of the total hip and/or spine performed within 1 year and a lumbar spine CT scan within 6 months of the physician visit., Results: Two hundred forty-four patients were included. The mean age was 68.3 years, with 70.5% female, 96.7% Caucasian, and the mean BMI was 28.8. Fracture history was reported in 53.8% of patients. The proportion of patients identified with osteoporosis on DXA, HUs, NBHA guidelines, and the authors' proposed "expanded spine" criteria was 25.4%, 36.5%, 75%, and 81.9%, respectively. Of the patients not identified with osteoporosis on DXA, 31.3% had osteoporosis based on HU, 55.1% had osteoporosis with NBHA, and 70.4% had osteoporosis with expanded spine criteria (p < 0.05), with poor correlations among the different assessment tools., Conclusions: Limitations in the use of DXA T-scores alone to diagnose osteoporosis in patients with lumbar spondylosis has prompted interest in additional methods of evaluating bone health in the spine, such as CT HU, TBS, and FRAX, to inform guidelines that aim to reduce fracture risk. However, no current osteoporosis assessment was developed with a focus on improving outcomes in spinal surgery. Therefore, the authors propose an expanded spine definition for osteoporosis to identify a more comprehensive cohort of patients with potential poor bone health who could be considered for preoperative optimization, although further study is needed to validate these results in terms of clinical outcomes.

Stereotactic navigation is quickly establishing itself as the gold standard for accurate placement of spinal instrumentation and providing real-time anatomic referencing. There have been substantial improvements in computer-aided navigation over the last decade producing improved accuracy with intraoperative scanning while shortening registration time. The newest iterations of modeling software create robust maps of the anatomy while tracking software localizes instruments in multiple display modes. As a result, stereotactic navigation has become an effective adjunct to spine surgery, particularly improving instrumentation accuracy in the setting of atypical anatomy. This article provides an overview of stereotactic navigation applied to complex cervical spine surgery, details the means for registration and direct referencing, and shares our preferred methods to implement this promising technology., Competing Interests: Conflicts of Interest: The series “Advanced Techniques in Complex Cervical Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. ISA served as the unpaid Guest Editors of the series “Advanced Techniques in Complex Cervical Spine Surgery” published in Journal of Spine Surgery. The other authors have no conflicts of interest to declare., (2020 Journal of Spine Surgery. All rights reserved.)

Objective: The authors sought to assess whether Hounsfield units (HU) increase following teriparatide treatment and to compare HU increases with changes in bone mineral density (BMD) as measured by dual-energy x-ray absorptiometry (DEXA)., Methods: A retrospective chart review was performed from 1997 to 2018 across all campuses at our institution. The authors identified patients who had been treated with at least 6 months of teriparatide and compared HU and BMD as measured on DEXA scans before and after treatment., Results: Fifty-two patients were identified for analysis (46 women and 6 men, average age 67 years) who underwent an average of 20.9 ± 6.5 months of teriparatide therapy. The mean ± standard deviation HU increase throughout the lumbar spine (L1-4) was from 109.8 ± 53 to 133.9 ± 61 HU (+22%, 95% CI 1.2-46, p value = 0.039). Based on DEXA results, lumbar spine BMD increased from 0.85 to 0.93 g/cm2 (+9%, p value = 0.044). Lumbar spine T-scores improved from -2.4 ± 1.5 to -1.7 ± 1.5 (p value = 0.03). Average femoral neck T-scores improved from -2.5 ± 1.1 to -2.3 ± 1.0 (p value = 0.31)., Conclusions: Teriparatide treatment increased both HU and BMD on DEXA in the lumbar spine, without a change in femoral BMD. The 22% improvement in HU surpassed the 9% improvement determined with DEXA. These results support some surgeons' subjective sense that intraoperative bone quality following teriparatide treatment is better than indicated by DEXA results. To the authors' knowledge, this is the first study demonstrating an increase in HU with teriparatide treatment.

