Aleem, Ilyas

Study Design Retrospective cohort study of a national database. Objectives This study investigates the association between preoperative antidepressant use and postoperative opioid utilization as well as overall outcomes following primary anterior cervical fusion (ACF) and posterior cervical fusion (PCF). Methods We conducted parallel retrospective cohort analyses utilizing TriNetX for patients aged ≥18 years old with ≥2-year follow-up undergoing primary ACF and PCF between December 31, 2006, and December 31, 2022. Cohorts were thoroughly matched resulting in 4575 ACF and 3497 PCF pairs. Medical outcomes, opioid abuse, healthcare utilization, mechanical and surgical outcomes were assessed through risk ratios (RR), risk differences, P -values, and Kaplan-Meier analysis. Results Antidepressant use was associated with increased new opioid prescriptions from 2 weeks to 2 years (ACF RR 1.090-1.130, P < 0.001; PCF RR 1.060-1.078, P < 0.001), higher hospital readmissions (RR 1.484, P < 0.001), prolonged inpatient stays (RR 1.329, P < 0.001), and ED visits from 6 weeks to 2 years (ACF RR 1.150-1.184, P < 0.001; PCF RR 1.092-1.144, P ≤ 0.034). Postoperative infections were elevated at 2 years (ACF RR 1.679-2.060, P ≤ 0.008; PCF RR 1.375-1.677, P ≤ 0.020). Opioid abuse was higher at 2 years (ACF RR 2.8000, P = 0.003; PCF RR 2.667, P = 0.001), and pulmonary embolism increased in ACF at 2 years (RR 1.633, P = 0.032). Reoperations were elevated at 1 and 2 years (RR 1.238-1.371, P ≤ 0.045), with reduced 2-year reoperation-free survival in ACF ( P = 0.001) and PCF ( P = 0.045). Conclusion Preoperative antidepressant use is associated with significantly increased risks of postoperative opioid utilization and both medical and surgical complications, including sepsis, infections, adjacent segment disease, and reoperations, up to 2 years after primary anterior or posterior cervical fusion.

Study Design: Literature review. Objectives: Surgical site infection (SSI) following spine surgery leads to significant patient morbidity, mortality, and increased health care costs. The purpose of this article is to identify risk factors and strategies to prevent SSIs following spine surgery, with particular focus on avoiding infections in posterior cervical surgery. Methods: We performed a literature review and synthesis to identify methods that can be used to prevent the development of SSI following spine surgery. Specific pearls for preventing infection in posterior cervical spine surgery are also presented. Results: SSI prevention can be divided into patient and surgeon factors. Preoperative patient factors include smoking cessation, tight glycemic control, weight loss, and nutrition optimization. Surgeon factors include screening and treatment for pathologic microorganisms, skin preparation using chlorhexidine and alcohol, antimicrobial prophylaxis, hand hygiene, meticulous surgical technique, frequent irrigation, intrawound vancomycin powder, meticulous multilayered closure, and use of closed suction drains. Conclusion: Prevention of SSI following spine surgery is multifactorial and begins with careful patient selection, preoperative optimization, and meticulous attention to numerous surgical factors. With careful attention to various patient and surgeon factors, it is possible to significantly reduce SSI rates following spine surgery.

Study Design: A retrospective study. Objectives: (1) To assess the reliability of using the posterior endplate valley (PEV) to predict the cranial-caudal location of the cervical pedicle intraoperatively; (2) to assess the impact of age on the cervical PEV-pedicle relationship, interpedicular distance, and foraminal height. Summary of Background Data: The cervical pedicle, which is the anatomic landmark defining the boundaries of the foramen, is hidden from view intraoperatively in the anterior cervical approach, potentially leading to incomplete foraminal decompression. An intraoperative landmark which heralds the location of the pedicle and therefore can be relied upon as a guide for decompression has not been previously described. Methods: We retrospectively reviewed cervical computed tomography images of younger (<50 y) and older (>50 y) patients. Using the coronal reconstructed image taken at the posterior margin of the vertebral body, we constructed a line between the superior aspect of the pedicles and measured the distance from this line to the PEV. Interpedicular distance and foraminal height were also measured. Results: One hundred patients were included in the final analysis. The mean distance (mm) from the pedicular line to the PEV from C3 to C7 respectively was 1.0±0.99, 0.01±0.76, 0.09±0.70, 0.20±0.71, and 0.27±0.79. No significant difference between young and elderly patients was noted (P<0.05). Intervertebral foraminal size was significantly greater in younger compared with elderly patients at all levels except C2–C3. The mean interpedicular distance was 23.05±1.76 mm. Conclusions: This study demonstrates, for the first time, that the PEV is an accurate surgical landmark that is consistently at most 1 mm from the superior aspect of the cervical pedicle in the subaxial spine. Furthermore, this study demonstrated that foraminal height was significantly larger in younger compared with elderly patients at all cervical levels below C3. Level of Evidence: Level 3.

