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Introduction: Hypnosis is a technique requiring no drugs that acts during the three phases of surgery, reducing stress at the pre-surgical phase and the adminstration of anesthetic drugs during the intraoperative phase, as well as leading to improved management of postoperative pain and quality of life management., Material Et Method: We carried out a retrospective study of 46 patients operated on for herniated disc or one or two-level laminectomy without arthrodesis. All patients benefited from a preoperative hypnosis session and completed a questionnaire about their possible concerns. The day after surgery, patients completed a second questionnaire on their postoperative experience following hypnosis., Resultats: Our results indicate that this technique had a positive impact on the management of preoperative stress (80% of patients) and on postoperative quality of life (48% of patients). Pain measured by decreased from 4.8/10 preoperatively to 0.9/10 postoperatively., Conclusion: Our results are consistent with previous findings in the literature as to the positive contribution of this technique in the management of preoperative stress and patient quality of life. Further studies are however required involving considerably larger cohorts and more extensive surgeries to confirm the effect of this technique on management of anesthesia and pain in spine surgery., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Study Design: Retrospective analysis of data from the National Surgical Quality Improvement Program (NSQIP)., Objective: We sought to compare the short-term outcomes of laminectomy with/without fusion for single-level lumbar degenerative spondylolisthesis (DS)., Summary of Background Data: Lumbar DS is a common cause of low back and radicular pain. Controversy remains over the safety and efficacy of fusion in addition to standard decompressive surgery., Methods: Patients with lumbar DS who underwent laminectomy alone or laminectomy plus posterolateral fusion at a single level were identified from the 2012-2017 NSQIP database. Outcomes included 30-day mortality, major complication, reoperation, readmission, as well as operative duration, need for blood transfusion, length of stay (LOS), and discharge destination. Outcomes were compared between treatment groups by multivariable regression, adjusting for age, sex, and comorbidities (modified Frailty Index). Effect sizes were reported by adjusted odds ratio (aOR) or mean difference (aMD)., Results: The study cohort consisted of 1804 patients; of these, 802 underwent laminectomy alone and 1002 laminectomy plus fusion. On both unadjusted and adjusted analyses, there was no difference in 30-day mortality, major complications, reoperation, or readmission. However, laminectomy plus fusion was associated with longer operative time (170.0 vs. 152.7 minutes; aMD 16.00 minutes, P < 0.001), longer hospital LOS (3.2 vs. 2.5 days; aMD 0.68, P < 0.001), more frequent need for intra- or postoperative blood transfusion (6.8% vs. 3.1%; aOR 2.24, P = 0.001), and less frequent discharge home (80.7% vs. 89.2%; aOR 0.46, P < 0.001)., Conclusion: We found single-level laminectomy plus fusion for lumbar DS to have a comparable short-term safety profile to laminectomy alone. However, fusion was associated with longer operative time and LOS, higher risk of blood transfusion, and greater need for inpatient rehabilitation. These factors should be recognized by clinicians and discussed with patients in the context of their values when weighing surgical treatment of lumbar DS.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Degenerative cervical myelopathy (DCM) results from compression of the cervical spine cord as a result of age related changes in the cervical spine, and affects up to 2% of adults, leading to progressive disability. Surgical decompression is the mainstay of treatment, but there remains significant variation in surgical approaches used. This survey was conducted in order to define current practice amongst spine surgeons worldwide, as a possible prelude to further studies comparing surgical approaches., Methods: An electronic survey was developed and piloted by the investigators using SurveyMonkey. Collected data was categorical and is presented using summary statistics. Where applicable, statistical comparisons were made using a Chi-Squared test. The level of significance for all statistical analyses was defined as p < 0.05. All analysis, including graphs was performed using R (R Studio)., Results: 127 surgeons, from 30 countries completed the survey; principally UK (66, 52%) and North America (15, 12%). Respondents were predominantly Neurosurgeons by training (108, 85%) of whom 84 (75%) reported Spinal Surgery as the principal part of their practice. The majority indicated they selected their surgical procedure for multi-level DCM on a case by case basis (62, 49%). Overall, a posterior approach was more popular for multi-level DCM (74, 58%). Region, speciality or annual multi-level case load did not influence this significantly. However, there was a trend for North American surgeons to be more likely to favour a posterior approach., Conclusions: A posterior approach was favoured and more commonly used to treat multi-level DCM, in an international cohort of surgeons. Posterior techniques including laminectomy, laminectomy and fusion or laminoplasty appeared to be equally popular., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Study Design: .: Post-hoc analysis of a prospective observational cohort study., Objective: .: To compare clinical outcomes following laminectomy and fusion versus laminectomy alone in an international series of individuals suffering from degenerative cervical myelopathy (DCM)., Summary of Background Data: .: Significant controversy exists regarding the role of instrumented fusion in the context of posterior surgical decompression for DCM. A previous study comparing laminectomy and fusion with laminoplasty showed no differences in outcomes between groups after adjusting for preoperative characteristics., Methods: .: Based on the operation they received, 208 of the 757 patients prospectively enrolled in the AO Spine North America or International studies at 26 global sites were included in the present study. Twenty-two patients were treated with laminectomy alone and 186 received a laminectomy with fusion. Patients were evaluated using the modified Japanese Orthopedic Association scale (mJOA), Nurick score, Neck Disability Index, and SF36 quality of life measure. Baseline and surgical characteristics were compared using a t test for continuous variables and a chi-square test for categorical variables. A mixed model analytic approach was used to evaluate differences in outcomes at 24 months between patients undergoing laminectomy and fusion versus laminectomy alone., Results: .: Surgical cohorts were comparable in terms of preoperative patient characteristics. Patients undergoing laminectomy with instrumented fusion had a significantly longer operative duration (P < 0.0001, 231.44 vs. 107.10 min) but a comparable length of hospital stay. In terms of outcomes, patients treated with laminectomy with fusion exhibited clinically meaningful improvements (in functional impairmentΔmJOA = 2.48, ΔNurick = 1.19), whereas those who underwent a laminectomy without fusion did not (ΔmJOA = 0.78; ΔNurick = 0.29). There were significant differences between surgical cohorts in the change in mJOA and Nurick scores from preoperative to 24-months postoperative (mJOA: -1.70, P = 0.0266; Nurick: -0.90, P = 0.0241). The rate of perioperative complications was comparable (P = 0.879)., Conclusion: .: Our findings suggest that cervical laminectomy with instrumented fusion is more effective than laminectomy alone at improving functional impairment in patients with DCM. These results warrant confirmation in larger prospective comparative studies., Level of Evidence: 2.

Study Design: A retrospective single-center study., Objective: The aim of this study was to investigate the influence of the K-line in the neck-flexed position (flexion K-line) on the surgical outcome after muscle-preserving selective laminectomy (SL) for cervical spondylotic myelopathy (CSM)., Summary of Background Data: Development of CSM is associated with dynamic factors and cervical alignment. The flexion K-line, which reflects both dynamic and alignment factors, provides an indicator of surgical outcome after posterior decompression surgery for patients with ossification of the posterior longitudinal ligament. However, the value of the flexion K-line for patients with CSM has not been evaluated., Methods: Our study group included 159 patients treated with SL for CSM. Patients were divided into a flexion K-line (+) group and a flexion K-line (-) group. The influence of the flexion K-line on radiological and surgical outcomes was analyzed, with multivariate analysis conducted to identify factors affecting the surgical outcome., Results: Patients in the flexion K-line (-) group were younger (P = 0.003), had a less lordotic cervical alignment (pre-and postoperatively, P < 0.001), a smaller C7 slope (pre-and postoperatively, P < 0.001), and a greater mismatch between the C7 slope and the C2-C7 angle (preoperatively, P = 0.047; postoperatively, P = 0.001). The postoperative increase in Japanese Orthopedic Association (JOA) score and the JOA score recovery rate (RR) were lower for the flexion K-line (-) than for the K-line (+) group (P < 0.001 and P < 0.001, respectively). On multivariate regression analysis, the flexion K-line (-) (β = -0.282, P < 0.001), high signal intensity (SI) changes on T2-weighted image (WI) combined with low SI changes on T1-WI in the spinal cord (β = -0.266, P < 0.001), and older age (β= -0.248, P = 0.001) were predictive of a lower JOA score RR., Conclusion: The flexion K-line may be a useful predictor of surgical outcomes after SL in patients with CSM., Level of Evidence: 4.

Study Design: Retrospective analysis of outcomes in single-level spine and primary hip and knee arthroplasty patients., Objective: The aim of this study was to compare baseline and postoperative outcomes in patients undergoing spine surgery procedures with total hip arthroplasty (THA) and total knee arthroplasty (TKA) to further define outcomes in orthopedic surgery., Summary of Background Data: Computer-adaptive Patient Reported Outcome Information System (PROMIS) allows for standardized assessment of the health-related quality of life across different disease states., Methods: Patients who underwent spine surgery (anterior cervical discectomy and fusion, cervical disc replacement, lumbar laminectomy, microscopic lumbar discectomy, transforaminal lumbar interbody fusion or adult reconstruction surgery [THA, TKA]) were grouped. Mean Charlson Comorbidity Index (CCI), Baseline (BL), and 6-month PROMIS scores of physical function, pain interference, and pain intensity were determined. Paired t tests compared differences in CCI, BL, 6 months, and change in PROMIS scores for spine and adult reconstruction procedures., Results: A total of 304 spine surgery patients (age = 58.1 ± 15.6; 42.9% female) and 347 adult reconstruction patients (age = 62.9 ± 11.8; 54.1% Female) were compared. Spine surgery groups had more disability and pain at baseline than adult reconstruction patients according to physical function ([21.0, 22.2, 9.07, 12.6, 10.4] vs. [35.8, 35.0], respectively, P < 0.01), pain interference ([80.1, 74.1, 89.6, 92.5, 90.6] vs. [64.0, 63.9], respectively, P < 0.01), and pain intensity ([53.0, 53.1, 58.3, 58.5, 56.1] vs. [53.4, 53.8], respectively, P < 0.01). At 6 months, spine surgery patients remained more disabled and had more pain compared to adult reconstruction patients. Over the 6-month timespan, spine patients experienced greater improvements than adult reconstruction patients in terms of physical function ([+8.7, +22.2, +9.7, +12.9, +12.1] vs. [+5.3, +3.9], respectively, P < 0.01) and pain interference scores ([-15.4,-28.1, -14.7, -13.1, -12.3] vs. [-8.3, -6.0], respectively, P < 0.01)., Conclusion: Spinal surgery patients had lower BL and 6-month PROMIS scores, but greater relative improvement in PROMIS scores compared to adult reconstruction patients., Level of Evidence: 3.

