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Chan AK, Park C, Shaffrey CI, Gottfried ON, Than KD, Bisson EF, Bydon M, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya CD, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Michalopoulos G, Sherrod BA, Agarwal N, Chou D, Haid RW, Mummaneni PV. What predicts the best 24-month outcomes following surgery for cervical spondylotic myelopathy? A QOD prospective registry study. J Neurosurg Spine 2024; 40:453-464. [PMID: 38181405 DOI: 10.3171/2023.11.spine23222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 11/09/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVE The aim of this study was to identify predictors of the best 24-month improvements in patients undergoing surgery for cervical spondylotic myelopathy (CSM). For this purpose, the authors leveraged a large prospective cohort of surgically treated patients with CSM to identify factors predicting the best outcomes for disability, quality of life, and functional status following surgery. METHODS This was a retrospective analysis of prospectively collected data. The Quality Outcomes Database (QOD) CSM dataset (1141 patients) at 14 top enrolling sites was used. Baseline and surgical characteristics were compared for those reporting the top and bottom 20th percentile 24-month Neck Disability Index (NDI), EuroQol-5D (EQ-5D), and modified Japanese Orthopaedic Association (mJOA) change scores. A multivariable logistic model was constructed and included candidate variables reaching p ≤ 0.20 on univariate analyses. Least important variables were removed in a stepwise manner to determine the significant predictors of the best outcomes (top 20th percentile) for 24-month NDI, EQ-5D, and mJOA change. RESULTS A total of 948 (83.1%) patients with 24-month follow-up were included in this study. For NDI, 204 (17.9%) had the best NDI outcome and 200 (17.5%) had the worst NDI outcome. Factors predicting the best NDI outcomes included symptom duration less than 12 months (OR 1.5, 95% CI 1.1-1.9; p = 0.01); procedure other than posterior fusion (OR 1.5, 95% CI 1.03-2.1; p = 0.03); higher preoperative visual analog scale neck pain score (OR 1.2, 95% CI 1.1-1.3; p < 0.001); and higher baseline NDI (OR 1.06, 95% CI 1.05-1.07; p < 0.001). For EQ-5D, 163 (14.3%) had the best EQ-5D outcome and 169 (14.8%) had the worst EQ-5D outcome. Factors predicting the best EQ-5D outcomes included arm pain-only complaints (compared to neck pain) (OR 1.9, 95% CI 1.3-2.9; p = 0.002) and lower baseline EQ-5D (OR 167.7 per unit lower, 95% CI 85.0-339.4; p < 0.001). For mJOA, 222 (19.5%) had the best mJOA outcome and 238 (20.9%) had the worst mJOA outcome. Factors predicting the best mJOA outcomes included lower BMI (OR 1.03 per unit lower, 95% CI 1.004-1.05; p = 0.02; cutoff value of ≤ 29.5 kg/m2); arm pain-only complaints (compared to neck pain) (OR 1.7, 95% CI 1.1-2.5; p = 0.02); and lower baseline mJOA (OR 1.6 per unit lower, 95% CI 1.5-1.7; p < 0.001). CONCLUSIONS Compared to the worst outcomes for EQ-5D, the best outcomes were associated with patients with arm pain-only complaints. For mJOA, lower BMI and arm pain-only complaints portended the best outcomes. For NDI, those with the best outcomes had shorter symptom durations, higher preoperative neck pain scores, and less often underwent posterior spinal fusions. Given the positive impact of shorter symptom duration on outcomes, these data suggest that early surgery may be beneficial for patients with CSM.
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Affiliation(s)
- Andrew K Chan
- 1Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York; The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Christine Park
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Oren N Gottfried
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Khoi D Than
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Erica F Bisson
- 3Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anthony L Asher
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 6Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 7Department of Neurosurgery, University of Tennessee; Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 8Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Scott Meyer
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 11Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag D Upadhyaya
- 12Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 14Barrow Neurological Institute, Phoenix, Arizona
| | | | - Brandon A Sherrod
- 3Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Nitin Agarwal
- 15Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Dean Chou
- 1Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, New York; The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Regis W Haid
- 16Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Praveen V Mummaneni
- 15Department of Neurological Surgery, University of California, San Francisco, California; and
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Park C, Shaffrey CI, Than KD, Bisson EF, Sherrod BA, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya C, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Agarwal N, Chan AK, Chou D, Chaudhry NS, Haid RW, Mummaneni PV, Michalopoulos GD, Bydon M, Gottfried ON. Does the number of social factors affect long-term patient-reported outcomes and satisfaction in those with cervical myelopathy? A QOD study. J Neurosurg Spine 2024; 40:428-438. [PMID: 38241683 DOI: 10.3171/2023.11.spine23127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 11/16/2023] [Indexed: 01/21/2024]
Abstract
OBJECTIVE It is not clear whether there is an additive effect of social factors in keeping patients with cervical spondylotic myelopathy (CSM) from achieving both a minimum clinically important difference (MCID) in outcomes and satisfaction after surgery. The aim of this study was to explore the effect of multiple social factors on postoperative outcomes and satisfaction. METHODS This was a multiinstitutional, retrospective study of the prospective Quality Outcomes Database (QOD) CSM cohort, which included patients aged 18 years or older who were diagnosed with primary CSM and underwent operative management. Social factors included race (White vs non-White), education (high school or below vs above), employment (employed vs not), and insurance (private vs nonprivate). Patients were considered to have improved from surgery if the following criteria were met: 1) they reported a score of 1 or 2 on the North American Spine Society index, and 2) they met the MCID in patient-reported outcomes (i.e., visual analog scale [VAS] neck and arm pain, Neck Disability Index [NDI], and EuroQol-5D [EQ-5D]). RESULTS Of the 1141 patients included in the study, 205 (18.0%) had 0, 347 (30.4%) had 1, 334 (29.3%) had 2, and 255 (22.3%) had 3 social factors. The 24-month follow-up rate was > 80% for all patient-reported outcomes. After adjusting for all relevant covariates (p < 0.02), patients with 1 or more social factors were less likely to improve from surgery in all measured outcomes including VAS neck pain (OR 0.90, 95% CI 0.83-0.99) and arm pain (OR 0.88, 95% CI 0.80-0.96); NDI (OR 0.90, 95% CI 0.83-0.98); and EQ-5D (OR 0.90, 95% CI 0.83-0.97) (all p < 0.05) compared to those without any social factors. Patients with 2 social factors (outcomes: neck pain OR 0.86, arm pain OR 0.81, NDI OR 0.84, EQ-5D OR 0.81; all p < 0.05) or 3 social factors (outcomes: neck pain OR 0.84, arm pain OR 0.84, NDI OR 0.84, EQ-5D OR 0.84; all p < 0.05) were more likely to fare worse in all outcomes compared to those with only 1 social factor. CONCLUSIONS Compared to those without any social factors, patients who had at least 1 social factor were less likely to achieve MCID and feel satisfied after surgery. The effect of social factors is additive in that patients with a higher number of factors are less likely to improve compared to those with only 1 social factor.
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Affiliation(s)
- Christine Park
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Khoi D Than
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Erica F Bisson
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Brandon A Sherrod
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Anthony L Asher
- 3Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 3Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 4Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 5Department of Neurosurgery, Semmes Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 6Department of Neurosurgery, University of Miami, Florida
| | - Kai-Ming Fu
- 7Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 7Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | | | - Scott Meyer
- 8Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 9Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag Upadhyaya
- 10Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 11Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 11Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 12Barrow Neurological Institute, Phoenix, Arizona
| | - Nitin Agarwal
- 13Department of Neurosurgery, Washington University in St. Louis, Missouri
| | - Andrew K Chan
- 14Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Dean Chou
- 14Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Nauman S Chaudhry
- 15Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Regis W Haid
- 16Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Praveen V Mummaneni
- 17Department of Neurosurgery, University of California, San Francisco, California; and
| | | | - Mohamad Bydon
- 18Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Oren N Gottfried
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
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3
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Park C, Shaffrey CI, Than KD, Michalopoulos GD, El Sammak S, Chan AK, Bisson EF, Sherrod BA, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya C, Shaffrey ME, Buchholz AL, Tumialán LM, Turner J, Agarwal N, Chou D, Chaudhry NS, Haid RW, Mummaneni PV, Bydon M, Gottfried ON. What factors influence surgical decision-making in anterior versus posterior surgery for cervical myelopathy? A QOD analysis. J Neurosurg Spine 2024; 40:206-215. [PMID: 37948703 DOI: 10.3171/2023.8.spine23194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/29/2023] [Indexed: 11/12/2023]
Abstract
OBJECTIVE The aim of this study was to explore the preoperative patient characteristics that affect surgical decision-making when selecting an anterior or posterior operative approach in patients diagnosed with cervical spondylotic myelopathy (CSM). METHODS This was a multi-institutional, retrospective study of the prospective Quality Outcomes Database (QOD) Cervical Spondylotic Myelopathy module. Patients aged 18 years or older diagnosed with primary CSM who underwent multilevel (≥ 2-level) elective surgery were included. Demographics and baseline clinical characteristics were collected. RESULTS Of the 841 patients with CSM in the database, 492 (58.5%) underwent multilevel anterior surgery and 349 (41.5%) underwent multilevel posterior surgery. Surgeons more often performed a posterior surgical approach in older patients (mean 64.8 ± 10.6 vs 58.5 ± 11.1 years, p < 0.001) and those with a higher American Society of Anesthesiologists class (class III or IV: 52.4% vs 46.3%, p = 0.003), a higher rate of motor deficit (67.0% vs 58.7%, p = 0.014), worse myelopathy (mean modified Japanese Orthopaedic Association score 11.4 ± 3.1 vs 12.4 ± 2.6, p < 0.001), and more levels treated (4.3 ± 1.3 vs 2.4 ± 0.6, p < 0.001). On the other hand, surgeons more frequently performed an anterior surgical approach when patients were employed (47.2% vs 23.2%, p < 0.001) and had intervertebral disc herniation as an underlying pathology (30.7% vs 9.2%, p < 0.001). CONCLUSIONS The selection of approach for patients with CSM depends on patient demographics and symptomology. Posterior surgery was performed in patients who were older and had worse systemic disease, increased myelopathy, and greater levels of stenosis. Anterior surgery was more often performed in patients who were employed and had intervertebral disc herniation.
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Affiliation(s)
- Christine Park
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Khoi D Than
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Sally El Sammak
- 2Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Andrew K Chan
- 3Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Erica F Bisson
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Brandon A Sherrod
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Anthony L Asher
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 6Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 7Department of Neurosurgery, University of Tennessee, Semmes Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 8Department of Neurosurgery, University of Miami, Florida
| | - Kai-Ming Fu
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Scott Meyer
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 11Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag Upadhyaya
- 12Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay Turner
- 14Barrow Neurological Institute, Phoenix, Arizona
| | - Nitin Agarwal
- 15Department of Neurosurgery, Washington University in St. Louis, Missouri
| | - Dean Chou
- 3Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Nauman S Chaudhry
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Regis W Haid
- 16Atlanta Brain and Spine Care, Atlanta, Georgia; and
| | - Praveen V Mummaneni
- 17Department of Neurosurgery, University of California, San Francisco, California
| | - Mohamad Bydon
- 2Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Oren N Gottfried
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
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4
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Yang E, Mummaneni PV, Chou D, Bydon M, Bisson EF, Shaffrey CI, Gottfried ON, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya CD, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Michalopoulos GD, Sherrod BA, Agarwal N, Haid RW, Chan AK. Cervical laminoplasty versus laminectomy and posterior cervical fusion for cervical myelopathy: propensity-matched analysis of 24-month outcomes from the Quality Outcomes Database. J Neurosurg Spine 2023; 39:671-681. [PMID: 37728378 DOI: 10.3171/2023.6.spine23345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/08/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVE Compared with laminectomy with posterior cervical fusion (PCF), cervical laminoplasty (CL) may result in different outcomes for those operated on for cervical spondylotic myelopathy (CSM). The aim of this study was to compare 24-month patient-reported outcomes (PROs) for laminoplasty versus PCF by using the Quality Outcomes Database (QOD) CSM data set. METHODS This was a retrospective study using an augmented data set from the prospectively collected QOD Registry Cervical Module. Patients undergoing laminoplasty or PCF for CSM were included. Using the nearest-neighbor method, the authors performed 1:1 propensity matching based on age, operated levels, and baseline modified Japanese Orthopaedic Association (mJOA) and visual analog scale (VAS) neck pain scores. The 24-month PROs, i.e., mJOA, Neck Disability Index (NDI), VAS neck pain, VAS arm pain, EQ-5D, EQ-VAS, and North American Spine Society (NASS) satisfaction scores, were compared. Only cases in the subaxial cervical region were included; those that crossed the cervicothoracic junction were excluded. RESULTS From the 1141 patients included in the QOD CSM data set who underwent anterior or posterior surgery for cervical myelopathy, 946 (82.9%) had 24 months of follow-up. Of these, 43 patients who underwent laminoplasty and 191 who underwent PCF met the inclusion criteria. After matching, the groups were similar for baseline characteristics, including operative levels (CL group: 4.0 ± 0.9 vs PCF group: 4.2 ± 1.1, p = 0.337) and baseline PROs (p > 0.05), except for a higher percentage involved in activities outside the home in the CL group (95.3% vs 81.4%, p = 0.044). The 24-month follow-up for the matched cohorts was similar (CL group: 88.4% vs PCF group: 83.7%, p = 0.534). Patients undergoing laminoplasty had significantly lower estimated blood loss (99.3 ± 91.7 mL vs 186.7 ± 142.7 mL, p = 0.003), decreased length of stay (3.0 ± 1.6 days vs 4.5 ± 3.3 days, p = 0.012), and a higher rate of routine discharge (88.4% vs 62.8%, p = 0.006). The CL cohort also demonstrated a higher rate of return to activities (47.2% vs 21.2%, p = 0.023) after 3 months. Laminoplasty was associated with a larger improvement in 24-month NDI score (-19.6 ± 18.9 vs -9.1 ± 21.9, p = 0.031). Otherwise, there were no 3- or 24-month differences in mJOA, mean NDI, VAS neck pain, VAS arm pain, EQ-5D, EQ-VAS, and distribution of NASS satisfaction scores (p > 0.05) between the cohorts. CONCLUSIONS Compared with PCF, laminoplasty was associated with decreased blood loss, decreased length of hospitalization, and higher rates of home discharge. At 3 months, laminoplasty was associated with a higher rate of return to baseline activities. At 24 months, laminoplasty was associated with greater improvements in neck disability. Otherwise, laminoplasty and PCF shared similar outcomes for functional status, pain, quality of life, and satisfaction. Laminoplasty and PCF achieved similar neck pain scores, suggesting that moderate preoperative neck pain may not necessarily be a contraindication for laminoplasty.
