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OBJECTIVE To analyze characteristics of surgically managed tear drop (TD) fractures of the C2 axis associated with other injuries such as hangman's fracture and C2-3 discoligamentous injury as well as treatment outcomes. METHODS A total of 14 patients (eight men and six women) with TD fractures of the C2 , who were surgically treated at four national trauma centers of tertiary university hospitals from January 2000 to December 2017, were included in this retrospective study. The mean age of the patients was 45.5 years (ranging from 19 to 74 years). The characteristics, surgical treatment methods (anterior fusion vs posterior fusion), and results of 14 TD fractures of the C2 were analyzed retrospectively. And the clinical relevance between C2 TD fracture and hangman's fracture and C2-3 discoligamentous injury was investigated through the co-occurrence between injuries. The mean follow-up time after surgery was 22.6 months (ranging from 12 to 60 months). RESULTS Among 14 patients with TD fracture of the C2 , four patients (28.6%) had anterior TD fracture and 10 patients (71.4%) had posterior TD fracture. All 10 posterior TD fracture patients had anterior C2-3 displacement. While two of four anterior TD fracture patients had posterior C2-3 displacement, the remaining two did not. All 14 patients of TD fracture had at least two or more other associated C2 injuries as well as C2-3 discoligamentous injuries. About 92.9% (13/14) of the patients had typical or atypical hangman's fracture; 100% (10/10) of the posterior TD fracture patients had hangman's fracture, but 75% (3/4) of the anterior TD fracture had hangman's fracture. At admission, 13 patients were neurologically intact. However, the remaining patient had spinal cord injury with American Spinal Injury Association (ASIA) impairment scale B with C2-3 bilateral facet dislocation. All four anterior TD fracture patients underwent posterior C2-3 fusion. While four of 10 posterior TD fracture patients underwent C2-3 anterior fusion, the remaining six underwent posterior fusion. At last follow-up, 100% (14/14) of the patients achieved solid fusion, and visual analog scale for neck pain was significantly improved (5.9 vs 2.2, P

STUDY DESIGN A retrospective study of prospective data. OBJECTIVE Determine the correlation between cervical sagittal alignment, either preoperative or postoperative, and the outcomes of laminoplasty. SUMMARY OF BACKGROUND DATA Cervical laminoplasty is a common surgical treatment for myelopathy. However, the effect of preoperative or postoperative cervical sagittal alignment on outcomes, such as neurological improvement and patient-reported outcomes, remains unclear. METHODS A total of 144 consecutive patients (2007-2017) with laminoplasty for myelopathy and a minimum of 1-year postoperative follow-up were reviewed. The severity of myelopathy was assessed by modified Japanese Orthopedic Association (mJOA) scores. Total pain was measured by the visual analog scale. Patient-reported outcome included neck disability index (NDI) and 12-item short-form survey (SF-12). Radiographic measures of cervical sagittal alignment on x-ray images consisted of C2-C7 angle, T1 slope, C2-C7 sagittal vertical axis (SVA), and C2-C7 forward pitch (FP). Patients were also divided into 2 groups based on the postoperative C2-C7 SVA (≥40 or

STUDY DESIGN A cross-sectional survey study. OBJECTIVE To determine the neuromonitoring (NM) usage patterns among cervical spine surgeons when performing degenerative, nondeformity cervical spine surgery. SUMMARY OF BACKGROUND DATA Intraoperative NM is frequently used in spine surgery. Although there is literature to support the use of NM in deformity surgery, its utility in degenerative cervical spine surgery remains unclear. MATERIALS AND METHODS A survey was distributed to members of the Cervical Spine Research Society to assess practice patterns of NM use during degenerative cervical spine surgery. The survey consisted of 17 multiple choice questions. The first 3 questions focus on practice experience. The remaining 14 questions pertain to NM practice patterns in the setting of radiculopathy and myelopathy. RESULTS Significantly more surgeons routinely (>75% of the time) used NM for myelopathy versus radiculopathy (64% vs. 38%, P

STUDY DESIGN A retrospective review of 40,919 cervical spine surgeries monitored with motor evoked potentials (MEPs) from a multi-institutional intraoperative neuromonitoring database. OBJECTIVE The objective of this study was to determine the clinical impact of interventions prompted by C5 spinal nerve root MEP alerts. SUMMARY OF BACKGROUND DATA MEPs have been shown to diagnose acute C5 palsies, but additional data are needed regarding the clinical impact of interventions in response to C5 MEP alerts. MATERIALS AND METHODS Procedures with isolated C5 MEP alerts were categorized as fully resolved, partially resolved, or unresolved based on the status of signals at closure. Clinical outcomes were based on neurological assessment in the immediate postoperative period. The sensitivity, specificity, likelihood ratios, and odds ratios (ORs) of C5 MEP alerts for acute C5 palsies were calculated. RESULTS The odds of an acute C5 palsy greatly increased if there was a C5 MEP alert [OR=340.9; 95% confidence (CI): 173.0, 671.6; P

Full-endoscopic lumbar discectomy (FELD) is a minimally invasive surgical option for recurrent lumbar disc herniation (LDH). Nonetheless, patients' clinical outcomes may be poorer after surgery for recurrent LDH than for primary LDH. Therefore, we compared patients' longitudinal clinical outcomes after FELD for recurrent LDH or primary LDH.The medical records of patients who underwent FELD for primary LDH (group A) or recurrent LDH (group B) were retrospectively reviewed. The inclusion criteria were: 1) single-level LDH or recurrent LDH at L4-5 or L5-S1, 2) age ≤60 years, 3) previous open discectomy (group B), and 4) ≥6 months of follow-up. In total, 244 patients (group A, 211; group B, 33) were included. Clinical outcomes (Oswestry Disability Index [ODI]; visual analogue pain score for the back and leg [VAS-B] and [VAS-L]) over 24 months of follow-up were compared between groups with a linear mixed-effects model.All clinical outcomes significantly improved from pre-operation to 3 months postoperatively (p 0.01), and the improvement was maintained for 24 months postoperatively in both groups. The clinical outcomes of groups A and B were not significantly different during 24 months follow-up (ODI, p = 0.94; VAS-B, p = 0.11; and VAS-L, p = 0.48). The reoperation rate was 3.3% in group A and 3.0% in group B, but the overall complication rate was higher in group B (9.8%) than in group A (6.6%).The longitudinal clinical outcomes after FELD for recurrent LDH may not be poor as feared. However, the higher complication rate in patients undergoing FELD for recurrent LDH should be noted.

Objective The demand for treating degenerative lumbar spinal disease has been increasing, leading to increased utilization of medical resources. Thus, we need to understand how the budget of insurance is currently used. The objective of the present study is to overview the utilization of the National Health Insurance Service (NHIS) by providing the direct insured cost between patients receiving surgery and patients receiving nonsurgical treatment for degenerative lumbar disease. Methods The NHIS-National Sample Cohort was utilized to select patients with lumbar disc herniation, spinal stenosis, spondylolisthesis or spondylolysis. A matched cohort study design was used to show direct medical costs of surgery (n = 2,698) and nonsurgical (n = 2,698) cohorts. Non-surgical treatment included medication, physiotherapy, injection, and chiropractic. The monthly costs of the surgery cohort and nonsurgical cohort were presented at initial treatment, posttreatment 1, 3, 6, 9, and 12 months and yearly thereafter for 10 years. Results The characteristics and matching factors were well-balanced between the matched cohorts. Overall, surgery cohort spent $50.84/patient/month, while the nonsurgical cohort spent $29.34/patient/month (p Conclusion Surgical treatment initially led to more government reimbursement than nonsurgical treatment, but the charges during follow-up period were not different. The results of the present study should be interpreted in light of the costs of medical services, indirect costs, societal cost, quality of life and societal willingness to pay in each country. The monetary figures are implied to be actual economic costs but those in the reimbursement system instead reflect reimbursement charges from the government.

