A review of the utility of obtaining repeated postoperative radiographs following single-level anterior cervical decompression, fusion, and plate placement

Complications of the Use Allograft in 1- or 2-Level Anterior Cervical Discectomy and Fusion: A Systematic Review

Study Design: Systematic literature reviewObjective: To critically analyze the literature and describe the complications associated with the use of allograft in 1- or 2- level anterior cervical discectomy and fusion (ACDF)Methods: A systematic search of PubMed/MEDLINE, EMBASE, and ClinicalTrials.gov databases was conducted for literature published between January 2000 and August 2020 reporting complications associated with the use of allograft in 1- or 2- level ACDF.Results: From 584 potentially relevant citations, 21 met the inclusion criteria (4 randomized controlled trials (RCT), 4 prospective, and 13 retrospective studies). The patient number varied between 26 and 463 in comparative studies (RCT and non-RCT) and between 29 and 345 in non-comparative studies. Fusion rate was reported in 14 studies and ranged between 68.5-100%. The most frequently reported complication was post-operative dysphagia or dysphonia, with incidences ranging between .5% and 14.4%. Revision surgery was the second most reported complication (14 studies) and ranged between 0% and 10.3%. Wound-related complications were reported in 6 studies and ranged between 0% and 22.8%.Conclusion: The overall reporting of complications was low with very few comparative studies. Reported complications with allografts are within the range of other osteobiologics and autografts and in most cases may not attributable to the use of osteobiologics and may be complications of the procedure itself. Comparative studies with a more robust methodology analyzing complications with allograft and other osteobiologics are needed to inform current practice with strong recommendations.

Routine In-Hospital Radiographs Following Anterior Cervical Discectomy and Fusion Surgery: Neither Necessary nor Cost-Effective?

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.

Evaluation of Benefit and Cost Utility of Immediate Postanesthesia Care Unit Radiographs to Predict Airway Compromise After Anterior Cervical Discectomy and Fusion

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.

Correlation Between Different Interbody Grafts and Pseudarthrosis After Anterior Cervical Discectomy and Fusion Compared with Control Group: Systematic Review

BACKGROUND

Cervical spine degenerative disease is one of the main causes of myelopathy. Anterior cervical discectomy and fusion (ACDF) is the most common surgical procedure used to treat cervical myelopathy. Therefore, it is important to study pseudarthrosis rates after ACDF and correlate them with the graft used.

METHODS

We performed a systematic review to evaluate the relationship between pseudarthrosis after ACDF and the interbody graft used.

RESULTS

A total of 3732 patients were evaluated in 46 studies. The mean age of the included patients was 51.5 ± 4.18 years (range, 42-59.6 years). ACDF is most often perforemd as single-level surgery and the level most impaired is C5-C6. The use of titanium cages, zero profile, recombinant human bone morphogenetic protein 2, and carbon cages was seen as a protective factor for pseudarthrosis compared with the autograft group (control group); with an odds ratio of 0.29, 0.51, 0.03, and 0.3, respectively; the results were statistically relevant. The use of polyetheretherketone, poly(methyl methacrylate), and trabecular metal was a risk factor for development of pseudarthrosis compared with the control group, with an odds ratio of 1.7, 8.7, and 6.8, respectively; the results were statistically relevant. Radiologic follow-up was an important factor for the pseudarthrosis rate; paradoxically, a short follow-up (<1 year) had lower rates of pseudarthrosis and follow-up >2 years increased the chance of finding pseudarthrosis.

CONCLUSIONS

Different types of grafts lead to a significant difference in pseudarthrosis rates. Follow-up time is also an important factor that affects the rate of pseudarthrosis after ACDF.

Unplanned Immediate Return to Operating Room After Spine Surgery: Significance of Immediate Postoperative Radiographs

STUDY DESIGN

Retrospective analysis; single center data.