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Affiliation(s)
- Eunice Yang
- 1Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Praveen V Mummaneni
- 2Department of Neurosurgery, University of California, San Francisco, California
| | - Dean Chou
- 1Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Mohamad Bydon
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Erica F Bisson
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | | | - Oren N Gottfried
- 5Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Anthony L Asher
- 6Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 6Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 7Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 8Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 9Department of Neurosurgery, University of Miami, Florida
| | - Kai-Ming Fu
- 10Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 10Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 11Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Scott Meyer
- 11Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 12Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag D Upadhyaya
- 13Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 14Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 14Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 15Barrow Neurological Institute, Phoenix, Arizona
| | | | - Brandon A Sherrod
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Nitin Agarwal
- 16Department of Neurosurgery, University of Pittsburgh, Pennsylvania; and
| | - Regis W Haid
- 17Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Andrew K Chan
- 1Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
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5
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Ambati VS, Macki M, Chan AK, Michalopoulos GD, Le VP, Jamieson AB, Chou D, Shaffrey CI, Gottfried ON, Bisson EF, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya C, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Sherrod BA, Haid RW, Bydon M, Mummaneni PV. Three-level ACDF versus 3-level laminectomy and fusion: are there differences in outcomes? An analysis of the Quality Outcomes Database cervical spondylotic myelopathy cohort. Neurosurg Focus 2023; 55:E2. [PMID: 37657103 DOI: 10.3171/2023.6.focus23295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/16/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE The authors sought to compare 3-level anterior with posterior fusion surgical procedures for the treatment of multilevel cervical spondylotic myelopathy (CSM). METHODS The authors analyzed prospective data from the 14 highest enrolling sites of the Quality Outcomes Database CSM module. They compared 3-level anterior cervical discectomy and fusion (ACDF) and posterior cervical laminectomy and fusion (PCF) surgical procedures, excluding surgical procedures crossing the cervicothoracic junction. Rates of reaching the minimal clinically important difference (MCID) in patient-reported outcomes (PROs) were compared at 24 months postoperatively. Multivariable analyses adjusted for potential confounders elucidated in univariable analysis. RESULTS Overall, 199 patients met the inclusion criteria: 123 ACDF (61.8%) and 76 PCF (38.2%) patients. The 24-month follow-up rates were similar (ACDF 90.2% vs PCF 92.1%, p = 0.67). Preoperatively, ACDF patients were younger (60.8 ± 10.2 vs 65.0 ± 10.3 years, p < 0.01), and greater proportions were privately insured (56.1% vs 36.8%, p = 0.02), actively employed (39.8% vs 22.8%, p = 0.04), and independently ambulatory (14.6% vs 31.6%, p < 0.01). Otherwise, the cohorts had equivalent baseline modified Japanese Orthopaedic Association (mJOA), Neck Disability Index (NDI), numeric rating scale (NRS)-arm pain, NRS-neck pain, and EQ-5D scores (p > 0.05). ACDF patients had reduced hospitalization length (1.6 vs 3.9 days, p < 0.01) and a greater proportion had nonroutine discharge (7.3% vs 22.8%, p < 0.01), but they had a higher rate of postoperative dysphagia (13.5% vs 3.5%, p = 0.049). Compared with baseline values, both groups demonstrated improvements in all outcomes at 24 months (p < 0.05). In multivariable analyses, after controlling for age, insurance payor, employment status, ambulation status, and other potential clinically relevant confounders, ACDF was associated with a greater proportion of patients with maximum satisfaction on the North American Spine Society Patient Satisfaction Index (NASS) (NASS score of 1) at 24 months (69.4% vs 53.7%, OR 2.44, 95% CI 1.17-5.09, adjusted p = 0.02). Otherwise, the cohorts shared similar 24-month outcomes in terms of reaching the MCID for mJOA, NDI, NRS-arm pain, NRS-neck pain, and EQ-5D score (adjusted p > 0.05). There were no differences in the 3-month readmission (ACDF 4.1% vs PCF 3.9%, p = 0.97) and 24-month reoperation (ACDF 13.5% vs PCF 18.6%, p = 0.36) rates. CONCLUSIONS In a cohort limited to 3-level fusion surgical procedures, ACDF was associated with reduced blood loss, shorter hospitalization length, and higher routine home discharge rates; however, PCF resulted in lower rates of postoperative dysphagia. The procedures yielded comparably significant improvements in functional status (mJOA score), neck and arm pain, neck pain-related disability, and quality of life at 3, 12, and 24 months. ACDF patients had significantly higher odds of maximum satisfaction (NASS score 1). Given comparable outcomes, patients should be counseled on each approach's complication profile to aid in surgical decision-making.
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Affiliation(s)
- Vardhaan S Ambati
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Mohamed Macki
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Andrew K Chan
- 2Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | | | - Vivian P Le
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Alysha B Jamieson
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Dean Chou
- 2Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | | | - Oren N Gottfried
- 4Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Erica F Bisson
- 5Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Anthony L Asher
- 6Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 6Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 7Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 8Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 9Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 10Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 10Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 11Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Scott Meyer
- 11Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 8Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Cheerag Upadhyaya
- 12Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 14Barrow Neurological Institute, Phoenix, Arizona; and
| | - Brandon A Sherrod
- 5Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Regis W Haid
- 15Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Mohamad Bydon
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
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6
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Chan AK, Shaffrey CI, Park C, Gottfried ON, Than KD, Bisson EF, Bydon M, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya CD, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Michalopoulos GD, Sherrod BA, Agarwal N, Chou D, Haid RW, Mummaneni PV. Do comorbid self-reported depression and anxiety influence outcomes following surgery for cervical spondylotic myelopathy? J Neurosurg Spine 2023; 39:11-27. [PMID: 37021762 DOI: 10.3171/2023.2.spine22685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 02/20/2023] [Indexed: 04/03/2023]
Abstract
OBJECTIVE Depression and anxiety are associated with inferior outcomes following spine surgery. In this study, the authors examined whether patients with cervical spondylotic myelopathy (CSM) who have both self-reported depression (SRD) and self-reported anxiety (SRA) have worse postoperative patient-reported outcomes (PROs) compared with patients who have only one or none of these comorbidities. METHODS This study is a retrospective analysis of prospectively collected data from the Quality Outcomes Database CSM cohort. Comparisons were made among patients who reported the following: 1) either SRD or SRA, 2) both SRD and SRA, or 3) neither comorbidity at baseline. PROs at 3, 12, and 24 months (scores for the visual analog scale [VAS] for neck pain and arm pain, Neck Disability Index [NDI], modified Japanese Orthopaedic Association [mJOA] scale, EQ-5D, EuroQol VAS [EQ-VAS], and North American Spine Society [NASS] patient satisfaction index) and achievement of respective PRO minimal clinically important differences (MCIDs) were compared. RESULTS Of the 1141 included patients, 199 (17.4%) had either SRD or SRA alone, 132 (11.6%) had both SRD and SRA, and 810 (71.0%) had neither. Preoperatively, patients with either SRD or SRA alone had worse scores for VAS neck pain (5.6 ± 3.1 vs 5.1 ± 3.3, p = 0.03), NDI (41.0 ± 19.3 vs 36.8 ± 20.8, p = 0.007), EQ-VAS (57.0 ± 21.0 vs 60.7 ± 21.7, p = 0.03), and EQ-5D (0.53 ± 0.23 vs 0.58 ± 0.21, p = 0.008) than patients without such disorders. Postoperatively, in multivariable adjusted analyses, baseline SRD or SRA alone was associated with inferior improvement in the VAS neck pain score and a lower rate of achieving the MCID for VAS neck pain score at 3 and 12 months, but not at 24 months. At 24 months, patients with SRD or SRA alone experienced less change in EQ-5D scores and were less likely to meet the MCID for EQ-5D than patients without SRD or SRA. Furthermore, patient self-reporting of both psychological comorbidities did not impact PROs at all measured time points compared with self-reporting of only one psychological comorbidity alone. Each cohort (SRD or SRA alone, both SRD and SRA, and neither SRD nor SRA) experienced significant improvements in mean PROs at all measured time points compared with baseline (p < 0.05). CONCLUSIONS Approximately 12% of patients who underwent surgery for CSM presented with both SRD and SRA, and 29% presented with at least one symptom. The presence of either SRD or SRA was independently associated with inferior scores for 3- and 12-month neck pain following surgery, but this difference was not significant at 24 months. However, at long-term follow-up, patients with SRD or SRA experienced lower quality of life than patients without SRD or SRA. The comorbid presence of both depression and anxiety was not associated with worse patient outcomes than either diagnosis alone.
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Affiliation(s)
- Andrew K Chan
- 1Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork/Presbyterian, New York, New York
| | | | - Christine Park
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Oren N Gottfried
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Khoi D Than
- 2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Erica F Bisson
- 3Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- 4Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anthony L Asher
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 6Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 7Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 8Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Scott Meyer
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 7Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
- 11Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag D Upadhyaya
- 12Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 14Barrow Neurological Institute, Phoenix, Arizona
| | | | - Brandon A Sherrod
- 3Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Nitin Agarwal
- 15Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Dean Chou
- 1Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork/Presbyterian, New York, New York
| | - Regis W Haid
- 16Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Praveen V Mummaneni
- 15Department of Neurological Surgery, University of California, San Francisco, California; and
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7
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Park C, Mummaneni PV, Gottfried ON, Shaffrey CI, Tang AJ, Bisson EF, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya C, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Sherrod BA, Agarwal N, Chou D, Haid RW, Bydon M, Chan AK. Which supervised machine learning algorithm can best predict achievement of minimum clinically important difference in neck pain after surgery in patients with cervical myelopathy? A QOD study. Neurosurg Focus 2023; 54:E5. [PMID: 37283449 DOI: 10.3171/2023.3.focus2372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 03/22/2023] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate the performance of different supervised machine learning algorithms to predict achievement of minimum clinically important difference (MCID) in neck pain after surgery in patients with cervical spondylotic myelopathy (CSM). METHODS This was a retrospective analysis of the prospective Quality Outcomes Database CSM cohort. The data set was divided into an 80% training and a 20% test set. Various supervised learning algorithms (including logistic regression, support vector machine, decision tree, random forest, extra trees, gaussian naïve Bayes, k-nearest neighbors, multilayer perceptron, and extreme gradient boosted trees) were evaluated on their performance to predict achievement of MCID in neck pain at 3 and 24 months after surgery, given a set of predicting baseline features. Model performance was assessed with accuracy, F1 score, area under the receiver operating characteristic curve, precision, recall/sensitivity, and specificity. RESULTS In total, 535 patients (46.9%) achieved MCID for neck pain at 3 months and 569 patients (49.9%) achieved it at 24 months. In each follow-up cohort, 501 patients (93.6%) were satisfied at 3 months after surgery and 569 patients (100%) were satisfied at 24 months after surgery. Of the supervised machine learning algorithms tested, logistic regression demonstrated the best accuracy (3 months: 0.76 ± 0.031, 24 months: 0.773 ± 0.044), followed by F1 score (3 months: 0.759 ± 0.019, 24 months: 0.777 ± 0.039) and area under the receiver operating characteristic curve (3 months: 0.762 ± 0.027, 24 months: 0.773 ± 0.043) at predicting achievement of MCID for neck pain at both follow-up time points, with fair performance. The best precision was also demonstrated by logistic regression at 3 (0.724 ± 0.058) and 24 (0.780 ± 0.097) months. The best recall/sensitivity was demonstrated by multilayer perceptron at 3 months (0.841 ± 0.094) and by extra trees at 24 months (0.817 ± 0.115). Highest specificity was shown by support vector machine at 3 months (0.952 ± 0.013) and by logistic regression at 24 months (0.747 ± 0.18). CONCLUSIONS Appropriate selection of models for studies should be based on the strengths of each model and the aims of the studies. For maximally predicting true achievement of MCID in neck pain, of all the predictions in this balanced data set the appropriate metric for the authors' study was precision. For both short- and long-term follow-ups, logistic regression demonstrated the highest precision of all models tested. Logistic regression performed consistently the best of all models tested and remains a powerful model for clinical classification tasks.
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Affiliation(s)
- Christine Park
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Praveen V Mummaneni
- 2Department of Neurosurgery, University of California, San Francisco, California
| | - Oren N Gottfried
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Anthony J Tang
- 3Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Erica F Bisson
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Anthony L Asher
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 5Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 6Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 7Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 8Department of Neurosurgery, University of Miami, Florida
| | - Kai-Ming Fu
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 9Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - John J Knightly
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Scott Meyer
- 10Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 11Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag Upadhyaya
- 12Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 13Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 14Barrow Neurological Institute, Phoenix, Arizona
| | - Brandon A Sherrod
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Nitin Agarwal
- 15Department of Neurosurgery, Washington University in St. Louis, Missouri
| | - Dean Chou
- 3Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
| | - Regis W Haid
- 16Atlanta Brain and Spine Care, Atlanta, Georgia; and
| | - Mohamad Bydon
- 17Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Andrew K Chan
- 3Department of Neurological Surgery, Columbia University Vagelos College of Physicians and Surgeons, The Och Spine Hospital at NewYork-Presbyterian, New York, New York
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8
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Bisson EF, Mummaneni PV, Michalopoulos GD, El Sammak S, Chan AK, Agarwal N, Wang MY, Knightly JJ, Sherrod BA, Gottfried ON, Than KD, Shaffrey CI, Goldberg JL, Virk MS, Hussain I, Shabani S, Glassman SD, Tumialan LM, Turner JD, Uribe JS, Meyer SA, Lu DC, Buchholz AL, Upadhyaya C, Shaffrey ME, Park P, Foley KT, Coric D, Slotkin JR, Potts EA, Stroink AR, Chou D, Fu KMG, Haid RW, Asher AL, Bydon M. Sleep Disturbances in Cervical Spondylotic Myelopathy: Prevalence and Postoperative Outcomes-an Analysis From the Quality Outcomes Database. Clin Spine Surg 2023; 36:112-119. [PMID: 36920372 DOI: 10.1097/bsd.0000000000001454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 01/25/2023] [Indexed: 03/16/2023]
Abstract
STUDY DESIGN Prospective observational study, level of evidence 1 for prognostic investigations. OBJECTIVES To evaluate the prevalence of sleep impairment and predictors of improved sleep quality 24 months postoperatively in cervical spondylotic myelopathy (CSM) using the quality outcomes database. SUMMARY OF BACKGROUND DATA Sleep disturbances are a common yet understudied symptom in CSM. MATERIALS AND METHODS The quality outcomes database was queried for patients with CSM, and sleep quality was assessed through the neck disability index sleep component at baseline and 24 months postoperatively. Multivariable logistic regressions were performed to identify risk factors of failure to improve sleep impairment and symptoms causing lingering sleep dysfunction 24 months after surgery. RESULTS Among 1135 patients with CSM, 904 (79.5%) had some degree of sleep dysfunction at baseline. At 24 months postoperatively, 72.8% of the patients with baseline sleep symptoms experienced improvement, with 42.5% reporting complete resolution. Patients who did not improve were more like to be smokers [adjusted odds ratio (aOR): 1.85], have osteoarthritis (aOR: 1.72), report baseline radicular paresthesia (aOR: 1.51), and have neck pain of ≥4/10 on a numeric rating scale. Patients with improved sleep noted higher satisfaction with surgery (88.8% vs 72.9%, aOR: 1.66) independent of improvement in other functional areas. In a multivariable analysis including pain scores and several myelopathy-related symptoms, lingering sleep dysfunction at 24 months was associated with neck pain (aOR: 1.47) and upper (aOR: 1.45) and lower (aOR: 1.52) extremity paresthesias. CONCLUSION The majority of patients presenting with CSM have associated sleep disturbances. Most patients experience sustained improvement after surgery, with almost half reporting complete resolution. Smoking, osteoarthritis, radicular paresthesia, and neck pain ≥4/10 numeric rating scale score are baseline risk factors of failure to improve sleep dysfunction. Improvement in sleep symptoms is a major driver of patient-reported satisfaction. Incomplete resolution of sleep impairment is likely due to neck pain and extremity paresthesia.
