The April 2023 Spine Roundup³⁶⁰ looks at: Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy; Spine surgical site infections: a single debridement is not enough; Lenke type 5, anterior, or posterior: systematic review and meta-analysis; Epidural steroid injections and postoperative infection in lumbar decompression or fusion; Noninferiority of posterior cervical foraminotomy versus anterior cervical discectomy; Identifying delays to surgical treatment for metastatic disease; Cervical disc replacement and adjacent segment disease: the NECK trial; Predicting complication in adult spine deformity surgery.

Aims

The optimal procedure for the treatment of ossification of the posterior longitudinal ligament (OPLL) remains controversial. The aim of this study was to compare the outcome of anterior cervical ossified posterior longitudinal ligament en bloc resection (ACOE) with posterior laminectomy and fusion with bone graft and internal fixation (PTLF) for the surgical management of patients with this condition.

The February 2023 Spine Roundup³⁶⁰ looks at: S2AI screws: At what cost?; Just how good is spinal deformity surgery?; Is 80 years of age too late in the day for spine surgery?; Factors affecting the accuracy of pedicle screw placement in robot-assisted surgery; Factors causing delay in discharge in patients eligible for ambulatory lumbar fusion surgery; Anterior cervical discectomy or fusion and selective laminoplasty for cervical spondylotic myelopathy; Surgery for cervical radiculopathy: what is the complication burden?; Hypercholesterolemia and neck pain; Return to work after surgery for cervical radiculopathy: a nationwide registry-based observational study.

Aims

The aim of this paper is to describe the impact of COVID-19 on spine surgery services in a district general hospital in England in order to understand the spinal service provisions that may be required during a pandemic.

Aims

The aim of this study was to characterize the relationship between pre- and postoperative opioid use among patients undergoing common elective orthopaedic procedures

Introduction. Aim was to compare the functional outcome of anterior cervical decompression and fusion (ACDF) with stand-alone tricotical iliac crest auto graft verses stand-alone PEEK cage. Material and methods. Prospectively collected data of 60 patients in each group was compared. Results. There was statistically significant improvement noted in postoperative Modified Japanese Orthopaedic Association scores at one year follow up for both the groups. Perioperative complications were significantly higher in the autograft group when compared with the PEEK cage group. Among the 94 patients who underwent single level non-instrumented ACDF only 4 (4.25%) had psuedoarthrosis. The fusion rate for single level ACDF in our series was 95.74%. Among the 25 patients operated for two level non-instrumented ACDF, 6 patients (24.00%) had pseudoarthrosis. The fusion rate for two levels ACDF in our series is 76.00%. There was no significant difference in fusion rates of the PEEK cage when compared to auto graft group. Conclusion. Fusion rates in ACDF are independent of interbody graft material. Fusion rates for single level ACDF is significantly higher than two levels ACDF. ACDF with PEEK is the fusion technique of choice with fewer complications and better functional recovery

Introduction. Aim was to compare the functional outcome of anterior cervical decompression and fusion (ACDF) with stand-alone tricotical iliac crest auto graft verses stand-alone PEEK cage. Material and methods. Prospectively collected data of 60 patients in each group was compared. Results. There was statistically significant improvement noted in postoperative Modified Japanese Orthopaedic Association scores at one year follow up for both the groups. Perioperative complications were significantly higher in the autograft group when compared with the PEEK cage group. Among the 94 patients who underwent single level non-instrumented ACDF only 4 (4.25%) had psuedoarthrosis. The fusion rate for single level ACDF in our series was 95.74%. Among the 25 patients operated for two level non-instrumented ACDF, 6 patients (24.00%) had pseudoarthrosis. The fusion rate for two levels ACDF in our series is 76.00%. There was no significant difference in fusion rates of the PEEK cage when compared to auto graft group. Conclusion. Fusion rates in ACDF are independent of interbody graft material. Fusion rates for single level ACDF is significantly higher than two levels ACDF. ACDF with PEEK is the fusion technique of choice with fewer complications and better functional recovery