Study Design: A retrospective study., Objectives: (1) To assess the reliability of using the posterior endplate valley (PEV) to predict the cranial-caudal location of the cervical pedicle intraoperatively; (2) to assess the impact of age on the cervical PEV-pedicle relationship, interpedicular distance, and foraminal height., Summary of Background Data: The cervical pedicle, which is the anatomic landmark defining the boundaries of the foramen, is hidden from view intraoperatively in the anterior cervical approach, potentially leading to incomplete foraminal decompression. An intraoperative landmark which heralds the location of the pedicle and therefore can be relied upon as a guide for decompression has not been previously described., Methods: We retrospectively reviewed cervical computed tomography images of younger (<50 y) and older (>50 y) patients. Using the coronal reconstructed image taken at the posterior margin of the vertebral body, we constructed a line between the superior aspect of the pedicles and measured the distance from this line to the PEV. Interpedicular distance and foraminal height were also measured., Results: One hundred patients were included in the final analysis. The mean distance (mm) from the pedicular line to the PEV from C3 to C7 respectively was 1.0±0.99, 0.01±0.76, 0.09±0.70, 0.20±0.71, and 0.27±0.79. No significant difference between young and elderly patients was noted (P<0.05). Intervertebral foraminal size was significantly greater in younger compared with elderly patients at all levels except C2-C3. The mean interpedicular distance was 23.05±1.76 mm., Conclusions: This study demonstrates, for the first time, that the PEV is an accurate surgical landmark that is consistently at most 1 mm from the superior aspect of the cervical pedicle in the subaxial spine. Furthermore, this study demonstrated that foraminal height was significantly larger in younger compared with elderly patients at all cervical levels below C3., Level of Evidence: Level 3.

The article Is the new ASNM intraoperative neuromonitoring supervision "guideline" a trustworthy guideline? A commentary, written by Stanley A. Skinner, Elif Ilgaz Aydinlar, Lawrence F. Borges, Bob S. Carter, Bradford L. Currier, Vedran Deletis, Charles Dong, John Paul Dormans, Gea Drost, Isabel Fernandez‑Conejero, E. Matthew Hoffman, Robert N. Holdefer, Paulo Andre Teixeira Kimaid, Antoun Koht, Karl F. Kothbauer, David B. MacDonald, John J. McAuliffe III, David E. Morledge, Susan H. Morris, Jonathan Norton, Klaus Novak, Kyung Seok Park, Joseph H. Perra, Julian Prell, David M. Rippe, Francesco Sala, Daniel M. Schwartz, Martín J. Segura, Kathleen Seidel, Christoph Seubert, Mirela V. Simon, Francisco Soto, Jeffrey A. Strommen, Andrea Szelenyi, Armando Tello, Sedat Ulkatan, Javier Urriza and Marshall Wilkinson, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 05 January 2019 without open access. With the author(s)' decision to opt for Open Choice the copyright of the article changed on 30 January 2019 to © The Author(s) 2019 and the article is forthwith distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made. The original article has been corrected.

Study Design: Prospective observational cohort study., Purpose: This study aims to evaluate the safety and efficacy of bone morphogenetic protein-2 (BMP-2) in transforaminal lumbar interbody fusion (TLIF) with regard to postoperative radiculitis., Overview of Literature: Bone morphogenetic protein (BMP) is being used increasingly as an alternative to iliac crest autograft in spinal arthrodesis. Recently, the use of BMP in TLIF has been examined, but concerns exist that the placement of BMP close to the nerve roots may cause postoperative radiculitis. Furthermore, prospective studies regarding the use of BMP in TLIF are lacking., Methods: This prospective study included 77 patients. The use of BMP-2 was determined individually, and demographic and operative characteristics were recorded. Leg pain was assessed using the Visual Analog Scale (VAS) for pain and the Sciatica Bothersome Index (SBI) with several secondary outcome measures. The outcome data were collected at each follow-up visit., Results: Among the 77 patients, 29 were administered with BMP. Postoperative leg pain significantly improved according to VAS leg and SBI scores for the entire cohort, and no clinically significant differences were observed between the BMP and control groups. The VAS back, Oswestry Disability Index, and Short-Form 36 scores also significantly improved. A significantly increased 6-month fusion rate was noted in the BMP group (82.8% vs. 55.3%), but no significant differences in fusion rate were observed at the 12- and 24-month follow-up. Heterotopic ossification was observed in seven patients: six patients and one patient in the BMP and control groups, respectively (20.7% vs. 2.1%). However, no clinical effect was observed., Conclusions: In this prospective observational trial, the use of BMP in TLIF did not lead to significant postoperative radiculitis, as measured by VAS leg and SBI scores. Back pain and other functional outcome scores also improved, and no differences existed between the BMP and control groups. The careful use of BMP in TLIF appears to be both safe and effective.

