Aims. This study, using a surgeon-maintained database, aimed to explore the risk factors for surgery-related complications in patients undergoing primary cervical spine surgery for degenerative diseases. Methods. We studied 5,015 patients with degenerative cervical diseases who underwent primary cervical spine surgery from 2012 to 2018. We investigated the effects of diseases, surgical procedures, and patient demographics on surgery-related complications. As subcategories, the presence of cervical kyphosis ≥ 10°, the presence of ossification of the posterior longitudinal ligament (OPLL) with a canal-occupying ratio ≥ 50%, and foraminotomy were selected. The surgery-related complications examined were postoperative upper limb palsy (ULP) with a manual muscle test (MMT) grade of 0 to 2 or a reduction of two grade or more in the MMT, neurological deficit except ULP, dural tear, dural leakage, surgical-site infection (SSI), and postoperative haematoma. Multivariate logistic regression analysis was performed. Results. The significant risk factors (p < 0.050) for ULP were OPLL (odds ratio (OR) 1.88, 95% confidence interval (CI) 1.29 to 2.75), foraminotomy (OR 5.38, 95% CI 3.28 to 8.82), old age (per ten years, OR 1.18, 95% CI 1.03 to 1.36), anterior spinal fusion (OR 2.85, 95% CI 1.53 to 5.34), and the number of operated levels (OR 1.25, 95% CI 1.11 to 1.40). OPLL was also a risk factor for neurological deficit except ULP (OR 5.84, 95% CI 2.80 to 12.8), dural tear (OR 1.94, 95% CI 1.11 to 3.39), and dural leakage (OR 3.15, 95% CI 1.48 to 6.68). Among OPLL patients, dural tear and dural leakage were frequently observed in those with a canal-occupying ratio ≥ 50%. Cervical rheumatoid arthritis (RA) was a risk factor for SSI (OR 10.1, 95% CI 2.66 to 38.4). Conclusion. The high risk of ULP, neurological deficit except ULP, dural tear, and dural leak should be acknowledged by clinicians and OPLL patients, especially in those patients with a canal-occupying ratio ≥ 50%. Foraminotomy and RA were dominant risk factors for ULP and SSI, respectively. An awareness of these risks may help surgeons to avoid surgery-related complications in these conditions. Cite this article: Bone Joint J 2021;103-B(1):157–163

Aims. Patients seeking cervical spine surgery are thought to be increasing in age, comorbidities and functional debilitation. The changing demographics of this population may significantly impact the outcomes of their care, specifically with regards to complications. In this study, our goals were to determine the rates of functionally dependent patients undergoing elective cervical spine procedures and to assess the effect of functional dependence on 30-day morbidity and mortality using a large, validated national cohort. Patients and Methods. A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program data files from 2006 to 2013 was conducted to identify patients undergoing common cervical spine procedures. Multivariate logistic regression models were generated to analyse the independent association of functional dependence with 30-day outcomes of interest. Results. Patients with lower functional status had significantly higher rates of medical comorbidities. Even after accounting for these comorbidities, type of procedure and pre-operative diagnosis, analyses demonstrated that functional dependence was independently associated with significantly increased odds of sepsis (odds ratio (OR) 5.04), pulmonary (OR 4.61), renal (OR 3.33) and cardiac complications (OR 4.35) as well as mortality (OR 11.08). Conclusions. Spine surgeons should be aware of the inherent risks of these procedures with the functionally dependent patient population when deciding on whether to perform cervical spine surgery, delivering pre-operative patient counselling, and providing peri-operative management and surveillance. Cite this article: Bone Joint J 2017;99-B:824–8

Background. The transverse skin incision for anterior cervical spine surgery is not extensile, thus it must be made at the accurate level. The use of palpable bony landmarks is unreliable due to anatomical variations and pre-operative fluoroscopy to identify the level takes up operating room time, increases the radiation dose to the patient and increases the overall cost of the operation. Objective. To describe a simple, fast and inexpensive method of accurate transverse skin incision placement for anterior cervical spine surgery and to report on its use in 54 consecutive adult patients. Patients and Methods. In each case a ratio was recorded on the lateral cervical spine radiograph based on the distance between the clavicle and mandible and the operative level; this was then applied to measurements on the patient's neck. Results. Procedures performed consisted of a mix of discectomy and fusion, disc replacement and combinations of both. The operative level ranged from C2-C3 to C7-T1, the most common being C5-C6. Twenty-three patients had a single-level, 26 a two level and 5 a three level procedure; all cases were performed through one single transverse incision. Conclusion. We describe the highly successful use of a straightforward method for accurate level transverse skin incision placement for cervical spine surgery In no case was it necessary to radically extend or to make a separate incision. There were no cases where the wrong level was operated on

