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The emergence of C8 radiculopathy is a known complication following cervicothoracic osteotomies. However, the clinical profile of C8 radiculopathy is not well understood. The aim of this study was to investigate the rate of C8 radiculopathy after cervicothoracic osteotomies and to form a clinical profile describing the characteristics through a systematic review of the literature.An electronic database search for full-text English articles was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The search yielded results on indications for cervicothoracic osteotomies, surgical approaches, mean follow-up time, and significant complications, including C8 radiculopathy.Our literature search yielded 2135 articles, of which 12 qualified to be included in the analysis. The 12 articles comprised 451 patients undergoing various osteotomy approaches. The mean age of subjects was 51.0 years (range, 11.4-63.2 years), and the majority of patients were male (66%, n = 298). Ankylosing spondylitis was the most frequent indication for surgery (44.8%, n = 202). The number of patients with postoperative C8 radiculopathy was found to decrease over time (1997-2020) by showing statistical significance (r = -0.65, P = 0.021).Of the 451 patients included in this study, 53 had C8 radiculopathy (11.8% of the total patient population). Moreover, the rate of C8 radiculopathy decreased over time in a statistically significant manner. An understanding of the factors associated with the incidence of C8 radiculopathy is essential for future improvement of patient outcomes.

Study Design Systematic Review and Meta-analysis Objective The purpose of this study is to synthesize recommendations for perioperative medical management of RA patients and quantify outcomes after spine surgery when compared to patients without RA. Methods A search of available literature on patients with RA and spine surgery was performed. Studies were included if they provided a direct comparison of outcomes between patients undergoing spine surgery with or without RA diagnosis. Meta-analysis was performed on operative time, estimated blood loss, hospital length of stay, overall complications, implant-related complications, reoperation, infection, pseudarthrosis, and adjacent segment disease. Results Included in the analysis were 9 studies with 703 patients with RA undergoing spine surgery and 2569 patients without RA. In RA patients compared to non-RA patients undergoing spine surgery, the relative risk of infection was 2.29 times higher (P = .036), overall complications 1.61 times higher (P < .0001), implant-related complications 3.93 times higher (P = .009), and risk of reoperation 2.45 times higher (P < .0001). Hospital length of stay was 4.6 days longer in RA patients (P < .0001). Conclusions Treatment of spinal pathology in patients with RA carries an increased risk of infection and implant-related complications. Spine-specific guidelines for perioperative management of antirheumatic medication deserve further exploration. All RA patients should be perioperatively co-managed by a rheumatologist. This review helps identify risk profiles in RA specific to spine surgery and may guide future studies seeking to medically optimize RA patients perioperatively.

OBJECTIVE Neurosurgeons generate an enormous amount of data daily. Within these data lie rigorous, valid, and reproducible evidence. Such evidence can facilitate healthcare reform and improve quality of care. To measure the quality of care provided objectively, evaluating the safety and efficacy of clinical activities should occur in real time. Registries must be constructed and collected data analyzed with the precision akin to that of randomized clinical trials to accomplish this goal. METHODS The Quality Outcomes Database (QOD) Tumor Registry was launched in February 2019 with 8 sites in its initial 1-year pilot phase. The Tumor Registry was proposed by the AANS/CNS Tumor Section and approved by the QOD Scientific Committee in the fall of 2018. The initial pilot phase aimed to assess the feasibility of collecting outcomes data from 8 academic practices across the United States; these outcomes included length of stay, discharge disposition, and inpatient complications. RESULTS As of November 2019, 923 eligible patients have been entered, with the following subsets: intracranial metastasis (17.3%, n = 160), high-grade glioma (18.5%, n = 171), low-grade glioma (6%, n = 55), meningioma (20%, n = 184), pituitary tumor (14.3%, n = 132), and other intracranial tumor (24%, n = 221). CONCLUSIONS The authors have demonstrated here, as a pilot study, the feasibility of documenting demographic, clinical, operative, and patient-reported outcome characteristics longitudinally for 6 common intracranial tumor types.

Interbody cages are currently being used to address diseases of the vertebra requiring surgical stabilization. Titanium cages were first introduced in 1988. Polyetheretherketone (PEEK) cages are used frequently as one of the alternatives to titanium cages in current practice. This study aimed to compare available cage materials by reviewing the surgical and radiographic outcomes following anterior cervical discectomy and fusion.A comprehensive search of several electronic databases was conducted following the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. Baseline characteristics, operative outcomes, arthrodesis rates, subsidence rates, and complications were collected from included studies. Collected outcomes were further stratified according to the procedure type, the number of levels operated, and graft used to compare cage materials.Following the screening for inclusion criteria, a total of 37 studies with 2363 patients were included. The median age was 49.5 years and the median follow-up was 26 months. Overall, no significant differences were found between PEEK and titanium cages regarding fusion, neurologic deficit, subsidence rates, or "good and excellent" outcome according to Odom criteria. However, the standalone comparison between PEEK, titanium, and poly-methyl-methacrylate (PMMA) cages showed a significantly lower fusion rate for PMMA (PEEK: 94%, PMMA: 56%, titanium: 95%, P0.01).In the present systematic review and meta-analysis, a comparison of the long-term patient-reported and the radiographic outcomes associated with the use of titanium and PEEK, intervertebral body cages showed similar findings. However, there were significantly lower fusion rates for PMMA cages when using a standalone cage without graft material.

Currently, large numbers of clinical trials are performed to investigate different forms of experimental therapy for patients suffering from chronic spinal cord injury (SCI). However, for the enrollment process, there are different views on how the time period between injury and interventions should be determined. Herein, we sought to evaluate the impact of time-to-enrollment in chronic SCI clinical trials. A data set comprising 957 clinical studies from clinicalTrials.gov was downloaded and analyzed focusing on the eligibility criteria for post-injury time-to-enrollment. We also aggregated individual patient data from nine clinical trials of regenerative interventions for chronic SCI selected by a systematic literature search from 1990 to 2018. Characteristics of the studies were assessed and compared by dividing into three groups based on time-to-enrollment (group 1 ≤ 12 months, group 2 = 12-23 months and group 3 ≥ 24 months). In ClinicalTrials.gov registry, 445 trials were identified for chronic SCI where 87% (385) were unrestricted in the maximum post-injury time for trial eligibility. From systematic literature search, nine studies and 156 patients (group 1 = 30, group 2 = 55 and group 3 = 71) were included. The range of time-to-enrollment was 0.5 to 321 months in those studies. We also observed various degrees of motor and sensory improvement in between three time-to-enrollment groups. Our results indicate that enrolling wide ranges of time-to-enrollment in a group may present imprecise outcomes. Clinical trial designs should consider appropriate post-injury time frames to evaluate therapeutic benefit.