Aims. The purpose of this retrospective study was to investigate the clinical relevance of increased facet joint distraction as a result of anterior cervical decompression and fusion (ACDF) for trauma. Patients and Methods. A total of 155 patients (130 men, 25 women. Mean age 42.7 years; 16 to 87) who had undergone ACDF between 1 January 2001 and 1 January 2016 were included in the study. Outcome measures included the Neck Disability Index (NDI) and visual analogue scale (VAS) for pain. Lateral cervical spine radiographs taken in the immediate postoperative period were reviewed to compare the interfacet distance of the operated segment with those of the facet joints above and below. Results. There was a statistically significant relationship between greater facet distraction and increased NDI and VAS pain scores. This was further confirmed by Spearman correlation, which showed evidence of a moderate correlation between both NDI score and facet joint distraction (Spearman correlation coefficient 0.34; p < 0.001) and VAS score and facet distraction (Spearman correlation coefficient 0.52; p < 0.001). Furthermore, there was a discernible transition point between outcome scores. Significantly worse outcomes, in terms of both NDI scores (17.8 vs 8.2; p < 0.001) and VAS scores (4.5 vs 1.3; p < 0.001), were seen with facet distraction of 3 mm or more. Patients who went on to have a posterior fusion also had increased NDI and VAS scores, independent of facet distraction. Conclusion. After undergoing ACDF for the treatment of cervical spine injury, patients with facet joint distraction of 3 mm or more have worse NDI and VAS pain scores. Cite this article: Bone Joint J 2018;100-B:1201–7

Aims. Cervical spondylosis is often accompanied by dizziness. It has recently been shown that the ingrowth of Ruffini corpuscles into diseased cervical discs may be related to cervicogenic dizziness. In order to evaluate whether cervicogenic dizziness stems from the diseased cervical disc, we performed a prospective cohort study to assess the effectiveness of anterior cervical discectomy and fusion on the relief of dizziness. Patients and Methods. Of 145 patients with cervical spondylosis and dizziness, 116 underwent anterior cervical decompression and fusion and 29 underwent conservative treatment. All were followed up for one year. The primary outcomes were measures of the intensity and frequency of dizziness. Secondary outcomes were changes in the modified Japanese Orthopaedic Association (mJOA) score and a visual analogue scale score for neck pain. Results. There were significantly lower scores for the intensity and frequency of dizziness in the surgical group compared with the conservative group at different time points during the one-year follow-up period (p = 0.001). There was a significant improvement in mJOA scores in the surgical group. Conclusion. This study indicates that anterior cervical surgery can relieve dizziness in patients with cervical spondylosis and that dizziness is an accompanying manifestation of cervical spondylosis. Cite this article: Bone Joint J 2018;100-B:81–7

C5 nerve root palsy is a rare and potentially debilitating complication of cervical spine surgery. Currently, however, there are no guidelines to help surgeons to prevent or treat this complication.

We carried out a systematic review of the literature to identify the causes of this complication and options for its prevention and treatment. Searches of PubMed, Embase and Medline yielded 60 articles for inclusion, most of which addressed C5 palsy as a complication of surgery. Although many possible causes were given, most authors supported posterior migration of the spinal cord with tethering of the nerve root as being the most likely.

Early detection and prevention of a C5 nerve root palsy using neurophysiological monitoring and variations in surgical technique show promise by allowing surgeons to minimise or prevent the incidence of C5 palsy. Conservative treatment is the current treatment of choice; most patients make a full recovery within two years.

Cite this article: Bone Joint J 2014;96-B:950–5.

The February 2014 Spine Roundup³⁶⁰ looks at: single posterior approach for severe kyphosis; risk factors for recurrent disc herniation; dysphagia and cervical disc replacement or fusion; hang on to your topical antibiotics; cost-effective lumbar disc replacement; anxiolytics no role to play in acute lumbar back pain; and surgery best for lumbar disc herniation.

