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Degenerative cervical myelopathy (DCM) is defined as dysfunction of the spinal cord as a result of compression from degenerative changes to surrounding joints, intervertebral disks, or ligaments. Symptoms can include upper extremity numbness and diminished dexterity, difficulty with fine manipulation of objects, gait imbalance, and incoordination, and compromised bowel and bladder function. Accurate diagnosis and evaluation of the degree of impairment due to degenerative cervical myelopathy remain a challenging clinical endeavor requiring a thorough and accurate history, physical examination, and assessment of imaging findings.A narrative review is presented summarizing the current landscape of imaging modalities utilized in DCM diagnostics and the future direction of research for spinal cord imaging.Current imaging modalities, particularly magnetic resonance imaging and, to a lesser extent, radiographs/CT, offer important information to aid in decision making but are not ideal as stand-alone tools. Newer imaging modalities currently being studied in the literature include diffusion tensor imaging, MR spectroscopy, functional magnetic resonance imaging, perfusion imaging, and positron emission tomography. These newer imaging modalities attempt to more accurately evaluate the physical structure, intrinsic connectivity, biochemical and metabolic function, and perfusion of the spinal cord in DCM. Although there are still substantial limitations to implementation, future clinical practice will likely be revolutionized by these new imaging modalities to diagnose, localize, surgically plan and manage, and follow patients with DCM.

OBJECTIVE In a healthcare landscape in which costs increasingly matter, the authors sought to distinguish among the clinical and nonclinical drivers of patient length of stay (LOS) in the hospital following elective lumbar laminectomy—a common spinal surgery that may be reimbursed using bundled payments—and to understand their relationships with patient outcomes and costs. METHODS Patients ≥ 18 years of age undergoing laminectomy surgery for degenerative lumbar spinal stenosis within the Cleveland Clinic health system between March 1, 2016, and February 1, 2019, were included in this analysis. Generalized linear modeling was used to assess the relationships between the day of surgery, patient discharge disposition, and hospital LOS, while adjusting for underlying patient health risks and other nonclinical factors, including the hospital surgery site and health insurance. RESULTS A total of 1359 eligible patients were included in the authors’ analysis. The mean LOS ranged between 2.01 and 2.47 days for Monday and Friday cases, respectively. The LOS was also notably longer for patients who were ultimately discharged to a skilled nursing facility (SNF) or rehabilitation center. A prolonged LOS occurring later in the week was not associated with greater underlying health risks, yet it nevertheless resulted in greater costs of care: the average total surgical costs for lumbar laminectomy were 20% greater for Friday cases than for Monday cases, and 24% greater for late-week cases than for early-week cases ultimately transferred to SNFs or rehabilitation centers. A Poisson generalized linear model fit the data best and showed that the comorbidity burden, surgery at a tertiary care center versus a community hospital, and the incidence of any postoperative complication were associated with significantly longer hospital stays. Discharge to home healthcare, SNFs, or rehabilitation centers, and late-week surgery were significant nonclinical predictors of LOS prolongation, even after adjusting for underlying patient health risks and insurance, with LOSs that were, for instance, 1.55 and 1.61 times longer for patients undergoing their procedure on Thursday and Friday compared to Monday, respectively. CONCLUSIONS Late-week surgeries are associated with a prolonged LOS, particularly when discharge is to an SNF or rehabilitation center. These findings point to opportunities to lower costs and improve outcomes associated with elective surgical care. Interventions to optimize surgical scheduling and perioperative care coordination could help reduce prolonged LOSs, lower costs, and, ultimately, give service line management personnel greater flexibility over how to use existing resources as they remain ahead of healthcare reforms.

OBJECTIVEIatrogenic spine injury remains one of the most dreaded complications of pedicle subtraction osteotomies (PSOs) and spine deformity surgeries. Thus, intraoperative multimodal monitoring (IOM), which has the potential to provide real-time feedback on spinal cord signal transmission, has become the gold standard in such operations. However, while the benefits of IOM are well established in PSOs of the thoracic spine and scoliosis surgery, its utility in PSOs of the lumbar spine has not been robustly documented. The authors’ aim was to determine the impact of IOM on outcomes in patients undergoing PSO of the lumbar spine.METHODSAll patients older than 18 years who underwent lumbar PSOs at the authors’ institution from 2007 to 2017 were analyzed via retrospective chart review and categorized into one of two groups: those who had IOM guidance and those who did not. Perioperative complications were designated as the primary outcome measure and postoperative quality of life (QOL) scores, specifically the Parkinson’s Disease Questionnaire–39 (PDQ-39) and Patient Health Questionnaire–9 (PHQ-9), were designated as secondary outcome measures. Data on patient demographics, surgical and monitoring parameters, and outcomes were gathered, and statistical analysis was performed to compare the development of perioperative complications and QOL scores between the two cohorts. In addition, the proportion of patients who reached minimal clinically important difference (MCID), defined as an increase of 4.72 points in the PDQ-39 score or a decrease of 5 points in the PHQ-9 score, in the two cohorts was also determined.RESULTSA total of 95 patients were included in the final analysis. IOM was not found to significantly impact the development of new postoperative deficits (p = 0.107). However, the presence of preoperative neurological comorbidities was found to significantly correlate with postoperative neurological complications (p = 0.009). Univariate analysis showed that age was positively correlated with MCID achievement 3 months after surgery (p = 0.018), but this significance disappeared at the 12-month postoperative time point (p = 0.858). IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period as measured by PDQ-39 (p = 0.398 and p = 0.156, respectively). Similarly, IOM was not found to significantly impact MCID achievement at either the 3- or 12-month postoperative period, as measured by PHQ-9 (p = 0.230 and p = 0.542, respectively). Multivariate analysis showed that female sex was significantly correlated with MCID achievement (p = 0.024), but this significance disappeared at the 12-month postoperative time point (p = 0.064). IOM was not found to independently correlate with MCID achievement in PDQ-39 scores at either the 3- or 12-month postoperative time points (p = 0.220 and p = 0.097, respectively).CONCLUSIONSIn this particular cohort, IOM did not lead to statistically significant improvement in outcomes in patients undergoing PSOs of the lumbar spine (p = 0.220). The existing clinical equipoise, however, indicates that future studies in this arena are necessary to achieve systematic guidelines on IOM usage in PSOs of the lumbar spine.

The use of intraoperative multimodal monitoring (IOM) in spinal deformity surgeries is well documented. In particular, pedicle subtraction osteotomy (PSO), a corrective procedure for sagittal deformity of the spine, often involves IOM usage. By providing immediate feedback to the operating surgeon, IOM has the potential to eliminate or at least minimize the risk of iatrogenic neurological injury. However, despite the widespread usage of IOM, there is currently no standardization of IOM usage in complex spine surgeries, including lumbar PSOs, and decisions concerning IOM utilization are often driven by surgeon experience and preference. This creates a state of clinical equipoise, which is further complicated by the varying degrees of benefit that IOM has on patient outcomes depending on the operation and spinal levels involved. For instance, while IOM use in thoracic PSOs has been shown to be effective, there is no established consensus on the net impact of IOM use in PSOs of the lumbar spine. While IOM has the potential to mitigate neurological damage, it also increases operation time and cost; thus, it should only be employed in operations where it will have a net positive impact on patient outcomes. The question thus becomes whether PSO of the lumbar spine is one such operation. To address this, we examine the most frequently employed IOM modalities and evaluate their current usage and efficacy in lumbar PSOs. Furthermore, we will also examine the utility of IOM for other surgeries of the lumbar spine, including corrective procedures for idiopathic scoliosis and degenerative scoliosis, and routine lumbar procedures, such as discectomies and decompression surgeries for foraminal and canal stenosis.

