Preoperative Assessment of Bone Density Using MRI-Based Vertebral Bone Quality Score Modified for Patients Undergoing Cervical Spine Surgery

STUDY DESIGN

Diagnostic accuracy study.

OBJECTIVES

Previous studies have reported the clinical application of the Vertebral Bone Quality (VBQ) scores for assessing bone density in operative lumbar spine patients. We aim to explore whether the method could be modified and applicable for patients undergoing cervical spine surgery.

METHODS

Adult patients receiving cervical spine surgery for degenerative diseases between September 2020 and March 2022 with non-contrast T1-weighted MRI and DEXA were included. Correlation between cervical VBQ scores and DEXA T-scores was analyzed using Pearson's correlation. Student's t test was used to present the discrepancy between the VBQ of patients with normal bone density (T ≥ -1.0) and patients with osteopenia/osteoporosis (T < -1.0). Statistical significance was set at P < .05.

RESULTS

Eighty-three patients (20 patients with T ≥ -1.0 vs 63 patients with T < -1.0 ) were included. Significant difference was found between the cervical VBQ between groups (2.99 ± .79 vs 3.80 ± .81, P < .001). Interclass correlation coefficient for inter-rater reliability was .82 (95% CI: .70-.93) and .91(95% CI: .84-.97) for intra-rater reliability. The area under the ROC curve was .78 (95% CI: .65-.90). The DEXA T-score of the femoral neck, total hip and the lowest DEXA T-score were found to be significantly correlated with the cervical VBQ score according to Pearson correlation analysis (P < .001).

CONCLUSIONS

This is the first study to apply the VBQ method to assess the bone density in preoperative cervical spine patients. Cervical VBQ scores were significantly correlated with DEXA T-score. With an overall accuracy of .78, the radiation-free and cost-effective method could be a potential tool for screening patients with osteopenia and osteoporosis before surgery.

Adjunctive Use of Bone Growth Stimulation Increases Cervical Spine Fusion Rates in Patients at Risk for Pseudarthrosis

STUDY DESIGN

A prospective multicenter clinical trial (NCT03177473) was conducted with a retrospective cohort used as a control arm.

OBJECTIVE

The purpose of this study was to evaluate cervical spine fusion rates in subjects with risk factors for pseudarthrosis who received pulsed electromagnetic field (PEMF) treatment.

SUMMARY OF BACKGROUND DATA

Certain risk factors predispose patients to pseudarthrosis, which is associated with prolonged pain, reduced function, and decreased quality of life.

METHODS

Subjects in the PEMF group were treated with PEMF for 6 months postoperatively. The primary outcome measure was fusion status at the 12-month follow-up period. Fusion status was determined using anterior/posterior, lateral, and flexion/extension radiographs and computed tomography (without contrast).

RESULTS

A total of 213 patients were evaluated (PEMF, n=160; Control, n=53). At baseline, the PEMF group had a higher percentage of subjects who used nicotine ( P =0.01), had osteoporosis ( P <0.05), multi-level disease ( P <0.0001), and were >65 years of age ( P =0.01). The PEMF group showed over two-fold higher percentage of subjects that had ≥3 risk factors (n=92/160, 57.5%) compared with the control group (n=14/53, 26.4%). At the 12-month follow-up, the PEMF group demonstrated significantly higher fusion rates compared with the control (90.0% vs. 60.4%, P <0.05). A statistically significant improvement in fusion rate was observed in PEMF subjects with multi-level surgery ( P <0.0001) and high BMI (>30 kg/m 2 ; P =0.0021) when compared with the control group. No significant safety concerns were observed.

CONCLUSIONS

Adjunctive use of PEMF stimulation provides significant improvements in cervical spine fusion rates in subjects having risk factors for pseudarthrosis. When compared with control subjects that did not use PEMF stimulation, treated subjects showed improved fusion outcomes despite being older, having more risk factors for pseudarthrosis, and undergoing more complex surgeries.

Reoperation Rates According to Surgical Approach After Operation for Degenerative Cervical Pathology in Patients With Athetoid Cerebral Palsy: A Nationwide Cohort Study

STUDY DESIGN

National population-based cohort study.

OBJECTIVE

The overall complication rate for patients with athetoid cerebral palsy (CP) undergoing cervical surgery is significantly higher than that of patients without CP. The study was conducted to compare the reoperation and complication rates of anterior fusion, posterior fusion, combined fusion, and laminoplasty for degenerative cervical myelopathy/radiculopathy in patients with athetoid cerebral palsy.

METHODS

The Korean Health Insurance Review and Assessment Service national database was used for analysis. Data from patients diagnosed with athetoid CP who underwent cervical spine operations for degenerative causes between 2002 and 2020 were reviewed. Patients were categorized into four groups for comparison: anterior fusion, posterior fusion, combined fusion, and laminoplasty.

RESULTS

A total of 672 patients were included in the study. The overall revision rate was 21.0% (141/672). The revision rate was highest in the anterior fusion group (42.7%). The revision rates of combined fusion (11.1%; hazard ratio [HR], .335; P = .002), posterior fusion (13.8%; HR, .533; P = .030) were significantly lower than that of anterior fusion. Revision rate of laminoplasty (13.1%; HR, .541; P = .240) was also lower than anterior fusion although the result did not demonstrate statistical significance.

CONCLUSION

Anterior fusion presented the highest reoperation risk after cervical spine surgery reaching 42.7% in patients with athetoid CP. Therefore, anterior-only fusion in patients with athetoid CP should be avoided or reserved for strictly selected patients. Combined fusion, with the lowest revision risk at 11.1%, could be safely applied to patients with athetoid CP.

Use of bispectral index for detection of partial cerebral hypoperfusion during cervical spine surgery: A case report

The BIS value may decrease by cerebral hypoperfusion. We report a case in which the BIS value suddenly decreased during cervical spine surgery, which led us to find cervical screws compressing the vertebral arteries. In a 79-year-old man undergoing cervical spine surgery, the BIS suddenly decreased from about 40 to 10-20, about 4 h after the start of surgery. Intraoperative 3-dementional computed tomography indicated that both the two tips of cervical screws inserted in the 6th cervical vertebra were within bilateral transverse foramens. These cervical screws were removed, and the BIS increased immediately. The cervical screws were re-inserted again thorough the same vertebra into the bilateral transverse foramens, and the BIS decreased immediately. Postoperatively, cerebral hypoperfusion due to compression of bilateral vertebral arteries by two cervical screws was identified. The BIS may be a useful to detect cerebral hypoperfusion due to compression of the vertebral artery by a cervical screw.

Successful management of cervical tuberculosis and severe kyphosis using polyetheretherketone expandable cage and titanium plate: A case report

Key Clinical Message

Successful management of cervical tuberculosis and severe kyphosis was achieved using a PEEK expandable cage and titanium plate, demonstrating favorable outcomes in restoring cervical alignment and stability. This approach represents a promising alternative for addressing complex cervical pathologies, highlighting the potential of PEEK-based interventions in surgical management.

Abstract

Cervical tuberculosis can lead to severe vertebral destruction and kyphosis, posing challenges in surgical management. Recent advancements, including the use of polyetheretherketone (PEEK) expandable cages and titanium plates, show promise in addressing multilevel cervical pathologies. This report details the successful treatment of a 27-year-old male with cervical tuberculosis and severe kyphosis. Surgical intervention involved prevertebral abscess evacuation, C5-C7 corpectomy, and insertion of a PEEK expandable cage with an anterior titanium plate. Postoperative care included a Philadelphia collar, and follow-up demonstrated restored cervical alignment and stability. The use of PEEK-based surgical interventions, as demonstrated in this case, represents a significant evolution in managing complex cervical conditions. The successful outcome highlights the potential benefits of PEEK expandable cages in addressing cervical tuberculosis and kyphosis. Further research is needed to validate these findings and establish PEEK-based interventions as a viable alternative in such cases.

Recurrent Zenker's Traction Diverticulum After Cervical Spine Surgery: Lessons Learned

This is a report of our institutional experience regarding pharyngoesophageal diverticula formation following anterior cervical spine surgery (ACSS). It is a retrospective chart review of institutional patients from January 2008 to May 2020. Patients at our institution were identified by our two senior authors. Inclusion criteria included patients > 18 years old, a history of prior ACSS, and a confirmed diagnosis of pharyngoesophageal diverticulum with radiographic imaging. Three patients were identified to have an ACSS-related diverticulum. The case presentations describe surgical management and the subsequent postoperative course. One patient had a particularly complicated course with recurrent diverticulum formation despite prior excision. The patient continued to have dense scar tissue adhering the posterior esophageal wall to the nearby cervical spine plates, despite prior excision and rotation of nearby tissue. This difficult case demonstrated the need for an open and aggressive approach. ACSS-related diverticula that form in patients with a history of prior anterior cervical spine surgery appear to be a form of traction diverticulum due to dense scar tissue that adheres the pharyngoesophageal mucosa to the adjacent cervical spinal plate. This type of diverticulum differs from Zenker's diverticulum. Surgical management is recommended to resolve patients' symptoms.

