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Background and Context: The impact of underlying liver disease on surgical outcomes has been recognized in a wide variety of surgical disciplines. However, less empiric data are available about the importance of liver disease in spinal surgery., Purpose: To measure the independent impact of underlying liver disease on 30-day outcomes following surgery for the degenerative cervical spine., Study Design: Retrospective comparative study., Patient Sample: A cohort of 21,207 patients undergoing elective surgery for degenerative disease of the cervical spine from the American College of Surgeons National Surgical Quality Improvement Program., Outcome Measures: Outcome measures included mortality, hospital length of stay, and postoperative complications within 30 days of surgery., Methods: The NSQIP dataset was queried for patients undergoing surgery for degenerative disease of the cervical spine from 2006 to 2015. Assessment of underlying liver disease was based on aspartate aminotransferase-to-platelet ratio index and Model of End-Stage Liver Disease-Sodium scores, computed from preoperative laboratory data. The effect of liver disease on outcomes was assessed by bivariate and multivariate analyses, in comparison with 16 other preoperative and operative factors., Results: Liver disease could be assessed in 21,207 patients based on preoperative laboratory values. Mild liver disease was identified in 2.2% of patients, and advanced liver disease was identified in 1.6% of patients. The 30-day mortality rates were 1.7% and 5.1% in mild and advanced liver diseases, respectively, compared with 0.6% in patients with healthy livers. The 30-day complication rates were 11.8% and 31.5% in these patients, respectively, compared with 8.8% in patients with healthy livers. In multivariate analysis, the presence of any liver disease (mild or advanced) was independently associated with an increased risk of mortality (OR=2.00, 95% CI=1.12-3.55, p=.019), morbidity (OR=1.35, 95% CI=1.07-1.70, p=.012), and length of hospital stay longer than 7 days (OR=1.73, 95% CI=1.40-2.13, p<.001), when compared with 18 other preoperative and operative factors. Liver disease was also independently associated with perioperative respiratory failure (OR=1.80, 95% CI=1.21-2.68, p=.004), bleeding requiring transfusion (OR=1.43, 95% CI=1.01-2.02, p=.044), wound disruption (OR=2.82, 95% CI=1.04-7.66, p=.042), and unplanned reoperation (OR=1.49, 95% CI=1.05-2.11, p=.025)., Conclusions: Liver disease independently predicts poor perioperative outcome following surgery for degenerative disease of the cervical spine. Based on these findings, careful consideration of a patient's underlying liver function before surgery may prove valuable in surgical decision-making, preoperative patient counseling, and postoperative patient care., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background Context: Anterior cervical discectomy and fusion (ACDF) and posterior cervical foraminotomy (PCF) are both used to surgically treat patients with cervical radiculopathy and have been shown to have similar outcomes. Nonetheless, ACDF has become increasingly more commonplace compared with PCF, in part because of a pervasive belief that PCF has a higher incidence of required reoperations., Purpose: To determine the reoperation rate at the index level of ACDF versus PCF 2 years postoperatively., Study Design: A retrospective case-control., Patient Sample: All patients that underwent ACDF and PCF for radiculopathy (excluding myelopathy indications) between January 2005 and December 2011., Outcome Measures: Revision surgery within 2 years, at the index level, was recorded., Methods: Propensity score analysis between the ACDF and PCF groups was done, matching for age, gender, race, body mass index, tobacco use, median income and insurance status, primary surgeon, level of surgery, surgery duration, and length of hospital stay., Results: Seven hundred ninety patients met the inclusion/exclusion criteria, including 627 ACDF and 163 PCF. Before propensity matching, the PCF group was found to be significantly older and more likely to be male. After matching, there were no significant differences between groups for any baseline characteristics. Reoperation rate at the index level was 4.8% for the ACDF group and 6.4% for the PCF group (p=.7) within 2 years of the initial surgery. Using equivalence testing, based on an a priori null hypothesis that a clinically meaningful difference between the two groups would be ≥5%, we found that the absolute difference of 1.6% was significantly (p=.01) less than our hypothesized difference., Conclusions: This study demonstrates that even after accounting for patient demographics, operative characteristics, and primary surgeon, there are no significant differences in 2-year reoperation rates at the index level between ACDF and PCF. The reoperation rates are statistically equivalent. Thus, spine surgeons can operate via the posterior approach without putting patients at increased risk for revision surgery at the index level., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background Context: In select patients, posterior cervical foraminotomy (PCF) and anterior cervical discectomy and fusion (ACDF) result in similar clinical outcomes when used to treat cervical radiculopathy. Nonetheless, ACDF is performed more frequently, in part because of surgeon perception that PCF requires operative revisions more frequently. The present study investigates the rate of ACDF reoperation at the index level after initial PCF., Purpose: To determine the rate of ACDF after initial PCF and to further describe any patient characteristics or preoperative or operative data that increase the rate of reoperation after PCF., Study Design: Retrospective chart review., Methods: Demographic, operative, and reoperation information was collected from the electronic medical records for all patients who underwent PCF at one institution between 2004 and 2011. All patients were subsequently contacted by telephone to identify postoperative complications and more conclusively determine whether any revision operation was performed at the index level., Results: One hundred seventy-eight patients who underwent a PCF were reviewed, with an average follow-up of 31.7 months. Nine (5%) patients underwent an ACDF revision operation at the index level. The reason for reoperation in these patients included cervical radiculopathy, foraminal stenosis, disc herniation, and cervical spondylosis. Patients who subsequently underwent ACDF at the index level were significantly younger (25 vs. 35 years, p=.03), had lower body mass index (25 vs. 29, p=.01), and more likely to take anxiolytic (56% vs. 22%, p=.04) or antidepressant medication (67% vs. 27%, p=.02), compared with those that did not have a revision operation., Conclusions: This is the first study to determine conversion to ACDF after PCF. The present study demonstrates that PCF is associated with a low reoperation rate, similar to the historical reoperation for ACDF. Accordingly, spine surgeons can operate via a PCF approach without a significant increased risk for ACDF revision surgery at the index level., (Published by Elsevier Inc.)

