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Longitudinal cohort study. [ABSTRACT FROM AUTHOR]

Atlanto-occipital dissociation (AOD) is an extremely common injury but often fatal. In a systematic review from 2010, AODs were present in almost 20% of blunt trauma fatalities. It is an injury many patients do not survive; therefore, few are treated, even at high volume trauma centers. In survivors, his injury is often missed or the diagnosis is often delayed. Mortality rates commonly reach beyond 60% when injury patterns go unrecognized. Approximately 50% of patients with AOD sustain blunt cerebrovascular injury and nearly 20% of patients present with traumatic brain injury (TBI) or stroke. This pathology was once considered uniformly fatal. However, over the last 20 years, significant advancements have been made both clinically and radiographically, to better identify and manage this injury pattern. Despite improvements in clinical comprehension and improved time to diagnosis, less than 75% of cases are currently recognized within 24 hours. Less than 40% of patients who suffer AOD are independent with functionality, without neurological impairment. This article reviews current literature regarding AOD in hopes to improve timing to diagnosis, subsequent prognosis, timing to fixation or stabilization, and postoperative recovery., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective comparative study., Objective: This study compared outcomes for patients managed with a lateral approach to interbody fusion [lateral (LLIF) or oblique (OLIF)] versus a posterior (PLIF) or transforaminal interbody fusion (TLIF) for treatment of adjacent segment disease (ASD) above or below a prior lumbar fusion construct., Summary of Background Data: No study has compared outcomes of lateral approaches to more traditional posterior approaches for the treatment of ASD., Methods: Retrospective review was performed of patients who underwent single-level lateral or posterior approaches for lumbar interbody fusion for symptomatic ASD between January 2010 and December 2021. Exclusion criteria included skeletal immaturity (age below 18 y old) and surgery indication for malignancy or infection. Patient demographics, medical comorbidities, operative details, postoperative complications, and revision surgery profiles were collected for all patients. Standard descriptive statistics were used to summarize data. Comparative statistical analyses were performed using Statistical Package for the Social Sciences (Version 28.0.1.0; Chicago, IL)., Results: A total of 152 patients (65±10 y) were included in the study with a mean duration of follow-up of 1.6±1.4 years. The cohort included 123 PLIF/TLIF (81%), 18 LLIF (12%), 11 OLIF (7%). TLIF/PLIF experienced greater mean operative time (210±62 min vs. 184±80 OLIF/105±64 LLIF, P<0.001) and estimated blood loss (414±254 mL vs. 49±29 OLIF/36±33 LLIF, P<0.001). No significant difference in rate of postoperative complications. Postoperative radicular pain was significantly greater in OLIF (7, 64%) and LLIF (7, 39%) compared with PLIF/TLIF (16, 13%), P<0.001. No statistically significant difference in health care utilization was noted between the groups., Conclusion: Lateral fusions to treat ASD demonstrated no significantly different risk of complication compared with posterior approaches. Our study demonstrated significantly increased operative time and estimated blood loss for the posterior approach and an increased risk of radicular pain from manipulation/retraction of psoas following lateral approaches., Level of Evidence: Level III., Competing Interests: P.V.R. reports subcommittee chair of early career advisor council of North American Spine Society. D.W.P. reports paid consultancy with Stryker, Globus Medical Inc. J.W.S. reports paid consultancy with Stryker and Wright Medical Technology Inc; editorial/governing board of Journal of Spinal Disorders and Techniques. The remaining authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective quantitative analysis study., Objectives: Pelvic incidence has been established as central radiographic marker which determines patient-specific correction goals during surgery for adult spinal deformity. In cases with sacral doming or sacral osteotomy where the PI cannot be calculated, reliable radiographic parameters need to be established to determine surgical goals. We aim to determine multiple radiographic parameters and formulas that can be utilized when the S1 superior endplate is obscured., Methods: Retrospective analysis was performed on 68 healthy volunteers without prior spine surgery with full-length radiographs. Pelvic incidence, sacral slope, and pelvic tilt were calculated for each patient. Additional measurements such as L4, L5, and S2 incidence, tilt, and slope were collected. A new radiographic parameter defined as the L4-Sciatic notch angle was measured. Regression analysis was performed on each value to determine its relationship with S1 based incidence, tilt, and slope., Results: Mean values for L5 incidence, L4 incidence, and L4 sciatic notch angle were 21.8° ± 8.9, 4.4° ± 8.1, and 44.4° ± 12, respectively. The linear regression analysis produced the following formulas which can be utilized to determine deformity correction goals when pelvic incidence can be calculated pre-operatively: L5i = .65*S1i-11.4, L4i = .44*S1i-18.6, and L4SNA = -.34*S1i + 66.5. In settings where pelvic incidence cannot be calculated, the following formulas can be utilized: L5i = .66*S2i-32.3 and L4SNA = -.02*S2i 2 + 1.1*S2i + 63.5. P -values for all regression analyses were <.001., Conclusion: This study provides target radiographic alignment values that can be utilized for patients with either pre-operative altered S1 endplates or in cases with intraoperative alteration of S1 (sacral osteotomy)., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Study Design: Retrospective cohort study., Objective: To investigate the relationships of low-density lipoprotein cholesterol and statin usage with pseudarthrosis following single-level posterior or transforaminal lumbar interbody fusion (PLIF/TLIF)., Summary of Background Data: Hypercholesterolemia can lead to atherosclerosis of the segmental arteries, which branch into vertebral bone through intervertebral foramina. According to the vascular hypothesis of disc disease, this can lead to ischemia of the lumbar discs and contribute to lumbar degenerative disease. Yet, little has been reported regarding the effects of cholesterol and statins on the outcomes of lumbar fusion surgery., Materials and Methods: TriNetX, a global federated research network, was retrospectively queried to identify 52,140 PLIF/TLIF patients between 2002 and 2021. Of these patients, 2137 had high cholesterol (≥130 mg/dL) and 906 had low cholesterol (≤55 mg/dL). Perioperatively, 18,275 patients used statins, while 33,415 patients did not. One-to-one propensity score matching for age, sex, race, and comorbidities was conducted to balance the analyzed cohorts. The incidence of pseudarthrosis was then assessed in the matched cohorts within the six-month, one-year, and two-year postoperative periods., Results: After propensity score matching, high-cholesterol patients had greater odds of developing pseudarthrosis six months [odds ratio (OR): 1.73, 95% confidence interval (CI): 1.28-2.33], one year (OR: 1.59, 95% confidence interval (CI): 1.20-2.10), and two years (OR: 1.57, 95% CI: 1.20-2.05) following a PLIF/TLIF procedure. Patients with statin usage had significantly lower odds of developing pseudarthrosis six months (OR: 0.74, 95% CI: 0.69-0.79), one year (OR: 0.76, 95% CI: 0.71-0.81), and two years (OR: 0.77, 95% CI: 0.72-0.81) following single-level PLIF/TLIF., Conclusions: The findings suggest that patients with hypercholesterolemia have an increased risk of developing pseudarthrosis following PLIF/TLIF while statin use is associated with a decreased risk. The data presented may underscore an overlooked opportunity for perioperative optimization in lumbar fusion patients, warranting further investigation in this area., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Given differences in residency training background, there has been increasing interest in characterizing differential outcomes between orthopaedic surgeons (OS) and neurosurgeons (NS) with regards to outcomes after cervical disc arthroplasty (CDA). This study aimed to assess if there were differences in perioperative outcomes of CDA between OS and NS., Methods: Patients who underwent a single-level CDA between 2012 and 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database using current procedural terminology codes. The patients were subsequently stratified into those who underwent CDA with OS versus NS, and propensity score-matched to adjust for differences in patient characteristics. Differences were assessed in medical and surgical complications, as well as operative time and healthcare utilization parameters [reoperations, readmissions, and lengths-of-stay (LOS)]., Results: A total of 2,148 patients were identified (NS: n=1,395; OS: n=753). After 1:1 propensity score matching (n=741 each), there were no differences in characteristics between patients who underwent CDA by OS versus NS (P>0.05). There were no significant differences in any of the medical or surgical complications between the two groups (P>0.05 for each). There was a significant difference in the operative time between NS and OS (103.7±36.18 vs. 98.75±36.69 minutes; P=0.009). There were no significant differences in readmissions, reoperations, or LOS between the two groups (P>0.05 for each)., Conclusions: There were no differences in medical or surgical complications, as well as in reoperations, readmissions, and LOS in patients who underwent a single-level CDA between OS and NS. There was a statistically significant shorter operative time of four minutes for OS as compared to NS, which is unlikely to have clinical relevance., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jss.amegroups.com/article/view/10.21037/jss-21-66/coif). The series “Complex Interdisciplinary Topics in Spine Surgery” was commissioned by the editorial office without any funding or sponsorship. D.W.P. is a paid consultant for Stryker. J.W.S. is a paid consultant for Stryker and Wright Medical Technology, Inc., he also serves as the Editorial or Governing Board Member of Journal of Spinal Disorders and Techniques. T.M. reports IP royalties from Stryker, he also is Editorial or Governing Board Member of The Spine Journal and Global Spine Journal, Board or Committee Member of North American Spine Society; besides, he reports stocks in Pearl Diver, Inc. The authors have no other conflicts of interest to declare., (2023 Journal of Spine Surgery. All rights reserved.)