Socioeconomic Status Correlates With Initial Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) Scores but Not the Likelihood of Spine Surgery

Objective To explore how socioeconomic status and patient characteristics may be associated with initial self-reports of pain and determine if there was an increased association with undergoing spine surgery. Methods Patients at an academic center between 2015 and 2021 who completed the Patient-Reported Outcomes Measurement Information System-Pain Interference (PROMIS-PI) questionnaire were included. Multivariable linear regression models were used to determine the association between insurance type and patient factors with initial reports of pain. Multivariable logistic regression models were used to determine the association between PI and the likelihood of surgery in two time periods, three and 12 months. Results The study included 9,587 patients. The mean PROMIS-PI scores were 61.93 (SD 7.82) and 63.74 (SD 6.93) in the cervical and lumbar cohorts, respectively. Medicaid and Workers' Compensation insurance patients reported higher pain scores compared to those with private insurance: Medicaid (cervical: 2.77, CI (1.76-3.79), p<0.001; lumbar (2.05, CI (1.52-2.59), p<0.001); Workers' Compensation (cervical: 2.12, CI (0.96-3.27), p<0.001; lumbar: 1.51, CI (0.79-2.23), p<0.001). Black patients reported higher pain compared to White patients (cervical: 1.50, CI (0.44-2.55), p=0.01; lumbar: 1.51, CI (0.94-2.08), p<0.001). Higher PROMIS-PI scores were associated with a higher likelihood of surgery. There was no increased association of likelihood of surgery in Black, Medicaid, or Workers' Compensation patients when controlling for pain severity. Conclusion Black patients and patients with Medicaid and Workers' compensation insurance were likely to report higher pain scores. Higher initial pain scores were associated with an increased likelihood of surgery. However, despite increased pain scores, Black patients and those with Medicaid and Workers' Compensation insurance did not have a higher likelihood of undergoing surgery.

Risk factors for C5 palsy: a systematic review and multivariate analysis

OBJECTIVE

Postoperative C5 palsy (C5P) is a known complication in cervical spine surgery. However, its exact pathophysiology is unclear. The authors aimed to provide a review of the current understanding of C5P by performing a comprehensive, systematic review of the existing literature and conducting a critical appraisal of existing evidence to determine the risk factors of C5P.

METHODS

A systematic search of PubMed/MEDLINE (January 1, 2019, to July 2, 2021), EMBASE (inception to July 2, 2021), and Cochrane (inception to July 2, 2021) databases was conducted. Preestablished criteria were used to evaluate studies for inclusion. Studies that adjusted for one or more of the following factors were considered: preoperative foraminal diameter (FD) at C4/5, posterior spinal cord shift at C4/5, preoperative anterior-posterior diameter (APD) at C4/5, preoperative spinal cord rotation, and change in C2-7 Cobb angle. Studies were rated as good, fair, or poor based on the Quality in Prognosis Studies (QUIPS) tool. Random effects meta-analyses were done using methods outlined by Cochrane methodologists for pooling of prognostic studies. Overall quality (strength) of evidence was based on Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methods for prognostic studies. The protocol for this review was published on the PROSPERO (CRD264358) website.

RESULTS

Of 303 potentially relevant citations of studies, 12 met the inclusion criteria set a priori. These works provide moderate-quality evidence that preoperative FD substantially increases the odds of C5P in patients undergoing posterior cervical surgery. Pooled estimates across 7 studies in which various surgical approaches were used indicate that the odds of C5P approximately triple for each millimeter decrease in preoperative FD (OR 3.05, 95% CI 2.07-4.49). Preoperative APD increases the odds of C5P, but the confidence is low. Across 3 studies, each using different surgical approaches, each millimeter decrease in preoperative APD was associated with a more than 2-fold increased odds of C5P (pooled OR 2.51, 95% CI 1.69-3.73). Confidence that there is an association with postoperative C5P and posterior spinal cord shift, change in sagittal Cobb angle, and preoperative spinal cord rotation is very low.

CONCLUSIONS

The exact pathophysiological process resulting in postoperative C5P remains an enigma but there is a clear association with foraminal stenosis, especially when performing posterior procedures. C5P is also related to decreased APD but the association is less clear. The overall quality (strength) of evidence provided by the current literature is low to very low for most factors. Systematic review registration no.: CRD264358 (https://www.crd.york.ac.uk/prospero/).

Comparison of Remimazolam versus Sevoflurane on the Postoperative Quality of Recovery in Cervical Spine Surgery: A Prospective Randomized Controlled Double-Blind Trial

Purpose

Remimazolam is a newly developed ultra-short-acting benzodiazepine. We compared overall functional recovery, including the postoperative Quality of Recovery-15 (QoR-15) questionnaire scores, between balanced inhalational anesthesia using sevoflurane and total intravenous anesthesia (TIVA) with remimazolam in patients undergoing anterior cervical discectomy and fusion (ACDF).

Patients and Methods

Seventy-two patients were randomized to the remimazolam (group R) or sevoflurane (group S) group. The primary outcome was the total QoR-15 score on postoperative day (POD) 1. We also assessed the total QoR-15 score on POD2, sub-scores of the QoR-15, perioperative parameters, and postoperative recovery profiles. Group-time interaction effects on the QoR-15 and its sub-scores were analyzed using a linear mixed model.

Results

The total QoR-15 score on POD1 (120.2 in group R vs 114.3 in group S, P=0.189) was not statistically different between the groups. There were no significant group-time interaction effects on total QoR-15 scores. Instead, patients in group R showed significantly better sub-scores in psychological and postoperative nausea and vomiting (PONV) items on POD1, as well as a lower degree of PONV, than those in group S. Among the five dimensions of the QoR-15, a significant group-time interaction effect was observed for psychological support. Group R showed significantly less changeability in blood pressure and heart rate with a lower dose of intraoperatively administered vasopressor than group S.

Conclusion

Considering QoR-15, including PONV reduction, and intraoperative hemodynamic stability, remimazolam can be used as the novel and safe anesthetic agent for maintaining general anesthesia instead of sevoflurane in patients undergoing ACDF.

Transcranial Motor Evoked Potentials as a Predictive Modality for Postoperative Deficit in Cervical Spine Decompression Surgery - A Systematic Review and Meta-Analysis

STUDY DESIGN

Systematic Review and Meta-analysis.

OBJECTIVE

The purpose of this study was to evaluate whether transcranial motor evoked potential (TcMEP) alarms can predict postoperative neurologic complications in patients undergoing cervical spine decompression surgery.

METHODS

A meta-analysis of the literature was performed using PubMed, Web of Science, and Embase to retrieve published reports on intraoperative TcMEP monitoring for patients undergoing cervical spine decompression surgery. The sensitivity, specificity, and diagnostic odds ratio (DOR), of overall, reversible, and irreversible TcMEP changes for predicting postoperative neurological deficit were calculated. A subgroup analysis was performed to compare anterior vs posterior approaches.

RESULTS

Nineteen studies consisting of 4608 patients were analyzed. The overall incidence of postoperative neurological deficits was 2.58% (119/4608). Overall TcMEP changes had a sensitivity of 56%, specificity of 94%, and DOR of 19.26 for predicting deficit. Reversible and irreversible changes had sensitivities of 16% and 49%, specificities of 95% and 98%, and DORs of 3.54 and 71.74, respectively. In anterior procedures, TcMEP changes had a DOR of 17.57, sensitivity of 49%, and specificity of 94%. In posterior procedures, TcMEP changes had a DOR of 21.01, sensitivity of 55%, and specificity of 94%.

CONCLUSION

TcMEP monitoring has high specificity but low sensitivity for predicting postoperative neurological deficit in cervical spine decompression surgery. Patients with new postoperative neurological deficits were 19 times more likely to have experienced intraoperative TcMEP changes than those without new deficits, with irreversible TcMEP changes indicating a much higher risk of deficit than reversible TcMEP changes.

Do Grip Strength Dynamometer Readings Improve After Cervical Spine Surgery?

STUDY DESIGN

Retrospective, cohort study.

OBJECTIVES

Hand function can be difficult to objectively assess perioperatively. In patients undergoing cervical spine surgery by a single-surgeon, we sought to: (1) use a hand dynamometer to report pre/postoperative grip strength, (2) distinguish grip strength changes in patients with radiculopathy-only vs myelopathy, and (3) assess predictors of grip strength improvement.

METHODS

Demographic and operative data were collected for patients who underwent surgery 2015-2018. Hand dynamometer readings were pre/postoperatively at three follow-up time periods (0-3 m, 3-6 m, 6-12 m).

RESULTS

262 patients (mean age of 59 ± 14 years; 37% female) underwent the following operations: ACDF (80%), corpectomy (25%), laminoplasty (19%), and posterior cervical fusion (7%), with 81 (31%) patients undergoing multiple operations in a single anesthetic setting. Radiculopathy-only was seen in 128 (49%) patients, and myelopathy was seen 134 (51%) patients. 110 (42%) had improved grip strength by ≥10-lbs, including 69/128 (54%) in the radiculopathy-only group, and 41/134 (31%) in the myelopathy group. Those most likely to improve grip strength were patients undergoing ACDF (OR 2.53, P = .005). Patients less likely to improve grip strength were older (OR = .97, P = .003) and underwent laminoplasty (OR = .44, 95% CI .23, .85, P = .014). Patients undergoing surgery at the C2/3-C5/6 levels and C6/7-T1/2 levels both experienced improvement during the 0-3-month time range (C2-5: P = .035, C6-T2: P = .015), but only lower cervical patients experienced improvement in the 3-6-month interval (P = .030).

CONCLUSIONS

Grip strength significantly improved in 42% of patients. Patients with radiculopathy were more likely to improve than those with myelopathy. Patients undergoing surgery from the C2/3-C5/6 levels and the C6/7-T1/2 levels both significantly improved grip strength at 3-month postoperatively.

Rehabilitation after cervical and lumbar spine surgery

The total number of spine surgeries is increasing, with a variable percentage of patients remaining symptomatic and functionally impaired after surgery. Rehabilitation has been widely recommended, although its effects remain unclear due to lack of research on this matter. The aim of this comprehensive review is to resume the most recent evidence regarding postoperative rehabilitation after spine surgery and make recommendations. The effectiveness of cervical spine surgery on the outcomes is moderate to good, so most physiatrists and surgeons agree that patients benefit from a structured postoperative rehabilitation protocol and despite best timing to start rehabilitation is still unknown, most programs start 4-6 weeks after surgery. Lumbar disc surgery has shown success rates between 78% and 95% after 2 years of follow-up. Postoperative rehabilitation is widely recommended, although its absolute indication has not yet been proven. Patients should be educated to start their own postoperative rehabilitation immediately after surgery until they enroll on a rehabilitation program usually 4-6 weeks post-intervention. The rate of lumbar interbody fusion surgery is increasing, particularly in patients over 60 years, although studies report that 25-45% of patients remain symptomatic. Despite no standardized rehabilitation program has been defined, patients benefit from a cognitive-behavioral physical therapy starting immediately after surgery with psychological intervention, patient education and gradual mobilization. Formal spine rehabilitation should begin at 2-3 months postoperatively. Rehabilitation has benefits on the recovery of patients after spine surgery, but further investigation is needed to achieve a standardized rehabilitation approach.

