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Study Design: Narrative review., Objective: To review indications and strategies for revision of cervical disc arthroplasty (CDA)., Summary of Background Data: No data were generated as part of this review., Methods: A narrative review of the literature was performed., Results: No results were generated as part of this review., Conclusions: CDA is a proven, motion-sparing surgical option for the treatment of myelopathy or radiculopathy secondary to cervical degenerative disc disease. As is the case with any operation, a small percentage of CDA will require revision, which can be a technically demanding endeavor. Here we review available revision strategies and associated indications, a thorough understanding of which will aid the surgeon in finely tailoring their approach to varying presentations., Competing Interests: K.D.R. receives royalties from Biomet, Happe Spine, and Nuvasive, consulting fees from Happe Spine and Nuvasive, travel support from Nuvasive, and owns stock in Axiomed, Expanding Orthopedics, Spineology, Spinal Kinetics, Amedica, Vertiflex, Benvenue Medical, Paradigm Spine, and Happe Spine. The remaining authors declare no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Competing Interests: J.M.R.: Alphatec Spine: Paid consultant; Paid presenter or speaker. Biomet: IP royalties. Cervical Spine Research Society: Board or committee member. Medtronic: Paid presenter or speaker. Stryker: IP royalties; Paid presenter or speaker. Wolters Kluwer Health—Lippincott Williams & Wilkins: Publishing royalties, financial or material support. Zimmer: Paid presenter or speaker. K.D.R.: Amedica: Stock or stock options. AOSpine: Board or committee member. AxioMed: Stock or stock options. Benvenue: Stock or stock options. Biomet: IP royalties; Paid presenter or speaker. Clinics in orthopedics: Editorial or governing board. European Spine Journal : Editorial or governing board. Expanding Orthopedics, PSD: Stock or stock options. Global Spine Journal : Editorial or governing board. HAPPE Spine: Unpaid consultant. Medtronic: Paid presenter or speaker. Neurosurgery : Editorial or governing board. North American Spine Society: Board or committee member. Nuvasive: Paid consultant; Paid presenter or speaker. Paradigm Spine: Stock or stock options. Spinal Kinetics: Stock or stock options. Spine : Editorial or governing board. Spine Surgery Today : Editorial or governing board. Spineology: Stock or stock options. Vertiflex: Stock or stock options. A.R.V.: Health Care Entity Relationships and Investments: Medtronics, Receipt of Royalty Payments; Stryker Spine, Receipt of Royalty Payments; Globus, Receipt of Royalty Payments, Stock / Stock Option Ownership Interests; Stout Medical, Stock / Stock Option Ownership Interests; Progressive Spinal Technologies, Stock / Stock Option Ownership Interests; Advanced Spinal Intellectual Properties, Stock / Stock Option Ownership Interests; Flagship Surgical, Stock / Stock Option Ownership Interests; Cytonics, Stock / Stock Option Ownership Interests; Electrocore, Stock / Stock Option Ownership Interests; AVKN Patient Driven Care, Stock / Stock Option Ownership Interests; FlowPharma, Stock / Stock Option Ownership Interests; Rothman Institute and Related Properties, Stock / Stock Option Ownership Interests; AO Spine, Member in good standing// Independent Contractor; Innovative Surgical Design, Stock / Stock Option Ownership Interests; Orthobullets, Stock / Stock Option Ownership Interests; Thieme, Receipt of Royalty Payments; Jaypee, Receipt of Royalty Payments; Elseviere, Receipt of Royalty Payments; Taylor Francis/Hodder and Stoughton, Receipt of Royalty Payments; Expert testimony, Member in good standing// Independent Contractor; Avaz Surgical, Stock/Stock Option Ownership Interests; Dimension Orthotics, LLC, Stock/Stock Option Ownership Interests; SpineWave, Receipt of Royalty Payments; Atlas Spine, Receipt of Royalty Payments, Stock/Stock Option Ownership Interests; Nuvasive, Stock/Stock Option Ownership Interests; Parvizi Surgical Innovation, Stock/Stock Option Ownership Interests; Jushi, Stock/Stock Option Ownership Interests; Deep Health, Stock/Stock Option Ownership Interests; ViewFi Health, Stock/Stock Option Ownership Interests; Sentryx, Service on Scientific Advisory Board/Board of Directors/Service on Committees,Stock/Stock Option Ownership Interests; National Spine Health Foundation (NSHF), Service on Scientific Advisory Board/Board of Directors/Service on Committees; Accellus, Service on Scientific Advisory Board/Board of Directors/Service on Committees, Stock/Stock Option Ownership Interests; Spinal Elements, Consulting/Independent Contractor, Receipt of Royalty Payments; Alphatec (Atec), Receipt of Royalty Payments; Harvard Medtech, Stock/Stock Option Ownership Interests.. T.J.A.: Augmedics: Stock or stock options. Back Story, LLC: Board or committee member. Biomet: IP royalties. Care Equity: Stock or stock options. CytoDyn Inc.: Stock or stock options. DePuy, A Johnson & Johnson Company: IP royalties. Hospital for Special Surgery: Board or committee member. HS2, LLC: Stock or stock options. In ViVo Therapeutics: Stock or stock options. Innovative Surgical Designs, Inc.: Stock or stock options. Journal of Bone and Joint Surgery — American : Editorial or governing board. JP Medical Publishers: Publishing royalties, financial or material support. Morphogenesis: Stock or stock options. Nuvasive: Paid consultant. Orthopedics Today : Board or committee member; Editorial or governing board. Paradigm Spine: Stock or stock options. Parvizi Surgical Innovations: Stock or stock options. Physician Recommended Nutriceuticals: Stock or stock options. Precision Orthopedics: Stock or stock options. Pulse Equity: Stock or stock options. Saunders/Mosby-Elsevier: Publishing royalties, financial or material support. Spine : Editorial or governing board. Spine Deformity Journal : Editorial or governing board. Spine Universe: Board or committee member. Spinicity: Stock or stock options. Springer: Publishing royalties, financial or material support. Strathspey Crown: Stock or stock options. Surg.IO LLC: Stock or stock options. Thieme: Publishing royalties, financial or material support. James S. Harrop, MD, MSHQS: DePuy: Honoraria. Stryker: Honoraria. NuVasive: Honoraria. The remaining authors no conflict of interest.