Introduction: Degenerative cervical myelopathy (DCM) is defined as dysfunction of the spinal cord as a result of compression from degenerative changes to surrounding joints, intervertebral disks, or ligaments. Symptoms can include upper extremity numbness and diminished dexterity, difficulty with fine manipulation of objects, gait imbalance, and incoordination, and compromised bowel and bladder function. Accurate diagnosis and evaluation of the degree of impairment due to degenerative cervical myelopathy remain a challenging clinical endeavor requiring a thorough and accurate history, physical examination, and assessment of imaging findings., Methods: A narrative review is presented summarizing the current landscape of imaging modalities utilized in DCM diagnostics and the future direction of research for spinal cord imaging., Results and Discussion: Current imaging modalities, particularly magnetic resonance imaging and, to a lesser extent, radiographs/CT, offer important information to aid in decision making but are not ideal as stand-alone tools. Newer imaging modalities currently being studied in the literature include diffusion tensor imaging, MR spectroscopy, functional magnetic resonance imaging, perfusion imaging, and positron emission tomography. These newer imaging modalities attempt to more accurately evaluate the physical structure, intrinsic connectivity, biochemical and metabolic function, and perfusion of the spinal cord in DCM. Although there are still substantial limitations to implementation, future clinical practice will likely be revolutionized by these new imaging modalities to diagnose, localize, surgically plan and manage, and follow patients with DCM., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To determine whether the L3-L4 disc angle may be a surrogate marker for global lumbar alignment in thoracolumbar fusion surgery and to explore the relationship between radiographic and patient-reported outcomes after thoracolumbar fusion surgery., Methods: Retrospective chart review was conducted on patients who had undergone a lumbar fusion involving levels from T9 to pelvis. EuroQol-Five Dimension (EQ-5D-3L) scores and adverse events including adjacent-segment disease and degeneration, pseudoarthrosis, proximal junctional kyphosis, stenosis, and reoperation were collected. Pre- and postoperative spinopelvic parameters were measured on weight-bearing radiographs, with the L3-L4 disc angle of novel interest. Univariate logistic and linear regression were performed to assess the associations of radiographic parameters with adverse event incidence and improvement in EQ-5D-3L, respectively., Results: In total, 182 patients met inclusion criteria. Univariable analysis revealed that increased magnitude of L3-L4 disc angle, anterior pelvic tilt, and pelvic incidence measures are associated with increased likelihood of developing postoperative adverse events. Conversely, increased lumbar lordosis demonstrated a decreased incidence of developing a postoperative adverse event. Linear regression showed that radiographic parameters did not significantly correlate with postoperative EQ-5D-3L scores, although scores were significantly improved postfusion in all dimensions except Self-Care (P = 0.51)., Conclusions: L3-L4 disc angle magnitude may serve as a surrogate marker of global lumbar alignment. The degree of spinopelvic alignment did not correlate to improvement in EQ-5D-3L score in the present study, suggesting that quality of life metric change may not be a sensitive or specific marker of postfusion alignment., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Prolonged operative time of single-level ACDF has been associated with adverse postoperative outcomes. The current literature does not contain a comprehensive quantitative description of these associations PURPOSE: This study characterized the associations between single-level anterior cervical discectomy and fusion(ACDF) operative time and (1)30-day postoperative healthcare utilization, and (2)the incidence of local wound complications, need for transfusion and mechanical ventilation., Design/setting: Retrospective database analysis PATIENT SAMPLE: The American College of Surgeons National Surgical Quality Improvement Program(ACS-NSQIP) database was queried for single-level ACDF cases(2012-2018) using current procedural terminology codes. A total of 24,593 cases were included., Outcome Measures: Primary outcomes included healthcare utilization(lengths of stay[LOS], discharge dispositions, 30-day readmissions, and reoperations) per operative time category. The secondary outcome was the incidence of wound complications, blood transfusion and need for ventilation per operative time category., Methods: Multivariate regression determined operative time categories associated with increased risk while adjusting for patient demographics and comorbidities. Predictive spline regression models visualized the associations., Results: Compared to the reference operative time of 81-100-minutes, the 101-120-minute category was associated with higher odds of LOS >2 days(OR:1.36,95%CI(1.18-1.568);p<.001) and non-home discharge(OR:1.341,95%CI(1.081-1.664);p=.008). Three-times greater odds of LOS >2 days(OR:3.367,95%CI(2.719-4.169); p<.001) and twice the odds of non-home discharge(OR:2.174,95%CI(1.563-3.022);p<.001) were detected at 181-200-minutes. The highest operative time category(≥221 minutes) was associated with the highest odds of LOS>2 days(OR:4.838,95%CI(4.032-5.804);p<.001), non-home discharge(OR:2.687,95%CI(2.045-3.531);p<.001) and reoperation(OR:1.794,95%CI(1.094-2.943);p=.021). Patients within the 201-220 and the ≥221-minute categories exhibited a significant association with greater odds of transfusion(OR:8.57,95%CI(2.321-31.639);p<.001, and OR:11.699, 95%CI(4.179-32.749);p=.001, respectively). Spline regression demonstrated that the odds of LOS >2 days, non-home discharge disposition, reoperation and bleeding requiring transfusion events began to rise, starting at 94, 91.6, 91.6, and 93.3 minutes of operative time, respectively., Conclusion: This study demonstrated that prolonged operative time is associated with increased odds of healthcare utilization and transfusion after single-level ACDF. Operative times greater than 91 minutes may carry higher odds of postoperative complications., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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

