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Study design Retrospective review of prospectively-collected registry data. Objectives The aim of this study was to determine how different combinations of preoperative neck pain (NP) and arm pain (AP) influence functional outcomes, patient satisfaction, and return-to-work in patients undergoing anterior cervical discectomy and fusion (ACDF) for degenerative cervical radiculopathy (DCR). Summary of background data Surgeons often base decisions on the traditional belief that the predominance of radicular upper extremity symptoms is a stronger indication for cervical spine surgery than axial pain. However, there is a paucity of literature supporting this notion. Methods A prospectively maintained registry was reviewed for all patients who underwent primary ACDF for DCR. Patients were categorized into three groups depending on predominant pain location: AP predominant ([APP]; AP > NP), NP predominant ([NPP]; NP > AP), and equal pain predominance ([EPP]; NP = AP). Patients were prospectively followed for at least 2 years. Results In total, 303 patients were included: 27.4% APP, 38.9% NPP, and 33.7% EPP cases. The APP group was significantly older (P = 0.030), although there were no other preoperative differences among the three groups. After adjusting for baseline differences, the SF-36 Physical Component Summary was significantly better in the APP group at 6 months (P = 0.048) and 2 years (P = 0.039). In addition, they showed a trend towards better 6-month Neck Disability Index (P = 0.077) and 2-year SF-36 Mental Component Summary (P = 0.059). However, an equal proportion of patients in each group achieved the Minimal Clinically Important Difference for each outcome, were satisfied, and returned to work 2 years after surgery. Conclusion Although patients with NPP had slightly poorer function and quality of life, all patients experienced a clinically meaningful improvement in patient-reported outcomes, regardless of the predominant pain location. High rates of satisfaction and return-to-work were also achieved. In the context of proper indications, these findings suggest that ACDF can be equally effective for DCR patients with varying combinations of NP or AP.Level of Evidence: 3.

Retrospective study using prospectively collected registry data.The authors examine the influence of preoperative mental health on outcomes after anterior cervical discectomy and fusion (ACDF) and determine the impact of ACDF on postoperative mental health.While studies have reported a negative correlation between preoperative mental health and outcomes following lumbar spine surgery, the influence on outcomes following cervical spine surgery remains relatively understudied.Prospectively collected registry data of 104 patients who underwent single-level ACDF for cervical spondylotic myelopathy were reviewed. Patients were dichotomized into top and bottom halves based on preoperative SF-36 MCS (Mental Component Summary) using a cutoff of 48. Outcomes assessed were visual analogue scale for neck pain, arm pain, AAOS Neck Pain and Disability, Neurogenic Symptoms, Neck Disability Index, Short-Form 36, Japanese Orthopaedic Association myelopathy score, return to work, return to function, satisfaction and expectation fulfilment up to 2 years postoperatively.The preoperative MCS was 37.5 ± 8.1 and 57.4 ± 6.3 in the Low and High MCS groups respectively (P 0.001). The Low MCS group had poorer preoperative scores (P 0.05). There was no significant difference in length of stay or comorbidities (P 0.05). The High MCS group had less neck pain (P = 0.002) and showed a trend towards lower Neck Disability Index (P = 0.062) at 2 years. The Low MCS group demonstrated greater improvement in Japanese Orthopaedic Association (P = 0.007) and similar improvement in other scores (P 0.05). There was no significant difference in proportion that achieved minimal clinically important difference for each score (P 0.05). Both groups had similar rates of return to work, return to function, expectation fulfilment, and satisfaction (P 0.05). Lower preoperative MCS was predictive of greater improvement in MCS (r = -0.477, P 0.001).Despite relatively greater pain and disability at 2 years, patients with poor baseline mental health experienced similar improvement in clinical outcomes, return to work, and satisfaction rates.3.