Introduction: Inadequate validation, floor/ceiling effects, and time constraints limit utilization of standardized patient-reported outcome measures. We aimed to validate Patient-reported Outcomes Measurement Information System (PROMIS) computer adaptive tests (CATs) for patients treated surgically for a lumbar disk herniation. Methods: PROMIS, CATs, Oswestry Disability Index, and Short Form-12 measures were administered to 78 patients treated with lumbar microdiskectomy for symptomatic disk herniation with radiculopathy. Results: PROMIS CATs demonstrated convergent validity with legacy measures; PROMIS scores were moderately to highly correlated with the Oswestry Disability Index and Short Form-12 physical component scores (r = 0.41 and 0.78, respectively). PROMIS CATs demonstrated similar responsiveness to change compared with legacy measures. On average, the PROMIS CATs were completed in 2.3 minutes compared with 5.7 minutes for legacy measures. Discussion: The PROMIS CATs demonstrate convergent and known groups' validity and are comparable in responsiveness to legacy measures. These results suggest similar utility and improved efficiency of PROMIS CATs compared with legacy measures. Levels of Evidence: Level II

Background: Repetitive lumbar hyperextension and rotation during athletic activity affect the structural integrity of the lumbar spine. While many sports have been associated with an increased risk of developing a pars defect, few previous studies have systematically investigated spondylolysis and spondylolisthesis in professional baseball players. Purpose: To characterize the epidemiology and treatment of symptomatic lumbar spondylolysis and isthmic spondylolisthesis in American professional baseball players. We also sought to report the return-to-play (RTP) and performance-based outcomes associated with the diagnosis of a pars defect in this elite athlete population. Study Design: Descriptive epidemiology study. Methods: A retrospective cohort study was conducted among all Major and Minor League Baseball (MLB and MiLB, respectively) players who had low back pain and underwent lumbar spine imaging between 2011 and 2016. Players with radiological evidence of a pars defect (with or without listhesis) were included. Analyses were conducted to assess the association between player-specific characteristics and RTP time. Baseball performance metrics were also compared before and after the injury episode to determine whether there was an association between the diagnosis of a pars defect and diminished player performance. Results: During the study period of 6 MLB seasons, 272 professional baseball players had low back pain and underwent lumbar spine imaging. Overall, 75 of these athletes (27.6%) received a diagnosis of pars defect. All affected athletes except one (98.7%) successfully returned to professional baseball, with a median RTP time of 51 days. Players with spondylolisthesis returned to play faster than those with spondylolysis, MLB athletes returned faster than MiLB athletes, and position players returned faster than pitchers. Athletes with a diagnosed pars defect did not show a significant decline in performance after returning to competition after their injury episode. Conclusion: Lumbar pars defects were a common cause of low back pain in American professional baseball players. The vast majority of affected athletes were able to return to competition without demonstrating a significant decline in baseball performance.

STUDY DESIGN. Prospective, cohort study. OBJECTIVE. Demonstrate validity of Patient reported outcomes measurement information system (PROMIS) physical function, pain interference, and pain behavior computer adaptive tests (CATs) in surgically treated lumbar stenosis patients. SUMMARY OF BACKGROUND DATA. There has been increasing attention given to patient reported outcomes associated with spinal interventions. Historical patient outcome measures have inadequate validation, demonstrate floor/ceiling effects, and infrequently used due to time constraints. PROMIS is an adaptive, responsive National Institutes of Health (NIH) assessment tool that measures patient-reported health status. METHODS. Ninety-eight consecutive patients were surgically treated for lumbar spinal stenosis and were assessed using PROMIS CATs, Oswestry disability index (ODI), Zurich Claudication Questionnaire (ZCQ), and Short-Form 12 (SF-12). Prior lumbar surgery, history of scoliosis, cancer, trauma, or infection were excluded. Completion time, preoperative assessment, 6 weeks and 3 months postoperative scores were collected. RESULTS. At baseline, 49%, 79%, and 81% of patients had PROMIS pain behavior (PB), pain interference (PI), and physical function (PF) scores greater than 1 standard deviation (SD) worse than the general population. 50.6% were categorized as severely disabled, crippled, or bed bound by ODI. PROMIS CATs demonstrated convergent validity through moderate to high correlations with legacy measures (r = 0.35–0.73). PROMIS CATs demonstrated known groups validity when stratified by ODI levels of disability. ODI improvements of at least 10 points on average had changes in PROMIS scores in the expected direction (PI = −12.98, PB = −9.74, PF = −7.53). PROMIS CATs demonstrated comparable responsiveness to change when evaluated against legacy measures. PROMIS PB and PI decreased 6.66 and 9.62 and PROMIS PF increased 6.8 points between baseline and 3-months post-op (P < 0.001). Completion time for the PROMIS CATs (2.6 min) compares favorably to ODI, ZCQ, and SF-12 scores (3.1, 3.6, and 3.0 min). CONCLUSION. PROMIS CATs demonstrate convergent validity, known groups validity, and responsiveness for surgically treated patients with lumbar stenosis to detect change over time and are more efficient than legacy instruments.

Relative value units (RVUs) are a compensation model based on the effort required to provide a procedure or service to a patient. Thus, procedures that are more complex and require greater technical skill and aftercare, such as multilevel spine surgery, should provide greater physician compensation. However, there are limited data comparing RVUs with operative time. Therefore, this study aims to compare mean (1) operative times; (2) RVUs; and (3) RVU/min between posterior segmental instrumentation of 3-6, 7-12, and ≥13 vertebral segments, and to perform annual cost difference analysis.A total of 437 patients who underwent instrumentation of 3-6 segments (Cohort 1, current procedural terminology [CPT] code: 22842), 67 patients who had instrumentation of 7-12 segments (Cohort 2, CPT code: 22843), and 16 patients who had instrumentation of ≥13 segments (Cohort 3, CPT code: 22844) were identified from the National Surgical Quality Improvement Program (NSQIP) database. Mean operative times, RVUs, and RVU/min, as well as an annualized cost difference analysis, were calculated and compared using Student t test. This study received no funding from any party or entity.Cohort 1 had shorter mean operative times than Cohorts 2 and 3 (217 minutes vs. 325 minutes vs. 426 minutes, p.05). Cohort 1 had a lower mean RVU than Cohorts 2 and 3 (12.6 vs. 13.4 vs. 16.4). Cohort 1 had a greater RVU/min than Cohorts 2 and 3 (0.08 vs. 0.05, p.05; vs. 0.08 vs. 0.05, p.05). A $112,432.12 annualized cost difference between Cohorts 1 and 2, a $176,744.76 difference between Cohorts 1 and 3, and a $64,312.55 difference between Cohorts 2 and 3 were calculated.The RVU/min takes into account not just the value provided but also the operative times required for highly complex cases. The RVU/min for fewer vertebral level instrumentation being greater (0.08 vs. 0.05), as well as the $177,000 annualized cost difference, indicates that compensation is not proportional to the added time, effort, and skill for more complex cases.