Introduction. The Odom's criteria are, since 1958, a widely used 4-point rating scale for assessing the clinical outcome after cervical spine surgery. Surprisingly, the Odom's criteria have never been validated. The aim of this study was to investigate the reliability and validity of the Odom's criteria for the evaluation of surgical procedures of the cervical spine. Methods. Patients with degenerative cervical spine disease were included and divided into two groups, based on their most predominant symptom: myelopathy or radiculopathy. Reliability was assessed with inter-rater and test-retest design using a quadratic weighted Kappa coefficient. Construct validity was assessed by means of hypothesis testing with related constructs. To evaluate if the Odom's criteria could act as a global perceived effect (GPE) scale, we assessed concurrent validity by comparing the areas under the curves (AUCs) of the receiver operating characteristic curves (ROCs) with both the Odom's criteria, as the GPE as an anchor. Results. A total of 110 patients were included in the study. Overall inter-rater reliability was k=0.77 and the test-retest reliability k=0.93. Inter-rater reliability for the radiculopathy patients was κ=0.81 and for myelopathy patients κ=0.68. More than 75% of the hypotheses were met. The AUCs showed similar characteristics between the Odom's criteria and GPE. Conclusion. The Odom's criteria meet the predefined criteria for reliability and validity. Therefore, the Odom's criteria may be used to measure surgical outcome after a cervical spine procedure. Results of previous studies that have been deemed less trustworthy, because of the use of the Odom's criteria, should be reconsidered. No conflicts of interests. No funding obtained

We retrospectively examined the prevalence and natural history of asymptomatic lumbar canal stenosis in patients treated surgically for cervical compressive myelopathy in order to assess the influence of latent lumbar canal stenosis on the recovery after surgery. Of 214 patients who had undergone cervical laminoplasty for cervical myelopathy, we identified 69 (32%) with myelographically documented lumbar canal stenosis. Of these, 28 (13%) patients with symptomatic lumbar canal stenosis underwent simultaneous cervical and lumbar decompression. Of the remaining 41 (19%) patients with asymptomatic lumbar canal stenosis who underwent only cervical surgery, 39 were followed up for ≥ 1 year (mean 4.9 years (1 to 12)) and were included in the analysis (study group). Patients without myelographic evidence of lumbar canal stenosis, who had been followed up for ≥ 1 year after the cervical surgery, served as controls (135 patients; mean follow-up period 6.5 years (1 to 17)). Among the 39 patients with asymptomatic lumbar canal stenosis, seven had lumbar-related leg symptoms after the cervical surgery. Kaplan–Meier analysis showed that 89.6% (95% confidence interval (CI) 75.3 to 96.0) and 76.7% (95% CI 53.7 to 90.3) of the patients with asymptomatic lumbar canal stenosis were free from leg symptoms for three and five years, respectively. There were no significant differences between the study and control groups in the recovery rate measured by the Japanese Orthopaedic Association score or improvement in the Nurick score at one year after surgery or at the final follow-up. These results suggest that latent lumbar canal stenosis does not influence recovery following surgery for cervical myelopathy; moreover, prophylactic lumbar decompression does not appear to be warranted as a routine procedure for coexistent asymptomatic lumbar canal stenosis in patients with cervical myelopathy, when planning cervical surgery

There is evidence that preoperative physical fitness impacts surgical outcomes, specifically preceding abdominal, cardiovascular and spine surgery. To our knowledge, there are no papers on self-reported exercise frequency as a predictor of cervical spine surgery outcomes. Our objectives were to quantify self-report of exercise frequency in cervical spine surgery patients, and to elucidate if self-reported exercise prior to surgery confers less pain, improved health state and/or less disability post-surgery. We performed a retrospective review of prospectively collected data from the Canadian Spine Outcomes and Research Network (CSORN) Database from the time of its inception. Inclusion criteria specified all elective cervical surgery patients over 18 years old with degenerative pathology who proceeded to surgery and completed the pre- and post-operative outcomes measures up to 24 months post surgery (n=460). Outcome measures were visual analog scales (VAS) for neck and arm pain, Neck Disability Index (NDI), and EuroQOL score at baseline and 3, 12 and 24 months post-op. Exercise frequency was self-reported as “none” (n=212) versus “some” (n=248). These groups were further categorized into “none due to physical limitations”, “none” (not due to physical limitations), those to exercised “once or less per week” and those that exercised “twice or more per week”. Student's t-tests were used to compare the mean scores of the outcome measures, and analysis of variance for subgroup comparisons, with results considered significant at p < 0 .05. At baseline, 56% of total patients reported exercise prior to surgery, of which 73% reported doing so twice or more per week. Of the 44% reporting no exercise, 74% could not exercise due to physical limitations. Those who reported “some” exercise had more favorable VAS neck and arm pain scores pre-operatively (neck: 5.55 vs 6.11, p < 0 .001) (arm: 5.69 vs 6.04, p=0.011), but no difference at 3 and 24 months post-operatively. Significantly lower NDI scores and higher EuroQOL Index scores were seen in the exercise group compared to the no exercise group pre-operatively (NDI: 39 vs 48, p < 0 .001) (EuroQOL: 0.60 vs 0.50 p < 0 .001) as well as at 3, 12, and 24 months post-op (NDI: 24 vs 31, p=0.007) (EuroQOL: 0.75 vs 0.68, p=0.001). Further subgroup analysis demonstrated that compared to the “no exercise due to physical limitation” group, the “twice or more” exercise group showed favorable NDI and EuroQOL scores up to 24 months post-op (NDI: 24.32 vs 32.33, p=0.001) (EuroQOL: 0.76 vs 0.66, p=0.001), whereas the “once or less times per week” group no longer demonstrated any significant difference at 24 months (NDI: 28.79 vs 32.33, p=1) (EuroQOL: 0.73 vs 0.66, p=0.269). Self-reported exercise prior to cervical spine surgery does not predict improved long-term neck and arm pain at 2 years post-op. However, self-reported exercise does demonstrate less disability and improved health state at baseline and up to 2 years post-op and this relationship is dose dependent

