Are Epidural Steroid Injections Beneficial for Patients With Degenerative Lumbar Spondylolisthesis? No abstract available

Odontoid Fractures: A Critical Review of Current Management and Future Directions Odontoid fractures represent one of the most common and controversial injury types affecting the cervical spine, being associated with a high incidence of nonunion, morbidity, and mortality. These complications are especially common and important in elderly patients, for which ideal treatment options are still under debate. Stable fractures in young patients maybe treated conservatively, with immobilization. Although halo-vest has been widely used for their conservative management, studies have shown high rates of complications in the elderly, and therefore current evidence suggests that the conservative management of these fractures should be carried out with a hard cervical collar or cervicothoracic orthosis. Elderly patients with stable fractures have been reported to have better clinical results with surgical treatment. For these and for all patients with unstable fractures, several surgical techniques have been proposed. Anterior odontoid fixation can be used in reducible fractures with ideal fracture patterns, with older patients requiring fixation with 2 screws. In other cases, C1–C2 posterior fixation maybe needed with the best surgical option depending on the reducibility of the fracture and vertebral artery anatomy. In this paper, current evidence on the management of odontoid fractures is discussed, and an algorithm for treatment is proposed.

Percutaneous Unilateral Biportal Endoscopic Spine Surgery Using a 30-Degree Arthroscope in Patients With Severe Lumbar Spinal Stenosis: A Technical Note Background: Unilateral biportal endoscopic surgery (UBESS) for severe lumbar central canal stenosis (LCCS) remains challenging. Objective: To describe the use of UBESS with a 30-degree arthroscope in patients with severe LCCS. Materials and Methods: Working and viewing portals were created in each unilateral paravertebral area at the target interlaminar level. After ensuring the visual field with a 30-degree arthroscope, effective tissue removal was possible through safe access to the bilateral hypertrophic yellow ligament with minimal osteotomy. The authors evaluated 58 patients and analyzed the clinical outcomes using the visual analog scale, Macnab criteria, and self-predicted walking distance. Results: The visual analog scale scores for low back and leg pains decreased from 7.1 to 1.9 and from 7.9 to 1.6, respectively, at 18 months after the procedure. According to the Macnab criteria, “excellent,” “good,” and “fair” results were obtained in 51.7%, 41.4%, and 6.9% subjects, respectively. Before surgery, the subjects could walk a mean of 305.8±468.1 m. After surgery, 43.1% of the patients could walk for >1 hour, whereas the remaining patients could walk 1521.8±1831.1 m. Conclusion: UBESS using a 30-degree arthroscope can be an efficient and safe intervention in patients with severe LCCS.

Comparison Between Stable Sagittal Vertebra and First Lordotic Vertebra Instrumentation for Prevention of Distal Junctional Kyphosis in Scheuermann Disease: Systematic Review and Meta-analysis Study Design: This study was a systematic review and meta-analysis. Objectives: To compare stable sagittal vertebra (SSV) and first lordotic vertebra (FLV) instrumentation for prevention of distal junctional kyphosis (DJK) in Scheuermann disease. Summary of Background Data: The SSV has been increasingly chosen as the lowest instrumented vertebra to prevent DJK, and some studies have provided supportive results. However, other studies demonstrate that lowest instrumented vertebra located in the FLV has similar DJK incidence with the benefit of saving levels. Materials and Methods: Electronic searches of PubMed, Embase, the Cochrane Database, and Web of Science were performed. Radiographic parameters, incidence of DJK, and revision surgery rates were compared between SSV and FLV groups. The odds ratio (OR) was used to identify differences between the groups and P<0.05 was considered statistically significant. Results: Four studies with a total of 173 patients were included. There were no differences between the SSV and FLV groups in most radiographic parameters. The incidence of DJK among 173 patients was 20.8% (36/173). The SSV group demonstrated a significantly lower DJK rate than the FLV group (OR, 0.11; 95% confidence interval, 0.04–0.30; P<0.0001; I2=39%). In this study, 5.9% (5/85) of the SSV group and 43.6% (24/55) of the FLV group developed DJK; 27.8% (10/36) who developed DJK underwent revision surgery, including 25.0% (6/24) in the FLV group and 40.0% (2/5) in the SSV group. The revision surgery rate was lower in the FLV group than in the SSV group, with no statistical difference (OR, 3.27; 95% confidence interval, 0.26–41.73; P=0.36; I2=0%). Conclusions: The overall DJK rate in Scheuermann disease was 20.8%, and 27.8% of DJK patients needed revision surgery. A distal fusion level including the SSV demonstrated a significantly lower DJK rate.