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

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

Background: The purpose of this study was to determine if oblique magnetic resonance imaging (MRI) sequences affect the surgical treatment recommendations for patients with cervical radiculopathy., Methods: In this cohort study consecutive clinical cases of persistent cervical radiculopathy requiring surgical intervention were randomized, blinded, and reviewed by 6 surgeons. Initially each surgeon recommended treatment based on the history, physical examination, and axial, coronal and sagittal preoperative magnetic resonance (MR) images; when reviewing the cases the second time, the surgeons were provided oblique MR images. This entire process was then repeated after 2 months. Change in surgical recommendation, interobserver and intraobserver reliability and the average number of levels fused was determined., Results: The addition of the oblique images resulted in the surgical recommendation being altered in 49.2% (59/120) of cases; however, the addition of oblique images did not substantially improve the interobserver reliability of the treatment recommendation (κ = .57 versus.57). Similarly, the overall intraobserver reliability using only traditional MRI sequences (κ = .64) was only slightly improved by the addition of oblique images (κ = .66). Lastly, the addition of oblique images did not change the average number of levels fused (traditional MRI = 1.38, oblique MRI = 1.41, P  = .53), or the total number of 3-level fusions recommended (6 versus 6, P  = 1.00)., Conclusions: The additional oblique images resulted in a change to the surgical plan in almost 50% of cases; however, it had no substantial effect on the reliability of surgical decision making. Further studies are needed to see if this alteration in treatment affects clinical outcomes., Level of Evidence: 3., Competing Interests: Disclosures and COI: No funds were received in support of this work. The authors disclose no direct or indirect conflicts of interest in the preparation of this manuscript. No pharmaceutical or medical devices were utilized during this study. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript. This included the National Institutes of Health (NIH); Wellcome Trust; Howard Hughes Medical Institute (HHMI). The authors had password-protected access to the data with nonessential patient demographics deidentified. Ethics Board Review Statement: This study was approved by the Institutional Review Board at Thomas Jefferson University Hospital. Each author certifies that our institution approved the human protocol for this investigation and that all investigations were conducted in conformity with ethical principles of research.

