In multilevel posterior cervical instrumented fusions, extending the fusion across the cervico-thoracic junction at T1 or T2 (CTJ) has been associated with decreased rate of re-operation and pseudarthrosis but with longer surgical time and increased blood loss. The impact on patient reported outcomes (PROs) remains unclear. The primary objective was to determine whether extending the fusion through the CTJ influenced PROs at 3 and 12 months after surgery. Secondary objectives were to compare the number of patients reaching the minimally clinically important difference (MCID) for the PROs and mJOA, operative time duration, intra-operative blood loss (IOBL), length of stay (LOS), discharge disposition, adverse events (AEs), re-operation within 12 months of the surgery, and patient satisfaction. This is a retrospective analysis of prospectively collected data from a multicenter observational cohort study of patients with degenerative cervical myelopathy. Patients who underwent a posterior instrumented fusion of 4 levels of greater (between C2-T2) between January 2015 and October 2020 with 12 months follow-up were included. PROS (NDI, EQ5D, SF-12 PCS and MCS, NRS arm and neck pain) and mJOA were compared using ANCOVA, adjusted for baseline differences. Patient demographics, comorbidities and surgical details were abstracted. Percentafe of patient reaching MCID for these outcomes was compared using chi-square test. Operative duration, IOBL, AEs, re-operation, discharge disposittion, LOS and satisfaction were compared using chi-square test for categorical variables and independent samples t-tests for continuous variables. A total of 206 patients were included in this study (105 patients not crossing the CTJ and 101 crossing the CTJ). Patients who underwent a construct extending through the CTJ were more likely to be female and had worse baseline EQ5D and NDI scores (p> 0.05). When adjusted for baseline difference, there was no statistically significant difference between the two groups for the PROs and mJOA at 3 and 12 months. Surgical duration was longer (p 0.05). Satisfaction with the surgery was high in both groups but significantly different at 12 months (80% versus 72%, p= 0.042 for the group not crossing the CTJ and the group crossing the CTJ, respectively). The percentage of patients reaching MCID for the NDI score was 55% in the non-crossing group versus 69% in the group extending through the CTJ (p= 0.06). Up to 12 months after the surgery, there was no statistically significant differences in PROs between posterior construct extended to or not extended to the upper thoracic spine. The adverse event profile did not differ significantly, but longer surgical time and blood loss were associated with construct extending across the CTJ

A retrospective follow-up study was done, assessing regional practices in acute cervical reduction in hospitals in the Western Cape. The constitutional court ruled on the urgency in managing cervical dislocations, and our task is to ensure that medical treatment is optimized to comply with best medical practice and the apex court. A questionnaire was distributed and completed by emergency departments at each hospital, the results retrieved, analysed, and compared to a similar survey done in 2016. Protocols for managing cervical spine dislocations had improved from 80% having no protocols to only over half of facilities (52,6%) not having protocols in place. Inadequate equipment availability remained a problem with only 50% of facilities having adequate equipment available in 2016 to 43,6% in 2023. 10,3% of participants did not know if there was equipment available. In terms of knowledge, there remained poor formal training with a drop from 93% participants identifying that the main indication to attempt emergency cervical reduction was acute cervical dislocation with worsening neurology, to only 46,2%. However, there was an increase in the number of participants who thought reduction was safe. The same percentage of participants from 2016 to 2023 would attempt emergency cervical reduction if given adequate training. Previously we found that most Western Cape hospitals had inadequate protocols, training, and equipment for cervical reductions. In 2023, more hospitals in the Province have protocols in place for cervical reductions and the same percentage of doctors would attempt emergency cervical reduction with adequate training. However, equipment and training for management of acute cervical dislocations has not improved. We conclude that most Western Cape Hospitals are unprepared to adequately manage acute cervical dislocations