The August 2014 Spine Roundup. 360 . looks at: rhBMP complicates cervical spine surgery; posterior longitudinal ligament revisited; thoracolumbar posterior instrumentation without fusion in burst fractures; risk modelling for VTE events in spinal surgery; the consequences of dural tears in microdiscectomy; trends in revision spinal surgery; radiofrequency denervation likely effective in facet joint pain and hooks optimally biomechanically transition posterior instrumentation

Resident involvement in the operating room is a vital component of their medical education. Conflicting and limited research exists regarding the effects of surgical resident participation on spine surgery patient outcomes. Our objective was to determine the effect of resident involvement on surgery duration, length of hospital stay and 30-day post-operative complication rates. This study was a multicenter retrospective analysis of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. All anterior cervical or posterior lumbar fusion surgery patients were identified. Patients who had missing trainee involvement information, surgery for cancer, preoperative infection or dirty wound classification, spine fractures, traumatic spinal cord injury, intradural surgery, thoracic surgery and emergency surgery were excluded. Propensity score for risk of any complication was calculated to account for baseline characteristic differences between the attending alone and trainee present group. Multivariate logistic regression was used to investigate the impact of resident involvement on surgery duration, length of hospital stay and 30 day post-operative complication rates. 1441 patients met the inclusion criteria: 1142 patients had surgeries with an attending physician alone and 299 patients had surgeries with trainee involvement. After adjusting using the calculated propensity score, the multivariate analysis demonstrated that there was no significant difference in any complication rates between surgeries involving trainees compared to surgeries with attending surgeons alone. Surgery times were found to be significantly longer for surgeries involving trainees. To further explore this relationship, separate analyses were performed for tertile of predicted surgery duration, cervical or lumbar surgery, instrumentation, inpatient or outpatient surgery. The effect of trainee involvement on increasing surgery time remained significant for medium predicted surgery duration, longer predicted surgery duration, cervical surgery, lumbar surgery, lumbar fusion surgery and inpatient surgery. There were no significant differences reported for any other factors. After adjusting for confounding, we demonstrated in a national database that resident involvement in surgeries did not increase complication rates, length of hospital stay or surgical duration of more routine surgical cases. We found that resident involvement in surgical cases that were generally more complexed resulted in increased surgery time. Further study is required to determine the relationship between surgery complexity and the effect of resident involvement on surgery duration

Purpose: To review the existing practice of coding in spinal surgery and ascertain its accuracy for surgical procedures, co-morbidities and complications. Methods: A retrospective review of 70 cervical and 100 lumbar consecutive spinal surgeries performed since April 2006 was conducted. The clinical coding data and hospital notes were reviewed. Results: Coding data of 5 cervical spine surgeries were not available. Of the 165 cases, the accuracy of primary procedural codes was 93.9% (90.8% cervical & 96% lumbar). This reduced to 77.6% (75.4% cervical & 79% lumbar) when the accuracy for entire description of performed surgery was considered. Medical co-morbidities were coded appropriately in 64.2% of the patients (55% cervical & 70% lumbar). The procedural codes did not specifically reflect the surgery performed and lacked reproducibility. Surgical levels were coded incorrectly in 9% of the cases. Cervical surgeries were coded as lumbar in 4 and posterior surgery as anterior in 3 cases respectively. The commonly missed co-morbidities were drug allergies, hypercholesterolemia, smoking and alcoholism. Post-op adverse events were coded in 75% of the cases (16/20 cervical & 5/8 lumbar). The accuracy was better for lumbar as compared to cervical spinal surgeries. Conclusion: Coding is a universal language of communication and its accuracy is important not just for PbR, but for data quality, audit and research purposes too. The financial implications regarding PbR governed by HRG codes (dictated by OPCS 4.4 & ICD–10 codes) are discussed. Following this study, a clinical coding facilitation form has been introduced to improve data quality. Ethics approval: None. Interest statement: None

Purpose: Published series of minimally invasive cervical foraminotomy (MICF) have shown excellent short-term relief of cervical radiculopathy (85–98%) with minimal surgical morbidity. There have been no long-term clinical series documenting the stability of these results over time. This is the first long-term follow-up of MICF patients to determine the incidence of recurrent symptoms and need for additional cervical spine surgery. Methods: We conducted a multi-center retrospective chart review of 73 patients who had MICF. Clinical outcome measures were assessed from clinic records, operative records, and telephone surveys. Results: At 3 months, 70/73 patients (96%) reported relief of radicular pain compared to their preoperative state. By 40 months, 15 patients reported symptoms of cervical radiculopathy. 8 patients experienced recurrent symptoms, and the remaining 7 had a new radicular pattern. Of 7 patients with symptoms at new levels, 6 had pre-existing radiographic abnormality. 15 patients underwent additional cervical surgery after MICF. 3 patients underwent repeat MICF at the same level. An additional 2 patients had MICF at a different level. 7 patients had ACDF at the same level and 2 had fusion at a different level. There were no cases of frank instability or spondylolisthesis noted. Conclusions: At 40 month follow-up, 21% or patients had radicular symptoms with 11% reporting recurrence of preoperative symptoms and 9% with radicular symptoms in a different distribution. 12% (9/73 patients) of the group required ACDF within the follow-up period. Thus, 64/73 patients were spared fusion in this series. Assuming the 2.5% per year incidence of adjacent level fusion cited in the literature, there would have been 6 cases likely to have required another fusion if all 73 patients had been treated with ACDF initially. From this perspective, MICF continues to be our procedure of choice for properly selected patients with cervical radiculopathy

