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OBJECTIVE Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has been used to treat degenerative lumbar spondylolisthesis and is associated with expedited recovery, reduced operative blood loss, and shorter hospitalizations compared to those with traditional open TLIF. However, the impact of MI-TLIF on long-term patient-reported outcomes (PROs) is less clear. Here, the authors compare the outcomes of MI-TLIF to those of traditional open TLIF for grade I degenerative lumbar spondylolisthesis at 60 months postoperatively. METHODS The authors utilized the prospective Quality Outcomes Database registry and queried for patients with grade I degenerative lumbar spondylolisthesis who had undergone single-segment surgery via an MI or open TLIF method. PROs were compared 60 months postoperatively. The primary outcome was the Oswestry Disability Index (ODI). The secondary outcomes included the numeric rating scale (NRS) for back pain (NRS-BP), NRS for leg pain (NRS-LP), EQ-5D, North American Spine Society (NASS) satisfaction, and cumulative reoperation rate. Multivariable models were constructed to assess the impact of MI-TLIF on PROs, adjusting for variables reaching p < 0.20 on univariable analyses and respective baseline PRO values. RESULTS The study included 297 patients, 72 (24.2%) of whom had undergone MI-TLIF and 225 (75.8%) of whom had undergone open TLIF. The 60-month follow-up rates were similar for the two cohorts (86.1% vs 75.6%, respectively; p = 0.06). Patients did not differ significantly at baseline for ODI, NRS-BP, NRS-LP, or EQ-5D (p > 0.05 for all). Perioperatively, MI-TLIF was associated with less blood loss (108.8 ± 85.6 vs 299.6 ± 242.2 ml, p < 0.001) and longer operations (228.2 ± 111.5 vs 189.6 ± 66.5 minutes, p < 0.001) but had similar lengths of hospitalizations (MI-TLIF 2.9 ± 1.8 vs open TLIF 3.3 ± 1.6 days, p = 0.08). Discharge disposition to home or home health was similar (MI-TLIF 93.1% vs open TLIF 91.1%, p = 0.60). Both cohorts improved significantly from baseline for the 60-month ODI, NRS-BP, NRS-LP, and EQ-5D (p < 0.001 for all comparisons). In adjusted analyses, MI-TLIF, compared to open TLIF, was associated with similar 60-month ODI, ODI change, odds of reaching ODI minimum clinically important difference, NRS-BP, NRS-BP change, NRS-LP, NRS-LP change, EQ-5D, EQ-5D change, and NASS satisfaction (adjusted p > 0.05 for all). The 60-month reoperation rates did not differ significantly (MI-TLIF 5.6% vs open TLIF 11.6%, p = 0.14). CONCLUSIONS For symptomatic, single-level grade I degenerative lumbar spondylolisthesis, MI-TLIF was associated with decreased blood loss perioperatively, but there was no difference in 60-month outcomes for disability, back pain, leg pain, quality of life, or satisfaction between MI and open TLIF. There was no difference in cumulative reoperation rates between the two procedures. These results suggest that in appropriately selected patients, either procedure may be employed depending on patient and surgeon preferences.

It remains unclear how type of insurance coverage affects long-term, spine-specific patient-reported outcomes (PROs). This study sought to elucidate the impact of insurance on clinical outcomes after lumbar spondylolisthesis surgery.The prospective Quality Outcomes Database registry was queried for patients with grade 1 degenerative lumbar spondylolisthesis who underwent single-segment surgery. Twenty-four-month PROs were compared and included Oswestry Disability Index, Numeric Rating Scale (NRS) back pain, NRS leg pain, EuroQol-5D, and North American Spine Society Satisfaction.A total of 608 patients undergoing surgery for grade 1 degenerative lumbar spondylolisthesis (mean age, 62.5 ± 11.5 years and 59.2% women) were selected. Insurance types included private insurance (n = 319; 52.5%), Medicare (n = 235; 38.7%), Medicaid (n = 36; 5.9%), and Veterans Affairs (VA)/government (n = 17; 2.8%). One patient (0.2%) was uninsured and was removed from the analyses. Regardless of insurance status, compared to baseline, all 4 cohorts improved significantly regarding ODI, NRS-BP, NRS-LP, and EQ-5D scores (P 0.001). In adjusted multivariable analyses, compared with patients with private insurance, Medicaid was associated with worse 24-month postoperative Oswestry Disability Index (β = 10.2; 95% confidence interval [CI], 3.9-16.5; P = 0.002) and NRS leg pain (β =1.3; 95% CI, 0.3-2.4; P = 0.02). Medicaid was associated with worse EuroQol-5D scores compared with private insurance (β = -0.07; 95% CI -0.01 to -0.14; P = 0.03), but not compared with Medicare and VA/government insurance (P 0.05). Medicaid was associated with lower odds of reaching ODI minimal clinically important difference (odds ratio, 0.2; 95% CI, 0.03-0.7; P = 0.02) compared with VA/government insurance. NRS back pain and North American Spine Society satisfaction did not differ by insurance coverage (P 0.05).Despite adjusting for potential confounding variables, Medicaid coverage was independently associated with worse 24-month PROs after lumbar spondylolisthesis surgery compared with other payer types. Although all improved postoperatively, those with Medicaid coverage had relatively inferior improvements.

BACKGROUND The factors driving the best outcomes following minimally invasive surgery (MIS) for grade 1 degenerative lumbar spondylolisthesis are not clearly elucidated. OBJECTIVE To investigate the factors that drive the best 24-mo patient-reported outcomes (PRO) following MIS surgery for grade 1 degenerative lumbar spondylolisthesis. METHODS A total of 259 patients from the Quality Outcomes Database lumbar spondylolisthesis module underwent single-level surgery for degenerative grade 1 lumbar spondylolisthesis with MIS techniques (188 fusions, 72.6%). Twenty-four-month follow-up PROs were collected and included the Oswestry disability index (ODI) change (ie, 24-mo minus baseline value), numeric rating scale (NRS) back pain change, NRS leg pain change, EuroQoL-5D (EQ-5D) questionnaire change, and North American Spine Society (NASS) satisfaction questionnaire. Multivariable models were constructed to identify predictors of PRO change. RESULTS The mean age was 64.2 ± 11.5 yr and consisted of 148 (57.1%) women and 111 (42.9%) men. In multivariable analyses, employment was associated with superior postoperative ODI change (β-7.8; 95% CI [-12.9 to -2.6]; P = .003), NRS back pain change (β -1.2; 95% CI [-2.1 to -0.4]; P = .004), EQ-5D change (β 0.1; 95% CI [0.01-0.1]; P = .03), and NASS satisfaction (OR = 3.7; 95% CI [1.7-8.3]; P

OBJECTIVEThe optimal minimally invasive surgery (MIS) approach for grade 1 lumbar spondylolisthesis is not clearly elucidated. In this study, the authors compared the 24-month patient-reported outcomes (PROs) after MIS transforaminal lumbar interbody fusion (TLIF) and MIS decompression for degenerative lumbar spondylolisthesis.METHODSA total of 608 patients from 12 high-enrolling sites participating in the Quality Outcomes Database (QOD) lumbar spondylolisthesis module underwent single-level surgery for degenerative grade 1 lumbar spondylolisthesis, of whom 143 underwent MIS (72 MIS TLIF [50.3%] and 71 MIS decompression [49.7%]). Surgeries were classified as MIS if there was utilization of percutaneous screw fixation and placement of a Wiltse plane MIS intervertebral body graft (MIS TLIF) or if there was a tubular decompression (MIS decompression). Parameters obtained at baseline through at least 24 months of follow-up were collected. PROs included the Oswestry Disability Index (ODI), numeric rating scale (NRS) for back pain, NRS for leg pain, EuroQol-5D (EQ-5D) questionnaire, and North American Spine Society (NASS) satisfaction questionnaire. Multivariate models were constructed to adjust for patient characteristics, surgical variables, and baseline PRO values.RESULTSThe mean age of the MIS cohort was 67.1 ± 11.3 years (MIS TLIF 62.1 years vs MIS decompression 72.3 years) and consisted of 79 (55.2%) women (MIS TLIF 55.6% vs MIS decompression 54.9%). The proportion in each cohort reaching the 24-month follow-up did not differ significantly between the cohorts (MIS TLIF 83.3% and MIS decompression 84.5%, p = 0.85). MIS TLIF was associated with greater blood loss (mean 108.8 vs 33.0 ml, p < 0.001), longer operative time (mean 228.2 vs 101.8 minutes, p < 0.001), and longer length of hospitalization (mean 2.9 vs 0.7 days, p < 0.001). MIS TLIF was associated with a significantly lower reoperation rate (14.1% vs 1.4%, p = 0.004). Both cohorts demonstrated significant improvements in ODI, NRS back pain, NRS leg pain, and EQ-5D at 24 months (p < 0.001, all comparisons relative to baseline). In multivariate analyses, MIS TLIF—as opposed to MIS decompression alone—was associated with superior ODI change (β = −7.59, 95% CI −14.96 to −0.23; p = 0.04), NRS back pain change (β = −1.54, 95% CI −2.78 to −0.30; p = 0.02), and NASS satisfaction (OR 0.32, 95% CI 0.12–0.82; p = 0.02).CONCLUSIONSFor symptomatic, single-level degenerative spondylolisthesis, MIS TLIF was associated with a lower reoperation rate and superior outcomes for disability, back pain, and patient satisfaction compared with posterior MIS decompression alone. This finding may aid surgical decision-making when considering MIS for degenerative lumbar spondylolisthesis.