Numerous clinical trials are being conducted in the field of spinal cord injury (SCI). These trials are typically registered on ClinicalTrials.gov. The objective of this study was to identify the characteristics of the completed SCI trials and characterize the potential factors associated with publication. ClinicalTrials.gov database was queried for all the completed trials on patients with SCI. Baseline characteristics of the completed trials were assessed. The publication status of these trials was identified using PubMed or Google Scholar. The secondary and primary outcomes reported in the publication were then compared to the outcomes registered in ClinicalTrial.gov. Multivariable logistic regression analysis was performed to determine the characteristics associated with publication status and time to publication. A total of 457 of 1,061 trials on SCI were completed. Of those, 60% were ultimately published. Trials that had received funding from sources besides the NIH, private industries, or the federal government were more likely to remain unpublished. The median time to publish was three years, with larger trials taking a longer time. The median sample size for completed trials was 30. Assessment of mismatch rates in primary outcomes of published data to registered outcomes was 8.9%. In SCI trials, outcomes registered on ClinicalTrial.gov often matched published results. Additionally, sample size and funding source play a significant role in the publication rate of these trials. Published data represents a reliable source for clinicians, researchers, and patients; efforts to curb publication bias and reporting bias are paramount for implementing evidence-based practices and ensure proper scientific conduct.

OBJECTIVE Optimizing patient discharge after surgery has been shown to impact patient recovery and hospital/physician workflow and to reduce healthcare costs. In the current study, the authors sought to identify risk factors for nonroutine discharge after surgery for cervical myelopathy by using a national spine registry. METHODS The Quality Outcomes Database cervical module was queried for patients who had undergone surgery for cervical myelopathy between 2016 and 2018. Nonroutine discharge was defined as discharge to postacute care (rehabilitation), nonacute care, or another acute care hospital. A multivariable logistic regression predictive model was created using an array of demographic, clinical, operative, and patient-reported outcome characteristics. RESULTS Of the 1114 patients identified, 11.2% (n = 125) had a nonroutine discharge. On univariate analysis, patients with a nonroutine discharge were more likely to be older (age ≥ 65 years, 70.4% vs 35.8%, p < 0.001), African American (24.8% vs 13.9%, p = 0.007), and on Medicare (75.2% vs 35.1%, p < 0.001). Among the patients younger than 65 years of age, those who had a nonroutine discharge were more likely to be unemployed (70.3% vs 36.9%, p < 0.001). Overall, patients with a nonroutine discharge were more likely to present with a motor deficit (73.6% vs 58.7%, p = 0.001) and more likely to have nonindependent ambulation (50.4% vs 14.0%, p < 0.001) at presentation. On multivariable logistic regression, factors associated with higher odds of a nonroutine discharge included African American race (vs White, OR 2.76, 95% CI 1.38–5.51, p = 0.004), Medicare coverage (vs private insurance, OR 2.14, 95% CI 1.00–4.65, p = 0.04), nonindependent ambulation at presentation (OR 2.17, 95% CI 1.17–4.02, p = 0.01), baseline modified Japanese Orthopaedic Association severe myelopathy score (0–11 vs moderate 12–14, OR 2, 95% CI 1.07–3.73, p = 0.01), and posterior surgical approach (OR 11.6, 95% CI 2.12–48, p = 0.004). Factors associated with lower odds of a nonroutine discharge included fewer operated levels (1 vs 2–3 levels, OR 0.3, 95% CI 0.1–0.96, p = 0.009) and a higher quality of life at baseline (EQ-5D score, OR 0.43, 95% CI 0.25–0.73, p = 0.001). On predictor importance analysis, baseline quality of life (EQ-5D score) was identified as the most important predictor (Wald χ2 = 9.8, p = 0.001) of a nonroutine discharge; however, after grouping variables into distinct categories, socioeconomic and demographic characteristics (age, race, gender, insurance status, employment status) were identified as the most significant drivers of nonroutine discharge (28.4% of total predictor importance). CONCLUSIONS The study results indicate that socioeconomic and demographic characteristics including age, race, gender, insurance, and employment may be the most significant drivers of a nonroutine discharge after surgery for cervical myelopathy.

Background Gonadotroph pituitary adenoma (Gn-PA) may rarely cause ovarian hyperstimulation syndrome, leading to infertility in women, although this remains poorly described. Methods We present a quantitative systematic review including 2 patients from our institutional and 48 from the literature with Gn-PA causing ovarian hyperstimulation syndrome to thoroughly describe the clinical features and therapeutic outcomes from multidisciplinary aspects. Results The patients had a mean age of 31.5 years and a mean follicle-stimulating hormone level of 14.4 IU/L. Estradiol level was high in 82% of patients, at >350 pg/mL. The mean maximal adenoma diameter was 22 mm, with a Knosp grade ≥3 in 10 patients. Abdominal surgery preceded adenoma resection in 24 patients (48%). Among 25 patients for whom extent of resection was recorded, total adenoma resection was achieved in 12. Through a mean follow-up of 25 months, adenoma recurrence was observed in 5 patients, who were treated with re-resection (n = 2), radiation (n = 2), and medical therapy followed by bilateral oophorectomy (n = 1). Medical therapies were partially effective or ineffective, and adenoma shrinkage did not follow; gonadotropin-releasing hormone agonists/antagonists were partially effective in 20% of patients (2/10), dopamine agonists in 44% (8/18), and somatostatin analogues in 50% (1/2). Four experienced swelling of tumor/ovaries after gonadotropin-releasing hormone agonists/antagonists administration. Overall, chemical remission was obtained in 26 of 28 patients, normalization of ovaries in 25 of 27, and successful pregnancy in 12 of 14. Conclusions Adenoma resection is the main treatment, leading to reduction in ovarian size and biochemical remission, with a high likelihood of subsequent spontaneous pregnancy. Increased awareness of this rare condition may help avoid unnecessary abdominal procedures.

Objective To highlight the early experience of implementing a robotic spine surgery program at a three-site medical center, evaluating the impact of increasing experience on the operative time and number of procedures performed. Patients and Methods A retrospective chart review of patients undergoing robotic screw placement between September 4, 2018, and October 16, 2019, was conducted. Baseline characteristics as well as intraoperative and post-operative outcomes were obtained. Results For a total of 77 patients, the mean age (SD) was 55.7 years (11.5) and 49.4% (n=38) were female. A total of 402 screws were placed (384 pedicle screws, 18 cortical screws) using robotic guidance with a median of two operative levels (interquartile range [IQR], 1 to 2). Median (IQR) estimated blood loss was 100 mL (50 to 200 mL) and the median (IQR) operative time was 224 minutes (193 to 307 minutes). With accrual of surgical experience, operative time declined significantly (R=-0.39; P Conclusion Early experience at our institution using a spinal robot has demonstrated no requirement for postoperative screw revisions and no complications related to screw malposition. The increased operative times were reduced as the frequency of procedures increased. Moreover, procedural times diminished over a short period with a weekly increasing number of procedures.