Introduction: Accurate and ethical coding is challenging and directly impacts on Payment by Results (PbR). The aims & objectives of this study were to review the existing pattern of coding for spinal surgery and ascertain its appropriateness & accuracy for surgical procedures, medical co-morbidities and post-op complications. Methods: A retrospective review of 70 consecutive cervical and 100 consecutive lumbar spine patients who were operated from April 2006 onwards was conducted. The excel sheet provided by coding department, hospital notes – clinic letters, physicians’ entries, theatre notes and laboratory reports (biochemistry/microbiology/histology) – were reviewed. Of the 170 cases, 165 were available for analysis. Results: Coding data of 5 patients who underwent cervical spine surgeries were not available. Of the 165 cases, the accuracy of primary procedural codes was 93.9% (90.8% cervical & 96% lumbar). However this reduced to 77.6% (75.4% cervical & 79% lumbar) when the accuracy for entire description of performed surgery was considered. The procedural codes did not specifically reflect the surgery performed and lacked reproducibility. Surgical levels were coded incorrectly in 9% of the cases. Cervical surgeries were coded as lumbar in 4 and posterior surgery as anterior in 3 cases respectively. Harvest of iliac crest bone graft was not coded in 5 cases. Medical comorbidities were coded appropriately in 64.2% of the patients (55% cervical & 70% lumbar). The commonly missed comorbidities were drug allergies, hypercholesterolemia, smoking and alcoholism. Post-op adverse events were coded in 75% of the cases (16/20 cervical & 5/8 lumbar). The accuracy was better for lumbar as compared to cervical spinal surgeries. Conclusion: Coding is a universal language of communication amongst healthcare professionals. Its accuracy is important not just for PbR, but for data quality, audit and research purposes too. The financial implications regarding PbR governed by HRG codes (dictated by OPCS 4.4 & ICD–10 codes) are discussed. The awareness of clinical coding is low amongst junior doctors. Following this study, a clinical coding facilitation form has been introduced to improve data quality. Our plan is to close the audit loop and re-evaluate. Literature emphasises qualification of coders, legible documentation by physicians and interaction between coders and clinicians

Introduction: Anterior cervical spine surgeries are associated with high incidence (up to 60%) of early postoperative dysphagia and hoarseness of voice. These symptoms have been attributed to retraction injury on the larynx, trachea and oesophagus. Pressure from retractors producing ischaemia might explain the soft tissues complications following anterior cervical approach. Conventional retractor systems rely on the soft tissues for stability and create a vertical surgical channel but a novel system (Seex retractor) is fixed directly to the spine and rotates to allow an oblique approach. This may reduce retraction pressure by the Seex retractor on tissues This is the first investigation of retraction pressures using any two different retractor systems for anterior cervical spine surgery. The aims of this study were to measure the retraction pressure on the larynx, trachea and oesophagus during the anterior surgical approach to the cervical spine, in cadavers using conventional (Cloward) retractor and Seex retractor and to investigate the effect of flat or curved blades on retraction pressure. Methods: In a cadaveric model, through a standard anteriomedial approach simulated anterior cervical discectomy procedure was performed in cadavers at C3/4, C4/5, C5/6 and C6/7 levels using Cloward retractor with curved blade (Cervical Large Retractor Set. No. C50-1380: Cloward Instrument Corporation), Seex retractor with flat blade and Seex retractor with curved blade (Patent holder Dr. K. Seex, No PCT/AU05/001205). An online pressure transducer (Tekscan pressure measurement system) was applied between the retractor blade and medial tissues. Retraction pressures were recorded for all the retractors at each level on two separate occasions. Average retraction pressure (ARP), average peak retraction pressure (APRP), pressure distribution along the area of retraction, pressure difference at the edge and surface of the retractor blades, pressure variation with flat and curved blades were determined and compared. Results: A total of 40 sets of pressure recordings were made from 5 cadavers. Cloward retractor system generated an ARP of 33 mmHg (range 16 – 66 mmHg). ARP of Seex retractor with curved blade was 20 mmHg (range 9 – 50 mmHg) and that of Seex retractor with flat blade was 25 mmHg (range 10 – 74 mmHg). At one level ARP was same for all the three retractors. At another level ARP was same for Cloward retractor and Seex retractor with flat blade but higher than that of Seex retractor with curved blade. At two other levels Seex retractor with flat blade showed higher ARP than others. At 36 levels Cloward retractor showed highest ARP. This was statistically significant with Pearson’s Chi-square test (X2=10.023, degree of freedom=1, p = 0.0015) and Fisher exact test, p = 0.0005. Cloward retractor system showed an APRP of 124 mmHg (37 – 255 mmHg). While that of the Seex retractor with curved blade was 69 mmHg (14 – 254 mmHg) and that of Seex retractor with flat blade was 94 mmHg (18 – 255 mmHg). Of the 40 sets of the recordings at 32 levels Cloward retractor system generated highest APRP. With the Seex retractor itself flat blade generated more APRP than curved blade in 31 sets of measurements; it was reverse in 3 sets and in 6 sets APRP was same. Only at one level curved blade generated higher ARP than flat blade, at 11 levels it was same. At 28 levels ARP was higher with flat blade. Discussion: Cloward retractor generated significantly high retraction pressure (peak and average contact pressure) than Seex retractor in majority of the cases. Curved blades generate less retraction pressure than the flat ones. Based on these findings a prospective randomised study is underway in live patients