BACKGROUND Given recent differing findings following 2 randomized clinical trials on degenerative lumbar spondylolisthesis (DLS) surgery, there is a need to better define how subsets of patients fare following surgery. OBJECTIVE To investigate the impact of obesity on patient-reported outcomes (PROs) following DLS surgery. METHODS A total of 12 high-enrolling sites were queried, and we found 797 patients undergoing surgery for grade 1 DLS. For univariate comparisons, patients were stratified by BMI ≥ 30 kg/m2 (obese) and

BACKGROUND Trials of lumbar spondylolisthesis are difficult to compare because of the heterogeneity in the populations studied. OBJECTIVE To define patterns of clinical presentation. METHODS This is a study of the prospective Quality Outcomes Database spondylolisthesis registry, including patients who underwent single-segment surgery for grade 1 degenerative lumbar spondylolisthesis. Twenty-four-month patient-reported outcomes (PROs) were collected. A k-means clustering analysis-an unsupervised machine learning algorithm-was used to identify clinical presentation phenotypes. RESULTS Overall, 608 patients were identified, of which 507 (83.4%) had 24-mo follow-up. Clustering revealed 2 distinct cohorts. Cluster 1 (high disease burden) was younger, had higher body mass index (BMI) and American Society of Anesthesiologist (ASA) grades, and globally worse baseline PROs. Cluster 2 (intermediate disease burden) was older and had lower BMI and ASA grades, and intermediate baseline PROs. Baseline radiographic parameters were similar (P > .05). Both clusters improved clinically (P

STUDY DESIGN Retrospective analysis of a prospective registry. OBJECTIVE We utilized the Quality Outcomes Database (QOD) registry to investigate the "July Effect" at QOD spondylolisthesis module sites with residency trainees. SUMMARY OF BACKGROUND DATA There is a paucity of investigation on the long-term outcomes following surgeries involving new trainees utilizing high-quality, prospectively collected data. METHODS This was an analysis of 608 patients who underwent single-segment surgery for grade 1 degenerative lumbar spondylolisthesis at 12 high-enrolling sites. Surgeries were classified as occurring in July or not in July (non-July). Outcomes collected included estimated blood loss, length of stay, operative time, discharge disposition, complications, reoperation and readmission rates, and patient-reported outcomes (Oswestry Disability Index [ODI], Numeric Rating Scale [NRS] Back Pain, NRS Leg Pain, EuroQol-5D [EQ-5D] and the North American Spine Society [NASS] Satisfaction Questionnaire). Propensity score-matched analyses were utilized to compare postoperative outcomes and complication rates between the July and non-July groups. RESULTS Three hundred seventy-one surgeries occurred at centers with a residency training program with 21 (5.7%) taking place in July. In propensity score-matched analyses, July surgeries were associated with longer operative times ( average treatment effect = 22.4 minutes longer, 95% confidence interval 0.9-449.0, P = 0.041). Otherwise, July surgeries were not associated with significantly different outcomes for the remaining perioperative parameters (estimated blood loss, length of stay, discharge disposition, postoperative complications), overall reoperation rates, 3-month readmission rates, and 24-month ODI, NRS back pain, NRS leg pain, EQ-5D, and NASS satisfaction score (P > 0.05, all comparisons). CONCLUSION Although July surgeries were associated with longer operative times, there were no associations with other clinical outcomes compared to non-July surgeries following lumbar spondylolisthesis surgery. These findings may be due to the increased attending supervision and intraoperative education during the beginning of the academic year. There is no evidence that the influx of new trainees in July significantly affects long-term patient-centered outcomes.Level of Evidence: 3.

OBJECTIVE The Neurosurgery Research and Education Foundation (NREF) provides research support for in-training and early career neurosurgeon-scientists. To define the impact of this funding, the authors assessed the success of NREF awardees in obtaining subsequent National Institutes of Health (NIH) funding. METHODS NREF in-training (Research Fellowship [RF] for residents) and early career awards/awardees (Van Wagenen Fellowship [VW] and Young Clinician Investigator [YCI] award for neurosurgery faculty) were analyzed. NIH funding was defined by individual awardees using the NIH Research Portfolio Online Reporting tool (1985–2014). RESULTS Between 1985 and 2014, 207 unique awardees were supported by 218 NREF awards ($9.84 million [M] in funding), including 117 RF ($6.02 M), 32 VW ($1.68 M), and 69 YCI ($2.65 M) awards. Subspecialty funding included neuro-oncology (79 awards; 36% of RF, VW, and YCI awards), functional (53 awards; 24%), vascular (37 awards; 17%), spine (22 awards; 10%), pediatrics (18 awards; 8%), trauma/critical care (5 awards; 2%), and peripheral nerve (4 awards; 2%). These awardees went on to receive $353.90 M in NIH funding that resulted in an overall NREF/NIH funding ratio of 36.0:1 (in dollars). YCI awardees most frequently obtained later NIH funding (65%; $287.27 M), followed by VW (56%; $41.10 M) and RF (31%; $106.59 M) awardees. YCI awardees had the highest NREF/NIH funding ratio (108.6:1), followed by VW (24.4:1) and RF (17.7:1) awardees. Subspecialty awardees who went on to obtain NIH funding included vascular (19 awardees; 51% of vascular NREF awards), neuro-oncology (40 awardees; 51%), pediatrics (9 awardees; 50%), functional (25 awardees; 47%), peripheral nerve (1 awardees; 25%), trauma/critical care (2 awardees; 20%), and spine (2 awardees; 9%) awardees. Subspecialty NREF/NIH funding ratios were 56.2:1 for vascular, 53.0:1 for neuro-oncology, 47.6:1 for pediatrics, 34.1:1 for functional, 22.2:1 for trauma/critical care, 9.5:1 for peripheral nerve, and 0.4:1 for spine. Individuals with 2 NREF awards achieved a higher NREF/NIH funding ratio (83.3:1) compared to those with 1 award (29.1:1). CONCLUSIONS In-training and early career NREF grant awardees are an excellent investment, as a significant portion of these awardees go on to obtain NIH funding. Moreover, there is a potent multiplicative impact of NREF funding converted to NIH funding that is related to award type and subspecialty.

Prospective database analysis.To assess the effect of age on patient-reported outcomes (PROs) and complication rates after surgical treatment for spondylolisthesis SUMMARY OF BACKGROUND DATA.: Degenerative lumbar spondylolisthesis affects 3% to 20% of the population and up to 30% of the elderly. There is not yet consensus on whether age is a contraindication for surgical treatment of elderly patients.The Quality Outcomes Database lumbar registry was used to evaluate patients from 12 US academic and private centers who underwent surgical treatment for grade 1 lumbar spondylolisthesis between July 2014 and June 2016.A total of 608 patients who fit the inclusion criteria were categorized by age into the following groups: less than 60 (n = 239), 60 to 70 (n = 209), 71 to 80 (n = 128), and more than 80 (n = 32) years. Older patients showed lower mean body mass index (P 0.001) and higher rates of diabetes (P = 0.007), coronary artery disease (P = 0.0001), and osteoporosis (P = 0.005). A lower likelihood for home disposition was seen with higher age (89.1% in60-year-old vs. 75% in80-year-old patients; P = 0.002). There were no baseline differences in PROs (Oswestry Disability Index, EuroQol health survey [EQ-5D], Numeric Rating Scale for leg pain and back pain) among age categories. A significant improvement for all PROs was seen regardless of age (P 0.05), and most patients met minimal clinically important differences (MCIDs) for improvement in postoperative PROs. No differences in hospital readmissions or reoperations were seen among age groups (P 0.05). Multivariate analysis demonstrated that, after controlling other variables, a higher age did not decrease the odds of achieving MCID at 12 months for the PROs.Our results indicate that well-selected elderly patients undergoing surgical treatment of grade 1 spondylolisthesis can achieve meaningful outcomes. This modern, multicenter US study reflects the current use and limitations of spondylolisthesis treatment in the elderly, which may be informative to patients and providers.4.

OBJECTIVEReturn to work (RTW) and satisfaction are important outcome measures after surgery for degenerative spine disease. The authors queried the prospective Quality Outcomes Database (QOD) to determine if RTW correlated with patient satisfaction.METHODSThe QOD was queried for patients undergoing surgery for degenerative lumbar spondylolisthesis. The primary outcome of interest was correlation between RTW and patient satisfaction, as measured by the North American Spine Society patient satisfaction index (NASS). Secondarily, data on satisfied patients were analyzed to see what patient factors correlated with RTW.RESULTSOf 608 total patients in the QOD spondylolisthesis data set, there were 292 patients for whom data were available on both satisfaction and RTW status. Of these, 249 (85.3%) were satisfied with surgery (NASS score 1–2), and 224 (76.7%) did RTW after surgery. Of the 68 patients who did not RTW after surgery, 49 (72.1%) were still satisfied with surgery. Of the 224 patients who did RTW, 24 (10.7%) were unsatisfied with surgery (NASS score 3–4). There were significantly more people who had an NASS score of 1 in the RTW group than in the non-RTW group (71.4% vs 42.6%, p < 0.05). Failure to RTW was associated with lower level of education, worse baseline back pain (measured with a numeric rating scale), and worse baseline disability (measured with the Oswestry Disability Index [ODI]).CONCLUSIONSThere are a substantial number of patients who are satisfied with surgery even though they did not RTW. Patients who were satisfied with surgery and did not RTW typically had worse preoperative back pain and ODI and typically did not have a college education. While RTW remains an important measure after surgery, physicians should be mindful that patients who do not RTW may still be satisfied with their outcome.