BackgroundCT-guided biopsy is a commonly used diagnostic procedure for spinal lesions. This meta-analysis aims to investigate its diagnostic performance and complications, as well as factors influencing outcomes.MethodsA systematic review of the literature was performed to identify studies reporting outcomes of CT-guided biopsies for spinal lesions. Diagnostic yield (ie, the rate of procedures resulting in a specific pathological diagnosis) and diagnostic accuracy (ie, the rate of procedures resulting in the correct diagnosis) were the primary outcomes of interest. Complications following biopsy procedures were also included.ResultsThirty-nine studies with 3917 patients undergoing 4181 procedures were included. Diagnostic yield per procedure was 91% (95% CI 88% to 94%) among 3598 procedures. The most common reason for non-diagnostic biopsies was inadequacy of sample. No difference in diagnostic yield between different locations and between lytic, sclerotic, and mixed lesions was found. Diagnostic yield did not differ between procedures using ≤13G and ≥14G needles. Diagnostic accuracy per procedure was 86% (95% CI 82% to 89%) among 3054 procedures. Diagnostic accuracy among 2426 procedures that yielded a diagnosis was 94% (95% CI 92% to 96%). Complication rate was 1% (95% CI 0.4% to 1.9%) among 3357 procedures. Transient pain and minor hematoma were the most common complications encountered.ConclusionIn our meta-analysis of 39 studies reporting diagnostic performance and complications of CT-guided biopsy, we found a diagnostic yield of 91% and diagnostic accuracy of 86% with a complication rate of 1%. Diagnostic yield did not differ between different locations, between lytic, sclerotic and mixed lesions, and between wide- and thin-bore needles.

Purpose: While previous studies have suggested that preoperative embolization of hypervascular spinal metastases may alleviate intraoperative blood loss and improve resectability, trends and driving factors for choosing this approach have not been extensively explored. Therefore, we evaluated the trends and assessed the factors associated with preoperative embolization utilization for spinal metastatic tumors using a national inpatient database.Materials and Methods: The National Inpatient Sample database of the Healthcare Cost and Utilization Project was queried for patients undergoing surgical resection for spinal metastasis between January 1, 2005 and December 31, 2017. Patients undergoing preoperative embolization were identified; trends in the utilization of preoperative embolization were analyzed using the Cochran-Armitage test. Multivariable regression was conducted to assess factors associated with higher preoperative embolization utilization.Results: A total of 11,508 patients with spinal metastasis were identified; 105 (0.91%) underwent preoperative embolization. Of those 105 patients, 79 (75.24%) patients had a primary renal cancer, as compared to 1,732 (15.19%) of those who did not undergo preoperative embolization (P0.05). Trends in preoperative embolization indicated an increase of 0.16% (standard error: 0.024%, P

Minimally invasive surgery (MIS) of the spine has been associated with lower complication rates and improved patient-reported outcomes in recent studies. In this study, we aimed to investigate operative and postoperative outcomes associated with both surgical techniques in elderly patients.Patients who are 65 years old or older underwent either minimally invasive or open surgery for lumbar degenerative conditions. Patients with a nondegenerative cause such as infection or trauma were excluded from the analysis. Patient characteristics such as demographics and associated comorbidities as well as perioperative and postoperative complications were collected. Outcomes of interest were operative time, estimated blood loss (EBL), length of stay (LOS), readmissions, reoperations, and any complications.A total of 107 elderly patients were identified for this study, with a median age of 73.0 years. Demographics and comorbidities in both groups were similar in both groups. Univariate analysis yielded an MIS group with significantly lower EBL (P0.001), operative time (P 0.001), and LOS (P0.001). In multivariable analysis, EBL and LOS were found to be significantly lower in the MIS group (P = 0.02 and 0.001, respectively). Rates of complications, readmissions (no readmissions in MIS group), reoperations, and pain improvement also favored the MIS group and although they were not found to be significantly different between the 2 groups on univariate and multivariable analysis, the results trended toward significance.These findings suggest that minimally invasive spine surgery in the elderly is safe and may pose a lower risk of associated perioperative and postoperative complications with faster recovery time.

OBJECTIVEThe National Surgical Quality Improvement Program (NSQIP) and National Readmissions Database (NRD) are two widely used databases for research studies. However, they may not provide generalizable information in regard to individual institutions. Therefore, the objective of the present study was to evaluate 30-day readmissions following anterior cervical discectomy and fusion (ACDF) and posterior lumbar fusion (PLF) procedures by using these two national databases and an institutional cohort.METHODSThe NSQIP and NRD were queried for patients undergoing elective ACDF and PLF, with the addition of an institutional cohort. The outcome of interest was 30-day readmissions following ACDF and PLF, which were unplanned and related to the index procedure. Subsequently, univariable and multivariable analyses were conducted to determine the predictors of 30-day readmissions by using both databases and the institutional cohort.RESULTSAmong all identified risk factors, only hypertension was found to be a common risk factor between NRD and the institutional cohort following ACDF. NSQIP and the institutional cohort both showed length of hospital stay to be a significant predictor for 30-day related readmission following PLF. There were no overlapping variables among all 3 cohorts for either ACDF or PLF. Additionally, the national databases identified a greater number of risk factors for 30-day related readmissions than did the institutional cohort for both procedures.CONCLUSIONSOverall, significant differences were seen among all 3 cohorts with regard to top predictors of 30-day unplanned readmissions following ACDF and PLF. The higher quantity of significant predictors found in the national databases may suggest that looking at single-institution series for such analyses may result in underestimation of important variables affecting patient outcomes, and that big data may be helpful in addressing this concern.

Teaching hospitals are responsible for the training and education of residents and have been centers of research and advancement in an era of evidence-based medicine. Several studies have reported conflicting findings regarding the effects of teaching status on the outcomes of patients. In the present study, we aimed to identify the differences in surgical outcomes among patients who had undergone anterior cervical discectomy and fusion (ACDF) between teaching and nonteaching hospitals.We queried the National Inpatient Sample for 2012-2015. We identified patients with cervical degenerative disease who had undergone single-level ACDF using the International Classification of Disease, 9th revision, diagnosis and procedure codes. One-to-one propensity score matching was conducted, using appropriate and clinically relevant variables. Stepwise multivariable logistic regression was performed to assess the effect of teaching status on the outcomes of interest. Finally, a marginal effect analysis was conducted to compare the differences in admission costs stratified by teaching status within each insurance type.A total of 52,212 patients who had undergone elective ACDF from 2012 to 2015 were identified and matched, with 26,106 patients in each group. On multivariable regression, after adjusting for demographics and hospital characteristics, teaching hospitals were associated with greater odds of nonroutine discharge (odds ratio, 1.25; P0.001) and higher admission cost (coefficient, 414.31; P = 0.002). However, teaching status was not associated with inpatient mortality or morbidity. The marginal effect analysis results indicated that privately insured patients incurred greater costs in nonteaching hospitals.Our results have shown that patients undergoing ACDF at nonteaching hospitals had a greater odds of routine discharge and higher admission costs compared with those at teaching hospitals but similar outcomes in terms of inpatient mortality and morbidity.