Study Design: Literature review. Objectives: A review of the literature identifying preoperative risk factors for developing surgical site infections after spine surgery and discussion of the preventive strategies to minimize risks. Methods: A review of the literature and synthesis of the data to provide an updated review on the preoperative management of surgical site infection. Results: Preoperative prevention strategies of reducing surgical site infections in spine surgery remains a challenging problem. Careful mitigation of modifiable patient comorbidities, blood glucose control, smoking, obesity, and screening for pathologic microorganisms is paramount to reduce this risk. Individualized antibiotic regimens, skin preparation, and hand hygiene also play a critical role in surgical site infection prevention. Conclusions: This review of the literature discusses the preoperative preventive strategies and risk management techniques of surgical site infections in spine surgery. Significant decreases in surgical site infections after spine surgery have been noted over the past decade due to increased awareness and implementation of the prevention strategies described in this article. However, it is important to recognize that prevention of surgical site infection requires a system-wide approach that includes the hospital system, the surgeon, and the patient. Continued efforts should focus on system-wide implementation programs including careful patient selection, individualized antibiotic treatment algorithms, identification of pathologic organisms, and preoperative decolonization programs to further prevent surgical site infections and optimize patient outcomes.

Study Design: This is a prospective cohort study. Objective: To characterize the accuracy of patient recollection of preoperative symptoms after cervical spine surgery. Summary of Background Data: Recall bias is a well-known source of systematic error. The accuracy of patient recall after cervical spine surgery remains unknown. Methods: Consecutive patients undergoing cervical spine surgery for myelopathy or radiculopathy were enrolled. Neck and arm numeric pain scores and Neck Disability Indices were recorded preoperatively. Patients were asked to recall their preoperative status at either short (<1 y) or long-term (≥1 y) follow-up. Actual and recalled scores were compared using paired t tests and relations were quantified using the Pearson correlation coefficients. Multivariable linear regression was used to identify factors impacting recollection. Results: In total, 73 patients with a mean age of 58.2 years were included. Compared with their preoperative scores, patients showed significant improvement in neck pain [mean difference (MD)=−2.9; 95% confidence intervals (CIs), −3.5 to −2.3], arm pain (MD, −3.4; 95% CI, −4.0 to −2.8), and disability (MD, −12.4%; 95% CI, −16.9 to −7.9). Patient recollection of preoperative status was significantly more severe than actual for neck pain (MD, +1.5; 95% CI, 0.8–2.2), arm pain (MD, +2.3; 95% CI, 1.6–3.0), and disability (MD, +5.8%; 95% CI, 2.4–9.2). Moderate correlation between actual and recalled scores with regard to neck (r=0.41), arm (r=0.50) pain, and disability (r=0.67) was seen. This was maintained across age, sex, and time between date of surgery and recollection. Over 30% of patients switched their predominant symptom from neck-to-arm pain or vice versa on recall of their preoperative symptoms. Conclusions: Relying on patient recollection does not provide an accurate measure of preoperative status after cervical spine surgery. Prospective and not retrospective collection of patient-reported outcomes remain the gold standard to measure and interpret outcomes after cervical spine surgery. Recall bias has the potential to affect patient satisfaction and requires further study.