OBJECTIVE Proximal junctional kyphosis (PJK) remains problematic following multilevel instrumented spine surgery. Previous biomechanical studies indicate that providing less rigid fixation at the cranial aspect of a long posterior instrumented construct, via transition rods or hooks at the upper instrumented vertebra (UIV), may provide a gradual transition to normal motion and prevent PJK. The purpose of this study was to evaluate the ability of posterior anchored polyethylene tethers to distribute proximal motion segment stiffness in long instrumented spine constructs. METHODS A finite element model of a T7–L5 spine segment was created to evaluate range of motion (ROM), intradiscal pressure, pedicle screw loads, and forces in the posterior ligament complex within and adjacent to the proximal terminus of an instrumented spine construct. Six models were tested: 1) intact spine; 2) bilateral, segmental pedicle screws (PS) at all levels from T-11 through L-5; 3) bilateral pedicle screws from T-12 to L-5 and transverse process hooks (TPH) at T-11 (the UIV); 4) pedicle screws from T-11 to L5 and 1-level tethers from T-10 to T-11 (TE-UIV+1); 5) pedicle screws from T-11 to L-5 and 2-level tethers from T-9 to T-11 (TE-UIV+2); and 6) pedicle screws and 3-level tethers from T-8 to T-11 (TE-UIV+3). RESULTS Proximal-segment range of motion (ROM) for the PS construct increased from 16% at UIV−1 to 91% at UIV. Proximal-segment ROM for the TPH construct increased from 27% at UIV−1 to 92% at UIV. Posterior tether constructs distributed ROM at the UIV and cranial adjacent segments most effectively; ROM for TE-UIV+1 was 14% of the intact model at UIV−1, 76% at UIV, and 98% at UIV+1. ROM for TE-UIV+2 was 10% at UIV−1, 51% at UIV, 69% at UIV+1, and 97% at UIV+2. ROM for TE-UIV+3 was 7% at UIV−1, 33% at UIV, 45% at UIV+1, and 64% at UIV+2. Proximal segment intradiscal pressures, pedicle screw loads, and ligament forces in the posterior ligament complex were progressively reduced with increasing number of posterior tethers used. CONCLUSIONS Finite element analysis of long instrumented spine constructs demonstrated that posterior tethers created a more gradual transition in ROM and adjacent-segment stress from the instrumented to the noninstrumented spine compared with all PS and TPH constructs. Posterior tethers may limit the biomechanical risk factor for PJK; however, further clinical research is needed to evaluate clinical efficacy.

Spinal deformity management can be difficult. The decision for surgery, approach, number of levels, and surgical technique all present challenges. Even when other issues are managed appropriately the process of how to correct the deformity needs special consideration. Numerous techniques have been studied including vertebra-to-rod, rod de-rotation, 3-rod-techniques, and cantilever maneuvers. While cantilever is the preferred technique when treating sagittal plane deformity, scoliosis often requires a combination of techniques due to the complexity of deformity in coronal and transverse planes. This video illustrates an adult scoliosis correction using sequential reduction towers and de-rotation techniques. Using this method the step of hook holders is eliminated and tension is distributed evenly across the rod using sequential reduction of the reduction towers across the length of the rod. This has led to a very efficient correction of our deformity as well as a powerful de-rotation tool. We routinely use this technique for flexible and rigid deformities, which is assessed pre-op with a computed tomography. The patient is a 67-yr-old female with prior lumbar decompressions and worsening back pain with radiculopathy. No significant sagittal malalignment is present but pelvic tilt is elevated and a coronal deformity exists. pelvic incidence measures 59°, LL50°, PT28° and lumbar scoliosis shows a coronal Cobb angle of 50.8°. Briefly, surgery involved transpedicular instrumentation from T10-S1 with bilateral iliac screw fixation. To achieve mobility posterior column osteotomies were performed at T12-L1, L1-2, L2-3, L3-4, L4-5, and L5-S1 levels. TLIF was performed at L4-5, L5-S1 for fusion. Postoperative scoliosis X-rays demonstrated improved sagittal and coronal alignment with PI59°, LL59°, PT22°, and coronal Cobb angle of 12°.

Understanding the role of regional segments of the spine in maintaining global balance has garnered significant attention recently. Long-cassette radiographs (LCR) are necessary to evaluate global spinopelvic alignment. However, it is unclear how LCRs impact operative decision-making for cervical spine pathology. To evaluate whether the addition of LCRs results in changes to respondents' operative plans compared to standard imaging of the involved cervical spine in an international survey of spine surgeons. Fifteen cases (5 control cases with normal and 10 test cases with abnormal global alignment) of cervical pathology were presented online with a vignette and cervical imaging. Surgeons were asked to select a surgical plan from 6 options, ranging from the least (1 point) to most (6 points) extensive. Cases were then reordered and presented again with LCRs and the same surgical plan question. One hundred fifty-seven surgeons completed the survey, of which 79% were spine fellowship trained. The mean response scores for surgical plan increased from 3.28 to 4.0 (P = .003) for test cases with the addition of LCRs. However, no significant changes (P = .10) were identified for the control cases. In 4 of the test cases with significant mid thoracic kyphosis, 29% of participants opted for the more extensive surgical options of extension to the mid and lower thoracic spine when they were provided with cervical imaging only, which significantly increased to 58.3% upon addition of LCRs. In planning for cervical spine surgery, surgeons should maintain a low threshold for obtaining LCRs to assess global spinopelvic alignment. HRQOL, health-related quality of lifeLCR, long-cassette radiographsSVA, sagittal vertical axis.

In the current study, we sought to compare baseline demographic, clinical, and operative characteristics, as well as baseline and follow-up patient reported outcomes (PROs) of patients with any depressive and/or anxiety disorder undergoing surgery for low-grade spondylolisthesis using a national spine registry.The Quality Outcomes Database (QOD) was queried for patients undergoing surgery for Meyerding grade 1 lumbar spondylolisthesis undergoing 1-2 level decompression or 1 level fusion at 12 sites with the highest number of patients enrolled in QOD with 2-year follow-up data.Of the 608 patients identified, 25.6 % (n = 156) had any depressive and/or anxiety disorder. Patients with a depressive/anxiety disorder were less likely to be discharged home (p 0.001). At 3=months, patients with a depressive/anxiety disorder had higher back pain (p 0.001), lower quality of life (p 0.001) and higher disability (p = 0.013); at 2 year patients with depression and/or anxiety had lower quality of life compared to those without (p 0.001). On multivariable regression, depression was associated with significantly lower odds of achieving 20 % or less ODI (OR 0.44, 95 % CI 0.21-0.94,p = 0.03). Presence of an anxiety disorder was not associated with decreased odds of achieving that milestone at 3 months. The presence of depressive-disorder, anxiety-disorder or both did not have an impact on ODI at 2 years. Finally, patient satisfaction at 2-years did not differ between the two groups (79.8 % vs 82.7 %,p = 0.503).We found that presence of a depressive-disorder may impact short-term outcomes among patients undergoing surgery for low grade spondylolisthesis but longer term outcomes are not affected by either a depressive or anxiety disorder.

The Quality Outcomes Database (QOD), formerly known as the National Neurosurgery Quality Outcomes Database (N2QOD), was established by the NeuroPoint Alliance (NPA) in collaboration with relevant national stakeholders and experts. The overarching goal of this project was to develop a centralized, nationally coordinated effort to allow individual surgeons and practice groups to collect, measure, and analyze practice patterns and neurosurgical outcomes. Specific objectives of this registry program were as follows: “1) to establish risk-adjusted national benchmarks for both the safety and effectiveness of neurosurgical procedures, 2) to allow practice groups and hospitals to analyze their individual morbidity and clinical outcomes in real time, 3) to generate both quality and efficiency data to support claims made to public and private payers and objectively demonstrate the value of care to other stakeholders, 4) to demonstrate the comparative effectiveness of neurosurgical and spine procedures, 5) to develop sophisticated ‘risk models’ to determine which subpopulations of patients are most likely to benefit from specific surgical interventions, and 6) to facilitate essential multicenter trials and other cooperative clinical studies.” The NPA has launched several neurosurgical specialty modules in the QOD program in the 7 years since its inception including lumbar spine, cervical spine, and spinal deformity and cerebrovascular and intracranial tumor. The QOD Spine modules, which are the primary subject of this paper, have evolved into the largest North American spine registries yet created and have resulted in unprecedented cooperative activities within our specialty and among affiliated spine care practitioners. Herein, the authors discuss the experience of QOD Spine programs to date, with a brief description of their inception, some of the key achievements and milestones, as well as the recent transition of the spine modules to the American Spine Registry (ASR), a collaboration between the American Association of Neurological Surgeons and the American Academy of Orthopaedic Surgeons (AAOS).