Background Dysphagia and dysphonia are the most common postoperative complications following anterior cervical discectomy and fusion (ACDF). Although most postoperative dysphagia is mild and transient, severe dysphagia can have profound effects on overall patient health and on surgical outcomes. The purpose of this study was to compare the efficacy of local to intravenous (IV) steroid administration during ACDF on postoperative dysphagia and dysphonia. Methods This was a single-blinded, prospective, randomized clinical trial. Seventy-five patients undergoing ACDF with cervical plating were randomized into 3 groups: control (no steroid), IV steroid (10 mg of IV dexamethasone at the time of closure), or local steroid (40 mg of local triamcinolone). Patient-reported outcome measures (PROMs) were collected for dysphagia, dysphonia, and neck pain postoperatively for 1 year. Results Patient demographics were similar. Postoperative day 1 PROMs showed significantly lower scores for dysphonia (p = 0.015) and neck pain (p = 0.034) in the local steroid group. At 2 weeks postoperatively, the local steroid cohort showed significantly decreased prevalence of severe dysphagia (Eating Assessment Tool-10 [EAT-10], severe dysphagia, p = 0.027) compared with the control and IV steroid groups. Both steroid groups had significantly less severe dysphagia when compared with the control group at the 6-week and 3-month time points. At 1 year postoperatively, both steroid groups had significantly reduced dysphagia rates (p = 0.014) compared with the control group. Conclusions Both local and IV steroid administration after cervical plating in ACDF yielded better PROMs for dysphagia compared with a control group. This finding is particularly evident in the reduced number of patients who reported severe dysphagia symptoms following ACDF with local steroid application within the first 2 postoperative weeks. Future studies should attempt to stratify dysphagia severity when reporting outcomes related to anterior cervical spine surgery. Level of evidence Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background Context Degenerative changes in the cervical spine occur in an age-dependent manner. As the US population continues to age, the incidence of age-dependent, multilevel, degenerative cervical pathologies is expected to increase. Similarly, the average age of patients with cervical spondylotic myelopathy (CSM) will likely trend upward. Posterior cervical fusion (PCF) is often the treatment modality of choice in the management of multilevel cervical spine disease. Although outcomes following anterior cervical fusion for degenerative disease have been studied among older patients (aged 80 years and older), it is unknown if these results extend to octogenarian patients undergoing PCF for the surgical management of CSM. Purpose The present study aimed to quantify surgical outcomes following PCF for the treatment of CSM among the octogenarian patient population compared with patients younger than 80 years old. Study Design/Setting This was a retrospective study that used the National Surgical Quality Improvement Program (NSQIP). Patient Sample The sample included patients aged 60–89 who had CSM and who underwent PCF from 2012 to 2014. Outcome Measures The outcome measures were multimorbidity, prolonged length of stay (LOS), discharge disposition (to home or skilled nursing/rehabilitation facility), 30-day all-cause readmission, and 30-day reoperation. Methods The NSQIP database was queried for patients with CSM (International Classification of Disease, Ninth Revision, Clinical Modification code 721.1) aged 60–89 who underwent PCF (Current Procedural Terminology code 22600) from 2012 to 2014. Cohorts were defined by age group (60–69, 70–79, 80–89). Data were collected on gender, race, elective or emergent status, inpatientor outpatient status, where patients were admitted from (home vs. skilled nursing facility), American Society of Anesthesiologists class, comorbidities, and single- or multilevel fusion. After controllingfor these variables, logistic regression analysis was used to compare outcome measures in the different age groups. Results A total of 819 patients with CSM who underwent PCF (416 aged 60–69, 320 aged 70–79, and 83 aged 80–89) were identified from 2012 to 2014. Of the PCF procedures, 79.7% were multilevel. There were no significant differences in the odds of multimorbidity, prolonged LOS, readmission, or reoperation when comparing octogenarian patients with CSM with patients aged 60–69 or 70–79. Patients aged 60–69 and 70–79 were significantly more likely to be discharged to home than patients over 80 (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.8–10.4, p Conclusions Compared with patients aged 60–69 and 70–79, octogenarian patients with CSM were significantly more likely to be discharged to a location other than home following PCF. After controlling for patient comorbidities and demographics, 80- to 89-year-old patients with CSM who underwent PCF did not differ in other outcomes when compared with the other age cohorts. These results can improve preoperative risk counseling and surgical decision-making.

Background Context Patients with spinal deformity may present with complaints related to either the deformity itself or the manifestations of the coexisting spinal stenosis. There are reports of successful management of lumbar pathology in the absence of global sagittal or coronal imbalance, with limited decompression and fusion, addressing only the symptomatic segment. Purpose Our study examined the long-term outcomes of transforaminal lumbar interbody fusion (TLIF), a less extensive procedure, based on the experience of the senior author over the past 10 years. Study Design/Setting This was a retrospective study of symptomatic lumbar spinal stenosis and spinal deformity managed by one surgeon at The Cleveland Clinic since 2003. Patient Sample Forty-one patients were included in the study. Outcome Measures The present study measures the long-term clinical functional outcomes of these patients through EQ-5D (EuroQol five dimensions questionnaire), PHQ-9 (Patient Health Questionnaire), and PDQ (Pain Disability Questionnaire) forms, along with documented radiographic parameters and Charlson Comorbidity Index (CCI). Methods There were no funding or potential conflicts of interest associated biases in the present study. Patients with symptomatic lumbar spinal stenosis with neutral global alignment in the sagittal and coronal planes and symptomatic stenosis at the deformity level were treated by limited fusion and TLIF, and had a follow-up period of at least 5 years. Excluded were patients under 18 years of age, had more than three levels of fusion, and had an active spinal malignancy or recent spinal trauma. The grouping variables were curve magnitude, revision surgeries, and TLIF levels. Clinical outcomes were compared in all the grouping variables. Analysis of variance (ANOVA) and chi-square tests were utilized; p Results The average age and follow-up period were 66±10 and 7.5 years, respectively. There was no statistical difference between patients with curves measuring between 10° and 20° and greater than 20° for EQ-5D, PHQ-9, and PDQ. Patients had worse PDQ data with larger curves compared with smaller curves at both 5 years and final follow-up. Although there was no statistical significance between preoperative coronal curve magnitude and revision surgeries, patients with curves greater than 20° had higher rates of revision surgeries (75%; p=.343) in the global lumbar curve deformity group. Although there was no statistical significance for patients who underwent revision surgeries,those patients had low PHQ-9 values at the final follow-up (p=.09). The revision surgery rate was 48% in one-level TLIF and 18% in two-level TLIF. Moderate pain disability scores were noticed for one-level TLIF patients (mean=75) compared with two-level TLIF patients (mean=27) at the final follow-up, and approached statistical significance in this comparison (p=.06). Conclusion Although this topic has a limited audience to spinal deformity surgeons, the prevalence of patients who present with adult spinal deformities has been increasing. Short segment fusion, in the setting of modest spinal deformity, is a reasonable and safe option. Further study on the concept of short segment fusions in the growing patient population is required as more comprehensive fusions do have noted complication rates, and a compromise must be reached between the extent of surgery that is enough to provide pain relief and disability and the degree of surgery that is too much to be tolerated in terms of complication rates.