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Affiliation(s)
- Erica F Bisson
- Department of Neurological Surgery, University of Utah, Salt Lake City, UT
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA
| | - Giorgos D Michalopoulos
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | - Sally El Sammak
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
| | - Andrew K Chan
- Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, NY
| | - Nitin Agarwal
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO
| | - Michael Y Wang
- Department of Neurosurgery, University of Miami, Miami, FL
| | | | - Brandon A Sherrod
- Department of Neurological Surgery, University of Utah, Salt Lake City, UT
| | - Oren N Gottfried
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
| | - Khoi D Than
- Department of Neurological Surgery, Duke University Medical Center, Durham, NC
| | | | - Jacob L Goldberg
- Department of Neurological Surgery, Weill Cornell Medical Center, New York
| | - Michael S Virk
- Department of Neurological Surgery, Weill Cornell Medical Center, New York
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical Center, New York
| | - Saman Shabani
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI
| | | | - Louis M Tumialan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Jay D Turner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | - Juan S Uribe
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ
| | | | - Daniel C Lu
- Department of Neurosurgery, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA
| | - Avery L Buchholz
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Cheerag Upadhyaya
- Department of Neurosurgery, School of Medicine, University of North Carolina, Chapel Hill, NC
| | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, VA
| | - Paul Park
- Department of Neurosurgery, University of Tennessee, Memphis, TN
| | - Kevin T Foley
- Department of Neurosurgery, University of Tennessee, Memphis, TN
| | - Domagoj Coric
- Neuroscience Institute, Carolina Neurosurgery and Spine Associates, Carolinas Healthcare System, Charlotte, NC
| | | | - Eric A Potts
- Department of Neurological Surgery, Indiana University, Goodman Campbell Brain and Spine, Indianapolis, IN
| | - Ann R Stroink
- Central Illinois Neuro Health Science, Bloomington, IL
| | - Dean Chou
- Department of Neurological Surgery, Columbia University, The Och Spine Hospital at NewYork-Presbyterian, New York, NY
| | - Kai-Ming G Fu
- Department of Neurological Surgery, Weill Cornell Medical Center, New York
| | | | - Anthony L Asher
- Neuroscience Institute, Carolina Neurosurgery and Spine Associates, Carolinas Healthcare System, Charlotte, NC
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN
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9
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Chan AK, Shaffrey CI, Gottfried ON, Park C, Than KD, Bisson EF, Bydon M, Asher AL, Coric D, Potts EA, Foley KT, Wang MY, Fu KM, Virk MS, Knightly JJ, Meyer S, Park P, Upadhyaya C, Shaffrey ME, Buchholz AL, Tumialán LM, Turner JD, Michalopoulos GD, Sherrod BA, Agarwal N, Chou D, Haid RW, Mummaneni PV. Cervical spondylotic myelopathy with severe axial neck pain: is anterior or posterior approach better? J Neurosurg Spine 2023; 38:42-55. [PMID: 36029264 DOI: 10.3171/2022.6.spine22110] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 06/23/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The aim of this study was to determine whether multilevel anterior cervical discectomy and fusion (ACDF) or posterior cervical laminectomy and fusion (PCLF) is superior for patients with cervical spondylotic myelopathy (CSM) and high preoperative neck pain. METHODS This was a retrospective study of prospectively collected data using the Quality Outcomes Database (QOD) CSM module. Patients who received a subaxial fusion of 3 or 4 segments and had a visual analog scale (VAS) neck pain score of 7 or greater at baseline were included. The 3-, 12-, and 24-month outcomes were compared for patients undergoing ACDF with those undergoing PCLF. RESULTS Overall, 1141 patients with CSM were included in the database. Of these, 495 (43.4%) presented with severe neck pain (VAS score > 6). After applying inclusion and exclusion criteria, we compared 65 patients (54.6%) undergoing 3- and 4-level ACDF and 54 patients (45.4%) undergoing 3- and 4-level PCLF. Patients undergoing ACDF had worse Neck Disability Index scores at baseline (52.5 ± 15.9 vs 45.9 ± 16.8, p = 0.03) but similar neck pain (p > 0.05). Otherwise, the groups were well matched for the remaining baseline patient-reported outcomes. The rates of 24-month follow-up for ACDF and PCLF were similar (86.2% and 83.3%, respectively). At the 24-month follow-up, both groups demonstrated mean improvements in all outcomes, including neck pain (p < 0.05). In multivariable analyses, there was no significant difference in the degree of neck pain change, rate of neck pain improvement, rate of pain-free achievement, and rate of reaching minimal clinically important difference (MCID) in neck pain between the two groups (adjusted p > 0.05). However, ACDF was associated with a higher 24-month modified Japanese Orthopaedic Association scale (mJOA) score (β = 1.5 [95% CI 0.5-2.6], adjusted p = 0.01), higher EQ-5D score (β = 0.1 [95% CI 0.01-0.2], adjusted p = 0.04), and higher likelihood for return to baseline activities (OR 1.2 [95% CI 1.1-1.4], adjusted p = 0.002). CONCLUSIONS Severe neck pain is prevalent among patients undergoing surgery for CSM, affecting more than 40% of patients. Both ACDF and PCLF achieved comparable postoperative neck pain improvement 3, 12, and 24 months following 3- or 4-segment surgery for patients with CSM and severe neck pain. However, multilevel ACDF was associated with superior functional status, quality of life, and return to baseline activities at 24 months in multivariable adjusted analyses.
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Affiliation(s)
- Andrew K Chan
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | | | - Oren N Gottfried
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Christine Park
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Khoi D Than
- 1Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Erica F Bisson
- 2Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Mohamad Bydon
- 3Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Anthony L Asher
- 4Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Domagoj Coric
- 4Neuroscience Institute, Carolinas Healthcare System and Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 5Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Kevin T Foley
- 6Department of Neurosurgery, University of Tennessee, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Michael Y Wang
- 7Department of Neurological Surgery, University of Miami, Florida
| | - Kai-Ming Fu
- 8Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | - Michael S Virk
- 8Department of Neurosurgery, Weill Cornell Medical Center, New York, New York
| | | | - Scott Meyer
- 9Atlantic Neurosurgical Specialists, Morristown, New Jersey
| | - Paul Park
- 10Department of Neurological Surgery, University of Michigan, Ann Arbor, Michigan
| | - Cheerag Upadhyaya
- 11Marion Bloch Neuroscience Institute, Saint Luke's Health System, Kansas City, Missouri
| | - Mark E Shaffrey
- 12Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Avery L Buchholz
- 12Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Jay D Turner
- 13Barrow Neurological Institute, Phoenix, Arizona
| | | | - Brandon A Sherrod
- 2Department of Neurological Surgery, University of Utah, Salt Lake City, Utah
| | - Nitin Agarwal
- 14Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Dean Chou
- 14Department of Neurological Surgery, University of California, San Francisco, California; and
| | - Regis W Haid
- 15Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Praveen V Mummaneni
- 14Department of Neurological Surgery, University of California, San Francisco, California; and
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10
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Yee TJ, Upadhyaya C, Coric D, Potts EA, Bisson EF, Turner J, Knightly JJ, Fu KM, Foley KT, Tumialan L, Shaffrey ME, Bydon M, Mummaneni P, Chou D, Chan A, Meyer S, Asher AL, Shaffrey C, Gottfried ON, Than KD, Wang MY, Buchholz AL, Haid R, Park P. Correlation of the Modified Japanese Orthopedic Association With Functional and Quality-of-Life Outcomes After Surgery for Degenerative Cervical Myelopathy: A Quality Outcomes Database Study. Neurosurgery 2022; 91:952-960. [PMID: 36149088 DOI: 10.1227/neu.0000000000002161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 07/06/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The modified Japanese Orthopedic Association (mJOA) score is a widely used and validated metric for assessing severity of myelopathy. Its relationship to functional and quality-of-life outcomes after surgery has not been fully described. OBJECTIVE To quantify the association of the mJOA with the Neck Disability Index (NDI) and EuroQol-5 Dimension (EQ-5D) after surgery for degenerative cervical myelopathy. METHODS The cervical module of the prospectively enrolled Quality Outcomes Database was queried retrospectively for adult patients who underwent single-stage degenerative cervical myelopathy surgery. The mJOA score, NDI, and EQ-5D were assessed preoperatively and 3 and 12 months postoperatively. Improvement in mJOA was used as the independent variable in univariate and multivariable linear and logistic regression models. RESULTS Across 14 centers, 1121 patients were identified, mean age 60.6 ± 11.8 years, and 52.5% male. Anterior-only operations were performed in 772 patients (68.9%). By univariate linear regression, improvements in mJOA were associated with improvements in NDI and EQ-5D at 3 and 12 months postoperatively (all P < .0001) and with improvements in the 10 NDI items individually. These findings were similar in multivariable regression incorporating potential confounders. The Pearson correlation coefficients for changes in mJOA with changes in NDI were -0.31 and -0.38 at 3 and 12 months postoperatively. The Pearson correlation coefficients for changes in mJOA with changes in EQ-5D were 0.29 and 0.34 at 3 and 12 months. CONCLUSION Improvements in mJOA correlated weakly with improvements in NDI and EQ-5D, suggesting that changes in mJOA may not be a suitable proxy for functional and quality-of-life outcomes.
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Affiliation(s)
- Timothy J Yee
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Cheerag Upadhyaya
- Saint Luke's Neurological and Spine Surgery, Kansas City, Missouri, USA
| | - Domagoj Coric
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | - Eric A Potts
- Goodman Campbell Brain and Spine, Carmel, Indiana, USA
| | - Erica F Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Jay Turner
- Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Jack J Knightly
- Altair Health Spine and Wellness, Morristown, New Jersey, USA
| | - Kai-Ming Fu
- Department of Neurological Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Kevin T Foley
- Department of Neurosurgery, University of Tennessee, Memphis, Tennessee, USA
| | - Luis Tumialan
- Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Praveen Mummaneni
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Andrew Chan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Scott Meyer
- Altair Health Spine and Wellness, Morristown, New Jersey, USA
| | - Anthony L Asher
- Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina, USA
| | - Christopher Shaffrey
- Department of Neurological Surgery, Duke University, Raleigh, North Carolina, USA
| | - Oren N Gottfried
- Department of Neurological Surgery, Duke University, Raleigh, North Carolina, USA
| | - Khoi D Than
- Department of Neurological Surgery, Duke University, Raleigh, North Carolina, USA
| | - Michael Y Wang
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Avery L Buchholz
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Regis Haid
- Atlanta Brain and Spine, Atlanta, Georgia, USA
| | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
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11
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Lee NJ, Leung E, Buchanan IA, Geiselmann M, Coury JR, Simhon ME, Zuckerman S, Buchholz AL, Pollina J, Jazini E, Haines C, Schuler TC, Good CR, Lombardi J, Lehman RA. A multicenter study of the 5-year trends in robot-assisted spine surgery outcomes and complications. J Spine Surg 2022; 8:9-20. [PMID: 35441099 PMCID: PMC8990386 DOI: 10.21037/jss-21-102] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/12/2022] [Indexed: 05/16/2023]
Abstract
BACKGROUND Although a growing amount of literature that suggests robots are safe and can achieve comparable outcomes to conventional techniques, much of this literature is limited by small sample sizes and single-surgeon or single center series. Furthermore, it is unclear what the impact of robotic technology has made on operative and clinical outcomes over time. This is the first and largest multicenter study to examine the trends in outcomes and complications after robot-assisted spine surgery over a 5-year period. METHODS Adult (≥18 years old) patients who underwent spine surgery with robot-assistance between 2015 and 2019 at four unique spine centers. The robotic systems used included the Mazor Renaissance, Mazor X, and Mazor Stealth Edition. Patients with incomplete data were excluded from this study. The minimum follow-up was 90 days. RESULTS A total of 722 adult patients were included (117 Renaissance, 477 X, 128 Stealth). Most patient and operative factors (e.g., sex, tobacco status, total instrumented levels, and pelvic fixation,) were similar across the years. Mean ± standard deviation Charlson comorbidity index (CCI) was 1.5±1.5. The most commonly reported diagnoses included high grade spondylolisthesis (40.6%), degenerative disc disease (18.4%), and degenerative scoliosis (17.6%). Mean (standard deviation) number of instrumented levels was 3.8±3.4. From 2015 to 2019, average robot time per screw improved from 7.2 to 5.5 minutes (P=0.004, R2=0.649). Average fluoroscopy time per screw improved from 15.2 to 9.4 seconds (P=0.002). Rates of both intraoperative screw exchange for misplaced screw (2015-2016: 2.7%, 2019: 0.8%, P=0.0115, R2=0.1316) and robot abandonment (2015-2016: 7.1%, 2019: 1.1%, P=0.011, R2=0.215) improved significantly over time. The incidence of other intraoperative complications (e.g., dural tear, loss of motor/sensory function, blood transfusion) remained consistently low, but similar throughout the years. The length of stay (LOS) decreased by nearly 1 day from 2015 to 2019 (P=0.007, R2=0.779). 90-day reoperation rates did not change significantly. CONCLUSIONS At four institutions among seven surgeons, we demonstrate robot screw accuracy, reliability, operative efficiency, and radiation exposure improved significantly from 2015 to 2019. 90-day complication rates remained low and LOS decreased significantly with time. These findings further validate continued usage of robot-assisted spine surgery and the path toward improved value-based care.
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Affiliation(s)
- Nathan J. Lee
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Eric Leung
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Ian A. Buchanan
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Matthew Geiselmann
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY, USA
| | - Josephine R. Coury
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Matthew E. Simhon
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Scott Zuckerman
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Avery L. Buchholz
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - John Pollina
- Department of Neurosurgery, State University of New York, Buffalo, NY, USA
| | - Ehsan Jazini
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA
| | - Colin Haines
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA
| | - Thomas C. Schuler
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA
| | | | - Joseph Lombardi
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Ronald A. Lehman
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
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12
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Yee TJ, Upadhyaya CD, Coric D, Potts EA, Bisson EF, Turner JD, Knightly JJ, Fu KMG, Foley KT, Tumialan LM, Shaffrey ME, Bydon M, Mummaneni PV, Chan AK, Meyer SA, Asher AL, Shaffrey CI, Gottfried ON, Than KD, Wang MY, Buchholz AL, Park P. 456 Assessing the Efficacy of the mJOA in Myelopathic Patients: A Cervical QOD Study. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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13
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Rethorn ZD, Cook CE, Park C, Somers T, Mummaneni PV, Chan AK, Pennicooke BH, Bisson EF, Asher AL, Buchholz AL, Bydon M, Alvi MA, Coric D, Foley KT, Fu KM, Knightly JJ, Meyer S, Park P, Potts EA, Shaffrey CI, Shaffrey M, Than KD, Tumialan L, Turner JD, Upadhyaya CD, Wang MY, Gottfried O. Social risk factors predicting outcomes of cervical myelopathy surgery. J Neurosurg Spine 2022; 37:1-8. [PMID: 35090132 DOI: 10.3171/2021.12.spine21874] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 12/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Combinations of certain social risk factors of race, sex, education, socioeconomic status (SES), insurance, education, employment, and one's housing situation have been associated with poorer pain and disability outcomes after lumbar spine surgery. To date, an exploration of such factors in patients with cervical spine surgery has not been conducted. The objective of the current work was to 1) define the social risk phenotypes of individuals who have undergone cervical spine surgery for myelopathy and 2) analyze their predictive capacity toward disability, pain, quality of life, and patient satisfaction-based outcomes. METHODS The Cervical Myelopathy Quality Outcomes Database was queried for the period from January 2016 to December 2018. Race/ethnicity, educational attainment, SES, insurance payer, and employment status were modeled into unique social phenotypes using latent class analyses. Proportions of social groups were analyzed for demonstrating a minimal clinically important difference (MCID) of 30% from baseline for disability, neck and arm pain, quality of life, and patient satisfaction at the 3-month and 1-year follow-ups. RESULTS A total of 730 individuals who had undergone cervical myelopathy surgery were included in the final cohort. Latent class analysis identified 2 subgroups: 1) high risk (non-White race and ethnicity, lower educational attainment, not working, poor insurance, and predominantly lower SES), n = 268, 36.7% (class 1); and 2) low risk (White, employed with good insurance, and higher education and SES), n = 462, 63.3% (class 2). For both 3-month and 1-year outcomes, the high-risk group (class 1) had decreased odds (all p < 0.05) of attaining an MCID score in disability, neck/arm pain, and health-related quality of life. Being in the low-risk group (class 2) resulted in an increased odds of attaining an MCID score in disability, neck/arm pain, and health-related quality of life. Neither group had increased or decreased odds of being satisfied with surgery. CONCLUSIONS Although 2 groups underwent similar surgical approaches, the social phenotype involving non-White race/ethnicity, poor insurance, lower SES, and poor employment did not meet MCIDs for a variety of outcome measures. This finding should prompt surgeons to proactively incorporate socially conscience care pathways within healthcare systems, as well as to optimize community-based resources to improve outcomes and personalize care for populations at social risk.