Objective:. To observe the incidence of intra-operative vascular injuries during anterior cervical decompression and fusion (ACDF). Secondly, management and monitoring of the outcome post vascular injury during ACDF. Methods:. This a prospective study. A review of all spinal patients' records was performed from June 2006 to April 2011. A comprehensive literature review was also utilized. Inclusion criteria – all patients had ACDF post trauma. All non-traumatic cases were excluded. Results:. The study consisted of 55 patients; 15 were females and 40 were males. The age distribution was 23–65 years. Two patients were excluded due to non-traumatic causes. Of the remaining 53 patients, four sustained intra-operative vascular injuries during ACDF surgery. All 4 patients had corpectomies, and one case was an iatrogenic injury. The commonly injured vessel during the ACDF surgery was the left vertebral artery. Haemostatic control was achieved via tamponade and haemostatic agents. The left common carotid was iatrogenically injured in one case and was treated by microvascular repair. Three patients were treated with antiplatelet therapy for three months duration. The patient with an iatrogenic injury was treated with anticoagulation therapy for three months duration. All computerized tomographic angiograms at three months follow up illustrated patent vessels. Conclusion:. There is an increased incidence of intra operative vascular injuries during ACDF associated with corpectomies. It is essential to be aware of the low incidence of intra operative arterial injury during ACDF and to have a management approach, such as tamponade or microvascular repair. Anticoagulation and antiplatelet therapy is effective in decreasing the complications of vascular injuries post ACDF

The purpose of this study was to investigate the clinical predictors of surgical outcome in patients with cervical spondylotic myelopathy (CSM). We reviewed a consecutive series of 248 patients (71 women and 177 men) with CSM who had undergone surgery at our institution between January 2000 and October 2010. Their mean age was 59.0 years (16 to 86). Medical records, office notes, and operative reports were reviewed for data collection. Special attention was focused on pre-operative duration and severity as well as post-operative persistence of myelopathic symptoms. Disease severity was graded according to the Nurick classification.

Our multivariate logistic regression model indicated that Nurick grade 2 CSM patients have the highest chance of complete symptom resolution (p < 0.001) and improvement to normal gait (p = 0.004) following surgery. Patients who did not improve after surgery had longer duration of myelopathic symptoms than those who did improve post-operatively (17.85 months (1 to 101) vs 11.21 months (1 to 69); p = 0.002). More advanced Nurick grades were not associated with a longer duration of symptoms (p = 0.906).

Our data suggest that patients with Nurick grade 2 CSM are most likely to improve from surgery. The duration of myelopathic symptoms does not have an association with disease severity but is an independent prognostic indicator of surgical outcome.

Cite this article: Bone Joint J 2013;95-B:966–71.

The February 2013 Spine Roundup³⁶⁰ looks at: complications with anterior decompression and fusion; lumbar claudication and peripheral vascular disease; increasing cervical instability in rheumatoids; kyphoplasty; cervical stenosis; exercise or fusion for chronic lower back pain; lumbar disc arthroplasty and adjacent level changes; and obese disc prolapses.