OBJECTIVE

The purpose of this study is to look at the utility and relevance of immediate postoperative radiographs in providing vital information leading to immediate revision after spine surgery.

SUMMARY OF BACKGROUND DATA

Immediate postoperative radiographs are routinely obtained in the recovery room after spine surgery to verify the level, alignment of the spine, implant position, and the adequacy of the procedure. However, with the ability to utilize intraoperative fluoroscopy imaging for the same purpose, the requirement for immediate postoperative radiographs needs to be validated. The purpose of this study is to look at the utility and relevance of these postoperative radiographs in providing critical information that may warrant immediate intervention.

METHODS

Retrospective analysis of all spine surgeries (elective and emergent), performed at a single center from 2011 to 2016, was done and cases returning to operating room within 48 hours were identified. Indication of immediate revision was reviewed and utility of immediate postoperative radiographs in guiding immediate revision was analyzed.

RESULTS

A total of 1804 elective and urgent spinal surgeries were performed by seven surgeons. Twenty-two patients returned to operating room within 48 hours of their index procedures. Of these 22 cases, only two patients were noted to have positive findings on recovery room radiographs. The findings of suboptimal spinal alignment or failed instrumentation led to the immediate revision in both cases. Both cases involved instrumentation at cervicothoracic region and intraoperative imaging provided only limited visualization.

CONCLUSION

Routine recovery room radiographs played a role in the decision to emergently return to the operating room in 0.10% (2/1804) cases at our institution. The potential benefit of immediate recovery room radiographs after spine surgery should be weighed against the added healthcare cost and patient discomfort associated with obtaining these radiographs routinely. Imaging may be delayed to a more elective time without any significant risk in majority of spine cases.

LEVEL OF EVIDENCE

3.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Utility of Routine Outpatient Cervical Spine Imaging Following Anterior Cervical Corpectomy and Fusion

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.

Utility of Computed Tomography following Anterior Cervical Diskectomy and Fusion

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.

Predicting radiographic changes at the first visit following operative repair of distal radius fractures

PURPOSE

To test the hypothesis that clinical assessment reliably identifies patients with radiographic changes (including loss of reduction, hardware failure, and hardware migration) at the initial visit following operative repair of distal radius fractures.

METHODS

We identified 102 patients undergoing operative repair of distal radius fractures. Radiographs and clinical notes were reviewed.

RESULTS

At the initial postoperative visit, 11 patients had more than normal postoperative pain, 0 had deformity, 0 had crepitus with gentle motion, and 0 had instability at the fracture site on examination. These 11 patients were considered to have positive clinical assessments, but none had radiographic changes on x-rays taken that day. Three patients had negative clinical assessments but had radiographic changes noted at the initial postoperative visit. There were no additional radiographic changes between the series taken at the initial postoperative visit and series taken at later postoperative visits.

CONCLUSIONS

These data suggest that for purposes of detecting radiographic changes, radiography at the initial visit is helpful, whereas radiography at subsequent visits may not be. Radiography at subsequent visits may be useful to monitor bony healing, which we did not investigate.

Utility of Postoperative Radiographs for Pediatric Scoliosis: Association Between History and Physical Examination Findings and Radiographic Findings

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.

Methods of evaluating lumbar and cervical fusion

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.

Do routine radiographs within the first two years following pediatric posterior spinal fusion prompt revision surgery?

STUDY DESIGN

This is a retrospective review of 265 consecutive patients with scoliosis treated by posterior spinal fusion (PSF) and 2990 postoperative radiographs at a single institution.

OBJECTIVE

To document implant-related complications on postoperative radiographs within the first 2 years after PSF and determine if these led to additional surgical procedures.

SUMMARY OF BACKGROUND DATA

To date, there is an absence of studies investing the utility of radiographs after pediatric PSF surgery.