Objective: Space-occupying spinal meningiomas (SM), commonly diagnosed due to gradual neurological deterioration, are treated surgically by decompression and tumor resection. In this series of patients with surgically treated SM, we determined individual predictors of functional outcome in the context of intraoperative neuromonitoring (IOM)., Methods: This retrospective study included 45 patients (39 women, 6 men; mean age 63 years). We reviewed pre- and postoperative charts, surgical reports, radiographic data for demographics, use of IOM, duration of symptoms, histopathology, co-morbidities, radiographic extension, surgical strategy, neurological performance (Japanese Orthopedic Association Score [JOA score]. Median follow-up was 34 months (12-190 months)., Results: Most frequent surgical approaches were laminectomy (71.1%, n = 32) and hemi-laminectomy (28.9%, n = 13). Predominant SM site was the thoracic spine (55.6%, n = 25). Most common symptoms were sensory deficits (77.8%, n = 35), gait disorders (55.6%, n = 25), motor deficits (42.2%, n = 19), and radiating pain (37.8%, n = 17). Simpson grade 1 resection was achieved in 6 patients, most common type of resection was Simpson grade 2 in 36 patients. During follow-up, 80.0% of patients had fully recovered sensory deficits (p < 0.001), 76.0% of patients with preoperative gait disorders had been asymptomatic (p < 0.001), and motor deficits in 12/19 (63.1%). Pain had decreased significantly from admission to follow-up (p = 0.001). IOM was used in 20 (44.4%) patients. Postoperatively, 6(13.3%) patients had developed a new neurological deficit, 4 of them operated without IOM., Conclusion: Resection of SM with IOM showed good recovery, excellent functional results with low surgical morbidity., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Study Design: Retrospective review., Objective: Compare postoperative infection rates and 30-day outcomes in spine surgery patients with and without a preoperative urinary tract infection (UTI)., Summary of Background Data: There is mixed evidence regarding safety and risks when operating on spine patients with a preoperative UTI., Methods: Using data from the American College of Surgeons National Surgical Quality Improvement Program, we identified all adult patients undergoing spine surgery between 2012 and 2017 with a preoperative UTI. Patients with other preoperative infections were excluded. Our primary outcome was any postoperative infection (pneumonia, sepsis, surgical site infection, and organ space infection). Our secondary outcomes included surgical site infections, non-infectious complications, return to operating room, and 30-day readmission and mortality. We used univariate, then multivariate Poisson regression models adjusted for demographics, comorbidities, laboratory values, and case details to investigate the association between preoperative UTI status and postoperative outcomes., Results: A total of 270,371 patients who underwent spine surgery were analyzed. The most common procedure was laminectomy (41.9%), followed by spinal fusion (31.7%) and laminectomy/fusion (25.6%). Three hundred fourty one patients had a preoperative UTI (0.14%). Patients with a preoperative UTI were more likely to be older, female, inpatients, emergency cases, with a higher American Society of Anesthesiologists score, and a longer operating time (for all, P < 0.001). Patients with a preoperative UTI had higher rates of infectious and non-infectious complications, return to operating room, and unplanned readmissions (for all, P < 0.001). However, there was no significant difference in mortality (0.6% vs. 0.2%, P = 0.108). Even after controlling for demographics, comorbidities, labs, and case details, preoperative UTI status was significantly associated with more postoperative infectious complications (incidence rate ratio [IRR]: 2.88, 95% confidence interval [CI]: 2.25-3.70, P < 0.001)., Conclusion: Preoperative UTI status is significantly associated with postoperative infections and worse 30-day outcomes. Spine surgeons should consider delaying or cancelling surgery in patients with a UTI until the infection has cleared to reduce adverse outcomes., Level of Evidence: 3.

Study Design: A prospective observational 10-year follow-up study., Objective: This study aimed to examine preoperative predictors for better surgical outcomes in patients with lumbar spinal stenosis (LSS) 10 years after surgery., Summary of Background Data: LSS is a leading cause of low back surgery in patients older than 65 years. Limited data are available for predictors of long-term surgical outcomes in patients with LSS., Methods: At the baseline, 102 patients with LSS underwent decompressive surgery, and 72 of the original study sample participated in a 10-year follow-up study. Study patients filled out a questionnaire preoperatively, and follow-up data were collected at 3 months, 6 months, 1 year, 2 years, 5 years, and 10 years postoperatively. Surgical outcomes were evaluated in terms of disability with the Oswestry Disability Index (ODI) and pain with the visual analog scale (VAS). Predictors in the models were nonsmoking status, absence of previous lumbar surgery, self-rated health, regular use of painkillers for symptom alleviation, and BMI. Statistical analyses included longitudinal associations, subgroup analyses, and cross-sectional analyses., Results: Using multivariate analysis, statistically significant predictors for lower ODI and VAS scores at 10 years were nonsmoking status, absence of previous lumbar surgery, better self-rated health, and regular use of painkillers for <12 months. Patients who smoked preoperatively or had previous lumbar surgery experienced more pain and disability at the 10-year follow-up., Conclusion: These study results can enhance informed decision-making processes for patients considering surgical treatment for LSS by showing preoperative predictors for surgical outcomes up to 10 years after surgery. Smokers and patients with previous lumbar surgery showed a decline in surgical benefits after 5 years., Level of Evidence: 3.

Study Design: Retrospective review of electronic medical records (EMR)., Objective: This study aims to (1) characterize the pattern of opioid utilization in patients undergoing spine surgery and (2) compare the postoperative course between patients with and without chronic preoperative opioid prescriptions., Summary of Background Data: Postoperative pain management for patients with a history of opioid usage remains a challenge for spine surgeons. Opioids are controversial in this setting due to side effects and potential for abuse and addiction. Given the increasing rate of opioid prescriptions for spine-related pain, more studies are needed to evaluate patterns and risks of preoperative opioid usage in surgical patients., Methods: EMR were reviewed for patients (age > 18) with lumbar spinal stenosis undergoing lumbar laminectomy in 2011 at our institution. Data regarding patient demographics, levels operated, pre/postoperative medications, and in-hospital length of stay were collected. Primary outcomes were length of stay and duration of postoperative opioid usage., Results: One hundred patients were reviewed. Fifty-five patients had a chronic opioid prescription documented at least 3 months before surgery. Forty-five patients were not on chronic opioid therapy preoperatively. The preoperative opioid group compared with the non-opioid group had a greater proportion of females (53% vs. 40%), younger mean age (63 yrs vs. 65 yrs), higher frequency of preoperative benzodiazepine prescription (20% vs. 11%), longer average in-hospital length of stay (3.7 d vs. 3.2 d), and longer duration on postoperative opioids (211 d vs. 79 d)., Conclusion: Patients on chronic opioids prior to spine surgery are more likely to have a longer hospital stay and continue on opioids for a longer time after surgery, compared with patients not on chronic opioid therapy. Spine surgeons and pain specialists should seek to identify patients on chronic opioids before surgery and evaluate strategies to optimize pain management in the pre- and postoperative course., Level of Evidence: 3.

Study Design: Retrospective cohort study., Objective: The objective of this study was to characterize the costs associated with American Society of Anesthesiologists (ASA) class, and to determine the extent to which ASA status is a predictor of increased cost and LOS following lumbar laminectomy and fusion (LLF)., Summary of Background Data: Spinal fusion accounts for the highest hospital costs of any surgical procedure performed in the United States, and ASA (American Society of Anesthesiologists) status is a known risk factor for cost and length of stay (LOS) in the orthopedic literature. There is a paucity of literature that directly addresses the influence of ASA status on cost and LOS following LLF., Methods: This is a retrospective cohort study of an institutional database of patients undergoing single-level LLF at an academic tertiary care facility from 2006 to 2016. Univariate comparisons were made using χ tests for categorical variables and t tests for continuous variables. Multivariate linear regression was utilized to estimate regression coefficients, and to determine whether ASA status is an independent risk factor for cost and LOS., Results: A total of 1849 patients met inclusion criteria. For every one-point increase in ASA score, intensive care unit (ICU) LOS increased by 0.518 days (P < 0.001), and hospital length of stay increased by 1.93 days (P < 0.001). For every one-point increase in ASA score, direct cost increased by $7474.62 (P < 0.001)., Conclusion: ASA status is a predictor of hospital LOS, ICU LOS, and direct cost. Consideration of the ways in which ASA status contributes to increased cost and prolonged LOS can allow for more accurate reimbursement adjustment and more precise targeting of efficiency and cost effectiveness initiatives., Level of Evidence: 3.

Aim: To investigate the role of bipolar electrocautery in the occurrence of epidural fibrosis following lumbar spine laminectomy in a rat model., Material and Methods: Fourteen male Sprague-Dawley rats (age: 4-6 months, weight: 250-300 g) were randomly divided into two groups, a bipolar group (Group I) and a control group (Group II). Laminectomy was performed between the L1 and L3 levels. In Group I (n=7), a laminectomy was carried out and soft tissue around the spinal cord was coagulated by using a bipolar electrocautery. In the control group (n=7), only laminectomy was performed. The animals were sacrificed 4 weeks after surgery, and post-laminectomy epidural fibrosis (PLEF) was evaluated. Macropathological, qualitative and quantitative histological evaluations as well as immunohistochemical staining including transforming growth factor-β (TGF-β), collagen I and collagen III were performed., Results: The numbers of TGF-β positive cells staining (PCS) were 3.00 ± 0.46 for Group I and 1.00 ± 0.52 for Group II. The numbers of collagen I PCS were 2.00 ± 0.93 for Group I and 1.25 ± 0.46 for Group II. The numbers of collagen III PCS were 2.25 ± 0.76 for Group I, 1.25 ± 0.46 for Group II, and TGF-β PCS than Group II (p≤0.05). Compared with the control group, Group I's formation of epidural fibrosis was significantly increased., Conclusion: Our study clearly demonstrated that the use of bipolar cauterisation is associated with increased PLEF in the experimental animal model. Thus, limiting the use of bipolar cauterisation may be effective in reducing this complication.