The adoption of the transradial approach (TRA) has been increasing in popularity as a primary method to conduct both diagnostic and therapeutic interventions. As this technique gains broader acceptance and use within the neuroendovascular community, comparing its complication profile with a better-established alternative technique, the transfemoral approach (TFA), becomes more important. This study aimed to evaluate the safety of TRA compared with TFA in patients undergoing diagnostic, therapeutic, and combined neuroendovascular procedures.A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of PubMed and other databases was conducted for studies from all available dates. To compare TRA and TFA, we performed an indirect meta-analysis between studies that mentioned the complications of the procedures.Our search yielded 532 studies, of which 108 met full inclusion criteria. A total of 54,083 patients (9137 undergoing TRA and 44,946 undergoing TFA) were included. Access site complication rate was lower in TRA (1.62%) compared with TFA (3.31%) (P0.01). Neurological complication rate was lower in TRA (1.64%) compared with TFA (3.82%) (P = 0.02 and P0.01, respectively). Vascular spasm rate was higher in TRA (3.65%) compared with TFA (0.88%) (P0.01). Wound infection complication rate was higher in TRA (0.32%) compared with TFA (0.2%) (P0.01).Patients undergoing TFA are significantly more likely to experience access site complications and neurological complications compared with patients undergoing TRA. Patients undergoing TRA are more likely to experience complications such as wound infections and vascular spasm.

BACKGROUND: The utility of intraoperative neurophysiological monitoring (IONM) is well established for some spine surgeries (eg, intramedullary tumor resection, scoliosis deformity correction), but its benefit for most degenerative spine surgery, including anterior cervical discectomy and fusion (ACDF), remains debated. National datasets provide “big data” approaches to study the impact of IONM on spine surgery outcomes; however, if administrative coding in these datasets misrepresents actual IONM usage, conclusions will be unreliable. The objective of this study was to compare estimated rates (administrative coding) to actual rates (chart review) of IONM for ACDF at our institution and extrapolate findings to estimated rates from 2 national datasets. METHODS: Patients were included from 3 administrative coding databases: the authors’ single institution database, the Nationwide Inpatient Sample (NIS), and the National Surgical Quality Improvement Program (NSQIP). Estimated and actual institutional rates of IONM during ACDF were determined by administrative codes (International Classification of Diseases [ICD] or Current Procedural Terminology [CPT]) and chart review, respectively. National rates of IONM during ACDF were estimated using the NIS and NSQIP datasets. RESULTS: Estimated institutional rates of IONM for ACDF were much higher with CPT than ICD coding (73.2% vs 16.5% in 2019). CPT coding for IONM better approximated actual IONM usage at our institution (74.6% in 2019). Estimated IONM utilization rates for ACDF in national datasets varied widely: 0.76% in CPT-based NSQIP and 18.4% in ICD-based NIS. CONCLUSIONS: ICD coding underestimated IONM usage during ACDF at our institution, whereas CPT coding was more accurate. Unfortunately, the CPT-based NSQIP is nearly devoid of IONM codes, as it has not been a collection focus of that surgical registry. ICD-based datasets, such as the NIS, likely fail to accurately capture IONM usage. Multicenter and/or national datasets with accurate IONM utilization data are needed to inform surgeons, insurers, and guideline authors on whether IONM has benefit for various spine surgery types. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: Currently available national databases based on administrative codes do not accurately reflect IONM usage.

Animal study. Umbilical cord-derived mesenchymal stem cells (UC-MSCs) have recently been shown to hold great therapeutic potential for spinal cord injury (SCI). However, majority of the studies have been done using human cells transplanted into the rat with immunosuppression; this may not represent the outcomes that occur in humans. Herein, we present the therapeutic effect of using rat UC-MSCs (rUC-MSC) without immunosuppression in a rat model of SCI. Mayo Clinic, Rochester, MN, USA. Twelve female rats were randomly divided into two groups, control, and rUC-MSC group, and then subjected to a T9 moderate contusion SCI. Next, 2 × 106 rUC-MSCs or ringer-lactate solution were injected through the tail vein at 7 days post injury. Rats were assessed for 14 weeks by an open-field Basso, Beattie, and Bresnahan (BBB) motor score as well as postmortem quantification of axonal sparing/regeneration, cavity volume, and glial scar. Animals treated with rUC-MSCs were found to have early and sustained motor improvement (BBB score of 14.6 ± 1.9 compared to 10.1 ± 1.7 in the control group) at 14 weeks post injury (mean difference: 4.55, 95% CI: 2.04 to 7.06; p value

Background Outpatient spine surgery has been increasingly used recently owing to its perceived cost benefits and its ability to offset the volume from the inpatient setting. However, the 30-day outcomes of outpatient posterior lumbar fusion (PLF) for low-risk patients have not been extensively studied. In the present study, we assessed the 30-day outcomes of outpatient PLF surgery for low-risk patients using a national surgical quality registry. Methods For the present study, we queried the American College of Surgeons National Surgical Quality Improvement Program for patients who had undergone PLF from 2009 to 2016. Only patients with an American Society of Anesthesiologists grade of 1–2 were included. The 30-day outcomes, including any complications, readmissions, and reoperations, were studied using multivariable logistic regression after adjustment for an array of patient-specific factors. Results A total of 29,830 cases were identified. Of these 29,830 cases, 1016 (3.4%) had been performed as outpatient cases and 28,814 (96.6%) as inpatient. After adjusting for an array of patient-specific factors, we did not find any significant association between the procedure setting and complication rate (odds ratio [OR], 0.8; 95% confidence interval [CI], 0.6–1.1; P = 0.15) or 30-day readmission rate (OR, 0.9; 95% CI, 0.6–1.4; P = 0.76). Patients undergoing outpatient PLF were more likely to have required a 30-day reoperation (OR, 1.6; 95% CI, 1.1–2.4; P = 0.02). Conclusion Our results have demonstrated that the 30-day outcomes of patients who have undergone outpatient PLF might be comparable to those of patients who have undergone PLF in an inpatient setting. However, outpatient surgery might be associated with a greater overall reoperation rate.

OBJECTIVEPlatelet-rich plasma (PRP) is a biological agent obtained by centrifuging a sample of blood and retrieving a high concentration of platelets and plasma components. The concentrate is then stimulated for platelet secretion of various growth factors and cytokines. Although it is not widely used in clinical practice, its role in augmenting bony union among patients undergoing spinal fusion has been assessed in several clinical studies. The objective of this study was to perform a systematic review and meta-analysis of the existing literature to determine the efficacy of PRP use in spinal fusion procedures.METHODSA comprehensive literature search was conducted using PubMed, Scopus, and EMBASE for studies from all available dates. From eligible studies, data regarding the fusion rate and method of assessing fusion, estimated blood loss (EBL), and baseline and final visual analog scale (VAS) scores were collected as the primary outcomes of interest. Patients were grouped by those undergoing spinal fusion with PRP and bone graft (PRP group) and those only with bone graft (graft-only group).RESULTSThe literature search resulted in 207 articles. Forty-five full-text articles were screened, of which 11 studies were included, resulting in a meta-analysis including 741 patients. Patients without PRP were more likely to have a successful fusion at the last follow-up compared with those with PRP in their bone grafts (OR 0.53, 95% CI 0.34–0.84; p = 0.006). There was no statistically significant difference with regard to change in VAS scores (OR 0.00, 95% CI −2.84 to 2.84; p > 0.99) or change in EBL (OR 3.67, 95% CI −67.13–74.48; p = 0.92) between the groups.CONCLUSIONSThis study found that the additional use of PRP was not associated with any significant improvement in patient-reported outcomes and was actually found to be associated with lower fusion rates compared with standard grafting techniques. Thus, PRP may have a limited role in augmenting spinal fusion.

