Sebastian, Arjun S.

Study Design Systematic Review and Meta-analysis Objective The purpose of this study is to synthesize recommendations for perioperative medical management of RA patients and quantify outcomes after spine surgery when compared to patients without RA. Methods A search of available literature on patients with RA and spine surgery was performed. Studies were included if they provided a direct comparison of outcomes between patients undergoing spine surgery with or without RA diagnosis. Meta-analysis was performed on operative time, estimated blood loss, hospital length of stay, overall complications, implant-related complications, reoperation, infection, pseudarthrosis, and adjacent segment disease. Results Included in the analysis were 9 studies with 703 patients with RA undergoing spine surgery and 2569 patients without RA. In RA patients compared to non-RA patients undergoing spine surgery, the relative risk of infection was 2.29 times higher (P = .036), overall complications 1.61 times higher (P < .0001), implant-related complications 3.93 times higher (P = .009), and risk of reoperation 2.45 times higher (P < .0001). Hospital length of stay was 4.6 days longer in RA patients (P < .0001). Conclusions Treatment of spinal pathology in patients with RA carries an increased risk of infection and implant-related complications. Spine-specific guidelines for perioperative management of antirheumatic medication deserve further exploration. All RA patients should be perioperatively co-managed by a rheumatologist. This review helps identify risk profiles in RA specific to spine surgery and may guide future studies seeking to medically optimize RA patients perioperatively.

Study Design: This was a multicenter retrospective cohort study. Objective: The purpose of this study was to compare the surgical and radiographic outcomes of patients undergoing posterior cervical fusion (PCF) with constructs extending from C2 to T2 to patients with constructs extending from C3 to T1. Summary of Background Data: Limited evidence exists regarding the appropriate level of proximal and distal extension of PCF constructs. Methods: A multicenter retrospective cohort study of patients who underwent PCF between 2012 and 2020 was performed. Surgical and radiographic outcomes were compared between those who had C3–T1 or C2–T2 constructs. Results: A total of 155 patients were included in the study (C2–T2: 106 patients, C3–T1: 49 patients). There were no significant differences in demographics or preoperative symptoms between cohorts. Fusion rates were significantly higher in the C2–T2 (93%) than the C3–T1 (80%, P=0.040) cohort. When comparing the C2–T2 to the C3–T1 cohort, the C3–T1 cohort had a significantly greater rate of proximal junctional failure (2% vs. 10%, P=0.006), distal junctional failure (1% vs. 20%, P<0.001) and distal screw loosening (4% vs. 15%, P=0.02). Although ∆C2–C7 sagittal vertical axis increased significantly in both cohorts (C2–T2: 6.2 mm, P=0.04; C3–T1: 8.4 mm, P<0.001), correction did not significantly differ between groups (P=0.32). The C3–T1 cohort had a significantly greater increase in ∆C2 slope (8.0 vs. 3.1 degrees, P=0.03) and ∆C0–C2 Cobb angle (6.4 vs. 1.2 degrees, P=0.04). Conclusion: In patients undergoing PCF, a C2–T2 construct demonstrated lower rates of pseudarthrosis, distal junctional failure, proximal junctional failure, and compensatory upper cervical hyperextension compared with a C3–T1 construct.

OBJECTIVE Hybrid surgery (HS) is the combination of anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) at different levels in the same operation. The aim of this study was to investigate perioperative variables, 30-day postoperative outcomes, and complications of HS in comparison with those of CDA and ACDF. METHODS The authors queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry for patients who underwent multilevel primary HS, CDA, and ACDF for degenerative disc disease from 2015 to 2019. The authors compared these three operations in terms of 30-day postoperative outcomes, specifically readmission and reoperation rates, discharge destination, and complications. RESULTS This analysis included 439 patients who underwent HS, 976 patients who underwent CDA, and 27,460 patients who underwent ACDF. Patients in the HS and CDA groups were younger, had fewer comorbidities, and myelopathy was less often the indication for surgery compared with patients who underwent ACDF. For the HS group, the unplanned readmission rate was 0.7%, index surgery–related reoperation rate was 0.3%, and nonroutine discharge rate was 2.1%. Major and minor complications were also rare, with rates of 0.2% for each. The mean length of stay in the HS group was 1.5 days. The association of HS with better outcomes in univariate analysis was not evident after adjustment for confounding factors. CONCLUSIONS The authors found that HS was noninferior to ACDF and CDA in terms of early postoperative outcomes among patients treated for degenerative disc disease.