Study Design: Retrospective cohort study. Objectives: Reported incidences and complications of heterotopic ossification (HO) after using recombinant human bone morphogenetic protein–2 (rhBMP-2) in transforaminal lumbar interbody fusion (TLIF) have been inconclusive. This study was designed to evaluate both incidences of radiologic and symptomatic HO in a large series of TLIFs using rhBMP-2. Methods: A total of 996 disc levels in 927 consecutive TLIF patients were retrospectively evaluated at 6-month postoperative follow-up in a single surgical practice. Subjects were separated into the BMP group and the control group. Operative reports, pre- and postoperative medical records were reviewed. Computed tomography (CT) scans were analyzed and graded independently for ossification at each disc level of TLIF. Results: A total of 933 disc levels were in the BMP group, and 63 were in the control group. Six-month fusion rate of interbody was 92.5% in the BMP group, which was significantly higher in contrast to 71.4% in the control group ( P < .001). The incidence of radiologic HO in the BMP group was 13.5%, which was significantly higher than 1.6% in the control group ( P = .006). After controlling for basic demographics and comorbidities, the presence of radiologic HO was significantly associated with the use of rhBMP-2 ( P = .026). However, only one case in the BMP group (0.11%) developed a symptomatic HO (mild-medium left buttock pain, treated nonsurgically) involving left foramen of L5-S1. Conclusions: rhBMP-2 can be safely used in TLIF with regard to HO. There was a low rate of radiologic HO and minimal symptomatic HO, with high fusion rates at 6 months postoperative.

Background Context Exposure of unintended levels (defined as a spinal segment outside the intended surgical levels) is unnecessary and potentially adds to operative time and patient morbidity. Wrong-level surgery (defined as decompression, instrumentation, or fusion of a spinal segment not part of the intended surgical procedure) clearly adds to morbidity as well as putting the surgeon at medicolegal risk. Purpose To describe a localization technique for posterior lumbar spine surgery to minimize both unintended-level exposure and wrong-level surgery. Study Design Consecutive case series. Patient Sample One thousand nine hundred and eighty-six consecutive posterior lumbar operations performed from January 2010 to January 2017 using this technique were reviewed. Outcome Measures The primary outcome measure was the incidence of unintended-level exposure and wrong-level surgery. Methods This localization technique was consistently used for determination of skin incision, soft tissue dissection, and identification of spinal levels for all patients undergoing posterior lumbar surgery during the time interval noted. Two spinal needles are inserted under sterile technique 3cm lateral to the midline before incision at the approximate cranial and caudal aspects of the anticipated incision based on external landmarks. A cross-table lateral X-ray before incision is obtained and the actual incision is adjusted based on the location of the spinal needles. Once dissection is carried down to the facet capsules, spinal needles are then placed in adjacent facets, and a second cross-table lateral film is obtained to confirm appropriate levels. A retrospective review of all posterior lumbar cases was performed to determine the incidence of unintended-level exposure and wrong-level surgery using this technique. Results There were no wrong-level surgeries during this time period. There were six (0.30%) cases of unintended-level exposure. Conclusions The technique described provides surgeons with a reliable, accurate, and easily reproducible method for localizing surgical levels during posterior lumbar spine surgery while minimizing exposure of uninvolved areas. This technique offers distinct advantages over previously proposed protocols and may lead to a widely accepted system for intraoperative spinal level identification.

Background: Multiple studies have demonstrated a strong correlation between sagittal malalignment and health-related quality of life measures. Thus, correction of sagittal vertical axis (SVA), pelvic tilt (PT), lumbar lordosis–pelvic incidence (LL-PI), and T1 spinopelvic inclination (T1SPi) have become a primary objective of adult spinal deformity surgery. Anterior column realignment (ACR) has emerged as a less invasive technique and while the addition of posterior osteotomies has shown greater correction in ACR, it is unknown if a pre-ACR posterior release is necessary for optimal correction. The purpose of this study was to determine if pre-ACR posterior release allows for greater sagittal deformity correction. Methods: Seventeen patients were identified that underwent minimum 1-level ACR. Ten patients underwent an anterior-posterior surgical sequence without a pre-ACR posterior release, and 7 underwent a posterior-anterior-posterior (PAP) sequence with a pre-ACR posterior release. Radiographic outcomes at final follow-up and complications were compared. Results: Both groups saw significant improvements in LL, LL-PI, PT, SVA, and T1SPi but the correction was not significantly different between cohorts. With the exception of PT in the PAP group, the improvements in LL-PI, PT, and SVA correlated to improvement in Scoliosis Research Society–Schwab classification. The correction achieved at the ACR level, represented by motion segment angle, was greater in the PAP group by a degree that approached statistical significance. Five patients (29%) had 6 complications. Conclusions: Both techniques achieved meaningful improvements in overall sagittal alignment. Our results suggest that a pre-ACR posterior release may allow for greater correction specifically at the ACR level but may not always be necessary to achieve clinically meaningful correction of sagittal plane deformity. Level of Evidence: 3 Clinical Relevance: We present our experience with and without pre-ACR posterior release. To our knowledge, this is the first study to show that pre-ACR posterior release may achieve greater correction at the ACR level.

Many anterior C2 (2nd cervical vertebra) tear drop (TD) fractures can be successfully managed with conservative treatment. However, due to the occurrence of nonunion, large-sized or complex anterior C2 TD fractures undergo surgical treatment. To date, no surgical treatment guidelines are available about anterior C2 TD fractures. Therefore, we performed this study to investigate the factors that may affect nonunion for anterior C2 TD fractures and to suggest surgical treatment guidelines. Thirty-three patients with anterior C2 TD fractures, who underwent conservative treatment and had a minimum 1-year follow-up, were divided into union (N = 26) and nonunion (N = 7) groups. Their radiological and clinical data were analyzed retrospectively and compared between the two groups. The avulsion fracture ratio (29.5% vs. 43.3%, p &lt, 0.05) and fracture displacement (3.6 mm vs. 5.1 mm, p &lt, 0.05) were higher in the nonunion group compared to the union group. Incidence of associated C2 injury was higher in the nonunion group compared to the union group (15.4% vs. 57.1%, p &lt, 0.05). Union status was negatively correlated with associated C2 injury (correlation coefficient, CC = −0.398, p &lt, 0.05). Our results suggest that surgical treatment could be considered for anterior C2 TD fractures with an avulsion fracture ratio &gt, 43%, fracture displacement &gt, 5 mm, or associated C2 injury.

Study Design: Retrospective cohort study. Objectives: Many patients undergoing posterior spinal fusion (PSF) for scoliosis have concurrent cerebral palsy (CP), which is associated with many medical comorbidities and inherent operative risk. We aimed to quantify the contribution of CP to increased cost, length of stay (LOS), and complication rates in patients with scoliosis undergoing PSF. Methods: Using the National Inpatient Sample database, we collected data regarding patient demographics, hospital characteristics, comorbidities, in-hospital complications, and mortality. Primary outcomes included complications, hospital LOS, and total hospital costs. Multivariate regression models assessed the contribution of CP to in-hospital complications, discharge status, and mortality. Linear regression identified the contribution of a diagnosis of CP on hospital LOS and inflation-adjusted cost. Results: Cerebral palsy was an independent predictor of several complications. The most striking differences were seen for mortality (odds ratio [OR]: 3.40, P < .001), a postoperative requirement for total parenteral nutrition (OR: 3.16, P < .001), urinary tract infection (OR: 2.75, P < .001), surgical site infection (OR: 2.67, P < .001), and pneumonia (2.21, P < .001). Patients with CP ultimately cost an additional $13 482 ( P < .001) with a 2.07-day greater LOS ( P < .001) than patients without CP. Conclusion: Most complications were seen in higher rates in the CP cohort, with higher cost and LOS in patients with CP versus those with idiopathic scoliosis (IS). Our findings represent important areas of emphasis during preoperative consultations with patients with CP and their families. Extra care in patient selection and multifaceted treatment protocols should continue to be implemented with further investigation on how to mitigate common complications.