OBJECTIVEThe American Association of Neurological Surgeons launched the Quality Outcomes Database (QOD), a prospective longitudinal registry that includes demographic, clinical, and patient-reported outcome (PRO) data, to measure the safety and quality of neurosurgical procedures, including spinal surgery. Differing results from recent randomized controlled trials have established a need to clarify the groups that would most benefit from surgery for degenerative lumbar spondylolisthesis. In the present study, the authors compared patients who were the most and the least satisfied following surgery for degenerative lumbar spondylolisthesis.METHODSThis was a retrospective analysis of a prospective, national longitudinal registry including patients who had undergone surgery for grade 1 degenerative lumbar spondylolisthesis. The most and least satisfied patients were identified based on an answer of “1” and “4,” respectively, on the North American Spine Society (NASS) Satisfaction Questionnaire 12 months postoperatively. Baseline demographics, clinical variables, surgical parameters, and outcomes were collected. Patient-reported outcome measures, including the Numeric Rating Scale (NRS) for back pain, NRS for leg pain, Oswestry Disability Index (ODI), and EQ-5D (the EuroQol health survey), were administered at baseline and 3 and 12 months after treatment.RESULTSFour hundred seventy-seven patients underwent surgery for grade 1 degenerative lumbar spondylolisthesis in the period from July 2014 through December 2015. Two hundred fifty-five patients (53.5%) were the most satisfied and 26 (5.5%) were the least satisfied. Compared with the most satisfied patients, the least satisfied ones more often had coronary artery disease (CAD; 26.9% vs 12.2%, p = 0.04) and had higher body mass indices (32.9 ± 6.5 vs 30.0 ± 6.0 kg/m2, p = 0.02). In the multivariate analysis, female sex (OR 2.9, p = 0.02) was associated with the most satisfaction. Notably, the American Society of Anesthesiologists (ASA) class, smoking, psychiatric comorbidity, and employment status were not significantly associated with satisfaction. Although there were no significant differences at baseline, the most satisfied patients had significantly lower NRS back and leg pain and ODI scores and a greater EQ-5D score at 3 and 12 months postoperatively (p < 0.001 for all).CONCLUSIONSThis study revealed that some patient factors differ between those who report the most and those who report the least satisfaction after surgery for degenerative lumbar spondylolisthesis. Patients reporting the least satisfaction tended to have CAD or were obese. Female sex was associated with the most satisfaction when adjusting for potential covariates. These findings highlight several key factors that could aid in setting expectations for outcomes following surgery for degenerative lumbar spondylolisthesis.

BACKGROUND There is a paucity of investigation on the impact of spondylolisthesis surgery on back pain-related sexual inactivity. OBJECTIVE To investigate predictors of improved sex life postoperatively by utilizing the prospective Quality Outcomes Database (QOD) registry. METHODS A total of 218 patients who underwent surgery for grade 1 degenerative lumbar spondylolisthesis were included who were sexually active. Sex life was assessed by Oswestry Disability Index item 8 at baseline and 24-mo follow-up. RESULTS Mean age was 58.0 ± 11.0 yr, and 108 (49.5%) patients were women. At baseline, 178 patients (81.7%) had sex life impairment. At 24 mo, 130 patients (73.0% of the 178 impaired) had an improved sex life. Those with improved sex lives noted higher satisfaction with surgery (84.5% vs 64.6% would undergo surgery again, P = .002). In multivariate analyses, lower body mass index (BMI) was associated with improved sex life (OR = 1.14; 95% CI [1.05-1.20]; P

OBJECTIVESince the enactment of the Affordable Care Act in 2010, providers and hospitals have increasingly prioritized patient-centered outcomes such as patient satisfaction in an effort to adapt the “value”-based healthcare model. In the current study, the authors queried a prospectively maintained multiinstitutional spine registry to construct a predictive model for long-term patient satisfaction among patients undergoing surgery for Meyerding grade I lumbar spondylolisthesis.METHODSThe authors queried the Quality Outcomes Database for patients undergoing surgery for grade I lumbar spondylolisthesis between July 1, 2014, and June 30, 2016. The primary outcome of interest for the current study was patient satisfaction as measured by the North American Spine Surgery patient satisfaction index, which is measured on a scale of 1–4, with 1 indicating most satisfied and 4 indicating least satisfied. In order to identify predictors of higher satisfaction, the authors fitted a multivariable proportional odds logistic regression model for ≥ 2 years of patient satisfaction after adjusting for an array of clinical and patient-specific factors. The absolute importance of each covariate in the model was computed using an importance metric defined as Wald chi-square penalized by the predictor degrees of freedom.RESULTSA total of 502 patients, out of a cohort of 608 patients (82.5%) with grade I lumbar spondylolisthesis, undergoing either 1- or 2-level decompression (22.5%, n = 113) or 1-level decompression and fusion (77.5%, n = 389), met the inclusion criteria; of these, 82.1% (n = 412) were satisfied after 2 years. On univariate analysis, satisfied patients were more likely to be employed and working (41.7%, n = 172, vs 24.4%, n = 22; overall p = 0.001), more likely to present with predominant leg pain (23.1%, n = 95, vs 11.1%, n = 10; overall p = 0.02) but more likely to present with lower Numeric Rating Scale score for leg pain (median and IQR score: 7 [5–9] vs 8 [6–9]; p = 0.05). Multivariable proportional odds logistic regression revealed that older age (OR 1.57, 95% CI 1.09–2.76; p = 0.009), preoperative active employment (OR 2.06, 95% CI 1.27–3.67; p = 0.015), and fusion surgery (OR 2.3, 95% CI 1.30–4.06; p = 0.002) were the most important predictors of achieving satisfaction with surgical outcome.CONCLUSIONSCurrent findings from a large multiinstitutional study indicate that most patients undergoing surgery for grade I lumbar spondylolisthesis achieved long-term satisfaction. Moreover, the authors found that older age, preoperative active employment, and fusion surgery are associated with higher odds of achieving satisfaction.

Object The purpose of this study was to determine long-term clinical outcomes in patients undergoing anterior cervical surgery in which a cervical disc prosthesis was used to treat single-level degenerative cervical disc disease. Methods In this prospective, nonblinded study, 541 patients at 32 investigational sites were randomly assigned to 1 of 2 treatment groups. The results of the investigational group, in which patients received the Prestige disc prosthesis, were compared with those of the control group, in which patients underwent an instrumented interbody fusion. Data were collected preoperatively, intraoperatively, and at 1.5, 3, 6, 12, 24, 36, and 60 months postoperatively. To date, 271 patients have completed 5 years of clinical follow-up (144 investigational and 127 control patients). Results Significant improvements in Neck Disability Index (NDI) scores, Physical Component Summary scores of the 36-Item Short-Form Health Survey, and neck and arm pain scores were achieved by 1.5 months in both groups and sustained at 5 years. The mean NDI improvements from preoperative scores were 35.4, 36.3, and 38.4 at 24, 36, and 60 months, respectively, in the investigational group. The corresponding mean NDI improvements were 33.9, 31.3, and 34.1 in the control group. The intergroup differences at both 36 and 60 months were significant (p = 0.008 and 0.022, respectively). The overall rates of maintenance or improvement in neurological status in the investigational group were 91.6%, 92.8%, and 95.0%, respectively, at 24, 36, and 60 months compared with 83.6%, 83.2%, and 88.9% in the control group (p = 0.006, 0.004, and 0.051, respectively). The implant effectively maintained angular motion, averaging more than 7.3° at 36 months and 6.5° at 60 months after surgery. No implant migration was observed up to 60 months. There were statistically significant differences between the investigational and control groups with regard to the rate of revision and supplemental fixation surgical procedures performed subsequent to the index procedure. Additional surgical procedures for adjacent-segment disease were observed in both treatment groups. Rates for surgery at adjacent levels trended lower in the investigational group (8 patients [11 surgeries]) compared with those in the control group (13 patients [16 surgeries]), but the differences were not statistically significant (p = 0.376). Some of the second surgeries involved both index and adjacent levels. Conclusions The Prestige disc maintains improved clinical outcomes and segmental motion after implantation at 5-year follow-up.

The technique for anterior cervical arthroplasty using the PRESTIGE LP (Medtronic Sofamor Danek, Memphis, TN) cervical disc is illustrated. Surgical positioning and the operative approach are demonstrated. Our methods of retractor placement and surgical exposure are discussed. The technique used for decompression and endplate preparation is presented in detail. Optimal arthroplasty device positioning is demonstrated. The surgical pearls and pitfalls of anterior cervical arthroplasty are highlighted.