Abstract. Introduction. There is paucity of evidence in predicting outcomes following cervical decompression in patients in octogenerians with cervical myelopathy. Our aim is to analyse the predictive value of Charlson comorbidity index (CCI) on clinical outcomes in this group. Methods. All patients age >80 years who underwent cervical decompression+/−stabilisation between January 2006-December 2021 at University Hospitals of Derby & Burton were included. Logistic regression analysis was performed using JASP. Results. Total 72 patients (n=32 male, n=28 female). Mean age 83.44 ± 3.21 years. 67 patients underwent posterior decompression+ stabilisation & 5 patients had posterior decompression alone. Mean CCI was 5; graded moderate in 32 (44%, CCI=<4) and severe in 40 (55.5%, CCI>4). Mean age and preoperative Nurick grade was similar between moderate and severe groups. Postoperative Nurick grade improved equally in both groups by 0.67 and 0.68 respectively (p=0.403). Mean LOS 16±16.12 days. 5 complications in the moderate group (21.8%) and 8 complications in severe group (21.6%); wound infection (n=7), other infection (n=2), electrolyte derangement (n=2), AKI (n=1), blood transfusion (n=1) and early death (n=3) (p=0.752). 1 early postoperative death <30 days occurred in the moderate group (4.3%) whereas 2 occurred in the severe group (5.3%) (p=0.984). No patients with moderate CCI required nursing home discharge whereas 7.9% of severe patients required this. Conclusion. Both groups benefitted from neurological improvement postoperatively, low 1 year mortality. No difference in hospital stay, complication rate and early mortality between both groups. More patients with severe CCI require nursing care after discharge than those with moderate CCI

The ability to calculate quality-adjusted life-years (QALYs) for degenerative cervical myelopathy (DCM) would enhance treatment decision making and facilitate economic analysis. QALYs are calculated using utilities, or health-related quality-of-life (HRQoL) weights. An instrument designed for cervical myelopathy disease would increase the sensitivity and specificity of HRQoL assessments. The objective of this study is to develop a multi-attribute utility function for the modified Japanese Orthopedic Association (mJOA) Score. We recruited a sample of 760 adults from a market research panel. Using an online discrete choice experiment (DCE), participants rated 8 choice sets based on mJOA health states. A multi-attribute utility function was estimated using a mixed multinomial-logit regression model (MIXL). The sample was partitioned into a training set used for model fitting and validation set used for model evaluation. The regression model demonstrated good predictive performance on the validation set with an AUC of 0.81 (95% CI: 0.80-0.82)). The regression model was used to develop a utility scoring rubric for the mJOA. Regression results revealed that participants did not regard all mJOA domains as equally important. The rank order of importance was (in decreasing order): lower extremity motor function, upper extremity motor function, sphincter function, upper extremity sensation. This study provides a simple technique for converting the mJOA score to utilities and quantify the importance of mJOA domains. The ability to evaluate QALYs for DCM will facilitate economic analysis and patient counseling. Clinicians should use these findings in order to offer treatments that maximize function in the attributes viewed most important by patients

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

Cervical spinal arthrodesis is the standard of care for the treatment of spinal diseases induced neck pain. However, adjacent segment disease (ASD) is the primary postoperative complication, which draws great concerns. At present, controversy still exists for the etiology of ASD. Knowledge of cervical spinal loading pattern after cervical spinal arthrodesis is proposed to be the key to answer these questions. Musculoskeletal (MSK) multi-body dynamics (MBD) models have an opportunity to obtain spinal loading that is very difficult to directly measure in vivo. In present study, a previously validated cervical spine MSK MBD model was developed for simulating cervical spine after single-level anterior arthrodesis at C5-C6 disc level. In this cervical spine model, postoperative sagittal alignment and spine rhythms of each disc level, different from normal healthy subject, were both taken into account. Moreover, the biomechanical properties of facet joints of adjacent levels after anterior arthrodesis were modified according to the experimental results. Dynamic full range of motion (ROM) flexion/extension simulation was performed, where the motion data after arthrodesis was derived from published in-vivo kinematic observations. Meanwhile, the full ROM flexion/extension of normal subject was also simulated by the generic cervical spine model for comparative purpose. The intervertebral compressive and shear forces and loading-sharing distribution (the proportions of intervertebral compressive and shear force and facet joint force) at adjacent levels (C3-C4, C4-C5 and C6-C7 disc levels) were then predicted. By comparison, arthrodesis led to a significant increase of adjacent intervertebral compressive force during the head extension movement. Postoperative intervertebral compressive forces at adjacent levels increased by approximate 20% at the later stage of the head extension movement. However, there was no obvious alteration in adjacent intervertebral compressive force, during the head flexion movement. For the intervertebral shear forces in the anterior-posterior direction, no significant differences were found between the arthrodesis subject and normal subject, during the head flexion/extension movement. Meanwhile, cervical spinal loading-sharing distribution after anterior arthrodesis was altered compared with the normal subject's distribution, during the head extension movement. In the postoperative loading-sharing distribution, the percentage of intervertebral disc forces was further increased as the motion angle increased, compared with normal subject. In conclusion, cervical spinal loading after anterior arthrodesis was significantly increased at adjacent levels, during the head extension movement. Cervical spine musculoskeletal MBD model provides an attempt to comprehend postoperative ASD after anterior arthrodesis from a biomechanical perspective

