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BACKGROUND CONTEXT Extension of long posterior cervical fusions into the thoracic spine has been recommended to decrease the risk of kyphosis and spondylolisthesis at the cervico-thoracic junction. In recent years, several studies have addressed this question with conflicting results. We hypothesized that extension of posterior cervical fusions into the upper thoracic spine improved clinical outcomes while decreasing kyphosis. PURPOSE To investigate if it is safe to stop at C7 spinal level during multilevel posterior cervical decompression and fusion surgery. STUDY DESIGN/SETTING Analysis of routinely collected data. PATIENT SAMPLE A total of 264 adult patients undergoing mutlilevel posterior cervical decompression and fusion. OUTCOME MEASURES Estimated blood loss, operative time, length of hospital stay, cervical lordosis, C2-C7 sagittal plumbline, T1 slope, visual analog scale, Oswestry Disability Index and revision rate METHODS Analysis of multicenter radiographic and clinical databases of patients who had undergone a three or more-level posterior cervical fusion for degenerative disease from January 2013 to May 2015, with at least two years of postop data. Patients were divided into three groups: Group I (fusion terminating at C6), Group II (fusion terminating at C7), Group III (fusion extending into the thoracic spine). All radiographic measurements were performed by an independent, experienced clinical researcher. RESULTS A total of 264 patient cases were reviewed and sorted into the three outlined groups, Group I (n=80), Group II (n=88) and Group III (n=96). Demographically, mean age, percentage of nonsmokers and anterior support were greater in Group III than in Groups I and II (p 0.05). Rate of revision was not clinically or statistically significantly different (p>0.05) between Group I (8.8%), Group II (7.95%) and Group III (9.4%). The majority of the revision surgeries occurred between two to five years postop. Groups I and II had greater number of subjacent degeneration/spondylolisthesis compared to Group III (3.8% vs 3.4% vs 1.2%). There were significant improvements in mean clinical outcomes (ie, visual analog scale [VAS] and Oswestry Disability Index [ODI]) at two years postoperative in the three groups, but there were no statistically significant differences between the groups (p>0.05). All groups had similar postop rate of return to work status (group I vs group II vs group III: 11.4 % vs 14.7% vs 12.5%). CONCLUSIONS All groups had similar clinical and radiographic outcomes and comparable revision rates. Higher EBL, OR and LOS in Group III suggest that, absent focal C7-T1 pathology, extension of posterior cervical fusions into the thoracic spine may not be necessary. Extension of posterior cervical fusions into the thoracic spine may be recommended for higher risk patients with limitations to strong C7 bone anchorage. In others, it is safe to stop at C7. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Degenerative cervical myelopathy (DCM) represents a collection of age-related degenerative processes of the cervical spine that can result in motor, sensory and autonomic dysfunction, leading to significant reductions in quality of life. Individuals with severe, nonambulatory forms of DCM are often treated with spinal decompression although the extent of neurological improvement for this patient population is unclear. PURPOSE The aim of this study was to better characterize outcomes following cervical decompression in those with severe, nonambulatory forms of DCM. We believe the results of this study can be used to better inform the decision-making process when considering the potential benefits and risks of decompression surgery for these patients. STUDY DESIGN/SETTING A retrospective analysis was done on 48 patients who underwent cervical decompression surgery at University Hospitals Cleveland Medical Center between January 2007 and December 2018. PATIENT SAMPLE Patients greater than 18 years of age, with severe, nonambulatory forms of DCM classified as a Nurick grade of IV or V were included in the study. OUTCOME MEASURES Changes in Nurick and mJOA scores were used as primary outcome measures. METHODS Paired t-tests and Wilcoxon-signed rank tests were used to compare Nurick and mJOA scores before and after surgery. Patient demographics, operative details, and postsurgical complications were analyzed using descriptive statistics. RESULTS Patients experienced significant improvements in both outcomes following cervical decompression surgery. The mean Nurick grade improved from 4.10 ± 0.31 to 2.21 ± 0.82 (p CONCLUSIONS Our study demonstrated that patients with severe forms of DCM experienced significant improvement in neurological function following cervical decompression surgery. These improvements indicate that cervical decompression surgery is effective in this patient population and has the potential to improve neurological status. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Several studies address the question of whether to extend a long-segment, posterior cervical fusions into the upper thoracic spine. Recommendations for appropriate caudal “end level” continue to vary. PURPOSE This systematic review seeks to compare fusion, reoperation and complication rates, estimated blood loss (EBL) and surgical time between multilevel instrumented fusions ending in the cervical spine and those that extend into the thoracic spine. STUDY DESIGN/SETTING Systematic review and Meta-analysis. OUTCOME MEASURES Fusion, reoperation and complication rates, EBL and surgical time. METHODS A comprehensive computerized literature search through multiple electronic databases without date limits up until April Week 3 2020 using combinations of key search terms and inclusion/exclusion criteria was performed. RESULTS Our comprehensive literature search yielded 3,852 studies. Of these, 8 articles consisting of 1,162 patients were included in the meta-analysis. In 61.2% of the patients the fusion did not cross the CTJ (the cervical end level CEL). In the remaining 38.8%, fusion extended into the upper thoracic spine (thoracic end level, TEL). Mean age of CEL group ranged from 57 to 67.8 years, and for TEL group, it was 55 to 65.3 years. Our direct analysis showed that odds of fusion were not statistically different between CEL and TEL groups (OR: 0.648, 95% CI: 0.336-1.252, p=0.197). Similarly, odds of reoperation (OR:0.726, 95% CI:0.493-1.068, p=0.104) and complication rates were similar between the two groups (OR:1.299, 95% CI:0.536-3.149, p=0.563). Standardized mean difference (SMD) for the blood loss (SMD: 0.728, 95% CI:0.554-0.901, p=0.000) and operative (SMD:0.653, 95% CI: 0.479-0.826, p=0.000) differed significantly between the two groups. The indirect analysis showed similar fusion (Effect Size (ES)crossing: 0.892, 95% CI: 0.840-0.928 vs ES not crossing:0.894, 95% CI:0.849-0.926); reoperation rate (EScrossing:0.112, 95% CI:0.075-0.164 vs ES not crossing: 0.125, 95% CI: 0.071-0.211) and complication rates (EScrossing: 0.108, 95% CI: 0.074-0.154 vs ES not crossing:0.081, 95% CI: 0.040-0.156). CONCLUSIONS Our meta-analysis showed that fusion, complication and reoperation rates did not differ significantly between patients in whom multi-level posterior fusions ended in the cervical spine versus those of which was extended into the thoracic spine. The mean blood loss, operative time and length of stay were significantly lower in patients with caudal level as C7 or below, compared to their counterparts. These data suggest that, absent focal C7-T1 pathology, extension of long posterior cervical fusions into the thoracic spine may not be necessary. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT While fusion in the context of anterior cervical discectomy and fusion (ACDF) has been reported to be as high as 97% at 4 years postop, little is known about the bridging of trabecular bone, radiolucency and interspinous motion (ISM) as definitive criterion for assessing fusion on radiographic X-ray imaging. While there is no conclusive method for quantifying interbody fusion (IBF), there is curiosity about whether these parameters can prove a spacer type to have a higher fusion rate than another. PURPOSE To determine whether the use of interbody cages (IC) promotes higher fusion rates in ACDF using plain X-ray studies. STUDY DESIGN/SETTING Single-center retrospective analysis of prospective consecutive database of multilevel ACDF. PATIENT SAMPLE This study included 94 patients and 232 levels were evaluated with 1-year postop images from August 2015 to November 2018. OUTCOME MEASURES Interspinous motion, bridging trabecular bone, fusion grade. METHODS A total of 32 published papers were reviewed to select the three best parameters for assessing cervical fusion: the passage of trabecula through the implant, the presence of a radiolucent line interfacing implant and vertebral plate, and the range of motion between two adjacent spinous processes. Radiolucency and bridging trabecular bone (BTB) parameters were combined to categorize each ACDF level as fused (≥75% BTB present) or not fused ( RESULTS A total of 234 surgical levels from 92 patients were included (age: 62.5, 42.4% F, BMI: 29.87). Median number of levels fused by patient was 2 (IQR: 1). Overall, 28.2% of the patients had at least 1 level with incomplete fusion. Patients with incomplete fusion (by BTM or ISM method) had longer ACDF than those with complete fusion (median=3 vs 2, p=0.022). No associations were found between demographic, smoking status and fusion rate (all p > 0.1). When investigating fusion level by level, using the BTB and ISM methods respectively, no significant differences were found based on IC type (bone graft vs cage; p=.867 and .585), iliac bone vs local (p =.869, .796) or allograft. Lower fusion rate was noticed for C6-C7 (58.1%) compared to more proximal disc spaces (71.4% to 78.7%, p = 0.049). Combination of IC and graft material revealed no significant difference (bonegraft + local=71.8% vs cage + iliac=66.7%, p = 0.517). Multivariate analysis, controlling for demographic and smoking status, demonstrated that only location of the fusion was an independent predictor of incomplete fusion. CONCLUSIONS There was no superiority within the allograft and autograft respective groups or between spacers, using the ISM or BTB techniques. More than 2mm of motion on dynamic X-ray studies, BTB and radiolucent interface between implant and endplates are efficient quantifiable methods to measure fusion on X-ray studies, as they are easily accessible and affordable within the health care field. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Since 2016, over half of US states have passed mandatory opioid-limiting laws. The impacts of such mandates on postoperative opioid prescribing and secondary outcomes following anterior cervical discectomy and fusion (ACDF) have not been previously described. PURPOSE The purpose of this study is to evaluate the impact of newly implemented statewide opioid-limiting regulations in Rhode Island on postoperative opioid prescriptions, emergency department (ED) visits, unplanned readmissions and reoperations following elective ACDF. STUDY DESIGN/SETTING Retrospective review of prospectively-collected data PATIENT SAMPLE A total of 211 patients undergoing primary elective 1-3 level ACDF during specified pre-law (12/01/15 - 06/30/16) and post-law (06/01/17 - 12/31/17) study periods were considered eligible for study inclusion. Patients undergoing ACDF for trauma or other emergencies, requiring corpectomy, undergoing simultaneous procedures, or undergoing ACDF as part of a staged procedure were excluded. OUTCOME MEASURES Primary outcome measures included the number of prescriptions and total morphine milligram equivalents (MMEs) filled at 30-day postoperative intervals for 4 months following ACDF. Secondary outcome measures included prescription refill requests as well as 30-day and 90-day ED visits, readmissions and reoperations. METHODS Demographic, medical, surgical, clinical and pharmacological data were collected from all eligible patients. Those not filling any opioid prescriptions within the 30-day preoperative period were considered opioid-naive. Patients filling at least one opioid prescription in the 30-day preoperative period were considered opioid-tolerant. Cumulative oral morphine milligram equivalents (MMEs) filled were compared at 30-day postoperative intervals following ACDF, before and after stratification by preoperative opioid-tolerance and pre/post-law status. The mean number of prescription refills required within 30-days of surgery was also compared between groups. Thirty- and 90-day ED visit, readmission and reoperation rates were calculated. Independent predictors of increased 30-day and chronic (>90 day) opioid utilization were evaluated using backwards stepwise linear and logistic regression modeling respectively. RESULTS Demographic, medical and surgical factors were similar between pre-law and post-law patients (all p>0.05). Post-law, ACDF patients received fewer opioids in their first postoperative prescription (26.65 pills post-law vs 62.08 pills pre-law, p 90 day) opioid requirements were associated with preoperative opioid-tolerance (OR 4.42, p 0.05). Pre- and post-law patients were similar in terms of 30- and 90-day ED visit, unplanned readmission, and reoperation rates (all p>0.05). CONCLUSIONS Implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization following ACDF, regardless of preoperative opioid tolerance and without a rebound increase in prescription refills, ED visits, unplanned hospital readmissions, or reoperations. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Anterior cervical decompression and fusion (ACDF) is one of the most successful and widely performed spine surgeries. Although high rates of fusion have been reported, there is a risk for pseudarthrosis. Urinary cross-linked n-telopeptide of type I collagen (uNTx), is an important marker of bone turnover and may prove useful as a predictor of fusion in pts undergoing ACDF. PURPOSE The purpose of present study was to examine the association of preop uNTx level and successful fusion after ACDF. STUDY DESIGN/SETTING Prospective cohort study. PATIENT SAMPLE Adult patients who underwent ACDF with allograft and plating technique. OUTCOME MEASURES Fusion status was assessed using radiographic criteria published by Song et al. METHODS Patients undergoing primary ACDF with allograft and plating technique from 2015 to 2017 by a single surgeon were consecutively enrolled and preop uNTx was measured. Revision cases, improperly timed uNTx collection, pts with a Cr>1.2 were excluded. Demographics, operative, laboratory and fusion data was assessed at 6 months, 1 year and 2 years. NDI and VAS outcome scores were compared between fusion and nonfusion groups. Regression analysis was performed to assess the association of preop uNTx and successful fusion. RESULTS Of the 97 patients enrolled, 67 met inclusion criteria and were studied. 41%, 33%, 18% and 8% underwent one, two, three and four level ACDFs, respectively. Fusion rates were 37.3% at 6 months (n=67), 70.9% at 1 year (n=55) and 95.3% at 2 years (n=43). The preop uNTx was higher in the fusion group at 6mo (31 vs. 22, p CONCLUSIONS Urinary NTx was higher in patients with successful ACDF fusion compared to patients with radiographic pseudarthrosis at 6 months and 1 year. A linear relationship between uNTx levels and Fusion was observed. Surgeons should consider measuring uNTx prior to cervical fusion procedures to identify patients at risk for pseudarthrosis.