Study Design: Retrospective review., Objective: This study aimed to investigate if smokers have both poorer early clinical and radiologic outcomes in cervical laminoplasty when compared with nonsmokers., Summary of Background Data: Cigarette smoking had been reported to increase rates of pseudoarthrosis following spinal instrumentation with fusion., Methodology: A retrospective review of all patients who underwent open-door cervical laminoplasty was performed. Nurick, neck pain visual analog scale, and neck disability index scores were reviewed. Cervical lordosis, range of motion (ROM), and intervertebral disc height were measured. The rates and reasons for revision surgery were recorded and classified according to the etiology of laminoplasty revision surgery., Results: Sixty patients were recruited, of which 20 patients (18 males, 2 females) were smokers and 40 patients (27 males, 13 females) were nonsmokers. There was no statistically significant difference between smokers and nonsmokers in preoperative and postoperative visual analog scale, neck disability index, and Nurick scores. A trend was noted toward a greater postoperative reduction in cervical lordosis (13±8 vs. 11±11 degrees). Furthermore, 41% of smokers versus 30% in nonsmokers had >10% loss of postoperative ROM, and 59% smokers versus 50% nonsmokers had >5% loss of postoperative ROM.Postoperative complications and intervertebral disc deterioration were similar in both groups. A higher reoperation rate was noted in smokers with 6 smokers (30%) as compared with 4 nonsmokers (10%), although this did not reach statistical significance. Among the smokers, 4 (20%) were because of cervical disease progression while 2 were technique related. In nonsmokers, all 4 (10%) were because of cervical disease progression., Conclusion: This study showed that while there was a nonstatistically significant trend noted toward higher rates of revision surgery in smokers, the laminoplasty outcomes were not significantly poorer in smokers. In heavy smokers with multilevel cervical myelopathy, laminoplasty may be the treatment of choice over anterior spinal decompression and fusion where a high risk of pseudoarthrosis is anticipated., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Orthopaedic surgeons prescribe an estimated 7.7% of all US opioid prescriptions, and understanding prescribing patterns is important to curtail the inappropriate dispensing of these drugs. The purpose of this study was to characterize recent trends in opioid prescribing patterns by orthopaedic surgeons within a Medicare population and to identify demographical characteristics associated with the highest prescribers., Methods: This study used Medicare Part D beneficiary prescription between 2013 and 2016. The number of prescriptions written per orthopaedic surgeon, prescriptions received by each beneficiary, and the length of each prescription were compared across years. Top prescribers were identified and compared with the remainder of prescribers to identify differences in sex, professional degree, and geographic regions., Results: Between 2013 and 2016, an average of 24,100 unique orthopaedic prescribers were identified. There was a decrease in the average number of prescriptions written per year from 157 to 148 and per beneficiary from 2.1 to 1.8 from 2013 to 2016, respectively. The most commonly prescribed opioids were hydrocodone/acetaminophen (47.1% of all opioids prescribed) and oxycodone/acetaminophen (17.5%). The total number of opioid prescriptions decreased by 372,045, and nonopioid pain medications increased by 269,917 between 2013 and 2016. Orthopaedic surgeons were more likely to have a high total opioid prescription count if they were male, lived in the south, and had an osteopathic degree (P < 0.001 for all)., Discussion: Orthopaedic surgeons prescribe an estimated 7.7% of all US opioid prescriptions; however, in recent years, there has been a decrease in the number of prescriptions written per surgeon, per beneficiary, total opioid prescriptions, and an increase in total nonopioid prescriptions. These changes may reflect an increase in public awareness of the opioid epidemic and subtle changes in physician behavior. Differences in opioid prescription volume by sex, professional degree, and region also illustrate a lack of consensus on opioid prescription guidelines in orthopaedic surgery., (Copyright © 2020 by the American Academy of Orthopaedic Surgeons.)