The Use of Intraoperative Neuromonitoring for Cervical Spine Surgery: Indications, Challenges, and Advances

Intraoperative neuromonitoring (IONM) has become an indispensable surgical adjunct in cervical spine procedures to minimize surgical complications. Understanding the historical development of IONM, indications for use, associated pitfalls, and recent developments will allow the surgeon to better utilize this important technology. While IONM has shown great promise in procedures for cervical deformity, intradural tumors, or myelopathy, routine use in all cervical spine cases with moderate pathology remains controversial. Pitfalls that need to be addressed include human error, a lack of efficient communication, variable alarm warning criteria, and a non-standardized checklist protocol. As the techniques associated with IONM technology become more robust moving forward, IONM emerges as a crucial solution to updating patient safety protocols.

Factors Associated With the Rate of Recovery After Cervical Decompression Surgery for Degenerative Cervical Myelopathy: A Retrospective Analysis

Introduction Degenerative cervical myelopathy (DCM) is a debilitating spinal condition with a wide variety of symptoms that can differ greatly among individuals. Common symptoms include numbness, extremity weakness, loss of balance, and gait instability. Decompression surgeries are commonly indicated for the treatment of DCM with varying outcomes reported in the literature. However, there is little evidence on the rate of recovery defined as the time until improvement in symptoms such as numbness, balance, and strength after surgery for DCM. The purpose of this study was to determine the rate of neurological recovery after surgery for DCM and its subsequent association with various risk factors to guide clinicians while providing care and improve patient education. Methods This study was a retrospective case series (n=180 patients) examining patients who underwent cervical decompression surgery for DCM. All patients had a clinical presentation of DCM, were diagnosed with DCM, had radiographic degenerative changes and cervical stenosis, and received surgical management from 2010 to 2020 in a tertiary hospital system. Data recorded included age, smoking status, duration of pre-operative symptoms, preoperative and postoperative pain, and postoperative rate of recovery (days until improvement) in numbness, upper extremity strength, and balance. Results Patients (n=180) had an average age of 65.7 years (SD ±9.2 years, range 43-93 years). The mean ± standard deviation for the rate of recovery (days until improvement) in numbness, upper extremity strength, and balance was 84.5 ± 94.4 days, 50.6 ± 42.8 days, and 60.4 ± 69.9 days, respectively. There was only a marginally significant association between the rate of recovery for numbness after surgery and patient age (p=0.053). The average rate of recovery in numbness for patients older than 60 years was significantly longer than those younger than 60 years (99.3 versus 60.2 days). Preoperative smoking status was significantly associated with persistent moderate to severe pain (p=0.032) within the six-month postoperative period. No significant correlations were seen between the rate of recovery for balance or strength and patient age or preoperative duration of symptoms. Conclusion There was great variability in the rate of recovery for postoperative symptoms after surgery for DCM. A longer time for improvement in postoperative numbness was only marginally correlated with the increased patient age after surgery for DCM. There was no correlation found between strength or balance recovery times and patient age. Smoking status was associated with moderate to severe postoperative pain after surgery for DCM. Furthermore, the duration of preoperative symptoms was not associated with improvement in postoperative symptoms after surgery for DCM. More research is needed to determine factors impacting the rate of recovery after surgery for DCM.

C1-C2 Facet Joint Penetration by C2 Pedicle Screws: Influence of Local Anatomy, Bone Mineral Density, and Screw Length

BACKGROUND

A challenge of C2 pedicle screw placement is to avoid penetration into the C1-C2 facet joint, as this may alter normal biomechanics and accelerate joint degeneration. Our objective was to clarify how local anatomy and surgical technique may relate to C2 pedicle screw penetration into the C1-C2 facet joint.

METHODS

C2 pedicle screws were inserted using a fluoroscopically assisted freehand technique. Independent fellowship-trained spine surgeons blindly reviewed intraoperative fluoroscopic and postoperative computed tomography (CT) images for evidence of facet joint penetration (FJP). C2 pedicle morphometry, the sagittal angle of the facet joint, axial and sagittal pedicle screw angles, and screw length were measured on the relevant CT images.

RESULTS

A total of 34 patients fulfilled the study criteria, and a total of 68 C2 pedicle screws were placed. Eight screws (16%) penetrated the C1-C2 facet joint. The mean sagittal angle of the C1-C2 facet joint was significantly lower in the FJP group compared with the non-FJP group. The mean sagittal angle of the screws was significantly higher in the FJP group compared with the non-FJP group. The mean screw length was significantly greater for screws causing FJP compared with the non-FJP group. The mean axial screw angle was significantly lower in the FJP group compared with the non-FJP group. Pedicle width, length, height, and transverse angle were not significantly associated with FJP. Independent reviewers were able to identify FJP on intraoperative fluoroscopic imaging in 2 out of 8 cases.

CONCLUSION

Lower sagittal angle of the facet joint, higher sagittal angle of the pedicle screw, and screw length >24 mm are associated with higher risk of C1-C2 FJP. When placing C2 pedicle screws under these conditions, caution should be taken to avoid FJP.

CLINICAL RELEVANCE

Several anatomical and technical factors may increase the risk of C1-C2 FJP during placement of C2 pedicle screws using a fluoroscopically assisted freehand technique, underscoring the importance of preoperative planning and limiting screw length.

LEVEL OF EVIDENCE: 3

Investigating the Association of Patient Body Mass Index With Posterior Subcutaneous Fat Thickness in the Cervical Spine: A Retrospective Radiographic Study

INTRODUCTION

Although BMI is often used as a surrogate for posterior cervical subcutaneous fat thickness (SFT), the association of BMI with cervical SFT is unknown. We performed a retrospective radiographic study to analyze the relationship between BMI and cervical SFT.

METHODS

This was a retrospective cohort study of patients with cervical CT scans. SFT was assessed by measuring the distance (mm) from the spinous processes of C2-C7 to the skin edge. Pearson correlations and linear regression were used to analyze the relationship between BMI and SFT. One-way ANOVA was used to analyze differences in C2-C7 distances while stratifying by BMI.

RESULTS

A total of 96 patients were included. BMI had a moderate correlation with average C2-C7 (r=0.546, p < 0.05) SFT, and a weak to moderate correlation with each individual C2-C7 distance. The strongest correlation was at the C7 level (r= 0.583, p < 0.05). These analyses remained significant controlling for potential confounders of patient age, sex, and diabetes. No difference was found in the average C2-C7 distance in patients with BMIs of 25-30 compared to those with BMIs of 30-40 (p=0.996), whereas in patients with BMI <25 and BMI >40, differences were significant (p < 0.05).

CONCLUSIONS

BMI is not strongly correlated with SFT in the cervical spine. Although BMI less than 25 or greater than 40 is correlated with respectively decreased or increased cervical SFT, BMI of 25-40 is not correlated with cervical SFT. This is clinically important information for surgeons counseling patients on perioperative risk before undergoing cervical spine procedures, namely infection. Further research delineating the relationship between posterior SFT and surgical site infection in the cervical spine is warranted.

Variation in Cervical Pedicle Morphology: Important Considerations for Posterior Cervical Procedures

BACKGROUND

Safe posterior cervical spine surgery requires in-depth understanding of the surgical anatomy and common variations. The cervical pedicle attachment site to the vertebral body (VB) affects the location of exiting nerve roots and warrants preoperative evaluation. The relative site of attachment of the cervical pedicle has not been previously described.

OBJECTIVE

To describe the site of the pedicle attachment to the VB in the subaxial cervical spine.

METHODS

Cervical spine computed tomography scans without any structural, degenerative, or traumatic pathology as read by a board-certified neuroradiologist during 2021 were reviewed. Multiplanar reconstructions were created and cross-registered. The pedicle's attachment to the VB was measured relative to the VB height using a novel calculation system.

RESULTS

Fifty computed tomography scans met inclusion criteria yielding 600 total pedicles between C3-T1 (100 per level). The average patient age was 26 ± 5.3 years, and 21/50 (42%) were female. 468/600 (78%) pedicles attached in the cranial third of the VB, 132/600 (22%) attached in the middle third, and 0 attached to the caudal third. The highest prevalence of variant anatomy occurred at C3 (36/100 C3 pedicles; 36%).

CONCLUSION

In the subaxial cervical spine, pedicles frequently attach to the top third of the VB, but significant variation is observed. The rate of variation is highest at C3 and decreases linearly with caudal progression down the subaxial cervical spine to T1. This is the first report investigating this morphological phenomenon.

Post-operative dysphagia following ventral cervical approach: complication or side-effect? Retrospective analysis and review of the literature

OBJECTIVE

To ameliorate the clinical decision-making process when debating between a ventral or dorsal cervical approach by elucidating whether post-operative dysphagia be regarded as a complication or a transient side effect.

METHODS

A literature review of studies comparing complication rates following ventral and dorsal cervical approaches was performed. A stratified complication rate excluding dysphagia was calculated and discussed. A retrospective cohort of patients operated for degenerative cervical myelopathy in a single institution comprising 665 patients was utilized to analyze complication rates using a uniform definition for dysphagia.