Spinal cord injury (SCI) is a devastating condition with limited pharmacological treatment options to restore function. Regenerative approaches have recently attracted interest as an adjuvant to current standard of care. Adipose tissue-derived (AD) mesenchymal stem cells (MSCs) represent a readily accessible cell source with high proliferative capacity. The CELLTOP study, an ongoing multidisciplinary phase 1 clinical trial conducted at Mayo Clinic (ClinicalTrials.gov Identifier: NCT03308565), is investigating the safety and efficacy of intrathecal autologous AD-MSCs in patients with blunt, traumatic SCI. In this initial report, we describe the outcome of the first treated patient, a 53-year-old survivor of a surfing accident who sustained a high cervical American Spinal Injury Association Impairment Scale grade A SCI with subsequent neurologic improvement that plateaued within 6 months following injury. Although he improved to an American Spinal Injury Association grade C impairement classification, the individual continued to be wheelchair bound and severely debilitated. After study enrollment, an adipose tissue biopsy was performed and MSCs were isolated, expanded, and cryopreserved. Per protocol, the patient received an intrathecal injection of 100 million autologous AD-MSCs infused after a standard lumbar puncture at the L3-4 level 11 months after the injury. The patient tolerated the procedure well and did not experience any severe adverse events. Clinical signs of efficacy were observed at 3, 6, 12, and 18 months following the injection in both motor and sensory scores based on International Standards for Neurological Classification of Spinal Cord Injury. Thus, in this treated individual with SCI, intrathecal administration of AD-MSCs was feasible and safe and suggested meaningful signs of improved, rather than stabilized, neurologic status warranting further clinical evaluation.

Surgical procedures, such as spinal fusion and disk replacement, are commonly used for treatment following failure of conservative treatment in degenerative spine disease. However, there is growing consensus that currently available surgical technologies may have long-term inefficacy for successful management. Intervertebral disk degeneration is the most common manifestation of degenerative spine disease, hence, replacement/repair of this tissue is an important component of surgical treatment. Restoration of spinal alignment and preservation of natural kinematics is also essential to a good outcome. This article reviews novel intervertebral implant technologies that have the potential to significantly impact elective spine surgery for degenerative spine disease.

Given the potential injury to the spinal cord and the nerve roots during the surgery and the necessity of minimal spinal cord manipulation during surgery, minimally invasive surgical techniques have emerged as alternatives to conventional open surgery in resection of ID-EM tumors.An electronic database search was conducted, and the review was carried out according to PRISMA guidelines and recommendations. Inclusion criteria were as follows; (i) comparative studies of MIS vs OS; (ii) studies reporting outcomes for patients undergoing surgery for ID-EM tumors. Variables collected were patient demographics, estimated blood loss (EBL), mean operative time, length of stay, complications, extent of tumor resection.The search identified a total of 275 studies. After the selection criterion was applied 7 comparative studies were included. A total of 302 patients were included in the analysis with 149 (49.3%) of them undergoing MIS and 153 of them (50.7%) undergoing open surgery. EBL, operative time, and LOS were significantly lower in MIS group (p 0.0001, p 0.0001, and p = 0.0002 respectively). Two groups were similar with regards to the rates of surgical complications, medical complications and gross total resection. The most common surgical complication was CSF leak (52.3% of all complications).Results of this meta-analysis show a significant reduction in EBL, operative time, and length of stay with MIS while proving safe and preserving high rates of gross-total resection. The findings suggest that the minimally invasive spine surgery may serve as a beneficial alternative for patients undergoing spine surgery for ID-EM tumors of the spinal cord.

PurposeA chromosomal 1p/19q codeletion was included as a required diagnostic component of oligodendrogliomas in the 2016 World Health Organization (WHO) classification of central nervous system tumors. We sought to evaluate disparities in reported testing for 1p/19q codeletion among oligodendroglioma and oligoastrocytoma patients before and after the guidelines.MethodsThe National Cancer Database (NCDB) was queried for patients with histologically-confirmed WHO grade II/III oligodendroglioma or oligoastrocytoma from 2011-2017. Adjusted odds of having a reported 1p/19q codeletion test for patient- and hospital-level factors were calculated before (2011-2015) and after (2017) the guidelines. The adjusted likelihood of receiving adjuvant treatment (chemotherapy and/or radiotherapy) based on reported testing was also evaluated.ResultsOverall, 6,404 patients were identified. The reported 1p/19q codeletion testing rate increased from 45.8% in 2011 to 59.8% in 2017. From 2011-2015, lack of insurance (OR 0.77; 95% CI 0.62-0.97;p=0.025), lower zip code-level educational attainment (OR 0.62; 95% CI 0.49-0.78;pConclusionDespite the 2016 WHO guidelines, disparities in reported 1p/19q codeletion testing by geographic region persisted while new disparities in race/ethnicity were identified, which may influence oligodendroglioma and oligoastrocytoma patient management.

IntroductionManagement approaches for intracranial atherosclerosis include medical, surgical, or endovascular treatment. Among endovascular treatments, recent studies have stated that submaximal angioplasty (SA) may offer considerable benefits and be a promising alternative to aggressive medical therapyand/or stenting in the treatment of intracranial atherosclerotic disease (ICAD).ObjectiveTo investigate the rates of periprocedural and long-term cerebrovascular accidents, mortality, and restenosis in patients with symptomatic ICAD who were treated with SA.MethodsAn electronic database search was performed for relevant studies that reported clinical outcomes of patients with ICAD following SA. Outcomes of interest were incidence of transient ischemic attack, intracerebral hemorrhage, stroke, and mortality in the periprocedural period and at 1 year. The periprocedural period was defined as the time from SA until 30 days after the procedure. Technical success and restenosis rates after the procedure were also analyzed.ResultsA total of 19 studies with 777 patients were identified. The technical success rate was 93% (95% CI 85% to 98%). The incidence of 30-day and 1-year stroke (all types) was 3% (95% CI 1% to 5%) and 5% (95% CI 4% to 8%), respectively. Thirty-day and 1-year mortality was found to be 1% (95% CI 0% to 2%) and 2% (95% CI 0% to 4%), respectively. The combined incidence of stroke or death was 5% (95% CI 3% to 8%) at 30 days, and 9% (95% CI 7% to 12%) at 1 year.ConclusionThe findings suggest that SA might be a promising alternative treatment in the treatment of symptomatic ICAD due to its favorable technical profile, periprocedural safety, and long-term efficacy. A randomized clinical trial is warranted to compare the safety and efficacy of SA with 'gold standard' medical treatment.

