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Shost MD, Jella TK, Ronald AA, Herring EZ, Sajatovic M, Smith GA. Clinical Utility of Routine Postoperative Imaging in Spinal Fusion Surgery: A Systematic Review. World Neurosurg 2022; 167:222-228.e1. [PMID: 35922007 DOI: 10.1016/j.wneu.2022.07.091] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Following spinal fusion surgery, routine imaging is often obtained in all patients regardless of clinical presentation. Such routine imaging may include x-ray, computed tomography, or magnetic resonance imaging studies in both the immediate postoperative period and after discharge. The clinical utility of this practice is questionable. Our goal is to assess the existing literature for evidence of impact on clinical care from routine radiographic surveillance following spinal fusion. METHODS A systematic search of Embase, Scopus, PubMed, Cochrane, and Ovid databases was performed for studies investigating postoperative imaging following spinal fusion surgery. Studies were analyzed for imaging findings and rates of change in management due to imaging. RESULTS In total, the review identified 9 studies that separated data by unique patient or by unique clinic visits. The 4 studies reporting per-patient data totaled 475 patients with 328 (69%) receiving routine imaging. Among these, 28 (8.5%) patients had abnormal routine findings with no patients having a change to their clinical course. Of the 5 studies that reported clinic visit data, 3119 patient visits were included with 2365 (76%) clinic visits accompanied by imaging. Across these 5 studies, 146 (6.2%) visits noted abnormal imaging with only 12 (0.5%) subsequent management changes. CONCLUSIONS Our analysis found that routine imaging after spinal fusion surgery had no direct benefit on clinical management. The utility of baseline imaging for long-term comparison and medicolegal concerns were not studied and remain up to the provider's judgment. Further research is necessary to identify optimal imaging criteria following spinal fusion surgery.
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Affiliation(s)
- Michael D Shost
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Tarun K Jella
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Andrew A Ronald
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Eric Z Herring
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA.
| | - Martha Sajatovic
- Department of Neurology and Psychiatry, Neurological and Behavioral Outcomes Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Gabriel A Smith
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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Kjelle E, Andersen ER, Krokeide AM, Soril LJJ, van Bodegom-Vos L, Clement FM, Hofmann BM. Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review. BMC Med Imaging 2022; 22:73. [PMID: 35448987 PMCID: PMC9022417 DOI: 10.1186/s12880-022-00798-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 04/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children. METHODS A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included. RESULTS A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations. CONCLUSIONS A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally. SYSTEMATIC REVIEW REGISTRATION PROSPERO: CRD42020208072.
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Affiliation(s)
- Elin Kjelle
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway.
| | - Eivind Richter Andersen
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Arne Magnus Krokeide
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
| | - Lesley J J Soril
- Department of Community Health Sciences and The Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Leti van Bodegom-Vos
- Medical Decision Making, Department of Biomedical Data Sciences, Leiden University Medical Center, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Fiona M Clement
- Department of Community Health Sciences and The Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, 3280 Hospital Dr NW, Calgary, AB, T2N 4Z6, Canada
| | - Bjørn Morten Hofmann
- Institute for the Health Sciences, The Norwegian University of Science and Technology (NTNU) at Gjøvik, NTNU Gjøvik, Postbox 191, 2802, Gjøvik, Norway
- Centre of Medical Ethics, The University of Oslo, Blindern, Postbox 1130, 0318, Oslo, Norway
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McCabe RM, Grainger M, Davis J. Routine In-Hospital Radiographs Following Anterior Cervical Discectomy and Fusion Surgery: Neither Necessary nor Cost-Effective? Cureus 2021; 13:e19975. [PMID: 34868794 PMCID: PMC8629684 DOI: 10.7759/cureus.19975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2021] [Indexed: 11/16/2022] Open
Abstract