Background: Carotid artery injury and stroke secondary to prolonged retraction remains an extremely rare complication in anterior cervical discectomy and fusion (ACDF). However, multiple studies have demonstrated that carotid artery retraction during the surgical approach may alter the normal blood flow, leading to a significant reduction in the cross-sectional area of the vessel. Others have suggested that dislodgment of atherosclerotic plaques following manipulation of the carotid artery can be a potential risk for intracranial embolus and stroke., Purpose: We aimed to evaluate: (1) the incidence of postoperative stroke following ACDF and (2) incidence of other postoperative complications in a cohort of patients who had a diagnosis of carotid artery stenosis (CAS) versus those who did not., Patient Sample: This study utilized the Statewide Planning and Research Cooperative System database from January 1, 2009 to December 31, 2013. All patients who underwent (ACDF) and had a preoperative diagnosis of CAS were identified using the International Classification of Disease, ninth revision codes. Those who had a previous history of stroke were excluded. Patients who had CAS were propensity score matched to patients without history of CAS for demographics and Charlson/Deyo comorbidity scores., Outcome Measures: Incidence of postoperative stroke and other complications were compared between the cohorts. The threshold for statistical significance was set at a p<.05. This study received no funding. The authors report no conflict of interests relevant to this study., Results: There were 34,975 patients who underwent an ACDF in the study time period. After excluding those under the age of 18 and with history of previous stroke, there were 61 patients who had CAS that were compared with a propensity-matched cohort. The CAS cohort had a significantly higher incidence of postoperative stroke during their hospitalization (6.6% vs 0%, p<.042). The CAS cohort also had higher rates of acute renal failure (27.9% vs 4.9%, p = .01) and sepsis (18% vs 4.9%, p = .023). There were no stroke related deaths., Conclusions: Patients with CAS who underwent ACDF had a statistically significant greater incidence of developing a postoperative stroke. To the best of our knowledge, no previous study has evaluated the development of postoperative stroke in patients with CAS undergoing ACDF. Larger, multicenter studies are needed to estimate the true incidence of stroke in this specific patient population. However, our results may illustrate the importance of preoperative optimization, approach-selection, and postoperative stroke surveillance in patients with a history of CAS who undergoes ACDF., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Deformity reconstruction surgery has been shown to improve quality of life (QOL) in cases of adult spinal deformity (ASD) but is associated with significant morbidity., Objective: To create a preoperative predictive nomogram to help risk-stratify patients and determine which would likely benefit from corrective surgery for ASD as measured by patient-reported health-related quality of life (HRQoL)., Methods: All patients aged 25-yr and older with radiographic evidence of ASD and QOL data that underwent thoracolumbar fusion between 2008 and 2014 were identified. Demographic and clinical parameters were obtained. The EuroQol 5 dimensions questionnaire (EQ-5D) was used to measure HRQoL preoperatively and at 12-mo postoperative follow-up. Logistic regression of preoperative variables was used to create the prognostic nomogram., Results: Our sample included data from 191 patients. Fifty-one percent of patients experienced clinically relevant postoperative improvement in HRQoL. Seven variables were included in the final model: preoperative EQ-5D score, sex, preoperative diagnosis (degenerative, idiopathic, or iatrogenic), previous spinal surgical history, obesity, and a sex-by-obesity interaction term. Preoperative EQ-5D score independently predicted the outcome. Sex interacted with obesity: obese men were at disproportionately higher odds of improving than nonobese men, but obesity did not affect odds of the outcome among women. Model discrimination was good, with an optimism-adjusted c-statistic of 0.739., Conclusion: The predictive nomogram that we developed using these data can improve preoperative risk counseling and patient selection for deformity correction surgery., (Copyright © 2018 by the Congress of Neurological Surgeons.)

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

Study Design: Prospective, cohort study., Objective: Demonstrate validity of Patient reported outcomes measurement information system (PROMIS) physical function, pain interference, and pain behavior computer adaptive tests (CATs) in surgically treated lumbar stenosis patients., Summary of Background Data: There has been increasing attention given to patient reported outcomes associated with spinal interventions. Historical patient outcome measures have inadequate validation, demonstrate floor/ceiling effects, and infrequently used due to time constraints. PROMIS is an adaptive, responsive National Institutes of Health (NIH) assessment tool that measures patient-reported health status., Methods: Ninety-eight consecutive patients were surgically treated for lumbar spinal stenosis and were assessed using PROMIS CATs, Oswestry disability index (ODI), Zurich Claudication Questionnaire (ZCQ), and Short-Form 12 (SF-12). Prior lumbar surgery, history of scoliosis, cancer, trauma, or infection were excluded. Completion time, preoperative assessment, 6 weeks and 3 months postoperative scores were collected., Results: At baseline, 49%, 79%, and 81% of patients had PROMIS pain behavior (PB), pain interference (PI), and physical function (PF) scores greater than 1 standard deviation (SD) worse than the general population. 50.6% were categorized as severely disabled, crippled, or bed bound by ODI. PROMIS CATs demonstrated convergent validity through moderate to high correlations with legacy measures (r = 0.35-0.73). PROMIS CATs demonstrated known groups validity when stratified by ODI levels of disability. ODI improvements of at least 10 points on average had changes in PROMIS scores in the expected direction (PI = -12.98, PB = -9.74, PF = 7.53). PROMIS CATs demonstrated comparable responsiveness to change when evaluated against legacy measures. PROMIS PB and PI decreased 6.66 and 9.62 and PROMIS PF increased 6.8 points between baseline and 3-months post-op (P < 0.001). Completion time for the PROMIS CATs (2.6 min) compares favorably to ODI, ZCQ, and SF-12 scores (3.1, 3.6, and 3.0 min)., Conclusion: PROMIS CATs demonstrate convergent validity, known groups validity, and responsiveness for surgically treated patients with lumbar stenosis to detect change over time and are more efficient than legacy instruments., Level of Evidence: 2.

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

Background Context: Degenerative changes in the cervical spine occur in an age-dependent manner. As the US population continues to age, the incidence of age-dependent, multilevel, degenerative cervical pathologies is expected to increase. Similarly, the average age of patients with cervical spondylotic myelopathy (CSM) will likely trend upward. Posterior cervical fusion (PCF) is often the treatment modality of choice in the management of multilevel cervical spine disease. Although outcomes following anterior cervical fusion for degenerative disease have been studied among older patients (aged 80 years and older), it is unknown if these results extend to octogenarian patients undergoing PCF for the surgical management of CSM., Purpose: The present study aimed to quantify surgical outcomes following PCF for the treatment of CSM among the octogenarian patient population compared with patients younger than 80 years old., Study Design/setting: This was a retrospective study that used the National Surgical Quality Improvement Program (NSQIP)., Patient Sample: The sample included patients aged 60-89 who had CSM and who underwent PCF from 2012 to 2014., Outcome Measures: The outcome measures were multimorbidity, prolonged length of stay (LOS), discharge disposition (to home or skilled nursing/rehabilitation facility), 30-day all-cause readmission, and 30-day reoperation., Methods: The NSQIP database was queried for patients with CSM (International Classification of Disease, Ninth Revision, Clinical Modification code 721.1) aged 60-89 who underwent PCF (Current Procedural Terminology code 22600) from 2012 to 2014. Cohorts were defined by age group (60-69, 70-79, 80-89). Data were collected on gender, race, elective or emergent status, inpatientor outpatient status, where patients were admitted from (home vs. skilled nursing facility), American Society of Anesthesiologists class, comorbidities, and single- or multilevel fusion. After controllingfor these variables, logistic regression analysis was used to compare outcome measures in the different age groups., Results: A total of 819 patients with CSM who underwent PCF (416 aged 60-69, 320 aged 70-79, and 83 aged 80-89) were identified from 2012 to 2014. Of the PCF procedures, 79.7% were multilevel. There were no significant differences in the odds of multimorbidity, prolonged LOS, readmission, or reoperation when comparing octogenarian patients with CSM with patients aged 60-69 or 70-79. Patients aged 60-69 and 70-79 were significantly more likely to be discharged to home than patients over 80 (odds ratio [OR] 4.3, 95% confidence interval [CI] 1.8-10.4, p<.0001, and OR 2.7, 95% CI 1.1-6.4, p=.0005, respectively)., Conclusions: Compared with patients aged 60-69 and 70-79, octogenarian patients with CSM were significantly more likely to be discharged to a location other than home following PCF. After controlling for patient comorbidities and demographics, 80- to 89-year-old patients with CSM who underwent PCF did not differ in other outcomes when compared with the other age cohorts. These results can improve preoperative risk counseling and surgical decision-making., (Copyright © 2018 Elsevier Inc. All rights reserved.)