Study Design: Retrospective case series. Objectives: An increasing focus has been placed on removing implicit (unconscious) bias from the surgical selection process. In spine surgery, there is the potential for implicit bias to affect the decision to either operate on a patient or not, given lack of definitive surgical indications for many elective procedures. The objective of this study was to analyze the surgical decision making of a single spine surgeon in an effort to understand surgical decision-making trends based on certain demographic factors. Methods: This was a retrospective study of 484 patients who had undergone a corrective procedure for cervical myelopathy by an orthopedic spine surgeon at our institution. The preoperative modified Japanese Orthopaedic Association score served as the metric of severity of disease for cervical myelopathy. The factors that have been associated with implicit bias that were evaluated were smoking status, narcotic use status, gender, body mass index, and age. Results: Multivariate linear regression analysis showed that even after controlling for comorbidities and confounders, the only variable which predicted likelihood to operate on a patient of a milder symptomology was age (odds ratio [OR] = −0.138; (confidence interval [CI] = −0.034 to −0.006). The other factors (smoking status, narcotic use status, gender, and body mass index) were not associated with surgical decision making. Conclusions: Our study demonstrates absence of association between commonly studied areas of implicit bias and the decision to operate on a patient with milder symptomology at initial presentation of cervical spondylotic myelopathy.

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.

STUDY DESIGN This is a prospective cohort study. OBJECTIVE To characterize the accuracy of patient recollection of preoperative symptoms after cervical spine surgery. SUMMARY OF BACKGROUND DATA Recall bias is a well-known source of systematic error. The accuracy of patient recall after cervical spine surgery remains unknown. METHODS Consecutive patients undergoing cervical spine surgery for myelopathy or radiculopathy were enrolled. Neck and arm numeric pain scores and Neck Disability Indices were recorded preoperatively. Patients were asked to recall their preoperative status at either short (

The cortical bone trajectory (CBT) screw technique yields effective mechanical and clinical results, improving the holding screw strength with a less invasive exposure. Accurate and safe screw placement is crucial. A patient-specific drill template with a preplanned trajectory was considered a promising solution; however, it is critical to assess the efficacy and safety of this technique. This study aims to evaluate the accuracy of patient-specific computed tomography (CT)-based rapid prototype drill guide templates for the CBT technique. CT scanning was performed in 7 cadaveric thoracolumbar spines, and a 3-dimensional reconstruction model was generated. By using computer software, we constructed drill templates that fit onto the posterior surface of thoracolumbar vertebrae with drill guides to match the CBT. In total, 80 guide templates from T11 to L5 were created from the computer models by using rapid prototyping. The drill templates were used to guide the drilling of CBT screws without any fluoroscopic control, and CT images were obtained after fixation. The entry point and direction of the planned and inserted screws were measured and compared. In total, 80 screws were inserted from T11 to L5. No misplacement or bony perforation was observed on postoperative CT scan. The patient-specific prototype template system showed the advantage of safe and accurate cortical screw placement in the thoracolumbar spine. This method showed its ability to customize the patient-specific trajectory of the spine, based on the unique morphology of the spine. The potential use of drill templates to place CBT screws is promising.

Prospective Cohort Study.The objective of this study is to evaluate and validate a patient-derived version of the modified Japanese Orthopaedic Association (the "P-mJOA") that a patient can complete along with other patient-derived outcome measures.The modified Japanese Orthopaedic Association (mJOA) is a validated instrument widely used in the assessment of cervical myelopathy; however, it is not a patient-derived outcome. If available and reliable, a patient-derived version of the mJOA (P-mJOA) could facilitate research because the data would be immediately available upon patient completion and also remove any potential physician bias. Currently, there is no patient-derived myelopathy survey with the widespread acceptance of the mJOA.The P-mJOA was created by very slightly modifying the verbiage of the mJOA to make it possible for a patient to complete the instrument while maintaining the questionnaire's core structure. A total of 100 consecutive consenting patients with cervical myelopathy were enrolled. After the patient completed the P-mJOA, the mJOA was scored by a physician blinded to the P-mJOA result.The P-mJOA and the mJOA had identical mean scores of 14.7 (mean difference±SD: 0.0±1.5; P=0.89). Several measures of reliability demonstrated agreement between the 2 surveys, including strong agreement with the intraclass correlation coefficient and Spearman ρ (both 0.83) and moderate to substantial agreement with weighted κ values (0.55 to 0.66). In addition, 67% of patients preferred to fill out the P-mJOA themselves, suggesting low patient burden.The P-mJOA provided identical mean scores to the mJOA in assessing myelopathy with moderate to strong agreement. Comprised of the same 4 questions as the mJOA but slightly reworded for patient comprehension, the P-mJOA also demonstrated low patient burden in completing the survey. We believe the P-mJOA is a promising tool in cervical myelopathy research with the benefits of a patient-derived outcome measure and low patient burden.Level II.

STUDY DESIGN Radiologic analysis. OBJECTIVE The objective was to compare C2 pedicle diameter and screw feasibility on reconstructed axial computed tomography (CT) cuts created "Inline" (IL) with the intended pedicle screw tract versus unaltered "Standard" (STD) axial cuts. BACKGROUND DATA Axial CT cuts through the C2 pedicle are commonly evaluated when planning pedicle screw fixation as medial aberrancies of the vertebral artery can significantly narrow pedicle diameter. STD axial CT cuts provided by radiology departments are typically formatted orthogonal to the long axis of the neck or the vertical plumb, which is often not IL with the axis of the intended C2 pedicle screw tract. MATERIALS AND METHODS A total of 89 cervical spine CT scans obtained by a single radiology department over 2 years (35 male, 54 female; mean age 64.9 y) were reviewed. STD axial cuts were not manipulated but were assessed as provided. IL axial cuts were created along the intended C2 pedicle screw tract using free, open-source DICOM viewer software. Inner and outer pedicle diameters were measured on axial cuts most closely approximating the isthmus of the intended tract. RESULTS On STD cuts, the mean outer and inner pedicle diameters were 5.05±1.45 and 2.01±1.31 mm, respectively. By contrast, IL measurements yielded significantly larger outer and inner diameters: 5.85±1.78 and 2.68±1.47 mm (P

Study design Prospective clinical pilot study. Objective To confirm the accuracy of thoracic pedicle screw placement by using the unilateral spinous noncovering hook type patient-specific drill template (PSDT) made through rapid prototyping (RP) and to analyze previously reported PSDT designs and their characteristics. Summary of background data Pedicle screw fixation is the most common form of the posterior instrumentation of the thoracic and lumbar spine. Various techniques have been introduced to improve pedicle screw placement. Among them PSDT with a preplanned trajectory has been considered a promising solution; however, we don't have consensus on proper character of the template. Methods Preoperative spiral three-dimensional (3D) computed tomography (CT) was performed on the thoracic spine. The images were stored in DICOM format and transferred to a workstation running MIMICS 17.0 software to generate a 3D reconstruction template for the desired thoracic vertebra. The accurate trajectory and screw diameter and length were calculated with UG Imageware 12.1. The guide template was sterilized and used intraoperatively to assist with the placement of thoracic pedicle screws. After all pedicle trajectory screws had been inserted. We reviewed 12 previous reports and classified them according to the shape and system of PSDT that met the inclusion criteria of the review. Results Ten screws were placed by using the PSDT without violating the single laminar cortex. There was no violation of the spinal canal or the cortex of pedicle on postoperative CT scans. The results of 13 PSDT types included in the current study suggested that there is no significant difference in accuracy between the PSDTs. Conclusion The unilateral spinous process noncovering hook type PSDT made through RP provided an accurate trajectory for the thoracic vertebra, and the classification of PSDT in this study could be helpful for further studies. Level of evidence 5.