Background Despite a paucity of evidence or literature to support routine in-hospital post-operative radiographs (POXR) of anterior cervical discectomy and fusion (ACDF) surgery, it remains accepted practice. Most spinal surgeons consider it part of their standard post-operative routine for ACDF despite nearly always documenting a ’satisfactory intra-operative image’ at the end of the operation. With an increasing financial pressure on NHS resources, our investigations should be clinically justified and evidence-based. Purpose To evaluate whether a post-operative radiograph of the cervical spine before discharge is either clinically justified or cost-effective in patients who have undergone an ACDF, despite having satisfactory intra-operative imaging. Design A retrospective review of 101 consecutive ACDF patients of radiographs performed before discharge, associated length of inpatient stay, and any complications involved. Methods A retrospective review was performed of 101 ACDF patients who had single or multi-level instrumentation for degenerative spinal disease from a single neurosurgical centre from all surgeons. Seventy-eight had an in-hospital post-operative anteroposterior (AP) and lateral radiograph, 23 did not. In 95 of these, it was documented that there was ‘satisfactory intra-operative imaging’ before the closure of skin, six lacked documentation of this. All patients had intra-operative imaging of completed instrumentation on the radiology system. Any post-operative complications were noted, and the length of hospital stay (LOS) was recorded. Six patients underwent ACDF following trauma, therefore leaving 95 elective cases. Study parameters also included: number of levels operated on, whether or not a plate was used with a cage, hospital costings for 2-view imaging and additional days of inpatient stay. Results There was one out of our 101 patients where the post-operative radiograph confirmed unsatisfactory placement of metalwork and warranted a return to surgery. However, the decision to perform this x-ray was based purely on the deteriorating post-operative clinical picture. In the cohort that had POXR’s, the average length of stay was 66.7 hours. Without POXR, it was 21 hours. The additional cost to the trust of performing the in-hospital radiographs was calculated to be £71,523 per year. Conclusion In patients who undergo ACDF surgery with an uneventful post-operative course and have satisfactory intra-operative imaging, in-hospital post-operative radiographs serve no clinical purpose and delay discharge. This gives additional cost to the trust, unnecessary radiation exposure and occupies potential bedspace.
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Affiliation(s)
- Rory M McCabe
- Trauma and Orthopaedics, Musgrove Park Hospital, Taunton, GBR
| | - Melvin Grainger
- Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
| | - James Davis
- Neurosurgery, Queen Elizabeth Hospital Birmingham, Birmingham, GBR
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Ronald AA, Herring EZ, Gerges C, Shost M, Jella T, Sajatovic M, Labak CM, Smith G. Immediate Postoperative Imaging Following Elective Lumbar Fusion Provides Little Clinical Utility. Spine (Phila Pa 1976) 2021; 46:958-964. [PMID: 33492086 DOI: 10.1097/brs.0000000000003953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review at a single institution of all adult patients who underwent elective lumbar fusion surgery for degenerative spinal disease from 2013 to 2018. Reoperation rates and change in clinical management due to routine imaging findings were the primary outcomes. OBJECTIVE To investigate what effects immediate routine postoperative imaging has on the clinical management of patients following lumbar fusion surgery. SUMMARY OF BACKGROUND DATA The clinical utility of routine postoperative imaging following lumbar fusion surgery remains uncertain. Existing studies on the clinical utility of postoperative imaging in lumbar fusion patients have largely focused on imaging obtained post-discharge. We present a retrospective analysis that to our knowledge is the first study reporting on the clinical utility of routine imaging in lumbar fusion patients during the immediate postoperative period. METHODS The medical records of patients who had undergone elective lumbar instrumented fusion for degenerative disease from 2013 to 2018 by neurosurgeons across one regional healthcare system were retrospectively analyzed. Inpatient records and imaging orders for patients were reviewed. Routine immediate postoperative imaging was defined by any lumbar spine imaging prior to discharge in the absence of specific indications. RESULTS Analysis identified 115 patients who underwent elective lumbar instrumented fusion for degenerative disease. One-hundred-twelve patients received routine postoperative imaging. Routine imaging was abnormal in four patients (4%). There was one instance (<1%) where routine immediate postoperative imaging led to change in clinical management. Abnormal routine imaging was not associated with either reoperation or development of neurological symptoms postoperatively (P = 0.10), however, new or worsening neurologic deficits did predict reoperation (P < 0.01). CONCLUSION New neurologic deficit was the only significant predictor of reoperation. Routine imaging, whether normal or abnormal, was not found to be associated with reoperation. The practice of routine imaging prior to discharge following elective lumbar fusion surgery appears to provide little utility to clinical management.Level of Evidence: 3.