Study Design. Prospective, randomized, controlled and double-blinded study on imaging of artificial discs. Objective. The purpose of this study is to compare postoperative imaging characteristics of the 4 currently available cervical arthroplasty devices at the level of implantation and at adjacent levels. of Background Data. Cervical arthroplasty is being performed increasingly frequently for degenerative disc disease and, in most cases, with frank neural compression. Unlike lumbar arthroplasty, performed mainly for axial back pain, decompression of neural elements may need to be confirmed with postoperative imaging after cervical arthroplasty. Methods. Preoperative and postoperative magnetic resonance imaging scans of 20 patients who had undergone cervical arthroplasty were assessed for imaging quality. Five cases each of the Bryan® (Medtronic Sofamor Danek, Memphis, TN), Prodisc-C® (Synthes Spine, Paoli, PA), Prestige LP® (Medtronic Sofamor Danek), and PCM® devices (Cervitech, Rockaway, NJ) were analyzed. Six blinded spinal surgeons scored twice sagittal and axial T2-weighted images using the Jarvik 4-point scale. Statistical analysis was performed comparing quality before surgery and after disc implantation at the operated and adjacent levels and between implant types. Results. Moderate intraobserver and interobserver reliability was noted. Preoperative images of patients in all implant groups had high-quality images at operative and adjacent levels. The Bryan and Prestige LP devices allowed satisfactory visualization of the canal, exit foramina, cord, and adjacent levels after arthroplasty. Visualization was significantly impaired in all PCM® and Prodisc-C® cases at the operated level in both the spinal canal and neural foramina. At the adjacent levels, image quality was statistically poorer in the PCM® and Prodisc-C® than those of Prestige LP® or Bryan®. Conclusions. Postoperative visualization of neural structures and adjacent levels after cervical arthroplasty is variable among current available devices. Devices containing nontitanium metals (cobalt-chrome-molybdenum alloys in the PCM® and Prodisc-C®) prevent accurate postoperative assessment with magnetic resonance imaging at the surgical and adjacent levels. Titanium devices, with or without polyethylene (Bryan® disc or Prestige LP®), allow for satisfactory monitoring of the adjacent and operated levels. This information is crucial for any surgeon who wishes to assess adequacy of neural decompression and where monitoring of adjacent levels is desired.

The past decade has witnessed significant advances in the surgical treatment of cervical myelopathy and myeloradiculopathy. In this article, we discuss in detail the indications for combined ventral and dorsal surgery for the treatment of cervical myelopathy and myeloradiculopathy. In addition, the advances in surgical technique and instrumentation in cervical spine surgery are explored. Finally, complication avoidance and management strategies are discussed. Combined ventral and dorsal decompression, reconstruction, and instrumentation procedures are viable options in the treatment of a select group of patients with complex cervical myelopathy or myeloradiculopathy.

A wide variety of pathologic processes can involve the cervicomedullary junction leading to spinal cord compression and mechanical instability. Effective surgical management involves accurate patient selection, appropriate operative planning, and meticulous surgical technique. Many different options for decompression exist, each associated with a unique set of risks and benefits. Spinal stabilization has been enhanced greatly through the evolution of posterior occipitocervical instrumentation constructs. Careful attention to detail may decrease the incidence of potential complications and provide the surgeon with an effective management strategy to maximize clinical outcome.

Object The authors present the early clinical results obtained in patients who underwent SPIRE spinous process plate fixation following anterior lumbar interbody fusion (ALIF). Methods Between May 2003 and January 2005, 32 patients underwent titanium cage and bone morphogenetic protein–augmented ALIF and subsequent SPIRE (21 cases) or bilateral pedicle screw (BPS; 11 cases) fixation. Pedicle screws were implanted using either the open approach (three cases) or using a tubular retractor (eight cases). Patients’ charts were reviewed for operative time, estimated blood loss (EBL), hospital length of stay (LOS), and evidence of pseudarthrosis or hardware failure. In SPIRE plate–treated patients, the median EBL (75 ml) was lower than in BPS-treated patients (open BPS [150 ml]; tubular BPS [125 ml]). The median operative time in SPIRE plate–treated patients was also shorter (164 minutes compared with 239 and 250 minutes in the open and tubular BPS, respectively). The median LOS was 3 days for both the SPIRE and tubular BPS groups, but 4 days in the open BPS group. There were no instances of major surgery-induced complication, pseudarthrosis, or hardware failure during mean follow-up periods of 5.5, 7.2, and 4.9 months in the SPIRE, open PS, and tubular BPS groups, respectively. Conclusions The SPIRE plate is easy to implant and is associated with minimal operative risk. Compared with BPS/rod constructs, SPIRE plate fixation leads to less EBL and shorter operative time, without an increase in the rate of pseudarthrosis. Hospital LOS was also shorter in SPIRE plate–treated patients, which is consistent with the goals of minimal access spinal technologies.

Study design Review of the literature. Objectives We discuss the indications and contraindications for posterolateral lumbar fusion and posterior approaches to lumbar interbody fusion. We also review the advances in minimal access surgical techniques, graft materials, and osteobiologics. Summary of background data Previously published data and our own surgical experience form the basis of this report. Methods A Pub Med online internet search for the keywords was performed. The pertinent articles were then cited. Results Posterior interbody fusion techniques have theoretical and demonstrable advantages over posterolateral fusion, but the former is also associated with greater morbidity. There are several approaches one may use to perform posterior interbody fusion, as well as multiple minimally invasive techniques and interbody spacer graft options. Bone morphogenetic protein offers an attractive alternative for achieving fusion. Conclusion Fusion of painful motion segments is widely used to treat patients with degenerative low back pain. Successful arthrodesis may be achieved using either posterolateral fusion with pedicle screw fixation or posterior interbody fusion, depending on the patient's situation. These techniques may be accomplished with a variety of minimal access strategies and various graft and spacer technologies. The modern spine surgeon should be proficient in using all these options to treat the painful lumbar motion segment.

Postlaminectomy cervical kyphosis is an important consideration when performing surgery. Identifying factors predisposing to postoperative deformity is essential. The goal is to prevent postlaminectomy cervical kyphosis while exposing the patient to minimal additional morbidity. When postlaminectomy kyphosis does occur, surgical correction is often required and performed via an anterior, posterior, or combined approach. The authors discuss the indications for surgical approaches as well as clinical results.

Background context: Bioabsorbable implants are commonplace in sports medicine surgeries, especially in shoulder and knee ligamentous reconstruction. Their use is now expanding to the realm of spinal reconstructive surgery. Newer polymers offer reduced incidence of the side effects of aseptic sterile sinus formation and have appropriate resorption time parameters for spine use. These new bioabsorbable materials confer initial and intermediate-term stability that is adequate for stable bony healing in various applications. The majority of human clinical applications in the spine that have been documented involve bone graft harvest site reconstruction, posterior spinal graft containment, anterior interbody reconstruction and anterior cervical and lumbar spine tension band plating. Purpose: The purpose of this review article is to highlight the indications and outcomes of the use of bioabsorbable implants in specific spinal applications. Study design: A comprehensive literature review of the English and non-English literature on bioabsorbable implant technology. Methods: A comprehensive literature review was performed to gather basic science, animal and human data on the use of bioabsorbable implants in spinal surgery. Results: Bioabsorbable implants have demonstrated strength and resorption characteristics commensurate with the physiologic and biomechanical requirements of the human spinal axis. Histologic sampling has demonstrated successful time-patterned resorption accompanied by bony replacement and remodeling of intervertebral cage devices in the animal model. Conclusion: Bioresorbable compounds appear to have a role in specific spinal reconstructive procedures. Their radiolucent nature improves image assessment of fusion healing, and their time-engineered resorption characteristics allow controlled dynamization in interbody and plate applications. Their widespread use and acceptance may increase dramatically as further research and clinical studies report on their safety and efficacy.

OBJECTIVEWith the proliferation of implant types available for use in posterior lumbar interbody fusion (PLIF) procedures, the choices for surgeons have become increasingly complex. The goal of this study was to retrospectively review a series of 49 patients who underwent PLIF with the use of allograft cylindrical threaded cortical bone dowels (TCBDs) and allograft impacted wedges. Nerve root injury rates, fusion rates, and clinical outcomes of the allograft impacted wedge group are compared with those in the allograft cylindrical TCBD group.METHODSWe performed a retrospective chart and radiographic review of 49 patients. Twenty-seven patients underwent PLIF with impacted allograft wedges, and 22 patients underwent PLIF with allograft cylindrical TCBD. Permanent nerve root injury rates, fusion rates, and clinical outcomes were assessed on the basis of a minimum of 1 year of follow-up data in this nonconsecutive series.RESULTSPermanent nerve root injuries in the impacted wedge and TCBD groups were documented with physical examinations conducted pre- and postoperatively. The cylindrical TCBD group showed a 13.6% rate of permanent nerve root injury, and the impacted wedge group demonstrated a 0% rate, and these rates were statistically significant (analysis of variance, P = 0.049). The fusion rate at a mean of 13.9 months of follow-up was 95.4% in patients in whom the cylindrical TCBD was implanted and 88.9% after a mean of 17.4 months of follow-up in patients in whom impacted wedges were used. The fusion rate difference between the TCBD and impacted wedge groups was not significant. The satisfactory outcome rate was 72.7% for the TCBD group and 85.1% for the impacted wedge group, and the impacted wedge group was found to have a significantly higher rate of satisfactory outcomes (P = 0.016, analysis of variance). Analysis of the patient outcomes in the TCBD and impacted wedge groups according to sex, mean length of follow-up, workman's compensation claim rate, and smoking habit yielded no significant difference.CONCLUSIONWith a minimum of 1 year of follow-up in this nonconsecutive series of 49 patients, a comparison of the use of allograft TCBD versus allograft impacted wedges in PLIF procedures reveals a statistically significant increase in permanent nerve root injury rates with the use of cylindrical TCBD implants as compared with impacted allograft wedges. There is no difference between the two groups in terms of fusion rates, and clinical outcomes with the use of impacted wedges were significantly better.