Retrospective study using prospectively collected registry data.To evaluate the effect of obesity on patient-reported outcome measures of pain, disability, quality of life, satisfaction, and return to work after single-level minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF).MIS-TLIF is an appealing alternative for obese patients with potentially lower complication risk. However, there is limited data investigating the influence of obesity on outcomes 5 years after MIS-TLIF.Prospectively collected registry data of 296 patients who underwent single-level MIS-TLIF at a single institution were reviewed. Patients had complete 2- and 5-year follow-up data. Patients were stratified into control (25.0 kg/m), overweight (25.0-29.9 kg/m), and obese (≥30.0 kg/m) groups. Outcomes assessed were visual analogue scale for back pain, leg pain, Oswestry Disability Index, Short-form 36, North American Spine Society score for neurogenic symptoms, return to work (RTW), return to function (RTF), satisfaction, and expectation fulfilment. Length of operation, length of stay, and comorbidities were recorded.Among the patients, 156 (52.7%) had normal weight, 108 (36.5%) were overweight, and 32 (10.8%) were obese. There was no difference in length of operation or hospitalization (P 0.05). All three groups had comparable preoperative scores at baseline (P 0.05). At 5 years, the control group had significantly higher PCS compared with the overweight (P = 0.043) and obese groups (P = 0.007), although the change in scores was similar (P 0.05). The rate of MCID attainment, RTW, RTF, expectation fulfilment, and satisfaction was comparable.Nonobese patients had better physical well-being in the mid-term, although obese patients experienced a comparable improvement in clinical scores. Obesity had no impact on patients' ability to RTW or RTF. Equivalent proportions of patients were satisfied and had their expectations fulfilled up to 5 years after MIS-TLIF.3.

Retrospective cohort study using prospectively collected registry data.To determine factors which influence return-to-work (RTW) in patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) and to determine if early RTW affects functional outcomes.MIS-TLIF has been associated with accelerated return to work. RTW in non-WC working-age adults after MIS-TLIF is not well understood.Prospectively collected registry data of 907 patients who underwent MIS-TLIF at a single institution from 2004 to 2013 were reviewed. One hundred ten working adults who underwent single-level MIS-TLIF with complete preoperative and 5-year postoperative follow-up data were included. Patients were assigned into Early RTW (≤60 d, n = 40) and Late RTW (60 d, n = 70). All patients were assessed pre- and postoperatively at 2 and 5 years. Length of operation, length of stay, and comorbidities were also recorded.The Early RTW group had significantly lower Oswestry Disability Index (ODI), North American Spine Society score for neurogenic symptoms (NASS NS), numerical pain rating scale (NPRS) back and leg pain scores than the Late RTW group (0.01) There were no significant differences in age, body mass index (BMI) and prevalence of medical comorbidities (P 0.05). In addition, there were no differences in terms of duration of surgery or length of hospitalization. There were no significant differences in ODI, NASS NS, Short-form 36 physical and mental component scores (SF-36 PCS/MCS), NPRS, satisfaction/expectation fulfilment between the Early and Late RTW groups at 2-year and 5-year follow-up. Both groups reported similar proportions that RTW without limitations and return-to-function (RTF) at 2-years and 5-years.Patients who RTW late have significantly poorer preoperative SF-36 physical component scores and higher ODI, NASS NS, NPRS back/leg pain scores. Surgeons should be cognizant that working adults with poorer preoperative function will tend to return to work later, but should reassure them that they will likely achieve similar clinical outcomes, satisfaction and expectation fulfilment when compared with patients who returned to work early.3.