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Affiliation(s)
- Andrew A Ronald
- School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Eric Z Herring
- School of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Christina Gerges
- School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Michael Shost
- School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Tarun Jella
- School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Martha Sajatovic
- School of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Collin M Labak
- School of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Gabriel Smith
- School of Medicine, Case Western Reserve University, Cleveland, OH
- Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, OH
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Evaluation of Benefit and Cost Utility of Immediate Postanesthesia Care Unit Radiographs to Predict Airway Compromise After Anterior Cervical Discectomy and Fusion. Spine (Phila Pa 1976) 2021; 46:671-677. [PMID: 33337673 DOI: 10.1097/brs.0000000000003896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective review. OBJECTIVE Anterior cervical discectomy and fusion (ACDF) is a commonly performed procedure that may be complicated by airway compromise postoperatively. This life-threatening complication may necessitate reintubation and reoperation. We evaluated the cost utility of conventional postoperative x-ray. SUMMARY OF BACKGROUND DATA Studies have demonstrated minimal benefit in obtaining an x-ray on postoperative day 1, but there is some utility of postanesthesia care unit (PACU) x-rays for predicting the likelihood of reoperation. METHODS We retrospectively reviewed the records of consecutive patients who underwent ACDF between September 2013 and February 2017. Patients were dichotomized into those who received PACU x-rays and those who did not (control group). Primary outcomes were reoperation, reintubation, mortality, and health care costs. RESULTS Eight-hundred and fifteen patients were included in our analysis: 558 had PACU x-rays; 257 did not. In those who received PACU x-rays, mean age was 53.7 ± 11.3 years, mean levels operated on were 2.0 ± 0.79, and mean body mass index (BMI) was 30.3 ± 6.9. In those who did not, mean age was 51.8 ± 10.9 years, mean levels operated on were 1.48 ± 0.65, and mean BMI was 29.9 ± 6.3. Complications in the PACU x-ray group were reintubation-0.4%, reoperation-0.7%, and death-0.3% (due to prevertebral swelling causing airway compromise). Complications in the control group were reintubation-0.4%, reoperation-0.8%, and death-0. There were no differences between groups with respect to reoperation (P = 0.92), reintubation (P = 0.94), or mortality (P = 0.49). The mean per-patient cost was significantly higher (P = 0.009) in those who received PACU x-rays, $1031.76 ± 948.67, versus those in the control group, $700.26 ± 634.48. Mean length of stay was significantly longer in those who had PACU x-rays (P = 0.01). CONCLUSION Although there were no differences in reoperation, reintubation, or mortality, there was a significantly higher cost for care and hospitalization in those who received PACU x-rays. Further studies are warranted to validate the results of the presented study.Level of Evidence: 3.
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Lechtig A, Barghi A, Wolf BT, Weaver M, Wixted JJ, Rodriguez EK, Appleton PT. The utility of post-operative hip radiographs in patients treated with hip hemiarthroplasty for femoral neck fractures. Injury 2019; 50:1448-1451. [PMID: 31320108 DOI: 10.1016/j.injury.2019.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/07/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patients treated with hip hemiarthroplasty for low energy femoral neck fractures routinely undergo hip radiographs at each postoperative clinic visit regardless of history and physical findings. No studies to date have evaluated the effectiveness of this accepted practice. The goal of this study was to identify the postoperative utility of both history and physical (H/P) and hip radiographs in the treatment course of patients treated with hip hemiarthroplasty for low energy femoral neck fractures. METHODS A retrospective chart review was performed on consecutive patients treated with hip hemiarthroplasty for low energy femoral neck fractures. An abnormal H/P and hip radiographs as well as a change in treatment course were recorded at each clinic or emergency department visit. RESULTS Five hundred and eighty-three patients met inclusion criteria, consisting of 1177 clinic and 50 emergency department (ED) visits. An abnormal radiograph in the presence of a normal H/P did not lead to a change in treatment course. An abnormal H/P alone changed treatment course in 28 (3%) clinic visits and 18 (36%) ED visits. An abnormal H/P and the presence of an abnormal hip radiograph changed the treatment course in 23 (2%) clinic visits and 18 (36%) ED visits. In only one case - 0.3% of abnormal radiographs or 0.08% of 1177 clinic visits - did an abnormal hip radiograph change treatment course in the setting of an abnormal H/P within 6 months from surgery. The average cost of a series of hip and pelvis radiographs was $242. CONCLUSIONS Abnormal radiographs do not change treatment course in the presence of a normal H/P. Hip radiographs obtained in clinic within 6 months of surgery rarely lead to a change in treatment course and thereby are a source of excess cost and radiation exposure to the patient.