RESULTS

Both the ventral and the dorsal approach groups exhibited comparable neurological improvement rates. Since transient dysphagia was not considered a complication, the dorsal approach was associated with higher level of overall complications.

CONCLUSIONS AND RELEVANCE

Inconsistencies in the definition of dysphagia following ventral cervical surgery impedes the interpretation of trials comparing dorsal and ventral complication rates. A uniform definition for complications and side effects may enhance the validity of medical trials.

Oberlin transfer for C5-6 palsy after posterior cervical spine surgery

Postoperative C5-6 palsies can occur in 5%-10% of cases after cervical spine surgery. In this video, the authors demonstrate operative techniques for nerve transfer to restore function for postoperative C5-6 palsy. The patient underwent C3-6 laminectomy and posterior fusion for cervical spondylotic myelopathy and developed weakness postoperatively in the C5-6 distribution bilaterally. He experienced spontaneous recovery to near full strength in the most affected muscle groups by 12 months except the left biceps (2/5), with at least antigravity shoulder abduction. He underwent left ulnar to musculocutaneous nerve fascicular transfer to improve elbow flexion and supination in the setting of good hand function. The video can be found here: https://stream.cadmore.media/r10.3171/2022.10.FOCVID22100.

The Impact of Obstructive Sleep Apnea on Clinical, Perioperative, and Cost Outcomes in Patients Who Underwent Posterior Cervical Decompression and Fusion: A Single-Center Retrospective Analysis From 2008 to 2016

BACKGROUND

Obstructive sleep apnea (OSA) is a pervasive problem that can result in diminished neurocognitive performance, increased risk of all-cause mortality, and significant cardiovascular disease. While previous studies have examined risk factors that influence outcomes following cervical fusion procedures, to our knowledge, no study has examined the cost or outcome profiles for posterior cervical decompression and fusion (PCDF) procedures in patients with OSA.

METHODS

All cases at a single institution between 2008 and 2016 involving a PCDF were included. The primary outcome was prolonged extubation, defined as an extubation that took place outside of the operating room. Secondary outcomes included admission to the intensive care unit (ICU), complications, extended hospitalization, nonhome discharge, readmission within 30 and 90 days, emergency room visit within 30 and 90 days, and higher total costs.

RESULTS

We reviewed 1191 PCDF cases, of which 93 patients (7.81%) had a history of OSA. At the univariate level, patients with OSA had higher rates of ICU admissions (33.3% vs 16.8%, P < 0.0001), total complications (29.0% vs 19.0%, P = 0.0202), and respiratory complications (12.9% vs 6.6%, P = 0.0217). Multivariate regression analyses revealed no difference in the odds of a prolonged extubation (P = 0.4773) and showed that history of OSA was not predictive of higher costs. However, a significant difference was observed in the odds of having an ICU admission (P = 0.0046).

CONCLUSION

While patients with sleep apnea may be more likely to be admitted to the ICU postoperatively, OSA status a lone is not a risk factor for poor primary and secondary clinical outcomes following posterior cervical fusion procedures.

CLINICAL RELEVANCE

Various deformities of the cervical spine can exert extraluminal forces that partially collapse or obstruct the airway, thereby predisposing patients to OSA; however, no study has examined the cost or outcome profiles for PCDF procedures in patients with OSA. Therefore, this investigation highlights the ways in which OSA influences the risks, outcomes, and costs following PCDF using medical data from an institutional registry.

LEVEL OF EVIDENCE: 3

Cervical spine microsurgery with the high-definition 3D exoscope: advantages and disadvantages

OBJECTIVE

The aim of this study was to evaluate our experience with a high-definition three-dimensional (3D) exoscope (EX) for cervical spine surgery versus a binocular operating microscope (OM).

METHODS

A retrospective review of patients undergoing a single-level anterior cervical discectomy and fusion (ACDF) procedure for the treatment of cervical myelopathy from March 2019 to May 2020 was performed. Demographic, perioperative, and clinical outcomes of 50 patients were included, 23 of whom received assistance from the 3D exoscope (EX group) and 27 of whom received assistance from the OM (OM group). Operative baseline and postoperative outcome parameters were evaluated. Periprocedural handling, visualization, and illumination by the EX, as well as surgeons' ergonomics, were scored using a questionnaire and rapid upper limb assessment (RULA).

RESULTS

Baseline characteristics were similar between the two groups. There were no significant differences between groups in mean operative time, blood loss, duration of admission, or postoperative improvement of symptoms. Both groups showed similar clinical improvements after surgery. There were no intraoperative complications in either group. According to the attending surgeons, the intraoperative handling of instruments for the EX was rated to be comparable to that of the OM. Surgeons rated the comfort level of the intraoperative posture for the EX as very high on the subjective questionnaire and equal to the OM on the objective RULA. When compared with the OM, depth perception, image quality, and illumination for the EX were rated as inferior in ACDF procedures with long approaches. The operative education and training function of the EX was rated to be superior to that of the OM.

CONCLUSIONS

Overall, our study showed that the EX appears to be a safe alternative for common ACDF with the unique advantage of excellent comfort and also serves a useful educational tool for the surgical team. However, our investigation revealed several important limitations of this system, including slightly inferior visualization and illumination quality compared with the OM.

Multimodal Analgesic Management for Cervical Spine Surgery in the Ambulatory Setting

BACKGROUND

Patient selection and analgesic techniques, such as the multimodal analgesic (MMA) protocol, aid in ambulatory surgical center (ASC) cervical spine surgery. The purpose of this case series is to characterize patients undergoing anterior cervical discectomy and fusion (ACDF) and total cervical disc replacement (CDR) in an ASC with an enhanced MMA protocol.

METHODS

A prospectively maintained registry was retrospectively reviewed for cervical surgeries between May 2013 and August 2019. Inclusion criteria included ASC patients who underwent single-level or multilevel CDR or ACDF using an MMA protocol. Baseline, intraoperative, and postoperative characteristics were recorded, including length of stay, visual analog scale pain scores, neck disability index, complications, and narcotics administered.

RESULTS

A total of 178 patients met inclusion criteria with 125 single-level, 52 two-level, and 1 three-level procedure. Of those patients, 127 underwent ACDF and 51 underwent CDR. The longest procedure was 95 minutes and the mean length of stay was 6.1 hours, with 2 patients requiring hospital admission. All other patients were discharged within 10 hours. One of the admitted patients experienced a postoperative seizure that was later determined to be secondary to drug use and serotonin syndrome. The second patient developed an anterior cervical hematoma 5 hours postoperatively, which was immediately evacuated. The patient was admitted for observation and discharged the next day.

CONCLUSION

In our study, patients experienced considerable improvement in disability scores, with a low likelihood of postoperative complications. A safe and effective MMA protocol may help facilitate anterior cervical surgery in the outpatient setting.

LEVEL OF EVIDENCE

3.

CLINICAL RELEVANCE

Transitioning anterior cervical discectomy and fusions to the ASC requires an appropriate MMA protocol. Our findings reveal that an enhanced MMA protocol will help improve disability scores while keeping the likelihood of postoperative complications low. This supports the ASC setting for cervical spine procedures in appropriate patient populations.

Stereotactic navigation in anterior cervical spine surgery: surgical setup and technique

Intraoperative stereotactic navigation in spine surgery is quickly becoming popularized for accurate placement of spinal instrumentation as well as assisting in the verification of anatomic landmarks. Navigation is less commonly utilized in anterior cervical spine surgery due to instrumentation being able to be placed under direct visualization. The utility of navigation in anterior cervical spine surgery is its ability to aid in the verification of anatomic location, particularly when anatomy is distorted or pathology comes close to critical neurovascular structures. We present a technique guide for anterior cervical spine navigation that we have applied at our institution and have found to be very beneficial in select patients, particularly those with complex anatomy, large body mass index, undergoing revision surgery, sustained spinal trauma and those patients with severe anterior ossification where depth or medial-lateral landmarks are difficult to visualize. We describe utilization of the technique using a case examples and specifically in a patient with significant ossification of the posterior longitudinal ligament and severe spinal cord compression that underwent multilevel cervical corpectomy. The described technique was found to be reproducible and effective, allowing cervical spine surgeons to perform more complex or minimally invasive procedures with safety and accuracy. We emphasize that navigation does not replace knowledge of anatomy or technical aspects of the procedure.

Patient Selection in Cervical Disc Arthroplasty

BACKGROUND

Patient selection for cervical disc arthroplasty (CDA) in the United States remains a topic of debate among surgeons. Many surgeons base US patient selection for CDA implantation on the Food and Drug Administration (FDA) indications/contraindications. While off-label use does occur, the frequency and extent of off-label use in the US remains largely unknown. Outside the United States, patient selection is notably less stringent; however such data also remain largely unpublished or presented/published with a low level of evidence. Here, we will review the current approved US on-label patient selection criteria for CDA and discuss the rationale and supporting evidence to expand these criteria in the United States.

METHODS

A PubMed literature search was completed using the keywords "cervical disc arthroplasty" and "cervical disc replacement." The articles were evaluated by the authors for patient selection criteria.

CONCLUSIONS

The current published data do not conclusively prove that the patients excluded from CDA by strict adherence to FDA indications would benefit from CDA surgery over anterior cervical discectomy and fusion. As surgeons, it is a difficult decision regarding when to expand indications to include off-label use of CDA. In our practice, generally CDA patient selection agrees with the FDA indications and contraindications, as there is a lack of level 1 evidence to confirm effectiveness of CDA outside of the current FDA indications. We will likely need more well-constructed studies to include prospective and controlled trials that specifically evaluate the "off-label" applications before US surgeons are convinced to expand indications and insurance companies agree to reimburse.