Object. Pedicle screw fixation with transverse process fusion has gained widespread acceptance since its inception. Improved rates of arthrodesis have been demonstrated when this technique is used. The authors present one of the largest series of patients to undergo this procedure at a single center; one of the goals was to correlate construct length and spinal disease with rates of successful arthrodesis by conducting a prospective analysis of lumbar fusion in which pedicle screws were placed. Methods. During a 7-year period, the senior author performed pedicle screw fixation with posterolateral fusion in 457 patients; the mean follow-up period was 28.4 months. Indications for fusion included metastatic tumor, single-level degenerative disc disease (DDD), trauma, degenerative scoliosis, and translational vertebral instability. Successful fusion was based on the radiographic demonstration of a bilateral contiguous osseous bridge over the transverse processes and absence of movement on dynamic x-ray films. Fusion rates were lowest in cases of tumors (54%) and highest in cases of trauma (96%). In patients with single-level DDD the rate was 91%, and in those with translational instability it was 89%. Fusion rates, however, declined steeply in relation to each additional motion segment in the translational instability group. In this group a strong linear trend for proportion was demonstrated (p < 0.001). The overall fusion rate in patients with degenerative scoliosis was 70%. The overall fusion rate for the entire group was 86%. Conclusions. The data in this study can be used as a benchmark with which to compare newer technologies. Although overall pedicle screw—assisted fusion rate in cases of trauma or selected degenerative lesions approached 90%, the arthrodesis rates are not uniform for the different diagnoses. This appears to be related to the underlying spinal disease and the number of segments included in the fusion.

OBJECTIVE The anterior lumbar interbody fusion (ALIF) procedure has become an accepted fusion technique for treating patients with degenerative disorders of the lumbar spine. Many consider laparoscopic ALIF to be the least invasive approach. A modification of the open laparotomy—the “mini-open” approach—is an attractive alternative. In this retrospective review, a comparison of these two ALIF approaches is presented. METHODS We conducted a retrospective review of 98 patients who underwent ALIF procedures between 1996 and 2001 in which either a mini-open or a laparoscopic approach was used. Patient demographics, intraoperative parameters, length of hospitalization, and technique-related complications associated with the use of these two approaches were compared. The subset of patients who underwent L5–S1 ALIF procedures was analyzed separately. Statistical analysis was conducted with χ2 and Student's paired t tests. RESULTS Between 1996 and 2001, a total of 98 patients underwent ALIF. A laparoscopic approach was used in 47 of these patients, and the mini-open technique was used in the other 51 patients. Operative preparation and procedure time were longer with the use of a laparoscopic approach, and significantly greater during L5–S1 ALIF procedures (P < 0.05). A marginal but significant increase in length of stay was observed after mini-open ALIF procedures (P < 0.05). The immediate postoperative complication rate was greater after mini-open ALIF procedures, 17.6 versus 4.3% (P < 0.05); however, the rate of retrograde ejaculation was higher in the laparoscopic group, 45 versus 6% (P < 0.05). CONCLUSION Both the laparoscopic and mini-open techniques are effective approaches to use when performing ALIF procedures. On the basis of the data obtained in this retrospective review, the laparoscopic approach does not seem to have a definitive advantage over the mini-open exposure, particularly in an L5–S1 ALIF procedure. In our opinion, the mini-open approach possesses a number of theoretical advantages; however, the individual surgeon's preference ultimately is likely to be the dictating factor.

The authors review historical and biomechanical aspects of anterior cervical plate (ACP) systems. They propose a novel classification system for ACPs based on the biomechanical and graft-loading properties of these systems. A retrospective review of the literature comprising both clinical and laboratory investigations regarding the ACP system was undertaken. Comparison of each system is considered in the context of the biomechanical attributes and graft-loading properties of each type of plate. Salient characteristics reviewed include restriction of screw backout, screw-angle variability, and mobility at the screw–plate interface. A new classification system for ACPs is proposed that primarily considers the ability of the construct to restrict screw backout, as well as the properties of the plate–screw interface—that is, the capacity for rotational or translational movement. A new classification system is presented that provides unified, biomechanically descriptive nomenclature. Using this nomenclature, the ACP devices currently available and those developed in the future can be uniformly categorized.

Object Standard lateral mass plate and screw systems are of limited use in patients with abnormal cervical anatomy and do not easily allow for extension to either the occipit or the thoracic spine. The objective of this study was to demonstrate the safety, surgical efficacy, and advantages of a new cervical polyaxial screw and rod system for posterior occipitocervicothoracic arthrodesis. Methods The authors reviewed a multicenter series of patients who underwent surgery in which they used a new posterior cervical polyaxial screw and rod system. The system was implanted in 32 (20 women and 12 men) adult patients (mean age 56.9 years, range 23–84 years). Twentythree of the patients were treated for spondylostenosis; four for cervical fracture/dislocations; four for kyphosis; and one patient was treated for pseudarthrosis that developed after prior surgery. The system was successfully implanted in all patients despite the presence of anatomical lateral mass anomalies in the majority of cases. The mean number of levels fused was 3.9 (range one–eight levels). This dynamic system allowed for screw placement into the occiput, C-1 lateral masses, C-2 pars, C3–7 lateral masses, and low cervical as well as upper thoracic pedicles. Selective application of compressive or distractive forces was possible in adjacent segments. Surgery-related complications included one dural tear and one malpositioned screw. There were two cases of wound infection. Conclusions Unlike standard lateral mass plate and screw systems, the new cervical polyaxial screw and rod system easily accommodates severe degenerative cervical spondylosis and curvatures. This instrumentation system allows for polyaxial screw placement with subsequent multiplanar rod contouring and offset attachment. The authors have used this system successfully, and without significant complications, to achieve posterior cervical arthrodesis.

Object The authors present a retrospective review of 77 patients in whom they performed anterior cervical discectomy and fusion (ACDF) in the treatment of radiculopathy and/or myelopathy. In all cases anterior interbody fusion was performed using the Atlantis locking plate system to treat the degenerative disease. Methods There were 41 men and 36 women (mean age 53.8 years), and 24 active cigarette smokers (31%) in the group. All patients presented with signs and symptoms of cervical radiculopathy and/or myelopathy, and magnetic resonance imaging or computerized tomography myelography demonstrated evidence of radicular and/or spinal cord compression at one or more cervical levels. Thirty-one patients underwent single-level ACDF, 20 patients underwent multilevel ACDF without posterior instrumentation, in eight patients one- to four-level corpectomies were supplemented with posterior fixation, 12 patients underwent single-level corpectomy, and six patients underwent multilevel corpectomy with no posterior instrumentation. The mean follow-up period was 15.33 months; overall good-to-excellent outcome was seen in 75% of patients; osseous fusion was demonstrated in 93.5%. In all patients except three, fibular allograft was used as graft material. The degree of overall cervical lordosis was measured at the last follow up and was compared with normal values obtained in age-matched individuals. In addition, the degree of cervical lordosis at fusion levels was compared with overall cervical lordosis. In patients in all five of the aforementioned categories significantly less lordosis was demonstrated than in age-matched controls. In patients who underwent single-level ACDF, single-level corpectomy, and multilevel ACDF significantly less lordosis was observed at the fusion segment than that in the overall cervical spine. Complications included one episode of chronic anterior wound drainage treated with intravenous antibiotic medication and one postoperative posterior wound infection, which required reoperation and intravenous antibiotic medication. Two cases (2.6%) of anterior screw backout and/or breakage were identified. One patient died of unrelated causes within 3 months of operation. Conclusions These initial results indicate that use of the Atlantis plate system for anterior cervical arthrodesis produces fusion rates and clinical outcomes that are comparable with those obtained using other locking plating systems. It has the unique advantage, however, of providing the surgeon with the choice of fixed, variable, or hybrid screw constructs as a way of tailoring screw angles to individual anatomical/biomechanical needs.

Object The authors assess the long-term safety and efficacy of cervical disc replacement with the Prestige Cervical Disc in a prospective, randomized, multicenter trial at 7 years of follow-up. Methods At 31 investigational sites, 541 patients with single-level cervical disc disease with radiculopathy were randomized to 1 of 2 treatment groups: 276 investigational group patients underwent anterior cervical discectomy and arthroplasty with the Prestige disc, and 265 control group patients underwent anterior cervical discectomy and fusion. Clinical outcomes included Neck Disability Index, the 36-Item Short-Form Health Survey, and neck and arm pain scores. Radiographs were assessed for angle of motion and fusion. Clinical and radiographic outcomes were evaluated preoperatively, intraoperatively, and at 1.5, 3, 6, 12, 24, 36, 60, and 84 months. Results Of the 541 patients treated, 395 patients (73%; 212 investigational and 183 control patients) completed 7 years of clinical follow-up. Significant improvements achieved by 1.5 months in both groups were sustained at 7 years. In the investigational group, mean Neck Disability Index improvements from preoperative scores were 38.2 and 37.5 at 60 and 84 months, respectively. In the control group, the corresponding means were 33.8 and 31.9. The differences between the investigational and control groups at the 60-month and 84-month periods were significant (p = 0.014 and 0.002, respectively). The overall rates of maintenance or improvement in neurological status in the investigational group were significantly higher: 92.2% and 88.2% at 60 months and 84 months, respectively, compared with 85.7% and 79.7% in the control group (p = 0.017 and 0.011, respectively). At 84 months, the percentage of working patients in the investigational group was 73.9%, and in the control group, 73.1%. Postoperatively, the implant effectively maintained average angular motion of 6.67° at 60 months and 6.75° at 84 months. Cumulative rates for surgery at the index level were lower (p < 0.001) in the investigational group (11 [4.8%] of 276) when compared with the control group (29 [13.7%] of 265) (based on life-table method), and there were statistical differences between the investigational and control groups with specific regard to the rate of subsequent revision and supplemental fixation surgical procedures. Rates for additional surgical procedures that involved adjacent levels were lower in the investigational group than in the control group (11 [4.6%] of 276 vs 24 [11.9%] of 265, respectively). Conclusions Cervical disc arthroplasty has the potential for preserving motion at the operated level while providing biomechanical stability and global neck mobility and may result in a reduction in adjacent-segment degeneration. The Prestige Cervical Disc maintains improved clinical outcomes and segmental motion after implantation at 7-year follow-up. Clinical trial registration no. NCT00642876 (ClinicalTrials.gov).