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Affiliation(s)
- Aron Lechtig
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States
| | - Ameen Barghi
- Harvard Medical School, Boston, MA, 02115, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States.
| | - Bryce T Wolf
- Maine Ortho, 1601 Congress Street, Portland, ME, 04102, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States
| | - Michael Weaver
- Brigham and Woman's Hospital, Boston, MA, 02215, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States
| | - John J Wixted
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States
| | - Edward K Rodriguez
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States
| | - Paul T Appleton
- Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, 02215, United States; Harvard Medical School Orthopedic Trauma Initiative, Boston, MA, 02215, United States
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Cervical sagittal alignment after different anterior discectomy procedures for single-level cervical degenerative disc disease: randomized controlled trial. Acta Neurochir (Wien) 2017; 159:2359-2365. [PMID: 28887690 PMCID: PMC5686251 DOI: 10.1007/s00701-017-3312-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/22/2017] [Indexed: 12/14/2022]
Abstract
Background The effect of anterior cervical discectomy without fusion (ACD), ACD with fusion by stand-alone cage (ACDF) or with arthroplasty (ACDA) on cervical sagittal alignment is not known and is the subject of this study. Methods A total of 142 adult patients with single-level cervical disease were at random allocated to different procedures: ACD (45), ACDF (47) and ACDA (50). Upright cervical spine radiographs were obtained. Angles of the involved angle and the angle between C2 and C7 were determined. Results After a mean follow-up of 25.4 ± 18.4 months, the angles of the involved level comparing ACD with ACDA and ACD with ACDF were different, reaching statistical significance. However, the angle between C2 and C7 did not differ between groups or between preoperative values and at follow-up. Conclusions Irrespective of the technique used for anterior cervical discectomy for single-level degenerative disc disease, the alignment of the cervical spine is unaltered.
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Martin SC, Dabbous BO, Ridgeon EE, Magdum SA, Cadoux-Hudson TA, Pereira EA. Routine radiographs one day after anterior cervical discectomy and fusion are neither necessary nor cost-effective. Br J Neurosurg 2016; 31:50-53. [DOI: 10.1080/02688697.2016.1233320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Sean C. Martin
- Department of Neurological Surgery, Oxford University Hospitals, Oxford, UK
| | - Bassam O. Dabbous
- Department of Neurological Surgery, Oxford University Hospitals, Oxford, UK
| | - Elliott E. Ridgeon
- Department of Neurological Surgery, Oxford University Hospitals, Oxford, UK
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Han SY, Kim HW, Lee CY, Kim HR, Park DH. Stand-Alone Cages for Anterior Cervical Fusion: Are There No Problems? KOREAN JOURNAL OF SPINE 2016; 13:13-9. [PMID: 27123025 PMCID: PMC4844655 DOI: 10.14245/kjs.2016.13.1.13] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 02/04/2016] [Accepted: 02/05/2016] [Indexed: 11/25/2022]
Abstract
Objective There are complications in stand-alone cage assisted anterior cervical discectomy and fusion (ACDF), such as cage subsidence and kyphosis. Here we report our clinical result on ACDF, comparing with stand-alone cages and with cervical plate system for degenerative cervical spine diseases. Methods Patients with degenerative cervical disease who were diagnosed and treated in Konyang University Hospital between January 2004 and December 2014 were included in this study. Patients who had operation in single level ACDF were selected. Patients scored the degree of pain using visual analog scale before and after the surgery. Subsidence was defined as ≥3-mm decrease of the segmental height, and cervical kyphosis was defined as progression of ≥5° at 12 months after postoperative follow-up compared to that measured at the immediate postoperative period. Results A total of 81 patients were enrolled for this study. Forty-five patients were included in a cervical plate group and the others were in stand-alone cage group. There was no statistical difference in pain score between the 2 groups. Segmental subsidence was observed in 7 patients (15.6%) in plate-assisted cervical fusion group, and 13 patients (36.1%) in stand-alone cage group. Segmental kyphosis was observed in 4 patients (8.9%) in plate-assisted cervical fusion group, and 10 patients (27.8%) in stand-alone cage group. There was statistical difference between the 2 groups. Conclusion There was no difference in pain between 2 groups. But stand-alone case group showed higher incidence rate than plate-assisted cervical fusion group in segmental subsidence and cervical kyphosis. When designing cervical fusion, more attention should be given selecting the surgical technique.