Outcomes in single-level posterior cervical spine surgeries performed in the sitting and prone positions

OBJECTIVE

The sitting or semisitting position in neurosurgery allows for several technical advantages, including improved visualization of the surgical field. However, it has also been associated with an increased risk of venous air embolisms and positioning-related complications that limit its commonplace adoption. The authors report a large, single-center series of cervical spine procedures performed with patients in the sitting or prone position in order to assess the perceived risk of intraoperative and postoperative complications associated with the sitting position.

METHODS

Noninstrumented, single-level posterior cervical spine procedures performed with patients in the sitting/semisitting or prone position from 2000 to 2016 at a single institution were reviewed. Institutional abstraction tools (DataMart and Chart Plus) were used to collect data from the medical records. The two positions were compared with regard to preoperative factors, intraoperative variables, and postoperative outcomes. Multivariable logistic regression models were fitted for 30-day readmission, 30-day return to the operating room, and complication rates.

RESULTS

A total of 750 patients (sitting, n = 480; prone, n = 270) were analyzed. The median age was 53 years for those who underwent surgery in the prone position and 50 years for those who underwent surgery in the sitting position (IQRs 45-62 years and 43-60 years, respectively), and 35% of the patients were female. Sitting cases were associated with significantly longer anesthetic times (221 minutes [range 199-252 minutes] vs 205 minutes [range 179-254 minutes]) and operative times (126 minutes [range 101-163 minutes] vs 149 minutes [120-181 minutes]). Cardiorespiratory events in the postanesthesia care unit (PACU) were comparable between the two groups, with the exception of episodes of apnea (2.6% vs 0.6%, p = 0.041) and hypoventilation (4.4% vs 0.8%, p < 0.003), which were more frequent in the prone-position cohort. On multivariable analysis, the effect of the sitting versus the prone position was not significant for 30-day readmission (OR 0.77, 95% CI 0.34-1.71, p = 0.52) or reoperation (OR 0.71, 95% CI 0.31-1.60, p = 0.40). The sitting position was associated with lower odds of developing any complication (OR 0.31, 95% CI 0.16-0.62, p < 0.001).

CONCLUSIONS

Based on the intraoperative and postoperative complications chosen in this study, the sitting position confers a similar safety profile to the prone position. This can be explained by a more anatomic positioning accounting for reduced temporary neurological deficits and reduced PACU-associated hypoventilation noted in this series. Nevertheless, the findings may also reflect institutional familiarity, experience, and mastery of this position type, and outcomes may not reflect practices in general.

Cervical Myelopathy in Patients Suffering from Rheumatoid Arthritis-A Case Series of 9 Patients and A Review of the Literature

Cervical myelopathy occurs in approximately 2.5% of patients suffering from rheumatoid arthritis (RA) and is associated with notable morbidity and mortality. However, the surgical management of patients affected by cervical involvement in the setting of RA remains challenging and not well studied. To address this, we conducted a retrospective analysis of our clinical database between May 2007 and April 2017, and report on nine patients suffering from cervical myelopathy due to RA. We included patients treated surgically for cervical myelopathy on the basis of diagnosed RA. Clinical findings, treatment and outcome were assessed and reported. In addition, we conducted a narrative review of the literature. Four patients were male. Mean age was 64.8 ± 20.5 years. Underlying cervical pathology was anterior atlantoaxial instability (AAI) associated with retrodental pannus in four cases, anterior atlantoaxial subluxation (AAS) in two cases and basilar invagination in three cases. All patients received surgical treatment via posterior fixation, and in addition two of these cases were combined with a transnasal approach. Preoperative modified Japanese orthopaedic association scale (mJOA) improved from 12 ± 2.4 to 14.6 ± 1.89 at a mean follow-up at 18.8 ± 23.3 months (range 3-60 months) in five patients. In four patients, no follow up was available, and the mJOA of these patients at time of discharge was stable compared to the preoperative score. One patient died two days after surgery, where a pulmonary embolism was assumed to be the cause of mortality, and one patient sustained a temporary worsening of his neurological deficit postoperatively. Surgery is generally an effective treatment method in patients with inflammatory arthropathies of the cervical spine. Given the nature of the RA and potential instability, fixation in addition to cord decompression is generally required.

Cervical laminoplasty: indication, technique, complications

Cervical laminoplasty is a non-fusion, decompression procedure for cervical spondylotic myelopathy (CSM). It is most commonly indicated for patients with multilevel stenosis who have preserved sagittal alignment and minimal to no axial neck pain related to spondylosis. Expansion of the laminar arch can allow for direct and indirect decompression of the spinal canal. Relative contraindications include those patients with significant preoperative neck pain, kyphotic alignment and substantial instability. Potential advantages over laminectomy and fusion include avoiding fusion-related complications, and the preservation of motion. Important technical considerations include meticulous extensor muscle management, with special attention being given to preserving the soft tissue attachments to C2. In the properly selected patient, outcomes are comparable, and in some studies superior, to other operations for CSM.

Proton Pump Inhibitor Use Affects Pseudarthrosis Rates and Influences Patient-Reported Outcomes

STUDY DESIGN

Retrospective cohort review.

OBJECTIVES

Cervical pseudarthrosis is a frequent cause of need for revision anterior cervical discectomy and fusion (ACDF) and may lead to worse patient-reported outcomes. The effect of proton pump inhibitors on cervical fusion rates are unknown. The purpose of this study was to determine if patients taking PPIs have higher rates of nonunion after ACDF.

METHODS

A retrospective cohort review was performed to compare patients who were taking PPIs preoperatively with those not taking PPIs prior to ACDF. Patients younger than 18 years of age, those with less than 1-year follow-up, and those undergoing surgery for trauma, tumor, infection, or revision were excluded. The rates of clinically diagnosed pseudarthrosis and radiographic pseudarthrosis were compared between PPI groups. Patient outcomes, pseudarthrosis rates, and revision rates were compared between PPI groups using either multiple linear or logistic regression analysis, controlling for demographic and operative variables.

RESULTS

Out of 264 patients, 58 patients were in the PPI group and 206 were in the non-PPI group. A total of 23 (8.71%) patients were clinically diagnosed with pseudarthrosis with a significant difference between PPI and non-PPI groups (P = .009). Using multiple linear regression, PPI use was not found to significantly affect any patient-reported outcome measure. However, based on logistic regression, PPI use was found to increase the odds of clinically diagnosed pseudarthrosis (odds ratio 3.552, P = .014). Additionally, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores (P = .022).

CONCLUSIONS

PPI use was found to be a significant predictor of clinically diagnosed pseudarthrosis following ACDF surgery. Furthermore, clinically diagnosed pseudarthrosis negatively influenced improvement in PCS-12 scores.

Unstable Hangman's fracture: Anterior or posterior surgery?

Context:

Literature evaluating the efficacy and long-term clinico-radiological outcomes of anterior cervical discectomy and fusion (ACDF) and posterior fixation at C2–C3 for the treatment of unstable hangman's fractures is scanty.

Aims:

The aim of this study is to compare the efficacy, clinical-radiological outcomes, and complications of ACDF and posterior fixation techniques performed for unstable hangman's fractures.

Settings and Design:

The study design involves retrospective comparative study.

Subjects and Methods:

This study conducted from 2012 to 2018 included 21 patients with unstable hangman's fracture (Levine and Edwards Type II, IIa and III). All patients were divided into two groups based on the approach taken for fracture fixation (Group A-anterior approach and Group B-posterior approach). Peri-operative clinical, radiological parameters, postoperative complications, and outcomes were evaluated and compared in both the groups.

Statistical Analysis Used:

Chi-square test and Student's t-test were used.

Results:

The mean age was 39.8 ± 4.5 years in-group A and 41.3 ± 6.7 years in-group B. The male patients outnumbered the female patients and road traffic accident was the most common cause of unstable fractures. There were statistical significant differences in surgical time (P = 0.15), operative blood loss, pain-free status postsurgery, and hospital stay (P = 0.15) between two groups. No statistically significant differences noted in clinic-radiological outcomes in the form of visual analog scale and fusion rate at final follow-up between two groups at final follow-up.

Conclusions:

The unstable hangman's fractures can be effectively managed with both anterior and posterior approaches with comparable clinico-radiological outcome. A minimally invasive nature, earlier pain-free status, early mobilization with reduced hospitalization make the ACDF efficacious, particularly in cases with no medullary canal in C2 pedicles and traumatic C2–3 disc herniation with listhesis compressing the spinal cord.

Degenerative Cervical Myelopathy in Higher-Aged Patients: How Do They Benefit from Surgery?

Background: Degenerative cervical myelopathy (DCM) is the most common reason for spinal cord disease in elderly patients. This study analyzes the preoperative status and postoperative outcome of higher-aged patients in comparison to young and elderly patients in order to determine the benefit to those patients from DCM surgery. Methods: A retrospective analysis of the clinical data, radiological findings, and operative reports of 411 patients treated surgically between 2007 and 2016 suffering from DCM was performed. The preoperative and postoperative neurological functions were evaluated using the modified Japanese Orthopedic Association Score (mJOA Score), the postoperative mJOA Score improvement, the neurological recovery rate (NRR) of the mJOA Score, and the minimum clinically important difference (MCID). The Charlson Comorbidity Index (CCI) was used to evaluate the impact of comorbidities on the preoperative and postoperative mJOA Score. The comparisons were performed between the following age groups: G1: ≤50 years, G2: 51–70 years, and G3: >70 years. Results: The preoperative and postoperative mJOA Score was significantly lower in G3 than in G2 and G1 (p < 0.0001). However, the mean mJOA Score’s improvement did not differ significantly (p = 0.81) between those groups six months after surgery (G1: 1.99 ± 1.04, G2: 2.01 ± 1.04, G: 2.00 ± 0.91). Furthermore, the MCID showed a significant improvement in every age-group. The CCI was evaluated for each age-group, showing a statistically significant group effect (p < 0.0001). Analysis of variance revealed a significant group effect on the delay (weeks) between symptom onset and surgery (p = 0.003). The duration of the stay at the hospital did differ significantly between the age groups (p < 0.0001). Conclusion: Preoperative and postoperative mJOA Scores, but not the extent of postoperative improvement, are affected by the patients’ age. Therefore, patients should be considered for DCM surgery regardless of their age.