Cervical total disc replacement has been in practice for years now as a viable alternative to cervical fusion in suitable cases, aspiring to preserve spinal motion and prevent adjacent segment disease. Reports are rife that neck pain emerges as an annoying feature in the early postoperative period. The facet joint appears to be the most likely source of pain. 50 patients were prospectively followed up through 5 years after having received disc replacement surgery, indicated for symptomatic soft disc herniation of the cervical spine presenting with radiculopathy. • All were skeletally mature and aged between 22 to 50. • All had failed a minimum of 6 months conservative therapy. • Up to 2 disc levels were addressed. C3 till C7 levels. • Single surgeon (first author). • NDI > 30% (15/50). • Deteriorating radicular neurology. We excluded those with degenerative trophic changes of the cervical spine, focal instability, trauma, osteoporosis, previous cervical spine surgery, previous infection, ossifying axial skeletal disease and inflammatory spondyloarthritides. The device used was an unconstrained implant with stabilizing teeth. Over the 5 years, we studied their postoperative comfort level via the Neck Disability Index (NDI) and Visual Analogue Score (VAS). Pre-operative and post-operative analysis of the sagittal axis and of involved facet joints were done. 22 patients suffered postoperative neck pain as reflected by the NDI and VAS scores. Of these, 10 reported of neck pain even 24 months after surgery. However, none were neurologically worse and all patients returned to their pre-morbid functions and were relieved of pain by 28 months. All 22 patients reported of rapid dissolution of neckache after peri-facetal injections of steroids were done under image guidance. We draw attention to the facet joint as the pain generator, triggered by inappropriate implant height, eccentric stresses via hybrid constructs, eccentric loading due to unconstrained devices and unaddressed Luschka joint degeneration. Such factors require careful selection of patients for surgery, necessitate proper pre-operative templating and call for appropriate technical solutions during surgery

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

Background:. Cervical spine injured patients often require prolonged ventilatory support due to intercostal paralysis and recurrent chest infections. This may necessitate tracheotomy. Concern exists around increased complications when anterior cervical spine surgery and tracheotomies are performed. Objective:. The primary aim of this study was to evaluate the effect of tracheostomy in anterior cervical surgery patients in term of complications. In addition, the aetiology of trauma and incidence of anterior surgery and ventilation in this patient group was assessed. Methods:. Patients undergoing anterior cervical surgery and requiring ventilation were identified from the unit's prospectively maintained database. These patients were further sub-divided into whether they had a tracheotomy or not. The aetiology of injury and incidence of complications were noted both from the database and a case note review. Results:. Of the 1829 admissions over an 8.5 year period, 444 underwent anterior cervical surgery. Of these 112 required ventilation, and 72 underwent tracheotomy. Motor vehicle accidents, followed by falls, were the most frequent cause of injury. There was a bimodal incidence of tracheostomy insertion; on the day of spine surgery and 6–8 days later. There was no difference in the general complication rate between the two groups. With regards to specific complications attributable to the surgical approach / tracheotomy, there was again no statistically significant difference. The timing of the tracheotomy equally had no effect on complication rate. Although the complications occurred mostly in the formal insertion group as opposed to percutaneous insertion technique, this was most likely due to selection bias. Conclusion:. Anterior cervical surgery and subsequent tracheostomy are safe despite the intuitive concerns. Timing does not affect the incidence of complications and there is no reason to delay the insertion of the tracheotomy. Ventilation in general is associated with increased complications rather the tracheotomy tube

To audit the routine measurement of Vitamin B12 levels prior to cervical decompressive surgery. Retrospective analysis of medical records and pathology results of patients who underwent decompressive cervical surgery for myelopathy over a 6 month period. 26 patients were identified from theatre records. 21 out of 26 patients did not have vitamin B12 levels checked prior to their decompressive surgery. The reports in the literature of co-existent B12 deficient myelopathy and mechanical compression are a cause for concern. Although the incidence of this is unknown and unlikely to be common, good clinical practice would suggest that we should be routinely monitoring B12 levels in myelopathic patients. We have introduced new standards for routinely checking B12 levels pre-operatively and intend to re-audit the effectiveness of these in six months time

The June 2023 Spine Roundup³⁶⁰ looks at: Characteristics and comparative study of thoracolumbar spine injury and dislocation fracture due to tertiary trauma; Sublingual sufentanil for postoperative pain management after lumbar spinal fusion surgery; Minimally invasive bipolar technique for adult neuromuscular scoliosis; Predictive factors for degenerative lumbar spinal stenosis; Lumbosacral transitional vertebrae and lumbar fusion surgery at level L4/5; Does recall of preoperative scores contaminate trial outcomes? A randomized controlled trial; Vancomycin in fibrin glue for prevention of SSI; Perioperative nutritional supplementation decreases wound healing complications following elective lumbar spine surgery: a randomized controlled trial.