Study Design: This is a retrospective analysis of national administrative hospital data., Objective: This study examines national trends in the surgical management of lumbar spinal stenosis (LSS) in patients with and without coexisting scoliosis between 2010 and 2014. The study also examines revision rates for LSS procedures., Summary of Background Data: There is wide variability in the surgical management of patients with LSS, with and without coexisting spinal deformity., Methods: Data were obtained from the Healthcare Cost and Utilization Project's National Inpatient Sample Database. International Classification of Diseases 9th revision- Clinical Modification codes were used to identify all patients with a primary diagnosis of lumbar spinal stenosis. These patients were divided into two groups: 1) LSS alone and 2) LSS with coexisting scoliosis. The two groups were examined for one of three surgical outcomes: 1) decompression alone (discectomy, laminectomy), 2) simple fusion, and 3) complex fusion (>three vertebrae or 360° fusion). The groups were then further examined for revision operations. National Inpatient Sample discharge weights were applied where relevant., Results: In 2014 national estimates of discharged patients indicated 76,275 patients with a primary diagnosis of LSS (population rate, 23.9; in the elderly (65+) the age-adjusted population rate was 95.4). Of these patients, 88.5% were managed through primary surgery (34.6% decompression, 47.2% simple fusion, 5.7% complex fusion). Between 2010 and 2014, the percentage of decompression decreased from 47.5% to 34.6%, the percent of simple fusion increased from 35.3% to 47.2%, and the percent of complex fusion increased from 5.7% to 7.1% (P < 0.01). In patients with coexisting scoliosis, lumbar spinal stenosis was predominantly managed by simple fusion and complex fusion (15.5% decompression, 51.9% simple fusion, 27.3% complex fusion, in 2014). Revision rates were highest among patients without scoliosis managed with complex fusion (15.8% in 2014) compared with patients with scoliosis (8.8% in 2014). Patients with scoliosis who underwent decompression only had revision rates of 1.7% and 0.62% in 2010 and 2014, respectively., Conclusion: We observed a leveling-off of the rate of operation for patients with a primary diagnosis of LSS at around 88%. There was an increase in the rate of fusion and a decrease in the rate of decompression across all patient groups. We report no difference in revision rates between patients with and without scoliosis, except in those undergoing a complex fusion., Level of Evidence: 3.

Purpose: Despite decades of experience and research, the etiology and management of Chiari I malformations (CM-I) continue to raise more questions than answers. Controversy abounds in every aspect of management, including the indications, timing, and type of surgery, as well as clinical and radiographic outcomes. This review aims to outline past experiences, consolidate current evidence, and recommend directions for the future management of the Chiari I malformation., Methods: A review of recent literature on the management of CM-I in pediatric patients is presented, along with our experience in managing 1073 patients who were diagnosed with CM-I over the past two decades (1998-2018) at Children's National Medical Center (CNMC) in Washington DC., Results: The general trend reveals an increase in the diagnosis of CM-I at younger ages with a significant proportion of these being incidental findings (0.5-3.6%) in asymptomatic patients as well as a rise in the number of patients undergoing Chiari posterior fossa decompression surgery (PFD). The type of surgical intervention varies widely. At our institution, 104 (37%) Chiari surgeries were bone-only PFD with/without outer leaf durectomy, whereas 177 (63%) were PFD with duraplasty. We did not find a significant difference in outcomes between the PFD and PFDD groups (p = 0.59). An analysis of failures revealed a significant difference between patients who underwent tonsillar coagulation versus those whose tonsils were not manipulated (p = 0.02)., Conclusion: While the optimal surgical intervention continues to remain elusive, there is a shift away from intradural techniques in favor of a simple, extradural approach (including dural delamination) in pediatric patients due to high rates of clinical and radiographic success, along with a lower complication rate. The efficacy, safety, and necessity of tonsillar manipulation continue to be heavily contested, as evidence increasingly supports the efficacy and safety of less tonsillar manipulation, including our own experience.

Study Design: Retrospective chart audit., Objectives: This study investigated changes in sagittal alignment in adults after excision of thoracic spinal cord tumors without spinal fixation., Setting: Single-center study at an academic orthopedic department in Japan., Methods: We retrospectively reviewed records for 32 adults who underwent excision of thoracic spinal cord tumors by multilevel laminectomies without fixation. The participants were divided according to whether the tumor was in the upper (T1-4), middle (T5-8), or lower (T9-12) thoracic spine. We analyzed parameters such as age, sex, time in surgery and estimated blood loss, follow-up period, and preoperative and follow-up the Japanese Orthopaedic Association (JOA) scores and radiographs., Results: Postoperative T1-12 kyphotic changes did not correlate with age, the number of resected laminae, or preoperative T1-12 kyphosis. JOA recovery rates were similar regardless of the tumor location. Participants with tumors in the upper thoracic spine had significant postoperative increases in T1-4 kyphosis, T1 slope (p < .05, respectively). In contrast, there were no significant changes in alignment in participants with tumors in the middle or lower thoracic spine., Conclusion: Even without fixation, sagittal alignment did not change after surgery to excise tumors in the middle and lower thoracic spine, indicating that fixation may not be necessary when excising spinal cord tumors in this region. In contrast, postoperative kyphosis may increase when the tumor is in the upper thoracic spine.

Background: Unilateral laminectomy for bilateral decompression (ULBD) for lumbar spinal stenosis (LSS) is a less invasive technique compared to conventional laminectomy. Recently, several authors have reported favorable results of low back pain (LBP) in patients of LSS treated with ULBD. However, the detailed changes and localization of LBP before and after ULBD for LSS remain unclear. Furthermore, unsymmetrical invasion to para-spinal muscle and facet joint may result in the residual unsymmetrical symptoms. To clarify these points, we conducted an observational study and used detailed visual analog scale (VAS) scores to evaluate the characteristics and bilateral changes of LBP and lower extremity symptoms., Methods: We included 50 patients with LSS treated with ULBD. A detailed visual analogue scale (VAS; 100 mm) score of LBP in three different postural positions: motion, standing, and sitting, and bilateral VAS score (approached side versus opposite side) of LBP, lower extremity pain (LEP), and lower extremity numbness (LEN) were measured. Oswestry Disability Index (ODI) was used to quantify the clinical improvement., Results: Detailed LBP VAS score before surgery was 51.5 ± 32.5 in motion, 63.0 ± 30.1 while standing, and 37.8 ± 31.8 while sitting; and showed LBP while standing was significantly greater than LBP while sitting (p < 0.01). After surgery, LBP while standing was significantly improved relative to that while sitting (p < 0.05), and levels of LBP in the three postures became almost the same with ODI improvement. Bilateral VAS scores showed significant improvement equally on both sides (p < 0.01)., Conclusions: ULBD improves LBP while standing equally on both sides in patients with LCS. The improvement of LBP by the ULBD surgery suggests radicular LBP improved because of decompression surgery. Furthermore, the symmetric improvement of LBP by the ULBD surgery suggests unsymmetrical invasion of the paraspinal muscles and facet joints is unrelated to residual LBP.