Study Design: Systematic review. Objectives: The objective of this study was to conduct a systematic review to determine (1) change in function, pain, and quality of life following structured nonoperative treatment for degenerative cervical myelopathy (DCM); (2) variability of change in function, pain, and quality of life following different types of structured nonoperative treatment; (3) differences in outcomes observed between certain subgroups (eg, baseline severity score, duration of symptoms); and (4) negative outcomes and harms resulting from structured nonoperative treatment. Methods: A systematic search was conducted in Embase, PubMed, and the Cochrane Collaboration for articles published between January 1, 1950, and February 9, 2015. Studies were included if they evaluated outcomes following structured nonoperative treatment, including therapeutic exercise, manual therapy, cervical bracing, and/or traction. The quality of each study was evaluated using the Newcastle-Ottawa Scale, and strength of the overall body of evidence was rated using guidelines outlined by the Grading of Recommendation Assessment, Development and Evaluation Working Group. Results: Of the 570 retrieved citations, 8 met inclusion criteria and were summarized in this review. Based on our results, there is very low evidence to suggest that structured nonoperative treatment for DCM results in either a positive or negative change in function as evaluated by the Japanese Orthopaedic Association score. Conclusion: There is a lack of evidence to determine the role of nonoperative treatment in patients with DCM. However, in the majority of studies, patients did not achieve clinically significant gains in function following structured nonoperative treatment. Furthermore, 23% to 54% of patients managed nonoperatively subsequently underwent surgical treatment.

Anterior interbody fusions are commonly used in the treatment of adult spinal deformity. The addition of anterior fusions to posterior constructs offers increased construct stability, improved fusion rates, and better lordosis restoration. The anterior column is most commonly accessed by the anterior retroperitoneal approach, in which the anterior longitudinal ligament is resected, or by the lateral transpsoas approach, which offers the ability to either leave the anterior longitudinal ligament intact or resect it as part of anterior column realignment. Complications are mostly approach-related and include vascular, visceral, and neurological injury.

Study Design: Retrospective radiographic study. Objective: The optimal radiographic modality for assessing cervical foraminal stenosis is unclear. Determination on conventional axial cuts is made difficult due in part to the complex, oblique orientation of the cervical neuroforamen. The utility of 3-dimensonal (3D) computed tomography (CT) reconstruction in improving neuroforaminal assessment is not well understood. The objective of this study is to determine inter-rater variability in grading cervical foraminal stenosis using 3 different CT imaging modalities: 3D CT surface reconstructions (3DSR), 2D sagittal oblique multiplanar reformations (2D-SOMPR), and conventional 2D axial CT imaging. Methods: Pretreatment CT scans of 25 patients undergoing surgery for cervical spondylotic radiculopathy were analyzed at 2 levels: C5-C6 and C6-C7. Simple interrater agreement and kappa-Fleiss coefficients were calculated for each imaging modality and stenosis grade. Image reviewers (attending spine surgeon, attending neuroradiologist, spine fellow) interpreted each CT scan in 3 different formats: axial, 2D-SOMPR, and 3DSR. Four cervical foramina at 2 spinal levels were graded as normal (no stenosis), mild (≤25% stenosis), moderate (25%-50% stenosis), or severe (>50% stenosis). Results: Across all imaging modalities, interrater reliability was fair when grading foraminal stenosis (κ < 0.4). Agreement was lowest for the axial images (κ = 0.119) and highest for the 3D CT reconstructions (κ = 0.334). 2D-SOMPR images also led to improved interrater reliability when compared with axial images (κ = 0.255). Conclusion: Grading cervical foraminal stenosis using conventional axial CT imaging is difficult with low interrater reliability. CT modalities that provide a circumferential view of the cervical foramen, such as 2D-SOMPR and 3D CT reconstruction, had higher rates of interobserver reliability in grading foraminal stenosis than conventional axial cuts, with 3D having the highest. As these 3D reconstructions can be obtained at no additional cost or radiation exposure over a conventional CT scan, and because they can provide useful information in determining levels being considered for surgical decompression, we recommend they be utilized when evaluating cervical foramina.

STUDY DESIGN Prospective cohort study. OBJECTIVE To characterize the accuracy of patient recollection of preoperative symptoms after lumbar spine surgery. SUMMARY OF BACKGROUND DATA Although patient-reported outcomes have become important in the evaluation of spine surgery patients, the accuracy of patient recall remains unknown. METHODS Patients undergoing lumbar decompression with or without fusion were enrolled. Back and leg Numeric Pain Scores and Oswestry Disability Indices were recorded preoperatively. Patients were asked to recall their preoperative status at a minimum of 1 year after surgery. Actual and recalled scores were compared using paired t tests and relations were quantified using Pearson correlation coefficients. Multivariable linear regression was used to identify factors that affected recollection. RESULTS Sixty-two patients with a mean age of 66.1 years were included. Compared to their preoperative scores, patients showed significant improvement in back pain (mean difference [MD] = -3.2, 95% CI -4.0 to -2.4), leg pain (MD -3.3, 95% CI -4.3 to -2.2), and disability (MD -25.0%, 95% CI -28.7 to -19.6). Patient recollection of preoperative status was significantly more severe than actual for back pain (MD +2.3, 95% CI 1.5-3.2), leg pain (MD +1.8, 95% CI 0.9-2.7), and disability (MD +9.6%, 95% CI 5.6-14.0). No significant correlation between actual and recalled scores with regards to back (r = 0.18) or leg (r = 0.24) pain and only moderate correlation with disability (r = 0.44) were seen. This was maintained across age, sex, and time between date of surgery and recollection. More than 40% of patients switched their predominant symptom from back pain to leg pain or leg pain to back pain on recall. CONCLUSION Relying on patient recollection does not provide an accurate measure of preoperative status after lumbar spine surgery. Recall bias indicates the importance of obtaining true baseline scores and patient-reported outcomes prospectively and not retrospectively. LEVEL OF EVIDENCE 2.

There is limited evidence available on treating the elite athlete with cervical stenosis. While many of the treatment principles from the general population can be applied to the elite athlete, the rigors of their sport require a nuanced, case-by-case approach. The presentation of cervical stenosis can range from an asymptomatic radiographic finding to quadriparesis. Return to play (RTP) for professional athletes with cervical stenosis is a controversial topic. Clinical history, physical exam, imaging characteristics, and sport played are the four critical factors to consider when providing recommendation to the elite athlete with CS. Most athletes can successfully RTP after a single-level anterior cervical discectomy and fusion (ACDF), and players have also RTP after multilevel procedures.

Background: The objective of this study is to demonstrate the epidemiology and trends in management of patients with central cord syndrome (CCS) who present to the emergency department. Recent literature has reported that surgical treatment for CCS have increased over the previous decades. Methods: The National Emergency Department Sample (NEDS) was queried from 2009 through 2012 to generate national estimates of patients who presented to the emergency department in the United States and were diagnosed with CCS. Results: From 2009 through 2012, there were 11,975 emergency room visits for CCS (mean age 60 years). The two most common injury mechanisms were: fall (55%) and motor vehicle accident (15%). Concomitant cervical fractures were found in 10% patients. Ninety-three percent of patients were admitted to the hospital directly or after transfer to another facility, and 7% were discharged home. Fifty-five percent of patients were treated non-operatively, 39% were treated with cervical fusion surgery and 6% were treated with laminoplasty. Of patients who underwent cervical fusion, 62% received anterior decompression and fusion, 32% received posterior decompression and fusion, and 6% received combined anterior-posterior decompression and fusion. The incidence of in-hospital mortality was 2.6%. Mortality was associated with older patient age (OR 1.06, P Conclusions: Majority of patients who presented to the emergency room for CCS in the United States were treated non-operatively. Advanced age and greater comorbidities were the factors that were most associated with increased risk of in-hospital mortality in patients with CCS.

Although cervical spondylosis is ubiquitous with aging, symptomatic cervical radiculopathy or myelopathy is much less common and is better named as cervical degenerative disease. Many people have degenerative radiographic changes without significant clinical symptoms. When symptomatic, cervical axial pain is generally managed nonsurgically. Cervical radiculopathy generally has a benign course, with improvement in days to weeks in the majority of patients. Surgery is reserved for those patients with severe pain refractory to medication and nonsurgical measures or those with progressive, significant neurological deficits. Cervical myelopathy due to spondylotic changes is the most common cause of spinal cord dysfunction in older adults. It is generally treated surgically, especially in those with progressive worsening. Recognizing signs and symptoms of severity are important for early referral of these patients for specific care, since surgical treatment may be necessary in some patients to improve or at least maintain neurological function.