OBJECTIVE We review a 6-year, single-center experience using the technique of C1–C2 transarticular screw fixation for atlantoaxial instability in 75 consecutive operations. METHODS The study group was composed of 43 men and 32 women, with a mean age of 44 years (range, 8–76 yr). Each patient had documented atlantoaxial instability. In 28 patients (37%), atlantoaxial instability was a result of trauma; in 22 patients, (29%), it was a result of rheumatoid arthritis; in 16 patients (21%), it was a result of prior surgery; and in 9 patients (12%), it was a result of congenital abnormalities. All patients underwent stabilization with C1–C2 transfacetal screws and a posterior interspinous construct. Nine patients had unilateral screws placed. Postoperatively, the patients were maintained in a rigid cervical orthosis for a mean of 11 weeks (range, 8–15 wk); five patients were immobilized with halo fixation for a mean of 13 weeks (range, 10–16 wk). The mean follow-up period was 2.4 years (range, 1–5.5 yr). RESULTS Osseous fusion was documented in 72 patients (96%). There were no hardware failures; however, three patients developed pseudarthrosis. Two superficial wound infections (one at the graft site and one at the cervical incision site) required antibiotic therapy. Four patients had transient suboccipital hypesthesia. No instances of an errant screw, dural laceration, or injury to the vertebral artery, spinal cord, or hypoglossal nerve were noted. CONCLUSION C1–C2 transarticular screw fixation supplemented with an interspinous construct yielded a 96% fusion rate, with a low incidence of complications. We attribute our successful outcomes to careful preoperative assessment and meticulous surgical technique.

The widespread use of fusion procedures in the management of spinal disorders has led investigators to explore the use of growth and differentiation factors in such procedures. As an adjuvant to allograft bone or as a replacement for harvested autograft, bone morphogenetic proteins (BMPs) appear to improve fusion rates after spinal arthrodesis in both animal models and humans, while reducing the donor-site morbidity previously associated with such procedures. The use of recombinant genetic technology in the production of BMP has improved the efficiency, cost effectiveness, and safety of producing and using such materials. Recombinant human BMP-2 (rhBMP-2), as one of the first factors identified in the process of endochondral bone formation, has been extensively researched over the past decade. The efficacy and dose profile of this differentiation factor in the context of various carrier substrates has been investigated. Based on the encouraging results of preliminary studies, the future role of rhBMP-2 may lie in its replacement of autologous bone grafting and, consequently, the reduced need for instrumented fixation, while concurrently improving overall fusion rates. The authors provide an overview of BMP and review its use in clinical and laboratory settings.

The different clinical presentations and treatment options available to treat neck pain from degenerative disc disease have been discussed. With proper patient selection, good correlation between clinical and radiographic findings, and selecting the correct procedure for each patient, surgical treatment of cervical radiculopathy and myelopathy can be one of the most gratifying operations performed in neurosurgery.

Objective Accepted management strategies for odontoid fractures include external immobilization and surgical stabilization using anterior or posterior approaches. Displaced Type II fractures and rostral Type III fractures are at high risk for nonunion. Anterior fixation of odontoid fractures with a single cortical lag screw is a relatively new technique that combines rigid internal stabilization with preservation of intrinsic C1-C2 motion. We retrospectively reviewed our series of 26 consecutive patients who underwent odontoid screw fixation, to further define the safety and efficacy of the technique. Methods During a 5-year period, 26 patients presented with acute traumatic Type II odontoid fractures. Ten patients were female and 16 were male, with a mean age of 35 years. All patients underwent anterior odontoid screw fixation by the senior surgeon (RWH), within a mean of 3 days after injury. All patients were postoperatively maintained in external orthoses, for a mean of 7.2 weeks, and were monitored with serial clinical and radiographic examinations. Results With a mean follow-up period of 30 months, radiographic fusion was documented for 25 of 26 patients (96%). No complications related to the surgical approach were identified, and all patients remained in neurologically stable condition. Two complications (8%) were related to the instrumentation; one patient required external immobilization because of suboptimal screw placement, and one patient required posterior atlantoaxial arthrodesis because of inadequate fracture reduction. Conclusion Single-screw anterior odontoid fixation was associated with a relatively low complication rate and a high fusion rate in this study. We think that this should be the preferred treatment method for acute Type II odontoid fractures.

STUDY DESIGN A retrospective review of 317 patients to determine the efficacy of allogeneic fibula arthrodesis after anterior cervical discectomy. OBJECTIVE To examine the efficacy of allogeneic fibula as an alternative fusion substrate after anterior cervical discectomy, and to determine the effects of cigarette smoking on the healing of fibula allografts. SUMMARY OF BACKGROUND DATA The use of autogeneic iliac crest is associated with graft harvest complications in up to 20% of patients. Most studies reporting on the use of allogeneic iliac crest cite a high collapse rate. Few studies exist that note the efficacy of allogeneic fibula in this procedure and the effects of cigarette smoking on fusion rate. METHODS From 1988 to 1993, 317 patients underwent grafting by the Smith-Robinson technique with allogeneic fibula after anterior cervical discectomy. Patients who described themselves as habitual cigarette smokers or who smoked during the perioperative or postoperative period were categorized as smokers. All patients were immobilized in a rigid cervical orthosis (Philadelphia collar) for at least 10 weeks postoperatively. RESULTS A minimum of 2 years follow-up was achieved in 289 patients. In all, 162 men and 127 women had a total of 311 levels grafted, and the mean follow-up period was 33 months (range, 24 to 51 months). Of patients who received allogeneic fibula at one level, 90% (242/269) achieved radiologic fusion. The fusion rate was 92% (182/198) among nonsmokers compared with 85% (60/71) among smokers (not a statistically significant difference; P = 0.120). After two-level procedures, 72% (13/18) of the patients showed fusion. The fusion rate was 50% (2/4) among smokers compared with 79% (11/14) among nonsmokers (P = 0.53). When one-level arthrodesis (90%) was compared with two-level arthrodesis (72%), the difference approached statistical significance (P = 0.054). Neither of the two patients, both nonsmokers, who received grafts at three levels achieved fusion. There were no infections, and no grafts collapsed. Two grafts extruded (0.6%), but these were partial and did not require reoperation. Both patients fused and constituted the only patients with more than 10 degrees of angulation in the series. Graft subsidence occurred in 5% (17/311) of the grafts, mostly in the beginning of the series, and was not problematic. This phenomenon was thought to have been caused by overaggressive removal of the cortical endplate. CONCLUSION Allogeneic fibula is an effective substrate for use in achieving fusion after anterior cervical discectomy. Maximal results are achieved with its use at one level in nonsmokers. Cigarette smoking decreased the fusion rate with allogeneic fibula in the anterior cervical spine, but not by a statistically significant amount.

The first 50 consecutive patients stabilized with Cotrel-Dubousset rods for lumbar or lumbosacral fusions were followed for an average of 2 years. The occurrence of fusion, maintenance of alignment, and rate of hardware complications were examined. There were 28 men and 22 women, ages 18-87 years, and 133 vertebral levels. Twenty-nine sets of 5-mm, and 21 pairs of 7-mm, rods were placed. Two hundred and sixty-eight pedicle screws were used. Forty-eight out of 50 (96%) patients demonstrated successful arthrodesis after their initial procedure. One pedicle screw became separated from the rod. No rods migrated or broke. Seven (2.6%) pedicle screws bent and 3 (1%) broke. Large and small diameter Cotrel-Dubousset rods allowed short segment lumbar and lumbosacral fusion with a high degree of reliability.