Factors Associated With C5 Palsy Following Cervical Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

C5 palsy (C5P) is a not uncommon and disabling postoperative complication with a reported incidence varying between 0% and 30%. Among others, one explanation for its occurrence includes foraminal nerve root tethering. Although different risk factors have been reported, controversy about its causation and prevention persists. Inconsistent study findings contribute to the persistent ambiguity leading to an assumption of a multifactorial nature of the underlying C5P pathophysiology. Here, we report the results of a systematic review on C5P with narrow inclusion criteria in the hope of elucidating risk factors for C5P due to a common pathophysiological mechanism.

METHODS

Electronic databases from inception to March 9, 2019 and references of articles were searched. Narrow inclusion criteria were applied to identify studies investigating demographic, clinical, surgical, and radiographic factors associated with postoperative C5P.

RESULTS

Sixteen studies were included after initial screening of 122 studies. Eighty-four risk factors were analyzed; 27 in ≥2 studies and 57 in single studies. The pooled prevalence of C5P was 6.0% (range: 4.2%-24.1%) with no consistent evidence that C5P was associated with demographic, clinical, or specific surgical factors. Of the radiographic factors assessed, specifically decreased foraminal diameter and preoperative cord rotation were identified as risk factors for C5P.

CONCLUSION

Although risk factors for C5P have been reported, ambiguity remains due to potentially multifactorial pathophysiology and study heterogeneity. We found foraminal diameter and cord rotation to be associated with postoperative C5P occurrence in our meta-analysis. These findings support the notion that factors contributing to, and acting synergistically with foraminal stenosis increase the risk of postoperative C5P.

Factors Related to Delayed Extubation in Cervical Spine Surgery in an Academic Hospital: A Retrospective Study of 506 Patients

Objective

The incidence of airway obstruction has been reported to be 1.2–6.1% after cervical spine surgery and up to 27% in posterior occipito-cervical spinal fusion. Communication between the anesthesiologist, surgeon, and staff responsible for postoperative care, and the identifi cation of patients at risk of airway complications are important. We aimed to determine the incidences of delayed extubation and reintubation, and the factors related to delayed extubation after cervical spine surgery.

Methods

A review was conducted of the medical records of patients who underwent cervical spine surgery in the orthopedic and neurosurgery units, Siriraj Hospital, between January 2012 and May 2017. The data included demographics, perioperative airway management, postoperative airway complications (delayed extubation and reintubation), and outcomes.

Results

Of the 506 patients analyzed, delayed extubation occurred in 116 (22.9%), and 15 (3.0%) were reintubated. The independent related factors for delayed extubation were blood loss ≥ 300 mL (odds ratio [OR], 2.71; 95% confi dence interval [CI], 1.33–5.49); intraoperative fl uid administration ≥ 2,000 mL (OR, 2.17; 95% CI, 1.08–4.36); anesthetic time of ≥ 300 min (OR, 3.74; 95% CI, 1.83–7.63); and case fi nished after service hours (OR, 3.18; 95% CI, 1.73–5.88).

Conclusion

The incidence of delayed extubation in cervical spine surgery patients was high, and reintubation was common. Anesthesiologists should be cognizant of the related risk factors before deciding between immediate or delayed extubation.

Finnish Trial on Practices of Anterior Cervical Decompression and Fusion (FACADE): a protocol for a prospective randomised non-inferiority trial comparing outpatient versus inpatient care

INTRODUCTION

Although a great majority of patients with cervical radiculopathy syndrome can successfully be treated non-operatively, a considerable proportion experience persistent symptoms, severe enough to require neurosurgical intervention. During the past decade, cervical spine procedures have increasingly been performed on an outpatient basis and retrospective database analyses have shown this to be feasible and safe. However, there are no randomised controlled studies comparing outpatient care with inpatient care, particularly with emphasis on the patients' perception of symptom relief and their ability to return to normal daily activities and work.

METHODS AND ANALYSIS

This is a prospective, randomised, controlled, parallel group non-inferiority trial comparing the traditional hospital surveillance (inpatient, patients staying in the hospital for 1-3 nights after surgery) with outpatient care (discharge on the day of the surgery, usually within 6-8 hours after procedure) in patients who have undergone anterior cervical decompression and fusion procedure. To determine whether early discharge (outpatient care) is non-inferior to inpatient care, we will randomise 104 patients to these two groups and follow them for 6 months using the Neck Disability Index (NDI) as the primary outcome. We expect that early discharge is not significantly worse than the current care in terms of change in NDI. Non-inferiority will be declared if the mean improvement for outpatient care is no worse than the mean improvement for inpatient care, by a margin of 17.3%. We hypothesise that a shorter hospital stay results in more rapid return to normal daily activities, shorter duration of sick leave and decreased secondary costs to healthcare system. Secondary outcomes in our study are arm pain and neck pain using the Numeric Rating Scale, operative success (Odom's criteria), patient's satisfaction to treatment, general quality of life (EQ-5D-5L), Work Ability Score, sickness absence days, return to previous leisure activities and complications.

ETHICS AND DISSEMINATION

The study was approved by the institutional review board of the Helsinki and Uusimaa Hospital District on 6 June 2019 (1540/2019) and duly registered at ClinicalTrials.gov. We will disseminate the findings of this study through peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT03979443.

A Case Report Describing Three Cases of Challenging or Failed Intubation after Cervical Spine Surgery: A Peril of Early Extubation

Postoperative airway complications can be a common, yet perhaps underappreciated, complication in patients undergoing cervical spine surgery. Presented here are three cases in which patients experienced postoperative airway compromise, resulting in difficulty establishing a secure airway following cervical spine operations. Establishing factors that contribute to airway complications after cervical spine surgery can aid in early identification of high-risk patients to create an appropriate airway management strategy. Ultimately, the frequency of airway difficulty after removal of the endotracheal tube in patients undergoing cervical spine surgery should not be taken lightly.

Smart flap of sternocleidomastoid muscle in anterior cervical spine surgery: Surgical anatomical dissection technique

The use of sternocleidomastoid muscle flap has firstly been described in 1909. In spine surgery, it is usually reserved in the cases of revision after anterior cervical spine procedures. The aim of this article is to introduce its usage as prophylactic measure in cases at high risk of iatrogenic fistula formation. The procedure consists of three main steps: sternocleidomastoid isolation, flap design and harvesting, and flap fixation. The use of a surgical anchor allows a better adherence to the plate preventing hematoma formation. The use of SCM smart flap in primary anterior cervical spine surgery as a prophylactic method could be considered a safe and feasible procedure in patients with a high risk of iatrogenic fistulas.

Adverse events and their risk factors 90 days after cervical spine surgery: analysis from the Michigan Spine Surgery Improvement Collaborative

OBJECTIVEThe Michigan Spine Surgery Improvement Collaborative (MSSIC) is a statewide, multicenter quality improvement initiative. Using MSSIC data, the authors sought to identify 90-day adverse events and their associated risk factors (RFs) after cervical spine surgery.METHODSA total of 8236 cervical spine surgery cases were analyzed. Multivariable generalized estimating equation regression models were constructed to identify RFs for adverse events; variables tested included age, sex, diabetes mellitus, disc herniation, foraminal stenosis, central stenosis, American Society of Anesthesiologists Physical Classification System (ASA) class > II, myelopathy, private insurance, anterior versus posterior approach, revision procedures, number of surgical levels, length of procedure, blood loss, preoperative ambulation, ambulation day of surgery, length of hospital stay, and discharge disposition.RESULTSNinety days after cervical spine surgery, adverse events identified included radicular findings (11.6%), readmission (7.7%), dysphagia requiring dietary modification (feeding tube or nothing by mouth [NPO]) (6.4%), urinary retention (4.7%), urinary tract infection (2.2%), surgical site hematoma (1.1%), surgical site infection (0.9%), deep vein thrombosis (0.7%), pulmonary embolism (0.5%), neurogenic bowel/bladder (0.4%), myelopathy (0.4%), myocardial infarction (0.4%), wound dehiscence (0.2%), claudication (0.2%), and ileus (0.2%). RFs for dysphagia included anterior approach (p < 0.001), fusion procedures (p = 0.030), multiple-level surgery when considering anterior procedures only (p = 0.037), and surgery duration (p = 0.002). RFs for readmission included ASA class > II (p < 0.001), while preoperative ambulation (p = 0.001) and private insurance (p < 0.001) were protective. RFs for urinary retention included increasing age (p < 0.001) and male sex (p < 0.001), while anterior-approach surgery (p < 0.001), preoperative ambulation (p = 0.001), and ambulation day of surgery (p = 0.001) were protective. Preoperative ambulation (p = 0.010) and anterior approach (p = 0.002) were protective of radicular findings.CONCLUSIONSA multivariate analysis from a large, multicenter, prospective database identified the common adverse events after cervical spine surgery, along with their associated RFs. This information can lead to more informed surgeons and patients. The authors found that early mobilization after cervical spine surgery has the potential to significantly decrease adverse events.

Trends in Nonoperative Treatment Modalities Prior to Cervical Surgery and Impact on Patient-Derived Outcomes: Two-Year Analysis of 1522 Patients From the Prospective Spine Treatment Outcome Study

Background

Effects of nonoperative treatments on surgical outcomes for patients who failed conservative management for cervical spine pathologies remain unknown. The objective is to describe conservative modality use in patients indicated for surgery for degenerative cervical spine conditions and its impact on perioperative outcomes.