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Affiliation(s)
- Zachary D Rethorn
- 1Department of Orthopaedics, Duke University, Durham
- 19Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Medical Center, Durham, North Carolina
| | - Chad E Cook
- 1Department of Orthopaedics, Duke University, Durham
- 3Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Christine Park
- 15Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Tamara Somers
- 3Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Praveen V Mummaneni
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | - Andrew K Chan
- 4Department of Neurological Surgery, University of California, San Francisco, California
| | | | - Erica F Bisson
- 6Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Anthony L Asher
- 7Department of Neurosurgery, Carolina Neurosurgery and Spine Associates and Neuroscience Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Avery L Buchholz
- 8Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Mohamad Bydon
- 9Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Mohammed Ali Alvi
- 9Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Domagoj Coric
- 7Department of Neurosurgery, Carolina Neurosurgery and Spine Associates and Neuroscience Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Kevin T Foley
- 10Department of Neurosurgery, University of Tennessee and Semmes-Murphey Clinic, Memphis, Tennessee
| | - Kai-Ming Fu
- 11Department of Neurological Surgery, Weill Cornell Medicine, New York, New York
| | | | - Scott Meyer
- 12Altair Health Spine and Wellness, Morristown, New Jersey
| | - Paul Park
- 13Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Eric A Potts
- 14Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Christopher I Shaffrey
- 15Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Mark Shaffrey
- 8Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Khoi D Than
- 15Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | | | - Jay D Turner
- 16Barrow Neurological Institute, Phoenix, Arizona
| | | | - Michael Y Wang
- 18Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida; and
| | - Oren Gottfried
- 15Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
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14
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Cook CE, George SZ, Asher AL, Bisson EF, Buchholz AL, Bydon M, Chan AK, Haid RW, Mummaneni PV, Park P, Shaffrey CI, Than KD, Tumialan LM, Wang MY, Gottfried ON. High-impact chronic pain transition in surgical recipients with cervical spondylotic myelopathy. J Neurosurg Spine 2022; 37:1-10. [PMID: 35061992 DOI: 10.3171/2021.11.spine211260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE High-impact chronic pain (HICP) is a recently proposed metric that indicates the presence of a severe and troubling pain-related condition. Surgery for cervical spondylotic myelopathy (CSM) is designed to halt disease transition independent of chronic pain status. To date, the prevalence of HICP in individuals with CSM and their HICP transition from presurgery is unexplored. The authors sought to define HICP prevalence, transition, and outcomes in patients with CSM who underwent surgery and identify predictors of these HICP transition groups. METHODS CSM surgical recipients were categorized as HICP at presurgery and 3 months if they exhibited pain that lasted 6-12 months or longer with at least one major activity restriction. HICP transition groups were categorized and evaluated for outcomes. Multivariate multinomial modeling was used to predict HICP transition categorization. RESULTS A majority (56.1%) of individuals exhibited HICP preoperatively; this value declined to 15.9% at 3 months (71.6% reduction). The presence of HICP was also reflective of other self-reported outcomes at 3 and 12 months, as most demonstrated notable improvement. Higher severity in all categories of self-reported outcomes was related to a continued HICP condition at 3 months. Both social and biological factors predicted HICP translation, with social factors being predominant in transitioning to HICP (from none preoperatively). CONCLUSIONS Many individuals who received CSM surgery changed HICP status at 3 months. In a surgical population where decisions are based on disease progression, most of the changed status went from HICP preoperatively to none at 3 months. Both social and biological risk factors predicted HICP transition assignment.
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Affiliation(s)
- Chad E Cook
- 1Department of Orthopaedics, Duke University, Durham, North Carolina
- 2Duke Clinical Research Institute, Duke University, Durham, North Carolina
- 3Department of Population Health Sciences, Durham, North Carolina
| | - Steven Z George
- 1Department of Orthopaedics, Duke University, Durham, North Carolina
- 2Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Anthony L Asher
- 4Department of Neurosurgery, Carolina Neurosurgery and Spine Associates and Neuroscience Institute, Carolinas HealthCare System, Charlotte, North Carolina
| | - Erica F Bisson
- 5Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Avery L Buchholz
- 6Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Mohamad Bydon
- 7Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Andrew K Chan
- 8Department of Neurological Surgery, University of California, San Francisco, California
| | - Regis W Haid
- 9PPG Atlanta Brain and Spine Care, Atlanta, Georgia
| | - Praveen V Mummaneni
- 8Department of Neurological Surgery, University of California, San Francisco, California
| | - Paul Park
- 10Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Christopher I Shaffrey
- 11Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Khoi D Than
- 11Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | | | - Michael Y Wang
- 13Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Oren N Gottfried
- 11Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
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15
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Lee NJ, Buchanan IA, Zuckermann SL, Boddapati V, Mathew J, Geiselmann M, Park PJ, Leung E, Buchholz AL, Khan A, Mullin J, Pollina J, Jazini E, Haines C, Schuler TC, Good CR, Lombardi JM, Lehman RA. What Is the Comparison in Robot Time per Screw, Radiation Exposure, Robot Abandonment, Screw Accuracy, and Clinical Outcomes Between Percutaneous and Open Robot-Assisted Short Lumbar Fusion?: A Multicenter, Propensity-Matched Analysis of 310 Patients. Spine (Phila Pa 1976) 2022; 47:42-48. [PMID: 34091564 PMCID: PMC8654274 DOI: 10.1097/brs.0000000000004132] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/09/2021] [Accepted: 05/03/2021] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Multicenter cohort. OBJECTIVE To compare the robot time/screw, radiation exposure, robot abandonment, screw accuracy, and 90-day outcomes between robot-assisted percutaneous and robot-assisted open approach for short lumbar fusion (1- and 2-level). SUMMARY OF BACKGROUND DATA There is conflicting literature on the superiority of robot-assisted minimally invasive spine surgery to open techniques. A large, multicenter study is needed to further elucidate the outcomes and complications between these two approaches. METHODS We included adult patients (≥18 yrs old) who underwent robot-assisted short lumbar fusion surgery from 2015 to 2019 at four independent institutions. A propensity score matching algorithm was employed to control for the potential selection bias between percutaneous and open surgery. The minimum follow-up was 90 days after the index surgery. RESULTS After propensity score matching, 310 patients remained. The mean (standard deviation) Charlson comorbidity index was 1.6 (1.5) and 53% of patients were female. The most common diagnoses included high-grade spondylolisthesis (grade >2) (48%), degenerative disc disease (22%), and spinal stenosis (25%), and the mean number of instrumented levels was 1.5(0.5). The operative time was longer in the open (198 min) versus the percutaneous group (167 min, P value = 0.007). However, the robot time/screw was similar between cohorts (P value > 0.05). The fluoroscopy time/ screw for percutaneous (14.4 s) was longer than the open group (10.1 s, P value = 0.021). The rates for screw exchange and robot abandonment were similar between groups (P value > 0.05). The estimated blood loss (open: 146 mL vs. percutaneous: 61.3 mL, P value < 0.001) and transfusion rate (open: 3.9% vs. percutaneous: 0%, P value = 0.013) were greater for the open group. The 90-day complication rate and mean length of stay were not different between cohorts (P value > 0.05). CONCLUSION Percutaneous robot-assisted spine surgery may increase radiation exposure, but can achieve a shorter operative time and lower risk for intraoperative blood loss for short-lumbar fusion. Percutaneous approaches do not appear to have an advantage for other short-term postoperative outcomes. Future multicenter studies on longer fusion surgeries and the inclusion of patient-reported outcomes are needed.Level of Evidence: 3.
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Affiliation(s)
- Nathan J. Lee
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY
| | - Ian A. Buchanan
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY
| | - Scott L. Zuckermann
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY
| | - Venkat Boddapati
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY
| | - Justin Mathew
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY
| | - Matthew Geiselmann
- New York Institute of Technology College of Osteopathic Medicine, Old Westbury, NY
| | - Paul J. Park
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY
| | - Eric Leung
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY
| | - Avery L. Buchholz
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA
| | - Asham Khan
- Department of Neurosurgery, State University of New York, Buffalo, NY
| | - Jeffrey Mullin
- Department of Neurosurgery, State University of New York, Buffalo, NY
| | - John Pollina
- Department of Neurosurgery, State University of New York, Buffalo, NY
| | - Ehsan Jazini
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA
| | - Colin Haines
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA
| | | | | | - Joseph M. Lombardi
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY
| | - Ronald A. Lehman
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY
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16
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Liounakos JI, Khan A, Eliahu K, Mao JZ, Good CR, Pollina J, Haines CM, Gum JL, Schuler TC, Jazini E, Chua RV, Shafa E, Buchholz AL, Pham MH, Poelstra KA, Wang MY. Ninety-day complication, revision, and readmission rates for current-generation robot-assisted thoracolumbar spinal fusion surgery: results of a multicenter case series. J Neurosurg Spine 2021:1-8. [PMID: 34826805 DOI: 10.3171/2021.8.spine21330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 08/24/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Robotics is a major area for research and development in spine surgery. The high accuracy of robot-assisted placement of thoracolumbar pedicle screws is documented in the literature. The authors present the largest case series to date evaluating 90-day complication, revision, and readmission rates for robot-assisted spine surgery using the current generation of robotic guidance systems. METHODS An analysis of a retrospective, multicenter database of open and minimally invasive thoracolumbar instrumented fusion surgeries using the Mazor X or Mazor X Stealth Edition robotic guidance systems was performed. Patients 18 years of age or older and undergoing primary or revision surgery for degenerative spinal conditions were included. Descriptive statistics were used to calculate rates of malpositioned screws requiring revision, as well as overall complication, revision, and readmission rates within 90 days. RESULTS In total, 799 surgical cases (Mazor X: 48.81%; Mazor X Stealth Edition: 51.19%) were evaluated, involving robot-assisted placement of 4838 pedicle screws. The overall intraoperative complication rate was 3.13%. No intraoperative implant-related complications were encountered. Postoperatively, 129 patients suffered a total of 146 complications by 90 days, representing an incidence of 16.1%. The rate of an unrecognized malpositioned screw resulting in a new postoperative radiculopathy requiring revision surgery was 0.63% (5 cases). Medical and pain-related complications unrelated to hardware placement accounted for the bulk of postoperative complications within 90 days. The overall surgical revision rate at 90 days was 6.63% with 7 implant-related revisions, representing an implant-related revision rate of 0.88%. The 90-day readmission rate was 7.13% with 2 implant-related readmissions, representing an implant-related readmission rate of 0.25% of cases. CONCLUSIONS The results of this multicenter case series and literature review suggest current-generation robotic guidance systems are associated with low rates of intraoperative and postoperative implant-related complications, revisions, and readmissions at 90 days. Future outcomes-based studies are necessary to evaluate complication, revision, and readmission rates compared to conventional surgery.
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Affiliation(s)
| | - Asham Khan
- 2Department of Neurosurgery, University at Buffalo, New York
| | - Karen Eliahu
- 1Department of Neurological Surgery, University of Miami, Florida
| | - Jennifer Z Mao
- 2Department of Neurosurgery, University at Buffalo, New York
| | | | - John Pollina
- 2Department of Neurosurgery, University at Buffalo, New York
| | | | - Jeffrey L Gum
- 4Norton Leatherman Spine Center, Louisville, Kentucky
| | | | | | | | - Eiman Shafa
- 6Twin Cities Spine Center, Minneapolis, Minnesota
| | - Avery L Buchholz
- 7Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Martin H Pham
- 8Department of Neurosurgery, UC San Diego School of Medicine, La Jolla, California; and
| | | | - Michael Y Wang
- 1Department of Neurological Surgery, University of Miami, Florida
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17
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Asuzu DT, Yun JJ, Alvi MA, Chan AK, Upadhyaya CD, Coric D, Potts EA, Bisson EF, Turner JD, Knightly JJ, Fu KM, Foley KT, Tumialan L, Shaffrey M, Bydon M, Mummaneni PV, Park P, Meyer S, Asher AL, Gottfried ON, Than KD, Wang MY, Buchholz AL. Association of ≥ 12 months of delayed surgical treatment for cervical myelopathy with worsened postoperative outcomes: a multicenter analysis of the Quality Outcomes Database. J Neurosurg Spine 2021; 36:568-574. [PMID: 34740180 DOI: 10.3171/2021.7.spine21590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/19/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Degenerative cervical myelopathy (DCM) results in significant morbidity. The duration of symptoms prior to surgical intervention may be associated with postoperative surgical outcomes and functional recovery. The authors' objective was to investigate whether delayed surgical treatment for DCM is associated with worsened postoperative outcomes. METHODS Data from 1036 patients across 14 surgical centers in the Quality Outcomes Database were analyzed. Baseline demographic characteristics and findings of preoperative and postoperative symptom evaluations, including duration of symptoms, were assessed. Postoperative functional outcomes were measured using the Neck Disability Index (NDI) and modified Japanese Orthopaedic Association (mJOA) scale. Symptom duration was classified as either less than 12 months or 12 months or greater. Univariable and multivariable regression were used to evaluate for the associations between symptom duration and postoperative outcomes. RESULTS In this study, 513 patients (49.5%) presented with symptom duration < 12 months, and 523 (50.5%) had symptoms for 12 months or longer. Patients with longer symptom duration had higher BMI and higher prevalence of anxiety and diabetes (all p < 0.05). Symptom duration ≥ 12 months was associated with higher average baseline NDI score (41 vs 36, p < 0.01). However, improvements in NDI scores from baseline were not significantly different between groups at 3 months (p = 0.77) or 12 months (p = 0.51). Likewise, the authors found no significant differences between groups in changes in mJOA scores from baseline to 3 months or 12 months (both p > 0.05). CONCLUSIONS Surgical intervention resulted in improved mJOA and NDI scores at 3 months, and this improvement was sustained in both patients with short and longer initial symptom duration. Patients with DCM can still undergo successful surgical management despite delayed presentation.
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Affiliation(s)
- David T Asuzu
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia.,2Surgical Neurology Branch, National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Jonathan J Yun
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Andrew K Chan
- 5Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | | | - Domagoj Coric
- 7Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Eric A Potts
- 8Goodman Campbell Brain and Spine, Carmel, Indiana
| | - Erica F Bisson
- 4Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Jay D Turner
- 9Barrow Neurological Institute, Phoenix, Arizona
| | | | - Kai-Ming Fu
- 11Department of Neurological Surgery, Weill Cornell Medicine, New York, New York
| | - Kevin T Foley
- 12Department of Neurosurgery, University of Tennessee, Memphis, Tennessee
| | | | - Mark Shaffrey
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Mohamad Bydon
- 3Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Praveen V Mummaneni
- 5Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Paul Park
- 13Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Scott Meyer
- 10Altair Health Spine and Wellness, Morristown, New Jersey
| | - Anthony L Asher
- 7Carolina Neurosurgery and Spine Associates, Charlotte, North Carolina
| | - Oren N Gottfried
- 14Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina; and
| | - Khoi D Than
- 14Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina; and
| | - Michael Y Wang
- 15Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Avery L Buchholz
- 1Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
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18
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Asuzu DT, Desai B, Maggio D, Mandell J, Ray-Chaudhury A, Abdullaev Z, Aldape K, Heiss J, Buchholz AL. FGFR1-TACC1 fusion associated with malignant transformation in a primary spinal cord glioma: a case report. J Spine Surg 2021; 7:434-438. [PMID: 34734147 DOI: 10.21037/jss-21-24] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 05/20/2021] [Indexed: 12/26/2022]
Abstract
Molecular mechanisms of malignant transformation in spinal cord gliomas are not well-understood. Our objective was to investigate genetic causes of malignant transformation in a primary spinal cord glioma. A 32-year-old female patient presented with bilateral lower extremity weakness and was diagnosed with a primary spinal cord glioma from T9 to T12, with a syrinx extending from the craniocervical junction to the conus. She underwent resection in 2006. Pathology showed an abundance of Rosenthal fibers, calcification and degenerative features consistent with a low-grade pilocytic astrocytoma. She presented in 2020 with tumor recurrence and underwent re-resection. Whole exome sequencing, DNA methylation profiling and immunohistochemistry were performed on her initial and recurrent tumor samples. Immunohistochemical profiling of her recurrent tumor showed pleomorphic cells with extensive necrosis consistent with a high-grade glioma. DNA methylation profiling showed that the initial tumor clustered with pilocytic astrocytomas, whereas the recurrent lesion clustered with anaplastic astrocytomas, confirming malignant transformation. Whole-exome sequencing showed interim acquisition of a rare fibroblast growth factor receptor-transforming acidic coiled-coil (FGFR1-TACC1) gene fusion. We report an FGFR1-TACC1 fusion associated with malignant transformation in a primary spinal cord glioma. Our study adds to growing reports of FGFR-TACC fusions, which are amenable to receptor tyrosine kinase inhibition.