Spinal epidural abscess is relatively infrequent diagnosis with life-threatening potential. Early diagnosis is imperative as neurological deficits negatively impact a patient’s prognosis. This process results from purulent material accumulating between the thecal sac and the osseous-ligamentous structures of the spine. Developments in imaging techniques have permitted earlier diagnosis of this condition. Emergent surgical decompression with intravenous antibiotics remains the cornerstone of treatment.

Background Context Open-door laminoplasty is a useful operation in the surgical management of cervical myelopathy with favorable outcomes and relatively low complications. One potential undesirable outcome is a decrease in cervical lordosis postoperatively. It is unknown whether the most proximal level undergoing laminoplasty affects the magnitude of loss of lordosis. Purpose This study aimed to compare the loss of cervical lordosis postoperatively in patients for whom the most proximal level undergoing laminoplasty is C3 versus C4. Study Design/Setting A retrospective radiographic review at an academic center was carried out. Patient Sample A total of 65 patients at a single institution who underwent plated open door laminoplasty for cervical myelopathy by multiple surgeons over a 5-year period were included. Outcome Measures The primary outcome was change in cervical lordosis, which was the difference in C2–T1 Cobb angle between the postoperative and preoperative films. Methods Patients were divided into two groups based on the most proximal vertebral level undergoing laminoplasty. There were 49 patients who underwent laminoplasty beginning at C3, whereas 16 patients underwent laminoplasty beginning at C4. The C2–T1 Cobb angle was measured on the preoperative film and on the final postoperative follow-up film. The difference between these values was calculated for each patient, and the mean of the differences for the C3 group was compared with that of the C4 group. Results When C3 was the proximal plated laminoplasty level, loss of lordosis averaged 9°. In contrast, when C4 was the proximal plated level, loss of lordosis was significantly less and averaged only 3° (p=.047). In the group as a whole, mean preoperative lordosis was 18° compared with 11° postoperatively, for an overall 7° loss of lordosis. Conclusions Starting the laminoplasty at C4 led to significantly less loss of lordosis than starting at C3. When the pattern of spinal cord compression does not require laminoplasty at C3, consideration should be given to making C4 the most cephalad laminoplasty level rather than C3 to better preserve lordosis.

Background Context The diagnosis of generalized anxiety disorder (GAD) and major depressive disorder (MDD) amongst adolescents is rising worldwide. Rates of these disorders are higher in those with adolescent idiopathic scoliosis. Purpose To elucidate whether or not depression and anxiety are associated with increased length of stay and total cost after posterior spinal fusion for adolescent idiopathic scoliosis. Study Design/Setting, Patient Sample This study utilized the Nationwide Inpatient Sample (NIS) to obtain a sample of n = 564 in the depression and anxiety cohort and n = 5,185 in the cohort without concomitant diagnosis of depression and anxiety. Outcome Measures Length of stay and total cost after posterior spinal fusion for adolescent idiopathic scoliosis. Methods The Nationwide Inpatient Sample (NIS) was queried for patients undergoing posterior spinal fusion (PSF) for adolescent idiopathic scoliosis with either the concomitant diagnosis of major depressive disorder or generalized anxiety disorder. Comorbidities and other confounders were controlled for using multivariate regression analysis to determine the effect of having either mood disorder on cost and length of stay (LOS) after PSF. Results We determined that after controlling for confounding variables and comorbidities through multivariate regression analysis, patients with either depression or anxiety had increased odds ratios for increased LOS but not for cost. Conclusions The emergence of adolescent MDD and GAD may have significant implications on the inpatient stay for patients undergoing major surgery, including PSF for adolescent idiopathic scoliosis.

Traditionally, cervical radiculopathy is thought to present with symptoms and signs in a standard, textbook, reproducible pattern as seen in a "Netter diagram." To date, no study has directly examined cervical radicular patterns attributable to single level pathology in patients undergoing ACDF.The purpose of this study is to examine cervical radiculopathy patterns in a surgical population and determine how often patients present with the standard textbook (ie, Netter diagram) versus nonstandard patterns.A retrospective study.Patients who had single-level radiculopathy with at least 75% improvement of preoperative symptoms following ACDF were included.Epidemiologic variables were collected including age, sex, weight, body mass index, laterality of symptoms, duration of symptoms prior to operative intervention, and the presence of diabetes mellitus. The observed pattern of radiculopathy at presentation, including associated neck, shoulder, upper arm, forearm, and hand pain and/or numbness, was determined from chart review and patient-derived pain diagrams.We identified all patients with single level cervical radiculopathy operated on between March 2011 and March 2016 by six surgeons. The observed pattern of radiculopathy was compared to a standard textbook pattern of radiculopathy that strictly adheres to a dermatomal map Fisher exact test was used to analyze categorical data and Student t test was used for continuous variables. A one-way ANOVA was used to determine differences in the observed versus expected radicular pattern. A logistic regression model assessed the effect of demographic variables on presentation with a nonstandard radicular pattern.Overall, 239 cervical levels were identified. The observed pattern of pain and numbness followed the standard pattern in only 54% (129 of 239; p=.35). When a nonstandard radicular pattern was present, it differed by 1.68 dermatomal levels from the standard (p.0001). Neck pain on the radiculopathy side was the most prevalent symptom; it was found in 81% (193 of 239) of patients and did not differ by cervical level (p=.72). In a logistic regression model, none of the demographic variables of interest were found to significantly impact the likelihood of presenting with a nonstandard radicular pattern.Observed patterns of cervical radiculopathy only followed the standard pattern in 54% of patients and did not differ by the cervical level involved. Cervical radiculopathy often presents with a nonstandard pattern. Surgeons should think broadly when identifying causative levels because they frequently may not adhere to textbook descriptions in actual clinical practice. We observed III level of evidence.

STUDY DESIGN Systematic review. OBJECTIVE To determine best criteria for radiological determination of postoperative subaxial cervical fusion to be applied to current clinical practice and ongoing future research assessing fusion to standardize assessment and improve comparability. SUMMARY OF BACKGROUND DATA Despite availability of multiple imaging modalities and criteria, there remains no method of determining cervical fusion with absolute certainty, nor clear consensus on specific criteria to be applied. METHODS A systematic search in MEDLINE/Cochrane Collaboration Library (through March 2014). Included studies assessed C2 to C7 via anterior or posterior approach, at 12 weeks or more postoperative, with any graft or implant. Overall body of evidence with respect to 6 posited key questions was determined using Grading of Recommendations Assessment, Development and Evaluation and Agency for Healthcare Research and Quality precepts. RESULTS Of plain radiographical modalities, there is moderate evidence that the interspinous process motion method (

Study design Independent retrospective review of prospectively collected data, comparative cohort study. Objective The objective of this study was to compare the clinical, radiographical, and cost/value of the addition of an interbody arthrodesis (IBA) to a posterolateral arthrodesis (PLA) in the surgical treatment of L4-L5 degenerative spondylolisthesis (DS). The authors hypothesized that the addition of IBA to PLA would produce added value while incurring minimal additional costs. Summary of background data Many lumbar surgical advances have been made during the past several decades, yet there is a paucity of strong evidence-based validation, let alone comparative value analyses. The addition of an IBA to a PLA has become increasingly popular during the past 2 decades, yet the potential added value for the patient has not been carefully defined. Methods Patients undergoing single-level arthrodesis for L4-L5 DS performed at our institution from 2004 to 2012 were identified. Exclusion criteria included multilevel arthrodesis, spinal stenosis requiring decompression at or above L2-L3, previous L4-L5 spinal fusion, spondylolisthesis of greater than 33% of the vertebral body, and use of minimally invasive surgery. Radiographical fusion status, epidemiological, surgical, and functional outcomes, and cost/value data were recorded or calculated. Results A total of 179 patients with follow-up meeting inclusion criteria were identified: 68 with PLA alone and 111 with PLA + IBA. No statistical differences were noted in Oswestry Disability Index, 36-item Short-Form Health Survey scores, fusion rates, or cost/value at 6 months and at more than 3 years despite the PLA cohort being significantly older with more medical comorbidities. When length of stay was normalized across cohorts, the addition of an IBA increased hospital costs ranging from $577 to $5276, but this did not reach statistical significance. Conclusion This single-center review of open surgical treatment of L4-L5 DS demonstrated that the addition of IBA to PLA added cost while producing equivalent results in fusion rates, Oswestry Disability Index, and 36-item Short-Form Health Survey scores when compared with PLA alone. Level of evidence 3.