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Affiliation(s)
- Sang Youp Han
- Department of Neurosurgery, Konyang University Hospital, Konyang University Collge of Medicine, Daejon, Korea
| | - Hyun Woo Kim
- Department of Neurosurgery, Konyang University Hospital, Konyang University Collge of Medicine, Daejon, Korea
| | - Cheol Young Lee
- Department of Neurosurgery, Konyang University Hospital, Konyang University Collge of Medicine, Daejon, Korea
| | - Hong Rye Kim
- Department of Neurosurgery, Konyang University Hospital, Konyang University Collge of Medicine, Daejon, Korea
| | - Dong Ho Park
- Department of Anesthesiology, Konyang University Hospital, Konyang University Collge of Medicine, Daejon, Korea
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10
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Ross DA. Letter to the Editor: Steroid use in anterior cervical discectomy and fusion. J Neurosurg Spine 2016; 24:998-1000. [PMID: 26918575 DOI: 10.3171/2015.9.spine151052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Desai A, Pendharkar AV, Swienckowski JG, Ball PA, Lollis S, Simmons NE. Utility of Routine Outpatient Cervical Spine Imaging Following Anterior Cervical Corpectomy and Fusion. Cureus 2015; 7:e387. [PMID: 26719830 PMCID: PMC4689583 DOI: 10.7759/cureus.387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Construct failure is an uncommon but well-recognized complication following anterior cervical corpectomy and fusion (ACCF). In order to screen for these complications, many centers routinely image patients at outpatient visits following surgery. There remains, however, little data on the utility of such imaging. Methods: The electronic medical record of all patients undergoing anterior cervical corpectomy and fusion at Dartmouth-Hitchcock Medical Center between 2004 and 2009 were reviewed. All patients had routine cervical spine radiographs performed perioperatively. Follow-up visits up to two years postoperatively were analyzed. Results: Sixty-five patients (mean age 52.2) underwent surgery during the time period. Eighteen patients were female. Forty patients had surgery performed for spondylosis, 20 for trauma, three for tumor, and two for infection. Forty-three patients underwent one-level corpectomy, 20 underwent two-level corpectomy, and two underwent three-level corpectomy, using an allograft, autograft, or both. Sixty-two of the fusions were instrumented using a plate and 13 had posterior augmentation. Fifty-seven patients had follow-up with imaging at four to 12 weeks following surgery, 54 with plain radiographs, two with CT scans, and one with an MRI scan. Unexpected findings were noted in six cases. One of those patients, found to have asymptomatic recurrent kyphosis following a two-level corpectomy, had repeat surgery because of those findings. Only one further patient was found to have abnormal imaging up to two years, and this patient required no further intervention. Conclusions: Routine imaging after ACCF can demonstrate asymptomatic occurrences of clinically significant instrument failure. In 43 consecutive single-level ACCF however, routine imaging did not change management, even when an abnormality was discovered. This may suggest a limited role for routine imaging after ACCF in longer constructs involving multiple levels.