Introduction. Anterior cervical decompression and fusion (ACDF) is considered a standard surgical treatment to degenerative discogenic diseases. Lately, the question arises whether or not ACDF significantly influences the progression of adjacent disc degeneration (ADD). The etiology of ADD is obscure and it has not been fully understood whether ADD is a consequence of fusion or it represents the aging pathway of the degenerative cervical process, thus making it a controversial topic [1-3]. There have been several discussions about the possibility of ACDF altering biomechanical conditions at adjacent segments, therefore resulting in increased load and excessive motion [3,4]. The purpose of this study was to compare the cervical segmental motion pre- and post-ACDF using novel 3D analytical techniques. Methods. Nine patients (2F/7M, mean age: 54.1 years, range 36–76 y.o.) underwent ACDF due to symptomatic cervical degenerative discogenic disease. One-level ACDF was performed in 4 patients, whereas 2-level ACDF was done in five, using cylindrical titanium porous cage implants. Pre- and post (postoperative periods ranged from 11-months, 25 days to 12-months, 22 days, mean postoperative period: 12.09 months) surgery, dynamic-CT examinations were conducted in neutral, flexion and extension positions. Subject-based 3D CT models were created for segmental motion analysis (Fig. 1). Six-degrees-of-freedom 3D segmental movements were analyzed using a validated Volume-Merge methods (accuracy: 0.1 mm in translation, 0.2°in rotation) [5]. The segmental translation was evaluated by the segmental translations of gravity centers of endplates (Fig. 2). Disc-height distribution was measured using a custom-written Visual C++ routine implementing a lease-distance calculation algorithm. The mean translation distance was calculated for the each adjacent level (Fig. 2). Differences of segmental motions and mean disc height between pre- and post-surgery at each level were compared by the Wilcoxon signed rank test. Results were presented mean±SEM. Results. Regarding the fusion level, the data shows decreases in both the flexion/extension (F/E) angular range of motion (ROM) (7.46±1.17°preoperatively vs. 3.14±0.56°post-operatively, p<0.003) and the segmental translation in the anterior/posterior direction (AP translation) after surgery (1.22±0.20 mm pre-operatively and 0.32±0.11 mm post-operatively, p<0.01). For the adjacent levels category (inferior and superior combined), the E/F angular ROM was larger after surgery (6.74±1.22°pre-operatively vs. 8.48±0.56°post-operatively, p<0.03). The lateral and axial rotational angular ranges of motion pre- and post-surgery did not show any statistically differences at the adjacent levels. The AP translation at the adjacent levels did not change after surgery (1.22±0.26 mm pre-operatively and 1.45±0.29 mm post-operatively). Translations in lateral and cranio-caudal directions also did not show change following surgery. The mean disc height in the adjacent level (2.39±0.14 mm) showed no differences with respect to the post-surgical measurements (2.40±0.19 mm). Conclusions. The use of a high-accuracy in vivo 3D kinematic analysis method enabled the detection of subtle changes in segmental movement between pre- and post-ACDF conditions. The result of the current study showed increased segmental movements in F/E angles at the adjacent level. These results are consistent with the some previous studies in the literature [4,6-11]. The magnitude of the increased movement, however, was only 1.74°from full-full-flexion to full-extension and no increase was found in AP translation. No disc height loss associated with disc degeneration was observed during a 1-year period after ACDF. Longer follow-up studies with larger patient cohorts will be required to investigate whether the increased F/E angle at the adjacent level effectively causes symptomatic ADD

Introduction: In comparison to anterior cervical decompression and fusion (ACDF), cervical disc arthroplasty has the potential of maintaining normal segmental lordosis, anatomical disc space height, and physiological motion patterns that may reduce or delay the onset of degenerative disc disease at adjacent cervical spinal motion segments. Aim: The objective of this study was to determine patient satisfaction post cervical disc arthroplasty. by evaluating each patient both clinically and radiologically. Materials and Methods: A retrospective study was performed on all patients with symptomatic cervical radiculopathy and/or myelopathy who had undergone cervical disc arthroplasty by a single surgeon after a standard anterior cervical discectomy. Outcome measures included the Short Form-36 (SF-36) and Neck Disability Index (NDI) questionnaires, neurological status, and radiographic status. Results: Over a 32 month period, 15 patients underwent cervical disc arthroplasty, with 12 patients undergoing single level arthroplasty. 2 patients undergoing 2 level arthroplasty and one patient undergoing a 3 level arthroplasty. The C5/C6 level was involved in 9 cases (60%). The male female ratio was 7:8. The mean age at presentation was 45 years (range, 28–59). The mean follow up was 24 months (range, 5–31). The mean improvement in NDI scores was 34.8. The mean PCS and MCS scores of the SF-36 test improved by 12.8 and 7.7 respectively. There was no neurological deficit. There were no cases of implant failures, migrations or subsidence. Conclusion: High patient satisfaction levels highlight the efficacy and safety of cervical disc arthroplasty, but longer term follow up is required to assess the long term functionality of the prosthesis and its protective influence on adjacent levels