Study Design: This is a prospective cohort study., Objective: To characterize the accuracy of patient recollection of preoperative symptoms after cervical spine surgery., Summary of Background Data: Recall bias is a well-known source of systematic error. The accuracy of patient recall after cervical spine surgery remains unknown., Methods: Consecutive patients undergoing cervical spine surgery for myelopathy or radiculopathy were enrolled. Neck and arm numeric pain scores and Neck Disability Indices were recorded preoperatively. Patients were asked to recall their preoperative status at either short (<1 y) or long-term (≥1 y) follow-up. Actual and recalled scores were compared using paired t tests and relations were quantified using the Pearson correlation coefficients. Multivariable linear regression was used to identify factors impacting recollection., Results: In total, 73 patients with a mean age of 58.2 years were included. Compared with their preoperative scores, patients showed significant improvement in neck pain [mean difference (MD)=-2.9; 95% confidence intervals (CIs), -3.5 to -2.3], arm pain (MD, -3.4; 95% CI, -4.0 to -2.8), and disability (MD, -12.4%; 95% CI, -16.9 to -7.9). Patient recollection of preoperative status was significantly more severe than actual for neck pain (MD, +1.5; 95% CI, 0.8-2.2), arm pain (MD, +2.3; 95% CI, 1.6-3.0), and disability (MD, +5.8%; 95% CI, 2.4-9.2). Moderate correlation between actual and recalled scores with regard to neck (r=0.41), arm (r=0.50) pain, and disability (r=0.67) was seen. This was maintained across age, sex, and time between date of surgery and recollection. Over 30% of patients switched their predominant symptom from neck-to-arm pain or vice versa on recall of their preoperative symptoms., Conclusions: Relying on patient recollection does not provide an accurate measure of preoperative status after cervical spine surgery. Prospective and not retrospective collection of patient-reported outcomes remain the gold standard to measure and interpret outcomes after cervical spine surgery. Recall bias has the potential to affect patient satisfaction and requires further study.

Study Design: Retrospective review., Objectives: This study investigates the prevalence of adverse postsurgical events, or osteoporosis-related complications (ORCs), following spinal fusion., Methods: Patients undergoing primary posterior thoracolumbar or lumbar fusion by 1 of 2 surgeons practicing at a single institution were analyzed from 2007 to 2014. ORCs were defined in one of the following categories: revision surgery, compression fracture, proximal junctional kyphosis, pseudarthrosis, or failure of instrumentation. Patients with a bone mineral density of the hips and/or spine performed within 1 year of the index procedure were included. Patients were stratified into normal bone density, osteopenia, and osteoporosis using WHO guidelines. Patients were excluded if they were younger than 18 years at the time of surgery, with infection, malignancy, skeletal dysplasia, neuromuscular disorders, concomitant or staged anterior-posterior procedure, or fusion performed because of trauma., Results: Out of 140 patients included, the prevalence of normal bone density was 31.4% (44/140), osteopenia 58.6% (82/140), and osteoporosis 10.0% (14/140). There were no differences between groups for gender, age, body mass index, and interbody device rate. The overall prevalence of ORCs was 32.1% (45/140). By group, there was a prevalence of 22.7% (10/44), 32.9% (27/82), and 50.0% (7/14) for normal bone density, osteopenia, and osteoporosis, respectively. These differences were significantly higher for both the osteopenia and osteoporosis groups., Conclusions: Patients with T scores below -1.0 undergoing posterior lumbar fusion have an increased prevalence of ORCs. Consideration of bone density plays a crucial role in patient selection, medical management, and counseling patient expectations., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The American Orthopaedic Association initiated the Own the Bone (OTB) quality improvement program in 2009. Herein we show that the data collected through this program is similar to that collected in other large studies. Thus, the OTB registry functions as an externally valid cohort for studying fragility fracture patients., Introduction: The American Orthopedic Association initiated the Own the Bone (OTB) quality improvement program in 2009 to improve secondary prevention of fragility fractures. In this study, we present a summary of the data collected by the OTB program and compare it to data from other large fragility fracture registries with an aim to externally validate the OTB registry., Methods: The OTB registry contained 35,038 unique cases of fragility fracture as of September, 2016. We report the demographics, presenting fracture characteristics, past fracture history, and bone mineral density (BMD) data and compare these to data from large fragility fracture studies across the world., Results: Seventy-three percent of the patients in the OTB registry were female, Caucasian, and post-menopausal. In 54.4% of cases, patients had a hip fracture; spine fractures were the second most common fracture type occurring in 11.1% of patients. Thirty-four percent of the patients had a past history of fragility fracture, and the most common sites were the spine and hip. The average femoral neck T-score was - 2.06. When compared to other studies, the OTB database showed similar findings with regard to patient age, gender, race, BMI, BMD profile, prior fracture history, and family history of fragility fractures., Conclusion: OTB is the first and largest multi-center voluntary fragility fracture registry in the USA. The data collected through the OTB program is comparable to that collected in international studies. Thus, the OTB registry functions as an externally valid cohort for further studies assessing the clinical characteristics, interventions, and outcomes achieved in patients who present with a fragility fracture in the USA.

