Jennifer Shue

Considerations for Prophylactic Surgery in Asymptomatic Severe Cervical Stenosis

BackgroundCervical spondylotic myelopathy (CSM) is a devastating pathology that can severely impair quality of life. The symptoms in CSM progress slowly and often do not manifest until they become severe and potentially irreversible. There is a consensus that surgical intervention is warranted in symptomatic patients. The recovery of the neurologic deficit after surgical decompression of the spinal cord varies, and halting the progression of the disease remains the principle aim of surgery.Questions/PurposesThe aim of this review is to address the key question of whether or not to intervene in cases that have radiographic evidence of significant cervical stenosis yet are asymptomatic or exhibit minimal symptoms?MethodsThe PubMed databases for publications that addressed asymptomatic cervical spondylotic myelopathy were reviewed. The relevant articles were selected after screening all the resulting abstracts. The references of the relevant articles were then reviewed, and cross references with titles discussing CSM were picked up for review.ResultsThe search identified 14 papers which were reviewed. Seven articles were found to be relevant to the subject in question. Going through the references of the relevant articles, three articles were found to be directly related to the topic in study.ConclusionThere is paucity of evidence to support for or against surgery in the setting of asymptomatic cervical spondylotic myelopathy despite radiographic evidence of severe stenosis. Patient factors such as age, level of activity, and risk of injury should be considered in formulating a management plan. Moreover, the patient should play an integral role in the process of decision making.

Emergent reintubation following elective cervical surgery: A case series

AIM To review cases of emergent reintubation after cervical surgery. METHODS Patients who were emergently intubated in the post-operative period following cervical surgery were identified. The patients’ prospectively documented demographic parameters, medical history and clinical symptoms were ascertained. Pre-operative radiographs were examined for the extent of their pathology. The details of the operative procedure were discerned. RESULTS Eight hundred and eighty patients received anterior- or combined anterior-posterior cervical surgery from 2008-2013. Nine patients (1.02%) required emergent reintubation. The interval between extubation to reintubation was 6.2 h [1-12]. Patients were kept intubated after reintubation for 2.3 d [2-3]. Seven patients displayed moderate postoperative edema. One patient was diagnosed with a compressive hematoma which was subsequently evacuated in the OR. Another patient was diagnosed with a pulmonary effusion and treated with diuretics. One patient received a late debridement for an infected hematoma. Six patients reported residual symptoms and three patients made a complete recovery. CONCLUSION Respiratory compromise is a rare but potentially life threatening complication following cervical surgery. Patients at increased risk should be monitored closely for extended periods of time post-operatively. If the airway is restored adequately in a timely manner through emergent re-intubation, the outcome of the patients is generally favorable.

Evaluation of Aesculap Implant Systems activl Artificial Disc for the treatment of degenerative disc disease

ABSTRACT Introduction: A primary cause of chronic low back pain and disability is lumbar degenerative disc disease (DDD). Surgical treatments are available for DDD including fusion or lumbar total disc replacement (TDR). Lumbar TDR is performed as a motion-preserving alternative to lumbar fusion. There are several marketed lumbar TDR devices including the Aesculap Implant Systems activL Artificial Disc, Charité Artificial Disc and the ProDisc-L Total Disc Replacement. Areas covered: Considering the various surgical options by which lumbar DDD can be managed, here we evaluate the biologic and biomechanical benefits and concerns of the Aesculap activL Artificial Disc. We review the use of the activL Artificial Disc compared to other lumbar TDRs and an alternative to fusion for skeletally mature patients diagnosed with isolated, symptomatic DDD. Expert commentary: Short-term follow-up studies suggest that under the right circumstances and precise patient selection, lumbar TDR with the Aesculap activL Artificial Disc is a safe and effective alternative to lumbar fusion. Long-term clinical data will provide information about the potential for adjacent level disease, effects of implant wear, and indications for revision surgery. Future clinical and biomechanical studies, as well as device-specific long-term outcome and comparison studies, will assist surgical decision making.

Cervical Spinal Fusion: 16-Year Trends in Epidemiology, Indications, and In-Hospital Outcomes by Surgical Approach