Methods

The current study comprises a retrospective review of a prospective multicenter database. A total of 1522 patients with 1- to 2-level degenerative cervical pathology who were undergoing surgical intervention were included. Outcome measures used were health-related quality-of-life scores, length of hospitalization, estimated blood loss, length of surgery, and return-to-work status at 2 weeks, 6 months, 1 year, and 2 years postoperatively. Patients were grouped by diagnosis (radiculopathy vs. myelopathy), then divided based on epidural injection(s), physical therapy (PT), or opioid use prior to enrollment. Univariate t-tests and χ² tests were performed to determine differences between groups and impact on outcomes.

Results

Among 1319 radiculopathy patients, 25.7% received preoperative epidural injections, 35.3% received PT, and 35.5% received opioids. Radiculopathy patients who received epidurals and PT had higher 1-year postoperative return-to-work rates (P < .05). Radiculopathy patients without preoperative PT had longer hospitalization times, whereas those who received PT had higher 36-Item Short Form Health Survey (SF-36) physical functioning and physical component scores, lower 2-year visual analog scale (VAS) neck/arm pain scores, and higher 2-year return-to-work incidence (P < .05). Of myelopathy patients (n = 203), 14.8% received epidural injections, 25.1% received opioids, and 41.5% received PT. Myelopathy patients with preoperative PT had worse VAS arm pain scores 2 years postoperatively (P < .05). Patients receiving opioids were younger and had greater baseline-2-year Neck Disability Index improvement (P < .05).

Conclusions

Radiculopathy patients receiving epidurals returned to work after 1 year more frequently. PT was associated with shorter hospitalizations, greater SF-36 bodily pain norm and physical component score improvements, and increased return-to-work rates after 1 and 2 years. No statistically significant nonoperative treatment was associated with return-to-work rate in myelopathy patients.

Clinical Relevance

These findings suggest certain preoperative conservative treatment modalities are associated with improved outcomes in radiculopathy patients.

[Post-intubation tracheal lacerations during cervical spine surgery: about 3 cases]

Nous rapportons 3 cas rares de plaies trachéales post-intubations découvertes au cours de chirurgie cervicale. Il s’agissait de 3 patientes âgées de 27, 30 et 42 ans admises au bloc opératoire pour une thyroïdectomie totale sous anesthésie générale indiquée devant un goitre hétéro-multi-nodulaire. L’intubation était orotrachéale à l’aide d’un guide rigide avec une sonde N°7,5 munie d’un ballonnet. Nous avons découvert en per opératoire une protrusion du ballonnet dans le champ opératoire à travers une effraction trachéale postéro-latérale. Le traitement avait consisté en une fermeture de la brèche trachéale dans 2 cas et une abstention chirurgicale dans le troisième cas suivi d’un drainage de la loge thyroïdienne. Les suites opératoires étaient simples. Les plaies trachéales post-intubations sont rares. Leur découverte per opératoire au cours d’une chirurgie cervicale est exceptionnelle. Les causes sont multiples. Il s’agit des difficultés d’intubation, d’une déchirure de la membraneuse par le bec de la sonde d’intubation, par un guide rigide, un effort de toux avec ballonnet gonflé au réveil, un sur-gonflage du ballonnet, de la modification structurale et anatomique de la trachée dans les goitres anciens. Il n’y a pas de consensus dans le traitement.

Delayed epidural pseudoaneurysm following cervical laminectomy and instrumentation in a patient with canal stenosis secondary to skeletal fluorosis: A case report

RATIONALE

The typical intraoperative presentation of vertebral artery injury (VAI) usually involves profuse bleeding and requires immediate treatment. However, an occult VAI may occur intraoperatively and result in delayed life-threatening epidural pseudoaneurysm several days postoperatively.

PATIENT CONCERNS

A 21-year-old man with compressive cervical myelopathy resulting from canal stenosis of skeletal fluorosis underwent decompression of C1 to C7 and instrumentation from C2 to C7. No impressive bleeding event occurred during the operation. On postoperative day 40, progressive quadriplegia developed.

DIAGNOSES

Pseudoaneurysm of the VA was established by angiography.

INTERVENTIONS

After occlusion of the right VA, the patient underwent hematoma clearing.

OUTCOMES

Fortunately, the patient experienced significant recovery of neurologic function after the second surgery.

LESSONS

From this case, we realize even in the absence of obvious signs of VAI during a cervical operation, postoperative evaluation should be mandatory for suspected bleeding events occurring at VAI-prone sites during surgery. Moreover, the bone morphological abnormality of skeletal fluorosis was determined to be the most important risk contributing to VAI in this case. The safety limits of bone removal should be determined preoperatively to avoid the effects of bone morphological abnormalities.

Successfull management of a cervical oesophageal injury after an anterior cervical approach: a case report

The anterior surgical approach for spinal repair, with or without the insertion of stabilizing hardware, is an established procedure in the management of anterior cervical spine (ACS) pathology. Esophageal injury during this approach is a rare complication that can be life threatening. No treatment protocol has yet been standardized. In addition to conservative measures, several surgical approaches have been presented, ranging from primary repair to reconstruction with local, regional, or distant flaps. The SCM muscle flap, used as reinforcement of a primary suture or as a patch to the lesion is in our opinion an effective treatment for persisting or recurring esophageal fistulae after anterior cervical spine surgery.

Factors Affecting Length of Stay Following Elective Anterior and Posterior Cervical Spine Surgery

Background

Disease of the cervical spine is widely prevalent, most commonly secondary to degenerative disc changes and spondylosis.

Objective

The goal of the paper was to identify a possible discrepancy regarding the length of stay (LOS) between the anterior and posterior approaches to elective cervical spine surgery and identify contributing factors.

Methods

A retrospective study was performed on 587 patients (341 anterior, 246 posterior) that underwent elective cervical spinal surgery between October 2001 and March 2014. Pre- and intraoperative data were analyzed. Statistical analysis was performed using GraphPad Prism 5 (GraphPad Software, Inc., La Jolla, CA) and the Statistical Package for Social Sciences (SPSS) (IBM SPSS Statistics, Armonk, NY).

Results

Average LOS was 3.21 ± 0.32 days for patients that benefited from the anterior approach cervical spinal surgery and 5.28 ± 0.37 days for patients that benefited from the posterior approach surgery, P-value < 0.0001. Anterior patients had lower American Society of Anesthesiologists scores (2.43 ± 0.036 vs. 2.70 ± 0.044). Anterior patients also had fewer intervertebral levels operated upon (2.18 ± 0.056 vs. 4.11 ± 0.13), shorter incisions (5.49 ± 0.093 cm vs. 9.25 ± 0.16 cm), lower estimated blood loss (EBL) (183.8 ± 9.0 cc vs. 340.0 ± 8.7 cc), and shorter procedure times (4.12 ± 0.09 hours vs. 4.47 ± 0.10 hours). Chi-squared tests for hypertension, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, and asthma showed no significant difference between groups.

Conclusions:

Patients with anterior surgery performed experienced a length of stay that was 2.07 days shorter on average. Higher EBL, longer incisions, more intervertebral levels, and longer operating time were significantly associated with the posterior approach. Future studies should include multiple surgeons. The goal would be to create a model that could accurately predict the postoperative length of stay based on patient and operative factors.

Iatrogenic Spinal Cord Injury Resulting From Cervical Spine Surgery

STUDY DESIGN

Retrospective cohort study of prospectively collected data.

OBJECTIVE

To examine the incidence of iatrogenic spinal cord injury following elective cervical spine surgery.

METHODS

A retrospective multicenter case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network was conducted. Medical records for 17 625 patients who received cervical spine surgery (levels from C2 to C7) between January 1, 2005, and December 31, 2011, were reviewed to identify occurrence of iatrogenic spinal cord injury.

RESULTS

In total, 3 cases of iatrogenic spinal cord injury following cervical spine surgery were identified. Institutional incidence rates ranged from 0.0% to 0.24%. Of the 3 patients with quadriplegia, one underwent anterior-only surgery with 2-level cervical corpectomy, one underwent anterior surgery with corpectomy in addition to posterior surgery, and one underwent posterior decompression and fusion surgery alone. One patient had complete neurologic recovery, one partially recovered, and one did not recover motor function.

CONCLUSION

Iatrogenic spinal cord injury following cervical spine surgery is a rare and devastating adverse event. No standard protocol exists that can guarantee prevention of this complication, and there is a lack of consensus regarding evaluation and treatment when it does occur. Emergent imaging with magnetic resonance imaging or computed tomography myelography to evaluate for compressive etiology or malpositioned instrumentation and avoidance of hypotension should be performed in cases of intraoperative and postoperative spinal cord injury.

A Multicenter Study of the Presentation, Treatment, and Outcomes of Cervical Dural Tears

STUDY DESIGN

Retrospective multicenter case series study.

OBJECTIVE

Because cervical dural tears are rare, most surgeons have limited experience with this complication. A multicenter study was performed to better understand the presentation, treatment, and outcomes following cervical dural tears.

METHODS

Multiple surgeons from 23 institutions retrospectively identified 21 rare complications that occurred between 2005 and 2011, including unintentional cervical dural tears. Demographic data and surgical history were obtained. Clinical outcomes following surgery were assessed, and any reoperations were recorded. Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA), Nurick classification (NuC), and Short-Form 36 (SF36) scores were recorded at baseline and final follow-up at certain centers. All data were collected, collated, and analyzed by a private research organization.

RESULTS

There were 109 cases of cervical dural tears among 18 463 surgeries performed. In 101 cases (93%) there was no clinical sequelae following successful dural tear repair. There were statistical improvements (P < .05) in mJOA and NuC scores, but not NDI or SF36 scores. No specific baseline or operative factors were found to be associated with the occurrence of dural tears. In most cases, no further postoperative treatments of the dural tear were required, while there were 13 patients (12%) that required subsequent treatment of cerebrospinal fluid drainage. Analysis of those requiring further treatments did not identify an optimum treatment strategy for cervical dural tears.