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

Background Context: Patients with spinal deformity may present with complaints related to either the deformity itself or the manifestations of the coexisting spinal stenosis. There are reports of successful management of lumbar pathology in the absence of global sagittal or coronal imbalance, with limited decompression and fusion, addressing only the symptomatic segment., Purpose: Our study examined the long-term outcomes of transforaminal lumbar interbody fusion (TLIF), a less extensive procedure, based on the experience of the senior author over the past 10 years., Study Design/setting: This was a retrospective study of symptomatic lumbar spinal stenosis and spinal deformity managed by one surgeon at The Cleveland Clinic since 2003., Patient Sample: Forty-one patients were included in the study., Outcome Measures: The present study measures the long-term clinical functional outcomes of these patients through EQ-5D (EuroQol five dimensions questionnaire), PHQ-9 (Patient Health Questionnaire), and PDQ (Pain Disability Questionnaire) forms, along with documented radiographic parameters and Charlson Comorbidity Index (CCI)., Methods: There were no funding or potential conflicts of interest associated biases in the present study. Patients with symptomatic lumbar spinal stenosis with neutral global alignment in the sagittal and coronal planes and symptomatic stenosis at the deformity level were treated by limited fusion and TLIF, and had a follow-up period of at least 5 years. Excluded were patients under 18 years of age, had more than three levels of fusion, and had an active spinal malignancy or recent spinal trauma. The grouping variables were curve magnitude, revision surgeries, and TLIF levels. Clinical outcomes were compared in all the grouping variables. Analysis of variance (ANOVA) and chi-square tests were utilized; p<.05 was considered statistically significant., Results: The average age and follow-up period were 66±10 and 7.5 years, respectively. There was no statistical difference between patients with curves measuring between 10° and 20° and greater than 20° for EQ-5D, PHQ-9, and PDQ. Patients had worse PDQ data with larger curves compared with smaller curves at both 5 years and final follow-up. Although there was no statistical significance between preoperative coronal curve magnitude and revision surgeries, patients with curves greater than 20° had higher rates of revision surgeries (75%; p=.343) in the global lumbar curve deformity group. Although there was no statistical significance for patients who underwent revision surgeries,those patients had low PHQ-9 values at the final follow-up (p=.09). The revision surgery rate was 48% in one-level TLIF and 18% in two-level TLIF. Moderate pain disability scores were noticed for one-level TLIF patients (mean=75) compared with two-level TLIF patients (mean=27) at the final follow-up, and approached statistical significance in this comparison (p=.06)., Conclusion: Although this topic has a limited audience to spinal deformity surgeons, the prevalence of patients who present with adult spinal deformities has been increasing. Short segment fusion, in the setting of modest spinal deformity, is a reasonable and safe option. Further study on the concept of short segment fusions in the growing patient population is required as more comprehensive fusions do have noted complication rates, and a compromise must be reached between the extent of surgery that is enough to provide pain relief and disability and the degree of surgery that is too much to be tolerated in terms of complication rates., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Magnetization transfer (MT) contrast has been established as a marker of myelin integrity, and cervical spondylotic myelopathy is known to cause demyelination. Ten patients with clinical and magnetic resonance imaging (MRI) manifestations of cervical spondylotic myelopathy (CSM) were compared to the MRIs of seven historic healthy controls, using the magnetization transfer ratio (MTR) and Nurick scores as the primary metrics. Transverse slices through the intervertebral discs of the cervical spine were acquired using a gradient echo sequence (MEDIC) with and without an MT saturation pulse on a 3 Tesla Siemens Prisma scanner (TR = 300 ms, TE eff  = 17 ms, flip angle = 30°, in-plane resolution = 0.47 × 0.47 mm 2 ). The CSM patients tended to have a lower mean MTR (30.4 ± 6.5) than the controls (34.8 ± 3.8), but the difference was not significant (independent samples t-test, p = 0.110, Cohen's d = 0.80). The mean MTR across all intervertebral disc levels was not significantly correlated to the Nurick score (Spearman's ρ = -0.489, p = 0.151). The intervertebral level with the lowest MTR in each cohort was not significantly different between groups (equal variances not assumed, t = 1.965, dof = 14.8, p = 0.068, Cohen's d = 0.88), but the CSM patients tended to have a lower MTR. The mean MTR at this level was negatively correlated to the Nurick score among CSM patients (Spearman's ρ = -0.725, p = 0.018). CSM patients tended to have decreased MTR indicating myelin degradation compared to our healthy subjects, and MTR was negatively correlated with the severity of CSM., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