Recovery Process After Anterior Cervical Decompression in Patients With Cervical Spondylotic Myelopathy With Different Natural History Study Design: An observational prospective cohort study. Objective: To investigate the influence of natural history on the recovery of patients with cervical spondylotic myelopathy (CSM) after anterior cervical decompression. Summary of Background Data: The natural history of CSM has not been clearly elucidated, it remains unclear whether the natural history of CSM is associated with the recovery process after surgical treatment. Materials and Methods: Patients with CSM (n=117) after anterior cervical decompression were stratified variously on the basis of natural history features. Baseline and postoperative neurological functions were rated using the Japanese Orthopaedic Association (JOA) and patient-based self-evaluation (PBSE) scores. The minimum and maximum recovery times for sensory function, and motor functions of the upper and lower extremities were analyzed separately at time points 1–60 months after surgery. Results: In all patients, the postoperative JOA and PBSE scores were significantly improved relative to baseline, in which sensory function recovered most quickly, followed by upper-extremity and lower-extremity motor functions. However, when compared with patients whose first symptom onset at the lower extremity, patients with the first onset at the upper extremity required less time to recover lower-extremity motor function, but more time to recover upper-extremity motor function. Patients with rapid progression had significantly lower preoperative and final JOA and PBSE scores compared with patients whose progression was steady or stepwise. Patients with preoperative symptoms ≥1 year had longer recovery time and poorer functional outcomes compared with those symptoms <1 year. Conclusions: In patients with CSM, the location of first symptom onset, progressive velocity of symptom, and duration of preoperative symptoms significantly influenced the recovery process after anterior cervical decompression. Level of Evidence: Level 2—observational prospective study.

A Novel Anatomic Landmark to Assess Adequate Decompression in Anterior Cervical Spine Surgery: The Posterior Endplate Valley (PEV) 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.

Decompression With or Without Fusion for Adjacent Segment Disease Without Instability: Erratum No abstract available

Periapical-dropout Screws Strategy For 3-Dimensional Correction of Lenke 1 Adolescent Idiopathic Scoliosis in Patients Treated by Posterior Spinal Fusion Study Design: This was a single-center, retrospective study. Objective: The objective of this study was to compare periapical-dropout screws strategy (PDSS) with traditional-multilevel pedicle screws strategy (TMSS) for 3-plane correction of Lenke 1 adolescent idiopathic scoliosis deformity. Summary of Background Data: There are limited data in 3-plane correction and the optimal pedicle screw (PS) configuration for Lenke 1 adolescent idiopathic scoliosis surgery. Materials and Methods: Sixty-one consecutive patients with Lenke 1 curves (range: 50–80 degrees), undergoing single-stage posterior spinal fusion with PS fixation, were included. Patients with a minimum follow-up of 1 year were divided into 2 groups according to PS strategy. The PDSS group included 33 patients with PS placement bilaterally at both ends and apex of the construct. The TMSS group included 28 patients with conventional PS placement. Baseline, immediate, and last follow-up demographic, radiographic, and clinical outcomes were analyzed. Radiographic outcomes were assessed in axial (using rib index and apical vertebral rotation using Raimondi ruler and Upasani methods), coronal, and sagittal planes. The implant costs were also evaluated. Results: There were no differences in demographic, preoperative radiographic parameters and levels fused. The number of PSs per level fused was significantly lower in the PDSS group (1.3 vs. 1.4; P=0.0002). At last follow-up, major Cobb correction averaged 79% for the PDSS group and 69.5% for the TMSS group (P=0.001). T2–T12 kyphosis angle changes were 1 degree in the PDSS group and −2.5 degrees in the TMSS group (P=0.35). Rib index correction was 28.2% for the PDSS group and 17.7% for the TMSS group (P=0.02). Upasani grade apical vertebral rotation was significantly better in the PDSS group (0.7 vs. 1.4; P=0.0001). Clinical outcomes evaluated by Scoliosis Research Society-30 scores were similar in both groups. Total implant costs were significantly lower in the PDSS group ($16,852 vs. $18,926; P<0.001). Conclusion: The PDSS construct provides better deformity correction in all 3 planes and helps decrease implant costs compared with the TMSS construct. Thus, the PDSS construct can be considered as a rational strategy and cost-effective technique when treating moderate Lenke 1 curves with posterior spinal fusion.