Background Context: Differentiating between multiple sclerosis (MS) and cervical stenosis (CS) can be difficult because of their overlapping symptoms. Although studies have shown preoperative imaging criteria that are predictive of outcomes in either MS or CS individually, no studies have investigated these factors in patients that have concurrent MS and CS., Purpose: To investigate the associations between preoperative magnetic resonance imaging (MRI) findings and postoperative outcomes in patients with concurrent MS and CS with myelopathy., Study Design: A retrospective review., Patient Sample: All patients presenting with myelopathy who underwent cervical decompression surgery at a single tertiary-care institution between January 1996 and July 2011, diagnosed with concurrent MS and CS., Outcome Measures: Pre- and postoperative severity of myelopathy was assessed using the modified Japanese Orthopaedic Association (mJOA) scale., Methods: Preoperative imaging was assessed for stenosis, lesions, signal intensity (graded low, intermediate, or high), extent of lesion (focal or diffuse), and cord atrophy. Imaging was then correlated with postoperative myelopathy outcomes., Results: Forty-eight patients with MS and CS were reviewed for an average follow-up of 53 months. In the short term after surgery, there were 24 patients (50%) who showed improvement in the mJOA myelopathy score and 24 (50%) who did not improve. Significantly greater percentage of patients in the improvement group had high-intensity lesions on preoperative MRI as compared with the no-improvement group (p=.03). At long-term follow-up, there were 18 patients (37.5%) who showed postoperative improvement and 30 patients (62.5%) with no improvement. No significant differences were identified on preoperative imaging between those who improved postoperatively and those who did not., Conclusions: Although certain characteristic preoperative MRI findings are associated with postoperative outcomes in cohorts of either MS or CS patients, we did not find this to be the case in patients with concurrent MS and CS. Accordingly, the treatment of the MS/CS patient population should be unique as their outcomes may not be as good as those with CS but no MS., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background Context: The presentation of myelopathy in patients with the concomitant diagnosis of cervical stenosis (CS) and multiple sclerosis (MS) complicates both diagnosis and treatment because of the similarities of presentation and disease progression. There are only a few published case series that examine this unique patient population., Purpose: To define the demographic features and presenting symptoms of patients with both MS and CS and to investigate the immediate and long-term outcomes of surgery in patients with MS and CS., Study Design/setting: Matched cohort-controlled retrospective review of 77 surgical patients in the MS group and 77 surgical patients in the control group. Outcome measures were immediate and long-term postoperative neck pain, radiculopathy, and myelopathy; Nurick Disability and modified Japanese Orthopaedic Association scores were collected as well., Methods: Retrospective review was performed for all patients presenting at one institution between January 1996 and July 2011 with coexisting diagnoses of MS and CS who had presenting symptoms of myelopathy and who then underwent cervical decompression surgery. Each study patient was individually matched to a control patient of the same gender and age that did not have MS, but that did have cervical spondylotic myelopathy or myeloradiculopathy. Each control patient underwent the same surgical procedure within the same year., Results: A total of 154 patients were reviewed, including 77 MS patients and 77 control patients, for an average follow-up of 58 months and 49 months, respectively. Patients in the control group were more likely to have preoperative neck pain (78% vs. 47%; p=.0001) and preoperative radiculopathy (90% vs. 75%; p=.03) than their counterparts in the MS group. Patients in the MS group had a significantly lower rate of postoperative resolution of myelopathic symptoms in both the short-term (39% in the MS group did not improve vs. 23% in the control group; p=.04) and the long-term (44% in the MS group did not improve vs. 19% in the control group; p=.004). Preoperative myelopathy scores were worse for the MS cohort as compared with the control cohort (1.8 vs. 1.2 in the Nurick scale, p<.0001; 13.7 vs. 15.0 in the modified Japanese Orthopaedic Association scale, p=.002). This difference in scores became even greater at the last follow-up visit with Nurick scores of 2.4 versus 0.9 (p<.0001) and modified Japanese Orthopaedic Association scores of 16.3 versus 12.4 (p<.0001) for the MS and control patients, respectively., Conclusions: Myelopathic patients with coexisting MS and CS improve after surgery, although at a lower rate and to a lesser degree than those without MS. Therefore, surgery should be considered for these patients. MS patients should be informed that myelopathy symptoms are less likely to be alleviated completely or may only be alleviated temporarily because of progression of MS and that surgery can help alleviate neck pain and radicular symptoms., (Copyright © 2014 Elsevier Inc. All rights reserved.)