Retrospective matched pair cohort study using prospectively collected registry data.The aim of this study was to determine whether patients with DM have poorer patient-reported outcomes and poorer fusion rates after undergoing a single-level anterior cervical discectomy and fusion (ACDF) for cervical myelopathy.ACDF remains the most common procedure in the treatment of cervical spondylotic myelopathy (CSM); however, there is a paucity of literature with regards to patient-reported outcome measures (PROMs), health-related quality-of-life (HRQOL) scores, and fusion rates post-ACDF in diabetic patients with CSM.From 2002 to 2012, 29 diabetic patients were matched with 29 nondiabetic controls. Patient demographics, perioperative data, and validated spine-specific scores including the Numerical Pain Rating Scale on Neck Pain and Upper Limb Pain, American Academy of Orthopaedic Surgeons (AAOS) neck pain and disability scores, AAOS Neurogenic Symptoms Score, Neck Disability Index, Japanese Orthopaedic Association Cervical Myelopathy Score, and Short Form 36 Physical/Mental Component Summaries were recorded. Fusion rates based on Bridwell grading were assessed at 2 years.After matching, there were no significant preoperative differences in patient demographics, clinical outcomes, PROMs or HRQoL measures between the DM and control group (P 0.05). There was no difference in either length of hospital stay (P = 0.92) or length of surgery (P = 0.92) between the two groups. At 2 years postoperatively, there were no significant differences between validated spine-specific scores, PROMs, HRQoL scores, satisfaction rates, or fulfilment of expectations between the two groups. Significant poorer Bridwell fusion grades were noted in the DM group at 2 years postoperatively (P 0.05). Subgroup analysis within the DM group demonstrated that glycated hemoglobin levels had no impact on functional outcomes, fulfilment of expectations, or patient satisfaction at 2 years (P 0.05).Despite poorer fusion outcomes following single-level ACDF for symptomatic CSM, there was no significant difference in validated spine outcome scores, PROMs, HRQoL measures, or satisfaction levels when compared to nondiabetic controls at short-term follow-up.3.

STUDY DESIGN This is a prospective study. OBJECTIVE A 2-year outcome of erectile dysfunction (ED) in patients younger than 50 years with fracture-unrelated lumbar spine disease requiring surgical decompression for ED is evaluated. Risk factors for ED were also evaluated. SUMMARY OF BACKGROUND DATA There is no literature documenting 2-year follow-up of ED status in young patients with atraumatic lumbar spine disease. METHODS All male patients younger than 50 years who underwent lumbar spine surgery between June 2006 and November 2007 without risk factors for ED were included. Patient demographics, neurological dysfunction, visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index, North American Spine Society score for neurogenic symptoms, and the international index of erectile function-5 scores were recorded preoperatively and at 2 years. Patients who did not complete a 2-year follow-up were excluded. RESULTS.: A total of 75 patients were eligible for the study. Nineteen patients did not complete a 2-year follow-up giving a response rate of 75%. There were 56 patients in the study with a mean age of 38.4 (SD, 7.2; range, 20-49). The most common diagnosis was prolapsed intervertebral disc (77%) for which patients underwent discectomy. Preoperatively, 21 of 56 (37.5%) patients had ED. Despite significant improvement in mean VAS scores for back pain and leg pain, Oswestry Disability Index, and North American Spine Society score for neurogenic symptoms at 2 years (P < 0.01), the mean international index of erectile function-5 scores remained stable. Patients with ED at 2 years had greater back pain (mean VAS score 3.4) compared with patients without back pain (mean VAS score, 1.6; P ≤ 0.01). CONCLUSION Despite excellent outcome in most spine scores postoperatively after lumbar spine surgery, one has to be less optimistic about any improvement in the ED status of patients after surgery. ED is still a problem 2 years after surgery. Back pain reduction may have a significant role in dealing with ED at 2 years postoperatively. LEVEL OF EVIDENCE 2.