Objectives: Few studies have evaluated surgical options in the treatment of cervical metastatic disease. The aim of this study is to report the surgical outcomes of patients treated with the posterior-only approach for metastatic cervical disease., Methods: In this retrospective analysis, all cases treated in our institution from 2009 to 2017 were reviewed. Six (20%) patients had intracompartimental lesions (Tomita 1-3), whereas 24 (80%) patients had extracompartimental lesions (Tomita 4-7), with extensive anterior column involvement. All patients were surgically treated with laminectomy and posterior stabilization. Pain and neurologic function were evaluated before and after surgery., Results: Thirty patients were included (15 female, 15 male), with a mean age of 60.6 ± 11.56 years (range 35-82 years). Lesions were located in 7 patients (23.3%) in the upper cervical spine and in 14 patients (46.6%) and in 9 patients (30,1%) in the mid-cervical and in the cervicothoracic junction, respectively. At a mean follow up of 13.7 ± 14.8 months, 15 (50%) patients died from their disease. Pain decreased in all patients after surgery, (preoperative NRS 5.57 ± 1.81 postoperative Numeric Rating Scale of 2.1 ± 1.0, P < 0.00001). Two patients (6.7%) had significant neurologic worsening after surgery. Two (6.9%) patients had surgical-site infection that required reintervention. No mechanical failures were observed., Conclusions: In our series, posterior-only fixation provided postoperative pain relief and achieve spinal stability, ultimately improving the quality of life. In conclusion, posterior-approach decompression and stabilization is a safe and feasible procedure in patients with neurologic or mechanical instability for cervical spine metastasis., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The pathogenesis of synovial cysts is largely unknown; however, they have been increasingly thought of as markers of spinal facet instability and typically associated with degenerative spondylosis. We specifically investigated the incidence of concomitant synovial cysts with underlying degenerative spondylolisthesis., Methods: A literature search was performed using 4 online databases to assess the association between lumbar synovial cysts and degenerative spinal pathological features. Meta-analyses were performed on the prevalence rates of coexisting degenerative spinal pathological entities and treatment modalities. A random effects model was used to calculate the mean and 95% confidence intervals., Results: A total of 17 studies encompassing 824 cases met the inclusion criteria. The pooled prevalence rates of concurrent spondylolisthesis, facet arthropathy, and degenerative disc disease at the same level of the synovial cysts were 42.5% (range, 39.0%-46.1%), 89.3% (range, 79.0%-94.8%), and 48.8% (range, 43.8%-53.9%), respectively. Among these, patients with coexisting spondylolisthesis were more likely to undergo spinal fusion surgery (vs. laminectomy alone) and reoperation than were patients without spondylolisthesis with a pooled odds ratio of 11.5 (95% confidence interval, 4.5-29.1; P < 0.0001) and 2.0 (95% confidence interval, 0.9-4.2; P = 0.088), respectively., Conclusions: Patients with a combination of synovial cysts and degenerative spondylolisthesis are more likely to undergo spinal fusion surgery than laminectomy alone compared with patients with synovial cysts and no preoperative spondylolisthesis. Furthermore, patients with synovial cysts and spondylolisthesis are more likely to require additional fusion surgery. The results from the present review lend credence to the argument that synovial cyst herniation might be a manifestation of an unstable spinal level., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: The purpose of the present study was to determine the learning curve for biportal endoscopic spinal surgery (BESS) for decompressive laminectomy in lumbar spinal stenosis using a learning curve cumulative summation test (LC-CUSUM)., Methods: The surgeon was proficient in open and microscopic decompressive laminectomy in lumbar spinal stenosis but did not have any experience with BESS or other endoscopic surgery techniques. The learning curve of BESS was investigated using LC-CUSUM analysis. Procedure success was defined as an operative time <75 minutes, the mean operative time with microscopic decompression laminectomy., Results: The present study included the first 60 patients who had undergone single-level decompressive laminectomy using BESS by a single orthopedic surgeon. The mean operative time for decompressive laminectomy by BESS was 83.8 ± 37.9 minutes. The mean operative time in the early learning period (≤30 cases) and late learning period (second 30 cases) was 105.3 ± 39.7 minutes and 62.4 ± 19.9 minutes, respectively. The overall complication rate was ∼10%. The LC-CUSUM signaled competency for surgery at the 58th operation, indicating that sufficient evidence had accumulated to prove that the surgeon was competent. Thus, a trainee with no experience with BESS had reached adequate performance at 58 cases., Conclusions: The results of the present study have demonstrated that a substantial learning period could be needed before adequate performance can be achieved with lumbar decompressive laminectomy using BESS., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objective: This study sought to determine whether a relationship exists between caudal instrumented level and revision rates, neck disability index scores, and cervical alignment in patients undergoing multilevel posterior cervical fusion., Methods: This study examined a dataset of all patients undergoing posterior cervical decompression and fusion at ≥3 levels, terminating between C4 and T4, between January 2010 and December 2015, with at least 12 months of clinical follow-up. Patients were separated into cohorts based on caudal level of the fusion: C6 (or more cranial), C7, T1, or T2 (or more caudal). Revision rate, neck disability index score, sagittal vertical axis, T1 slope, and cervical lordosis were recorded. Linear regression and multivariate analysis were performed to identify independent predictors of patient outcomes and disparities between ending constructs in the cervical and the thoracic spine., Results: The overall revision rate was 10.8% (n = 24). No statistically significant difference in the revision rate was identified between fusions terminating at C6 or cranial, C7, T1, or T2 and caudal (P = 0.74). Revision correlated strongly with increased sagittal vertical axis (P = 0.002) and T1 slope (P = 0.04). Increased neck disability index score correlated with revision rate (P = 0.01), cervical kyphosis (P < 0.001), and increased sagittal vertical axis (P = 0.04)., Conclusions: This study suggests that constructs terminating in the proximal thoracic spine have similar revision rates, postoperative neck disability index scores, and radiographic measurements as those terminating in the cervical spine. Poor cervical alignment, as evidenced by increased sagittal vertical axis, cervical kyphosis and T1 slope, predicts need for revision and of poorer clinical outcomes., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Aim: To clarify the effects of topical application of curcumin on the prevention of epidural fibrosis., Material and Methods: Twenty-one rats were randomly divided into three equal groups (control, spongostan, local curcumin) and a laminectomy procedure was performed between T11 and L1 in all rats. Subsequently, spongostan soaked with curcumin (100 mg/kg) was applied topically. After four weeks, the vertebral column from T9 to L3, which included the paraspinal muscles and epidural scar tissue, was removed as a single piece and the epidural fibrosis and arachnoidal scarring were graded and histopathological analysis carried out accordingly. Kruskal-Wallis and Pearson Chi-Square tests were used for statistical analysis. A p-value of less than 0.05 was considered to be significant., Results: The grading of epidural fibrosis was far lower in the experimental group with curcumin compared to the control and spongostan groups, but the difference was not statistically significant., Conclusion: The findings of this study show that local curcumin decreases the formation of epidural fibrosis and this effect of curcumin is thought to be mediated by reducing the functions of inflammatory cells such as macrophages, neutrophils and fibroblasts, and the anti-inflammatory and antioxidant effects.

Objective: Causation and avoidance of C5 palsy after laminectomy have proven elusive, with multiple factors incriminated including width of the laminectomy, spinal cord migration, C5 neural foraminal stenosis, or intraoperative C5 root traction. In an attempt to identify risk factors for C5 palsy after decompression in cervical stenosis and myelopathy, the following review was conducted. This report is from a single center with consistent criteria for diagnosis and management of cervical stenosis and myelopathy., Patients and Methods: We retrospectively reviewed 63 patients with cervical stenosis and myelopathy who had been treated with laminectomy with instrumentation at the C4-6 level. Imaging studies reviewed included plain X-ray films, magnetic resonance imaging (MRI), and computed tomography (CT) scans of the cervical spine. Health-related outcomes were assessed before and at follow-up and included Visual Analog Scale (VAS) for pain (1-10), Japanese Orthopedic Association (JOA) score for myelopathy (0-18), and SF-36 physical functioning, energy and fatigue, and general health categories (0-100)., Results: In 53 patients (control group), decompression and instrumentation was accomplished without incident, but 5 patients developed lasting postoperative C5 palsy. At follow-up, there were overall significant improvements in VAS, JOA, and SF-36 physical functioning and general health domains. Subsequent to surgery, a loss of lordosis of 5° and an increase in C2 sagittal vertical axis (SVA) of 17 mm was significant. There was, however, no significant difference between control and C5 palsy patients in lordosis and C2 SVA, before or after surgery. Postoperative MRI studies were obtained in 15 of the control patients and 6 of the C5 palsy patients. Postoperative width of the laminectomy as well as the caliber of the C5 neural foramina in the control and C5 palsy cohorts were not statistically different. Though the posterior displacement of the cord in the C5 palsy cohort was larger than in controls, this difference was also not significant., Conclusion: The above findings suggest that the cause of C5 palsy remains elusive. Though our incidence of lasting C5 palsy subsequent to laminectomy and instrumentation was 8%, it is probably under-reported. In our experience, laminectomy and instrumentation failed to increase lordosis and, in fact, were associated with an increase in positive cervical balance. Complications with cervical laminectomy and instrumentation are not by any means rare, and need to be emphasized in counselling patients, and selecting the approach., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Purpose: The Functional Independence Measure for children (WeeFIM) is a user-friendly functional outcomes tool that has been validated across other traditional functional scales. Historically, the significant neurologic and functional deficits of intramedullary spinal cord tumors (IMSCTs) have been monitored by coarse or overbearing functional outcomes tools that make it difficult to measure the slow improvement/decline seen in these patients. This study is the first to report WeeFIM outcomes on a series of IMSCTs with emphasis on an aggressive surgical strategy., Methods: A retrospective review from 2005 to 2014 was performed for nine patients who underwent resective surgery for intramedullary spinal cord tumors with intraoperative ultrasound and neurophysiologic monitoring. WeeFIM scales were assessed at admission and discharge to evaluate changes in severity of disability and need for assistance., Results: At the time of this submission, 7/9 patients are alive. The mean WeeFIM improvement was 27 points (8-50 points) with a mean WeeFIM efficiency of 2.0 points/day., Conclusions: The WeeFIM scale is an appropriate and useful scale for measuring postoperative improvements in patients with IMSCTs undergoing aggressive resective surgery. Attention to intraoperative spinal cord monitoring and prevention of spinal column instability may prevent morbidity related to surgery, and functional outcomes do not appear to be compromised by an aggressive surgical approach.

Study Design: Systematic review and meta-analysis., Objective: Examine the functional outcomes and complications following laminectomy for thoracic myelopathy due to ossification of the ligamentum flavum (OLF)., Summary of Background Data: OLF is a rare condition that can cause thoracic myelopathy. Laminectomy is a procedure that can be performed to decompress the spinal cord in patients with thoracic myelopathy due to OLF. Few studies have examined postoperative outcomes and complications following laminectomy for thoracic myelopathy secondary to OLF., Methods: A systematic review and meta-analysis was performed. Literature search yielded six studies that met our selection criteria. Study characteristics and baseline patient demographics were extracted from each study. Primary outcomes included pre- and postoperative Japanese Orthopedic Association (JOA) scores and perioperative complications including dural tears, cerebrospinal fluid (CSF) leaks, neurological deficits, surgical site infections, and other complications. We calculated pooled proportion estimates for JOA scores and complications using a random effects model., Results: A total of 137 patients were included. The pooled pre- and postoperative JOA scores were 5.08 (95% confidence interval [CI], 2.70-7.47; I = 98%) and 8.29 (95% CI, 7.73-8.85; I = 18%), respectively, with a mean improvement of +3.03 points (95% CI, 1.08-4.98; I = 88%). Pooled proportion estimates for dural tears, CSF leaks, infections, and early neurological deficits were 18.4% (95% CI, 12.6-26.1; I = 0%), 12.1% (95% CI, 6.6-21.2; I = 0%), 5.8% (95% CI, 2.1-15.4; I = 0%), and 5.7% (95% CI, 2.2-14.3; I = 0%), respectively., Conclusion: Thoracic myelopathy secondary to OLF can be treated with laminectomy. However, despite some improvement in JOA score, functional status remains poor postoperatively. Perioperative complications are common, with dural tears and CSF leaks occurring most frequently. OLF is an uncommon condition and more research is needed to better understand how we can improve the outcomes of laminectomy alone for the treatment of thoracic myelopathy due to OLF., Level of Evidence: 3.