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Affiliation(s)
- Atman Desai
- Department of Neurosurgery, Stanford University School of Medicine
| | | | | | - Perry A Ball
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center
| | - Scott Lollis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center
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12
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Derakhshan A, Lubelski D, Steinmetz MP, Benzel EC, Mroz TE. Utility of Computed Tomography following Anterior Cervical Diskectomy and Fusion. Global Spine J 2015; 5:411-6. [PMID: 26430596 PMCID: PMC4577315 DOI: 10.1055/s-0035-1554773] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Accepted: 03/16/2015] [Indexed: 11/22/2022] Open
Abstract
Study Design Retrospective case series. Objective To assess the utility of postoperative computed tomography (CT) following anterior cervical diskectomy and fusion (ACDF) and to determine the clinical circumstances most likely to lead to an abnormal CT scan. Methods Patients who underwent ACDF at a tertiary center over a span of 5 years were investigated. Only patients who had a minimum of 6 months' postoperative follow-up and a CT within 2 years after the surgery were included in the study group. All the postoperative notes were reviewed to determine indications for the CT, abnormalities identified, and whether the scan led to an alteration in the treatment course. Results The charts of 690 patients who underwent ACDF were reviewed. Of the 690 patients, 45 (7%) had postoperative CTs. These patients accounted for 53 postoperative CT scans, 45 (85%) of which were taken for patients who expressed persistent postoperative symptoms and/or had abnormal imaging. There were no indications for 8 (15%) of the CTs. Patients who had a CT for persistent symptoms and/or abnormal preliminary imaging were significantly more likely to have an abnormal CT (p = 0.03) and/or an alteration in treatment course (p = 0.04) compared with those with no symptomatic or radiologic indication for CT. Conclusions CT is associated with minimal utility regarding the alteration of treatment course when employed in asymptomatic patients. Postoperative CT should be ordered solely for symptomatic patients or those with other abnormal preliminary imaging. Judicious use of postoperative CT will limit the radiation exposure and cost.
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Affiliation(s)
- Adeeb Derakhshan
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Daniel Lubelski
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Michael P. Steinmetz
- Department of Neurosciences and Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio, United States
| | - Edward C. Benzel
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States
| | - Thomas E. Mroz
- Department of Neurological Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, United States,Address for correspondence Thomas E. Mroz, MD Departments of Orthopaedic and Neurological SurgeryCenter for Spine Health, The Cleveland Clinic, 9500 Euclid Avenue, S-40, Cleveland, OH 44195United States
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Shau DN, Bible JE, Gadomski SP, Samade R, Armaghani S, Mencio GA, Devin CJ. Utility of Postoperative Radiographs for Pediatric Scoliosis: Association Between History and Physical Examination Findings and Radiographic Findings. J Bone Joint Surg Am 2014; 96:1127-1134. [PMID: 24990978 DOI: 10.2106/jbjs.l.01357] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Postoperative radiographs are routinely obtained following surgery for the correction of scoliosis in pediatric patients. The purpose of this study was to comprehensively evaluate the utility of obtaining routine postoperative radiographs in the management of these patients. METHODS A total of 1969 clinic notes and corresponding radiographs regarding 451 consecutive patients with scoliosis (age range, ten to eighteen years) who had surgical correction over a ten-year period at a single institution were retrospectively reviewed. Curve etiology, preoperative curve characteristics, and surgical procedures performed were recorded. All postoperative clinic notes and radiographs were reviewed for abnormalities and changes in treatment course. It was then determined whether clinical signs and symptoms and/or abnormal radiographic findings led to a change in treatment course, which was defined as a therapeutic intervention or further diagnostic testing. RESULTS Of the 451 patients in this study (average age [and standard deviation], 14.7 ± 2.4 years), 72.5% had adolescent idiopathic scoliosis, 23.3% had neuromuscular scoliosis, and 4.2% had other underlying causes of scoliosis. A change in treatment course occurred in the cases of forty-two patients, all of whom had symptomatic findings on postoperative history and physical examination and only fifteen of whom had supportive abnormal findings on postoperative radiographs. Curve etiology and surgical procedures performed had no impact on radiographic utility. A significant increase in utility was seen for radiographs obtained at visits one year or more following surgery compared with those obtained at visits less than one year following surgery (1.7% compared with 0.3%, p = 0.001). The overall sensitivity, specificity, positive predictive value, and negative predictive value of routine postoperative radiographs in guiding treatment course were 35.7%, 98.1%, 28.8%, and 98.6%, respectively. CONCLUSIONS Routine radiographs provide low utility in guiding the course of treatment for asymptomatic pediatric patients following surgery for scoliosis. The results of this study suggest that patient or caregiver complaints, comorbidities, and clinical suspicion should be considered before obtaining radiographs at postoperative visits in order to minimize radiation exposure in pediatric patients and reduce medical costs without compromising care. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- David N Shau