Transdiscal screw fixation through the Boachie screw technique at the lumbosacral junction is a well-accepted procedure in the treatment of high-grade spondylolisthesis. This technique allows for partial reduction of the spondylolisthesis, decompression of the neural elements, and reliable posterior lumbosacral fixation. When performed properly, this procedure produces reliable results and high rates of arthrodesis with relief of preoperative neurological symptoms.

Study Design This study is a retrospective case control. Objectives This study aims to determine whether cervical degenerative spondylolisthesis (DS) is associated with increased baseline neck/arm pain and inferior health quality states compared to a similar population without DS. Methods Patient demographics, pre-operative radiographs, and baseline PROMs were reviewed for 315 patients undergoing anterior cervical decompression and fusion (ACDF) with at least 1 year of follow-up. Patients were categorized based on the presence (S) or absence of a spondylolisthesis (NS). Statistically significant variables were further explored using multiple linear regression analysis. Results 49/242 (20%) patients were diagnosed with DS, most commonly at the C4–5 level (27/49). The S group was significantly older than the NS group (58.0 ± 10.7 vs 51.9 ± 9.81, P = .001), but otherwise, no demographic differences were identified. Although a higher degree of C2 slope was found among the S cohort (22.5 ± 8.63 vs 19.8 ± 7.78, P = .044), no differences were identified in terms of preoperative visual analogue scale (VAS) neck pain or NDI. In the univariate analysis, the NS group had significantly increased VAS arm pain relative to the S group (4.93 ± 3.16 vs 3.86 ± 3.30, P = .045), which was no longer significant in the multivariate analysis. Conclusions Although previous reports have suggested an association between cervical DS and neck pain, we could not associate the presence of DS with increased baseline neck or arm pain. Instead, DS appears to be a relatively frequent (20% in this series) age-related condition reflecting radiographic, rather than necessarily clinical, disease.

Study Design Retrospective cohort study Objective Substantial variability in both the measurement and classification of subsidence limits the strength of conclusions that can be drawn from previous studies. The purpose of this study was to precisely characterize patterns of cervical cage subsidence utilizing computed tomography (CT) scans, determine risk factors for cervical cage subsidence, and investigate the impact of subsidence on pseudarthrosis rates. Methods We performed a retrospective review of patients who underwent one- to three-levels of anterior cervical discectomy and fusion (ACDF) utilizing titanium interbodies with anterior plating between the years 2018 and 2020. Subsidence measurements were performed by two independent reviewers on CT scans obtained 6 months postoperatively. Subsidence was then classified as mild if subsidence into the inferior and superior endplate were both ≤2 mm, moderate if the worst subsidence into the inferior or superior endplate was between 2 to 4 mm, or severe if the worst subsidence into the inferior or superior endplate was ≥4 mm. Results A total of 51 patients (100 levels) were included in this study. A total of 48 levels demonstrated mild subsidence (≤2 mm), 38 demonstrated moderate subsidence (2-4 mm), and 14 demonstrated severe subsidence (≥4 mm). Risk factors for severe subsidence included male gender, multilevel constructs, greater mean vertebral height loss, increased cage height, lower Taillard index, and lower screw tip to vertebral body height ratio. Severe subsidence was not associated with an increased rate of pseudarthrosis. Conclusion Following ACDF with titanium cervical cages, subsidence is an anticipated postoperative occurrence and is not associated with an increased risk of pseudarthrosis.

As physician burnout and wellness become increasingly recognized as vital themes for the medical community to address, the topic of chronic work-related conditions in surgeons must be further evaluated. While improving ergonomics and occupational health have been long emphasized in the executive and business worlds, particularly in relation to company morale and productivity, information within the surgical community remains relatively scarce. Chronic peripheral nerve compression syndromes, hand osteoarthritis, cervicalgia and back pain, as well as other repetitive musculoskeletal ailments affect many spinal surgeons. The use of ergonomic training programs, an operating microscope or exoscope, powered instruments for pedicle screw placement, pneumatic Kerrison punches and ultrasonic osteotomes, as well as utilizing multiple surgeons or microbreaks for larger cases comprise several methods by which spinal surgeons can potentially improve workspace health. As such, it is worthwhile exploring these areas to potentially improve operating room ergonomics and overall surgeon longevity.