Background: The treatment options for patients with Chiari malformation type 1 (CM1) and Chiari malformation type 1.5 (CM1.5) have not yet been standardized. In these malformations, the main factors include obstruction at the level of the foramen magnum and dural and ligamentous thickening. Here we present our outcomes of surgery and decompression using a minimally invasive surgery (MIS) technique., Methods: Sixty-one patients admitted to our clinics between 2009 and 2016 due to CM1 or CM1.5 and who had undergone MIS were investigated retrospectively. All patients were followed up for a mean period of 55 months, both clinically and radiologically, and the outcomes were recorded., Results: All 61 patients underwent foramen magnum decompression through a 1.5-cm mini-open incision, C1 laminectomy and C2 medial inner side tour, posterior atlanto-occipital membrane removal, external dural delamination, and widening of the internal dura with longitudinal incisions. Fifty-six patients (91.8%) were satisfied with the outcome, 4 patients (6.5%) remained the same, and 1 patient (1.6%) reported a poor outcome. Forty-five percent of the patients with syringomyelia demonstrated resolution within 2 years, and 92% demonstrated resolution in 5 years. Scoliosis was seen in 5 patients (8.1%). The rate of benefit from the surgical procedure was statistically significant (P = 0.0045), and no patient required additional surgery because of poor decompression., Conclusions: MIS is effective for uncomplicated cases of CM1 and CM1.5 due to its minimal connective and muscular tissue damage, short surgical duration, short recovery time, early mobilization, effective posterior foramen magnum widening, lack of liquor fistula development, and better clinical and radiologic improvement during long-term follow-up., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Epidural tumors in the lumbar spine represent a unique cohort of lesions with individual risks and challenges to resection. Knowledge of modifiable risk factors are important in minimizing postoperative complications., Objective: To determine the risk factors for 30-day morbidity and mortality in patients undergoing extradural lumbar tumor resection., Methods: A retrospective study of prospectively collected data using the American College of Surgeons National Quality Improvement Program database was performed. Adults who underwent laminectomy for excision of lumbar spine tumors between 2011 and 2014 were included in the study. Demographics and medical comorbidities were collected, along with morbidities and mortalities within 30 postoperative days. A multivariate binary logistic analysis of these clinical variables was performed to determine covariates of morbidity and mortality., Results: The database search yielded 300 patients, of whom 118 (39.3%) were female. Overall, complications within 30 days of surgery occurred in 102 (34%) patients. Significant risk factors for morbidity included preoperative anemia (P < 0.0001), the need for preoperative blood transfusion (P = 0.034), preoperative hypoalbuminemia (P = 0.002), American Society of Anesthesiologists score 3 or 4 (P = 0.0002), and operative time >4 hours (P < 0.0001). Thirty-day mortality occurred in 15 (5%) patients and was independently associated with preoperative anemia (odds ratio 3.4, 95% confidence interval 1.8-6.5) and operative time >4 hours (odds ratio 2.6, 95% confidence interval 1.1-6.0)., Conclusions: Excision of epidural lumbar spinal tumors carries a relatively high complication rate. This series reveals distinct risk factors that contribute to 30-day morbidity and mortality, which may be optimized preoperatively to improve surgical safety., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Study Design: A retrospective multicenter study., Objective: To identify the incidence of anterior arch fracture (AAF) of the atlas following C1 (first cervical vertebra) laminectomy without fusion, and its risk factors., Summary of Background Data: C1 laminectomy without fusion is a widely accepted surgical procedure performed to decompress the spinal cord that is compromised at the C1/C2 level, but without instability. Several case series have reported spontaneous AAF following this procedure. However, the incidence of post-laminectomy AAF and its risk factors have not been studied., Methods: This retrospective study included patients who underwent C1 laminectomy without fusion in any of the four participating institutions between April 2002 and March 2016. The incidence of AAF following C1 laminectomy was determined, and the included patients were grouped into those who developed AAF (AAF group) and those who did not (non-AAF group). Patient demographics and radiographic parameters including subaxial cervical balance on x-ray (C2-7 sagittal vertical axis, C2-7 lordosis, C2-7 coronal cobb angle, and T1-slope), and morphology of the atlas on computed tomography (CT) scan were compared with the AAF and non-AAF groups., Results: Seventy patients who underwent C1 laminectomy without fusion were included in the study. The incidence of AAF was 14.2% (10/70). Multivariate analysis revealed that a large inferior facet angle (IFA, defined as the coronal inclination angle of the C1/2 facet as measured on CT) and the presence of subaxial ankylosis (bony ankylosis below C2 on CT) were independent risk factors for AAF. There were no significant differences in the subaxial cervical balance as measured on x-ray between the AAF and non-AAF groups (P > 0.05)., Conclusion: The incidence of AAF after C1 laminectomy without fusion is not uncommon. Preoperative assessment using CT may identify patients at high risk of AAF., Level of Evidence: 4.

Spine surgery is a key target for cost reduction within the United States health care system. One possible strategy involves the transition of inpatient surgeries to the ambulatory setting. Lumbar laminectomy with or without discectomy, lumbar fusion, anterior cervical discectomy and fusion, and cervical disc arthroplasty all represent promising candidates for outpatient surgeries in select populations. In this focused review, the authors clarify the different definitions used in studies describing outpatient spine surgery. They also discuss the body of evidence supporting each of these procedures and summarize the proposed cost savings. Finally, they examine several patient- and surgeon-specific considerations to highlight the barriers in translating outpatient spine surgery into actual practice.

Study Design: Retrospective cohort study of a nationwide database., Objective: The primary objective was to summarize the use of surgical methods for lumbar herniated intervertebral disc disease (HIVD) at two different time periods under the national health insurance system. The secondary objective was to perform a cost-effectiveness analysis by utilizing incremental cost-effectiveness ratio (ICER)., Summary of Background Data: The selection of surgical method for HIVD may or may not be consistent with cost effectiveness under national health insurance system, but this issue has rarely been analyzed., Methods: The data of all patients who underwent surgeries for HIVD in 2003 (n = 17,997) and 2008 (n = 38,264) were retrieved. The surgical methods included open discectomy (OD), fusion surgery, laminectomy, and percutaneous endoscopic lumbar discectomy (PELD). The hospitals were classified as tertiary-referral hospitals (≥300 beds), medium-sized hospitals (30-300 beds), or clinics (<30 beds). ICER showed the difference in the mean total cost per 1% decrease in the reoperation probability among surgical methods. The total cost included the costs of the index surgery and the reoperation., Results: In 2008, the number of surgeries increased by 2.13-fold. The number of hospitals increased by 34.75% (731 in 2003 and 985 in 2008). The proportion of medium-sized hospitals increased from 62.79% to 70.86%, but the proportion of surgeries performed at those hospitals increased from 61.31% to 85.08%. The probability of reoperation was highest after laminectomy (10.77%), followed by OD (10.50%), PELD (9.20%), and fusion surgery (7.56%). The ICERs indicated that PELD was a cost-effective surgical method. The proportion of OD increased from 71.21% to 84.12%, but that of PELD decreased from 16.68% to 4.57%., Conclusion: The choice of surgical method might not always be consistent with cost-effectiveness strategies, and a high proportion of medium-sized hospitals may be responsible for this change., Level of Evidence: 4.

Study Design: Case report and review of literature., Objective: To present an exceedingly rare occurrence of obstructive hydrocephalus secondary to intraventricular hemorrhage after incidental durotomy during lumbar spine surgery., Summary of Background Data: Incidental durotomies are uncommon but well recognized complications associated with spine surgery. Whereas mostly considered benign with no untoward clinical sequele, it can be symptomatic and present with spinal headaches, pseudomeningoceles, wound infection, meningitis and rarely intracerebral hemorrhage., Methods: A 76-year-old woman underwent L3-S1 laminectomies and fusion for lumbar spondylosis and stenosis. Intraoperatively, a small incidental durotomy was encountered and primarily repaired., Results: The patient developed altered mental status on postoperative day 2. Computed tomography of the brain revealed obstructive hydrocephalus and intraventricular hemorrhage. The patient was immediately transferred to the neurosurgery intensive care unit and an external ventricular drain was placed emergently with high opening pressure. Her mental status improved immediately after cerebral spinal fluid diversion. The external ventricular drain was successfully removed after 8 days. The patient made a full recovery and was discharged in stable condition., Conclusion: Obstructive hydrocephalus after intraventricular hemorrhage is an exceptionally rare but potentially life-threatening complication of incidental durotomies. Spine surgeons should be aware of this rare but serious complication., Level of Evidence: 4.

Background: To date, the traditional approach to intraspinal tumors has been open laminectomy or laminoplasty followed by microsurgical tumor resection. Recently, however, minimally invasive approaches have been attempted by some., Objective: To investigate the feasibility and safety of minimally invasive surgery (MIS) for primary intradural spinal tumors., Methods: Medical charts of 83 consecutive patients treated with MIS for intradural spinal tumors were reviewed. Patients were followed up during the study year, 2015, by either routine history/physical examination or by telephone consultation, with a focus on tumor status and surgery-related complications., Results: Mean age at surgery was 53.7 yr and 52% were female. There were 49 schwannomas, 18 meningeomas, 10 ependymomas, 2 hemangioblastomas, 1 neurofibroma, 1 paraganglioma, 1 epidermoid cyst, and 1 hemangiopericytoma. The surgical mortality was 0%. In 87% of cases, gross total resection was achieved. The complication rate was 11%, including 2 cerebrospinal fluid leakages, 1 asymptomatic pseudomeningocele, 2 superficial surgical site infections, 1 sinus vein thrombosis, and 4 cases of neurological deterioration. There were no postoperative hematomas, and no cases of deep vein thrombosis or pulmonary embolism. Ninety-three percent of patients were ambulatory and able to work at the time of follow-up., Conclusion: This study both demonstrates that it is feasible and safe to remove select, primary intradural spinal tumors using MIS, and augments the previous literature in favor of MIS for these tumors.

Aim: It is well known that treatment modalities against secondary damage due to spinal cord injury (SCI) are very important. This phase has been researched in many experimental studies. Apoptosis is one of the major mechanisms of secondary damage on spinal cord. The present study was undertaken to determine if quetiapine, a 5-HT2 receptor blocker atypical antipsychotic agent can rescue neuronal cells from apoptosis in a SCI model., Material and Methods: Thirty-two female Wistar rats were separated to 4 equal groups. Total laminectomy was performed at T5-7 level and spinal cord injury was produced by using the clip compression technique. Each rat from groups "1 day" (D-I) and "7 days" (D-II) was daily injected intraperitoneally with Quetiapine (10 mg/kg/day). No treatment was administered to the control groups "1 day" (K-I) and "7 days" (K-II). At the end of follow-up periods, all animals were sacrificed and spinal cords were removed. Apoptotic cells were evaluated by using immunohistochemical technique (TUNEL) in injured spinal cord specimens., Results: There was a statistically significant difference while counting ApopTag positive cells, both at 1 day groups of K-I and D-I (p=0.00000008) and at 7 day groups of K-II and D-II (p=0.000005). Unlike the 1-day period, a statistically significant difference was found between grey and white matter ApopTag positive cells at the 7 < sup > th < /sup > day (p=0.0001)., Conclusion: Quetiapine has a protective effect on secondary damage caused by SCI, while also can be used in post-traumatic stress disorder, depression and agitation as a versatile agent.