Study Design: This was a post hoc analysis of a prospective FDA-IDE study., Objective: The purpose of this study is to determine the effectiveness of a 2-level anterior cervical discectomy and fusion (ACDF) or cervical disk arthroplasty (CDA) at relieving headaches associated with cervical radiculopathy or myelopathy at 10 years postoperative., Background: To our knowledge, there is no large, prospective study that has examined the efficacy of cervical spine surgery for relieving headaches associated with radiculopathy or myelopathy at 10 years postoperative., Materials and Methods: This was a post hoc analysis of a prospective FDA-IDE study for the Prestige LP versus ACDF for radiculopathy or myelopathy due to 2 levels. Preoperatively and out to 10 years, their Neck Disability Index documented if they had headaches (0: no headaches; 1: infrequent slight; 2: infrequent moderate; 3: frequent moderate; 4: frequent severe; 5: nearly constant)., Results: Three hundred ninety-seven patients were randomized to CDA (209) or ACDF (188). Preoperatively 86% had headaches and 55.9% (52.2% of CDA, 60.1% of ACDFs) had frequent moderate, severe, or nearly constant headache (grades 3-5). By 6 weeks postoperative, 64.4% had headaches and only 12.5% had grades 3-5 headaches (9.3% of CDA and 16% of ACDFs). The benefit lasted to the 10-year follow-up such that 60.3% had any headaches and 16.8% had grades 3-5 headaches (10.9% CDA; 24.3% ACDF)., Conclusions: These results suggest that 86% of patients with radiculopathy or myelopathy complain of headaches preoperatively, with 55.9% having frequent or constant, moderate to severe headaches (grades 3-5). By 6 weeks postoperative, only 12.5% had grades 3-5 headaches. At 10-year follow-up, 16.8% had grades 3-5 headaches. Both arthroplasty and ACDF are often effective at alleviating headaches associated with radiculopathy or myelopathy.