Thoracolumbar burst fractures are high-energy vertebral injuries, which commonly can be treated nonoperatively. Consideration of the injury pattern, extent of comminution, neurological status, and integrity of the posterior ligamentous complex may help determine whether operative management is appropriate. Several classification systems are contingent upon these factors to assist with clinical decision-making. A multitude of operative procedures have been shown to have good radiographic and clinical outcomes with extended follow-up, and treatment choice should be based on the individual's clinical and radiographic presentation.

Background Context Transforaminal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion with percutaneous pedicle screws (ALIFPS) offer significantly higher radiographic fusion rates than other fusion techniques for L5–S1 isthmic spondylolisthesis (IS). As it stands, there is a relative paucity of comparative data of the two techniques. Purpose To define the clinical, radiographic, and financial differences between TLIF and ALIFPS for L5–S1 IS. Design/Setting A retrospective cohort study conducted at a single tertiary care center. Patient Sample Sixty-six patients who underwent either TLIF or ALIPFS for L5–S1 IS at a single tertiary care center between 2009 and 2014. Outcome Measures Quality of life outcome scores including the EuroQol-5 Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9). Sagittal balance parameters including: pelvic incidence, pelvic tilt, sacral slope, segmental lordosis, total lordosis, degree of slip, disc height, and L1-axis S1 distance (LASD). Cost measures included in-hospital charges, hospital length of stay (LOS), and post-admission costs accrued over 1 year. Methods Quality of life (QoL) outcome scores, radiographic data, and financial data were collected with a minimum of 1-year follow-up. Clinical results were investigated using the PDQ, PHQ-9, and EQ-5D. Radiographic measurements included lumbar lordosis, segmental lordosis, pelvic tilt, pelvic incidence, height of disc, L-1 axis S-1 distance, and the degree of slip. Cost data were generated based on patient-level resource utilization. Comparative data were presented as median with interquartile range (IQR). Continuous variables were compared using either independent Student t tests assuming unequal variance or Mann-Whitney U tests for parametric and nonparametric variables, respectively. The minimally clinical important difference (MCID) used for each questionnaire was as follows: PDQ (26), PHQ-9 (5), and EQ-5D (0.4). Results A total of 66 patients met inclusion criteria. In the ALIFPS cohort, PDQ scores improved from 69 [47, 82] to 26 [18.2, 79.7], p=.02. In the TLIF cohort, PDQ scores improved from 73 [46, 85] to 48.5 [23, 67.5], p=.01. Both groups also showed a significant improvement in EQ-5D scores at 1 year, but the ALIFPS group showed a significantly greater improvement in EQ-5D scores at 1 year (0.1 [0,0.2] vs. 0.2 [0.1, 0.4], p=.02). Furthermore, only the ALIFPS cohort showed a significant improvement in segmental lordosis. The ALIFPS cohort showed a significantly greater improvement in disc height than did TLIF (3.5 [2, 5.5] vs. 6.7 [4.1, 10], p=.01). No significant differences were found in the direct costs of both procedures. Conclusions Our findings suggest that anterior lumbar interbody fusion with percutaneous pedicle screws can achieve better clinical outcomes compared with TLIF for the treatment of IS. We believe the superior radiographic outcomes achieved through ALIFPS, namely a greater restoration of segmental lordosis and disc height, may have contributed to the improved clinical outcomes presented in the current study.

In the United States, cervical total disk arthroplasty (TDA) is US Federal Drug Administration (FDA) approved for use in both 1 and 2-level constructions for cervical disk disease resulting in myelopathy and/or radiculopathy. TDA designs vary in form, function, material composition, and even performance in?vivo. However, the therapeutic goals are the same: to remove the painful degenerative/damaged elements of the intervertebral discoligamenous joint complex, to preserve or restore the natural range of spinal motion, and to mitigate stresses on adjacent spinal segments, thereby theoretically limiting adjacent segment disease (ASDis). Cervical vertebrae exhibit complex, coupled motions that can be difficult to artificially replicate. Commonly available TDA designs include ball-and-socket rotation-only prostheses, ball-and-trough rotation and anterior-posterior translational prostheses, as well as unconstrained elastomeric disks that can rotate and translate freely in all directions. Each design has its respective advantages and disadvantages. At this time, available clinical evidence does not favor 1 design philosophy over another. The superiority of cervical TDA over the gold-standard anterior cervical discectomy and fusion is a subject of great controversy. Although most studies agree that cervical TDA is at least as effective as anterior cervical discectomy and fusion at reducing or eliminating preoperative pain and neurological symptoms, the clinical benefits of motion preservation- that is, reduced incidence of ASDis-are far less clear. Several short-to-mid-term studies suggest that disk arthroplasty reduces the radiographic incidence of adjacent segment degeneration; however, the degree to which this is clinically significant is disputed. At this time, TDA has not been clearly demonstrated to reduce symptomatic?ASDis.

BACKGROUND Scoliosis X-rays are the gold standard for assessing preoperative lumbar lordosis; however, particularly for flexible lumbar deformities, it is difficult to predict from these images the extent of correction required, as standing radiographs cannot predict the thoracolumbar alignment after intraoperative positioning. OBJECTIVE To determine the utility of preoperative MRI in surgical planning for patients with flexible sagittal imbalance. METHODS We identified 138 patients with sagittal imbalance. Radiographic parameters including pelvic incidence and lumbar lordosis were obtained from images preoperatively. RESULTS The mean difference was 2.9° between the lumbar lordosis measured on supine MRI as compared to the intraoperative X-rays, as opposed to 5.53° between standing X-rays and intraoperative X-ray. In patients with flexible deformities (n = 24), the lumbar lordosis on MRI measured a discrepancy of 3.08°, as compared to a discrepancy of 11.46° when measured with standing X-ray. CONCLUSION MRI adequately determined which sagittal deformities were flexible. Furthermore, with flexible sagittal deformities, lumbar lordosis measured on MRI more accurately predicted the intraoperative lumbar lordosis than that measured on standing X-ray. The ability to preoperatively predict intraoperative lumbar lordosis with positioning helps with surgical planning and patient counseling regarding expectations and risks of surgery.

Background Spine surgery is complicated by an incidence of 1% to 9% of surgical site infection (SSI). The most common organisms are gram-positive bacteria and are endogenous, that is are brought to the hospital by the patient. Efforts to improve safety have been focused on reducing SSI using a bundle approach. The bundle approach applies many quality improvement efforts and has been shown to reduce SSI in other surgical procedures. Objective To provide a narrative review of practical solutions to reduce SSI in spine surgery. Methods Literature review and synthesis to identify methods that can be used to prevent SSI. Results SSI prevention starts with proper patient selection and optimization of medical conditions, particularly reducing smoking and glycemic control. Screening for staphylococcus organisms and subsequent decolonization is a promising method to reduce endogenous bacterial burden. Preoperative warming of patients and timely administration of antibiotics are critical to prevent SSI. Skin preparation using chlorhexidine and alcohol solutions are recommended. Meticulous surgical technique and maintenance of sterile techniques should always be performed. Postoperatively, traditional methods of tissue oxygenation and glycemic control remain essential. Newer wound care methods such as silver impregnation dressing and wound-assisted vacuum dressing are encouraging but need further investigation. Conclusion Significant reduction of SSIs is possible, but requires a systems approach involving all stakeholders. There are many simple and low-cost components that can be adjusted to reduce SSIs. Systematic efforts including understanding of pathophysiology, prevention strategies, and system-wide quality improvement programs demonstrate significant reduction of SSI.