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Affiliation(s)
- David T Asuzu
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Bhargav Desai
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Dominic Maggio
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA.,Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - James Mandell
- Division of Neuropathology, University of Virginia, Charlottesville, Virginia, USA
| | - Abhik Ray-Chaudhury
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Zied Abdullaev
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Kenneth Aldape
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - John Heiss
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Avery L Buchholz
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
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19
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Lee NJ, Zuckerman SL, Buchanan IA, Boddapati V, Mathew J, Leung E, Park PJ, Pham MH, Buchholz AL, Khan A, Pollina J, Mullin JP, Jazini E, Haines C, Schuler TC, Good CR, Lombardi JM, Lehman RA. Is there a difference between navigated and non-navigated robot cohorts in robot-assisted spine surgery? A multicenter, propensity-matched analysis of 2,800 screws and 372 patients. Spine J 2021; 21:1504-1512. [PMID: 34022461 DOI: 10.1016/j.spinee.2021.05.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 03/23/2021] [Accepted: 05/12/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Robot-assisted spine surgery continues to rapidly develop as evidenced by the growing literature in recent years. In addition to demonstrating excellent pedicle screw accuracy, early studies have explored the impact of robot-assisted spine surgery on reducing radiation time, length of hospital stay, operative time, and perioperative complications in comparison to conventional freehand technique. Recently, the Mazor X Stealth Edition was introduced in 2018. This robotic system integrates Medtronic's Stealth navigation technology into the Mazor X platform, which was introduced in 2016. It is unclear what the impact of these advancements have made on clinical outcomes. PURPOSE To compare the outcomes and complications between the most recent iterations of the Mazor Robot systems: Mazor X and Mazor X Stealth Edition. STUDY DESIGN Multicenter cohort PATIENT SAMPLE: Among four different institutions, we included adult (≥18 years old) patients who underwent robot-assisted spine surgery with either the Mazor X (non-navigated robot) or Stealth (navigated robot) platforms. OUTCOME MEASURES Primary outcomes included robot time per screw, fluoroscopic radiation time, screw accuracy, robot abandonment, and clinical outcomes with a minimum 90 day follow up. METHODS A one-to-one propensity-score matching algorithm based on perioperative factors (e.g. demographics, comorbidities, primary diagnosis, open vs. percutaneous instrumentation, prior spine surgery, instrumented levels, pelvic fixation, interbody fusion, number of planned robot screws) was employed to control for the potential selection bias between the two robotic systems. Chi-square/fisher exact test and t-test/ANOVA were used for categorical and continuous variables, respectively. RESULTS From a total of 646 patients, a total of 372 adult patients were included in this study (X: 186, Stealth: 186) after propensity score matching. The mean number of instrumented levels was 4.3. The mean number of planned robot screws was 7.8. Similar total operative time and robot time per screw occurred between cohorts (p>0.05). However, Stealth achieved significantly shorter fluoroscopic radiation time per screw (Stealth: 7.2 seconds vs. X: 10.4 seconds, p<.001) than X. The screw accuracy for both robots was excellent (Stealth: 99.6% vs. X: 99.1%, p=0.120). In addition, Stealth achieved a significantly lower robot abandonment rate (Stealth: 0% vs. X: 2.2%, p=0.044). Furthermore, a lower blood transfusion rate was observed for Stealth than X (Stealth: 4.3% vs. X: 10.8%, p=0.018). Non-robot related complications such as dura tear, motor/sensory deficits, return to the operating room during same admission, and length of stay was similar between robots (p>0.05). The 90-day complication rates were low and similar between robot cohorts (Stealth: 5.4% vs. X: 3.8%, p=0.456). CONCLUSION In this multicenter study, both robot systems achieved excellent screw accuracy and low robot time per screw. However, using Stealth led to significantly less fluoroscopic radiation time, lower robot abandonment rates, and reduced blood transfusion rates than Mazor X. Other factors including length of stay, and 90-day complications were similar.
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Affiliation(s)
- Nathan J Lee
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA.
| | - Scott L Zuckerman
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Ian A Buchanan
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Venkat Boddapati
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Justin Mathew
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Eric Leung
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Paul J Park
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Martin H Pham
- Department of Neurosurgery, University of San Diego Health, Sand Diego, CA, USA
| | - Avery L Buchholz
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Asham Khan
- Department of Neurosurgery, State University of New York, Buffalo, NY, USA
| | - John Pollina
- Department of Neurosurgery, State University of New York, Buffalo, NY, USA
| | - Jeffrey P Mullin
- Department of Neurosurgery, State University of New York, Buffalo, NY, USA
| | - Ehsan Jazini
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA
| | - Colin Haines
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA
| | - Thomas C Schuler
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA
| | | | - Joseph M Lombardi
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
| | - Ronald A Lehman
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, New York, NY, USA
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20
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Asuzu DT, Buchholz AL. MAZOR-X robotic-navigated percutaneous C2 screw placement for hangman's fracture: a case report. J Spine Surg 2021; 7:439-444. [PMID: 34734148 PMCID: PMC8511574 DOI: 10.21037/jss-20-676] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 04/25/2021] [Indexed: 05/26/2023]
Abstract
Robotic-navigated screw placement has potential for higher precision and accuracy. Robotic assistance is well-described in the lumbar spine, however only few studies have evaluated its use in the cervical spine. Surgical treatment for hangman's fractures after nonunion typically involves C2-3 anterior fusion or posterior occipito-cervical fusion. However, occipito-cervical fusion involves loss of mobility in the cervical spine with associated morbidity. We have previously described a minimally invasive approach using percutaneous screw fixation with X-ray navigation. Robotic assistance is ideally suited for cervical fusion given smaller bony anatomy and adjacent critical structures. We describe a young healthy patient who presented with a hangman's fracture initially managed conservatively with immobilization. She presented with nonunion and persistent symptoms. Surgical options considered included anterior cervical discectomy and fusion, or posterior cervical fusion with or without extension to the occiput. These options would have involved some loss of flexion/extension and rotational motion with associated morbidity. We performed percutaneous screw fixation of the hangman's fracture using MAZOR-X robotic navigation and achieved good radiographic fracture reduction with accurate screw placement. To our knowledge this is the first case of a robotic-assisted percutaneous screw fixation for a hangman's fracture. Robotic-navigated screw placement can be used safely and accurately for cervical spine fractures.
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Affiliation(s)
- David T. Asuzu
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
- Surgical Neurology Branch, National Institute of Neurologic Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - Avery L. Buchholz
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
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21
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Tempel ZJ, Hlubek RJ, Kachmann MC, Body A, Okonkwo DO, Kanter AS, Buchholz AL, Krueger BM. Novel Distributed Loading Technique Using Multimaterial, Long-Segment Spinal Constructs to Prevent Proximal Junctional Pathology in Adult Spinal Deformity Correction-Operative Technique and Radiographic Findings. World Neurosurg 2021; 155:e264-e270. [PMID: 34418605 DOI: 10.1016/j.wneu.2021.08.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/09/2021] [Accepted: 08/11/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Proximal junctional kyphosis (PJK) and proximal junction failure are common and costly complications after long-segment adult spinal deformity (ASD) correction. Although much research has focused on the concept of "softening the landing" to prevent proximal junction pathologies, long-segment constructs largely deviate from the force-deformation curve of the physiologic spine. Our novel distributed loading technique for ASD correction is described using multimaterial, long-segment constructs to create a biomechanically sound, yet physiologic, decremental stiffness toward the rostral end. METHODS Operative steps detail the custom-designed constructs of dual-headed pedicle screws and varied rod diameters and materials (cobalt chromium or titanium) for an initial 20 patients (mean 66.6 ± 4.8 years). Standing scoliosis films were obtained preoperatively and at regular intervals postoperatively to assess for PJK. RESULTS No patient had evidence of PJK or proximal junction failure at latest radiographic follow-up (mean 17.9 months, range 13-25 months). Radiographic findings for sagittal vertical axis averaged 11.2 ± 5.6 cm preoperatively and 3.6 ± 2.3 cm postoperatively. Compared with preoperative parameters, postoperative reductions in pelvic incidence-lumbar lordosis mismatch averaged 28.7 ± 12.9 degrees, and sagittal vertical axis averaged 7.6 ± 5.2 cm while PJA was essentially unchanged. CONCLUSIONS Preliminary results suggest that the distributed loading technique is promising for prevention of PJK with stiffness gradients that mimic the force-deformation curve of the physiologic posterior tension band. Our technique may optimize the degree of stress at the proximal junction without overwhelming the anterior column bony while remodeling and mature arthrodesis takes place.
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Affiliation(s)
| | | | | | - Alaina Body
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Adam S Kanter
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Avery L Buchholz
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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22
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Buell TJ, Buchholz AL, Mazur MD, Mullin JP, Chen CJ, Sokolowski JD, Yen CP, Shaffrey ME, Shaffrey CI, Smith JS. Kickstand Rod Technique for Correcting Coronal Imbalance in Adult Scoliosis: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 19:E163-E164. [PMID: 31584101 DOI: 10.1093/ons/opz306] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Accepted: 07/15/2019] [Indexed: 11/14/2022] Open
Abstract
Restoration of spinal alignment and balance is a major goal of adult scoliosis surgery. In the past, sagittal alignment has been emphasized and was shown to have the greatest impact on functional outcomes. However, recent evidence suggests the impact of coronal imbalance on pain and functional outcomes has likely been underestimated.1,2 In addition, iatrogenic coronal imbalance may be common and frequently results from inadequate correction of the lumbosacral fractional curve.2,3 The "kickstand rod" is a recently described technique to achieve and maintain significant coronal-plane correction.4 Also, of secondary benefit, the kickstand rod may function as an accessory supplemental rod to offload stress and bolster primary instrumentation. This may reduce occurrence of rod fracture (RF) or pseudarthrosis (PA).5 Briefly, this technique involves positioning the kickstand rod on the side of coronal imbalance (along the major curve concavity or fractional curve convexity in our video demonstration). The kickstand rod spans the thoracolumbar junction proximally to the pelvis distally and is secured with an additional iliac screw placed just superior to the primary iliac screw. By using the iliac wing as a base, powerful distraction forces can reduce the major curve to achieve more normal coronal balance. This operative video illustrates the technical nuances of utilizing the kickstand rod technique for correction of severe lumbar scoliosis and coronal malalignment in a 60-yr-old male patient. Alignment correction was achieved and maintained without evidence of RF/PA after nearly 6 mo postoperatively. The patient gave informed consent for surgery and to use imaging for medical publication.
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Affiliation(s)
- Thomas J Buell
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia.,Department of Neurosurgery, Auckland City Hospital, Auckland, New Zealand
| | - Avery L Buchholz
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Marcus D Mazur
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Jeffrey P Mullin
- Department of Neurosurgery, University at Buffalo, Buffalo, New York
| | - Ching-Jen Chen
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jennifer D Sokolowski
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Chun-Po Yen
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Mark E Shaffrey
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | | | - Justin S Smith
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
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23
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Lee NJ, Buchanan IA, Boddapati V, Mathew J, Marciano G, Park PJ, Leung E, Buchholz AL, Pollina J, Jazini E, Haines C, Schuler TC, Good CR, Lombardi JM, Lehman RA. Do robot-related complications influence 1 year reoperations and other clinical outcomes after robot-assisted lumbar arthrodesis? A multicenter assessment of 320 patients. J Orthop Surg Res 2021; 16:308. [PMID: 33980261 PMCID: PMC8114480 DOI: 10.1186/s13018-021-02452-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Robot-assisted platforms in spine surgery have rapidly developed into an attractive technology for both the surgeon and patient. Although current literature is promising, more clinical data is needed. The purpose of this paper is to determine the effect of robot-related complications on clinical outcomes METHODS: This multicenter study included adult (≥18 years old) patients who underwent robot-assisted lumbar fusion surgery from 2012-2019. The minimum follow-up was 1 year after surgery. Both bivariate and multivariate analyses were performed to determine if robot-related factors were associated with reoperation within 1 year after primary surgery. RESULTS A total of 320 patients were included in this study. The mean (standard deviation) Charlson Comorbidity Index was 1.2 (1.2) and 52.5% of patients were female. Intraoperative robot complications occurred in 3.4% of patients and included intraoperative exchange of screw (0.9%), robot abandonment (2.5%), and return to the operating room for screw exchange (1.3%). The 1-year reoperation rate was 4.4%. Robot factors, including robot time per screw, open vs. percutaneous, and robot system, were not statistically different between those who required revision surgery and those who did not (P>0.05). Patients with robot complications were more likely to have prolonged length of hospital stay and blood transfusion, but were not at higher risk for 1-year reoperations. The most common reasons for reoperation were wound complications (2.2%) and persistent symptoms due to inadequate decompression (1.5%). In the multivariate analysis, robot related factors and complications were not independent risk factors for 1-year reoperations. CONCLUSION This is the largest multicenter study to focus on robot-assisted lumbar fusion outcomes. Our findings demonstrate that 1-year reoperation rates are low and do not appear to be influenced by robot-related factors and complications; however, robot-related complications may increase the risk for greater blood loss requiring a blood transfusion and longer length of stay.
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Affiliation(s)
- Nathan J Lee
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, 161 Fort Washington Avenue, New York, NY, 10032, USA.
| | - Ian A Buchanan
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Venkat Boddapati
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Justin Mathew
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Gerard Marciano
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Paul J Park
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Eric Leung
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Avery L Buchholz
- Department of Neurosurgery, University of Virginia Health System, Charlottesville, VA, USA
| | - John Pollina
- Department of Neurosurgery, State University of New York, Buffalo, NY, USA
| | - Ehsan Jazini
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA
| | - Colin Haines
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA
| | - Thomas C Schuler
- Department of Orthopaedics, Virginia Spine Institute, Reston, VA, USA
| | | | - Joseph M Lombardi
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, 161 Fort Washington Avenue, New York, NY, 10032, USA
| | - Ronald A Lehman
- Department of Orthopaedics, Columbia University Medical Center, The Och Spine Hospital at New York-Presbyterian, 161 Fort Washington Avenue, New York, NY, 10032, USA
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24
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Rabinovich EP, Snyder MH, McClure JJ, Buell TJ, Smith JS, Shaffrey CI, Buchholz AL. Posterior Polyethylene Tethers Reduce Occurrence of Proximal Junctional Kyphosis After Multilevel Spinal Instrumentation for Adult Spinal Deformity: A Retrospective Analysis. Neurosurgery 2021; 89:227-235. [PMID: 33971008 DOI: 10.1093/neuros/nyab123] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 01/30/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Proximal junctional kyphosis (PJK) is a common postoperative complication after adult spinal deformity (ASD) surgery and may manifest with neurological decline, worsening spinal deformity, and spinal instability, which warrant reoperation. Rates of PJK may be as high as 69.4% after ASD surgery. OBJECTIVE To evaluate the efficacy of junctional tethers for PJK prophylaxis after multilevel instrumented surgery for ASD with minimum 2-yr follow-up. METHODS Single-center retrospective analysis of adult patients (age ≥18 yr) who underwent ASD surgery with index operations performed between November 2010 and June 2016 and achieved minimum 2-yr follow-up. Patients with ASD were subdivided into 3 treatment cohorts based on institutional protocol: no tether (NT), polyethylene tether-only (TO), and tether with crosslink (TC). PJK was defined as a proximal junctional angle (PJA) >10° and 10° greater than the corresponding preoperative measurement. Patient demographics, operative details, standard radiographic scoliosis measurements (including PJA and assessment of PJK), and complications were analyzed. RESULTS Of 184 patients, 146 (79.3%) achieved minimum 2-yr follow-up (mean = 45 mo; mean age = 67 yr; 67.8% women). PJK rates reported for the NT, TO, and TC cohorts were 60.7% (37/61), 35.7% (15/42), and 23.3% (10/43), respectively. PJK rates among TC patients were significantly lower than NT (P = .01601). CONCLUSION Junctional tethers with crosslink significantly reduced the incidence of PJK and revisions for PJK among ASD patients treated with long-segment posterior instrumented fusions who achieved minimum 2-yr follow-up.
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Affiliation(s)
- Emily P Rabinovich
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - M Harrison Snyder
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Jesse J McClure
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA.,Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Christopher I Shaffrey
- Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina, USA.,Department of Orthopedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Avery L Buchholz
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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McClure JJ, Desai BD, Ampie L, You W, Smith JS, Buchholz AL. A Systematic Review of the Cost-Utility of Spinal Cord Stimulation for Persistent Low Back Pain in Patients With Failed Back Surgery Syndrome. Global Spine J 2021; 11:66S-72S. [PMID: 33890806 PMCID: PMC8076810 DOI: 10.1177/2192568220970163] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
STUDY DESIGN Systematic Review. OBJECTIVES To review the literature surrounding the cost-effectiveness of implanting spinal cord stimulators for failed back surgery syndrome. METHODS A systematic review was conducted inclusive of all publications in the Medline database and Cochrane CENTRAL trials register within the last 10 years (English language only) assessing the cost-effectiveness of Spinal Cord Stimulator device implantation (SCSdi) in patients with previous lumbar fusion surgery. RESULTS The majority of reviewed publications that analyzed cost-effectiveness of SCSdi compared to conventional medical management (CMM) or re-operation in patients with failed back surgery syndrome (FBSS) showed an overall increase in direct medical costs; these increased costs were found in nearly all cases to be offset by significant improvements in patient quality of life. The cost required to achieve these increases in quality adjusted life years (QALY) falls well below $25 000/QALY, a conservative estimate of willingness to pay. CONCLUSIONS The data suggest that SCSdi provides both superior outcomes and a lower incremental cost: effectiveness ratio (ICER) compared to CMM and/or re-operation in patients with FBSS. These findings are in spite of the fact that the majority of studies reviewed were agnostic to the type of device or innervation utilized in SCSdi. Newer devices utilizing burst or higher frequency stimulation have demonstrated their superiority over traditional SCSdi via randomized clinical trials and may provide lower ICERs.