Degenerative disk disease of the spine is a major cause of back pain and disability. Optimization of regenerative medical therapies for degenerative disk disease requires a deep mechanistic understanding of the factors controlling the structural integrity of spinal tissues. In this investigation, we sought to identify candidate regulatory genes controlling extracellular matrix synthesis in spinal tissues. To achieve this goal we performed high throughput next generation RNA sequencing on 39 annulus fibrosus and 21 nucleus pulposus human tissue samples. Specimens were collected from patients undergoing surgical discectomy for the treatment of degenerative disk disease. Our studies identified associations between extracellular matrix genes, growth factors, and other important regulatory molecules. The fibrous matrix characteristic of annulus fibrosus was associated with expression of the growth factors platelet derived growth factor beta (PDGFB), vascular endothelial growth factor C (VEGFC), and fibroblast growth factor 9 (FGF9). Additionally we observed high expression of multiple signaling proteins involved in the NOTCH and WNT signaling cascades. Nucleus pulposus extracellular matrix related genes were associated with the expression of numerous diffusible growth factors largely associated with the transforming growth signaling cascade, including transforming factor alpha (TGFA), inhibin alpha (INHA), inhibin beta A (INHBA), bone morphogenetic proteins (BMP2, BMP6), and others., Clinical Significance: this investigation provides important data on extracellular matrix gene regulatory networks in disk tissues. This information can be used to optimize pharmacologic, stem cell, and tissue engineering strategies for regeneration of the intervertebral disk and the treatment of back pain. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1356-1369, 2018., (© 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.)

Study Design: Prospective observational study., Objectives: Quantify the amount of lumbar lordosis achieved on a hinged operative table in neutral, flexion, and extension., Summary of Background Data: Hinged operative tables may allow surgeons to adjust lumbar spine positioning intraoperatively. The amount of lumbar lordosis in neutral, flexion, and extension positions has not been quantified prospectively using a hinged table., Methods: Thirty patients undergoing elective lumbar surgery were enrolled. Standing x-rays taken in neutral, maximal flexion, and maximal extension were obtained. After prone positioning on a hinged operative table, x-rays in neutral, maximal flexion, and maximal extension were taken. Total lumbar lordosis was calculated for all six images by two physicians. Disc degeneration was graded using Pfirrmann grades., Results: Lumbar lordosis on the operative table was 56.5 ± 2.1, 43.6 ± 2.2, 63.2 ± 2.0 compared with 46.9 ± 3.1, 33.2 ± 2.8, 52.3 ± 3.3 on the standing films in neutral, flexion, and extension, respectively. Average flexion (12.9 ± 1.1) and extension (6.7 ± 1.2) were significantly different from neutral on the table (P < 0.001). Lumbar lordosis was significantly higher on the operative table (P < 0.001). Total range of motion was 19.6 ± 1.9 on the table and 19.1 ± 2.0 with standing (P = 0.42). Average Pfirrmann disc grade was 2.77 ± 0.10 that did not correlate with range of motion (P = 0.40)., Conclusion: In this cohort, the hinged operative table allowed for a physiologic arc of motion of nearly 20 from flexion to extension. A considerable amount of lumbar sagittal motion can be obtained on hinged operative tables without decreasing overall lumbar lordosis below physiologic levels., Level of Evidence: 3.