Atlanto-axial rotatory-subluxation (AARS) is the most common pediatric cervical spine injury. Patients usually present with contralateral rotation and inclination of the upper cervical spine after minor trauma, or associated with an infection of the upper respiratory tract. According to the authors, initial management of patients with acute and chronic AARS type I-II should comprise closed reduction and immobilization with a cervical collar or a Halo-Body-Jacket. Surgical options of open reduction or C1/2 fusion should be restricted to irreducible or recurrent subluxations. This paper reviews the detailed technique of transoral closed reduction of AARS, as well as the preoperative and postoperative considerations.

The purpose of this study is to assess the role of bioskills in orthopaedic and neurosurgical resident education. A survey of the utilization and perceived efficacy of bioskills was submitted to Lumbar Spine Research Society (LSRS) members. 36/104 surgeons responded, including 25 orthopaedic, 7 neurosurgical, and 4 integrated respondents. 63% of orthopaedic and 83% of neurosurgery faculty, reported using bioskills. When asked if completion of bioskills modules would encourage advancing trainees' participation (1-10 scale, 10 greatly increase), neurosurgical faculty reported 4.00 versus orthopaedics 6.43. Although orthopaedic faculty perceive greater efficacy of bioskills, the clinical impact of this difference remains uncertain.

Background: Surgical site infections (SSIs) represent a devastating complication after spine surgery. Many factors have been identified, but the influence of operating room (OR) size on infection rate has not been assessed. Methods: Two thousand five hundred and twenty-three patients who underwent open lumbar spine fusion at a single institution between 2010 and 2016 were included. Patients were dichotomized into large versus small groups based on OR volume. Bivariate logistic regression and a final multivariate model following a multicollinearity check were used to calculate odds of infection for all variables. Results: A total of 63 patients (2.5%) developed SSIs with 46 (73%) in the larger OR group and 17 (27%) in the smaller OR group. The rate of SSIs in larger ORs was 3.02% compared with 1.81% in smaller ORs. Significant parameters impacting SSI in bivariate analysis included an earlier year of surgery, BMI > 30, more comorbidities, more levels decompressed and fused, smoking, and larger OR volumes. Multivariate analysis identified BMI > 30, Elixhauser scores, smoking, and increasing levels decompressed as significant predictors. Topical vancomycin was found to significantly decrease rate of infection in both analyses. Conclusions: OR size (large versus small) was ultimately not a significant predictor of infection related to rates of SSIs, although it did show a clinical trend toward significance, suggesting association. Future prospective analysis is warranted. Level of Evidence: 3.

The thoracic spine is characterized by significant biomechanical stability and functions in athletics to stabilize the trunk and enable coordinated upper extremity actions. While pathologies are rare, they may range from muscular injuries that are treated conservatively to life-threatening neurologic injury such as complete paraplegia requiring operative decompression and stabilization. Comprehensive history and physical and radiographic imaging are the initial workup for thoracic injuries, with computed tomography and magnetic resonance imaging playing important roles in furthering our understanding of individual pathologies such as fractures, disc herniations, and spinal cord injuries. Because the incidence of thoracic spine injuries is relatively rare, there remains no consensus regarding return-to-play recommendations, although full strength without neurologic deficit and full painless range of motion are useful return-to-play criteria.

Background: The purpose of this study was to determine if oblique magnetic resonance imaging (MRI) sequences affect the surgical treatment recommendations for patients with cervical radiculopathy. Methods: In this cohort study consecutive clinical cases of persistent cervical radiculopathy requiring surgical intervention were randomized, blinded, and reviewed by 6 surgeons. Initially each surgeon recommended treatment based on the history, physical examination, and axial, coronal and sagittal preoperative magnetic resonance (MR) images; when reviewing the cases the second time, the surgeons were provided oblique MR images. This entire process was then repeated after 2 months. Change in surgical recommendation, interobserver and intraobserver reliability and the average number of levels fused was determined. Results: The addition of the oblique images resulted in the surgical recommendation being altered in 49.2% (59/120) of cases; however, the addition of oblique images did not substantially improve the interobserver reliability of the treatment recommendation (κ = .57 versus.57). Similarly, the overall intraobserver reliability using only traditional MRI sequences (κ = .64) was only slightly improved by the addition of oblique images (κ = .66). Lastly, the addition of oblique images did not change the average number of levels fused (traditional MRI = 1.38, oblique MRI = 1.41, P = .53), or the total number of 3-level fusions recommended (6 versus 6, P = 1.00) Conclusions: The additional oblique images resulted in a change to the surgical plan in almost 50% of cases; however, it had no substantial effect on the reliability of surgical decision making. Further studies are needed to see if this alteration in treatment affects clinical outcomes. Level of Evidence: 3

OF BACKGROUND DATA Dysphagia and dysphonia are the most common complications after anterior cervical diskectomy and fusion (ACDF). No consensus system exists currently in the spine literature for the classification of these conditions postoperatively. OBJECTIVE The purpose of this analysis was to evaluate the validity and reliability of the Eating Assessment Tool (EAT-10) in the assessment of dysphagia when compared with the Bazaz score. A secondary goal was to assess the Voice Handicap Index (VHI-10) scores among patients following ACDF. METHODS Patients treated with ACDF (one, two, or three level) for cervical radiculopathy and/or cervical myelopathy at two tertiary hospitals were administered patient-reported outcome metrics preoperatively as well as at multiple time points postoperatively. The metrics administered included the EAT-10, VHI-10, Bazaz, Neck Disbability Index, and EuroQol Five Dimensions questionnaire (EQ-5D)/visual analog scale. RESULTS One hundred patients were included in this study. Eighty-nine percentage had a 1-year follow-up, and 100% had a 12-week follow-up. Mean Neck Disbability Index, EQ-5D, and EQ-visual analog scale scores all improved from baseline at both 6 months and 1 year postoperatively. Both the EAT-10 and VHI-10 demonstrated excellent internal reliability (α = 0.95 and α = 0.90, respectively). Analysis of variance of EAT-10 and VHI-10 scores by time point demonstrated a statistically significant relationship (P < 0.0001). The EAT-10 and VHI-10 scores were statistically greater on postoperative day 1 than at all other times (Tukey posthoc, P < 0.0001 and P < 0.004, respectively). Across all time points, 176 instances of clinically significant dysphagia (EAT-10 ≥ 3) were noted, 57 (32%) of which were classified as "None" on the Bazaz classification. CONCLUSIONS The EAT-10 score is an accurate measure for mild to severe dysphagia and better captured significant dysphagia that would have otherwise been missed when the Bazaz score is used. EAT-10 and VHI-10 are better measures of postoperative dysphagia and dysphonia than the current metrics used in spine surgery. STUDY DESIGN This was a prospective cohort study of consecutive patients.

The Smith-Robinson approach to the anterior cervical spine is being increasingly used, but it is not without complication. Dysphagia and dysphonia are the most common complications of the procedure. Many classification systems have been developed to stage and grade postoperative dysphagia and dysphonia, but inconsistent usage and lack of consensus adoption has limited research progress. A discussion of the merits and limitations of the most common classification systems is outlined within this review. Broad adoption of comprehensive and simple classification metrics is needed, but, first, prospective reliability and validity must be established in the anterior cervical fusion population.