This study is a radiographic analysis.To compare the fusion rates after anterior cervical discectomy and fusion (ACDF) using x-rays versus computerized tomography (CT).Although fusion status may be obvious when evaluating ACDFs performed in the remote past, determining the presence of a solid fusion at earlier time points after ACDF is often ambiguous but a necessary part of practice. Commonly used tools include radiographs and CT scans. Currently, there is no gold standard imaging modality to determine fusion status.Twenty-two patients status post-ACDF (cortical allograft with anterior plates) at 34 levels with CT scans and dynamic x-rays obtained at 3, 6, and 12 months postoperatively were included. Four spine surgeons blinded to the time point independently determined fusion status according to the criteria.On the basis of the x-ray criteria, the fusion rates were 26%, 41%, and 65% at 3, 6, and 12 months, respectively, postoperatively. On the basis of CT criteria, the fusion rates were 79%, 79%, and 91% at 3, 6, and 12 months, respectively. There was a significant difference in the predicted fusion rate at each time point comparing x-ray versus CT criteria. In addition, at 3 months, 41% of the levels (11/27) thought to be fused by CT criteria demonstrated1 mm motion on dynamic x-rays. At 6 months, 33% (9/27) of the levels thought to be fused by CT demonstrated persistent motion of ≥1 mm. At 12 months, 23% (7/31) of the levels considered fused by CT still had persistent motion.X-ray criteria for fusion, which incorporate both static and dynamic factors, predicted lower fusion rates at each time point when compared with CT scans, which evaluate only static factors. Depending on the time point, anywhere from 23% to 41% of levels thought to be fused by CT criteria demonstrated persistent motion on dynamic x-rays. Although1 mm motion is not a sufficient criteria for fusion by itself, levels demonstrating1 mm motion are less likely to be solidly fused. Thus, we conclude that CT scans may overestimate the fusion rate during the early stages of ACDF healing with cortical allograft, and that CT scans alone may not accurately determine fusion status. Reliable determination of fusion may thus require dynamic information obtained from flexion-extension x-ray in association with high-resolution static information from CT.

BACKGROUND CONTEXT: The skills and knowledge that residents have to master has increased, yet the amount of hours that the residents are allowed to work has been reduced. There is a strong need to improve training techniques to compensate for these changes. One approach is to use simulation-training methods to shorten the learning curve for surgeons in training. PURPOSE: To analyze the effect of surgical training using three-dimensional (3D) simulation on the placement of lateral mass screws in the cervical spine on either cadavers or sawbones. STUDY DESIGN: A blinded randomized control study. METHODS: Fifteen orthopedic residents, postgraduate year (PGY) 1 to 6, were asked to simulate Magerl lateral mass screw trajectories from C3–C7 on cadavers using a navigated drill guide, but with no feedback as to the actual trajectory within the bone (Baseline 1). This was repeated to determine baseline accuracy (Baseline 2). They were then randomized into three groups: Group 1, control, did not receive any training, whereas Groups 2 and 3 received 3D navigational feedback as to the intended drill trajectory on sawbones and cadavers, respectively. All three groups then performed final simulated drilling (final test). All 3D images were deidentified and reviewed by a blinded single fellowship-trained orthopedic spine surgeon. Each image/screw was measured for the starting site, caudad/cephalad angle, and medial/lateral angle to determine trajectory accuracy. RESULTS: The aggregate mean difference from a perfect screw was compiled for each session for each group. A negative difference shows improvement, whereas a positive difference shows regression.ThedifferencebetweenfinaltestandBaseline1inthecontrolgroupwas2.4 � ,suggestingregression. In contrast, the differences forgroups sawbone and cadaver were � 8.2 � and � 7.2 � , respectively, suggesting improvement. When comparing the difference in aggregate sum angle for the sawbones and cadaver groups with the control group, the difference was statistically significant (p!.0001). CONCLUSIONS: Training with 3D navigation significantly improved the ability of orthopedic residents to properly drill simulated lateral mass screws. As such, training with 3D navigation may be a useful adjunct in resident surgical education. Published by Elsevier Inc.

Study Design: Systematic review (update). Objective: Degenerative cervical myelopathy (DCM) is a progressive degenerative spine disease that is increasingly managed surgically. The objective of this study is to determine the role of nonoperative treatment in the management of DCM by updating a systematic review published by Rhee and colleagues in 2013. The specific aims of this review were (1) to determine the comparative efficacy, effectiveness, and safety of nonoperative and surgical treatment; (2) to assess whether myelopathy severity differentially affects outcomes of nonoperative treatment; and (3) to evaluate whether activities or minor injuries are associated with neurological deterioration. Methods: Methods from the original review were used to search for new literature published between July 20, 2012, and February 12, 2015. Results: The updated search yielded 2 additional citations that met inclusion criteria and compared the efficacy of conservative management and surgical treatment. Based on a single retrospective cohort, there were no significant differences in posttreatment Japanese Orthopaedic Association (JOA) or Neck Disability Index scores or JOA recovery ratios between patients treated nonoperatively versus operatively. A second retrospective study indicated that the incidence rate of hospitalization for spinal cord injury was 13.9 per 1000 person-years in a nonoperative group compared with 9.4 per 1000 person-years in a surgical group (adjusted hazard ratio = 1.57; 95% confidence interval = 1.11-2.22; P = .011). Conclusion: Nonoperative management results in similar outcomes as surgical treatment in patients with a modified JOA ≥ 13, single-level myelopathy and intramedullary signal change on T2-weighted magnetic resonance imaging. Furthermore, patients managed nonoperatively for DCM have higher rates of hospitalization for spinal cord injury than those treated surgically. The overall level of evidence for these findings was rated as low.

Study Design: Guideline development. Objectives: The objective of this study is to develop guidelines that outline how to best manage (1) patients with mild, moderate, and severe myelopathy and (2) nonmyelopathic patients with evidence of cord compression with or without clinical symptoms of radiculopathy. Methods: Five systematic reviews of the literature were conducted to synthesize evidence on disease natural history; risk factors of disease progression; the efficacy, effectiveness, and safety of nonoperative and surgical management; the impact of preoperative duration of symptoms and myelopathy severity on treatment outcomes; and the frequency, timing, and predictors of symptom development. A multidisciplinary guideline development group used this information, and their clinical expertise, to develop recommendations for the management of degenerative cervical myelopathy (DCM). Results: Our recommendations were as follows: (1) “We recommend surgical intervention for patients with moderate and severe DCM.” (2) “We suggest offering surgical intervention or a supervised trial of structured rehabilitation for patients with mild DCM. If initial nonoperative management is pursued, we recommend operative intervention if there is neurological deterioration and suggest operative intervention if the patient fails to improve.” (3) “We suggest not offering prophylactic surgery for non-myelopathic patients with evidence of cervical cord compression without signs or symptoms of radiculopathy. We suggest that these patients be counseled as to potential risks of progression, educated about relevant signs and symptoms of myelopathy, and be followed clinically.” (4) “Non-myelopathic patients with cord compression and clinical evidence of radiculopathy with or without electrophysiological confirmation are at a higher risk of developing myelopathy and should be counselled about this risk. We suggest offering either surgical intervention or nonoperative treatment consisting of close serial follow-up or a supervised trial of structured rehabilitation. In the event of myelopathic development, the patient should be managed according to the recommendations above.” Conclusions: These guidelines will promote standardization of care for patients with DCM, decrease the heterogeneity of management strategies and encourage clinicians to make evidence-informed decisions.

