Cho, Samuel K.

Study Design: A national prospective cervical spine surgery registry was developed to archive radiographic studies, patient-reported outcome measures (PROMs), and surgical implant data to assess long-term safety. Objective: To describe the design, development, funding, and implementation of a cervical spine data registry for 1000 patients with myelopathy and radiculopathy. Summary of Background Data: While surgery for cervical radiculopathy and myelopathy is safe and effective, there is significant practice variation among spine surgeons. While randomized clinical trials (RCTs) can provide high-quality comparative effectiveness data, RCTs lack the ability to evaluate the safety and effectiveness of various surgical procedures and implants among heterogenous real-world patient populations. The CSRS Registry was designed to collect patient demographics, outcomes, radiographic imaging, surgical approach, and implant data for the purpose of conducting high-quality research. Methods: Patients with cervical myelopathy or radiculopathy were enrolled in the CSRS National Registry. De-identified patient data, validated PROMs, radiographic data, and implant data were collected from multiple clinical sites across the United States. Results: One thousand patients [mean age, 58 y; 456 (46%) women] were enrolled, with 31% follow-up at 1 year. Five hundred ninety-two patients were diagnosed with radiculopathy, 252 with myelopathy, and 156 with radiculopathy and myelopathy. Patients had significant improvements in their PROMs after surgery. At 1 year, the mean NDI score improved from 37.2 to 20.9 ( P <0.001). The mean self-reported P-mJOA score at baseline was 14.2 and improved to 15.2 by 1 year ( P <0.001). Baseline CSDI score was 23.6 and improved with a 1-year decrease to an average score of 13.6 ( P <0.001). There was significant improvement in PROMIS-10 Physical Health score from 41.0 to 45.9 (n=311; P <0.001) at 1-year follow-up. Conclusions: The CSRS Registry has successfully collected clinical outcomes data that is being leveraged for comparative effectiveness research and evaluations of the long-term safety and effectiveness of spinal implants.

Study Design. Secondary analysis of a large administrative database. Objective. The objectives of this study are to: 1) identify the incidence and cause of 90-day readmissions following primary elective lumbar spine surgery, 2) offer insight into potential risk factors that contribute to these readmissions, and 3) quantify the cost associated with these readmissions. Summary of Background Data. As bundled-payment models for the reimbursement of surgical services become more popular in spine, the focus is shifting toward long-term patient outcomes in the context of 90-day episodes of care. With limited data available on national 90-day readmission statistics available, we hope to provide evidence that will aid in the development of more cost-effective perioperative care models. Methods. Using ICD-9 coding, we identified all patients 18 years of age and older in the 2014 Nationwide Readmissions Database (NRD) who underwent an elective, inpatient, primary lumbar spine surgery. Using multivariate logistic regression, we identified independent predictors of 90-day readmission while controlling for a multitude of confounding variables and completed a comparative cost analysis. Results. We identified 169,788 patients who underwent a primary lumbar spine procedure. In total 4268 (2.5%) were readmitted within 90 days. There was no difference in comorbidity burden between cohorts (readmitted vs. not readmitted) as quantified by the Elixhauser Comorbidity index. Independent predictors of increased odds of 90-day readmission were: anemia, uncomplicated diabetes and diabetes with chronic complications, surgical wound disruption and acute myocardial infarction at the time of the index admission, self-pay status, and an anterior surgical approach. Implant complications were identified as the primary related cause of readmission. These readmissions were associated with a significant cost increase. Conclusion. There are clearly identifiable risk factors that increase the odds of hospital readmission within 90 days of primary lumbar spine surgery. An overall 90-day readmission rate of 2.5%, while relatively low, carries significantly increased cost to both the patient and hospital. Level of Evidence: 3

Study Design: Review article. Objectives: A review of the literature on postoperative spinal infections, their diagnosis, and management. Methods: A systematic computerized Medline literature search was performed using PubMed, Cochrane Database of Systematic Reviews, and EMBASE. The electronic databases were searched for publication dates from the last 10 years. The searches were performed from Medical Subject Headings (MeSH) used by the National Library of Medicine. Specifically, MeSH terms “spine,” “infections,” “management,” and “diagnosis” were used. Results: Currently, the gold standard for diagnosis of postoperative spine infection is positive deep wound culture. Many of the current radiologic and laboratory tests can assist with the initial diagnosis and monitoring treatment response. Currently erythrocyte sedimentation rate, C-reactive protein, computed tomography scan, and magnetic resonance imaging with and without contrast are used in combination to establish diagnosis. Management of postoperative spine infection involves thorough surgical debridement and targeted antibiotic therapy. Conclusions: Postoperative spine infection is a not uncommon complication following surgery that may have devastating consequences for a patient’s short- and long-term health. A high index of suspicion is needed to make an early diagnosis.