To determine if adolescent athletics increases the risk of structural abnormalities in the lumbar spine. A retrospective review of patients (ages 10–18) between 2004 and 2012 was performed. Pediatric patients with symptomatic low back pain, a lumbar spine MRI, and reported weekly athletic activity were included. Patients were stratified to an “athlete” and “non-athlete” group. Lumbar magnetic resonance and plain radiographic imaging was randomized, blinded, and evaluated by two authors for a Pfirrmann grade, herniated disc, and/or pars fracture. A total of 114 patients met the inclusion criteria and were stratified into 66 athletes and 48 non-athletes. Athletes were more likely to have abnormal findings compared to non-athletes (67 vs. 40 %, respectively, p = 0.01). Specifically, the prevalence of a spondylolysis with or without a slip was higher in athletes vs. non-athletes (32 vs. 2 %, respectively, p = 0.0003); however, there was no difference in the average Pfirrmann grade (1.19 vs. 1.14, p = 0.41), percentage of patients with at least one degenerative disc (39 vs. 31 %, p = 0.41), or disc herniation (27 vs. 33 %, p = 0.43). Body mass index, smoking history, and pelvic incidence (51.5° vs. 48.7°, respectively, p = 0.41) were similar between the groups. Adolescents with low back pain have a higher-than-expected prevalence of structural pathology regardless of athletic activity. Independent of pelvic incidence, adolescent athletes with low back pain had a higher prevalence of spondylolysis compared to adolescent non-athletes with back pain, but there was no difference in associated disc degenerative changes or herniation.

Cervical radiculopathy presents with upper extremity pain, decreased sensation, and decreased strength caused by irritation of specific nerve root(s). After failure of conservative management, surgical options include anterior cervical decompression and fusion, disk arthroplasty, and posterior cervical foraminotomy. In this review, we discuss indications, techniques, and outcomes of posterior cervical laminoforaminotomy.

Study Design: Prospective randomized study. Objectives: To define the impact of an inexpensive, user-friendly, and reproducible lumbar pedicle screw instrumentation bioskills training module and evaluation protocol. Methods: Participants were randomized to control (n = 9) or intervention (n = 10) groups controlling for level of experience (medical students, junior resident, or senior resident). The intervention group underwent a 20-minute bioskills training module while the control group spent the same time with self-directed study. Pre- and posttest performance was self-reported (Physician Performance Diagnostic Inventory Scale [PPDIS]). Objective outcome scores were obtained from a blinded fellowship-trained attending orthopedic spine surgeon using Objective Structured Assessment of Technical Skills (OSATS) and Objective Pedicle Instrumentation Score metrics. In addition, identification of pedicle breach and breach anatomic location was measured pre- and posttest in lumbar spine models. Results: The intervention group showed a 30.8% improvement in PPDIS scores, compared with 13.4% for the control group ( P = .01). The intervention group demonstrated statistically significant 66% decrease in breaches ( P = .001) compared with 28% decrease in the control group ( P = .06). Breach identification demonstrated no change in accuracy of the control group (incorrect identification from 32.2% pre- to posttest 35%; P = .71), whereas the intervention group’s improvement was statistically significant (42% pre- to posttest 36.5%; P = .0047). Conclusions: We conclude that a concise lumbar pedicle screw instrumentation bioskills training session can be a useful educational tool to augment clinical education.

The Spine Patient Outcomes Related Trial (SPORT) is arguably one of the most impactful and insightful studies conducted in spine surgery. Designed as a prospective, multicenter study with a randomized and observational cohort, SPORT has provided vast data on the pathogenesis, treatment effects, clinical outcomes, cost effectiveness of both disk herniation and lumbar spinal stenosis. With regards to lumbar disk herniation, SPORT has demonstrated a sustained benefit from surgical intervention and acceptable cost-effectiveness at 2, 4, and 8 years postoperatively. Myriad subgroup analyses have subsequently been performed that have also resulted in clinically relevant findings. These analyses have assessed optimal timing for surgery, incidence and risk factors for reoperation, impact of obesity and other comorbidities, influence of epidural injections, and evaluation of socioeconomic factors. This has resulted in significant findings that may allow spine surgeons to optimize patient outcomes while managing expectations appropriately.

Carotid artery injury and stroke secondary to prolonged retraction remains an extremely rare complication in anterior cervical discectomy and fusion (ACDF). However, multiple studies have demonstrated that carotid artery retraction during the surgical approach may alter the normal blood flow, leading to a significant reduction in the cross-sectional area of the vessel. Others have suggested that dislodgment of atherosclerotic plaques following manipulation of the carotid artery can be a potential risk for intracranial embolus and stroke.We aimed to evaluate: (1) the incidence of postoperative stroke following ACDF and (2) incidence of other postoperative complications in a cohort of patients who had a diagnosis of carotid artery stenosis (CAS) versus those who did not.This study utilized the Statewide Planning and Research Cooperative System database from January 1, 2009 to December 31, 2013. All patients who underwent (ACDF) and had a preoperative diagnosis of CAS were identified using the International Classification of Disease, ninth revision codes. Those who had a previous history of stroke were excluded. Patients who had CAS were propensity score matched to patients without history of CAS for demographics and Charlson/Deyo comorbidity scores.Incidence of postoperative stroke and other complications were compared between the cohorts. The threshold for statistical significance was set at a p.05. This study received no funding. The authors report no conflict of interests relevant to this study.There were 34,975 patients who underwent an ACDF in the study time period. After excluding those under the age of 18 and with history of previous stroke, there were 61 patients who had CAS that were compared with a propensity-matched cohort. The CAS cohort had a significantly higher incidence of postoperative stroke during their hospitalization (6.6% vs 0%, p.042). The CAS cohort also had higher rates of acute renal failure (27.9% vs 4.9%, p = .01) and sepsis (18% vs 4.9%, p = .023). There were no stroke related deaths.Patients with CAS who underwent ACDF had a statistically significant greater incidence of developing a postoperative stroke. To the best of our knowledge, no previous study has evaluated the development of postoperative stroke in patients with CAS undergoing ACDF. Larger, multicenter studies are needed to estimate the true incidence of stroke in this specific patient population. However, our results may illustrate the importance of preoperative optimization, approach-selection, and postoperative stroke surveillance in patients with a history of CAS who undergoes ACDF.

Surgical site infections (SSIs) are a potentially devastating complication of spine surgery. SSIs are defined by the Centers for Disease Control and Prevention as occurring within 30 days of surgery or within 12 months of placement of foreign bodies, such as spinal instrumentation. SSIs are commonly categorized by the depth of surgical tissue involvement (ie, superficial, deep incisional, or organ and surrounding space). Postoperative infections result in increased costs and postoperative morbidity. Because continued research has improved the evaluation and management of spinal infections, spine surgeons must be aware of these modalities. The controversies in evaluation and management of SSIs in spine surgery will be reviewed.