BACKGROUND Postoperative readmissions are a significant driver of variation in bundled care costs associated with cervical spine surgery. OBJECTIVE To determine the factors predicting the cost of readmission episodes following elective anterior cervical discectomy and fusion (ACDF). METHODS We queried the Healthcare Cost and Utilization Project Nationwide Readmissions Database for patients undergoing elective ACDF during 2012 to 2015. Multivariable linear regression was performed to establish the factors associated with the cost of each 30-/90-d readmission episode. RESULTS A total of 139 877 and 113 418 patients met inclusion criteria for the evaluation of 30- and 90-d readmissions, respectively. Among these, the national rates of 30- and 90-d readmission after an elective ACDF were 3% and 6%, respectively. The median cost of a 30- and 90-d readmission episode was $6727 (IQR: $3844-$13 529) and $8507 (IQR: $4567-$17 460), respectively. Relative predictor importance analysis revealed that the number of procedures at index admission (IA), length of stay at IA, and time elapsed between index surgical admission and readmission were the top predictors of both 30- and 90-d readmission costs (all P

Objective The National Cancer Database (NCDB) and the SEER (Surveillance Epidemiology and End Results) program are the 2 largest cancer registries in the United States. However, considerable differences exist between them regarding the sampling frame as well as the participating facility characteristics. In this study, NCDB and SEER are compared for primary central nervous system (CNS) tumors with the aims of discussing the implications for researchers and evaluating the generalizability of both databases. Methods Patients with primary CNS (brain and spinal cord) tumors from 2004 to 2013 were identified using the International Classification of Diseases for Oncology, Third Edition topographic codes. Patient demographics, tumor characteristics, and treatment-related variables were compared between the 2 databases using standardized differences, with values >0.1 denoting statistical significance. Results A total of 588,534 primary brain tumor (NCDB, 416,162; SEER, 172,372) and 34,827 primary spinal cord tumor (NCDB, 26,602; SEER, 8225) cases were identified. We found significant differences regarding age (sd. diff., 0.16 for brain; 0.13 for spinal cord), and Hispanic origin (sd. diff., 0.34 for brain; 0.61 for spinal cord). For NCDB and SEER patients, estimated 5-year overall survival was 59% and 64%, respectively. Conclusions Analysis of 623,361 patients with primary CNS tumors, which are identified using both the NCDB and SEER databases, showed significant differences in age, histopathologic classification of tumors, tumor behavior, and treatment of tumors between 2 databases. Overall, the differences observed between 2 databases provide helpful points for the researchers who would like to use NCDB or SEER. These observations should be taken into account when researchers design studies using these databases and discuss the generalizability of their findings.

Background Chordomas are slow-growing but locally invasive tumors. The standard of care consists of surgical resection and radiotherapy (RT) when complete resection is not possible. The reported data has reached equivocal results regarding the effect of adding RT to increase patient survival. We investigated the effect of adjuvant RT on patient survival. Methods The National Cancer Database was queried for patients with a diagnosis of sacral and vertebral column chordoma from 2004 to 2010. The primary outcome was overall survival, which was assessed using Kaplan-Meier plots. Cox proportional hazards were performed to evaluate the effect of each treatment modality on survival after adjusting for an array of patient demographics, facility type, and tumor characteristics. Results The data from 282 patients with chordoma were analyzed; 209 patients (74.1%) had undergone gross total resection (GTR) alone. The median follow-up period for the GTR alone and GTR plus RT groups was 63.4 and 67.6 months, respectively. The mean survival was comparable between patients receiving GTR alone and those receiving adjuvant RT, for both sacral (7.7 and 6.9 years, respectively; P = 0.56) and vertebral chordoma (8.8 and 6.2 years, respectively; P = 0.59). Using Cox proportional hazards, we found that compared with GTR alone, GTR plus adjuvant RT did not add any significant survival benefit, for patients with either sacral chordoma (hazard ratio, 0.55; P = 0.43) or vertebral chordoma (hazard ratio, 7.29; P = 0.23). Conclusion Using data from a large national cancer registry, we found that the available evidence is not enough to suggest that the addition of RT offers a survival benefit for patients with sacral and spinal chordoma after GTR. Given the non-negligible complications associated with RT, the balance of benefits and risks must be considered during preoperative tailoring of the treatment decisions.

The majority of spinal meningiomas are grade I tumors, as defined by World Health Organization (WHO) classification making atypical (grade II) or anaplastic (grade III) tumors extremely rare lesions to encounter in clinical practice. Here, we present our institutional experience of management of grade II and III spinal meningiomas. Following IRB approval, we queried all available institutional electronic medical records for patients undergoing surgical resection of pathology-proven spinal meningiomas, with further review of patients with grade II and III. Variables of interest included age, sex, histological type, tumor size, symptoms at baseline, treatment characteristics, symptom resolution at the last follow-up, recurrence, NF-2 status, concurrent intracranial meningioma, and mortality. Kaplan Meier curves were constructed to study time to progression/recurrence. A total of 188 patients undergoing surgical resection of spinal meningioma between 1988 and 2018 were identified. Among those, 172 (91.5%) patients had grade I meningioma and 16 (8.5%) patients had high grade meningiomas [grade II (15) and III (1)]. Over a median (IQR) follow-up of 8.0 years (5.1–13.0), mortality and recurrence rates were 18.8% (n = 3) and 47.1% (n = 8), respectively. In univariate analysis, adjuvant radiotherapy and thoracic segment involvement were associated with lower rates of recurrence while male sex was associated with a higher rate of recurrence. Results showed variations in clinical outcomes for patients with high grade spinal meningiomas, especially the recurrence. Adjuvant radiotherapy and thoracic segment involvement was associated with lower rates of recurrence while recurrence ocurred at a higher rate in males.

OBJECTIVE Hybrid surgery (HS) is the combination of anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) at different levels in the same operation. The aim of this study was to investigate perioperative variables, 30-day postoperative outcomes, and complications of HS in comparison with those of CDA and ACDF. METHODS The authors queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry for patients who underwent multilevel primary HS, CDA, and ACDF for degenerative disc disease from 2015 to 2019. The authors compared these three operations in terms of 30-day postoperative outcomes, specifically readmission and reoperation rates, discharge destination, and complications. RESULTS This analysis included 439 patients who underwent HS, 976 patients who underwent CDA, and 27,460 patients who underwent ACDF. Patients in the HS and CDA groups were younger, had fewer comorbidities, and myelopathy was less often the indication for surgery compared with patients who underwent ACDF. For the HS group, the unplanned readmission rate was 0.7%, index surgery–related reoperation rate was 0.3%, and nonroutine discharge rate was 2.1%. Major and minor complications were also rare, with rates of 0.2% for each. The mean length of stay in the HS group was 1.5 days. The association of HS with better outcomes in univariate analysis was not evident after adjustment for confounding factors. CONCLUSIONS The authors found that HS was noninferior to ACDF and CDA in terms of early postoperative outcomes among patients treated for degenerative disc disease.