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Affiliation(s)
- Jesse J. McClure
- Department of Neurosurgery, UVA School of Medicine, Charlottesville, VA, USA
| | - Bhargav D. Desai
- Department of Neurosurgery, UVA School of Medicine, Charlottesville, VA, USA
| | - Leonel Ampie
- Department of Neurosurgery, UVA School of Medicine, Charlottesville, VA, USA,Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, USA
| | - Wen You
- Department of Neurosurgery, UVA School of Medicine, Charlottesville, VA, USA
| | - Justin S. Smith
- Department of Neurosurgery, UVA School of Medicine, Charlottesville, VA, USA
| | - Avery L. Buchholz
- Department of Neurosurgery, UVA School of Medicine, Charlottesville, VA, USA,Avery L. Buchholz, Department of Neurosurgery, UVA School of Medicine, Charlottesville, VA, USA.
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Soldozy S, Montgomery SR, Sarathy D, Young S, Skaff A, Desai B, Sokolowski JD, Sandhu FA, Voyadzis JM, Yağmurlu K, Buchholz AL, Shaffrey ME, Syed HR. Diagnostic, Surgical, and Technical Considerations for Lumbar Interbody Fusion in Patients with Osteopenia and Osteoporosis: A Systematic Review. Brain Sci 2021; 11:brainsci11020241. [PMID: 33673005 PMCID: PMC7918554 DOI: 10.3390/brainsci11020241] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/29/2021] [Accepted: 02/02/2021] [Indexed: 12/11/2022] Open
Abstract
Objective: Osteoporosis is increasing in incidence as the ageing population continues to grow. Decreased bone mineral density poses a challenge for the spine surgeon. In patients requiring lumbar interbody fusion, differences in diagnostics and surgical approaches may be warranted. In this systematic review, the authors examine studies performing lumbar interbody fusion in patients with osteopenia or osteoporosis and suggest avenues for future study. Methods: A systematic literature review of the PubMed and MEDLINE databases was performed for studies published between 1986 and 2020. Studies evaluating diagnostics, surgical approaches, and other technical considerations were included. Results: A total of 13 articles were ultimately selected for qualitative analysis. This includes studies demonstrating the utility of Hounsfield units in diagnosis, a survey of surgical approaches, as well as exploring the use of vertebral augmentation and cortical bone screw trajectory. Conclusions: This systematic review provides a summary of preliminary findings with respect to the use of Hounsfield units as a diagnostic tool, the benefit or lack thereof with respect to minimally invasive approaches, and the question of whether or not cement augmentation or cortical bone trajectory confers benefit in osteoporotic patients undergoing lumbar interbody fusion. While the findings of these studies are promising, the current state of the literature is limited in scope and, for this reason, definitive conclusions cannot be drawn from these data. The authors highlight gaps in the literature and the need for further exploration and study of lumbar interbody fusion in the osteoporotic spine.
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Affiliation(s)
- Sauson Soldozy
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA; (S.S.); (D.S.); (B.D.); (J.D.S.); (K.Y.); (A.L.B.); (M.E.S.)
| | - Samuel R. Montgomery
- Department of Orthopedic Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA; (S.R.M.J.); (A.S.)
| | - Danyas Sarathy
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA; (S.S.); (D.S.); (B.D.); (J.D.S.); (K.Y.); (A.L.B.); (M.E.S.)
| | - Steven Young
- Department of Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA;
| | - Anthony Skaff
- Department of Orthopedic Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA; (S.R.M.J.); (A.S.)
| | - Bhargav Desai
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA; (S.S.); (D.S.); (B.D.); (J.D.S.); (K.Y.); (A.L.B.); (M.E.S.)
| | - Jennifer D. Sokolowski
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA; (S.S.); (D.S.); (B.D.); (J.D.S.); (K.Y.); (A.L.B.); (M.E.S.)
| | - Faheem A. Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC 3800, USA; (F.A.S.); (J.-M.V.)
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC 3800, USA; (F.A.S.); (J.-M.V.)
| | - Kaan Yağmurlu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA; (S.S.); (D.S.); (B.D.); (J.D.S.); (K.Y.); (A.L.B.); (M.E.S.)
| | - Avery L. Buchholz
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA; (S.S.); (D.S.); (B.D.); (J.D.S.); (K.Y.); (A.L.B.); (M.E.S.)
| | - Mark E. Shaffrey
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA; (S.S.); (D.S.); (B.D.); (J.D.S.); (K.Y.); (A.L.B.); (M.E.S.)
| | - Hasan R. Syed
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, VA 22903, USA; (S.S.); (D.S.); (B.D.); (J.D.S.); (K.Y.); (A.L.B.); (M.E.S.)
- Correspondence: ; Tel.: +1-434-924-2735
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Dunn LK, Chen CJ, Taylor DG, Esfahani K, Brenner B, Luo C, Buell TJ, Spangler SN, Buchholz AL, Smith JS, Shaffrey CI, Nemergut EC, Durieux ME, Naik BI. Postoperative Low-Dose Tranexamic Acid After Major Spine Surgery: A Matched Cohort Analysis. Neurospine 2020; 17:888-895. [PMID: 33401867 PMCID: PMC7788407 DOI: 10.14245/ns.2040114.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/08/2020] [Indexed: 01/04/2023] Open
Abstract
Objective This was a retrospective, cohort study investigating the efficacy and safety of continuous low-dose postoperative tranexamic acid (PTXA) on drain output and transfusion requirements following adult spinal deformity surgery.
Methods One hundred forty-seven patients undergoing posterior instrumented thoracolumbar fusion of ≥ 3 vertebral levels at a single institution who received low-dose PTXA infusion (0.5–1 mg/kg/hr) for 24 hours were compared to 292 control patients who did not receive PTXA. The cohorts were propensity matched based on age, sex, American Society of Anesthesiologist physical status classification, body mass index, number of surgical levels, revision surgery, operative duration, and total intraoperative TXA dose (n = 106 in each group). Primary outcome was 72-hour postoperative drain output. Secondary outcomes were number of allogeneic blood transfusions.
Results There was no significant difference in postoperative drain output in the PTXA group compared to control (660 ±420 mL vs. 710 ±490 mL, p = 0.46). The PTXA group received significantly more crystalloid (6,100 ±3,100 mL vs. 4,600 ±2,400 mL, p < 0.001) and red blood cell transfusions postoperatively (median [interquartile range]: 1 [0–2] units vs. 0 [0–1] units; incidence rate ratio [95% confidence interval], 1.6 [1.2–2.2]; p = 0.001). Rates of adverse events were comparable between groups.
Conclusion Continuous low-dose PTXA infusion was not associated with reduced drain output after spinal deformity surgery. No difference in thromboembolic incidence was observed. A prospective dose escalation study is warranted to investigate the efficacy of higher dose PTXA.
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Affiliation(s)
- Lauren K Dunn
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Davis G Taylor
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Kamilla Esfahani
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Brian Brenner
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Charles Luo
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Sarah N Spangler
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Avery L Buchholz
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Christopher I Shaffrey
- Departments of Neurosurgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Edward C Nemergut
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Marcel E Durieux
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
| | - Bhiken I Naik
- Department of Anesthesiology, University of Virginia Health Science Center, Charlottesville, VA, USA.,Department of Neurological Surgery, University of Virginia Health Science Center, Charlottesville, VA, USA
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McClure JJ, Desai BD, Shabo LM, Buell TJ, Yen CP, Smith JS, Shaffrey CI, Shaffrey ME, Buchholz AL. A single-center retrospective analysis of 3- or 4-level anterior cervical discectomy and fusion: surgical outcomes in 66 patients. J Neurosurg Spine 2020:1-7. [PMID: 33036003 DOI: 10.3171/2020.6.spine20171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 06/12/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Anterior cervical discectomy and fusion (ACDF) is a safe and effective intervention to treat cervical spine pathology. Although these were originally performed as single-level procedures, multilevel ACDF has been performed for patients with extensive degenerative disc disease. To date, there is a paucity of data regarding outcomes related to ACDFs of 3 or more levels. The purpose of this study was to compare surgical outcomes of 3- and 4-level ACDF procedures. METHODS The authors performed a retrospective chart review of patients who underwent 3- and 4-level ACDF at the University of Virginia Health System between January 2010 and December 2017. In patients meeting the inclusion/exclusion criteria, demographics, fusion rates, time to fusion, and reoperation rates were evaluated. Fusion was determined by < 1 mm of change in interspinous distance between individual fused vertebrae on lateral flexion/extension radiographs and lack of radiolucency between the grafts and vertebral bodies. Any procedure requiring a surgical revision was considered a failure. RESULTS Sixty-six patients (47 with 3-level and 19 with 4-level ACDFs) met the inclusion/exclusion criteria of having at least one lateral flexion/extension radiograph series ≥ 12 months after surgery. Seventy percent of 3-level patients and 68% of 4-level patients had ≥ 24 months of follow-up. Ninety-four percent of 3-level patients and 100% of 4-level patients achieved radiographic fusion for at least 1 surgical level. Eighty-eight percent and 82% of 3- and 4-level patients achieved fusion at C3-4; 85% and 89% of 3- and 4-level patients achieved fusion at C4-5; 68% and 89% of 3- and 4-level patients achieved fusion at C5-6; 44% and 42% of 3- and 4-level patients achieved fusion at C6-7; and no patients achieved fusion at C7-T1. Time to fusion was not significantly different between levels. Revision was required in 6.4% of patients with 3-level and in 16% of patients with 4-level ACDF. The mean time to revision was 46.2 and 45.4 months for 3- and 4-level ACDF, respectively. The most common reason for revision was worsening of initial symptoms. CONCLUSIONS The authors' experience with long-segment anterior cervical fusions shows their fusion rates exceeding most of the reported fusion rates for similar procedures in the literature, with rates similar to those reported for short-segment ACDFs. Three-level and 4-level ACDF procedures are viable options for cervical spine pathology, and the authors' analysis demonstrates an equivalent rate of fusion and time to fusion between 3- and 4-level surgeries.
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Affiliation(s)
- Jesse J McClure
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Bhargav D Desai
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Leah M Shabo
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Thomas J Buell
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Chun-Po Yen
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Justin S Smith
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Christopher I Shaffrey
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and.,2Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Mark E Shaffrey
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Avery L Buchholz
- 1Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia; and
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Buza JA, Good CR, Lehman RA, Pollina J, Chua RV, Buchholz AL, Gum JL. Robotic-assisted cortical bone trajectory (CBT) screws using the Mazor X Stealth Edition (MXSE) system: workflow and technical tips for safe and efficient use. J Robot Surg 2020; 15:13-23. [DOI: 10.1007/s11701-020-01147-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 09/22/2020] [Indexed: 12/13/2022]
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Buchholz AL, Buell TJ, Shaffrey ME, Haid RW, Shaffrey CI. Deformity Correction Through the Use of Reduction Towers: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 19:E157-E158. [PMID: 31828343 DOI: 10.1093/ons/opz356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 09/12/2019] [Indexed: 11/13/2022] Open
Abstract
Spinal deformity management can be difficult. The decision for surgery, approach, number of levels, and surgical technique all present challenges. Even when other issues are managed appropriately the process of how to correct the deformity needs special consideration. Numerous techniques have been studied including vertebra-to-rod, rod de-rotation, 3-rod-techniques, and cantilever maneuvers. While cantilever is the preferred technique when treating sagittal plane deformity, scoliosis often requires a combination of techniques due to the complexity of deformity in coronal and transverse planes. This video illustrates an adult scoliosis correction using sequential reduction towers and de-rotation techniques. Using this method the step of hook holders is eliminated and tension is distributed evenly across the rod using sequential reduction of the reduction towers across the length of the rod. This has led to a very efficient correction of our deformity as well as a powerful de-rotation tool. We routinely use this technique for flexible and rigid deformities, which is assessed pre-op with a computed tomography. The patient is a 67-yr-old female with prior lumbar decompressions and worsening back pain with radiculopathy. No significant sagittal malalignment is present but pelvic tilt is elevated and a coronal deformity exists. pelvic incidence measures 59°, LL50°, PT28° and lumbar scoliosis shows a coronal Cobb angle of 50.8°. Briefly, surgery involved transpedicular instrumentation from T10-S1 with bilateral iliac screw fixation. To achieve mobility posterior column osteotomies were performed at T12-L1, L1-2, L2-3, L3-4, L4-5, and L5-S1 levels. TLIF was performed at L4-5, L5-S1 for fusion. Postoperative scoliosis X-rays demonstrated improved sagittal and coronal alignment with PI59°, LL59°, PT22°, and coronal Cobb angle of 12°.
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Affiliation(s)
- Avery L Buchholz
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
| | - Thomas J Buell
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
| | - Mark E Shaffrey
- University of Virginia, Department of Neurosurgery, Charlottesville, Virginia
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Laratta J, Carreon LY, Buchholz AL, Yew AY, Bisson EF, Mummaneni PV, Glassman SD. Effects of preoperative obesity and psychiatric comorbidities on minimum clinically important differences for lumbar fusion in grade 1 degenerative spondylolisthesis: analysis from the prospective Quality Outcomes Database registry. J Neurosurg Spine 2020; 33:1-8. [PMID: 32707556 DOI: 10.3171/2020.4.spine20296] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 04/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Medical comorbidities, particularly preoperatively diagnosed anxiety, depression, and obesity, may influence how patients perceive and measure clinical benefit after a surgical intervention. The current study was performed to define and compare the minimum clinically important difference (MCID) thresholds in patients with and without preoperative diagnoses of anxiety or depression and obesity who underwent spinal fusion for grade 1 degenerative spondylolisthesis. METHODS The Quality Outcomes Database (QOD) was queried for patients who underwent lumbar fusion for grade 1 degenerative spondylolisthesis during the period from January 2014 to August 2017. Collected patient-reported outcomes (PROs) included the Oswestry Disability Index (ODI), health status (EQ-5D), and numeric rating scale (NRS) scores for back pain (NRS-BP) and leg pain (NRS-LP). Both anchor-based and distribution-based methods for MCID calculation were employed. RESULTS Of 462 patients included in the prospective registry who underwent a decompression and fusion procedure, 356 patients (77.1%) had complete baseline and 12-month PRO data and were included in the study. The MCID values for ODI scores did not significantly differ in patients with and those without a preoperative diagnosis of obesity (20.58 and 20.69, respectively). In addition, the MCID values for ODI scores did not differ in patients with and without a preoperative diagnosis of anxiety or depression (24.72 and 22.56, respectively). Similarly, the threshold MCID values for NRS-BP, NRS-LP, and EQ-5D scores were not statistically different between all groups. Based on both anchor-based and distribution-based methods for determination of MCID thresholds, there were no statistically significant differences between all cohorts. CONCLUSIONS MCID thresholds were similar for ODI, EQ-5D, NRS-BP, and NRS-LP in patients with and without preoperative diagnoses of anxiety or depression and obesity undergoing spinal fusion for grade 1 degenerative spondylolisthesis. Preoperative clinical and shared decision-making may be improved by understanding that preoperative medical comorbidities may not affect the way patients experience and assess important clinical changes postoperatively.