The best algorithm, measurements, and criteria for screening children with Down syndrome for upper cervical instability are controversial. Many authors have recommended obtaining flexion and extension views. We noted that patients who require surgical stabilization due to myelopathy or cord compression typically have grossly abnormal radiographic measurements on the neutral upright lateral cervical spine radiograph (NUL). This study was designed to determine whether a full series of cervical spine images including flexion/extension lateral radiographs (FEL) was important to avoid missing upper cervical instability. This is a retrospective evaluation of cervical spine images obtained between 2006 and 2012 for the purposes of “screening” children with Down syndrome for evidence of instability. The atlanto-dental interval, space available for cord, and basion axial interval were measured on all films. The Weisel-Rothman measurement was made in the FEL series. Clinical outcome of those with abnormal measurements were reviewed. Sensitivity, specificity, positive and negative predictive values of NUL and FEL x-rays for identifying clinically significant cervical spine instability were calculated. Two-hundred and forty cervical spine series in 213 patients with Down syndrome between the ages of four months and 25 years were reviewed. One hundred and seventy-two children had a NUL view, and 88 of these patients also had FEL views. Only one of 88 patients was found to have an abnormal ADI (≥6mm), SAC (≤14mm), or BAI (>12mm) on an FEL series that did not have an abnormal measurement on the NUL. This patient had no evidence of cord compression or myelopathy. Obtaining a single NUL x-ray is an efficient method for radiographic screening of cervical spine instability. Further evaluation may be required if abnormal measurements are identified on the NUL x-ray. We also propose new “normal” values for the common radiographic measurements used in assessing risk of cervical spine instability in patients with Down syndrome

In February 2004, our institute began to perform routine cervical CT scans in addition to head CT examinations on patients with blunt head trauma who had received high energy injuries. We present the findings of 108 patients who underwent a routine cervical CT within the last year and the usefulness of routine cervical CT examinations is discussed. The present report is, to our knowledge, the only prospective study to examine the utility of routine cervical CT examinations. Among the patients admitted to the emergency room of our institute after receiving high energy injuries, 108 patients had blunt head trauma and underwent a routine cervical CT examination in addition to the head CT examination specified by our original protocol for cervical clearance. The mechanism of injury and the presence of cervical bone lesions were noted in each case. 76 males and 32 females ranging in age from 13 to 77 years (average, 41.0 years) were included in the study. Among these 108 cases, cervical fractures or subluxation were visible in 5 cases on plain films. Although no fractures were seen on the plain films taken in the remaining 103 cases, the additional cervical CT examinations demonstrated 14 cervical fractures in 13 (12.6%) of these cases. For patients with blunt head trauma, a cervical CT examination is not usually performed if no evidence of a cervical fracture is found on plain films and no neurological deficits are present. Nevertheless, the present findings suggest that many cervical fractures may have been missed on plain films in the past, and the routine inclusion of a cervical CT examination in addition to a head CT examination might be appropriate in the evaluation of patients with blunt head trauma who have been involved in a high energy injury