Dorsal root ganglia (DRG) are anatomically well defined structures that contain all primary sensory neurons below the head. This fact makes DRG attractive targets for injection of novel therapeutics aimed at treating chronic pain. In small animal models, laminectomy has been used to facilitate DRG injection because it involves surgical removal of the vertebral bone surrounding each DRG. We demonstrate a technique for intraganglionic injection of lumbar DRG in a large animal species, namely, swine. Laminotomy is performed to allow direct access to DRG using standard neurosurgical techniques, instruments, and materials. Compared with more extensive bone removal via laminectomy, we implement laminotomy to conserve spinal anatomy while achieving sufficient DRG access. Intraoperative progress of DRG injection is monitored using a non-toxic dye. Following euthanasia on post-operative day 21, the success of injection is determined by histology for intraganglionic distribution of 4',6-diamidino-2-phenylindole (DAPI). We inject a biologically inactive solution to demonstrate the protocol. This method could be applied in future preclinical studies to target therapeutic solutions to DRG. Our methodology should facilitate testing the translatability of intraganglionic small animal paradigms in a large animal species. Additionally, this protocol may serve as a key resource for those planning preclinical studies of DRG injection in swine.

Study Design: Retrospective multicenter case series., Objective: To assess the rate of perioperative vision loss following cervical spinal surgery., Methods: Medical records for 17 625 patients from 21 high-volume surgical centers from the AOSpine North America Clinical Research Network who received cervical spine surgery (levels from C2 to C7) between January 1, 2005, and December 31, 2011, inclusive, were reviewed to identify occurrences of vision loss following surgery., Results: Of the 17 625 patients in the registry, there were 13 946 patients assessed for the complication of blindness. There were 9591 cases that involved only anterior surgical approaches; the remaining 4355 cases were posterior and/or circumferential fusions. There were no cases of blindness or vision loss in the postoperative period reported during the sampling period., Conclusions: Perioperative vision loss following cervical spinal surgery is exceedingly rare., 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: Brandon C. Gabel reports grants from AOSpine North America during the conduct of the study; Jens Chapman reports grants from AOSpine North America during the conduct of the study; Rod J. Oskouian Jr reports grants from AOSNA during the conduct of the study; Ahmad Nassr reports grants from AOSNA during the conduct of the study; Bradford L. Currier reports grants from AOSpine North America during the conduct of the study, personal fees from DePuy Spine, personal fees from Stryker Spine, personal fees from Zimmer Spine, other from Zimmer Spine, other from Tenex, other from Spinology, other from LSRS, other from AOSNA, outside the submitted work; Arjun S. Sebastian reports grants from AOSpine North America during the conduct of the study; Steven R. Hamilton 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 AOSNA 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.

Study Design: A multicenter, retrospective case series., Objective: In the past several years, screw fixation of the cervical spine has become commonplace. For the most part, this is a safe, low-risk procedure. While rare, screw backout or misplaced screws can lead to morbidity and increased costs. We report our experiences with this uncommon complication., Methods: A multicenter, retrospective case series was undertaken at 23 institutions in the United States. Patients were included who underwent cervical spine surgery from January 1, 2005, to December 31, 2011, and had misplacement of screws requiring reoperation. Institutional review board approval was obtained at all participating institutions, and detailed records were sent to a central data center., Results: A total of 12 903 patients met the inclusion criteria and were analyzed. There were 11 instances of screw backout requiring reoperation, for an incidence of 0.085%. There were 7 posterior procedures. Importantly, there were no changes in the health-related quality-of-life metrics due to this complication. There were no new neurologic deficits; a patient most often presented with pain, and misplacement was diagnosed on plain X-ray or computed tomography scan. The most common location for screw backout was C6 (36%)., Conclusions: This study represents the largest series to tabulate the incidence of misplacement of screws following cervical spine surgery, which led to revision procedures. The data suggest this is a rare event, despite the widespread use of cervical fixation. Patients suffering this complication can require revision, but do not usually suffer neurologic sequelae. These patients have increased cost of care. Meticulous technique and thorough knowledge of the relevant anatomy are the best means of preventing this complication., 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: Jeremy C. Peterson 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 G. Fehlings reports grants from AOSpine North America during the conduct of the study; Robert A. Hart reports grants from AOSpine North America during the conduct of the study, other from CSRS, other from ISSLS, other from ISSG Exec Board, personal fees from Depuy Synthes, personal fees from Globus, personal fees from Medtronic, other from Evans, Craven & Lackie, other from Benson, Bertoldo, Baker, & Carter, personal fees from Seaspine, personal fees from Depuy Synthes, other from Spine Connect, personal fees from Depuy Synthes, 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; Tony Tannoury reports grants from AOSpine North America during the conduct of the study; Thomas E. Mroz reports other from AO Spine during the conduct of the study, personal fees from Stryker, personal fees from Ceramtec, other from Pearl Diver, outside the submitted work; Bradford L. Currier reports grants from AOSpine North America during the conduct of the study, personal fees from DePuy Spine, personal fees from Stryker Spine, personal fees from Zimmer Spine, other from Zimmer Spine, other from Tenex, other from Spinology, other from LSRS, other from AOSNA, outside the submitted work; Jeremy L. Fogelson reports grants from AOSpine North America during the conduct of the study and Previous Consultant for one day to Depuy-Synthes March 2014; Bruce C. Jobse 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; 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, plaintiff, 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; 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; Zachary A. Smith reports grants from AOSpine North America during the conduct of the study; Ahmad Nassr reports grants from AOSpine North America during the conduct of the study; 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. Chadi A. Tannoury reports grants from AOSpine North America during the conduct of the study; Anthony F. De Giacomo Dr. De Giacomo reports grants from AOSpine North America during the conduct of the study.