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Affiliation(s)
| | | | - Avery L Buchholz
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Andrew Y Yew
- 3Department of Neurosurgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Erica F Bisson
- 4Department of Neurosurgery, University of Utah Health Care, Salt Lake City, Utah; and
| | - Praveen V Mummaneni
- 5Department of Neurosurgery, University of California, San Francisco Medical Center-Spine Center, San Francisco, California
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Buell TJ, Yener U, Wang TR, Buchholz AL, Yen CP, Shaffrey ME, Shaffrey CI, Smith JS. Sacral insufficiency fractures after lumbosacral arthrodesis: salvage lumbopelvic fixation and a proposed management algorithm. J Neurosurg Spine 2020; 33:1-12. [PMID: 32217798 DOI: 10.3171/2019.12.spine191148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 12/31/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sacral insufficiency fracture after lumbosacral (LS) arthrodesis is an uncommon complication. The objective of this study was to report the authors' operative experience managing this complication, review pertinent literature, and propose a treatment algorithm. METHODS The authors analyzed consecutive adult patients treated at their institution from 2009 to 2018. Patients who underwent surgery for sacral insufficiency fractures after posterior instrumented LS arthrodesis were included. PubMed was queried to identify relevant articles detailing management of this complication. RESULTS Nine patients with a minimum 6-month follow-up were included (mean age 73 ± 6 years, BMI 30 ± 6 kg/m2, 56% women, mean follow-up 35 months, range 8-96 months). Six patients had osteopenia/osteoporosis (mean dual energy x-ray absorptiometry hip T-score -1.6 ± 0.5) and 3 received treatment. Index LS arthrodesis was performed for spinal stenosis (n = 6), proximal junctional kyphosis (n = 2), degenerative scoliosis (n = 1), and high-grade spondylolisthesis (n = 1). Presenting symptoms of back/leg pain (n = 9) or lower extremity weakness (n = 3) most commonly occurred within 4 weeks of index LS arthrodesis, which prompted CT for fracture diagnosis at a mean of 6 weeks postoperatively. All sacral fractures were adjacent or involved S1 screws and traversed the spinal canal (Denis zone III). H-, U-, or T-type sacral fracture morphology was identified in 7 patients. Most fractures (n = 8) were Roy-Camille type II (anterior displacement with kyphosis). All patients underwent lumbopelvic fixation via a posterior-only approach; mean operative duration and blood loss were 3.3 hours and 850 ml, respectively. Bilateral dual iliac screws were utilized in 8 patients. Back/leg pain and weakness improved postoperatively. Mean sacral fracture anterolisthesis and kyphotic angulation improved (from 8 mm/11° to 4 mm/5°, respectively) and all fractures were healed on radiographic follow-up (mean duration 29 months, range 8-90 months). Two patients underwent revision for rod fractures at 1 and 2 years postoperatively. A literature review found 17 studies describing 87 cases; potential risk factors were osteoporosis, longer fusions, high pelvic incidence (PI), and postoperative PI-to-lumbar lordosis (LL) mismatch. CONCLUSIONS A high index of suspicion is needed to diagnose sacral insufficiency fracture after LS arthrodesis. A trial of conservative management is reasonable for select patients; potential surgical indications include refractory pain, neurological deficit, fracture nonunion with anterolisthesis or kyphotic angulation, L5-S1 pseudarthrosis, and spinopelvic malalignment. Lumbopelvic fixation with iliac screws may be effective salvage treatment to allow fracture healing and symptom improvement. High-risk patients may benefit from prophylactic lumbopelvic fixation at the time of index LS arthrodesis.
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Affiliation(s)
- Thomas J Buell
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Ulas Yener
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Tony R Wang
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Avery L Buchholz
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Chun-Po Yen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Mark E Shaffrey
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
| | - Christopher I Shaffrey
- 2Department of Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Justin S Smith
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia; and
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Snyder MH, Ampie L, Forrester VJ, Wilson JC, Nguyen JH, Shaffrey CI, Buchholz AL. Postoperative pyoderma gangrenosum after spinal fusion with instrumentation: case report. J Neurosurg Spine 2020; 32:285-291. [DOI: 10.3171/2019.7.spine19708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/31/2019] [Indexed: 11/06/2022]
Abstract
Pyoderma gangrenosum (PG) is a rare inflammatory dermatosis that is most often associated with inflammatory bowel disease, but which can occur as a pathergic reaction around surgical incisions. The authors report the case of a patient who developed postoperative PG over the course of several months after undergoing extensive spinal instrumentation between the T4 and iliac levels. This is only the second such case occurring after spine surgery to be reported. The authors additionally review the literature to characterize treatment approaches and outcomes for this condition. The case highlights a potentially severe adverse effect of surgery that can be difficult to recognize and causes delays in effective treatment. It also demonstrates the importance of multidisciplinary collaboration in the effective care of patients.
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Affiliation(s)
| | | | - Vernon J. Forrester
- 2Dermatology, University of Virginia Health System, Charlottesville, Virginia; and
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Abstract
STUDY DESIGN Review article. OBJECTIVE A review of the literature on postoperative initiation of thrombophylactic agents following spine surgery. METHODS A review of the literature and synthesis of the data to provide an update on venous thromboprophylaxis following spine surgery. RESULTS Postoperative regimens of venous thromboprophylaxis measures following spine surgery remain a controversial issue. Recommendations regarding mechanical versus chemical prophylaxis vary greatly among institutions. CONCLUSION Postoperative spine surgery initiation of thromboprophylaxis remains controversial regarding optimal timing and agent selection. The benefits of deep vein thrombosis/pulmonary embolism prophylaxis must be weighed against the possible postoperative complications associated with spine surgery.
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Affiliation(s)
- Anthony M. Alvarado
- University of Kansas Medical Center, Kansas City, KS, USA,Anthony M. Alvarado, Department of Neurosurgery, University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66061, USA.
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Abstract
STUDY DESIGN Literature review. OBJECTIVE Preoperative management of therapeutic anticoagulation in spine surgery is critical to minimize risk of thromboembolic events yet prevent postsurgical complications. Limited research is available, and most guidelines are based on drug half-lives. We aim to clarify current guidelines and available evidence for safe practice of spine surgery in this patient population. METHODS A literature search in PubMed was done encompassing comprehensive search terms to locate published literature on anticoagulation and spine surgery. Predefined inclusion and exclusion criteria were applied and data extraction was performed. RESULTS A total of 17 articles met the final inclusion criteria. Of these, 12 articles were retrospective chart reviews, 3 were prospective observational studies, and 2 were systematic reviews. Current practice suggests holding warfarin until international normalized ratio <1.4, anti-Xa drugs for 48 to 72 hours, 12 to 24 hours for low-molecular-weight heparin, and 4 to 24 hours for heparin, before surgery. Antiplatelet agents can be stopped for 1 to 3 days prior to operation (81-500 mg) but must be stopped for 1 week for doses >1 g/d. For Plavix, 5 to 7 days of discontinuation advised to prevent complications. CONCLUSIONS This review provides an overview of main anticoagulation agents seen in preoperative setting for spine patients. Although data is mixed and no true randomized control trials are available, there is growing evidence suggesting the aforementioned guidelines are needed to optimize anticoagulation in setting of spine surgery. Further studies are needed to elucidate risk of complications while operating under therapeutic levels of anticoagulation for a variety of comorbid conditions.
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Affiliation(s)
| | | | | | - Paul M. Arnold
- Carle Illinois College of Medicine and Carle Foundation Hospital, Urbana, IL, USA
| | - Avery L. Buchholz
- University of Virginia, Charlottesville, VA, USA,Avery L. Buchholz, Department of Neurosurgery, University of Virginia, Hospital West Complex, Barringer Wing Room 3453, Charlottesville, VA 22903, USA.
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Buell TJ, Chen CJ, Nguyen JH, Christiansen PA, Murthy SG, Buchholz AL, Yen CP, Shaffrey ME, Shaffrey CI, Smith JS. Surgical correction of severe adult lumbar scoliosis (major curves ≥ 75°): retrospective analysis with minimum 2-year follow-up. J Neurosurg Spine 2019; 31:1-14. [PMID: 31226681 DOI: 10.3171/2019.3.spine1966] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 03/28/2019] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Prior reports have demonstrated the efficacy of surgical correction for adult lumbar scoliosis. Many of these reports focused on mild to moderate scoliosis. The authors' objective was to report their experience and to assess outcomes and complications after deformity correction for severe adult scoliosis. METHODS The authors retrospectively analyzed consecutive adult scoliosis patients with major thoracolumbar/lumbar (TL/L) curves ≥ 75° who underwent deformity correction at their institution. Those eligible with a minimum 2 years of follow-up were included. Demographic, surgical, coronal and sagittal plane radiographic measurements, and health-related quality of life (HRQL) scores were analyzed. RESULTS Among 26 potentially eligible patients, 22 (85%) had a minimum 2 years of follow-up (range 24-89 months) and were included in the study (mean age 57 ± 11 years; 91% women). The cohort comprised 16 (73%), 4 (18%), and 2 (9%) patients with adult idiopathic scoliosis, de novo degenerative scoliosis, and iatrogenic scoliosis, respectively. The surgical approach was posterior-only and multistage anterior-posterior in 18 (82%) and 4 (18%) patients, respectively. Three-column osteotomy was performed in 5 (23%) patients. Transforaminal and anterior lumbar interbody fusion were performed in 14 (64%) and 4 (18%) patients, respectively. All patients had sacropelvic fixation with uppermost instrumented vertebra in the lower thoracic spine (46% [10/22]) versus upper thoracic spine (55% [12/22]). The mean fusion length was 14 ± 3 levels. Preoperative major TL/L and lumbosacral fractional (L4-S1) curves were corrected from 83° ± 8° to 28° ± 13° (p < 0.001) and 34° ± 8° to 13° ± 6° (p < 0.001), respectively. Global coronal and sagittal balance significantly improved from 5 ± 4 cm to 1 ± 1 cm (p = 0.001) and 9 ± 8 cm to 2 ± 3 cm (p < 0.001), respectively. Pelvic tilt significantly improved from 33° ± 9° to 23° ± 10° (p < 0.001). Significant improvement in HRQL measures included the following: Scoliosis Research Society (SRS) pain score (p = 0.009), SRS appearance score (p = 0.004), and SF-12/SF-36 physical component summary (PCS) score (p = 0.026). Transient and persistent neurological deficits occurred in 8 (36%) and 2 (9%) patients, respectively. Rod fracture/pseudarthrosis occurred in 6 (27%) patients (supplemental rods were utilized more recently in 23%). Revisions were performed in 7 (32%) patients. CONCLUSIONS In this single-center surgical series for severe adult scoliosis (major curves ≥ 75°), a posterior-only or multistage anterior-posterior approach provided major curve correction of 66% and significant improvements in global coronal and sagittal spinopelvic alignment. Significant improvements were also demonstrated in HRQL measures (SRS pain, SRS appearance, and SF-12/SF-36 PCS). Complications and revisions were comparable to those of other reports involving less severe scoliosis. The results of this study warrant future prospective multicenter studies to further delineate outcomes and complication risks for severe adult scoliosis correction.
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Affiliation(s)
- Thomas J Buell
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
- 2Department of Neurological Surgery, Auckland City Hospital, Auckland, New Zealand; and
| | - Ching-Jen Chen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - James H Nguyen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Peter A Christiansen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Saikiran G Murthy
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Avery L Buchholz
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Chun-Po Yen
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Mark E Shaffrey
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Christopher I Shaffrey
- 3Departments of Orthopaedic and Neurological Surgery, Duke University Medical Center, Durham, North Carolina
| | - Justin S Smith
- 1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Labaran L, Jain N, Puvanesarajah V, Jain A, Buchholz AL, Hassanzadeh H. A Retrospective Database Review of the Indications, Complications, and Incidence of Subsequent Spine Surgery in 12,297 Spinal Cord Stimulator Patients. Neuromodulation 2019; 23:634-638. [DOI: 10.1111/ner.12952] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/18/2019] [Accepted: 03/06/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Lawal Labaran
- Department of Orthopaedic Surgery University of Virginia Charlottesville VA USA
| | - Nikhil Jain
- Department of Orthopaedic Surgery University of Virginia Charlottesville VA USA
| | | | - Amit Jain
- Department of Orthopaedic Surgery Johns Hopkins Hospital Baltimore MD USA
| | - Avery L. Buchholz
- Department of Neurological Surgery University of Virginia Charlottesville VA USA
| | - Hamid Hassanzadeh
- Department of Orthopaedic Surgery University of Virginia Charlottesville VA USA
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Buell TJ, Chen CJ, Quinn JC, Buchholz AL, Mazur MD, Mullin JP, Nguyen JH, Taylor DG, Bess S, Line BG, Ames CP, Schwab FJ, Lafage V, Shaffrey CI, Smith JS. Alignment Risk Factors for Proximal Junctional Kyphosis and the Effect of Lower Thoracic Junctional Tethers for Adult Spinal Deformity. World Neurosurg 2019; 121:e96-e103. [DOI: 10.1016/j.wneu.2018.08.242] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 11/25/2022]
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Spiotta AM, Buchholz AL, Pierce AK, Dahlkoetter J, Armonda R. The Neurosurgeon as a High-Performance Athlete: Parallels and Lessons Learned from Sports Psychology. World Neurosurg 2018; 120:e188-e193. [DOI: 10.1016/j.wneu.2018.08.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 10/28/2022]
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Taylor DG, Buchholz AL, Sure DR, Buell TJ, Nguyen JH, Chen CJ, Diamond JM, Washburn PA, Harrop J, Shaffrey CI, Smith JS. Presentation and Outcomes After Medical and Surgical Treatment Versus Medical Treatment Alone of Spontaneous Infectious Spondylodiscitis: A Systematic Literature Review and Meta-Analysis. Global Spine J 2018; 8:49S-58S. [PMID: 30574438 PMCID: PMC6295820 DOI: 10.1177/2192568218799058] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
STUDY DESIGN Systematic literature review. OBJECTIVES The aims of this study were to (1) describe the clinical features, disabilities, and incidence of neurologic deficits of pyogenic spondylodiscitis prior to treatment and (2) compare the functional outcomes between patients who underwent medical treatment alone or in combination with surgery for pyogenic spondylodiscitis. METHODS A systematic literature review was performed using PubMed according to PRISMA guidelines. No year restriction was put in place. Statistical analysis of pooled data, when documented in the original report (ie, number of patients with desired variable and number of patients evaluated), was conducted to determine the most common presenting symptoms, incidence of pre- and postoperative neurologic deficits, associated comorbidities, infectious pathogens, approach for surgery when performed, and duration of hospitalization. Outcomes data, including return to work status, resolution of back pain, and functional recovery were also pooled among all studies and surgery-specific studies alone. Meta-analysis of studies with subgroup analysis of pain-free outcome in surgical and medical patients was performed. RESULTS Fifty of 1286 studies were included, comprising 4173 patients undergoing either medical treatment alone or in combination with surgery. Back pain was the most common presenting symptom, reported in 91% of patients. Neurologic deficit was noted in 31% of patients. Staphylococcus aureus was the most commonly reported pathogen, seen in 35% of reported cases. Decompression and fusion was the most commonly reported surgical procedure, performed in 80% of the surgically treated patients. Combined anterior-posterior procedures and staged surgeries were performed in 33% and 26% of surgeries, respectively. The meta-analysis comparing visual analog scale score at follow-up was superior among patients receiving surgery over medical treatment alone (mean difference -0.61, CI -0.90 to -0.25), while meta-analysis comparing freedom from pain in patients receiving medical treatment alone versus combined medical and surgical treatment demonstrated superior pain-free outcomes among surgical series (odds ratio 5.35, CI 2.27-12.60, P < .001), but was subject to heterogeneity among studies (I 2 = 56%, P = .13). Among all patients, freedom from pain was achieved in 79% of patients, and an excellent outcome was achieved in 73% of patients. CONCLUSION Medical management remains first-line treatment of infectious pyogenic spondylodiscitis. Surgery may be indicated for progressive pain, persistent infection on imaging, deformity or neurologic deficits. If surgery is required, reported literature shows potential for significant pain reduction, improved neurologic function and a high number of patients returning to a normal functional/work status.