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

Background Context: Transforaminal lumbar interbody fusion (TLIF) or anterior lumbar interbody fusion with percutaneous pedicle screws (ALIFPS) offer significantly higher radiographic fusion rates than other fusion techniques for L5-S1 isthmic spondylolisthesis (IS). As it stands, there is a relative paucity of comparative data of the two techniques., Purpose: To define the clinical, radiographic, and financial differences between TLIF and ALIFPS for L5-S1 IS., Design/setting: A retrospective cohort study conducted at a single tertiary care center., Patient Sample: Sixty-six patients who underwent either TLIF or ALIPFS for L5-S1 IS at a single tertiary care center between 2009 and 2014., Outcome Measures: Quality of life outcome scores including the EuroQol-5 Dimensions (EQ-5D), Pain Disability Questionnaire (PDQ), and Patient Health Questionnaire-9 (PHQ-9). Sagittal balance parameters including: pelvic incidence, pelvic tilt, sacral slope, segmental lordosis, total lordosis, degree of slip, disc height, and L1-axis S1 distance (LASD). Cost measures included in-hospital charges, hospital length of stay (LOS), and post-admission costs accrued over 1 year., Methods: Quality of life (QoL) outcome scores, radiographic data, and financial data were collected with a minimum of 1-year follow-up. Clinical results were investigated using the PDQ, PHQ-9, and EQ-5D. Radiographic measurements included lumbar lordosis, segmental lordosis, pelvic tilt, pelvic incidence, height of disc, L-1 axis S-1 distance, and the degree of slip. Cost data were generated based on patient-level resource utilization. Comparative data were presented as median with interquartile range (IQR). Continuous variables were compared using either independent Student t tests assuming unequal variance or Mann-Whitney U tests for parametric and nonparametric variables, respectively. The minimally clinical important difference (MCID) used for each questionnaire was as follows: PDQ (26), PHQ-9 (5), and EQ-5D (0.4)., Results: A total of 66 patients met inclusion criteria. In the ALIFPS cohort, PDQ scores improved from 69 [47, 82] to 26 [18.2, 79.7], p=.02. In the TLIF cohort, PDQ scores improved from 73 [46, 85] to 48.5 [23, 67.5], p=.01. Both groups also showed a significant improvement in EQ-5D scores at 1 year, but the ALIFPS group showed a significantly greater improvement in EQ-5D scores at 1 year (0.1 [0,0.2] vs. 0.2 [0.1, 0.4], p=.02). Furthermore, only the ALIFPS cohort showed a significant improvement in segmental lordosis. The ALIFPS cohort showed a significantly greater improvement in disc height than did TLIF (3.5 [2, 5.5] vs. 6.7 [4.1, 10], p=.01). No significant differences were found in the direct costs of both procedures., Conclusions: Our findings suggest that anterior lumbar interbody fusion with percutaneous pedicle screws can achieve better clinical outcomes compared with TLIF for the treatment of IS. We believe the superior radiographic outcomes achieved through ALIFPS, namely a greater restoration of segmental lordosis and disc height, may have contributed to the improved clinical outcomes presented in the current study., (Copyright © 2017 Elsevier Inc. All rights reserved.)

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

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

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

Background: Spine surgery is complicated by an incidence of 1% to 9% of surgical site infection (SSI). The most common organisms are gram-positive bacteria and are endogenous, that is are brought to the hospital by the patient. Efforts to improve safety have been focused on reducing SSI using a bundle approach. The bundle approach applies many quality improvement efforts and has been shown to reduce SSI in other surgical procedures., Objective: To provide a narrative review of practical solutions to reduce SSI in spine surgery., Methods: Literature review and synthesis to identify methods that can be used to prevent SSI., Results: SSI prevention starts with proper patient selection and optimization of medical conditions, particularly reducing smoking and glycemic control. Screening for staphylococcus organisms and subsequent decolonization is a promising method to reduce endogenous bacterial burden. Preoperative warming of patients and timely administration of antibiotics are critical to prevent SSI. Skin preparation using chlorhexidine and alcohol solutions are recommended. Meticulous surgical technique and maintenance of sterile techniques should always be performed. Postoperatively, traditional methods of tissue oxygenation and glycemic control remain essential. Newer wound care methods such as silver impregnation dressing and wound-assisted vacuum dressing are encouraging but need further investigation., Conclusion: Significant reduction of SSIs is possible, but requires a systems approach involving all stakeholders. There are many simple and low-cost components that can be adjusted to reduce SSIs. Systematic efforts including understanding of pathophysiology, prevention strategies, and system-wide quality improvement programs demonstrate significant reduction of SSI., (Copyright © 2016 by the Congress of Neurological Surgeons)

Lumbar facet cysts are a rare but increasingly common cause of symptomatic nerve root compression and can lead to radiculopathy, neurogenic claudication, and cauda equina syndrome. The cysts arise from the zygapophyseal joints of the lumbar spine and commonly demonstrate synovial herniation with mucinous degeneration of the facet joint capsule. Lumbar facet cysts are most common at the L4-L5 level and often are associated with spondylosis and degenerative spondylolisthesis. Advanced imaging studies have increased diagnosis of the cysts; however, optimal treatment of the cysts remains controversial. First-line treatment is nonsurgical management consisting of oral NSAIDs, physical therapy, bracing, epidural steroid injections, and/or cyst aspiration. Given the high rate of recurrence and the relatively low satisfaction with nonsurgical management, surgical options, including hemilaminectomy or laminotomy to excise the cyst and decompress the neural elements, are typically performed. Recent studies suggest that segmental fusion of the involved levels may decrease the risks of cyst recurrence and radiculopathy.

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

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

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

Study Design: Retrospective Cross-Sectional Study OBJECTIVE.: Identify the pathoanatomical features of the cervical spine associated with congenital stenosis SUMMARY OF BACKGROUND DATA.: Congenital cervical stenosis (CCS) describes a patient with a decreased spinal canal diameter at multiple levels of the cervical spine in the absence of degenerative changes. Despite recognition of CCS throughout the literature, the anatomical features that lead to this condition have not been established. Knowledge of the pathoanatomy behind CCS may lead to alterations in surgical technique for this patient population that may improve outcomes., Methods: From 1000 cervical MRIs between January 2000 and December 2014, CCS was identified in 68 patients using a strict definition of age less than 50 years with mid-sagittal canal diameters (mid-SCD) (<10  mm) at multiple sub-axial cervical levels (C3-C7). A total of 68 patients met the inclusion criteria for this group. Fourteen controls with normal SCDs (>14  mm) at all cervical levels were used for comparison. Anatomic measurements obtained at each level (C3-C7) included: coronal vertebral body, AP vertebral body, pedicle width, pedicle length, laminar length, AP lateral mass, posterior canal distance, lamina-pedicle angle, and lamina-disc angle (LDA). Statistical significance was defined as P < 0.01., Results: CCS patients demonstrated significantly different anatomical measurements when compared with controls. Significantly smaller lateral masses, lamina lengths, lamina-pedicle angles, and larger LDAs were identified at levels C3 to C7 in the CCS group (P < 0.01). These anatomic components form a right triangle that illustrates the cumulative narrowing effect on space for the spinal cord., Conclusion: The pathoanatomy of CCS is associated with a decrease in the lamina-pedicle angle and an increase in the LDA ultimately leading to a smaller SCD. The global changes in CCS are best illustrated by this triangle model and are driven by the posterior elements of the cervical spine., Level of Evidence: 4.