Introduction: Anterior cervical corpectomy and fusion (ACCF) for cervical ossification of the posterior longitudinal ligament (OPLL) is associated with a high incidence of surgery-related complications. A novel anterior decompression technique (vertebral body sliding osteotomy [VBSO]) has been developed to prevent such complications. This study attests the efficacy and safety of VBSO versus those of standard ACCF., Methods: Patients requiring surgery for cervical OPLL underwent VBSO (24 patients) or ACCF (38 patients). Operating time, estimated blood loss, neurologic outcomes, complications, and various radiographic parameters were investigated., Results: The VBSO group showed a shorter mean operating time and less estimated blood loss versus the ACCF group. Sixteen patients in the ACCF group experienced various complications, namely neurologic deficit (two patients), cerebrospinal fluid leakage (four patients), graft migration (three patients), and pseudarthrosis (seven patients). In the VBSO group, only pseudarthrosis was reported (two patients)., Conclusions: VBSO provides similar neurologic outcomes with a shorter operating time and less bleeding compared with ACCF. Surgeons do not need to directly manipulate the OPLL mass or dissect the interspace between the OPLL and dura mater. Therefore, this technique may decrease the incidence of surgery-related complications., Study Design: Retrospective comparative study.

Case: We report a rare cervical hyperlordotic deformity in a 19-year-old woman with Emery-Dreifuss muscular dystrophy and concomitant scoliosis. After standard posterolateral instrumentation and fusion of C2-T1 and extensive soft-tissue release, her neck pain improved and unassisted maintenance of cervical alignment and horizontal gaze were preserved through an 8-year follow-up. More importantly, she exhibited reciprocal correction of compensatory global sagittal malalignment, including lumbar lordosis., Conclusions: This case highlights the importance of full-spine analysis for all patients with spinal deformity to identify and differentiate primary driver(s) of deformity from compensatory mechanisms to individualize treatment toward what truly drives the patient's disability.

Introduction: Despite the proven success of anterior cervical surgery (ACS) postoperative issues can arise, with retropharyngeal hematoma (RH) being one of the most feared. A recent USA Today article highlighted the failed management and subsequent death of patients developing RH after ACS. The article calls into question the safety of performing ACS in an outpatient setting., Methods: We tested the knowledge of 20 healthcare professionals (4 surgeons, 16 ancillary providers) regarding ways to minimize the post-ACS complications. We used a multiple-choice and fill-in-the-blank test. We then developed a No S.C.A.R.E. safety protocol and after teaching the same professionals, re-administered the examination to assess improvement., Results: We identified large gaps in knowledge between spine surgeons and other providers (92.3% versus 31.2%) on preintervention testing. Postintervention testing showed significant improvement in nonsurgeon scores (31.2% to 86.1%, P < 0.01). Improvement was also seen in provider confidence after completion of the education module., Conclusion: Previous studies demonstrate that the incidence of RH necessitating evacuation after ACS is extremely small (<1%). For rare complications, healthcare teams may benefit from educational modules and standardized protocols. After implementation of our No S.C.A.R.E. protocol, provider knowledge and confidence markedly improved. We recommend similar education modules and protocols be used at other institutions performing ACS.

Background: Tethered drains are a complication of drain usage and may result in unintentional retained broken drains, as well as anxiety and uncertainty for the surgeon and the patient. To date, no study has examined the optimal approach for management and removal of tethered drains., Methods: The study design sought to identify suture size, mechanism of drain fixation (through versus around), points of constriction (one versus multiple) and the efficacy of weighted traction as potential sources of tethered drains by means of four study arms. (1) Arm one compared drains sutured through the tubing versus a tight closure of the surrounding fascia, which were then subjected to weighted suspension. (2) Arm two compared drains sutured into the fascia using eight each of 4-0, 2-0 and 0 vicryl and then subject to manual traction. (3) Arm three compared drains sutured to the fascia through the tubing versus local tissue incarceration followed by manual traction. (4) Lastly, group four examined drains tethered at two distinct points after which they were subject to manual traction., Results: Our results showed a 25% drain retention rate when manual traction was applied to 0 vicryl and 2-0 vicryl suture. In contrast, there were no instances of drain retention when suture was closed with 4-0 vicryl. When evaluating for multiple points of fixation, drains tethered in two locations were retained in 87.5% of trials versus drains with a single tether point (25%) representing a statistical significance (P = 0.041). There was no difference in rates of drain retention when pierced through the tubing versus incarcerated in local fascia. Only one of the 16 drains was successfully removed by weighted suspension (8.3%). Attempts at manual traction following weighted suspension resulted in a 50% drain retention rate which was higher than the rates of immediate manual traction (18.8%)., Conclusion: Our results found that manual traction is a reasonable first line approach to address drains tethered by all methods and suture sizes. The use of weighted traction for the management of tethered drains is less effective than manual traction and may result in more retained drain fragments., Level of Evidence: Level IV.