Background: Cervical myelopathy and radiculopathy has been treated commonly with anterior cervical decompression and fusion with autologous bone graft and anterior cervical plating. Long term results have shown excellent pain relief and 73%–90% fusion rates. However, the development of late adjacent-level disease has been reported following anterior cervical arthrodesis which recently have been correlated to clinical findings. The Bryan disc arthroplasty device was developed to preserve the kinematics of the functional spine unit thus preventing adjacent level disease. There have been few studies comparing the incidence of adjacent level changes in patients undergoing ACDF compared to implantation of a Bryan disc arthroplasty device. Objectives: The object of this study is to compare the clinical results and radiographic outcomes of anterior cervical decompression and fusion versus cervical disc replacement using the Bryan Cervical Disc Prosthesis (Medtronic Sofamor Danek, Memphis, TN) in terms of overall range of motion (ROM) of the cervical spine; ROM, anterior intervertebral height (AIH), posterior intervertebral height (PIH) and radiographic changes at the implanted and adjacent levels. Methods: The study consisted of 105 patients with symptomatic single or two-level cervical disc disease. Fifty-one received the Bryan Cervical Artificial Disc Prosthesis (Medtronic Sofamor Danek, Memphis, TN). A total of 63 Bryan disc were placed in these 51 patients. A single-level procedure was performed in 39 patients and a two-level procedure in the other twelve. The patient group who underwent ACDF totaled 54 patients which consisted of 26 single level cases and 28 double level cases. The Bryan group had a mean follow-up 19 months (12–38). The mean follow-up for the ACDF group was 20 months (12–40 months). All patients were evaluated using static and dynamic cervical spine radiographs as well as MR imaging. All patients underwent anterior cervical discectomy followed by anterior cervical plating or implantation of the Bryan artificial disc prosthesis, done by one surgeon. Clinical evaluation included the visual analogue scale (VAS), and neck disability index (NDI). Radiographic evaluation included static and dynamic flexion-extension radiographs in an upright position using the computer software (Infinitt PiviewSTAR 5051) program. Range of motion/disc space angle and inter vertebral height were measured at the operative site and adjacent levels. Functional spinal unit (FSU) and overall sagittal alignment (C2–C7) were also measured pre-operatively, postoperatively and at final follow-up. ROM was calculated for all 3 areas and data collected were compared from pre operative to last follow-up as well as between the two groups. Radiographic assessment for adjacent level changes was also done. Radiologic change was analyzed using chi square test (95% confidence interval). Other data were analyzed using the mixed model. (SAS enterprise guide 4.1 version). Results: There was clinical improvement within each group in terms of VAS and NDI scores from pre-op to final follow-up for both single (VAS: p=0.8371, NDI: p=0.2872) and double (VAS: p=0.2938, NDI: p=0.6753) level surgeries but not significantly between the two groups. Overall, ROM and intervertebral height was relatively well maintained during the follow-up in the Bryan group compared to ACDF. Comparing the pattern of ROM measurements from pre-op to final follow-up between the two arms regardless of the number of levels operated on; significant differences were noted for overall ROM of the cervical spine (p< .0001) and all other levels except at the upper level for single level surgeries (p=0.2872). In terms of inter vertebral height measurements from pre-op to final follow-up, statistically significant (p< 0.0001 and p=0.0172) differences in the pattern between the two groups were noted at all levels except for the AIH of single level surgeries at the upper (p=0.1264) and lower (p=0.7598) levels as well as PIH for double level surgeries at the upper (p=0.8363) level. Radiologic change was 3.5 times more observed for the ACDF group compared to the Bryan group. Conclusion: Clinical status of both groups, regardless of the number of levels, showed improvement. Although clinical outcomes between the two groups were not significantly different at final follow-up, radiographic parameters, namely ROM and intervertebral heights at the operated site, some adjacent levels as well as FSU and overall sagittal alignment of the cervical spine were relatively well maintained in our Bryan group compared to our ACDF group. We surmise that to a certain degree, the maintenance of these parameters could contribute to reduce development of adjacent level change. Noteworthy is that radiographic change was 3.5 times more observed for ACDF surgeries. A longer period of evaluation is needed, to see if all these radiographic changes will translate to symptomatic adjacent level disease