Study design This is a prospective cohort study. Objective To evaluate the effect of cervical decompression surgery on the biomechanics of the spine and lower extremities in cervical spondylotic myelopathy (CSM) patients and compare with asymptomatic controls. Summary of background data Difficulties with balance and gait are one of the most common manifestations of CSM. Patients with CSM have a slower gait speed, prolonged double support duration, and reduced cadence compared with healthy controls. Surgical decompression was found to improve clinical outcomes, but conflicting results are noted when examining function. Materials and methods In total, 25 subjects with symptomatic CSM underwent clinical gait analysis performed a week before (pre) and 3 months after the surgery (post). Clinical gait analysis was performed on 30 matched asymptomatic controls as well. Spine and lower extremity kinematics, spatiotemporal parameters, and clinical outcome were measured. Results CSM patients demonstrated slower walking speed (P=0.006), reduced cadence (P=0.001), longer step time (P=0.013) wider step width (P=0.001), greater ankle range of motion (ROM) (P=0.019), less hip ROM (P=0.050), increased pelvis (P=0.001), and lumbar spine (P=0.049) ROM compared with controls. Postoperatively CSM patients demonstrated a faster walking speed (P=0.002), increased cadence (P=0.029), longer step length (P=0.015), narrower step width (P=0.004), greater knee (P=0.043), and hip ROM (P=0.007), less pelvis (P=0.002), lumbar spine (P=0.035), and cervical spine (P=0.044) ROM, and improved clinical outcomes (neck pain disability index questionnaire, oswestry disability index, and visual analog scale; P=0.001) compared with their preoperative values. Postsurgical CSM patients did not present with any differences compared with controls, beside pelvis ROM (P=0.019). Conclusions Preoperatively, CSM patients clearly showed altered gait parameters compared with controls. However, after cervical decompression surgery, CSM patients exhibited improved gait pattern, spatiotemporal parameters, spine and lower extremity ROM, as well as patient-reported outcomes. Postoperatively, CSM patients did not show major differences in gait when compared with matched asymptomatic controls.

COMMENTARY ON: Seng C, Tow BPB, Siddiqui MA, et al. Surgically treated cervical myelopathy: a functional outcome comparison study between multilevel anterior cervical decompression fusion with instrumentation and posterior laminoplasty. Spine J 2013;13:723–31 ( in this issue ).

OBJECTIVE: Resorbable spinal implants have generated increasing interest. There are minimal data in the literature on the use of resorbable anterior cervical plates. The purpose of this study is twofold. First, we present clinical outcomes of anterior cervical decompression and fusion (ACDF) for single-level degenerative disease using the first commercially available resorbable cervical plate. Second, we compare x-ray outcomes, including pseudarthrosis rates and angulation of healing, between patients receiving resorbable plates and a control group of patients receiving titanium plates. METHODS: Twenty-four consecutive patients treated with single-level ACDF using a resorbable anterior cervical plate were prospectively evaluated with minimum 12-month follow-up (mean, 15 mo). As a control group, 93 consecutive patients treated with single-level ACDF using a titanium plate with minimum 1-year followup were assessed. RESULTS: Overall outcomes were good in the resorbable plate group at a mean 15 months follow-up. Neck Disability Index scores decreased from a mean of 64.0 to 20.1% at follow-up (P 0.001). Numerical Rating Scale pain scores decreased from a mean of 8.0 preoperatively to 2.9 at follow-up (P 0.001). Three cases of pseudarthrosis [three of 24 (12.5%)] were identified in the resorbable plate group compared with two cases in the control group [two of 93 (2.2%)]. This difference was significant (P 0.047). Angulation was measured on final x-rays using Cobb angles. Patients in the resorbable plate group healed with a mean 4.52-degree kyphosis, whereas patients in the titanium plate group healed with a mean 2.41-degree lordosis (P 0.001). CONCLUSION: This report describes, to our knowledge, the first series of patients to undergo ACDF with the first commercially available resorbable cervical plate. Healing in kyphosis and pseudarthrosis was significantly more likely with resorbable implants as compared with the use of titanium plating. Although ultimate clinical outcomes were good, x-ray outcomes may be better with the use of titanium plating.