Study Design: Retrospective cohort study of prospectively collected data., Objective: To examine the incidence of iatrogenic spinal cord injury following elective cervical spine surgery., Methods: A retrospective multicenter case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network was conducted. Medical records for 17 625 patients who received cervical spine surgery (levels from C2 to C7) between January 1, 2005, and December 31, 2011, were reviewed to identify occurrence of iatrogenic spinal cord injury., Results: In total, 3 cases of iatrogenic spinal cord injury following cervical spine surgery were identified. Institutional incidence rates ranged from 0.0% to 0.24%. Of the 3 patients with quadriplegia, one underwent anterior-only surgery with 2-level cervical corpectomy, one underwent anterior surgery with corpectomy in addition to posterior surgery, and one underwent posterior decompression and fusion surgery alone. One patient had complete neurologic recovery, one partially recovered, and one did not recover motor function., Conclusion: Iatrogenic spinal cord injury following cervical spine surgery is a rare and devastating adverse event. No standard protocol exists that can guarantee prevention of this complication, and there is a lack of consensus regarding evaluation and treatment when it does occur. Emergent imaging with magnetic resonance imaging or computed tomography myelography to evaluate for compressive etiology or malpositioned instrumentation and avoidance of hypotension should be performed in cases of intraoperative and postoperative spinal cord injury., 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: Alan H. Daniels reports grants from AOSpine North America during the conduct of the study, personal fees from Stryker, personal fees from Depuy, other from Globus, nonfinancial support from Medtronic, 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; 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; 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; Elizabeth L. Lord 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; 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; Ahmad Nassr reports grants from AOSpine North America during the conduct of the study; Bradford L. Currier reports grants from AOSpine North America during the conduct of the study, personal fees from DePuy Spine, personal fees from Stryker Spine, personal fees from Zimmer Spine, other from Zimmer Spine, other from Tenex, other from Spinology, other from LSRS, other from AOSNA, outside the submitted work; Arjun S. Sebastian 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; 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 workPaul 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 case series and review of the literature., Objective: To determine the rate of esophageal perforations following anterior cervical spine surgery., Methods: As part of an AOSpine series on rare complications, a retrospective cohort study was conducted among 21 high-volume surgical centers to identify esophageal perforations following anterior cervical spine surgery. Staff at each center abstracted data from patients' charts and created case report forms for each event identified. Case report forms were then sent to the AOSpine North America Clinical Research Network Methodological Core for data processing and analysis., Results: The records of 9591 patients who underwent anterior cervical spine surgery were reviewed. Two (0.02%) were found to have esophageal perforations following anterior cervical spine surgery. Both cases were detected and treated in the acute postoperative period. One patient was successfully treated with primary repair and debridement. One patient underwent multiple debridement attempts and expired., Conclusions: Esophageal perforation following anterior cervical spine surgery is a relatively rare occurrence. Prompt recognition and treatment of these injuries is critical to minimizing morbidity and mortality., 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: Stuart H. Hershman reports grants from AOSpine North America during the conduct of the study; William A. Kunkle reports grants from AOSpine North America during the conduct of the study; Michael P. Kelly reports grants from AOSpine North America during the conduct of the study; Wilson Z. Ray reports grants from NIH/NINDs, grants from Department of Defense, grants from DARPA, other from Depuy/Synthes, other from Ulrich, other from Harvest Technologies, 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; 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; Colleen M. Peters 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; Bradford L. Currier reports grants from AOSpine North America during the conduct of the study, personal fees from DePuy Spine, personal fees from Stryker Spine, personal fees from Zimmer Spine, other from Zimmer Spine, other from Tenex, other from Spinology, other from LSRS, other from AOSNA, 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; 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; Sara E. Thompson 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; Elizabeth L. Lord 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; Michael G. Fehlings reports grants from AOSpine North America during the conduct of the study; 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; 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, plaintiff, 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; Jacob M. Buchowski reports grants from AOSpine North America during the conduct of the study; personal fees from Advance Medical, personal fees from DePuy, personal fees from CoreLink, Inc., personal fees from Globus Medical, Inc., personal fees from K2M, Inc., personal fees from Medtronic, Inc., personal fees from Stryker, Inc., personal fees from Broadwater/Vertical Health, personal fees from DePuy Synthes, personal fees from Globus Medical, Inc., personal fees from Orthofix, personal fees from Stryker, Inc., personal fees from Wolters Kluwer Health, Inc., personal fees from Globus Medical, Inc., outside the submitted work; and AO Foundation (parent organization to AO Spine). AO FOUNDATION is a non for profit organization. “Other”, “Teaching”, “Not for Profit Organization” Weerasak Singhatanadgige reports grants from AOSpine North America during the conduct of the study; Jin Young Kim Dr. Kim reports grants from AOSpine North America, during the conduct of the study; Zachary A. Smith Dr. Smith reports grants from AOSpine North America, during the conduct of the study; Ahmad Nassr reports grants from AOSpine North America during the conduct of the study; 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: Systematic review and meta-analysis., Objectives: The safety of new technology such as cervical total disc replacement (TDR) is of paramount importance and is best evaluated in randomized clinical trials (RCT). We compared complication risks of TDR to fusion using data from Investigational Device Exemptions., Methods: A systematic review of FDA Summary of Safety and Effectiveness reports of the 8 approved cervical TDRs was performed. These were all randomized controlled trials comparing anterior cervical discectomy and fusion (ACDF) to TDR. Important outcome variables were dysphagia, wound infection, neurologic injuries, heterotopic ossification, death, and secondary surgeries. A random effects model was selected a priori. Data on adverse events was abstracted and analyzed by calculating relative risk of ACDF to TDR by meta-analysis techniques., Results: The study included 3027 patients with 1377 randomized to ACDF and 1652 to TDR. No statistical differences were present between the 2 groups in dysphagia/dysphonia, hardware related, heterotopic ossification, death, and overall neurologic adverse events and incidence of neurologic deterioration. The relative risk of wound-related problems ACDF to TDR was 0.76 (95% confidence interval [CI] = 0.59, 0.98) favoring ACDF, which was statistically significant, but these were minor and never required a second surgical procedure for deep wound infection. The relative risk of ACDF to TDR in surgical-related neurologic events and secondary surgeries was 1.62 (95% CI = 1.04, 2.53) and 1.79 (95% CI = 1.17, 2.74), both favoring TDR., Conclusions: Cervical TDR appears to be as safe as or safer than ACDF at 2-year follow-up., 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: Paul A. Anderson reports grants from AOSpine North America during the conduct of the study; other from Stryker, other from RTI, other from SI BOne, other from Spartec, other from Expanding orthopedics, other from Titan Spine, outside the submitted work; Bradford L. Currier reports grants from AOSpine North America during the conduct of the study, personal fees from DePuy Spine, personal fees from Stryker Spine, personal fees from Zimmer Spine, other from Zimmer Spine, other from Tenex, other from Spinology, other from LSRS, other from AOSNA, outside the submitted work; Arjun S. Sebastian 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; Ahmad Nassr reports grants from AOSpine North America, during the conduct of the study; 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.