Study Design: A questionnaire survey., Objective: To report the current use of recombinant human bone morphogenetic protein-2 (rhBMP-2) in lumbar fusion procedures for the treatment of degenerative spondylolisthesis (DS), and identify associated factors including fusion technique, surgeon location, surgeon specialty, or surgeon practice model., Summary of Background Data: The prevalence of rhBMP-2 use in fusions increased dramatically from 0.7% in 2002 to 24.7% in 2006, however more recent studies have identified significant complications with its use. Furthermore, an independent review of the industry-sponsored trial data has demonstrated no significant difference in fusion rates or clinical results with the use of rhBMP-2 compared with iliac-crest autograft., Methods: In July 2014, a survey was sent requesting information on the usage of rhBMP-2 in the treatment of DS. Determinants included the fusion technique, geographic location, specialty, and associated practice models. No funding was received for this work., Results: Overall, 7.8% +/- 2.0% of surgeons reported using rhBMP-2 when performing an open L4-L5 posterolateral fusion for DS; 6.2% +/- 1.8% reported using rhBMP-2 for an open L4-L5 interbody fusion, and 12.1% +/- 2.5% reported using rhBMP-2 for a L4-L5 minimally invasive (MIS) interbody fusion. The variables that were statistically associated with the use of rhBMP-2 were North America surgeons (P < 0.0001) and the type of procedure (P = 0.0005)., Conclusion: Compared with historical data, there has been a dramatic decrease in the number of surgeons using rhBMP-2 in lumbar fusion procedures for the treatment of DS. Currently, rhBMP-2 is more commonly used by surgeons in North America and those performing MIS interbody fusions., Level of Evidence: N/A.

Lumbar disk herniations occur frequently and are often associated with leg pain, weakness, and paresthesias. Fortunately, the natural outcomes of radiculopathy due to a disk herniation are generally favorable, and the vast majority of patients improve with nonoperative care. Surgical intervention is reserved for patients who have significant pain that is refractory to at least 6 weeks of conservative care, patients who have a severe or progressive motor deficit, or patients who have any symptoms of bowel or bladder dysfunction. This paper reviews the preoperative and postoperative considerations, as well as the surgical technique, for a microdiscectomy for a lumbar intervertebral disk herniation.

Study Design: Cross-sectional observational study., Objective: To formulate a reliable method and modality for preoperative planning and to determine the effects of height, body mass index (BMI), and age on accessibility to the upper thoracic vertebrae through an anterior cervical approach., Summary of Background Data: Various modalities have been proposed to determine the lowest spinal-level accessible through a traditional anterolateral cervical approach and the consequent need for manubriotomy. Past methods have routinely involved a variety of imaging studies such as plain radiographs and computed tomography but the reliability of these methods has not been assessed., Methods: The Magnetic Resonance Imaging (MRI) images of 180 patients classified by age and gender were evaluated and the most caudal accessible intervertebral disc space was determined from an approach angle beginning at the suprasternal notch. Plain cervical radiographs were also reviewed when available. In patients with multiple imaging studies, the reliability of the measurements was compared. Rate of accessibility was compared across different heights, BMIs, and ages., Results: A novel algorithm that utilized both the scout and mid-sagittal T2 MRIs was able to determine the most caudal cervicothoracic level accessible for anterior access in 93.3% of patients with a reliability of 96.8%. Conversely, plain radiograph evaluation led to low reliability (66.7%) and low agreement with MRI (60%) with an average error of one spinal level. In this patient sample, the T1 to T2 disc space was accessible in 82.7% of patients. Age and BMI were independent variables associated with accessibility (p < 0.01) while height was determined not to be significant (p = 0.09)., Conclusion: Data in this study suggest an MRI-based algorithm with a combination of scout and sagittal T2 images offers a reliable and consistent assessment of accessibility to upper thoracic levels through an anterior approach. Age and body mass index are major determinants of accessibility.

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

Study Design: A questionnaire survey., Objective: The aim of this study was to determine the effect of patient age, dynamic instability, and/or low back pain on the treatment of patients with a degenerative spondylolisthesis, and if the operative approach is affected by surgeon specialty, location, or practice model., Summary of Background Data: The classic treatment for patients with symptomatic degenerative spondylolisthesis is decompression and fusion; however in a select group of patients, an isolated decompression may be reasonable., Methods: A survey was sent to surgeon members of the Lumbar Spine Research Society and AOSpine requesting information regarding their preferred treatment of degenerative spondylolisthesis for a number of different clinical scenarios. Determinants included patient age, the presence of instability, symptoms of low back pain, surgeon's location, surgeon's specialty, and practice model., Results: A total of 223 spine surgeons completed the survey. Age of the patient, the presence of instability, and low back pain all significantly (P < 0.0001) affected the recommended treatment, which were independent of surgeon factors. Older patients were significantly less likely to be offered an interbody fusion and more likely to be recommended for an isolated decompression (P < 0.0001), and the presence of dynamic instability made an interbody fusion more likely than an isolated decompression (P < 0.0001). Of those who responded, 53.2% of surgeons reported they would recommend an isolated decompression for a properly selected patient with a degenerative spondylolisthesis., Conclusion: The most common operative treatment for a degenerative spondylolisthesis is a decompression and fusion; however, the results of this survey demonstrate that surgeons consider degenerative spondylolisthesis a heterogeneous condition that requires an individualized surgical plan. Future studies are needed to evaluate the effect of variables such as age, the presence of low back pain, and the presence of dynamic instability on patient reported outcomes from various surgical options., Level of Evidence: N/A.