Study design This is a prospective study. Objective The prevalence of erectile dysfunction (ED) in patients younger than 50 years with fracture-unrelated lumbar spine disease requiring surgical decompression without other risk factors for ED is evaluated. Summary of background data There is little literature documenting ED in young patients with atraumatic lumbar spine disease. Methods All male patients younger than 50 years who underwent lumbar spine surgery during June 2006 to November 2007 without risk factors for ED were included. Patient demographics, neurological dysfunction, visual analogue scale (VAS) for back and leg pain, Oswestry Disability Index (ODI), North American Spine Society score for neurogenic symptoms (NS), and the International Index of Erectile function (IIEF-5) scores were recorded preoperatively, at 1, 3, and 6 months. Results There were 61 patients with mean age 38.4 years (SD = 7.0; range, 20-49). Most of patients had (43 or 70.5%) prolapsed intervertebral disc with discectomy being the commonest operation. Mean VAS scores, ODI, and NS improved significantly postoperatively. However, the mean IIEF-5 scores did not. Preoperatively, there was no correlation between ED and VAS scores on back pain (P = 0.70), leg pain (P = 0.91), ODI (P = 0.93), or NS (P = 0.51). At 6 months, patients with NS > 70 had an increased risk of ED (P = 0.03). Eighty percent of patients with NS > 70 had ED compared with 30% of patients with NS ≤ 70. There was, however, no correlation between ED with ODI (P = 0.38) and VAS scores on back pain (P = 0.20) or leg pain (P = 0.08) at 6 months. Conclusion The incidence of ED in patients younger than 50 years with nonfracture-related lumbar spine disease undergoing surgery without risk factors was 34.3%. Despite improvement in VAS, ODI, and NS scores postoperatively, ED did not improve. Patients with NS > 70 postoperatively were more likely to have ED reflecting possible permanent nerve damage from lumbar spine pathology.

Study design We present the case study of a 31-year-old lady who had a spontaneous cervical spinal epidural hematoma in the postpartum period and who presented with sudden onset of neck pain and lower limb weakness for which an emergency decompressive laminectomy was performed with neurological recovery. Objective To report on the spontaneous spinal epidural hematoma in the postpartum period, which is a rare complication during pregnancy and requires early recognition and expedient intervention to prevent permanent neurological sequelae. Summary of background data This complication has been described only once previously in the postpartum period. The recovery of the patient described here highlights the importance of early recognition and surgical intervention. Methods A case report of a spontaneous cervical spinal epidural haematoma in the postpartum period is presented and the pertinent literature is then reviewed. Results The patient had neurological recovery at 1-year follow-up, although she required clean intermittent self-catheterization once daily for bladder dysfunction. Conclusion Early recognition and intervention for our patient allowed for neurological recovery with a spontaneous cervical spinal epidural hematoma in the postpartum period.

STUDY DESIGN prospective study. OBJECTIVE present results of Prestige LP artificial cervical disc replacement (ADR). SUMMARY OF BACKGROUND DATA motion preservation with ADR can potentially reduce adjacent segment degeneration. METHODS.: Forty patients with 59 Prestige LP ADR were analyzed. Cervical range of motion, Neck Disability Index, Visual Analogue, Short Form-36, Modified American Academy of Orthopedic Surgeons, and Japanese Orthopedic Association scores and radiographs were evaluated. Clinical results were compared with anterior cervical discectomy and fusion. RESULTS there were 21 females and 19 males. Mean age was 43.9 years. Mean follow-up was 2.9 years. Of the patients, 62.5% had single level replacement-mainly C56 level (56%); 52.5% had myelopathy and 47.5% radiculopathy; 50% of neural compression was due to herniated disc, 45% due to spondylosis, and 5% due to both. There was significant improvement in the American Academy of Orthopedic Surgeons and Visual Analogue scores (P < 0.05) at 6 months and 2 years. There was significant improvement in the Neck Disability Index from a mean of 42.2 preoperation to 16.4 at 6 months and 15.2 at 2 years (P < 0.05). The mean Japanese Orthopedic Association score improved significantly from 14.7 preoperation to 15.7 at 6 months and 15.6 at 2 years (P < 0.05). There was significant improvement in all aspects of the Short Form-36 scores except general health (P < 0.05) at 6 months and 2 years. There was no significant difference in the clinical outcomes between ADR and anterior cervical discectomy and fusion. Segmental alignment (mean 8°, 14°, and 13° lordotic at preoperation, 6 months, and 2 years postoperation, respectively) and global alignment (mean 15.7°, 16.2°, and 17.3° lordotic at preoperation, 6 months, and 2 years postoperation, respectively) were maintained. Dynamic radiographs showed significant segmental motion with a 6 month's mean motion of 11.1° and a 2-year mean motion of 13.9° (P < 0.05). CONCLUSION prestige LP ADR showed significant improvement in clinical outcomes at 2 years. It restores segmental lordosis and preserves segmental motion up to 2 years postoperation.