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Affiliation(s)
- Davis G. Taylor
- University of Virginia, Charlottesville, VA, USA,Davis G. Taylor, Department of Neurological Surgery, University of Virginia, P.O. Box 800212, Charlottesville, VA 22908, USA.
| | | | - Durga R. Sure
- St. Mary’s Hospital, Essential Health Duluth Clinic, Duluth, MN, USA
| | | | | | | | | | | | - James Harrop
- Thomas Jefferson University, Philadelphia, PA, USA
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Abstract
STUDY DESIGN Systematic review. OBJECTIVES Spinal epidural abscesses (SEAs) are rare, but when missed or when diagnosis is delayed, SEA can lead to permanent neurological impairment or death. Limited information exists on the optimal treatment modalities for SEA, especially in the lumbar spine. We synthesize the current literature to identify the clinical features, diagnosis, management, and outcomes of lumbar SEA. METHODS Queries in 4 databases-EMBASE, MEDLINE, Scopus, and Web of Science-were performed using comprehensive search terms to locate published literature on lumbar SEA. RESULTS Ten articles reporting results for 600 cases of lumbar SEA were included, published between 2000 and 2017. Negative prognostic factors included diabetes, older age, methicillin-resistant Staphylococcus aureus, immune compromise, and more severe disease at presentation. Early first-line surgically treated patients responded better, specifically in terms of motor recovery, than those undergoing medical management or failing medical treatment, despite generally worse initial presentation. Elevated C-reactive protein, leukocytosis, and positive blood cultures predicted medical management failure. CONCLUSIONS This systematic review provides guidance to neurological and orthopedic spine surgeons seeking the best treatment for lumbar-localized SEA. This study is limited by a dearth of high-quality publications to support evidenced-based management recommendations. Surgical treatment appears to provide better outcomes than medical treatment alone, especially in those who present with a motor deficit. Further investigation is needed to confirm this finding. What is clear is that early recognition and treatment remains crucial to minimizing morbidity and mortality of SEA.
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Affiliation(s)
- Charles N. de Leeuw
- Cleveland Clinic, Cleveland, OH, USA,Case Western Reserve University, Cleveland, OH, USA,Charles N. de Leeuw, Center for Spine Health, Department of Neurosurgery, Neurological Institute, The Cleveland Clinic, 9500 Euclid Avenue, S-80, Cleveland, OH 44195, USA.
| | - Patrick R. Fann
- Cleveland Clinic, Cleveland, OH, USA,Case Western Reserve University, Cleveland, OH, USA
| | - Joseph E. Tanenbaum
- Cleveland Clinic, Cleveland, OH, USA,Case Western Reserve University, Cleveland, OH, USA
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Abstract
STUDY DESIGN Systematic review. OBJECTIVES Past research has demonstrated increased speed and severity of progression for spinal epidural abscesses (SEAs) of the thoracic level, specifically, when compared with SEAs of other spinal cord levels. Untreated, this infection can result in permanent neurological sequelae with eventual progression to death if inadequately managed. Despite the seriousness of this disease, no articles have focused on the presentation, diagnosis, and treatment of SEAs of the thoracic level. For this reason, specific focus on SEAs of the thoracic level occurred when researchers designed and implemented the following systematic review. METHODS A query of Ovid-Medline and EMBASE, Cochrane Central, and additional review sources was conducted. Search criteria focused on articles specific to thoracic epidural abscesses. RESULTS Twenty-five articles met inclusion criteria. The most commonly reported symptoms present on admission included back pain, paraparesis/paraplegia, fever, and loss of bowel/bladder control. Significant risk factors included diabetes, intravenous drug use, and advanced age (P = .001). Patients were most often treated surgically with either laminectomy, hemilaminectomy, or radical decompression with debridement. Patients who presented with neurological deficits and had delayed surgical intervention following a failed antibiotic course tended to do worse compared with their immediate surgical management counterparts (P < .005). CONCLUSIONS For the first time researchers have focused specifically on SEAs of the thoracic level, as opposed to previously published general analysis of SEAs as a whole. Based on the results, investigators recommend early magnetic resonance imaging of the spine, laboratory workup (sedimentation rate/C-reactive protein, complete blood count), abscess culture followed by empiric antibiotics, and immediate surgical decompression when neurological deficits are present.
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Affiliation(s)
- Benjamin A. Howie
- Cleveland Clinic, Cleveland, OH, USA
- Northeast Ohio Medical University, Rootstown, OH, USA
| | | | - Joseph E. Tanenbaum
- Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
| | | | | | | | - Thomas E. Mroz
- Cleveland Clinic, Cleveland, OH, USA
- Case Western Reserve University, Cleveland, OH, USA
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Buchholz AL, Henderson F, Lowe S, Alshareef M, Wolgamott L, Patel S, Spiotta AM. Perspectives from a Residency Training Program Following the Implementation of a Wellness Initiative. World Neurosurg 2018; 119:e947-e955. [DOI: 10.1016/j.wneu.2018.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/31/2018] [Accepted: 08/02/2018] [Indexed: 11/24/2022]
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Buell TJ, Buchholz AL, Quinn JC, Mullin JP, Garces J, Mazur MD, Shaffrey ME, Yen CP, Shaffrey CI, Smith JS. Extended Asymmetrical Pedicle Subtraction Osteotomy for Adult Spinal Deformity: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2018; 16:52-53. [DOI: 10.1093/ons/opy160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 05/24/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
Pedicle subtraction osteotomy (PSO) is an effective technique to correct fixed sagittal malalignment. A variation of this technique, the “trans-discal” or “extended” PSO (Schwab grade IV osteotomy), involves extending the posterior wedge resection of the index vertebra to include the superior adjacent disc for radical discectomy. The posterior wedge may be resected in asymmetric fashion to correct concurrent global coronal malalignment.
This video illustrates the technical nuances of an extended asymmetrical lumbar PSO for adult spinal deformity. A 62-yr-old female with multiple prior lumbar fusions presented with worsening back pain and posture. Preoperative scoliosis X-rays demonstrated severe global sagittal and coronal malalignment (sagittal vertical axis [SVA, C7-plumbline] of 13.5 cm, pelvic incidence [PI] of 60°, lumbar lordosis [LL] of 14° [in kyphosis], pelvic tilt [PT] of 61°, thoracic kyphosis [TK] of 18°, and rightward coronal shift of 9.3 cm). The patient gave informed consent to surgery and for use of her imaging for medical publication. Briefly, surgery first involved transpedicular instrumentation from T10 to S1 with bilateral iliac screw fixation, and then T11-12 and T12-L1 Smith-Petersen osteotomies were performed. Next, an extended asymmetrical L4 PSO was performed and a 12° lordotic cage (9 × 14 × 40 mm) was placed at the PSO defect. Rods were placed from T10 to iliac bilaterally, and accessory supplemental rods spanning the PSO were attached. Postoperative scoliosis X-rays demonstrated improved alignment: SVA 5.5 cm, PI 60°, LL 55°, PT 36°, TK 37°, and 3.7 cm of rightward coronal shift. The patient had uneventful recovery.
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Affiliation(s)
- Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Avery L Buchholz
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - John C Quinn
- Department of Neurological Surgery, University of Texas Health Science Center, Houston, Texas
| | - Jeffrey P Mullin
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Juanita Garces
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Marcus D Mazur
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Mark E Shaffrey
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Chun-Po Yen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Christopher I Shaffrey
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Buell TJ, Mullin JP, Nguyen JH, Taylor DG, Garces J, Mazur MD, Buchholz AL, Shaffrey ME, Yen CP, Shaffrey CI, Smith JS. A Novel Junctional Tether Weave Technique for Adult Spinal Deformity: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2018; 16:45-46. [DOI: 10.1093/ons/opy148] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/14/2018] [Indexed: 11/13/2022] Open
Abstract
Abstract
Proximal junctional kyphosis (PJK) is a common problem after multilevel spine instrumentation for adult spinal deformity. Various anti-PJK techniques such as junctional tethers for ligamentous augmentation have been proposed. We present an operative video demonstrating technical nuances of junctional tether “weave” application. A 70-yr-old male with prior L2-S1 instrumented fusion presented with worsening back pain and posture. Imaging demonstrated pathological loss of lumbar lordosis (flat back deformity), proximal junctional failure, and pseudarthrosis. The patient had severe global and segmental sagittal malalignment, with sagittal vertical axis (SVA, C7-plumbline) measuring 22.3 cm, pelvic incidence (PI) 55°, lumbar lordosis (LL) 8° in kyphosis, pelvic tilt (PT) 30°, and thoracic kyphosis (TK) 6°. The patient gave informed consent for surgery and use of imaging for medical publication. Briefly, surgery first involved re-instrumentation with bilateral pedicle screws from T10 to S1. After right-sided iliac screw fixation (left-sided iliac screw fixation was not performed due to extensive prior iliac crest bone graft harvesting), we then completed a L2-3 Smith–Petersen osteotomy, extended L4 pedicle subtraction osteotomy, and L3-4 interbody arthrodesis with a 12° lordotic cage (9 × 14 × 40 mm). Cobalt Chromium rods were placed spanning the instrumentation bilaterally, and accessory supplemental rods spanning the PSO were attached. An anti-PJK junctional tether “weave” was then implemented using 4.5 mm polyethylene tape (Mersilene tape [Ethicon, Somerville, New Jersey]). Postoperative imaging demonstrated improved alignment (SVA 2.8 cm, PI 55°, LL 53°, PT 25°, TK 45°) and no significant neurological complications occurred during convalescence or at 6 mo postop.
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Affiliation(s)
- Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jeffrey P Mullin
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - James H Nguyen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Davis G Taylor
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Juanita Garces
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Marcus D Mazur
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Avery L Buchholz
- Department of Neurological Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Mark E Shaffrey
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Chun-Po Yen
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Christopher I Shaffrey
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Buell TJ, Buchholz AL, Quinn JC, Bess S, Line BG, Ames CP, Schwab FJ, Lafage V, Shaffrey CI, Smith JS. A Pilot Study on Posterior Polyethylene Tethers to Prevent Proximal Junctional Kyphosis After Multilevel Spinal Instrumentation for Adult Spinal Deformity. Oper Neurosurg (Hagerstown) 2018; 16:256-266. [DOI: 10.1093/ons/opy065] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 04/04/2018] [Indexed: 01/14/2023] Open
Abstract
AbstractBACKGROUNDProximal junctional kyphosis (PJK) is a common problem after multilevel spine instrumentation.OBJECTIVETo determine if junctional tethers reduce PJK after multilevel instrumented surgery for adult spinal deformity (ASD).METHODSASD patients who underwent posterior instrumented fusion were divided into 3 groups: no tether (NT), polyethylene tether-only (TO; tied securely through the spinous processes of the uppermost instrumented vertebra [UIV] + 1 and UIV-1), and tether with crosslink (TC; passed through the spinous process of UIV+1 and tied to a crosslink between UIV-1 and UIV-2). PJK was defined as proximal junctional angle ≥ 10° and ≥ 10° greater than the corresponding preoperative measurement.RESULTSOne hundred eighty-four (96%) of 191 consecutive patients achieved minimum 3-mo follow-up (mean = 20 mo [range:3-56 mo]; mean age = 66 yr; 67.4% female). There were no significant differences between groups based on demographic, surgical, and sagittal radiographic parameters. PJK rates were 45.3% (29/64), 34.4% (22/64), and 17.9% (10/56) for NT, TO, and TC, respectively. PJK rate for all tethered patients (TO + TC; 26.7% [32/120]) was significantly lower than NT (P = .011). PJK rate for TC was significantly lower than NT (P = .001). Kaplan-Meier analysis showed significant time-dependent PJK reduction for TC vs NT (log rank test, P = .010). Older age and greater change in lumbar lordosis were independent predictors of PJK, while junctional tethers had a significant protective effect.CONCLUSIONJunctional tethers significantly reduced occurrence of PJK. This difference was progressive from NT to TO to TC, but only reached pairwise significance for NT vs TC. This suggests potential benefit of tethers to reduce PJK, and that future prospective studies are warranted.
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Affiliation(s)
- Thomas J Buell
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Avery L Buchholz
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - John C Quinn
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Shay Bess
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Breton G Line
- Denver International Spine Center, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, Colorado
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Frank J Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Christopher I Shaffrey
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
| | - Justin S Smith
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia
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Buell TJ, Buchholz AL, Quinn JC, Shaffrey CI, Smith JS. Importance of Sagittal Alignment of the Cervical Spine in the Management of Degenerative Cervical Myelopathy. Neurosurg Clin N Am 2018; 29:69-82. [DOI: 10.1016/j.nec.2017.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Buchholz AL, Frankel BM. Response. J Neurosurg Spine 2016; 24:672. [PMID: 27482580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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Rodríguez FP, Campos D, Ryser ET, Buchholz AL, Posada-Izquierdo GD, Marks BP, Zurera G, Todd E. A mathematical risk model for Escherichia coli O157:H7 cross-contamination of lettuce during processing. Food Microbiol 2011; 28:694-701. [PMID: 21511129 DOI: 10.1016/j.fm.2010.06.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2010] [Revised: 06/20/2010] [Accepted: 06/23/2010] [Indexed: 11/25/2022]
Abstract
A stochastic simulation modelling approach was taken to determine the extent of Escherichia coli O157:H7 contamination in fresh-cut bagged lettuce leaving the processing plant. A probabilistic model was constructed in Excel to account for E. coli O157:H7 cross contamination when contaminated lettuce enters the processing line. Simulation of the model was performed using @Risk Palisade© Software, providing an estimate of concentration and prevalence in the final bags of product. Three different scenarios, named S1, S2, and S3, were considered to represent the initial concentration on the contaminated batch entering the processing line which corresponded to 0.01, 1 and 100 cfu/g, respectively. The model was satisfactorily validated based on Standard Error of Prediction (SEP), which ranged from 0.00-35%. ANOVA analysis performed on simulated data revealed that the initial concentration in the contaminated batch (i.e., S1, S2, and S3) did not influence significantly (p=0.4) the E. coli O157:H7 levels in bags derived from cross contamination. In addition, significantly different (p<0.001) prevalence was observed at the different levels simulated (S1; S2 and S3). At the lowest contamination level (0.01 cfu/g), bags were cross-contaminated sporadically, resulting in very low E. coli O157:H7 populations (mean: ≤2 cfu/bag) and prevalence levels (<1%). In contrast, higher average prevalence levels were obtained for S2 and S3 corresponding to 3.05 and 13.39%, respectively. Furthermore, the impact of different interventions on E. coli O157:H7 cross-contamination (e.g., pathogen testing, chlorination, irradiation, and cleaning and disinfection procedures) was evaluated. Model showed that the pathogen was able to survive and be present in the final bags in all simulated interventions scenarios although irradiation (0.5 KGy) was a more effective decontamination step in reducing prevalence than chlorination or pathogen testing under the same simulated conditions.
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Schreiber JJ, Anderson PA, Rosas HG, Buchholz AL, Au AG. Hounsfield units for assessing bone mineral density and strength: a tool for osteoporosis management. J Bone Joint Surg Am 2011; 93:1057-63. [PMID: 21655899 DOI: 10.2106/jbjs.j.00160] [Citation(s) in RCA: 493] [Impact Index Per Article: 37.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Measurements obtained from clinical computed tomography examinations may yield information leading to the diagnosis of decreased bone mineral density, without added expense to the patient. The purpose of the present study was to determine if Hounsfield units, a standardized computed tomography attenuation coefficient, correlate with bone mineral density and compressive strength. METHODS Twenty-five patients (including eighteen female and seven male patients with a mean age of 71.3 years) undergoing both lumbar spine dual x-ray absorptiometry scans and computed tomography imaging were evaluated to determine if Hounsfield units correlated with bone mineral density and T-scores. Normative data were generated from lumbar spine computed tomography examinations for eighty consecutive trauma patients and were stratified by age and sex. Separately, polyurethane foam blocks of varying densities were imaged with computed tomography and were subjected to mechanical testing to determine compressive strength. Compressive strength values and Hounsfield units were analyzed for correlation. RESULTS Significant correlations were found between Hounsfield units and bone mineral density, age, and T-scores and between Hounsfield units and compressive strength (p < 0.001). CONCLUSIONS Hounsfield units obtained from clinical computed tomography scans that are made for other purposes correlate with dual x-ray absorptiometry scores as well as compressive strengths based on osseous models and potentially provide an alternative method for determining regional bone mineral density at no additional cost to the patient. The information could conceivably be applied toward fracture risk assessment, diagnosis of osteoporosis, and early initiation of needed treatment.
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Affiliation(s)
- Joseph J Schreiber
- Department of Orthopedics and Rehabilitation, University of Wisconsin, Madison, Wisconsin, USA
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