Introduction: Several clinical trials evaluating the efficacy of a carotid revascularization procedure excluded patients above age 80. In the current study, we sought to assess the differences in characteristics of octogenarians undergoing carotid endarterectomy (CEA) and carotid artery stenting (CAS) for carotid stenosis using “real-world” data from a national surgical quality registry. Methods: The National Surgical Quality Improvement Program (NSQIP) targeted datasets for CEA and CAS were queried for patients aged ≥80 years between 2012-2018. Results: We identified 5,814 patients undergoing CEA and 189 patients undergoing CAS. Patients in the CAS group were more likely to be ≥90 years (p=0.004), diabetic (p=0.04), had a history of CHF (p=0.012) and a bleeding-disorder (p80%-100%) of the ipsilateral carotid, while 13(14.5%) in the CAS group and 302 (11%) in the CEA group had severe or total stenosis of contralateral carotid. Among symptomatic patients, 58(61.7%) in the CAS group and 1527 (57.5%) in the CEA group were found to have severe/total stenosis of the ipsilateral-carotid, while 12(12.8%) in the CAS group and 208(7.8%) in the CEA group were found to have severe/total occlusion of the contralateral carotid. In the carotid endarterectomy group, 12.2% (n=711) underwent CEA-alone, 44.3% (n=2,575) CEA with angioplasty, 29.9% (n=1,737) CEA with angioplasty and shunt, 2.9% (n=166) CEA with shunt and 10.7%(n=166) eversion CEA. In the CAS group, 52.4%(n=99) underwent CAS with a single tapered stent, 29.1%(n=55) CAS with single tapered stent with CPD, 11.1%(n=21) single straight stent with CPD and 1.6%(n=3) a single straight stent alone. Conclusion: These analyses from real-world data show that there may be some differences in demographic and comorbid characteristics between octogenarians undergoing CAS and CEA.

Introduction: Due to their exclusion from most clinical trials, outcomes of carotid revascularization via a carotid endarterectomy (CEA) or carotid artery stenting (CAS) among octogenarians are not well studied. Herein, we present analysis of thirty-day stroke and mortality of patients aged ≥ 80 using real-world data from a national surgical quality registry. Methods: The National Surgical Quality Improvement Program (NSQIP) targeted dataset for CEA and CAS was queried for patients aged ≥ 80 undergoing CEA and CAS between 2012-2018. Results: A total of 94 and 2,656 patients aged ≥ 80 with symptomatic carotid stenosis undergoing CAS and CEA (respectively) were identified. Patients in the CAS group were more likely to be over 90 (p=0.006). Patients in the CAS group were more likely to have high-risk anatomy (p Conclusion: Real world analysis from a surgical quality registry show that both CAS and CEA are associated with optimal 30-day outcomes among octogenarians with symptomatic carotid stenosis.

Background: Chordomas are rare tumors that arise from notochordal remnants. Although maximal safe resection is the preferred initial management, radiotherapy is used in the adjuvant setting or primarily in nonsurgical candidates. Carbon ion radiotherapy (CIRT), as an alternative to surgery alone or conventional radiotherapy modalities, has shown promising results to date. Methods: Baseline and tumor-related characteristics from two institutional cohorts were collected for patients diagnosed with sacral chordomas. Univariable logistic regression was performed to evaluate the association between treatment type and oncologic and toxicity outcomes. Overall survival (OS) and progression-free survival were estimated using the Kaplan-Meier method and compared using the Cox proportional hazards model. The National Cancer Database (NCDB) was also queried for sacral chordoma patients and included in OS analyses. Additionally, a comparison of cost between surgery and CIRT therapy was performed. Findings: A total of 919 patients were included in the study. Comparison of the institutional cohort (en bloc resection) to CIRT showed similar oncologic and toxicity outcomes, despite larger tumors in the CIRT group. The CIRT group experienced lower rates of peripheral motor neuropathy (OR: 0.13 [95% CI 0.04-0.40], p

Aim Anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) are commonly employed cervical spine procedures for degenerative cervical spine pathology. However, patients may require a revision procedure, most commonly due to recurrence of same-level pathology, adjacent segment disease or hardware related complications. In the current study, we sought to utilize a national surgical quality registry to compare 30-day quality outcomes between repeat ACDF and CDA Material and Methods: The National Surgical Quality Improvement Project (NSQIP) Participant User Files (PUF) for the years 2005- 2018 was queried for patients undergoing repeat ACDF and CDA using current procedural terminology (CPT) and international classification of disease (ICD)-9th version codes. We compared demographic and baseline clinical characteristics, operative characteristics and 30-day readmissions, reoperations, and complications between the two groups. We also performed multivariable analyses to assess the impact of repeat procedure type on outcomes of interest. Results A total of 3,957 patients were identified, of which 182 patients underwent a revision/removal of arthroplasty while 3,775 patients underwent revision or removal of fusion. Up to 4.6% patients (n=179) in the repeat ACDF group had a complication, compared to 0.5% (n=1) in the CDA group. The 30-day readmission rate was found to be similar between the two groups (repeat-ACDF: 3.8% (n=145), vs repeat-CDA: 2.2% (n=4); p=0.23). Similarly, the 30-day reoperation rate was also not found to be different between the two groups (repeat-ACDF: 3.9% (n=149) vs repeat-CDA: 2.7% (n=5);p=0.39). On multivariable analysis, removal or revision ACDF was only found to be significantly associated with an increased risk of 30-day complications (OR: 8.00, 95% CI: 1.07-59.79, p=0.04). Conclusion Repeat ACDF or repeat CDA can be performed safely and are associated with optimal 30-day outcomes, comparable to those for index procedures. However, patients undergoing revision ACDF, compared to those undergoing revision CDA may be slightly more likely to have a complication.

Introduction Poor bone health can create challenges in management which are amplified for patients undergoing spinal fusion. Although previously shown to improve outcomes postoperatively, the impact of preoperative teriparatide use on long-term complications remains unclear. In this study, we investigated the complication rates within two years of surgery for osteoporotic and osteopenic patients using teriparatide prior to lumbar fusion procedures. Methods Patients with poor bone health undergoing any lumbar fusion surgery at a single institution between 2008 and 2018 were identified and subsequently divided into two groups as teriparatide and non-teriparatide group. Baseline demographics, patient and surgery related factors, and two-year complications were collected through a retrospective chart review. Multivariable logistic regression was performed to evaluate the association between teriparatide usage and development of any related postoperative complication. Results A total of 42 and 114 patients were identified for the teriparatide and non-teriparatide groups, respectively. The median age (IQR) for the teriparatide group was 62 years (55.8−68.8), while the non-teriparatide group had a median (IQR) age of 70 years (64−75.8). Overall, there were no statistically significant differences in terms of individual complications between the groups. However, on adjusted regression analysis, teriparatide use was associated with significantly lower odds of related complications for lumbar fusion patients (p = 0.049). Conclusion Teriparatide use prior to lumbar fusion procedures resulted in reduced rate of osteoporosis-related complications within two years postoperatively. Results suggest improved outcomes might be seen in patients with osteopenia and osteoporosis when pre-treating with teriparatide.