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 4200, MCE-South Tower, Nashville, TN 37232-8618. E-mail address for C.J. Devin:
| | - Jesse E Bible
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 4200, MCE-South Tower, Nashville, TN 37232-8618. E-mail address for C.J. Devin:
| | - Stephen P Gadomski
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 4200, MCE-South Tower, Nashville, TN 37232-8618. E-mail address for C.J. Devin:
| | - Richard Samade
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 4200, MCE-South Tower, Nashville, TN 37232-8618. E-mail address for C.J. Devin:
| | - Sheyan Armaghani
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 4200, MCE-South Tower, Nashville, TN 37232-8618. E-mail address for C.J. Devin:
| | - Gregory A Mencio
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 4200, MCE-South Tower, Nashville, TN 37232-8618. E-mail address for C.J. Devin:
| | - Clinton J Devin
- Department of Orthopedic Surgery, Vanderbilt University Medical Center, 1215 21st Avenue South, Suite 4200, MCE-South Tower, Nashville, TN 37232-8618. E-mail address for C.J. Devin:
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Gum JL, Buchowski JM. Commentary: methods of evaluating lumbar and cervical fusion. Spine J 2014; 14:540-1. [PMID: 24529488 DOI: 10.1016/j.spinee.2013.09.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 09/20/2013] [Accepted: 09/27/2013] [Indexed: 02/03/2023]
Affiliation(s)
- Jeffrey L Gum
- Department of Orthopaedic Surgery, Washington University in St. Louis, 425 S. Euclid Ave., Campus Box 8233, St. Louis, MO 63110, USA
| | - Jacob M Buchowski
- Department of Orthopaedic Surgery, Washington University in St. Louis, 425 S. Euclid Ave., Campus Box 8233, St. Louis, MO 63110, USA.
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15
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Gruskay JA, Webb ML, Grauer JN. Methods of evaluating lumbar and cervical fusion. Spine J 2014; 14:531-9. [PMID: 24183750 DOI: 10.1016/j.spinee.2013.07.459] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 06/12/2013] [Accepted: 07/21/2013] [Indexed: 02/09/2023]
Abstract
Introduced in 1911, spinal fusion is now widely used to stabilize the cervical, thoracic, and lumbar spine. Despite advancements in surgical techniques, including the use of instrumentation and optimizing bone graft options, pseudarthrosis remains one of the most significant causes of clinical failure following attempted fusion. Diagnosis of this common complication is based on a focused clinical assessment and imaging studies. Pseudarthrosis classically presents with the onset of or return of axial or radicular symptoms during the first postoperative year. However, this diagnosis is complicated because other diagnoses can mimic these symptoms (such as infection or adjacent segment degeneration) and because many cases of pseudarthrosis are asymptomatic. Computed tomography and assessment of motion on flexion/extension radiographs are the two preferred imaging modalities for establishing the diagnosis of pseudarthrosis. The purpose of this article was to review the current status of imaging and clinical practices for assessing fusion following spinal arthrodesis.
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Affiliation(s)
- Jordan A Gruskay
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA
| | - Matthew L Webb
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, PO Box 208071, New Haven, CT 06520-8071, USA.
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Melloh M, Barz T. A case of cervical metastases in a patient with preexisting cervical disc replacement and fusion after 2-year symptom-free interval: when do we need interdisciplinary diagnostics? EVIDENCE-BASED SPINE-CARE JOURNAL 2013; 3:51-6. [PMID: 23526906 PMCID: PMC3592761 DOI: 10.1055/s-0032-1327810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Recurrent cervical symptoms frequently occur after cervical disc replacement and fusion. To date, no algorithm for the diagnostic assessment of these symptoms has been established. We present a case report and review of the literature to illustrate the need for interdisciplinary diagnostics in recurrent cervicobrachialgia without pathological cervical imaging. The hospital chart, medical history, physical examination, and imaging of a single patient were reviewed. A 53-year-old man with preexisting cervical disc replacement and fusion presented with a new episode of cervicobrachialgia after a 2-year symptom-free interval. Cervical magnetic resonance imaging (MRI) showed no pathological findings. Six months later the patient reported increasing symptoms including numbness and weakness of the right arm. Repeated cervical MRI and thoracic computed tomography revealed cervical metastases with intraspinal tumor growth and an underlying extensive small cell bronchial carcinoma. In recurrent cervicobrachialgia, without pathological cervical imaging, interdisciplinary diagnostics are needed. Basic diagnostic tests may assist to exclude severe non-vertebrogenic pathologies.