Introduction:. Cervical spondylotic myelopathy (CSM) is a degenerative condition that results in a non-traumatic, progressive and chronic compression of the cervical spinal cord. Surgery is indicated for patients with moderate to severe myelopathy or progressive myelopathy. Literature shows that decompressive surgery halts progression of the condition. We undertook this study to see if there is a worthwhile improvement in function in patients who had spine decompression for cervical spondylotic myelopathy. Material and Method:. From a retrospective review of our medical records, a total of 61 patients had decompressive surgery for cervical myelopathy during the period between January 2008 and January 2014. 11 Patients were excluded because their cervical myelopathy was due to compression from tuberculosis or a tumour. 33 patients had incomplete records. We are reporting on the 17 patients who had complete records. From the patients' notes we recorded the detailed preoperative neurologic examination usually done for these patients in our clinic. This was compared to the neurological examination done at 6 months, 12 months and at more than 2 years follow-up. Where this examination was not adequate, patients were called in for the neurologic examination. Results:. 13 Patients had a Nurick grading of 3 and above pre-operatively and 16 had a Ranawat classification of IIIA and above preoperatively. Post-operatively 14 patients had a Nurick grading of 1 or 0 and 15 had a Ranawat classification of II or I. There was also improvement of the physical signs that are diagnostic of myelopathy. The results were subjected to statistical analysis, but this was not conclusive because of the small numbers. Conclusion:. Decompressive surgery in this small series does not only stop progression of the myelopathy, but also improves neurologic function

Purpose of Study. Debate exists in the literature about the surgical management of sub-axial cervical burst fractures regarding the approach and types of fixation of these injuries. Our Acute Spinal Injury (ASCI) unit prefers anterior only cervical corpectomy and plate fixation in the management of these injuries. The objective of this study was to radiologically assess the long term outcomes (minimum 2 yrs) of our series. Patients and Methods. Patients were identified using the Acute Spinal Injury Unit (ASCI) database that had had anterior only corpectomy and plate fixation for trauma as a standardised procedure between 2006 and 2009. Initial post-op radiological review included the sagittal alignment, hardware characteristics and surgical technique. Radiological review after a minimum of 24 months involved the union, sagittal alignment, hardware characteristics, graft incorporation and adjacent level degeneration at the site of injury. Results. A total of 51 patients were identified but only 11 were available for review at the minimum 24 months. There were 10 males and 1 female with an average age of 28.1years (18–62). The follow up duration was on average 50.6months (27–71) median 60 months. The levels fused were C3-5 (2), C4-6 (5), C5-7 (3), and C4-7 (1 double level). There was NO metalwork failure, NO screw osteolysis and a varying degree of degenerative changes but a 100% FUSION RATE. The average loss of cervical lordosis was 2.5 ° over the follow up period. Conclusion. Anterior stand alone cervical corpectomy and plating alone appears to be a safe, cost effective and time saving alternative in the management of cervical burst fractures in the sub axial spine with no significant long term complications. NO DISCLOSURES

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

The posterior midline approach used in spinal surgery has been associated with a significant rate of wound dehiscence. This study investigates anatomical study of the arterial supply of the cervical and thoracic spinal muscles and overlying skin at each vertebral level. It aimed to provide possible anatomical basis for such wound complications. A dissection and angiographic study was undertaken on 8 cadaveric neck and posterior torso from 6 embalmed and 2 fresh human cadavers. Harvested cadavers were warmed and hydrogen peroxide was injected into the major arteries. Lead oxide contrast mixture was injected in stepwise manner into the subclavian and posterior intercostal arteries of each specimen. Specimens were subsequently cross-sectioned at each vertebral level and bones elevated from the soft tissue. Radiographs were taken at each stage of this process and analysed. The cervical paraspinal muscles were supplied by the deep cervical arteries, transverse cervical arteries and vertebral arteries. The thoracic paraspinal muscles were supplied by the superior intercostal arteries, transverse cervical arteries and posterior intercostal arteries. In the thoracic region, two small vessels provide the longitudinal connection between the segmental arteries and in the cervical region, deep cervical arteries provide such connection from C3 to C6. The arterial vessels supplying the paraspinal muscles on the left and right side anastomose with each other, posterior to the spinous processes in all vertebral levels. At cervical vertebral levels, source arteries travel near the surgical field and are not routinely cauterised; Haematoma is postulated to be the cause of wound complications. At thoracic levels, source arteries travel in the surgical field and tissue ischemia is a contributing factor to wound complications, especially in operations over extensive levels. Post-operative wound complications is a multi-factorial clinical problem, the anatomical findings in this study provide possible explanations for wound dehiscence in the posterior midline approach. It is postulated that drain tubes may reduce the incidence of haematoma in the cervical level