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 number of patients undergoing surgery for degenerative cervical radiculopathy has increased. In many countries, public hospitals have limited capacity. This has resulted in long waiting times for elective treatment and a need for supplementary private healthcare. It is uncertain whether the management of patients and the outcome of treatment are equivalent in public and private hospitals. The aim of this study was to compare the management and patient-reported outcomes among patients who underwent surgery for degenerative cervical radiculopathy in public and private hospitals in Norway, and to assess whether the effectiveness of the treatment was equivalent.

Purpose. Patient expectations influence post-treatment outcomes, both surgical and non-surgical. Existing studies evaluate the technical aspects of interventions and functional outcomes but fail to take into account patient expectations. This retrospective analysis of prospectively collected multi-center data aims to explore the relationship between pre-operative expectations and post-operative outcomes and satisfaction in lumbar and cervical spine surgery. The authors hypothesized that expectations dramatically affect spine patient satisfaction independent of functional outcomes. Method. Patient data from lumbar and cervical spine patients collected prospectively using a patient health survey system was analyzed. The study included patients who underwent operative intervention (decompression with or without fusion) with at least a 3-month period of follow-up. Pre-operative expectations were measured using the MODEMS expectation survey. Post-operative satisfaction and fulfillment of expectations were measured using the MODEMS satisfaction survey. Post-operative functional outcomes were measured using the ODI and SF-36. Multi-variate ordinal logistic regression modeling was used to examine predictors of post-operative satisfaction. Multi-variate linear regression modeling was used to examine predictors of functional outcomes. Results. 402 patients were included in the study. Significant predictors of increased satisfaction include: higher fulfillment of expectations regarding work (p=0.003) and pain relief (p=0.008), greater post-operative SF-36 (p=0.04), and lower pre-operative expectations regarding ability to exercise (p=0.03). Lumbar spine patients were more satisfied than cervical-spine patients. Significant predictors of better post-operative function include: higher expectations regarding sleep (p<0.0002), fulfillment of expectations regarding work (p<0.0001), sleep (p=0.03), and daily activities (p=0.02). Cervical spine patients had better functional outcomes (p=0.006). Conclusion. This study showed that pre-operative expectations and their fulfillment influence post-operative satisfaction in lumbar and cervical spine patients. This underlines the importance of taking pre-operative expectations into account in order to obtain an informed choice based on patient preferences

Stereotactic navigation in cranial surgery is a well-established technique, in routine clinical use since the turn of the century. The advent of computer guided stereotaxis since the early 1990’s has led to an explosion in applications for the technology in cranial surgery, with the development of new surgical techniques, minimal access and consequent claimed reduction in morbidity and mortality. Computer guidance also allows application of stereotactic techniques in spinal surgery. Early interventions have concentrated on the insertion of pedicle screws with improvement in accuracy and certainty of optimal screw placement. The use of fluoroscopic guidance allows the insertion of percutaneous pedicle screws and truly minimal access fusion techniques for the lumbar spine. More recently the development of improved registration has allowed the application of this technology to thoracic spinal surgery and to the cervical spine. Percutaneous techniques for C1/C2 arthrodesis, image guided vertebrectomy and transoral surgery, have been reported. The technology allows the development of surgical techniques designed not only for individual pathology but adapted to the anatomy of the individual patient. Disadvantages include a significant learning curve, especially for cervical spine surgery, the cost and need for registration which may be time consuming. Advantages include claimed accuracy in decompression, hardware placement, minimal access techniques and a three-dimensional solution to what is essentially a three dimensional problem. More recently non-computer based navigation systems have become available with improved hardware placement without the problems associated with computer based systems. The purpose of this paper is to review computer guided spinal surgery, present new techniques based on its application to the adult spine, discuss advantages and disadvantages of those techniques and present the results of studies on the new non-computer based navigation systems

Objective: Measuring outcomes from chronic disease in terms of generic, health-related quality of life (HRQoL) instruments is of increasing importance to allow valid comparison of interventions and to accurately assess efficacy of treatment from the patient’s perspective. In this context we sought to establish the role of the generic SF-36 health survey in measuring outcomes from spinal surgery. Method: A prospective observational study of patients undergoing elective cervical discectomy, lumbar discectomy, and lumbar laminectomy using both disease specific (Myelopathy Disability Index [MDI], Roland Morris Disability Scale [RMDS], Visual Analogue Scales [VAS], Hospital Anxiety and Depression Scales [HADS]) and SF-36 assessment pre-operatively and at 3 months and 12–24 months following surgery. The generic instrument was tested for the components of construct validity in comparison to the established specific measures. Analysis was performed with non-parametric statistics within SPSS. Results: Six-hundred and twenty patients were followed between 1998 and 2005 (median age 53 years; 203 lumbar discectomy, 177 lumbar laminectomy, 240 cervical discectomy). The principal SF-36 physical domains (Physical Functioning, Bodily Pain) strongly correlated with disease specific scores in all patients (Spearman’s ρ=0.5–0.74, p< 0.001) and similarly SF-36 mental domains correlated with the HADS subscales (ρ=0.30–0.45, p< 0.001) indicating concurrent/convergent validity. Discriminant validity was confirmed by the absence of significant correlation between SF-36 physical domains and the HADS (ρ=0.014–0.14, p> 0.05). In the lumbar laminectomy and cervical discectomy patients disease-specific physical scores prior to surgery strongly predicted early and late outcome (area under the receiver-operating characteristics curve [AUC] = 0.79–0.86, p< 0.001) and the same pattern was mirrored in the SF-36 physical domains (AUC = 0.76–0.78, p< 0.001) demonstrating the predictive validity of the generic measure. Physical Function and Bodily Pain SF-36 domains both had excellent response to change by Cohen’s criteria with effect sizes (standardised mean difference) of 0.86–1.57. Conclusion: The SF-36 has been shown to possess the necessary features of construct validity in relation lumbar and cervical surgery to be considered as a suitable adjunct or alternative to measuring outcome with disease specific scores. As a widely employed HRQoL instrument the SF-36 should be a convenient means of assessing patients with spinal morbidity in all healthcare settings and the generic measure will permit easier comparison of the clinical and economic efficacy of different interventions