Study Design: Analysis of 2- and 7-year outcomes from a clinical trial comparing 2-level cervical disk arthroplasty (CDA) to anterior cervical discectomy and fusion (ACDF) in 287 patients with radiculopathy alone, and 110 patients with myelopathy alone or myelopathy with radiculopathy., Objective: To compare the long-term safety and effectiveness of CDA for myelopathy versus radiculopathy., Summary of Background Data: CDA for myelopathy is safe and effective in short term., Materials and Methods: We analyzed Neck Disability Index (NDI), neck/arm pain, SF-36, neurological status, adverse events (AEs), and secondary surgeries at index and adjacent levels., Results: All groups improved significantly for NDI, neck/arm pain, and physical component summary (PCS) scores from preoperative to postoperative. CDA Myelopathy versus CDA Radiculopathy: 2- and 7-year improvements were not significantly different. The 7-year score improvements for CDA Myelopathy and CDA Radiculopathy were: NDI (37.8 vs. 35.8, P=0.352), neck pain (12.0 vs. 12.1, P=0.477), arm pain (11.6 vs. 9.6, P=0.480), and PCS (14.1 vs. 13.7, P=0.863). The 2 groups had similar proportions of patients who maintained or improved their neurological status (87.2% vs. 93.5%, P=0.218), similar rates of serious AEs (54.5% vs. 57.5%, P=0.291) and similar rates of secondary surgeries at index (3.7% vs. 4.4%, P=0.839) and adjacent levels (3.7% vs. 7.6%, P=0.367). CDA Myelopathy versus ACDF myelopathy: 2 and 7-year improvements were not significantly different. The 7-year CDA and ACDF score improvements were: NDI (37.8 vs. 31.1, P=0.147), neck pain (12.0 vs. 10.4, P=0.337), arm pain (11.6 vs. 11.4, P=0.791), and PCS (14.1 vs. 11.2, P=0.363). The 2 groups had statistically similar proportions who maintained or improved their neurological status (87.2% vs. 96.2%, P=0.409), statistically similar overall rates of secondary surgeries at the index levels (3.7% vs. 9.4%, P=0.374), and statistically similar rates of secondary surgeries at adjacent levels (3.7% vs. 15.4%, P=0.088). CDA group demonstrated lower rates of serious AEs than ACDF (54.5% vs. 65.9%, P=0.019)., Conclusions: CDA for myelopathy is a safe and effective long-term treatment.

Study Design: Prospective randomized, 2-center, clinical trial., Objective: To prospectively compare adjacent level degeneration between the Bryan Cervical Disc Prosthesis and anterior cervical discectomy and fusion (ACDF), and assess the reliability of our measurements utilizing a method not previously described., Summary of Background Data: ACDF is a reliable and proven procedure for the treatment of radiculopathy and/or myelopathy. Despite a successful track record several limitations including adjacent segment degeneration/disease, loss of viscoelastic disc properties, perioperative immobilization, graft site morbidity, pseudarthrosis, and plating complications have been identified. An original driving force and theoretical basis for total disc arthroplasty was prevention of adjacent level degeneration., Materials and Methods: Seventy-nine patients were enrolled and followed prospectively at 2 centers in a multicenter, Food and Drug Administration Investigational Device Exemption trial for the Bryan Cervical Disc arthroplasty. Neutral lateral radiographs were obtained preoperatively and postoperatively, and at 1-, 2-, 4-, and out to 7-year follow-up after surgery. The cephalad, adjacent level above the blinded procedure level was analyzed for all patients and time points by measuring the anteroposterior distance and the vertical disc height. A ratio was created using disc height/anteroposterior distance., Results: Seventy patients (Bryan Cervical Disc N=34 and ACDF N=36) met inclusion criteria. Both fusion and arthroplasty groups showed a significant (P=0.001) decrease in disc height over time, indicative of adjacent level degeneration. Overall change in disc height between groups was not significantly different. Using our measurement technique, the overall interreviewer reliability was good [intrareviewer correlation coefficients (95% confidence interval)=0.77 (0.55-0.85)] and intrareviewer reliability was excellent [0.93 (0.91-0.94) and 0.85 (0.81-0.87)]., Conclusions: Adjacent level degeneration occurs in a similar manner in both the ACDF and total disc arthroplasty group. Our measurement technique is reliable and to the best of our knowledge not previously reported in the literature.