STUDY DESIGN A questionnaire survey. OBJECTIVE The aim of this study was to determine the effect of patient age, dynamic instability, and/or low back pain on the treatment of patients with a degenerative spondylolisthesis, and if the operative approach is affected by surgeon specialty, location, or practice model. SUMMARY OF BACKGROUND DATA The classic treatment for patients with symptomatic degenerative spondylolisthesis is decompression and fusion; however in a select group of patients, an isolated decompression may be reasonable. METHODS A survey was sent to surgeon members of the Lumbar Spine Research Society and AOSpine requesting information regarding their preferred treatment of degenerative spondylolisthesis for a number of different clinical scenarios. Determinants included patient age, the presence of instability, symptoms of low back pain, surgeon's location, surgeon's specialty, and practice model. RESULTS A total of 223 spine surgeons completed the survey. Age of the patient, the presence of instability, and low back pain all significantly (P

Lumbar disc herniations are relatively common and often a source of leg pain, paresthesias, or weakness. Fortunately, the natural history outcome of lumbar radiculopathy due to a disc herniation is favorable, and most patients (70%-80%) improve with nonoperative care. Surgical intervention is indicated in patients who continue to have severe pain despite conservative treatment, and outcomes have been shown to be quite favorable in terms of alleviating leg pain and returning to function. There appears to be no difference in outcomes when comparing minimally invasive surgery or tubular discectomy vs open discectomy, and surgeons should offer the procedure that they are most comfortable and technically competent at performing in an effort to minimize complications. Finally, there is an abundant amount of literature that supports that elite athletes can successfully return to sport after undergoing a lumbar microdiscectomy.

STUDY DESIGN The thoracolumbar injury classification system (TLICS) was evaluated in 20 consecutive pediatric spine trauma cases. OBJECTIVE The purpose of this study was to determine the reliability and validity of the TLICS in pediatric spine trauma. SUMMARY OF BACKGROUND DATA The TLICS was developed to improve the categorization and management of thoracolumbar trauma. TLICS has been shown to have good reliability and validity in the adult population. METHODS The clinical and radiographical findings of 20 pediatric thoracolumbar fractures were prospectively presented to 20 surgeons with disparate levels of training and experience with spinal trauma. These injuries were consecutively scored using the TLICS. Cohen unweighted κ coefficients and Spearman rank order correlation values were calculated for the key parameters (injury morphology, status of posterior ligamentous complex, neurological status, TLICS total score, and proposed management) to assess the inter-rater reliabilities. Five surgeons scored the same cases 3 months later to assess the intra-rater reliability. The actual management of each case was then compared with the treatment recommended by the TLICS algorithm to assess validity. RESULTS The inter-rater κ statistics of all subgroups (injury morphology, status of the posterior ligamentous complex, neurological status, TLICS total score, and proposed treatment) were within the range of moderate to substantial reproducibility (0.524-0.958). All subgroups had excellent intra-rater reliability (0.748-1.000). The various indices for validity were calculated (80.3% correct, 0.836 sensitivity, 0.785 specificity, 0.676 positive predictive value, 0.899 negative predictive value). Overall, TLICS demonstrated good validity. CONCLUSION The TLICS has good reliability and validity when used in the pediatric population. The inter-rater reliability of predicting management and indices for validity are lower than those in adults with thoracolumbar fractures, which is likely due to differences in the way children are treated for certain types of injuries. TLICS can be used to reliably categorize thoracolumbar injuries in the pediatric population; however, modifications may be needed to better guide treatment in this specific patient population. LEVEL OF EVIDENCE 4.

Background: It is currently unknown how pre-existing lumbar spine conditions may affect the medical evaluation, draft status, and subsequent career performance of National Football League (NFL) players. Purpose: To determine if a pre-existing lumbar diagnosis affects a player’s draft status or his performance and longevity in the NFL. Study Design: Cohort study; Level 3. Methods: The investigators evaluated the written medical evaluations and imaging reports of prospective NFL players from a single franchise during the NFL Scouting Combine from 2003 to 2011. Players with a reported lumbar spine diagnosis and with appropriate imaging were included in this study. Athletes were then matched to control draftees without a lumbar spine diagnosis by age, position, year, and round drafted. Career statistics and performance scores were calculated. Results: Of a total of 2965 athletes evaluated, 414 were identified as having a pre-existing lumbar spine diagnosis. Players without a lumbar spine diagnosis were more likely to be drafted than were those with a diagnosis (80.2% vs 61.1%, respectively, P < .001). Drafted athletes with pre-existing lumbar spine injuries had a decrease in the number of years played compared with the matched control group (4.0 vs 4.3 years, respectively, P = .001), games played (46.5 vs 50.8, respectively, P = .0001), and games started (28.1 vs 30.6, respectively, P = .02) but not performance score (1.4 vs 1.8, respectively, P = .13). Compared with controls, players were less likely to be drafted if they had been diagnosed with spondylosis (62.37% vs 78.55%), a lumbar herniated disc (60.27% vs 78.43%), or spondylolysis with or without spondylolisthesis (64.44% vs 78.15%) ( P < .001 for all), but there was no appreciable effect on career performance; however, the diagnosis of spondylolysis was associated with a decrease in career longevity ( P < .05). Notably, 2 athletes who had undergone posterior lateral lumbar fusion were drafted. One played in 125 games, and the other is still active and has played in 108 games. Conclusion: The data in this study suggest that athletes with pre-existing lumbar spine conditions were less likely to be drafted and that the diagnosis is associated with a decrease in career longevity but not performance. Players with lumbar fusion have achieved successful careers in the NFL.

Study Design: Randomized, prospective study within an orthopedic surgery resident program at a large urban academic medical center. Objectives: To develop an inexpensive, user-friendly, and reproducible lumbar laminectomy bioskills training module and evaluation protocol that can be readily implemented into residency training programs to augment the clinical education of orthopedic and neurosurgical physicians-in-training. Methods: Twenty participants comprising senior medical students and orthopedic surgical residents. Participants were randomized to control (n = 9) or intervention (n = 11) groups controlling for level of experience (medical students, junior resident, or senior resident). The intervention group underwent a 40-minute bioskills training module, while the control group spent the same time with self-directed study. Pre- and posttest performance was self-reported by each participant (Physician Performance Diagnostic Inventory Scale [PPDIS]). Objective outcome scores were obtained from a blinded fellowship-trained attending orthopedic spine surgeon using Objective Structured Assessment of Technical Skills (OSATS) and Objective Decompression Score metrics. Results: When compared with the control group, the intervention group yielded a significant mean improvement in OSATS ( P = .022) and PPDIS ( P = .0001) scores. The Objective Decompression Scores improved in the intervention group with a trend toward significance ( P = .058). Conclusions: We conclude that a concise lumbar laminectomy bioskills training session can be a useful educational tool for to augment clinical education. Although no direct clinical correlation can be concluded from this study, the improvement in trainee’s technical and procedural skills suggests that Sawbones training modules can be an efficient and effective tool for teaching fundamental spine surgical skills outside of the operating room.