The purpose of the study was to determine the effectiveness of rhBMP-2 when applied to an absorbable collagen sponge for interbody fusion with allograft spacers. Seventy-seven consecutive patients requiring inter-body fusion with one hundred and eighteen levels were included in the study. In thirty-six patients cervical or lumbar interbody fusions were performed using allograft and rhBMP-2. In the remaing allograft was used with demineralised bone matrix. In patients undergoing anterior cervical decompression and fusion (ALIF) machined allograft spacers were supplemented with anterior locking plates. In those scheduled for anterior lumbar inter-body fusion (ALIF) or transforaminal lumbar interbody fusion (TLIF), machined allograft spacers were supplemented with posterior pedicle screw constructs. There were no stand alone ALIF procedures. All patients undergoing surgery were assessed preoperatively and at two weeks, six weeks, three, six, twelve, twenty-four months following surgery.Their Oswestry disability index (ODI) questionaires, Visual analogue scale (VAS) scores and a pain diagram were recorded. Radiographic measurements were made on the electronic public access computer system (EPACS). All patients with allograft plus rhBMP-2 showed radiographic evidence of fusion by six months following surgery. The allograft with demineralised bone matrix group took considerably longer to achieve the same radiographic end plate appearance. Subsidence was obvious on radiographs in greater than 50% of cases with allograft and rhBMP-2 at three months. It was noted to occur between six weeks and three months and there was no significant subsidence after six months. This was statistically significant with a p< 0.0001 (fisher exact test). The average subsidence for the entire rhBMP-2 group at twelve months was 16.5%(SE 2.5% and range 0–58%) and for the allograft and bone matrix group was 4.6%(SE.74% range 0–15%)with a p< 0.0001 (independant t test). Although high rates of fusion can be accomplished with allograft and rhBMP-2 (100%), significant subsidence occurs in greater than 50% of lumbar spine cases and 30% of cervical spine cases. This is possibly a result of early bone turnover with loss of structural support of the allograft spacer and end plate resorption

Background: Smaller versions of threaded lumbar cages were developed for cervical spine to obviate the need for allograft, iliac autograft use and to provide initial stability before fusion. Clinical trials of threaded cervical fusion cages have shown higher fusion rates and lower rates of graft-donor site complications. Study design/Aims: Prospective. Radiological and clinical outcomes of an age, sex and diagnosis matched patient population who underwent cervical fusion with (A) BAK/C cages filled with autograft reamings (Center-pulse Spine-tech Inc., Minneapolis, MN) (N=50) were compared with (B) Anterior cervical decompression and fusion (ACDF, N=50). Methods: Patients with symptomatic cervical discogenic radiculopathy were treated with either anterior cervical discectomy with uninstrumented bone-only fusion (ACDF) or BAK/C fusion cage(s). Independent radiographic assessment of fusion was made and patient-based outcome was assessed by a Short Form (SF)-36 Health Status Questionnaire. All patients had minimum follow up of at least 2 years. Results: Similar outcomes were noted for duration of surgery, hospital stay, improvements in neck pain and radicular pain in the affected limb, improvements in the SF-36 Physical Component subscale and Mental Component subscale, and the patients’ perception of overall surgical outcome. Symptom improvements were maintained at 2 years. Iliac crest harvesting was carried out as a standard procedure in all cases of ACDF whereas only 2 cases in BAK/C group required the same. Average operative time of 115 minutes and 145 minutes, blood loss of 110ml and 175ml and hospital stay of 1.5 and 3.5 days were noted for BAK/C and ACDF groups respectively. Successful fusion was achieved in 49 cases in BAK/C and 46 patients in ACDF group. None of the patients in the BAK/C group had reappearance of symptoms while 3 patients in ACDF group had developed symptomatic adjacent level disc disease. The complication rate for the ACDF group was 9% compared with an overall complication rate of 3% with BAK/C. Complications that necessitated a second operative procedure included. Graft dislodgement (N=3) and. Cage subsidence, both requiring re-operation in the form of ACDF with plate supplementation. Conclusions: These results demonstrate that outcomes after a cervical fusion procedure with a threaded cage are the same as those of a conventional uninstrumented bone-only anterior discectomy and fusion with a low risk of complications, less operative time and rare need for autogenous bone graft harvest