METHODS

The patient's average age was 14.9 years (8.2-21.8 yr). Positive radiographical findings included implant loosening, fracture, migration, or loss of fixation. We also noted which patients' required additional surgery for a radiographical finding and/or clinical finding (neurological deficit, intractable back pain, fever, and elevated erythrocyte sedimentation rate, c-reactive protein, or while blood cell count).

RESULTS

At an average follow-up of 16.3 months (12-24), only 18 (0.60%) radiographs demonstrated a positive finding. Of these, only 5 (0.17%) radiographs (along with clinical presentation) prompted revision. No patient returned to the operating room purely from a radiographical finding. The remaining 13 (0.37%) abnormal plain images were not associated with a clinical abnormality and were managed nonoperatively. The timing of the second operation was in the range from 1 day to 23 months (average, 11 mo). Postoperative plain radiographs had a sensitivity of 26.5%, a specificity of 99.5%, and a positive predictive value of 25%.

CONCLUSION

Only 0.60% of postoperative images (18/2990) demonstrated an implant-related complication, and in the absence of clinical indications, none of these patients required surgical intervention. Isolated postoperative radiographs did not lead to any change in management, and consideration should be given to reviewing current protocols for plain radiographs as a monitoring tool after PSF.

The utility of routine postoperative radiographs after cervical spine fusion

BACKGROUND CONTEXT

The senior author (JAG) recently published an article questioning the utility of routine postoperative radiographs after lumbar spine fusion. That study concluded that routine postoperative radiographs in the presence of a normal physical examination rarely change the clinician's management of these patients. Our aim was to repeat this protocol in patients after cervical spine fusion. We hypothesized that routine postoperative radiographs are unnecessary in most cases after cervical spine fusion.

PURPOSE

The purpose of this study was to determine the usefulness of routine postoperative cervical spine radiographs after cervical spine fusion as to whether they help to guide clinical decision making within the first postoperative year.

STUDY DESIGN

This is a retrospective chart review of 383 patients who underwent a cervical spine fusion over a 5-year period. Seven different surgeons performed the cervical spine fusions. Our review assessed a total of 1,155 postoperative clinic visits.

METHODS

Each clinical postoperative visit was reviewed. The history and exam were graded as either normal or abnormal, and any plain radiographs obtained were graded similarly as either normal or abnormal. Each patient's notes were followed up to 1 year postoperatively. Each patient had to have at least two postoperative visits with X-rays to be included in the study. We then noted any further action taken by the clinician based on the appearance of the radiograph in conjunction with the history and exam.

RESULTS

In patients with normal history and exam presentations, further action was taken only 5/879 (0.57%) of the time, sometimes even in the presence of abnormal radiographs. The actions included two surgical revisions, two prolongations of cervical collar immobilization, and one patient who underwent a flexion/extension radiographic evaluation and subsequent prolonged cervical collar immobilization. There were 276 visits with abnormal history and exam; of these, 34/276 (12.3%) had abnormal X-rays. Of the clinic visits with abnormal history and exam and abnormal X-rays, 15/34 (44%) went on to revision.

CONCLUSIONS

Routine postoperative radiographs after cervical spine fusion rarely appear to be of value when patients present with a normal history and exam and may expose patients to unnecessary diagnostic studies and expenses. Patients exhibiting a normal postoperative history and exam are likely to have no further additional action taken in the presence of either normal or abnormal radiographs.

Postanesthesia care unit imaging is unnecessary when intraoperative imaging is used during anterior cervical decompression and fusion procedures

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To characterize the clinical utility of imaging in the postanesthesia care unit (PACU) after anterior cervical decompression and fusion (ACDF) procedures.

SUMMARY OF BACKGROUND DATA

Two sets of imaging are often taken at the end of ACDF procedures: one intraoperatively and the other in the PACU. The latter may have low clinical utility.

MATERIALS AND METHODS

One hundred four patients who underwent ACDF procedures with anterior plate/screw constructs were identified. A panel assessed intraoperative and PACU series for adequacy of images to detect potential issues with placement of the surgical construct and for any actual visible issues with placement of the surgical construct.