CONCLUSIONS

In this multicenter study, we report our findings on the largest reported series (n = 109) of cervical dural tears. In a vast majority of cases, no subsequent interventions were required and no clinical sequelae were observed.

Brachial Plexopathy After Cervical Spine Surgery

STUDY DESIGN

Retrospective, multicenter case-series study and literature review.

OBJECTIVES

To determine the prevalence of brachial plexopathy after cervical spine surgery and to review the literature to better understand the etiology and risk factors of brachial plexopathy after cervical spine surgery.

METHODS

A retrospective case-series study of 12 903 patients at 21 different sites was performed to analyze the prevalence of several different complications, including brachial plexopathy. A literature review of the US National Library of Medicine and the National Institutes of Health (PubMed) database was conducted to identify articles pertaining to brachial plexopathy following cervical spine surgery.

RESULTS

In our total population of 12 903 patients, only 1 suffered from postoperative brachial plexopathy. The overall prevalence rate was thus 0.01%, but the prevalence rate at the site where this complication occurred was 0.07%. Previously reported risk factors for postoperative brachial plexopathy include age, anterior surgical procedures, and a diagnosis of ossification of the posterior longitudinal ligament. The condition can also be due to patient positioning during surgery, which can generally be detected via the use of intraoperative neuromonitoring.

CONCLUSIONS

Brachial plexopathy following cervical spine surgery is rare and merits further study.

C5 Palsy After Cervical Spine Surgery: A Multicenter Retrospective Review of 59 Cases

STUDY DESIGN

A multicenter, retrospective review of C5 palsy after cervical spine surgery.

OBJECTIVE

Postoperative C5 palsy is a known complication of cervical decompressive spinal surgery. The goal of this study was to review the incidence, patient characteristics, and outcome of C5 palsy in patients undergoing cervical spine surgery.

METHODS

We conducted a multicenter, retrospective review of 13 946 patients across 21 centers who received cervical spine surgery (levels C2 to C7) between January 1, 2005, and December 31, 2011, inclusive. P values were calculated using 2-sample t test for continuous variables and χ² tests or Fisher exact tests for categorical variables.

RESULTS

Of the 13 946 cases reviewed, 59 patients experienced a postoperative C5 palsy. The incidence rate across the 21 sites ranged from 0% to 2.5%. At most recent follow-up, 32 patients reported complete resolution of symptoms (54.2%), 15 had symptoms resolve with residual effects (25.4%), 10 patients did not recover (17.0%), and 2 were lost to follow-up (3.4%).

CONCLUSION

C5 palsy occurred in all surgical approaches and across a variety of diagnoses. The majority of patients had full recovery or recovery with residual effects. This study represents the largest series of North American patients reviewed to date.

Epidural Hematoma Following Cervical Spine Surgery

STUDY DESIGN

A multicentered retrospective case series.

OBJECTIVE

To determine the incidence and circumstances surrounding the development of a symptomatic postoperative epidural hematoma in the cervical spine.

METHODS

Patients who underwent cervical spine surgery between January 1, 2005, and December 31, 2011, at 23 institutions were reviewed, and all patients who developed an epidural hematoma were identified.

RESULTS

A total of 16 582 cervical spine surgeries were identified, and 15 patients developed a postoperative epidural hematoma, for a total incidence of 0.090%. Substantial variation between institutions was noted, with 11 sites reporting no epidural hematomas, and 1 site reporting an incidence of 0.76%. All patients initially presented with a neurologic deficit. Nine patients had complete resolution of the neurologic deficit after hematoma evacuation; however 2 of the 3 patients (66%) who had a delay in the diagnosis of the epidural hematoma had residual neurologic deficits compared to only 4 of the 12 patients (33%) who had no delay in the diagnosis or treatment (P = .53). Additionally, the patients who experienced a postoperative epidural hematoma did not experience any significant improvement in health-related quality-of-life metrics as a result of the index procedure at final follow-up evaluation.

CONCLUSION

This is the largest series to date to analyze the incidence of an epidural hematoma following cervical spine surgery, and this study suggest that an epidural hematoma occurs in approximately 1 out of 1000 cervical spine surgeries. Prompt diagnosis and treatment may improve the chance of making a complete neurologic recovery, but patients who develop this complication do not show improvements in the health-related quality-of-life measurements.

Harlequin sign concomitant with Horner syndrome after anterior cervical discectomy: a case of intrusion into the cervical sympathetic system

Harlequin syndrome is a rare autonomic disorder referring to the sudden development of flushing and sweating limited to one side of the face. Like Horner syndrome, associating miosis, ptosis, and anhidrosis, Harlequin syndrome is caused by disruption of the cervical sympathetic pathways. Authors of this report describe the case of a 55-year-old female who presented with both Harlequin sign and Horner syndrome immediately after anterior cervical discectomy (C6-7) with cage fusion and anterior spondylodesis. They discuss the pathophysiology underlying this striking phenomenon and the benign course of this condition. Familiarity with this unusual complication should be of particular interest for every specialist involved in cervical and thoracic surgery.

Primary atypical teratoid rhabdoid tumor in the adult spine

Background:

Atypical teratoid/rhabdoid tumor (ATRT) is a highly aggressive tumor of the central nervous system (WHO grade IV), which is most frequently found intracranially in young children and infants. Only three prior cases of primary ATRT involving the adult spine were found following a literature review, and the average survival for these patients was only 20 postoperative months.

Case Description:

A 43 year-old female presented with an acute exacerbation of chronic neck pain. While awaiting magnetic resonance (MR) studies of the cervical spine, she was found pulseless in her room. Although cardiopulmonary resuscitation was successful, she was found to be quadriplegic. The subsequent cervical MR imaging revealed a C1-3 intradural, extramedullary ventrolateral mass, markedly compressing the upper cervical spinal cord. Following successful surgical resection of the lesion, which proved pathologically to be an ATRT, she was treated with a full course of fractionated radiation therapy. Over the successive 6-month period, her neurological examination continued to improve to 4-/5 functional strength in her upper extremities, however, remained with 2/5 nonfunctional strength in her legs.

Conclusions:

ATRT involving the adult spine are rare and may often be misdiagnosed. This study points out that aggressive surgery followed by radiation therapy may improve outcome.

Cervical spine surgery performed in ambulatory surgical centers: Are patients being put at increased risk?

Background:

Spine surgeons are being increasingly encouraged to perform cervical operations in outpatient ambulatory surgical centers (ASC). However, some studies/data coming out of these centers are provided by spine surgeons who are part or full owners/shareholders. In Florida, for example, there was a 50% increase in ASC (5349) established between 2000–2007; physicians had a stake (invested) in 83%, and outright owned 43% of ASC. Data regarding “excessive” surgery by ASC surgeon-owners from Idaho followed shortly thereafter.

Methods:

The risks/complications attributed to 3279 cervical spine operations performed in 6 ASC studies were reviewed. Several studies claimed 99% discharge rates the day of the surgery. They also claimed major complications were “picked up” within the average postoperative observation window (e.g., varying from 4–23 hours), allowing for appropriate treatment without further sequelae.

Results:

Morbidity rates for outpatient cervical spine ASC studies (e.g. some with conflicts of interest) varied up to 0.8–6%, whereas morbidity rates for 3 inpatient cervical studies ranged up to 19.3%. For both groups, morbidity included postoperative dysphagia, epidural hematomas, neck swelling, vocal cord paralysis, and neurological deterioration.

Conclusions:

Although we have no clear documentation as to their safety, “excessive” and progressively complex cervical surgical procedures are increasingly being performed in ASC. Furthermore, we cannot rely upon ASC-based data. At least some demonstrate an inherent conflict of interest and do not veridically report major morbidity/mortality rates for outpatient procedures. For now, cervical spine surgery performed in ASC would appear to be putting patients at increased risk for the benefit of their surgeon-owners.

Thromboembolic Disease after Cervical Spine Surgery: A Review of 5,405 Surgical Procedures and Matched Cohort Analysis

STUDY DESIGN

Retrospective matched cohort analysis.

OBJECTIVE

The majority of the literature on venous thromboembolism (VTE) after spine surgery is limited to studies of thoracolumbar surgery. Less is known regarding the incidence of VTE and associated risk factors following cervical spine surgery.

METHODS

A total of 5,405 patients at our institution underwent cervical diskectomy, laminectomy, corpectomy, laminoplasty, or fusion between 1995 and 2012; 85 of the 5,405 patients (1.57%) suffered either a DVT (55) or pulmonary embolus (51) within 30 days postoperatively. The cases were matched 1:2 to controls based on age, sex, and date of surgery. Data regarding multiple perioperative factors, demographics, and comorbidities was collected.

RESULTS

Several risk factors were identified for VTE. Significant medical comorbidities included chronic venous insufficiency (odds ratio [OR] = 3.40), atrial fibrillation (OR = 2.69), obesity (OR = 2.67), and ischemic heart disease (OR = 2.18). Staged surgery (OR = 28.0), paralysis (OR = 19.0), combined approach (OR = 7.46), surgery for infection (OR = 18.5), surgery for trauma (OR = 11.1), comorbid traumatic injuries (OR > 10), oncologic procedures (OR = 5.2), use of iliac crest autograft (OR = 4.16), two or more surgical levels (OR = 3.48), blood loss > 300 mL (OR = 1.66), and length of stay 5 days or greater (OR = 3.47) were all found to be risk factors for VTE (p < 0.05) in univariate analysis. Multivariate analysis found staged surgery (OR = 35.7), paralysis (OR = 7.86), and nonelective surgery (OR = 6.29) to be independent risk factors for VTE.

CONCLUSIONS

Although the incidence of VTE following cervical spine surgery is low, we identified several risk factors that may be predictive. More aggressive approaches to prophylaxis and surveillance in certain patient populations may be warranted.