Background: The surgical management of adult spinal deformity (ASD) is a major surgical undertaking associated with considerable perioperative risk and a substantial complication profile. Although the natural history and risk factors associated with proximal junctional kyphosis (PJK) and proximal junctional failure are widely reported, distal junctional failure (DJF) is less well understood. Study Design: A systematic review was carried out. Objectives: The primary objective is to identify the risk factors associated with DJF. The secondary objective is to delineate the incidence rate and causative factors associated with DJF. Methods: A systematic review of articles in Medline/PubMed and The Cochrane Library databases was performed according to preferred reporting items for systematic reviews and meta-analyses guidelines. Data was collated to determine the prevalence of DJF and overall revision rates, and identify potential risk factors for development of DJF. Results: Twelve studies were included for systematic review. There were 81/2261 (3.6%) cases of DJF. Overall, DJF represented 27.3% of all revision surgeries. Anterior-posterior surgery had a reduced incidence of postoperative DJF [5.0% vs. 8.7%; P=0.08; relative risk (RR)=1.73], as did patients below 60 years of age at the time of surgery (2.9% vs. 3.9%; P=0.09; RR=1.34). There was a higher incidence of DJF among those patients who received interbody fusion (9.9% vs. 5.1%; P=0.06; RR=1.93) compared with those who did not. However, none of these findings reached statistical significance. There were significantly more rates of DJF for fusions ending on L5 compared with constructs fused to the sacrum (11.7% vs. 3.6%; P=0.02; RR=3.28). Conclusions: Cohorts 60 years and above of age at the time of surgery and patients managed with posterior-only fusion or interbody fusion have increased incidences of DJF. Fusion to L5 instead of the sacrum significantly influences DJF rates. However, the quality of available evidence is low and further high-quality studies are required to more robustly analyze the clinical, radiographic, and surgical risk factors associated with the development of DJF after ASD surgery.

Abstract BACKGROUND Low bone mineral density (BMD) on dual energy x-ray absorptiometry (DXA) is likely a risk factor for proximal junctional kyphosis (PJK) and proximal junctional failure (PJF). However, prior instrumentation and degenerative changes can preclude a lumbar BMD measurement. Hounsfield units (HU) represent an alternative method to estimate BMD via targeted measurements at the intended operative levels. OBJECTIVE To determine if patients with lower HU at the upper instrumented vertebrae (UIV) and vertebral body superior to the UIV (UIV + 1) are at greater risk for PJK and PJF. METHODS A retrospective chart review identified patients at least 50 yr of age who underwent instrumented lumbar fusion with pelvic fixation, a UIV from T10 to L2, and a preoperative computed tomography (CT) encompassing the UIV. HU were measured at the UIV, UIV + 1, and the L3-L4 vertebral bodies. RESULTS A total of 150 patients (80 women and 70 men) were included with an average age of 66 yr and average follow-up of 32 mo. Multivariable logistic regression analysis with an area under the curve (AUC) of 0.89 demonstrated HU at the UIV/UIV + 1 as the only independent predictor of PJK/PJF with an odds ratio of 0.94 ( P -value = .031) for a change in a single HU. Patients with HU at UIV/UIV + 1 of <110 (n = 35), 110 to 160 (n = 73), and >160 (n = 42) had a rate of PJK/PJF of 63%, 27%, and 12%, respectively ( P -value < .001). CONCLUSION Patients with lower HU at the UIV and UIV + 1 were significantly associated with PJK and PJF, with an optimal cutoff of 122 HU that maximizes sensitivity and specificity.

Study Design: This was a retrospective chart review. Objective: The objective of this study was to compare the effect of teriparatide on Hounsfield Units (HU) in the cervical spine, thoracic spine, lumbar spine, sacrum, and pelvis. Second, to correlate HU changes at each spinal level with bone mineral density (BMD) on dual-energy x-ray absorptiometry (DXA). Summary of Background Data: HU represent a method to estimate BMD and can be used either separately or in conjunction with BMD from DXA. Materials and Methods: A retrospective chart review included patients who had been treated with at least 6 months of teriparatide. HU were measured in the vertebral bodies of the cervical, thoracic, and lumbosacral spine and iliac crests. Lumbar and femoral neck BMD as measured on DXA was collected when available. Results: One hundred twenty-five patients were identified for analysis with an average age of 67 years who underwent a mean (±SD) of 22±8 months of teriparatide therapy. HU improvement in the cervical spine was 11% (P=0.19), 25% in the thoracic spine (P=0.002), 23% in the lumbar spine (P=0.027), 17% in the sacrum (P=0.11), and 29% in the iliac crests (P=0.09). Lumbar HU correlated better than cervical HU with BMD as measured on DXA. Conclusions: Teriparatide increased average HU in the thoracolumbar spine to a proportionally greater extent than the cervical spine. The cervical spine had a higher baseline starting HU than the thoracolumbar spine. Lumbar HU correlated better than cervical and thoracic HU with BMD as measured on DXA.