Aim: To investigate the effects of local and systemic administration of etanercept on the formation of epidural fibrosis., Material and Methods: Twenty-eight rats were randomly divided into four equal groups (Control, SpongostanTM, Local etanercept and Systemic etanercept) and laminectomy was performed between T11 and L1 in all rats. SpongostanTM was soaked with saline (0.1 mg/kg), local etanercept (300 ?g/kg) was applied with SpongostanTM and systemic etanercept (300 ?g/kg/week) was applied subcutaneously. Four weeks later, the vertebral column from T9 to L3, including the paraspinal muscles and epidural scar tissue, was removed en bloc, and epidural fibrosis and arachnoidal involvement were graded and evaluated histopathologically., Results: The grading of epidural fibrosis was statistically significantly lower in systemic and local administration of etanercept groups compared to the control group (p < 0.005), but systemic etanercept administration was more effective., Conclusion: Systemic administration of etanercept can be effective in reducing epidural fibrosis in rats after laminectomy.

Study Design: Retrospective database review., Objective: The aim of the present study was to examine how often spine surgery is being performed in an outpatient hospital setting versus a more "true" ambulatory setting, specifically ambulatory surgery centers (ASCs) in which admission and discharge are required on the same calendar day., Summary of Background Data: Recent studies have assessed the safety, satisfactory clinical outcomes, and increasing utilization of both cervical and lumbar spinal surgeries performed in the outpatient setting. No studies have delineated between true ambulatory settings and outpatient hospitals when assessing the rates of these procedures., Methods: A retrospective review of the Truven Health Marketscan Research Databases was conducted for patients undergoing spine operations between 2003 and 2014. The frequency of each Common Procedural Terminology code was identified per year, and then categorized into each of "inpatient hospital," "outpatient hospital," or "ASC" in states that clearly define ASCs as facilities in which patients are discharged on the same calendar day of the operation, and do not stay overnight., Results: During the period between 2003 and 2014, the procedures that had the most dramatic increase as an outpatient hospital procedure included lumbar decompression laminotomy first level (18.7%-68.5%) and posterior cervical decompression laminectomy without facetectomy discectomy first level (0%-46.7%). ASC procedures had more modest increases during this time period with the most significant increases in lumbar decompression laminotomy first level (0.7%-10.6%) and posterior cervical decompression laminotomy first level (0%-23.4%)., Conclusion: "True" ambulatory surgeries are not increasing at the same rate as outpatient procedures with 23-hour observation capacity. Although prior studies have demonstrated the safety of outpatient spine surgery, one possible reason for this trend may be that surgeons feel that this safety may not be comparable to that of other outpatient procedures., Level of Evidence: 3.

Background: Duloxetine, Etoricoxib and opioid are of the commonly administered drugs in Lumbar laminectomy. The aim of this study is to assess the effect of perioperative use of Duloxetine in combination with Etoricoxib on postoperative pain and opioid requirements., Methods: One hundred twenty patients with ASA physical status were enrolled with age between 18 and 70 years. Patients were divided randomly into four groups of 30 patients: group P received placebo, group E received etoricoxib 120 mg, group D received duloxetine 60 mg and group D/E received duloxetine 60 mg capsules and etoricoxib 120 mg; 1 h before surgery and 24 h after., Results: Neither Duloxetine nor etoricoxib individually had effect on pain with movement, while their combination revealed a significant reduction in pain scores over the entire postoperative period at rest and on movement. Etoricoxib showed a significant decrease in pain at all times at rest when compared with group P, while it showed significant pain decrease only at 0, 2 and 4 h when compared with group D. On the other hand duloxetine alone showed significant decrease in pain at rest at 24 h and 48 h when compared with group P. ConcerningMorphine requirement after 24 h.; it wassignificantly lower in the D/E group in comparison with groups P, E and D. It should be noted also that there was a significant decrease morphine requirement in both groups E and D., Conclusion: The perioperative administration of the combination of etoricoxib and duloxetine improved analgesia and reduced opioid consumption without significant side effects., Trial Registration: ISRCTN48329522 . 17 June 2017.

Background: Cervical spondylotic myelopathy (CSM) is a disorder that can cause neurologic deterioration. Studies on paraspinal muscular atrophy (PMA) in the lumbar spine have shown that these changes are caused by several perioperative factors. It is possible that PMA in the cervical spine could behave similarly. In this retrospective study, we compared the degree of PMA after laminoplasty versus laminectomy and fusion (LF) using a standard posterior approach to the cervical spine., Methods: 18 laminoplasty and 43 LF patients were included in this study. For each patient, preoperative and postoperative MRI files were obtained and transferred into OsiriX imaging software. Atrophy rate was obtained and reported as percentage change in cross-sectional area of the cervical paraspinal muscles from preoperative to postoperative imaging., Results: Mean cross-sectional cervical muscle atrophy rates were 6% and 13.1% for laminoplasty and LF, respectively, representing a 2.19 times increase in the degree of atrophy (P < 0.001). Independently, LF was associated with a 5.84% increase in the rate of PMA (P = 0.03). Involvement of C3 as the cephalad surgical level was associated with a 5.78% decrease in the rate of PMA (P = 0.03). For each degree increase in postoperative Cobb angle, there was a 0.66% decrease in the rate of PMA (P = 0.02)., Conclusion: PMA should be part of the decision making process when a posterior approach is considered, inasmuch as this study demonstrates that cervical laminoplasty was associated with significantly lower rates of PMA compared with cervical laminectomy and fusion. Additionally, these results suggest that minimizing PMA may help preserve cervical lordosis., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Patients recovering from decompressive laminectomy without fusion may require assistance with activities of daily living and physical/occupational therapy upon hospital discharge., Objective: To examine comorbidities and perioperative characteristics of patients undergoing lumbar decompression for associations with discharge status using a multicenter database., Methods: A multicenter database was used for this retrospective cohort analysis. Patients admitted from home with degenerative spine disease for lumbar decompression without fusion were included. Thirty-day outcomes and operative characteristics were compared as a function of patient discharge using chi-square and Wilcoxon Rank Sum tests. Multivariable logistic regression was used to determine factors associated with discharge to a nonhome facility., Results: Of the 8627 patients included for analysis, 9.7% were discharged to a nonhome facility. On multivariable analysis, age (85+ vs <65, odds ratio [OR] 13.59), number of levels of decompression (3+ vs 1, OR 1.75), African American race vs Non-Hispanic or Hispanic White (OR 1.87), female vs male gender (OR 1.97), body mass index (BMI) (40+ vs 18.5-24.9, OR 1.74), American Society of Anesthesiologists physical classification status (4 vs 1 or 2, OR 2.35), hypertension (OR 1.29), dependent functional status (OR 3.92), diabetes (OR 1.47), smoking (OR 1.40), hematocrit (<35 vs 35+, OR 1.76), international normalized ratio (≥1.3 vs <1.3, OR 2.32), and operative time (3+ h vs <1 h, OR 5.34) were significantly associated with an increased odds of discharge to nonhome facilities., Conclusion: Preoperative status and operative course variables can influence discharge disposition in lumbar decompression patients. Identifying specific factors that contribute to a greater likelihood of dismissal to skilled facility or rehabilitation unit can further inform both surgeons and patients during preoperative counseling and disposition planning., (Copyright © 2017 by the Congress of Neurological Surgeons)

Background: The causes of ASD are still relatively unknown. Correlation between clinical status of patients and radiological MRI findings is of primary importance. The radiological classifications proposed by Pfirmann and Oner are most commonly used to assess intradiscal degenerative changes. The aim of the study was to assess the influence of the extension of spine fixation on the risk of developing ASD in a short time after surgery., Methods: A total of 332 patients with spinal tumors were treated in our hospital between 2010 and 2013. Of these patients, 287 underwent surgeries. A follow-up MRI examination was performed 12 months after surgical treatment. The study population comprised of 194 patients. Among metastases, breast cancer was predominant (29%); neurological deficits were detected in 76 patients. Metastases were seen in the thoracic (45%) and lumbar (30%) spine; in 25% of cases, they were of multisegmental character. Pathological fractures concerned 88% of the patients. Statistical calculations were made using the χ2 test. Statistical analysis was done using the Statistica v. 10 software. A p value <0.05 was accepted as statistically significant. The study population was divided on seven groups according to applied treatment., Results: Clinical signs of ASD were noted in only seven patients. Two patients had symptoms of nerve root irritation in the lumbar spine. Twenty-two patients (11%) were diagnosed with ASD according to the MRI classifications by Oner, Rijt, and Ramos, while the more sensitive Pfirmann classification allowed to detect the disease in 46 patients (24%). Healthy or almost healthy discs of Oner type I correlated with the criteria of Pfirmann types II and III. The percentage of the incidence of ASD diagnosed 1 year after the surgery using the Pfirmann classifications was significantly higher than diagnosed according to the clinical examination., Conclusions: The incidence of ASD in patients after spine surgeries due to cancer metastases does not differ between the study groups. ASD detectability based on clinical signs is significantly lower than ASD detectability based on MR images according to the system by Pfirrmann et.al. ASD risk increase among patients with multilevel fixation.