The aim of our study was to determine independent predictors of discharge disposition to rehabilitation or skilled care (SC) facilities and investigate whether discharge location is associated with unplanned readmission and/or reoperation rates. All elective spinal surgery patients in a national surgical registry were analyzed using between 2011 and 2012. Multivariable logistic regression analysis was used to assess for predictors of discharge to rehabilitation or SC facilities versus home as well as to determine whether discharge disposition was significantly associated with the 30-day unplanned readmission or reoperation. Of 34,023 elective spinal surgery patients, the distribution of discharge locations was as follows: 30,606 (90.0%) discharged home, 1674 (4.9%) discharged to rehabilitation, and 1743 (5.1%) discharged to SC. Patients discharged home were associated with the lowest complication rate relative to rehabilitation and SC facilities. Following multivariable regression analysis, there was a significant increase in the odds of discharge to rehabilitation associated with age, male gender, current smoking, ASA class three and four, history of diabetes, operative time, total hospital length of stay, preoperative neurologic morbidity and having at least one postoperative morbidity event. Moreover, there were 804 (4.06%) 30-day unplanned readmissions and 822 (2.45%) unplanned reoperations. After risk adjustment, discharge to rehabilitation was independently associated with decreased odds of 30-day unplanned readmission (OR=0.41; p=0.008) but not reoperation., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Study Design: Prospective cohort study., Objective: To characterize the accuracy of patient recollection of preoperative symptoms after lumbar spine surgery., Summary of Background Data: Although patient-reported outcomes have become important in the evaluation of spine surgery patients, the accuracy of patient recall remains unknown., Methods: Patients undergoing lumbar decompression with or without fusion were enrolled. Back and leg Numeric Pain Scores and Oswestry Disability Indices were recorded preoperatively. Patients were asked to recall their preoperative status at a minimum of 1 year after surgery. Actual and recalled scores were compared using paired t tests and relations were quantified using Pearson correlation coefficients. Multivariable linear regression was used to identify factors that affected recollection., Results: Sixty-two patients with a mean age of 66.1 years were included. Compared to their preoperative scores, patients showed significant improvement in back pain (mean difference [MD] = -3.2, 95% CI -4.0 to -2.4), leg pain (MD -3.3, 95% CI -4.3 to -2.2), and disability (MD -25.0%, 95% CI -28.7 to -19.6). Patient recollection of preoperative status was significantly more severe than actual for back pain (MD +2.3, 95% CI 1.5-3.2), leg pain (MD +1.8, 95% CI 0.9-2.7), and disability (MD +9.6%, 95% CI 5.6-14.0). No significant correlation between actual and recalled scores with regards to back (r = 0.18) or leg (r = 0.24) pain and only moderate correlation with disability (r = 0.44) were seen. This was maintained across age, sex, and time between date of surgery and recollection. More than 40% of patients switched their predominant symptom from back pain to leg pain or leg pain to back pain on recall., Conclusion: Relying on patient recollection does not provide an accurate measure of preoperative status after lumbar spine surgery. Recall bias indicates the importance of obtaining true baseline scores and patient-reported outcomes prospectively and not retrospectively., Level of Evidence: 2.