OBJECT The authors compared the rates of postoperative adverse events and reoperation of patients who underwent lumbar spinal fusion with bone morphogenetic protein (BMP) to those of patients who underwent lumbar spinal fusion without BMP. METHODS The authors retrospectively analyzed the PearlDiver Technologies, Inc., database, which contains the Medicare Standard Analytical Files, the Medicare Carrier Files, the PearlDiver Private Payer Database (UnitedHealthcare), and select state all-payer data sets, from 2005 to 2010. They identified patients who underwent lumbar spinal fusion with and without BMP. The ICD-9-CM code 84.52 was used to identify patients who underwent spinal fusion with BMP. ICD-9-CM diagnosis codes identified complications that occurred during the initial hospital stay. ICD-9-CM procedural codes were used to identify reoperations within 90 days of the index procedure. The relative risks (and 95% CIs) of BMP use compared with no BMP use (control) were calculated for the association of any complication with BMP use compared with the control. RESULTS Between 2005 and 2010, 460,773 patients who underwent lumbar spinal fusion were identified. BMP was used in 30.7% of these patients. The overall complication rate in the BMP group was 18.2% compared with 18.7% in the control group. The relative risk of BMP use compared with no BMP use was 0.976 (95% CI 0.963-0.989), which indicates a significantly lower overall complication rate in the BMP group (p < 0.001). In both treatment groups, patients older than 65 years had a statistically significant higher rate of postoperative complications than younger patients (p < 0.001). CONCLUSIONS In this large-scale institutionalized database study, BMP use did not seem to increase the overall risk of developing a postoperative complication after lumbar spinal fusion surgery.

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

Background: Surgical-site infections (SSIs) can lead to greater postoperative morbidity, mortality, and health care costs. Despite current prophylactic measures, rates of SSIs have been reported in up to 15% of patients undergoing spine surgery. The adjunctive local application of vancomycin powder in spine surgery is a low-cost strategy to help reduce SSIs. Vancomycin is active against skin pathogens that can potentially contaminate the wound during spinal surgery. The local application of vancomycin in its powder form ensures adequate surgical-site concentrations while minimizing adverse effects caused by undetectable systemic distribution. However, clinical studies have produced conflicting results, and the clinical evidence behind the use of vancomycin powder in modern spinal surgery practices is not clear., Purpose: To examine the current clinical evidence on the use of vancomycin powder in spine surgery., Study Design: Systematic review and meta-analysis of literature., Methods: A comprehensive search of the English literature was conducted with PubMed (MEDLINE). The inclusion criteria consisted of intrawound vancomycin powder use in spine surgery as a prophylactic agent for SSIs. Studies that investigated nonspine surgeries, selected patients on the basis of clinical suspicion, or included patients with infections were excluded. Studies that compared intrawound vancomycin in spine surgery against their standard practice were pooled in the meta-analysis using a random-effects model., Results: A total of 671 abstracts were reviewed, and 18 papers met inclusion/exclusion criteria and were included in this review. These included 1 randomized controlled trial, 13 comparative studies, and 4 case series. The level of evidence in hierarchical order was as follows: 1 level II, 13 level III, and 4 level IV. Fourteen of the studies, 1 randomized controlled trial and 13 comparative studies, were eligible for the meta-analysis. The odds of developing a deep infection with intrawound vancomycin powder were 0.23 times the odds of experiencing an infection without intrawound vancomycin (95% confidence interval 0.11-0.50, P = 0.0002, I(2) = 47%). For combined superficial and deep infections the odds ratio was 0.43 (95% confidence interval 0.22-0.82, P = 0.01, I(2) = 36%)., Conclusions: Numerous clinical studies have confirmed the safety of using vancomycin powder in the surgical site. The pooled clinical data supports the use of vancomycin to prevent SSIs in adult spine surgeries. The majority of the supporting literature is class III evidence. Existing studies use different definitions for surgical site infections and different pre-, peri-, and postoperative antibiotic regimens. Further high-quality investigations should use standardized protocols to confirm these findings., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: It is currently unknown how pre-existing lumbar spine conditions may affect the medical evaluation, draft status, and subsequent career performance of National Football League (NFL) players., Purpose: To determine if a pre-existing lumbar diagnosis affects a player's draft status or his performance and longevity in the NFL., Study Design: Cohort study; Level 3., Methods: The investigators evaluated the written medical evaluations and imaging reports of prospective NFL players from a single franchise during the NFL Scouting Combine from 2003 to 2011. Players with a reported lumbar spine diagnosis and with appropriate imaging were included in this study. Athletes were then matched to control draftees without a lumbar spine diagnosis by age, position, year, and round drafted. Career statistics and performance scores were calculated., Results: Of a total of 2965 athletes evaluated, 414 were identified as having a pre-existing lumbar spine diagnosis. Players without a lumbar spine diagnosis were more likely to be drafted than were those with a diagnosis (80.2% vs. 61.1%, respectively, P < .001). Drafted athletes with pre-existing lumbar spine injuries had a decrease in the number of years played compared with the matched control group (4.0 vs. 4.3 years, respectively, P = .001), games played (46.5 vs. 50.8, respectively, P = .0001), and games started (28.1 vs. 30.6, respectively, P = .02) but not performance score (1.4 vs. 1.8, respectively, P = .13). Compared with controls, players were less likely to be drafted if they had been diagnosed with spondylosis (62.37% vs. 78.55%), a lumbar herniated disc (60.27% vs. 78.43%), or spondylolysis with or without spondylolisthesis (64.44% vs. 78.15%) (P < .001 for all), but there was no appreciable effect on career performance; however, the diagnosis of spondylolysis was associated with a decrease in career longevity (P < .05). Notably, 2 athletes who had undergone posterior lateral lumbar fusion were drafted. One played in 125 games, and the other is still active and has played in 108 games., Conclusion: The data in this study suggest that athletes with pre-existing lumbar spine conditions were less likely to be drafted and that the diagnosis is associated with a decrease in career longevity but not performance. Players with lumbar fusion have achieved successful careers in the NFL., (© 2015 The Author(s).)