Anterior decompression and adequate spine fixation in patients with cervical radiculopathy and myelopathy are essential for functional restoration of cervical spine. In this study, we performed evaluation and comparative radiological assessment of several types of spinal implants in terms of bone block formation, sagittal alignment and effectiveness as a structural support. Materials and Methods: From 1993 to 2003, 165 patients with radiculopathy and myelopathy due to degenerative disease of cervical spine were operated on. The age of patients was 32–74 years (mean age 57, 8). The interbody fusion was performed by several methods. Group1. Autograft – 91 patients. Group 2. TiNi alloy cages – 74 patients. Group 3. Varilift expandable cages without plate fixation – 22 patients. Group 4. Verilift cages with plate fixation – 8 patients. Group 5. Bone substitute spacer and plate fixation – 3 patients. Results: In groups 1 and 2, the bone and bone-metal block was formed during the first 3–4 months after surgery in all patients. There were no cases of bone resorbtion around the TiNi cages or loosening of the device. In patients with one-level (15 patients) interbody fusion by Varilift cages (group 3); formation of the bone block during the same time period was observed in 14 out of 15 patients. In cases with two-level fusion (7 patients), the bone block at the second level was not formed for longer than 6 months. There were 7 cases of subsiding and segmental kyphosis. In group 4, we did not detect any cases of loosening, subsiding or segmental kyphosis. In group 5, no bone block formation was observed after 6 months despite plate fixation. Conclusions: A high fusion rate was achieved after a single or multi-level discectomy and interbody fusion by autograft and TiNi cages, which did not subside due to their design and superelasticity and can therefore be used without plate fixation. Varilift cages were also very effective, but if used without plate fixation may be associated with subsiding effect. The use of the bone substitute spacer is questionable in cervical spine surgery. Cervical plate fixation is effective as a prophylactic measure against segmental kyphosis in all types of interbody fusion

Dysphagia is a common complication of anterior surgery of the cervical spine. The incidence of post-operative dysphagia may be as high as 71% within the first two weeks after surgery, but gradually decreases during the following months. However, 12% to 14% of patients may have some persistent dysphagia one year after the procedure. It has been shown that female gender, advanced age, multilevel surgery, longer operating time and severe pre-operative neck pain may be risk factors. Although the aetiology remains unclear and is probably multifactorial, proposed causes include oesophageal retraction, prominence of the cervical plate and prevertebral swelling. Recently, pre-operative tracheal traction exercises and the use of retropharyngeal steroids have been proposed as methods of reducing post-operative dysphagia.

We performed a systematic review to assess the incidence, aetiology, risk factors, methods of assessment and management of dysphagia following anterior cervical spinal surgery.

Cite this article: Bone Joint J 2013;95-B:868–73.

Aims

We aimed to evaluate the temperature around the nerve root during drilling of the lamina and to determine whether irrigation during drilling can reduce the chance of nerve root injury.

Wrong-level surgery is a unique pitfall in spinal surgery and is part of the wider field of wrong-site surgery. Wrong-site surgery affects both patients and surgeons and has received much media attention. We performed this systematic review to determine the incidence and prevalence of wrong-level procedures in spinal surgery and to identify effective prevention strategies. We retrieved 12 studies reporting the incidence or prevalence of wrong-site surgery and that provided information about prevention strategies. Of these, ten studies were performed on patients undergoing lumbar spine surgery and two on patients undergoing lumbar, thoracic or cervical spine procedures. A higher frequency of wrong-level surgery in lumbar procedures than in cervical procedures was found. Only one study assessed preventative strategies for wrong-site surgery, demonstrating that current site-verification protocols did not prevent about one-third of the cases. The current literature does not provide a definitive estimate of the occurrence of wrong-site spinal surgery, and there is no published evidence to support the effectiveness of site-verification protocols. Further prevention strategies need to be developed to reduce the risk of wrong-site surgery.

The effective capture of outcome measures in the healthcare setting can be traced back to Florence Nightingale’s investigation of the in-patient mortality of soldiers wounded in the Crimean war in the 1850s.

Only relatively recently has the formalised collection of outcomes data into Registries been recognised as valuable in itself.