Study Design  Retrospective clinical study of a prospectively collected, national database. Objective  Determine the 30-day incidence, timing, and risk factors for venous thromboembolism (VTE) following thoracolumbar spine surgery. Methods  The American College of Surgeons National Surgical Quality Improvement Program Participant Use File identified 43,777 patients who underwent thoracolumbar surgery from 2005 to 2012. Multiple patient characteristics were identified. The incidence and timing (in days) of deep vein thrombosis (DVT) and pulmonary embolus (PE) were determined. Multivariable regression analysis was performed to identify significant risk factors. Results  Of the 43,777 patients identified as having had thoracolumbar surgery, 202 cases of PE (0.5%) and 311 cases of DVT (0.7%) were identified. VTE rates were highest in patients undergoing corpectomy, with a 1.7% PE rate and a 3.8% DVT rate. Independent risk factors for VTE included length of stay (LOS) ≥ 6 days (odds ratio [OR] 4.07), disseminated cancer (OR 1.77), white blood cell count > 12 (OR 1.76), paraplegia (OR 1.75), albumin < 3 (OR 1.73), American Society of Anesthesiologists class 4 or greater (OR 1.54), body mass index > 40 (OR 1.49), and operative time > 193 minutes (OR 1.43). LOS < 3 days was protective (OR 0.427). Conclusions  We report an overall 30-day PE rate of 0.5% and DVT rate of 0.7% following thoracolumbar spine surgery. Patients undergoing corpectomy were at highest risk for VTE. Multiple VTE risk factors were identified. Further studies are needed to develop algorithms to stratify VTE risk and direct prophylaxis accordingly.