BACKGROUND The rate of cervical spinal fusion has been increasing significantly. However, there is a paucity of literature describing trends based on surgical approach using complete population databases. We investigated the approach-based trends in epidemiology, indications, and in-hospital outcomes of cervical spinal fusion. METHODS New Yorks Statewide Planning and Research Cooperative System database was queried to identify patients who underwent primary subaxial cervical fusion from 1997 to 2012. Demographic and clinical information was obtained. Subgroup analyses were performed based on surgical approach: anterior (A), posterior (P), and circumferential (C). RESULTS A total of 87,045 cervical fusions were included. Over the study period, the population-adjusted annual fusion rate increased from 23.7 to 50.6 per 100,000 population (P < 0.001). A fusion was most common (85.2%), followed by P (12.3%), and C (2.5%). Mean ages were 49.8 ± 11.9, 59.9 ± 15.2, and 55.1 ± 14.5 years (P < 0.001), respectively. Although rates remained steady among younger patients, they increased for older patients. Overall, degenerative conditions were the predominant indications for surgery and increased in rate over time. The mean length of stay was: A, 3.1 ± 10.5; P, 9.1 ± 14.1; and C, 14.1 ± 22.5 days (P < 0.001). Rates of in-hospital complications were A, 3.0%; P, 10.5%; and C, 18.9% (P < 0.001), and mortality was A, 0.3%, P, 1.8%, and C, 2.5% (P < 0.001). CONCLUSIONS The rate of subaxial spinal fusions increased 114% from 1997 to 2012 in New York State. Rates remained stable in younger patients but increased in the older population. Preoperative indications and postoperative courses differed significantly among the various approaches, with patients undergoing anterior fusion having better short-term outcomes.

BMI and gender increase risk of sacral fractures after multilevel instrumented spinal fusion compared with bone mineral density and pelvic parameters

BACKGROUND CONTEXT Sacral fractures are a rare but potentially devastating complication. Long-fusion constructs, including the sacrum, that do not extend to the pelvis may result in sacral fractures. Besides established risk factors including gender, age, and number of levels fused, body mass index (BMI), pelvic parameters, and bone mineral density (BMD) have also been proposed as potential risk factors for postoperative sacral fractures. The literature supporting this, however, is limited. PURPOSE The aim of the present study was to assess whether preoperative pelvic parameters, BMI, or BMD of patients with sacral fracture are different compared with age, gender, and fusion level-matched non-fracture controls. STUDY DESIGN/SETTING This is a case-control study. PATIENT SAMPLE Patients undergoing posterior instrumented fusion at a single academic institution between 2002 and 2016 were included in the study. OUTCOME MEASURES The outcome measure was occurrence of a postoperative sacral fracture. METHODS Patients with sacral fractures after posterior instrumented spinal fusion, including the sacrum, were retrospectively identified and matched 2:1 with non-fracture controls based on gender, age, and number of levels fused. Patients with concurrent spinopelvic fixation or missing preoperative computed tomography (CT) imaging were excluded. Preoperative sagittal balance was assessed using lateral radiographs. Quantitative computed tomography (QCT) assessment included standard measurements at L1/L2 and additional experimental measurements of the S1 body and sacral ala. RESULTS Twenty-one patients with sacral fracture were matched to non-fracture controls. The majority of the patients with sacral fracture was female (76.2%) and of advanced age (mean 66.4 years). Fracture and control groups were well matched with respect to gender, age, and number of levels fused. Standard measurements at L1/L2 showed no significant difference in BMD between the fracture and the control groups (109.9 mg/cm3 vs. 116.4 mg/cm3, p=.414). Similarly, there was no significant BMD differences between the groups using the experimental measurements of the S1 body (183.6 mg/cm3 vs. 176.2 mg/cm3, p=.567) and the sacral ala (8.9 mg/cm3 vs. 4.8 mg/cm3, p=.616). Mean preoperative pelvic incidence-lumbar lordosis mismatch and pelvic tilt were not significantly different between the groups. Univariate conditional logistic regression analysis revealed that the odds of experiencing a sacral fracture was approximately six times higher for obese patients compared with normal or underweight patients. After controlling for BMI in multivariate conditional logistic regression models, BMD was still not significantly associated with the odds of experiencing sacral fractures. CONCLUSIONS To our knowledge, this is the first study to assess the association of preoperative BMD measured by QCT, pelvic parameters, and BMI with postoperative sacral fractures in a large patient cohort. Interestingly, our data do not show any difference in preoperative pelvic parameters and BMD between the groups. This is in line with previous reports that indicate only a few patients with sacral fracture after fusion surgery have clear evidence of osteoporosis. Bone mineral density as a measure of bone quantity, rather than bone quality, may not be as important in these fractures as previously thought. Obesity, however, was associated with higher odds of experiencing postoperative sacral fractures. The present study thereby challenges the widespread concept that obesity is a protective factor against fractures in the elderly. In summary, our results suggest that BMI and gender, more than pelvic parameters and BMD, are risk factors for postoperative sacral fractures.

Regional Bone Mineral Density Differences measured by QCT: Does the Standard Clinically Used L1-L2 Average Correlate with the Entire Lumbosacral Spine?