With the advent of surgeon league tables and a move towards value based health care, individuals are being driven to collect, store and interpret data.

Following the success of the National Joint Registry, the British Association of Spine Surgeons instituted the British Spine Registry. Since its launch in 2012, over 650 users representing the whole surgical team have registered and during this time, more than 27 000 patients have been entered onto the database.

There has been significant publicity regarding the collection of outcome measures after surgery, including patient-reported scores. Over 12 000 forms have been directly entered by patients themselves, with many more entered by the surgical teams.

Questions abound: who should have access to the data produced by the Registry and how should they use it? How should the results be reported and in what forum?

Cite this article: Bone Joint J 2015;97-B:871–4.

We investigated the incidence of anomalies in the vertebral arteries and Circle of Willis with three-dimensional CT angiography in 55 consecutive patients who had undergone an instrumented posterior fusion of the cervical spine.

We recorded any peri-operative and post-operative complications. The frequency of congenital anomalies was 30.9%, abnormal vertebral artery blood flow was 58.2% and vertebral artery dominance 40%.

The posterior communicating artery was occluded on one side in 41.8% of patients and bilaterally in 38.2%. Variations in the vertebral arteries and Circle of Willis were not significantly related to the presence or absence of posterior communicating arteries. Importantly, 18.2% of patients showed characteristic variations in the Circle of Willis with unilateral vertebral artery stenosis or a dominant vertebral artery, indicating that injury may cause lethal complications. One patient had post-operative cerebellar symptoms due to intra-operative injury of the vertebral artery, and one underwent a different surgical procedure because of insufficient collateral circulation.

Pre-operative assessment of the vertebral arteries and Circle of Willis is essential if a posterior spinal fusion with instrumentation is to be carried out safely.

Cite this article: Bone Joint J 2014;96-B:535–40.

Cerebral venous sinus thrombosis is a rare condition, which is difficult to diagnose. It has not previously been reported following surgery to the cervical spine . We report such a case in a 45-year-old man after cervical disc replacement. A high index of suspicion, with early imaging of the brain and prompt treatment, can produce a favourable outcome, albeit not in this case.

We carried out a prospective study to determine whether the addition of a recombinant human bone morphogenetic protein (rhBMP-2) to a machined allograft spacer would improve the rate of intervertebral body fusion in the spine. We studied 77 patients who were to undergo an interbody fusion with allograft and instrumentation. The first 36 patients received allograft with adjuvant rhBMP-2 (allograft/rhBMP-2 group), and the next 41, allograft and demineralised bone matrix (allograft/demineralised bone matrix group). Each patient was assessed clinically and radiologically both pre-operatively and at each follow-up visit using standard methods. Follow-up continued for two years.

Every patient in the allograft/rhBMP-2 group had fused by six months. However, early graft lucency and significant (> 10%) subsidence were seen radiologically in 27 of 55 levels in this group. The mean graft height subsidence was 27% (13% to 42%) for anterior lumbar interbody fusion, 24% (13% to 40%) for transforaminal lumbar interbody fusion, and 53% (40% to 58%) for anterior cervical discectomy and fusion. Those who had undergone fusion using allograft and demineralised bone matrix lost only a mean of 4.6% (0% to 15%) of their graft height.

Although a high rate of fusion (100%) was achieved with rhBMP-2, significant subsidence occurred in more than half of the levels (23 of 37) in the lumbar spine and 33% (6 of 18) in the cervical spine. A 98% fusion rate (62 of 63 levels) was achieved without rhBMP-2 and without the associated graft subsidence. Consequently, we no longer use rhBMP-2 with allograft in our practice if the allograft has to provide significant structural support.

We have reviewed 1858 patients who had undergone a cervical laminoplasty and identified 43 (2.3%) who had developed a C5 palsy with a MMT (MRC) grade of 0 to 2 in the deltoid, with or without involvement of the biceps, but with no loss of muscular strength in any other muscles. The clinical features and radiological findings of patients with (group P; 43 patients) and without (group C; 100 patients) C5 palsy were compared. CT scanning of group P revealed a significant narrowing of the intervertebral foramen of C5 (p < 0.005) and a larger superior articular process (p < 0.05). On MRI, the posterior shift of the spinal cord at C4–5 was significantly greater in group P, than in group C (p < 0.01).

This study is the first to correlate impairment of the C5 nerve root with a C5 palsy. It may be that early foraminotomy in susceptible individuals and the avoidance of tethering of the cord by excessive laminoplasty may prevent a post-operative palsy of the C5 nerve root.

We evaluated the use of surgical stabilisation for atlantoaxial subluxation after a follow-up of 24 years in 50 rheumatoid patients who had some degree of pain but no major neurological deficit.

The mortality of patients treated by atlantoaxial fusion was significantly lower than for those who received conservative treatment. The deaths resulted from infection or comorbid conditions. The significantly high relative risks of mortality from conservative treatment compared with surgical treatment were mutilating disease and susceptible factors on both of the HLA-DRB1 alleles. Relief from pain and neurological and functional recovery were better, and the radiological degree of atlantoaxial translocation was less in those who were surgically treated compared with those who were not. Two patients had superficial local infections after surgery. We conclude that prophylactic atlantoaxial fusion is better than conservative treatment in these patients.