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Affiliation(s)
- Markus Melloh
- Western Australian Institute for Medical Research, University of Western Australia
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17
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Utility of postoperative radiographs for cervical spine fusion: a comprehensive evaluation of operative technique, surgical indication, and duration since surgery. Spine (Phila Pa 1976) 2012; 37:1994-2000. [PMID: 22565389 DOI: 10.1097/brs.0b013e31825c0130] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective study. OBJECTIVE To assess the utility of postoperative radiographs in patients across a spectrum of cervical fusion procedures, surgical indication, and time since surgery. SUMMARY OF BACKGROUND DATA Postoperative radiographs are routinely obtained after cervical spine fusion despite lack of evidence supporting such practice. Studies assessing postoperative radiographical utility in the cervical spine have been limited. To date, no study has comprehensively evaluated the utility of obtaining such radiographs across multiple cervical fusion procedures. METHODS A total of 972 clinic notes from 301 patients during a 10-year period at a single institution were retrospectively reviewed. Patients in this study underwent an anterior cervical discectomy and fusion, anterior corpectomy and fusion, a combined anterior cervical discectomy and fusion and anterior corpectomy and fusion (hybrid), posterior spine fusion, or 360° fusion. All postoperative clinic notes and radiographs were reviewed for abnormalities and changes in treatment course. It was determined whether an abnormal radiograph alone led to a change in treatment course among the various operative techniques, surgical indication, or time since surgery. RESULTS No statistical significant difference in radiograph utility between anterior cervical discectomy and fusion (0 changes in treatment course due to radiograph alone out of 332 clinic notes), anterior corpectomy and fusion (0 of 140), hybrid procedure (1 of 72), posterior spine fusion (5 of 357), and 360° fusion (0 of 71) was found. Surgical indication (trauma vs. degeneration) and duration from surgery yielded no statistical significant difference in radiograph utility. The overall sensitivity, specificity, and positive and negative predictive values of radiographs were 33.8%, 87.6%, 19.0%, and 93.9%, respectively. CONCLUSION Regardless of operative techniques performed, surgical indication, and time since surgery, routine postoperative radiographs provide low utility in guiding treatment course in asymptomatic patients. Although radiographs may provide important diagnostic utility in certain individual cases, the results of this study provide further evidence that radiographs should not be considered routine during postoperative visits, thus minimizing unnecessary radiation exposure and medical costs.
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Yang L, Gu Y, Liang L, Gao R, Shi S, Shi J, Yuan W. Stand-alone anchored spacer versus anterior plate for multilevel anterior cervical diskectomy and fusion. Orthopedics 2012; 35:e1503-10. [PMID: 23027488 DOI: 10.3928/01477447-20120919-20] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to compare the clinical outcomes and radiological changes of 3- and 4-level anterior cervical diskectomy and fusion with stand-alone anchored spacers and with traditional anterior plates. A total of 51 consecutive patients with cervical spondylotic myelopathy who underwent 3- or 4-level anterior cervical diskectomy and fusion were divided into 2 groups: group A (n=23) received anchored spacers and group B (n=28) received an anterior plate. Mean follow-up was 14.6 months. Solid fusion was achieved in all patients at final follow-up. No significant difference existed between multilevel anterior cervical diskectomy and fusion with stand-alone anchored implants and with an anterior cervical plate in achieving clinical symptomatic improvement, fusion rate, and lordotic curvature improvement. The dysphagia rate of group A at 2-month follow-up was significantly lower than that of group B. No statistically significant difference existed between the 2 groups at the other time points. Swallowing Quality of Life of group A at 48 hours and 2 months postoperatively were significantly higher than those of group B. The thickness of the prevetebral soft tissue at 48 hours and 2 months postoperatively were significantly lower in group A than in group B. Compared with using an anterior plate, anterior cervical diskectomy and fusion with a stand-alone anchored spacer achieved a similar clinical outcome with less irritation to the prevertebral soft tissue and a lower dysphagia rate in the first 2 months.
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Affiliation(s)
- Lili Yang
- Department of Orthopedics, Changzheng Hospital, Second Military Medical University, Shanghai, China
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