Introduction: The operating microscope (OM) has become instrumental in aiding surgeons during key microdissection with greater safety and detail. An exoscope offers similar detail with improved functionality and greater implications for live teaching and improved operating room flow., Methods: Eleven senior neurosurgery residents and fellows performed unilateral, single-level laminotomies on fresh cadavers using an OM and exoscope. Three attending spine surgeons blinded for the visualization technique used then reviewed and graded each decompression. Data points gathered included time of procedure, grading of decompression (1-5), and complications, including dural tear, nerve root injury, and pars fracture., Results: Operative times between the 2 systems were not significantly different (14.9 minutes OM vs. 15.6 minutes exoscope, P = 0.766). Despite high variability between evaluators in assessing complications and adequacy of decompression, there was no significant difference between either system. Postprocedural surveys indicated greater comfort with the exoscope, greater ease of use, and superior teaching potential for the exoscope over the standard OM., Conclusion: In our simulated operating room model, an exoscope is a valid alternative to the standard OM that affords the surgeon greater comfort with greater teaching potential while maintaining many of the microscope's benefits., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Due to the risk associated with exposure to ionizing radiation, there is an urgent need to identify areas of CT scanning overutilization. While increased use of diagnostic spinal imaging has been documented, no previous research has estimated the magnitude of follow-up imaging used to evaluate the postoperative spine., Methods: This retrospective cohort study quantifies the association between spinal surgery and CT utilization. An insurance database (Humana, Inc.) with ≈ 19 million enrollees was employed, representing 8 consecutive years (2007-2014). Surgical and imaging procedures were captured by anatomic-specific CPT codes. Complex surgeries included all cervical, thoracic and lumbar instrumented spine fusions. Simple surgeries included discectomy and laminectomy. Imaging was restricted to CT and MRI. Postoperative imaging frequency extended to 5-years post-surgery., Results: There were 140,660 complex spinal procedures and 39,943 discectomies and 49,889 laminectomies. MRI was the predominate preoperative imaging modality for all surgical procedures (median: 80%; range: 73-82%). Postoperatively, CT prevalence following complex procedures increased more than two-fold from 6 months (18%) to 5 years (≥40%), and patients having a postoperative CT averaged two scans. For simple procedures, the prevalence of postoperative CT scanning never exceeded 30%., Conclusions: CT scanning is used frequently for follow-up imaging evaluation following complex spine surgery. There is emerging evidence of an increased cancer risk due to ionizing radiation exposure with CT. In the setting of complex spine surgery, actions to mitigate this risk should be considered and include reducing nonessential scans, using the lowest possible radiation dose protocols, exerting greater selectivity in monitoring the developing fusion construct, and adopting non-ferromagnetic implant biomaterials that facilitate MRI postoperatively.

Aim: A quantitative model of postlaminectomy was designed in rats. The effects of Momordica Charantia (MC) and Ankaferd blood stopper (ABS) on the bone and scar formation after laminectomy were concurrently evaluated., Material and Methods: Eighteen adult Wistar albino rats underwent lumbar laminectomy at L2-L3 vertebral levels, and were randomly assigned to one of three groups of six rats each. The Treatment group received MC and ABS treatment and the Control group was left untreated. Rats were sacrificed 4 weeks after treatment. Then; the lumbar spine was excised en-block, fixed and decalcified. Sections were stained with hematoxylin and eosin (H&E) and Masson"s trichrome, and evaluated for peridural fibrosis (PF), new bone formation, and vascular proliferation., Results: Total volume of new bone in the MC group was significantly increased in comparison to the Control group (p < 0.05). Also; there was highly significant increase in terms of the total volume of fibrous tissue in the MC and ABS groups when compared with the Control group (p < 0.01). Besides; there was a highly significant difference between the MC and the Control groups (p < 0.01) in point of total volume of vessel., Conclusion: Both MC and ABS are not convenient to prevent the PF formation and MC may promote new bone formation and angiogenesis after lumbar laminectomy in rats.

OBJECTIVE Surgical excision is the mainstay treatment for resectable low-grade intramedullary spinal cord tumors (IMSCTs) in the pediatric age group. Chemotherapy and radiation treatments are generally reserved for progressive or recurrent disease. Given the indolent nature of low-grade tumors and the potential side effects of these approaches, their long-term treatment benefits are unclear. The aim of the study was to determine long-term disease outcomes and the therapeutic roles of surgery and adjuvant therapies in pediatric patients with low-grade IMSCTs over an extended follow-up period. METHODS Case records for all pediatric patients (< 21 years of age) with a histopathological diagnosis of low-grade IMSCT were selected over a period from January 1975 to January 2010. Outcome variables including McCormick functional grade, overall survival (OS), and progression-free survival (PFS) were analyzed with respect to demographic and treatment variables. RESULTS Case records of 37 patients with low-grade IMSCTs were identified, with a mean follow-up duration of 12.3 ± 1.4 years (range 0.5-37.2 years). Low-grade astrocytomas were the most prevalent histological subtype (n = 22, 59%). Gross-total resection (GTR) was achieved in 38% of patients (n = 14). Fusion surgery was required in 62% of patients with pre- or postoperative deformity (10 of 16). On presentation, functional improvement was observed in 87% and 46% of patients in McCormick Grades I and II, respectively, and in 100%, 100%, and 75% in Grades III, IV, and V, respectively. Kaplan-Meier PFS rates were 63% at 5 years, 57% at 10 years, and 44% at 20 years. OS rates were 92% at 5 years, 80% at 10 years, and 65% at 20 years. On multivariate analysis, shunt placement (hazard ratio [HR] 0.33, p = 0.01) correlated with disease progression. There was a trend toward improved 5-year PFS in patients who received adjuvant chemotherapy and radiation therapy (RT; 55%) compared with those who did not (36%). Patients who underwent subtotal resection (STR) were most likely to undergo adjuvant therapy (HR 7.86, p = 0.02). CONCLUSIONS This extended follow-up duration in patients with low-grade IMSCTs beyond the first decade indicates favorable long-term OS up to 65% at 20 years. GTR improved PFS and was well tolerated with sustained functional improvement in the majority of patients. Adjuvant chemotherapy and RT improved PFS in patients who underwent STR. These results emphasize the role of resection as the primary treatment approach, with adjuvant therapy reserved for patients at risk for disease progression and those with residual tumor burden.

Background: Epidural fibrosis often causes serious complications in patients after lumbar laminectomy and discectomy and is associated with the proliferation of fibroblasts. Suramin is known to have an obvious inhibitory effect on the coactions of many growth factors and their receptors, but little was previously known about the effect of suramin on fibroblast proliferation and the progress of epidural fibrosis., Methods: We illustrated the effect of suramin on cultured fibroblasts of rats with different concentrations (0, 200, 400, 600 mg/l). The proliferation of suramin-treated fibroblasts was evaluated by CCK-8 and western blot analysis. Additionally, in a rat model of laminectomy, different concentrations of suramin (100, 200, and 300 mg/ml) and saline were applied to the laminectomy sites locally. The effect of suramin on preventing epidural fibrosis was detected by the Rydell classification, hydroxyproline content, histological analysis, and collagen density analyses., Results: The results of CCK-8 shown that suramin could significantly inhibit fibroblasts proliferation in a dose-dependent manner. The western blotting shown that the expression levels of the cell proliferation markers such as cyclin D1, cyclin E, and PCNA were down-regulated. Moreover, in a rat model, we found that suramin could reduce epidural fibrosis as well as inhibit fibroblast proliferation, and 300 mg/ml suramin had better effect., Conclusions: Topical application of suramin could reduce epidural fibrosis after laminectomy, and the application of suramin could inhibit the proliferation of fibroblasts in rats. This study indicates that suramin is a potent antifibrotic agent that may have therapeutic potential for patients with epidural fibrosis.

Study Design: A retrospective study., Objective: The aim of this study was to analyze the clinical outcomes and related factors of C5 palsy (C5P) following posterior cervical laminectomy with fusion (LF) compared with laminoplasty (LP)., Summary of Background Data: C5P is more common after LF than after LP. There have not been any studies on C5P-LF compared with C5P-LP., Methods: We retrospectively analyzed consecutive cases that underwent cervical LF for nontraumatic cervical myelopathy or myeloradiculopathy (CMR). To analyze the related factors, C5P-LF and non-C5P-LF groups were compared. To assess the clinical parameters, preoperative diagnosis, clinical symptoms, surgical procedures, and outcome instruments were analyzed. Radiographically, we analyzed preoperative maximal spinal cord compression ratio, presence of C4-5 foraminal stenosis (FS), and correction angles on the sagittal plane. To compare with C5P-LP, we analyzed the incidence, time of onset, grade of muscle weakness, other accompanying cervical nerve root palsies, recovery time, and degree of final recovery in the C5P-LF and the C5P-LP groups of 100 consecutive LPs., Results: A total of 90 LF patients were enrolled (M:F = 54:36, mean age 61.1 yr, mean follow-up 35 months). C5P occurred in 26 patients (28.9%), and 14 cases (53.8%) demonstrated other cervical nerve root palsies. Clinically significant differences were observed between the C5P-LF and non-C5P-LF groups with regard to preoperative clinical diagnosis (CMR 88.5:42.2%, P < 0.001) and presence of preoperative upper extremity weakness (57.7:32.3%, P = 0.02). Comparison between the C5P-LF and C5P-LP groups showed significant differences between incidence (28.9:4%), mean grade of weakness (2.1:3.5), accompanying nerve root symptoms (53.8:0%), recovery time (20.8:10.5 weeks), and incidence of incomplete recovery (15.4:0%)., Conclusion: C5P-LF patients showed higher incidence, more severe weakness, frequent involvement of multiple cervical nerve roots, and longer recovery time than C5P-LP patients. Preoperative clinical manifestation of CMR and preexisting upper extremity weakness were the related factors of C5 palsy., Level of Evidence: 3.