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

Purpopse. Few Cervical Total Disc Replacement (TDR) devices are engineered to address both the Center of Balance (COB) and the Center of Rotation (COR) of the cervical motion segments. The COB is the axis in the intervertebral disc through which the axial compressive load is transmitted. TDRs placed posterior of this point tend to fall into kyphosis while devices placed anterior of this point tend to fall into lordosis. Thus from a “balancing” point of view the ideal placement would be at the COB. However, the COR position has been shown to be posterior and inferior to the disc space. It has also been shown that constrained devices tend to lose motion when there is a mismatch between device and anatomic centers. Mobile core devices may be placed at the COB since their unconstrained rotations and translations allow for the device COR to follow the anatomic COR, but they rely heavily on the facet joints and other anatomic features to resist the paradoxiacal motion. The TriLobe cervical TDR (Figure 2) was engineered for both the COB and COR. The purpose of this study was to compare the 3D kinematic and biomechanical performance of the TriLobe to a ball and trough(BT) cervical TDR in an augmented pure moment cadaveric study to find the ideal AP implant placement. Materials and methods. Specimen were CT imaged for three-dimensional reconstruction. Visual, CT, and DEXA screening was utilized to verify that specimens are free from any defects. Specimens were prepared by resecting all nonligamentous soft tissue leaving the facet joint capsules and spinal ligaments intact. C2 and T1 were potted to facilitate mounting in the testing apparatus (7-axis Spine Tester, Univ. of Utah, Salt Lake City, UT). OptoTRAK motion tracking flags were attached to each vertebra including C2/C3 and T1 to track the 3D motion of each vertebra. •. Specimens C2–T1. •. Treatment Level C5–C6. •. Insertion of fixture pins under fluoro. •. Load Control Testing to 2.5Nm in FE, LB, AR at 0.5Hz. •. 15 Pre-cycles in load control in FE / LB / AR (2.5Nm). •. Test implants in load control in FE / LB / AR to 2.5Nm for 4 cycles with data recorded for all cycles. Results. [Results Table - Figure 1]. Discussion. This study showed that the TriLobe had better control of motion compared to the ball and trough both in ROM and varibility for FE, LB, and AR. The TriLobe had better control of limiting kyphosis over the ball and trough by 41% of the flexion motion. The neutral zone slope, an measure for device stability, showed that the TriLobe was 51% more stable than the BT. AP placement of devices showed there was a general trend of decreasing stability from anterior to posterior placement; however, statistical significance was not established

The use of cervical pedicle screws as anchors in posterior reconstruction surgery has not been widely accepted due to the neurological or vascular injury. We thus sought to investigate the accuracy of free-handed pedicle screw placement in the cervical and upper thoracic spine at the early stage of clinical application. Eight patients (five males and three females) were included in this study. Mean age was 63 years (31 to 78 years). There were three patients with rheumatoid arthritis, three with cervical fracture-dislocation, and two with spinal metastasis. Twenty-four pedicle screws (3.5 mm diameter: Vertex, Medtronic Sofamordanek) were placed into the pedicle from C2 to T2 level by free-handed technique2). Grade of breaching of pedicle cortex was divided into four groups (Grade 0–3). In addition, screw axis angle (SAA) were calculated from the horizontal and sagittal CT images and compared with pedicle transverse angle (PTA). Furthermore, perioperative complications were also examined. Our free-handed pedicle screw placement with carving technique is as follows: A longitudinal gutter was created at the lamina-lateral mass junction and then transverse gutter perpendicular to the longitudinal gutter was made at the lateral notch of lateral mass. The entry point of the pedicle screw was on the midline of lateral mass. Medial pedicle cortex through the ventral lamina was identified using the probes to create the hole within the pedicle. The hole was tapped and the screw was gently introduced into the pedicle to ensure the sagittal trajectory using fluoroscopy. In the transverse direction, 22 out of 24 screws (92%) were entirely contained within the pedicle (Grade 0). In contrast, only teo screws (8%) produced breaches less than half the screw diameter (Grade 1). In the sagittal direction, all screws were within the pedicle (Grade 0). Screw trajectories were not consistent with anatomical pedicle axis angle; the mean SAA were smaller than the mean PTA at all levels. The pedicle diameter ranged from 3.9 to 9.2 mm. The mean value gradually increased toward the caudal level. There were no neurological and vascular complications related to screw placement