RESULTS

Intraoperative series were adequate to detect potential issues with construct placement for 78.8% of cases, whereas PACU series were adequate for only 58.7% of cases (significant difference, P<0.001). For both series, nearly all inadequacies were because of the shoulders obstructing the lateral view. Accordingly, cases with lower inferior operative levels were much more likely to have inadequate intraoperative and PACU series than cases with higher inferior operative levels (significant differences, P<0.001 for both). In no case was an issue with construct placement visible on a PACU series that was not also visible on an intraoperative series.

CONCLUSIONS

This study demonstrates that PACU images are inferior to intraoperative images and offer little or no incremental clinical utility for detecting issues with surgical construct placement after ACDF procedures. PACU imaging after ACDF procedures might be discontinued to realize savings in time, cost, and radiation exposure.

Utility of postoperative radiographs for cervical spine fusion: a comprehensive evaluation of operative technique, surgical indication, and duration since surgery

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.

Routine imaging for anterior cervical decompression and fusion procedures: a survey study establishing current practice patterns

The number of anterior cervical decompression and fusion procedures performed annually in the United States rose 8-fold from 1990 to 2004. Imaging for anterior cervical decompression and fusion procedures contributes to health care costs and exposes patients and staff to radiation. Despite this, no standard of care for such imaging has been defined, and imaging practices have remained largely uncharacterized. The authors distributed a questionnaire at the 2011 Spine Study Group meeting. They received 72 responses (80% response rate) and included 67 in the analysis. All participants were attending spine surgeons practicing in the United States, 97% of whom had completed spine surgery fellowships. Median practice duration was 8 years. Practice type was evenly split between private and academic, and the median annual number of anterior cervical decompression and fusion procedures was 50. Intraoperatively, 68% of surgeons use fluoroscopy and 32% use plain radiographs; 60% take at least 1 image prior to incision; 78% place the localizer in the disk, whereas 22% place it in the vertebral body, and 45% always save these localizer images; 100% take images of the final construct before leaving the operating room, and 74% always save the final-construct images. Postoperatively but before discharge, 12% of surgeons take images in the recovery room, 33% take images in the radiology suite, and 2% take images in both locations. After discharge, surgeons follow their patients for a mean of 1.6 years, 96% with lateral views, 96% with anteroposterior views, 46% with flexion-extension radiographs, and 14% with computed tomography scans.

The rationale of postoperative radiographs after cervical anterior discectomy with stand-alone cage for radicular pain

Object

Cervical anterior discectomy with stand-alone cage (CADC) placement is a known treatment for cervical radiculopathy due to a herniated intervertebral disc or an osteophyte. Routine radiographs are obtained at regular postoperative intervals, but the consequences of routinely obtained radiographs are not known. In this study, the authors evaluated whether postoperative plain radiographs influenced the medical or surgical treatment of patients who underwent CADC placement.

Methods

The charts and radiographs of all patients who underwent CADC placement in 2007 were retrieved and reviewed retrospectively. In addition, the charts and radiographs of 50 consecutive patients who were seen after a CADC was placed during a period in 2008 were studied prospectively. Special emphasis was given to any abnormalities seen on the radiographs and especially their influence on further treatment.

Results

The charts and radiographs of 82 patients were retrospectively examined. A total of 138 levels were addressed, and in the prospective series 75 levels were surgically treated. The subsidence rate in the retrospective series was 14.5%. In 1 patient a slight anteroposition of the cage was seen. None of the radiographic abnormalities were related to the outcome of the patient or contributed to a change in the patient's treatment.

Conclusions

Routine radiographs after CADC placement are not warranted. Intraoperative verification of the position of the cage is recommended. Obtaining radiographs are only mandatory when signs or symptoms suggesting a postoperative complication are present. The authors propose a new algorithm for the follow-up of patients after CADC placement.