STUDY DESIGN Retrospective cohort study of prospectively collected data. OBJECTIVE To determine if laminoplasty (LP) is associated with worsening axial neck pain in patients with multilevel cervical myelopathy, and to compare neck pain, clinical outcomes, and radiographic measures in a group undergoing laminectomy and fusion (LF). SUMMARY OF BACKGROUND DATA Postoperative new or worsening axial neck pain is commonly cited as a major disadvantage of laminoplasty. However, there remains a paucity of corroborative data from large series. METHODS Following institutional review board approval, we reviewed the medical records, radiographs, and prospective clinical outcomes database of 85 patients undergoing LP and 52 patients undergoing LF for cervical myelopathy with minimum 1-year radiographic follow-up and average clinical follow-up of 18.5 months. LP was performed in those with neutral to lordotic C2-7 alignment and who did not complain of diffuse axial pain. Otherwise, LF was performed. Clinical outcomes included visual analogue score (VAS)-neck pain, VAS-total pain, neck disability index (NDI), short form 36, modified Japanese Orthopaedic Association (mJOA), and several radiographic parameters. RESULTS VAS-neck did not worsen in LP (-0.2, P = 0.54) and did improve in LF (-2.0, P = 0.0013). VAS-total improved significantly in both groups (LF -1.04 ± 0.52, P = 0.05; LP -1.4 ± 0.51, P = 0.008). NDI improved in both groups, but was significant in only LP (LP decreased 6.79 ± 2.25, P = 0.0032; LF decreased 4.01 ± 3.05, P = 0.19). mJOA scores improved significantly in both groups (LP improved 2.89 ± 0.27, P

Laminoplasty represents a powerful motion-preserving technique for the treatment of multilevel cervical stenosis. Laminoplasty has a significantly lower complication rate than multilevel anterior procedures, and if the anatomy is favorable for dorsal decompression, it provides a reliable outcome and high rate of neurologic recovery. The model laminoplasty patient would have multilevel stenosis, minimal or secondary axial complaints, and lordotic sagittal alignment and is ideally k-line positive and has a less than 50% ventral occupation ratio. There are a multitude of technical considerations when performing laminoplasty in order to optimize outcomes. Maintaining the extensor musculature, particularly at the C2 and C7 attachments, is paramount for avoiding postoperative kyphosis and minimizing postoperative neck pain. Despite the large expanding body of evidence and proven utility of laminoplasty, there continues to be significant regional variability in the utilization of this valuable technique.

BACKGROUND CONTEXT Cervical total disc replacement (TDR) has emerged as a motion-preserving alternative to anterior cervical discectomy fusion. Biomechanical studies have demonstrated that the TDR preserves motion at the diseased segment and minimizes motion and stress at adjacent segments compared to fusion. There has been growing interest in performing a TDR adjacent to a cervical fusion. The kinematics of a cervical TDR adjacent to a multilevel fusion construct (>2 levels) has not been investigated. PURPOSE The purpose of this study was to evaluate the motion of a cervical total disc replacement after fusing adjacent cervical segments both caudal and cranial to the implant. OUTCOME MEASURES The primary outcome measure was the segmental flexion-extension range of motion at the level of a cervical total disc repalcement. The secondary outcome measures were the overall cervical range of motion and the segemental motion of the remaining cervical segments. METHODS Seven fresh-frozen human cadaveric cervical spine specimens from C1-T1 were used (average age 56.2±7.3 years). A C6-7 TDR was tested adjacent to a C5-6, C4-6 and C3-6 fusion. A C2-3 TDR was tested adjacent to a C3-4, C3-5 and C3-6 fusion. The protocol consisted of taking lateral radiographs of each construct at maximal angular displacement in flexion and extension. Cobb angles were measured on the digital radiographs to determine flexion-extension range of motion. RESULTS The segmental ROM of the C6-7 TDR in the unfused spine was 11.3±1.9°. After performing a three-level fusion (C3-6) the segmental motion of the C6-7 TDR increased to 12.9±1.3°(p=.33). The difference between the motion of the C6-7 TDR and the C6-7 native segment caudal to a three-level fusion was not statistically significant; 12.9±1.3° versus 11.3±1.9°, respectively (p=.30).The segmental ROM of the C2-3 TDR in the unfused spine was 5.0 ±1.1. After performing a three-level fusion (C3-6), the C2-3 TDR segmental motion was 6.1±1.3° (p=.09). The difference in motion of the TDR cranial to a three-level fusion and the native disc cranial to a three-level fusion was not statistically significant; 6.1± 1.3° versus 6.4± 0.8°, respectively (p=.15). CONCLUSIONS The TDR had similar flexion extension motion to the native segment when instrumented either caudal or cranial to the single, two and three level fusions. The TDR had a trend toward increased motion as additional fusion levels were added adjacent to the implant. Biomechanically, performing a TDR adjacent to a long fusion construct did not subject the implant to greater motion than when instrumented alone. This result suggests that a TDR adjacent to a long segment fusion may not necessarily be subjected to greater mechanical stress. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

BACKGROUND CONTEXT Surgery for cervical degenerative myelopathy or radiculopathy focuses on addressing pain and disability while improving the patients’ quality of life. Although patient-reported outcomes (PROs) are being widely adopted, their ability to be interpreted may be limited by the accuracy of a patient's ability to recall preintervention impairment. PURPOSE Recall bias has been previously investigated in multiple orthopedic and lumbar spine studies, but recall accuracy in cervical spine patients remains unknown. We sought to characterize the accuracy of patient recall as a function of time on validated outcomes after cervical spine surgery. STUDY DESIGN/SETTING Retrospective review of prospectively collected outcomes. PATIENT SAMPLE Consecutive series of patients undergoing cervical spine surgery for myelopathy or radiculopathy. OUTCOME MEASURES Numeric pain scale, neck disability index. METHODS We analyzed a consecutive series of patients undergoing cervical spine surgery for degenerative myelopathy or radiculopathy at a single institution. Using standardized questionnaires, we recorded preoperative neck and arm numeric pain scores (NPS), neck disability indices (NDI) and 36-Item Short Form Health Survey (SF-36). Patients were asked to recall their preoperative status through a standardized phone call script and were subsequently stratified based on the timing of their recall into short-term ( 1 year) follow-up sub-groups. Actual and recalled scores were compared using McNemar's or paired t tests, and relations were quantified using Pearson correlation coefficients. Characteristics between the subgroups were compared using Wilcoxon rank sum tests, t-tests, chi-square tests, or Fisher's exact tests as appropriate. RESULTS Seventy-three patients with a mean age of 58.2 years (range 22 to 83 years) were included, with 34 and 39 patients in the short-term and long-term follow-up subgroups patients respectively. The mean period of recall from surgery was 4.6 months and 22.2 months for the short-term and long-term follow-up subgroups respectively. Compared to the preoperative scores, patients showed significant improvement in neck NPS (mean difference [MD]=−2.9, 95% CI −3.5 to −2.3), arm NPS (MD −3.4, 95% CI −4.0 to −2.8), and NDI (MD −12.4%, 95% CI −16.9 to −7.9). Patient recollection of preoperative status was more severe than actual for neck NPS (MD +1.5, p CONCLUSIONS Relying on retrospectively recalled data for outcome assessment does not provide an accurate measure of preoperative status. Prospective collection of PROs remains the gold standard to measure outcomes following cervical spine surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Although not as common as lumbar degenerative instability, instability in the cervical and thoracic spines, when present, typically manifests as a spondylolisthesis, or the forward translation of the cephalad vertebra on the caudal one. Cervical degenerative spondylolisthesis can occur at C1–2 or subaxially. It can result in a spectrum of symptoms ranging from axial neck pain, atlantoaxial or subaxial instability, radiculopathy and myelopathy. The pattern and severity of cord compression as well as the degree of instability determine the surgical approach. Bone quality available for fixation must also be considered. Thoracic degenerative spondylolisthesis is relatively rare due to the inherit stability in this region. Generally a posterior fusion with instrumentation is recommended when decompressing a thoracic level with associated spondylolisthesis, especially in cases where there is dynamic change in the spondylolisthesis on upright or flexion/extension radiographs.