Introduction: Several studies have evaluated the efficacy of home use of chlorhexidine before surgery to reduce bacterial colonization. However, these studies have provided conflicting evidence about the potential efficacy of this strategy in decreasing bacterial loads and infection rates across surgical populations, and no prior study has analyzed the benefit of this intervention before spine surgery. We prospectively analyzed the effectiveness of chlorhexidine gluconate wipes for decreasing bacterial counts on the posterior neck., Methods: Sixteen healthy adults participated in this prospective study. The right side of each participant's neck was wiped twice (the night before and the morning of the experiment) with chlorhexidine gluconate wipes. The left side was used as the control region. Bacterial swabs were obtained as a baseline upon enrollment in the study, then upon arrival at the hospital, and, finally, after both sides of the neck had received standard preoperative scrubbing., Results: All patients had positive baseline bacterial growth (median >1,000 colonies/mL). When chlorhexidine gluconate wipes were used, decreased bacterial counts were noted before the preoperative scrub, but this finding was not statistically significant (P = 0.059). All patients had zero bacteria identified on either side of their neck after completion of the preoperative scrub., Conclusion: At-home use of chlorhexidine gluconate wipes did not decrease the topical bacterial burden. Therefore, using chlorhexidine gluconate wipes at home before surgery may offer no added benefit.

Study Design: Retrospective cohort study., Objective: This study investigates the incidence of long-term dysphagia in cervical disc arthroplasty, and anterior cervical discectomy and fusion (ACDF) patients., Summary of Background Data: No long-term comparison of dysphagia between cervical arthroplasty and fusion patients has been published. Widely variable short-term postsurgical dysphagia rates have been reported., Materials and Methods: Cohorts for this study are patients with single-level cervical degenerative disc disease previously enrolled in a randomized clinical trial comparing cervical arthroplasty and ACDF. Subjective modified Bazaz Dysphagia Severity questionnaires were distributed to each patient at a minimum of 5 years postoperative for the long-term assessment. Dysphagia severity data were pooled to compare the rate of patients with dysphagia (grade>1) to asymptomatic (grade=1)., Results: In the arthroplasty cohort, 15 of 22 (68%) patients completed long-term swallowing questionnaires with no reports of dysphagia. Eighteen of 25 (72%) ACDF patients completed questionnaires, with 5 of 18 (28%) reporting dysphagia. This is a statistically significant difference (P=0.042) favoring lower rates of long-term dysphagia after cervical arthroplasty at an average interval of 7 years postoperative (range, 5.5-8.5 y). No significant difference between rates of self-reported short-term dysphagia was noted with 12% (3/25) and 9% (2/22) in the ACDF and arthroplasty groups, respectively (P=0.56). All short-term dysphagia cases in the arthroplasty cohort reported complete resolution of symptoms within 12 months postoperative. In the ACDF cohort, persistent symptoms at 7 years were noted in all responding patients. Three ACDF patients reported new late-onset, which was not noted in the arthroplasty cohort., Conclusions: To date, these findings represent the longest reported follow-up interval comparing rates of dysphagia between randomized cohorts of cervical arthroplasty and fusion patients. Our study suggests that cervical arthroplasty is less likely than ACDF to cause sustained long-term or late-presenting dysphagia.