There are now 3 randomized, multicenter, US FDA investigational device exemption, industry-sponsored studies comparing arthroplasty with anterior cervical discectomy and fusion (ACDF) for single-level cervical disease with 2 years of follow-up. These 3 studies evaluated the Prestige ST, Bryan, and ProDisc-C artificial discs. The authors analyzed the combined results of these trials.A total of 1213 patients with symptomatic, single-level cervical disc disease were randomized into 2 treatment arms in the 3 randomized trials. Six hundred twenty-one patients received an artificial cervical disc, and 592 patients were treated with ACDF. In the three trials, 94% of the arthroplasty group and 87% of the ACDF group have completed 2 years of follow-up. The authors analyzed the 2-year data from these 3 trials including previously unpublished source data. Statistical analysis was performed with fixed and random effects models.The authors' analysis revealed that segmental sagittal motion was preserved with arthroplasty (preoperatively 7.26° and postoperatively 8.14°) at the 2-year time point. The fusion rate for ACDF at 2 years was 95%. The Neck Disability Index, 36-Item Short Form Health Survey Mental, and Physical Component Summaries, neck pain, and arm pain scores were not statistically different between the groups at the 24-month follow-up. The arthroplasty group demonstrated superior results at 24 months in neurological success (RR 0.595, I(2) = 0%, p = 0.006). The arthroplasty group had a lower rate of secondary surgeries at the 2-year time point (RR 0.44, I(2) = 0%, p = 0.004). At the 2-year time point, the reoperation rate for adjacent-level disease was lower for the arthroplasty group when the authors analyzed the combined data set using a fixed effects model (RR 0.460, I(2) = 2.9%, p = 0.030), but this finding was not significant using a random effects model. Adverse event reporting was too heterogeneous between the 3 trials to combine for analysis.Both anterior cervical discectomy and fusion as well as arthroplasty demonstrate excellent 2-year surgical results for the treatment of 1-level cervical disc disease with radiculopathy. Arthroplasty is associated with a lower rate of secondary surgery and a higher rate of neurological success at 2 years. Arthroplasty may be associated with a lower rate of adjacent-level disease at 2 years, but further follow-up and analysis are needed to confirm this finding.

✓ The authors report on the management of occipital neuralgia secondary to an abnormality of the atlas in which the posterior arch was separated by a fibrous band from the lateral masses, resulting in C-2 nerve root compression. The causes and treatments of occipital neuralgia as well as the development of the atlas are reviewed.

✓ The authors describe two cases of calcifying pseudoneoplasms, rare degenerative lesions that mimic tumor or infection. One case involved the cervical spine and the second the thoracic spine. Both patients experienced progressive myelopathy from extradural compression of the spinal cord. The radiological evaluation, pathological findings in the lesions, treatment, and follow up are described. Total or subtotal excision can relieve symptoms and prevent recurrence of this lesion.

The treatment of cervical kyphotic deformity is challenging. Few prior reports have examined combined anterior/posterior correction methods, and fusion rates and standardized outcomes are rarely cited in literature examining these techniques. The authors present their midterm results with cervical kyphosis correction.The authors retrospectively reviewed the charts of 30 patients with cervical kyphotic deformity who underwent circumferential spine surgery between 2001 and 2007. The causes of the deformity included chronic fracture in 17 patients, degenerative disease in 10, and tumor in 3. Anterior procedures included discectomies and corpectomies/osteotomies at 1 or more levels with fusion. Posterior operations included decompression and/or osteotomies with lateral mass or pedicle fixation. Preoperative and postoperative Ishihara kyphosis indices, modified Japanese Orthopaedic Association (mJOA) scores, and Nurick grades were analyzed. Arthrodesis was assessed via dynamic radiographs, and CT scans were used to assess fusion in questionable cases.One patient was lost to follow-up. Two patients died within 1 month of surgery. The follow-up period in the remaining 27 patients ranged from 1 to 6.4 years (mean 2.6 years). Ishihara indices improved from a preoperative mean of -17.7 to a postoperative mean of +11.4. The mean Nurick grades improved from 3.2 preoperatively to 1.3 postoperatively. The mJOA scores improved from a preoperative mean of 10 to 15 postoperatively. All surviving patients who underwent follow-up showed postoperative fusion except 1 patient with renal failure and osteoporosis (95% fusion rate). The overall rate of complications (major and minor) was 33.3%.In cases of cervical kyphosis, management with decompression, osteotomy, and stabilization from both anterior and posterior approaches can restore cervical lordosis. Furthermore, such surgical techniques can produce measurable improvements in neurological function (as measured with Nurick grades and mJOA scores) and achieve high fusion rates. However, there is a significant rate of complications.

✓ Only four cases of Type I odontoid fracture have been previously described in the English literature. Most authors consider this lesion to be stable, although the mechanism(s) of injury has not been clearly elucidated. A case of Type I odontoid fracture in association with atlanto-occipital and atlantoaxial dislocation resulting in death is presented. The normal ligamentous anatomy is reviewed and proposed mechanisms for this injury are discussed. The radiographic features of all reported cases of this type are reviewed. It is proposed that the Type I odontoid fracture is a likely manifestation of atlanto-occipital instability and rarely occurs as an isolated or stable injury.

Object The authors report the results of a prospective randomized multicenter study in which the results of cervical disc arthroplasty were compared with anterior cervical discectomy and fusion (ACDF) in patients treated for symptomatic single-level cervical degenerative disc disease (DDD). Methods Five hundred forty-one patients with single-level cervical DDD and radiculopathy were enrolled at 32 sites and randomly assigned to one of two treatment groups: 276 patients in the investigational group underwent anterior cervical discectomy and decompression and arthroplasty with the PRESTIGE ST Cervical Disc System (Medtronic Sofamor Danek); 265 patients in the control group underwent decompressive ACDF. Eighty percent of the arthroplasty-treated patients (223 of 276) and 75% of the control patients (198 of 265) completed clinical and radiographic follow-up examinations at routine intervals for 2 years after surgery. Analysis of all currently available postoperative 12- and 24-month data indicated a two-point greater improvement in the neck disability index score in the investigational group than the control group. The arthroplasty group also had a statistically significant higher rate of neurological success (p = 0.005) as well as a lower rate of secondary revision surgeries (p = 0.0277) and supplemental fixation (p = 0.0031). The mean improvement in the 36-Item Short Form Health Survey Physical Component Summary scores was greater in the investigational group at 12 and 24 months, as was relief of neck pain. The patients in the investigational group returned to work 16 days sooner than those in the control group, and the rate of adjacent-segment reoperation was significantly lower in the investigational group as well (p = 0.0492, log-rank test). The cervical disc implant maintained segmental sagittal angular motion averaging more than 7°. In the investigational group, there were no cases of implant failure or migration. Conclusions The PRESTIGE ST Cervical Disc System maintained physiological segmental motion at 24 months after implantation and was associated with improved neurological success, improved clinical outcomes, and a reduced rate of secondary surgeries compared with ACDF.

The decision whether to use allograft or autograft in ventral cervical fusions has been widely discussed. The literature includes several prospective randomized trials. Extensive clinical evidence indicates that autograft use results in increased arthrodesis rates and less graft collapse. However, autograft harvest has a substantial morbidity rate. Allografts avoid the morbidity associated with autograft harvest but result in decreased arthrodesis rates and increased graft collapse rates. The decreased arthrodesis rate associated with allografts becomes more significant in multilevel surgery and in patients who smoke. The introduction and use of ventral cervical plates have made allograft use more attractive by increasing arthrodesis rates and decreasing graft collapse.

STUDY DESIGN A retrospective magnetic resonance imaging (MRI) review of a series of patients who underwent a single-level anterior cervical discectomy and fusion followed by anterior plate stabilization using an anterior cervical resorbable mesh plate and screw system. OBJECTIVE MRI evaluation of the long-term implant resorption properties of a bioresorbable anterior cervical plate and the adjacent peri-implant soft tissue environment. SUMMARY OF BACKGROUND DATA The use of bioresorbable anterior cervical plates for immediate cervical stabilization following an anterior cervical discectomy and fusion presents several distinct advantages over metallic instrumentation. Bioresorbable polymers may diminish, by their resorbability, implant-related complications such as loosening, migration, and failure of instrumentation, as well as stress shielding of the underlying fusion. Information on the intermediate and long-term bony and soft tissue reaction to the resorption byproducts of these biomaterials is limited. METHODS There were 9 consecutive patients who underwent single-level anterior cervical decompression and fusion using allograft cortical bone, followed by bioresorbable polylactide anterior mesh plate and screw fixation. Following institutional review board approval, 5 of the 9 patients agreed to postoperative MRI assessment of the peri-implant area. An independent radiologist then characterized implant degradation, and the presence of soft tissue inflammation and swelling during the resorption phase of the bioresorbable plate. RESULTS At an average follow-up of 32 months, MRI assessment showed no evidence of soft tissue swelling or inflammation related to the resorption of a bioresorbable anterior plate in any of the 5 patients. In addition, none of the patients complained of any dysphagia or phonation difficulties. CONCLUSIONS Based on MRI assessment, these devices, at more than 2-year follow-up, did not indicate any local chronic inflammation or swelling resulting from their degradation. Clinical symptoms of dysphagia or dysarthria, a common reported problem following anterior cervical spine procedures, were not observed in any patient.

The authors present their radiographic criteria for assessing fusion of the lumbar spine after anterior interbody fusion with intradiscal implants. These criteria include the assessment of plain radiographs, dynamic motion radiographs, and thin-cut computerized tomography scans. Fusion within the instrumented spinal motion segment can be determined using radiographic evaluation to assess spinal alignment on sequential examinations, angular and translational changes on dynamic motion studies, and device–host interface, and to identify new bone formation and bone remodeling. Finally, to aid the clinician in assessing fusion, the authors describe the five zones of fusion within the intervertebral disc space.