Cervical spine fusion have gained interest in the literature since these procedures are now ever more frequently being performed in an outpatient setting with few complications and acceptable results. The purpose of this study was to assess the rate of blood transfusion after cervical fusion surgery, and its effect, if any on complication rates. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent cervical fusion surgery from 2010 to 2013. Univariate and multivariate regression analysis was used to determine post-operative complications associated with transfusion and cervical fusion. We identified 11,588 patients who had cervical spine fusion between 2010 and 2013. The overall rate of transfusion was found to be 1.47%. All transfused patients were found to have increased risk of: venous thromboembolism (TBE) (OR 3.19, CI: 1.16–8.77), myocardial infarction (MI) (OR 9.12, CI: 2.53–32.8), increased length of stay (LOS) (OR 28.03, CI: 14.28–55.01) and mortality (OR 4.14, CI: 1.44–11.93). Single level fusion had increased risk of: TBE (OR 3.37, CI: 1.01–11.33), MI (OR 10.5, CI: 1.88–59.89), and LOS (OR 14.79, CI: 8.2–26.67). Multilevel fusion had increased risk of: TBE (OR 5.64, CI: 1.15–27.6), surgical site infection (OR 16.29, CI: 3.34–79.49), MI (OR 10.84, CI: 2.01–58.55), LOS (OR 26.56, CI: 11.8–59.78) and mortality (OR 10.24, CI: 2.45–42.71). ACDF surgery had an increased risk of: TBE (OR 4.87, CI: 1.04–22.82), surgical site infection (OR 9.73, CI: 2.14–44.1), MI (OR 9.88, CI: 1.87–52.2), LOS (OR 28.34, CI: 13.79–58.21) and mortality (OR 6.3, CI: 1.76–22.48). Posterior fusion surgery had increased risk of: MI (OR 10.45, CI: 1.42–77.12) and LOS (OR 4.42, CI: 2.68–7.29). Our results demonstrate that although cervical fusions can be done as outpatient procedures special precautions and investigations should be done for patients who receive transfusion after cervical fusion surgery. These patients are demonstrated to have higher rate of MI, DVT, wound infection and mortality when compared to those who do not receive transfusion

INTRODUCTION:. As a consequence from cervical arthroplasty, spine structural stiffness, loading and kinematics are changed, resulting in issues like adjacent segment degeneration and altered range of motion. However, complex anatomical structures and lack of adequate precision to study the facet joint (FJ) segmental motion in 3D have prevented proper quantitative analyses. In the current study, we investigate the innovative use of a local coordinate system on the surface of the superior articular process of the caudal vertebral body in order to analyze FJ segmental motion using CT-based 3D vertebral models in flexion/extension. METHODS:. CT images were obtained from six patients (2F/4M, mean age: 53 y.o.) with cervical degenerative disc disease in neutral, flexion and extension positions. CT data was used to create subject-specific surface mesh models of each vertebral body. From these, mean normal vectors were calculated for all FJ surfaces and posterior walls from C3/4 down to C6/7 (Fig. 1). The global coordinate system (x, y, z) corresponds to the CT scanner. Within this system, a new local coordinate system (u, v, w) was set on the centroid of each FJ surface (Fig. 1), where the u-, v-, and w- axes correspond to the normal-to-the-FJ, right-left and cranio-caudal directions, respectively. In flexion/extension, translations in mm were calculated as differences in the FJ centroid position and rotations were calculated in degrees as angular differences of the vector of the opposing surface in flexion/extension. Results are presented as mean ± SD. Differences within vertebral levels and left/right FJs were sought using 1- or 2-way ANOVA, respectively. RESULTS:. The flexion/extension segmental motion was described in its six degrees-of-freedom. Among the three translations, the largest movement was observed in the cranio-caudal direction (u = −0.22 ± 0.47 mm, v = 0.11 ± 0.89 mm, w = −2.06 ± 1.60 mm); while the three rotations about the (u, v, w) axes showed a dominant rotation about the v-axis (u = −0.41 ± 4.42°, v = −5.12 ± 5.61°, w = −0.01 ± 2.71°). Comparing translational and rotational motions by cervical level, movements at C6/7 were shown to be smaller than those at the other levels (p < 0.05) (Figs. 2, 3). There were no significant differences in the movement of the FJ between left and right sides (p > 0.05). DISCUSSION:. A key finding of this study was that along with the expected translation in the w-axis, there was rotation about the v-axis consistent with the overall neck flexion-to-extension motion. If the rotation about the v-axes were negligible, the FJ motion could be considered as a pure translation (sliding), but the data suggests otherwise. This finding supports the hypothesis of a rolling-sliding type of facet segmental motion that might be influenced by the facet surface curvature. Future studies will focus on analyses of the changes in FJ gap with motion and characterization of the facet surfaces' curvature and congruence. SIGNIFICANCE: An innovative look into flexion/extension motion from the FJ point of view describes FJ segmental motion as a sliding-rolling motion instead of the traditional concept of sliding-only mechanism