Study Design: A retrospective study., Objective: To evaluate radiographic changes of patients with osteophytes at the anterior border of the caudal vertebral body who were treated with anterior cervical discectomy and fusion using dynamic rotational plates., Summary of Background Data: Dynamic cervical plates are widely used in surgeries of the anterior cervical spine. One concern in using dynamic plates is that the subjacent anterior osteophytes might act as a bony block and prevent dynamization of the plate. To our knowledge, there are no studies that have investigated the validity of this concern., Materials and Methods: Twenty-eight patients were selected for the study out of patients who had undergone 1-level anterior cervical discectomy and fusion using a dynamic rotational plate. They were divided into 2 groups on the basis of the presence of osteophytes located at the anterior border of the subjacent vertebrae. Thirteen patients had osteophytes and 15 control patients did not. The mean follow-up period was 10.8±8.4 months (range, 6-36 mo). Lateral radiographs were taken preoperatively, immediately postoperatively, and at the final follow-ups to assess changes in the following radiographic parameters: Cobb angle of the adjacent segments and fused segment, horizontal distance between C2 and C7 plumb lines, height of the bone graft, vertebral heights of the operated segment, and migration distance of the plate., Results: No statistical significance was found in the Cobb angles of the adjacent segments and fused segment, distance between the C2-C7 plumb lines, height of the graft, height of vertebral bodies of the operated segment, and migration distance of the plate through the preoperative, postoperative, and final follow-ups between the 2 groups., Conclusion: Osteophytes did not appear to affect the dynamization of plates in any of the measured radiographic parameters.

Cervical spine surgery is broadly divided into fusion and nonfusion procedures. Anterior cervical diskectomy and fusion (ACDF) is a common procedure, although adjacent segment disease following the surgery is an ongoing clinical concern. Adjacent segment cervical disease occurs in approximately 3% of patients per year, with an expected incidence of 25% within the first 10 years following fusion. Nonfusion procedures such as anterior diskectomy and posterior foraminotomy do not decrease the rate of adjacent segment disease compared with ACDF. Recently, enthusiasm has developed for artificial disk replacement as a motion-sparing alternative to fusion. To date, however, multiple clinical trials and subsequent follow-up studies have failed to demonstrate significant reduction of adjacent segment disease when artificial disk replacement is performed instead of fusion.

Dropped head syndrome (DHS) is characterized by severe weakness of the cervical paraspinal muscles that results in the passively correctable chin-on-chest deformity. DHS is most commonly associated with neuromuscular disorders. However, it is not always accompanied by electromyographic findings or noticeable changes on muscle biopsy. In such cases, the term isolated neck extensory myopathy (INEM) is used instead. The literature on the management of INEM is limited. Most reports suggest that nonsurgical interventions help to stabilize the deformity. The literature on surgical management of INEM is limited and mixed, with outcomes ranging from poor to excellent. The prevalence of DHS likely will increase as life expectancy increases. Recent advances in our understanding of sagittal malalignment and surgical techniques have improved our ability to provide better quality of life for patients with cervical deformity.

Anterior cervical procedures for neurologic decompression and fusion, including cervical diskectomy and cervical corpectomy, are commonly performed by orthopaedic surgeons and spinal neurosurgeons. These procedures are highly successful in treating most patients with persistent pain and neurologic symptoms that have not responded to nonsurgical methods. Adverse events occur infrequently, but several have been described, including esophageal injury, vertebral artery injury, dural tear, postoperative airway compromise, spinal cord injury, hematoma, dysphagia, dysphonia, and graft dislodgement. Newer procedures, such as cervical total disk replacement and the use of bone morphogenetic protein as a supplement to fusion, have raised unique concerns. Appropriate strategies must be utilized to avoid these adverse events, and the treating surgeon should have an understanding of how to detect and manage such events when they do arise.