Viral infections have been associated with the deleterious damage to nervous system resulting in impairment of the central nervous system (CNS) as late sequalae infections. Since the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), several studies have reported patients developing adverse neurological signs and symptoms. Like the outbreak of severe acute respiratory syndrome (SARS) in 2003, the recent outbreak has undermined the norm of the nervous system. This review will summarize the possible mechanism of neurological manifestations, the clinical presentations of patients with such symptoms secondary to SARS coronaviruses, and the prospective role of neurology and neurosurgery practice in managing these symptoms in the current climate.

OBJECTIVE The impact of the type of pain presentation on outcomes of spine surgery remains elusive. The aim of this study was to assess the impact of predominant symptom location (predominant arm pain vs predominant neck pain vs equal neck and arm pain) on postoperative improvement in patient-reported outcomes. METHODS The Quality Outcomes Database cervical spine module was queried for patients undergoing 1- or 2-level anterior cervical discectomy and fusion (ACDF) for degenerative spine disease. RESULTS A total of 9277 patients were included in the final analysis. Of these patients, 18.4% presented with predominant arm pain, 32.3% presented with predominant neck pain, and 49.3% presented with equal neck and arm pain. Patients with predominant neck pain were found to have higher (worse) 12-month Neck Disability Index (NDI) scores (coefficient 0.24, 95% CI 0.15–0.33; p < 0.0001). The three groups did not differ significantly in odds of return to work and achieving minimal clinically important difference in NDI score at the 12-month follow-up. CONCLUSIONS Analysis from a national spine registry showed significantly lower odds of patient satisfaction and worse NDI score at 1 year after surgery for patients with predominant neck pain when compared with patients with predominant arm pain and those with equal neck and arm pain after 1- or 2-level ACDF. With regard to return to work, all three groups (arm pain, neck pain, and equal arm and neck pain) were found to be similar after multivariable analysis. The authors’ results suggest that predominant pain location, especially predominant neck pain, might be a significant determinant of improvement in functional outcomes and patient satisfaction after ACDF for degenerative spine disease. In addition to confirmation of the common experience that patients with predominant neck pain have worse outcomes, the authors’ findings provide potential targets for improvement in patient management for these specific populations.

Expandable cages have been increasingly used in cervical and lumbar reconstructions; however, there is a paucity in the literature on how they compare with traditional nonexpandable cages in the cervical spine. We present a systematic review and meta-analysis, comparing the clinical and radiologic outcomes of expandable versus nonexpandable corpectomy cage use in the cervical spine.A database search identified studies detailing the outcomes of expandable and nonexpandable titanium cage use in the cervical spine. These studies were screened using the PRISMA protocol. Fixed-effects and random-effects models were used with a 95% confidence interval. Two analyses were carried out for each outcome: one including all studies and the other including only studies reporting on exclusively 1-level and 2-level cases.Forty-one studies were included. The mean change in segmental lordosis was significantly greater in expandable cages (all, 6.72 vs. 3.69°, P0.001; 1-level and 2-level, 6.81° vs. 4.31°, P0.001). The mean change in cervical lordosis was also significantly greater in expandable cages (all, 5.71° vs. 3.11°, P = 0.027; 1-level and 2-level, 5.71° vs. 2.07°, P = 0.002). No significant difference was found between the complication rates (all, P = 0.43; 1-level and 2-level, P = 0.94); however, the proportion of revisions was significantly greater in expandable cages (all, 0.06 vs. 0.02, P = 0.03; 1-level and 2-level, 0.08 vs. 0.01, P = 0.017).The use of expandable cages may carry a modest improvement in radiologic outcomes compared with nonexpandable cages in the cervical spine; however, they may also lead to a higher rate of revisions based on our analyses.

Background Intraoperative vascular injuries in the cervical spine are rare, but carry significant morbidity and mortality when they do occur. There is a need to better characterize the risk of vertebral artery injury (VAI) after posterior C1-C2 fusion. The aim of this study was to investigate the rate of VAI in patients undergoing posterior C1-C2 cervical fusion. Methods An electronic database search was performed to identify studies that reported rates of VAI following posterior cervical fusion at C1-C2 level. Patient-specific risk factors, surgical indication, surgical technique, and other data were collected for each study. Forest plots were created to outline the pooled ratios of VAI in the literature. Results Eleven studies with 773 patients were identified. Mean age of patients was 48.47 years (range, 6–78 years), and most patients were female (61.7%, n = 399). Trauma was the most frequent indication for surgery (18.8%, n = 146), followed by inflammatory processes affecting the vertebrae (13.2%, n = 102). The rate of VAI per patient was 2% (95% confidence interval = 1%–4%) among 773 patients, while injury rate per screw was 1% (95% confidence interval = 0%–2%) among 2238 screws placed. Conclusions The rate of VAI after C1-C2 posterior cervical fusion was found to be 2% for each operated patient and 1% for each screw placed.

Frailty is an increasingly studied tool for preoperative risk stratification, but its prognostic value for anterior cervical discectomy and fusion (ACDF) patients is unclear. We sought to evaluate the association of the 5-item modified Frailty Index (5i-mFI) with 30-day adverse outcomes following ACDF and its predictive performance compared with other common metrics.The National Surgical Quality Improvement Program was queried from 2016-2018 for patients undergoing elective ACDF for degenerative diseases. Outcomes of interest included 30-day complications, extended length of stay (LOS), non-home discharge, and unplanned readmissions. Unadjusted/adjusted odds ratios were calculated. The discriminatory performance of the 5i-mFI compared with age, American Society of Anesthesiologists (ASA) classification, and body mass index was computed using the area under the receiver operating characteristic curve (AUC).A total of 23,754 patients were identified. On adjusted analysis, an index of 1 was significantly associated with extended LOS, non-home discharge, and unplanned readmissions (P0.001, P = 0.023, P = 0.003, respectively), but not complications (all P0.05). An index ≥2 was significantly associated with each outcome (all P0.001). The 5i-mFI was found to have a significantly higher AUC than body mass index for each outcome, a similar AUC compared with ASA classification and age for complications and unplanned readmissions, and a significantly lower AUC than ASA classification and age for extended LOS and non-home discharge.The 5i-mFI was found to be significantly associated with 30-day adverse outcomes following ACDF but had similar or lesser predictive performance compared with more universally available and easily implemented metrics, such as ASA classification and age.