Abstract: The American Orthopaedic Association-Japanese Orthopaedic Association (AOA-JOA) Traveling Fellowship, which began in 1992 as a collaborative effort between the 2 orthopaedic communities, is aimed at fostering leadership among early-career surgeons through clinical, academic, and cultural exchange. Over 3 weeks, we experienced an extraordinary journey that led us across nearly 800 miles of the picturesque Japanese countryside, with stops at 6 distinguished academic centers. The opportunity to become personally acquainted with orthopaedic leaders in Japan, learn from their experiences, and immerse ourselves in the ancient and storied culture of a beautiful country was one that we will not soon forget. Along the way, we accumulated a wealth of information while enjoying the legendary hospitality of the Japanese people. There is a ubiquitous challenge in delivering cost-effective, accessible health care while maintaining a commitment to education and research. The U.S. orthopaedic community may take solace in the fact that our Japanese colleagues stand with us as partners in this pursuit, and our relationship with them continues to grow stronger through endeavors such as the AOA-JOA Traveling Fellowship. We look forward to honoring our Japanese colleagues in 2017 when we host them in the United States.

Study Design: A multicenter, retrospective review of C5 palsy after cervical spine surgery. Objective: Postoperative C5 palsy is a known complication of cervical decompressive spinal surgery. The goal of this study was to review the incidence, patient characteristics, and outcome of C5 palsy in patients undergoing cervical spine surgery. Methods: We conducted a multicenter, retrospective review of 13 946 patients across 21 centers who received cervical spine surgery (levels C2 to C7) between January 1, 2005, and December 31, 2011, inclusive. P values were calculated using 2-sample t test for continuous variables and χ 2 tests or Fisher exact tests for categorical variables. Results: Of the 13 946 cases reviewed, 59 patients experienced a postoperative C5 palsy. The incidence rate across the 21 sites ranged from 0% to 2.5%. At most recent follow-up, 32 patients reported complete resolution of symptoms (54.2%), 15 had symptoms resolve with residual effects (25.4%), 10 patients did not recover (17.0%), and 2 were lost to follow-up (3.4%). Conclusion: C5 palsy occurred in all surgical approaches and across a variety of diagnoses. The majority of patients had full recovery or recovery with residual effects. This study represents the largest series of North American patients reviewed to date.

Study Design: Retrospective multicenter case series study. Objective: Because cervical dural tears are rare, most surgeons have limited experience with this complication. A multicenter study was performed to better understand the presentation, treatment, and outcomes following cervical dural tears. Methods: Multiple surgeons from 23 institutions retrospectively identified 21 rare complications that occurred between 2005 and 2011, including unintentional cervical dural tears. Demographic data and surgical history were obtained. Clinical outcomes following surgery were assessed, and any reoperations were recorded. Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA), Nurick classification (NuC), and Short-Form 36 (SF36) scores were recorded at baseline and final follow-up at certain centers. All data were collected, collated, and analyzed by a private research organization. Results: There were 109 cases of cervical dural tears among 18 463 surgeries performed. In 101 cases (93%) there was no clinical sequelae following successful dural tear repair. There were statistical improvements ( P < .05) in mJOA and NuC scores, but not NDI or SF36 scores. No specific baseline or operative factors were found to be associated with the occurrence of dural tears. In most cases, no further postoperative treatments of the dural tear were required, while there were 13 patients (12%) that required subsequent treatment of cerebrospinal fluid drainage. Analysis of those requiring further treatments did not identify an optimum treatment strategy for cervical dural tears. Conclusions: In this multicenter study, we report our findings on the largest reported series (n = 109) of cervical dural tears. In a vast majority of cases, no subsequent interventions were required and no clinical sequelae were observed.

Study Design: Multicenter retrospective study. Objectives: To investigate the risk of symptomatic recurrent laryngeal nerve palsy (RLNP) following cervical spine surgery, to examine risk factors for its development, and to report its treatment and outcomes. Methods: A multicenter study from 21 high-volume surgical centers from the AOSpine North America Clinical Research Network was performed. Each center screened for rare complications following cervical spine surgery, including RLNP. Patients were included if they underwent cervical spine surgery (levels from C2 to C7) between January 1, 2005 and December 31, 2011. Data were analyzed with regard to complication treatment and outcome. Cases were compared to a control group from the AOSpine CSM and CSM-I studies. Results: Three centers reported 19 cases of RLNP from a cohort of 1345 patients. The reported incidence of RLNP ranged from 0.6% to 2.9% between these 3 centers. Fifteen patients (79%) in the RLNP group were approached from the left side. Ten patients (52.6%) required treatment for RLNP—6 required medical therapy (steroids), 1 interventional treatment (injection laryngoplasty), and 3 conservative therapy (speech therapy). When examining outcomes, 73.7% (14/19) of cases resolved completely, 15.8% (3/19) resolved with residual effects, and in 10.5% (2/19) of cases this could not be determined. Conclusions: In this multicenter study examining rare complications following cervical spine surgery, the risk of RLNP after cervical spine surgery ranged from 0.6% to 2.9% between centers. Though rare, it was found that 16% of patients may experience partial resolution with residual effects, and 74% resolve completely.