Graft- and plate-related complications are not uncommon problems associated with anterior cervical fusion surgery. Although the reasons for such complications are protean, one potential set of etiologies centers on plate design. Dynamic cervical plates, which allow for better load sharing while providing overall resistance to motion, address perceived biomechanical deficiencies of rigid cervical plates. However, despite the theoretic advantages of dynamic plating over rigid plate fixation, there are concerns that settling associated with dynamic plates could lead to segmental kyphosis or foraminal narrowing and that excessive motion may lead to inferior fusion rates. The surgeon using these implants should be familiar with differences among the various types of dynamic plates and should perform the plating procedure appropriately to accommodate the expected settling.

Cervical radiculopathy is a disorder involving dysfunction of cervical nerve roots that commonly manifests as pain radiating from the neck into the distribution of the affected root. Acute cervical radiculopathy generally has a self-limited clinical course, with up to a 75% rate of spontaneous improvement. Thus, nonsurgical treatment is the appropriate initial approach for most patients. When nonsurgical treatment fails to relieve symptoms or if a significant neurologic deficit exists, surgical decompression may be necessary. Surgical outcomes for relief of arm pain range from 80% to 90% with either anterior or posterior approaches.

Cervical myelopathy caused by atlantal hypoplasia has been reported in only 11 patients. Atlantal hypoplasia combined with torticollis has not been reported. Rotation of the atlantoaxial joint causes spinal canal narrowing at the atlantoaxial level and stretches the vertebral artery, which may aggravate the symptoms and signs of compressive cervical myelopathy from atlantal hypoplasia. We present a patient with cervical myelopathy from atlantal hypoplasia, retrodental pseudotumor, and torticollis.

Titanium mesh cages have been used widely for spinal reconstruction since 1986 when they first were introduced. Despite their popularity, relatively few studies have been published on their use in the cervical spine. These cages can be used as structural devices containing autologous local bone or iliac crest bone graft, obviating the need to harvest large structural bone grafts. The main disadvantages of their use are the increased costs and the difficulty of assessing fusion status. The authors review surgical techniques that can be used using titanium mesh cages in cervical spine applications and discuss some of their advantages and disadvantages.

Correction of deformity including restoration of sagittal plane malalignment in patients with spinal disorders is facilitated by placement of structural allografts and cages into the anterior column. The effectiveness of these implants will be reviewed with a focus on anterior column implantation of titanium mesh cages. In a consecutive study of adult patients who had spinal fusions for sagittal plane deformities using structural titanium mesh cages, cage status, fusion status, and outcome were assessed. Followup ranged from 24 to 62 months (average, 33 months). No cage failure of extrusion was observed. The average segmental improvement in lordosis with cage implantation was 11 degrees with a loss of correction of less than 1 degree at latest followup. No radiographic gold standard for fusion assessment with metallic implants in the anterior column could be found in the literature. The use of radiographic techniques for fusion assessment and functional outcome data for patients with implanted titanium mesh cages will be discussed.

Electromyographic responses in 44 shoulders from 30 subjects were examined. Fourteen shoulders from 13 patients had documented rotator cuff tears. The remaining volunteers had normal cuff integrity by history and examination. Electromyographic responses were recorded from the long head of the biceps, brachioradialis (elbow control), and from the supraspinatus (shoulder control). Elbow related biceps activity was minimized by using a brace locked in neutral forearm rotation and 100 degrees flexion. Analysis of normal and rotator cuff deficient data was performed in a masked fashion and electromyographic activity normalized as a percent of maximal muscle contraction during 10 shoulder motions based on the scapular plane. Normal shoulders in all ranges of active motion exhibited significant supraspinatus activity (20%-50% maximum muscle contraction). The response followed patterns expected for a shoulder stabilizer. In contrast, with every normal shoulder, biceps and brachioradialis activity remained insignificant (1.7%-3.6% maximum muscle contraction) and did not follow a patterned response. In patients with rotator cuff tears, biceps activity remained low (1.6%-4.4% maximum muscle contraction). As opposed to previous studies using electromyography about the shoulder, this trial examined shoulder specific biceps activity by relaxing the elbow. No significant biceps activity was observed in any shoulder, including patients with rotator cuff tears. Given these findings, any function of the long head of the biceps in shoulder motion does not involve active contractions.