Background Deformity reconstruction surgery has been shown to improve quality of life (QOL) in cases of adult spinal deformity (ASD) but is associated with significant morbidity. Objective To create a preoperative predictive nomogram to help risk-stratify patients and determine which would likely benefit from corrective surgery for ASD as measured by patient-reported health-related quality of life (HRQoL). Methods All patients aged 25-yr and older with radiographic evidence of ASD and QOL data that underwent thoracolumbar fusion between 2008 and 2014 were identified. Demographic and clinical parameters were obtained. The EuroQol 5 dimensions questionnaire (EQ-5D) was used to measure HRQoL preoperatively and at 12-mo postoperative follow-up. Logistic regression of preoperative variables was used to create the prognostic nomogram. Results Our sample included data from 191 patients. Fifty-one percent of patients experienced clinically relevant postoperative improvement in HRQoL. Seven variables were included in the final model: preoperative EQ-5D score, sex, preoperative diagnosis (degenerative, idiopathic, or iatrogenic), previous spinal surgical history, obesity, and a sex-by-obesity interaction term. Preoperative EQ-5D score independently predicted the outcome. Sex interacted with obesity: obese men were at disproportionately higher odds of improving than nonobese men, but obesity did not affect odds of the outcome among women. Model discrimination was good, with an optimism-adjusted c-statistic of 0.739. Conclusion The predictive nomogram that we developed using these data can improve preoperative risk counseling and patient selection for deformity correction surgery.

Magnetization transfer (MT) contrast has been established as a marker of myelin integrity, and cervical spondylotic myelopathy is known to cause demyelination. Ten patients with clinical and magnetic resonance imaging (MRI) manifestations of cervical spondylotic myelopathy (CSM) were compared to the MRIs of seven historic healthy controls, using the magnetization transfer ratio (MTR) and Nurick scores as the primary metrics. Transverse slices through the intervertebral discs of the cervical spine were acquired using a gradient echo sequence (MEDIC) with and without an MT saturation pulse on a 3 Tesla Siemens Prisma scanner (TR = 300 ms, TEeff = 17 ms, flip angle = 30°, in-plane resolution = 0.47 × 0.47 mm2). The CSM patients tended to have a lower mean MTR (30.4 ± 6.5) than the controls (34.8 ± 3.8), but the difference was not significant (independent samples t-test, p = 0.110, Cohen’s d = 0.80). The mean MTR across all intervertebral disc levels was not significantly correlated to the Nurick score (Spearman’s ρ = −0.489, p = 0.151). The intervertebral level with the lowest MTR in each cohort was not significantly different between groups (equal variances not assumed, t = 1.965, dof = 14.8, p = 0.068, Cohen’s d = 0.88), but the CSM patients tended to have a lower MTR. The mean MTR at this level was negatively correlated to the Nurick score among CSM patients (Spearman’s ρ = −0.725, p = 0.018). CSM patients tended to have decreased MTR indicating myelin degradation compared to our healthy subjects, and MTR was negatively correlated with the severity of CSM.

OBJECTIVEThe flexed posture of the proximal (L1–3) or distal (L4–S1) lumbar spine increases the diameter of the spinal canal and neuroforamina and can relieve symptoms of neurogenic claudication. Distal lumbar flexion can result in pelvic retroversion; therefore, in cases of flexible sagittal imbalance, pelvic retroversion may be compensatory for lumbar stenosis and not solely compensatory for the sagittal imbalance as previously thought. The authors investigate underlying causes for pelvic retroversion in patients with flexible sagittal imbalance.METHODSOne hundred thirty-eight patients with sagittal imbalance who underwent a total of 148 fusion procedures of the thoracolumbar spine were identified from a prospective clinical database. Radiographic parameters were obtained from images preoperatively, intraoperatively, and at 6-month and 2-year follow-up. A cohort of 24 patients with flexible sagittal imbalance was identified and individually matched with a control cohort of 23 patients with fixed deformities. Flexible deformities were defined as a 10° change in lumbar lordosis between weight-bearing and non–weight-bearing images. Pelvic retroversion was quantified as the ratio of pelvic tilt (PT) to pelvic incidence (PI).RESULTSThe average difference between lumbar lordosis on supine MR images and standing radiographs was 15° in the flexible cohort. Sixty-eight percent of the patients in the flexible cohort were diagnosed preoperatively with lumbar stenosis compared with only 22% in the fixed sagittal imbalance cohort (p = 0.0032). There was no difference between the flexible and fixed cohorts with regard to C-2 sagittal vertical axis (SVA) (p = 0.95) or C-7 SVA (p = 0.43). When assessing for postural compensation by pelvic retroversion in the stenotic patients and nonstenotic patients, the PT/PI ratio was found to be significantly greater in the patients with stenosis (p = 0.019).CONCLUSIONSFor flexible sagittal imbalance, preoperative attention should be given to the root cause of the sagittal misalignment, which could be compensation for lumbar stenosis. Pelvic retroversion can be compensatory for both the lumbar stenosis as well as for sagittal imbalance.

Flatback syndrome can be a significant source of disability, affecting stance and gait, and resulting in significant pain. Although the historical instrumentation options for thoracolumbar fusion procedures have been commonly regarded as the etiology of iatrogenic flatback, inappropriate selection, or application of modern instrumentation can similarly produce flatback deformities. Patients initially compensate with increased lordosis at adjacent lumbar segments and reduction of thoracic kyphosis. As paraspinal musculature fatigues and discs degenerate, maintaining sagittal balance requires increasing pelvic retroversion and hip extension. Ultimately, disc degeneration at adjacent levels overcomes compensatory mechanisms, resulting in sagittal imbalance and worsening symptoms. Nonoperative management for sagittally imbalanced (sagittal vertical axis>5 cm) flatback syndrome is frequently unsuccessful. Despite significant complication rates, surgical management to recreate lumbar lordosis using interbody fusions and/or osteotomies can significantly improve quality of life.

Vertebroplasty and kyphoplasty have been used to treat osteoporotic compression fractures for many years. In 2009, two randomized controlled trials demonstrated limited effectiveness of vertebroplasty over sham treatment; thus, the American Academy of Orthopaedic Surgeons published evidence-based guidelines recommending "against vertebroplasty for patients who present with an osteoporotic spinal compression fracture." However, several other trials have since been published that contradict these conclusions. A recent meta-analysis cited strong evidence in favor of cement augmentation in the treatment of symptomatic vertebral compression fractures.

Background context Anterior cervical spine surgery is one of the most common spinal procedures performed around the world, but dysphagia is a frequent postoperative complication. Many factors have been associated with an increased risk of swallowing difficulties, including multilevel surgery, revision surgery, and female gender. Purpose The objective of this study was to review and define potential preventative measures that can decrease the incidence of dysphagia after anterior cervical spine surgery. Study design This was a systematic literature review. Methods A systematic review in the Medline database was performed. Articles related to dysphagia after anterior cervical spine surgery and potential preventative measures were included. Results Twenty articles met all inclusion and exclusion criteria. These articles reported several potential preventative measures to avoid postoperative dysphagia. Preoperative measures include performing tracheal exercises before the surgical procedure. Intraoperative measures can be summarized as avoiding a prolonged operative time and the use of recombinant human bone morphogenetic protein in routine anterior cervical spine surgery, using small and smoother cervical plates, using anchored spacers instead of plates, application of steroid before wound closure, performing arthroplasty instead of anterior cervical fusion for one-level disease, decreasing tracheal cuff pressure during medial retraction, using specific retractors, and changing the dissection plan. Conclusions Current literature supports several preventative measures that may decrease the incidence of postoperative dysphagia. Although the evidence is limited and weak, most of these measures did not appear to increase other complications and can be easily incorporated into a surgical practice, especially in patients who are at high risk for postoperative dysphagia.