The aim of the present study was to identify risk factors for perioperative complications associated with spinal surgery for cervical, thoracic, and lumber spinal stenosis in a Japanese cohort. Patients with spinal stenosis who underwent spinal surgery between 2008 and 2012 were included. Neurological and/or surgical site complications within 30 days of index surgery were retrospectively collected, and the rates of complications were calculated. Using univariate and multivariate logistic regression analyses, risk factors for complications were identified. A total of 364 patients underwent 407 spinal surgeries. Of the 407 surgeries performed, 236 were cervical, 28 were thoracic, and 143 were lumbar surgeries. Ossification of the ligamentum flavum was the most common diagnosis in patients with thoracic stenosis (85%), whereas spinal degenerative stenosis and disc herniation were the two most common diagnoses in patients with cervical and lumbar stenosis. Laminoplasty and laminectomy alone were the two most frequently performed procedures. The rate of complications was greater in patients with thoracic stenosis (36%) than in those with cervical (16%) or lumbar stenosis (13%, p=0.013). After a multivariate analysis, only thoracic stenosis (odds ratio 2.87) remained an independent risk factor for surgical complications. The novel result of the present study was that the level of stenosis in the spine had a significant impact on complications after spinal surgery in a Japanese cohort. The result can be explained by the fact that challenging ossified lesions are a common cause of thoracic stenosis in eastern Asia., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Object: Despite extensive clinical experience with laminoplasty, the efficacy of the procedure and its advantages over laminectomy remain unclear. Specific clinical elements, such as incidence or progression of kyphosis, incidence of axial neck pain, postoperative cervical range of motion, and incidence of postoperative C-5 palsies, are of concern. The authors sought to comprehensively review the laminoplasty literature over the past 10 years while focusing on these clinical elements., Methods: The authors conducted a literature search of articles in the Medline database published between 2003 and 2013, in which the terms "laminoplasty," "laminectomy," and "posterior cervical spine procedures" were used as key words. Included was every single case series in which patient outcomes after a laminoplasty procedure were reported. Excluded were studies that did not report on at least one of the above-mentioned items., Results: A total of 103 studies, the results of which contained at least 1 of the prespecified outcome variables, were identified. These studies reported 130 patient groups comprising 8949 patients. There were 3 prospective randomized studies, 1 prospective nonrandomized alternating study, 15 prospective nonrandomized data collections, and 84 retrospective reviews. The review revealed a trend for the use of miniplates or hydroxyapatite spacers on the open side in Hirabayashi-type laminoplasty or on the open side in a Kurokawa-type laminoplasty. Japanese Orthopaedic Association (JOA) scoring was reported most commonly; in the 4949 patients for whom a JOA score was reported, there was improvement from a mean (± SD) score of 9.91 (± 1.65) to a score of 13.68 (± 1.05) after a mean follow-up of 44.18 months (± 35.1 months). The mean preoperative and postoperative C2-7 angles (available for 2470 patients) remained stable from 14.17° (± 0.19°) to 13.98° (± 0.19°) of lordosis (average follow-up 39 months). The authors found significantly decreased kyphosis when muscle/posterior element-sparing techniques were used (p = 0.02). The use of hardware in the form of hydroxyapatite spacers or miniplates did not influence the progression of deformity (p = 0.889). An overall mean (calculated from 2390 patients) of 47.3% loss of range of motion was reported. For the studies that used a visual analog scale score (totaling 986 patients), the mean (cohort size-adjusted) postoperative pain level at a mean follow-up of 29 months was 2.78. For the studies that used percentages of patients who complained of postoperative axial neck pain (totaling 1249 patients), the mean patient number-adjusted percentage was 30% at a mean follow-up of 51 months. The authors found that 16% of the studies that were published in the last 10 years reported a C-5 palsy rate of more than 10% (534 patients), 41% of the studies reported a rate of 5%-10% (n = 1006), 23% of the studies reported a rate of 1%-5% (n = 857), and 12.5% reported a rate of 0% (n = 168)., Conclusions: Laminoplasty remains a valid option for decompression of the spinal cord. An understanding of the importance of the muscle-ligament complex, plus the introduction of hardware, has led to progress in this type of surgery. Reporting of outcome metrics remains variable, which makes comparisons among the techniques difficult.

Study Design: Retrospective radiological study., Objective: We aimed to determine whether the sagittal profiles of patients with lumbar spinal canal stenosis (LCS) change after decompressive laminectomy., Summary of Background Data: Decompressive laminectomy is the standard technique in the surgical treatment for LCS. Numerous studies have reported favorable clinical outcomes. However, few studies have quantitatively evaluated the radiological outcome of the procedure, including the global balance of the spine and associated pelvic posture., Methods: This study involved 40 consecutive patients with LCS treated with decompressive laminectomy and a control cohort of 40 age- and sex-matched patients with LCS who were treated conservatively. The radiological parameters of the 2 groups including (1) global sagittal balance (C7 plumb line [C7PL], C7/sacrofemoral distance ratio, and spinosacral angle), (2) spinopelvic morphology (pelvic incidence, sacral slope, and pelvic tilt), and (3) spinal parameters (lumbar lordosis and thoracic kyphosis) were measured and compared at baseline, 1-year, and 2-year follow-ups., Results: The demographics and baseline radiological parameters were similar between the 2 groups. The mean C7PL of the laminectomy group was 3.9 ± 2.5 cm at baseline, which decreased significantly to 2.0 ± 1.9 cm at the 1-year follow-up (P = 0.006) and was maintained at this level at the 2-year follow-up (2.3 ± 2.1 cm) (P = 0.013). The mean lumbar lordosis of the laminectomy group was 31.4°± 15.1° at baseline, which increased significantly to 35.6°± 11.7° at the 1-year follow-up (P = 0.021) and was maintained at this level at the 2-year follow-up (35.1°± 14.8°) (P = 0.044)., Conclusion: In this study, decompressive laminectomy caused posterior migration of the C7PL and increased the lumbar lordosis., Level of Evidence: 3.

Study Design: Retrospective propensity score-matched analysis on a national database (MarketScan) between 2006 and 2010., Objective: To compare rates of neurological deficits after elective single-level spinal procedures with and without intraoperative neuromonitoring, as well as associated payment differences and geographic variance., Summary of Background Data: Intraoperative neurophysiologic monitoring is a technique that may contribute to avoiding permanent neurological injury during some spine surgery procedures. However, it is unclear whether all patients undergoing spine surgery benefit from neuromonitoring., Methods: An identified 85,640 patients underwent single-level spinal procedures including anterior cervical discectomy and fusion (ACDF), lumbar fusion, lumbar laminectomy, or lumbar discectomy. Neuromonitoring was identified with appropriate Current Procedural Terminology (CPT) codes. Cohorts were balanced on baseline comorbidities and procedure characteristics using propensity score matching. Trauma and spinal tumors cases were excluded., Results: Patients (12.66%) received neuromonitoring intraoperatively. Lumbar laminectomies had reduced 30-day neurological complication rate with neuromonitoring (0.0% vs. 1.18%, P=0.002). Neuromonitoring did not correlate with reduced intraoperative neurological complications in ACDFs (0.09% vs. 0.13%), lumbar fusions (0.32% vs. 0.58%), or lumbar discectomy (1.24% vs. 0.91%). With the addition of neuromonitoring, payments for ACDFs increased 16.24% ($3842), lumbar fusions 7.84% ($3540), lumbar laminectomies 24.33% ($3704), and lumbar discectomies 22.54% ($2859). Significant geographic variation was evident. Some states had no recorded single-level spinal cases with concurrent neuromonitoring. Rates for ACDFs and lumbar fusions, laminectomies, and discectomies ranged as high as 61%, 58%, 22%, and 21%, respectively., Conclusion: With intraoperative neurological monitoring in single-level procedures, neurological complications were decreased only among lumbar laminectomies. No difference was observed in ACDFs, lumbar fusions, or lumbar discectomies. There was a significant increase in total payments associated with the index procedure and hospitalization. We demonstrate significant geographic variation in neuromonitoring., Level of Evidence: 3.

Study Design: Analysis of the National Hospital Discharge Survey database from 1990 to 2007., Objective: To evaluate the influence of preoperative depression, anxiety, schizophrenia, or dementia on in-hospital (1) adverse events, (2) mortality, and (3) nonroutine discharge in patients undergoing major spine surgery., Summary of Background Data: Psychiatric comorbidity is a known risk factor for impaired health-related quality of life and poor long-term outcomes after spine surgery, yet little is known about its impact in the perioperative spine surgery setting., Methods: Using the National Hospital Discharge Survey database, all patients undergoing either spinal fusion or laminectomy between 1990 and 2007 were identified and separated into groups with and without psychiatric disorders. Multivariable regression analysis was performed for each of the outcome variables., Results: Between 1990 and 2007, a total estimated number of 5,382,343 spinal fusions and laminectomies were performed. The prevalence of diagnosed depression, anxiety, and schizophrenia among the study population increased significantly over time. Depression, anxiety, schizophrenia, and dementia were associated with higher rates of nonroutine discharge. Depression, schizophrenia, and dementia were associated with higher rates of adverse events. Dementia was the only psychiatric disorder associated with a higher risk of in-hospital mortality., Conclusion: Patients with preoperative psychiatric disorders undergoing major spine surgery are at increased risk for perioperative adverse events and posthospitalization care, but its effect in perioperative mortality is more limited. Presurgical psychological screening of candidates undergoing spine surgery might ultimately lead to the enhancement of perioperative outcomes in this growing segment of the US population., Level of Evidence: N/A.

Study Design: Retrospective analysis using national administrative data., Objective: This study presents US nationwide trends in the surgical management of patients with lumbar spinal stenosis (LSS) with and without coexisting spondylolisthesis and scoliosis from 2004 to 2009., Summary of Background Data: Lack of consensus and wide variability exists in surgical decision making for patients with LSS., Methods: Data were obtained from the Nationwide Inpatient Sample, a database developed as part of the Healthcare Cost and Utilization Project. All discharged patients with a primary diagnosis of LSS were identified. Three subgroups were studied: (1) LSS alone, (2) LSS with spondylolisthesis, and (3) LSS with scoliosis. Surgical treatment was divided into 3 groups: (1) decompression only (laminectomy, discectomy), (2) simple fusion (1-2 disc levels, single approach), and (3) complex fusion (>2 disc levels or a combined posterior and anterior approach)., Results: Between 2004 and 2009, national estimates for the annual number of discharged inpatients with a primary diagnosis of LSS increased from 94,011 (population rate, [the age adjusted population rate per 100,000] 32.1) to 102,107 (population rate, 33.3). The rate of decompressions decreased from 58.5% to 49.2% for discharged patients with LSS from 2004 to 2009 (P < 0.05), whereas the rate of simple fusions increased from 21.5% to 31.2% (P < 0.05) and the rate of complex fusions did not change at 6.7%. From 2004 to 2009, the use of bone morphogenetic protein more than doubled from 14.5% to 33.0% of all fusions, and the use of interbody devices increased from 28.5% to 45.1% (P < 0.05). In 2009, 26.2% of patients with LSS without instability underwent a fusion procedure, while 82.7% of patients with LSS with coexisting spondylolisthesis and 67.6% of patients with coexisting scoliosis underwent a fusion procedure., Conclusion: This study demonstrates that the rate of simple fusion surgery has increased for treatment of LSS compared with decompression only., Level of Evidence: 4.