Study Design. Systematic review and meta-analysis of observational studies. Objective. The aim of the study is to evaluate different treatment modalities in the management of sacrococcygeal chordoma. Summary of Background Data. Chordomas are primary malignant bone tumors associated with considerable morbidity and mortality. Methods. We searched MEDLINE, EMBASE, Cochrane Central-Register of Controlled Trials, and Scopus from inception to July 2015. Eligible studies included patients with sacrococcygeal chordoma treated exclusively with surgery, radiotherapy, or both. Two reviewers independently assessed the eligibility of potential studies, risk of bias, and extracted data. Outcomes of interest were all-cause mortality, progression-free survival, and metastases. We analyzed further surgical outcomes by resection margin. All outcomes were assessed at 60 months and more than 60 months following intervention. Results. We included 33 noncomparative studies reporting on 501 patients (mean age 57 years). Overall mortality rate was (16%) after surgical resection with adjuvant radiotherapy and (28%) after surgical resection, and (43%) after radiotherapy (P = 0.28). All-cause mortality following wide surgical resection was (32%) compared to (40%) after marginal resection (P = 0.51). Overall progression-free survival rate was (58%) after surgical resection with adjuvant radiotherapy and (55%) after surgery (P = 0.92). However, at more than 60 months follow-up, progression-free survival rates were significantly higher (P = 0.024) following surgical resection with adjuvant radiotherapy (74%) in comparison to surgery (55%) and radiotherapy (36%). Overall progression-free survival rates were nonsignificantly higher after wide surgical resection (66%) than marginal resection (33%) (P = 0.16). However, at 60 months follow-up, progression-free survival rates were significantly higher following wide surgical resection (73%) than marginal resection (33%) (P = 0.047). Conclusion. Sacrococcygeal chordoma is a difficult to treat disease entity. Until comparative studies become available, wide surgical resection and multidisciplinary management are the recommended approaches to improve patient outcomes. Level of Evidence: 3

Study Design: Retrospective review. Objectives: This study investigates the prevalence of adverse postsurgical events, or osteoporosis-related complications (ORCs), following spinal fusion. Methods: Patients undergoing primary posterior thoracolumbar or lumbar fusion by 1 of 2 surgeons practicing at a single institution were analyzed from 2007 to 2014. ORCs were defined in one of the following categories: revision surgery, compression fracture, proximal junctional kyphosis, pseudarthrosis, or failure of instrumentation. Patients with a bone mineral density of the hips and/or spine performed within 1 year of the index procedure were included. Patients were stratified into normal bone density, osteopenia, and osteoporosis using WHO guidelines. Patients were excluded if they were younger than 18 years at the time of surgery, with infection, malignancy, skeletal dysplasia, neuromuscular disorders, concomitant or staged anterior-posterior procedure, or fusion performed because of trauma. Results: Out of 140 patients included, the prevalence of normal bone density was 31.4% (44/140), osteopenia 58.6% (82/140), and osteoporosis 10.0% (14/140). There were no differences between groups for gender, age, body mass index, and interbody device rate. The overall prevalence of ORCs was 32.1% (45/140). By group, there was a prevalence of 22.7% (10/44), 32.9% (27/82), and 50.0% (7/14) for normal bone density, osteopenia, and osteoporosis, respectively. These differences were significantly higher for both the osteopenia and osteoporosis groups. Conclusions: Patients with T scores below −1.0 undergoing posterior lumbar fusion have an increased prevalence of ORCs. Consideration of bone density plays a crucial role in patient selection, medical management, and counseling patient expectations.

Study Design. Prospective cohort study. Objective. To characterize the accuracy of patient recollection of preoperative symptoms after lumbar spine surgery. Summary of Background Data. Although patient-reported outcomes have become important in the evaluation of spine surgery patients, the accuracy of patient recall remains unknown. Methods. Patients undergoing lumbar decompression with or without fusion were enrolled. Back and leg Numeric Pain Scores and Oswestry Disability Indices were recorded preoperatively. Patients were asked to recall their preoperative status at a minimum of 1 year after surgery. Actual and recalled scores were compared using paired t tests and relations were quantified using Pearson correlation coefficients. Multivariable linear regression was used to identify factors that affected recollection. Results. Sixty-two patients with a mean age of 66.1 years were included. Compared to their preoperative scores, patients showed significant improvement in back pain (mean difference [MD] = −3.2, 95% CI −4.0 to −2.4), leg pain (MD −3.3, 95% CI −4.3 to −2.2), and disability (MD −25.0%, 95% CI −28.7 to −19.6). Patient recollection of preoperative status was significantly more severe than actual for back pain (MD +2.3, 95% CI 1.5–3.2), leg pain (MD +1.8, 95% CI 0.9–2.7), and disability (MD +9.6%, 95% CI 5.6–14.0). No significant correlation between actual and recalled scores with regards to back (r = 0.18) or leg (r = 0.24) pain and only moderate correlation with disability (r = 0.44) were seen. This was maintained across age, sex, and time between date of surgery and recollection. More than 40% of patients switched their predominant symptom from back pain to leg pain or leg pain to back pain on recall. Conclusion. Relying on patient recollection does not provide an accurate measure of preoperative status after lumbar spine surgery. Recall bias indicates the importance of obtaining true baseline scores and patient-reported outcomes prospectively and not retrospectively. Level of Evidence: 2