BACKGROUND CONTEXT Quantitative computed tomography (QCT) of the lumbar spine is used as an alternative to dual-energy X-ray absorptiometry in assessing bone mineral density (BMD). The average BMD of L1-L2 is the standard reportable metric used for diagnostic purposes according to current recommendations. The density of L1 and L2 has also been proposed as a reference value for the remaining lumbosacral vertebrae and is commonly used as a surrogate marker for overall bone health. Since regional BMD differences within the spine have been proposed, it is unclear if the L1-L2 average correlates with the remainder of the lumbosacral spine. PURPOSE The aim of this study was to determine possible BMD variations throughout the lumbosacral spine in patients undergoing lumbar fusion and to assess the correlation between the clinically used L1-L2 average and the remaining lumbosacral vertebral levels. STUDY DESIGN/SETTING This is a retrospective case series. PATIENT SAMPLE Patients undergoing posterior lumbar spinal fusion from 2014 to 2017 at a single, academic institution with available preoperative CT imaging were included in this study. OUTCOME MEASURES The outcome measure was BMD measured by QCT. METHODS Standard QCT measurements at the L1 and L2 vertebra and additional experimental measurements of L3, L4, L5, and S1 were performed. Subjects with missing preoperative lumbar spine CT imaging were excluded. The correlations between the L1-L2 average and the other vertebral bodies of the lumbosacral spine (L3, L4, L5, S1) were evaluated. RESULTS In total, 296 consecutive patients (55.4% female, mean age of 63.1 years) with available preoperative CT were included. The vertebral BMD values showed a gradual decrease from L1 to L3 and increase from L4 to S1 (L1=118.8 mg/cm3, L2=116.6 mg/cm3, L3=112.5 mg/cm3, L4=122.4 mg/cm3, L5=135.3 mg/cm3, S1=157.4 mg/cm3). There was strong correlation between the L1-L2 average and the average of the other lumbosacral vertebrae (L3-S1) with a Pearsons correlation coefficient (r=0.85). We also analyzed the correlation between the L1-L2 average and each individual lumbosacral vertebra. Similar relationships were observed (r value, 0.67-0.87), with the strongest correlation between the L1-L2 average and L3 (r=0.87). CONCLUSIONS Our data demonstrate regional BMD differences throughout the lumbosacral spine. Nevertheless, there is high correlation between the clinically used L1-L2 average and the BMD values in the other lumbosacral vertebrae. We, therefore, conclude the standard clinically used L1-L2 BMD average is a useful bone quantity measure of the entire lumbosacral spine in patients undergoing lumbar spinal fusion.

Does the Addition of Either a Lateral or Posterior Interbody Device to Posterior Instrumented Lumbar Fusion Decrease Cost Over a 6-Year Period?:

Study Design: Retrospective case-control study. Objectives: Few studies have compared the costs of single-level (1) posterior instrumented fusion alone (PSF), (2) posterior interbody fusion with PSF (PLIF), and (3) lateral interbody fusion with PSF (circumferential LLIF). The purpose of this study was to compare costs associated with these procedures. Methods: Charts were reviewed and patients followed-up with a telephone questionnaire. Medicare reimbursement data was used for cost estimation from the payer’s perspective. Multivariate survival analysis was performed to assess time to elevated resource use (greater than 90% of study patients or

Effect of Steroid-Soaked Gelatin Sponge on Soft Tissue Swelling Following Anterior Cervical Discectomy and Fusion: A Radiographic Analysis

68 672). Results: A total of 337 patients (PSF, 45; PLIF, 222; circumferential LLIF, 70) were included (63% follow-up at 6 years). PSF and circumferential LLIF patients were 3 times more likely to reach the cutoff value compared with PLIF patients (P = .017). Conclusions: Circumferential LLIF and PSF patients were more likely to have higher resource use than PLIF patients and thus incur greater costs at 6-year follow-up.

Postoperative pain following posterior iliac crest bone graft harvesting in spine surgery: a prospective, randomized trial

Study Design Retrospective radiological review and analysis of 79 patients who underwent primary anterior cervical discectomy and fusion (ACDF) of 2 or 3 levels between 2011 and 2013. Purpose This study aimed to determine the effect of the local placement of a steroid-soaked gelatin sponge after ACDF on prevertebral soft tissue swelling. Overview of Literature Although ACDF has become a popular choice for cervical fusion, the surgical involvement of the delicate anatomy of the neck frequently results in tissue irritation and edema. Swelling of the prevertebral soft tissue may consequently lead to mild-to-severe complications, ranging from dysphonia to dyspnea. Methods Out of the 79 patients who underwent primary ACDF, 52 received a gelatin sponge soaked with 40 mg of Depo-Medrol placed adjacent to the operated cervical levels. Prevertebral soft tissue swelling was detected using postoperative lateral X-ray. The radiographic values were compared to those of 27 patients who did not receive the treatment. Results Soft tissue swelling was markedly decreased in patients who received the placement of the steroid-soaked gelatin sponge next to their fused levels after surgery compared with that in patients who did not receive it. No complications were documented with the use of steroids. Conclusions The placement of a steroid-soaked gelatin sponge markedly reduces postoperative soft tissue swelling following 2- or 3-level primary ACDF.