The aim of the study was to highlight the absence of an important pitfall in the Advanced Trauma Life Support protocol in application of rigid collar to patients with potentially unstable cervical spine injury. We present a case series of two patients with ankylosed cervical spines who developed neurological complications following application of rigid collar for cervical spine injuries as per the ATLS protocol. This has been followed up with a survey of A&E and T&O doctors who regularly apply cervical collars for suspected unstable cervical spine injuries. The survey was conducted telephonically using a standard questionnaire. 75 doctors completed the questionnaire. A&E doctors = 42, T&O = 33. Junior grade = 38, middle grade = 37. Trauma management frontline experience >1yr = 50, <1yr = 25. Of the 75 respondents 68/75 (90.6%) would follow the ATLS protocol in applying rigid collar in potentially unstable cervical spine injuries. 58/75 (77.3%) would clinically assess the patient prior to applying collar. Only 43/75 (57.3%) thought the patients relevant past medical history would influence collar application. Respondents were asked whether they were aware of any pitfalls to rigid collar application in suspected neck injuries. 34/75 (45.3%) stated that they were NOT aware of pitfalls. The lack of awareness was even higher 17/25 (68%) amongst doctors with less that 12 months frontline experience. When directly asked whether ankylosing spondylitis should be regarded as a pitfall then only 43/75 (57.3%) answered in the affirmative. We would like to emphasise the disastrous consequences of applying a rigid collar in patients with ankylosed cervical spine. The survey demonstrates the lack of awareness (∼ 50%) amongst A&E and T&O doctors regarding pitfalls to collar application. We recommend the ATLS manual highlight a pitfall for application of rigid collars in patients with ankylosed spines and suspected cervical spine injuries

Spondylodiscitis rarely coexists with endocarditis (around 5% of patients with endocarditis). Furthermore, viridans streptococci are not common pathogens of spondylodiscitis and finally the combination of spondylodiscitis and right – sided endocarditis due to viridans streptococci is rare. We present a case of right-sided native valve endocarditis due to Streptococcus mutans presenting as cervical and lumbar spondylodiscitis in a patient with obstructive cardiomyopathy. A 52 year – old man with a history of hypertrophic obstructive cardiomyopathy was admitted with fever and back pain of ten days duration, followed by torticollis. He had undergone dental therapy some weeks before symptom appearance, due to bad oral hygiene, without receiving any chemoprophylaxis. Magnetic resonance imaging revealed L4-L5 and C4-C5 spondylodiscitides. Four blood cultures drawn were all positive for Streptococcus mutans, while fine needle aspiration of the lumbar lesion was unsuccessful. Transesophageal echocardiogram revealed tricuspid and possible pulmonary valve vegetations. The patient was treated with ceftriaxone plus gentamicin for 2 weeks and then ceftriaxone only, for a total of 3 months. He had an uneventful recovery and was referred for cardiosurgical consultation. Physicians managing cases of spondylodiscitides should bear in mind to rule out endocarditis, especially in cases with underlying cardiopathy. The possibility of coexistence is even greater when there is sustained bacteremia and the pathogen isolated from blood cultures is a common pathogen for endocarditis