Study design Cadaveric. Objective Determine optimal fluoroscopic views for detecting cervical lateral mass screw (LMS) violations. Summary of background data Single plane intraoperative x-rays are commonly used but frequently inadequate due to its complex trajectory. Fluoroscopy can be taken in multiple planes, but the ideal fluoroscopic view to assess malposition is not known: depending on the view, any given screw may look "in" or "out." Methods C3-6 LMS were inserted in three cadavers. To evaluate neuroforaminal violation, LMS were inserted into the foramen with the tip penetrating the anterior cortex by 0, 2, and 4 mm. To assess facet joint violation, LMS were inserted toward the subjacent facet joint with the tip penetrating the anterior cortex by 0 and 2 mm. Fluoroscopic views were taken 0°, 10°, 20°, 30°, and 40° to the lateral plane. Views were independently evaluated by three blinded spine surgeons. Results Twenty-degree oblique view correctly identified a 2 mm penetration into the neuroforamen in 79%, and a 4 mm penetration in 86%, for a sensitivity of 83% and specificity of 90%. Thirty-degree view had lower sensitivity (76%) but slightly higher specificity (93%). Twenty-degree and 30° views were significantly more sensitive than the other views. Zero-degree view correctly identified a 2 mm penetration into the facet joint in 93%, for a sensitivity of 93% and specificity of 92%. Ten-degree view had lower sensitivity (72%) but higher specificity (100%). The 0° view was significantly more sensitive than the other views. Conclusion Twenty-degree and 30° oblique views significantly provided the most sensitive assessment of LMS potentially violating the neuroforamen, whereas the 0° neutral lateral view significantly provided the most sensitive assessment of facet violations. The specificities were also high (in the 90% range) for these views. We recommend the use of these views intraoperatively when assessing proper placement of LMS fluoroscopically. Level of evidence N/A.

Anterior cervical discectomy and fusion can be performed for a variety of pathologies but is most commonly used for the treatment of cervical radiculopathy or myelopathy. The procedure involves an anterior decompression of the disc space followed by interbody grafting and fusion. Supplemental anterior plating is commonly performed, and in certain circumstances, posterior instrumentation may provide additional fixation. The procedure includes the following steps: (1) The use of an anterior approach to the cervical spine, most commonly the Smith-Robinson approach medial to the sternocleidomastoid muscle and the carotid sheath. (2) Confirmation of the proper spinal level. (3) Elevation of the longus colli muscle, which acts as a cuff for the placement of retractors. (4) Removal of the involved disc and decompression of the spinal cord and nerve roots. This is facilitated by disc space distraction, most commonly via distraction pins. Osteophytes along the floor of the spinal canal impinging on the spinal cord are removed with a burr. Soft disc and anular material are also removed, usually with curets and rongeurs. Uncovertebral osteophyte resection and foraminotomies are completed to decompress the exiting nerve roots. (5) Carpentry and decortication of the end plates in preparation for fusion. (6) Sizing of the disc space followed by insertion of an interbody graft. (7) Anterior fixation, most commonly via application of a plate-and-screw construct. (8) Hemostasis and closure.

Background Context Gorham disease is a rare osteolytic condition, with only 17 reported cases primarily affecting the cervical spine. Purpose We report the case of a 31-year-old woman with severe kyphotic instability and myelopathy of the upper cervical spine secondary to massive osteolysis of the posterior elements. The surgical management, clinical outcome, and review of the relevant literature are discussed. Study Design This is a case report and a literature review. Patient Sample This is a report of one patient with Gorham disease of the cervical spine. Methods We report the case of a 31-year-old woman with Gorham disease affecting the upper cervical spine. Combined posterior and anterior stabilization and fusion was performed from the occiput to the thoracic spine. Results Six-year follow-up with annual computed tomography imaging showed solid fusion from the occiput to T2. No spread or local recurrence has developed to date. Conclusions Correction of severe instability with myelopathy due to Gorham disease of the upper cervical spine was achieved through posterior and anterior occipito-cervical-thoracic fusion.

Study design: Cross-sectional survey. Objectives: To obtain information from the global community regarding cervical artificial disc replacement (C-ADR) use and trends before and after US Food and Drug Administration (FDA) approval of devices in 2007 and summarize available information on utilization and government approval for devices. Methods: Data on utilization and approval were sought from PubMed, Google, FDA, and manufacturers’ websites. The 6195 members of AOSpine International were invited to participate in a survey to assess global C-ADR use and trends. Results: Publically available data on utilization, trends, and approval outside of the US and Europe is limited. No studies of utilization were found. Of 1479 professionals responding to the survey, 50% had C-ADR specific training and reported ever performing C-ADR. Most respondents believed that C-ADR was safe and effective, but approximately one quarter responded that they did not know. Of those who had done C-ADR, 49% reported performing ≥ 1 before December compared with 92% after January 2008 and 51.3% indicated that all their C-ADRs were placed in a single level; 27% reported ≥ 1 failures that required revision. The majority foresee that C-ADR use will increase in the next 5 years. Most respondents believed that the best indication is radiculopathy from soft-disc pathology rather than myelopathy or disorders arising from spondylotic (hard-disc) pathology. Conclusion: More C-ADR has been performed after January 2008. Most respondents expect the number to increase. There may be differences in failure rates when performed inside or outside of a sponsored research trial.

Iatrogenic deformities of the cervical spine are not uncommon and may be associated with either anterior or posterior operations. To minimize the “footprints” left behind from surgical interventions on the cervical spine, it is imperative not only to treat the present disorder but also avoid sowing the seeds of future problems, or at least create a milieu in which they can be easily addressed should they occur. Doing so requires attention to either correcting or preventing cervical deformities whenever possible during the index operation because the optimal method of treating iatrogenic cervical deformity remains its prevention. In treating established deformities, surgical decision making hinges on whether the deformity is rigid, flexible, or fused.

COMMENTARY ON Goode AP, Richardson WJ, Schectman RM, Carey TS. Complications, revision fusions, readmissions, and utilization over a 1-year period after bone morphogenetic protein use during primary cervical spine fusions. Spine J 2014;14:2051-9 ( in this issue ).

BACKGROUND CONTEXT Recent literature has reported that surgical treatment for central cord syndrome (CCS) has increased significantly over the last decade. PURPOSE The aim of our study was to investigate the patient and hospital characteristics, treatment practices, and in-hospital mortality associated with management of CCS. STUDY DESIGN/SETTING Retrospective. PATIENT SAMPLE Patients with central cord syndrome. OUTCOME MEASURES Mortality, discharge disposition. METHODS The National Emergency Department Sample was queried from 2009 to 2012 to generate national estimates of patients who presented to the emergency room in the United States and were diagnosed with central cord syndrome. Linkage variables were used to query the associated in-patient stay during the same time period. Significance was set at P RESULTS From 2009 to 2012, there were 11,975 emergency room visits for CCS (mean age 60 years), of which 80.5% patients initially presented to a trauma center. Most common injury mechanisms were fall (55%), and motor vehicle accident (15%). Concomitant cervical fractures were found in 10% patients. A total of 93% patients were admitted to the hospital directly or after transfer to another facility. Of all patients who were admitted to the hospital, 55% patients were treated nonoperatively, 39% were treated with cervical fusion surgery (62% with anterior cervical decompression and fusion, 32% with posterior cervical decompression and fusion) and 6% were treated with laminoplasty. Post-hospitalization, 61% patients were discharged to a rehabilitation facility and 39% were discharged to home. The overall incidence of in-hospital mortality was 2.6%, and on multivariate analysis, mortality was associated significantly with older patient age (OR 1.06, P CONCLUSIONS The majority of patients who presented to the emergency room for central cord syndrome in the United States were treated nonoperatively. Advanced age and greater comorbidities were the factors that were most associated with increased risk of in-hospital mortality in patients with central cord syndrome.