Comparison of the Effects of Milrinone, Sodium Nitroprusside, and Nitroglycerine for Induced Hypotension in Elderly Patients Undergoing Spine Surgery: A Randomized Controlled Trial Background: The use of induced hypotension is limited because of concerns about hypoperfusion to major organs in elderly patients. The aim of this study was to compare the effects of milrinone with those of other vasodilating hypotensive agents on induced hypotension in elderly patients undergoing spine surgery. Methods: In total, 60 patients older than 60 years who underwent lumbar fusion surgeries were randomized to groups M (milrinone), S (sodium nitroprusside), and N (nitroglycerine). The study drug was infused after perivertebral muscle retraction until complete interbody fusion occurred. The infusion dose was adjusted to achieve a fall of 30% in systolic blood pressure or mean blood pressure to 60 to 65 mm Hg. Intraoperative blood loss, grade of the surgical field, and urine output were recorded. Results: Intraoperative blood loss per fused spine level was 288.5±94.4 mL in group M, 399.8±60.3 mL in group S, and 367.0±122.5 mL in group N (P=0.002). The grade of the surgical field was similar among the 3 groups (P=0.439). Hourly urine output was 1.4±0.5 mL in group M, 0.7±0.3 mL in group S, and 0.9±0.4 mL in group N (P<0.001). Conclusions: The use of milrinone for induced hypotension led to less intraoperative blood loss and higher urine output than the use of sodium nitroprusside or nitroglycerine in elderly patients undergoing spine surgery.

Analysis of Outcomes and Cost of Inpatient and Ambulatory Anterior Cervical Disk Replacement Using a State-level Database Background: Outpatient cervical artificial disk replacement (ADR) is a promising candidate for cost reduction. Several studies have demonstrated low overall complications and minimal readmission in anterior cervical procedures. Objective: The objective of this study was to compare clinical outcomes and cost associated between inpatient and ambulatory setting ADR. Materials and Methods: Outcomes and cost were retrospectively analyzed for patients undergoing elective ADR in California, Florida, and New York from 2009 to 2011 in State Inpatient and Ambulatory Databases. Results: A total of 1789 index ADR procedures were identified in the inpatient database (State Inpatient Databases) compared with 370 procedures in the ambulatory cohort (State Ambulatory Surgery and Services Databases). Ambulatory patients presented to the emergency department 19 times (5.14%) within 30 days of the index procedure compared with 4.2% of inpatients. Four unique patients underwent readmission within 30 days in the ambulatory ADR cohort (1% total) compared with 2.2% in the inpatient ADR group. No ambulatory ADR patients underwent a reoperation within 30 days. Of the inpatient ADR group, 6 unique patients underwent reoperation within 30 days (0.34%, Charlson Comorbidity Index zero=0.28%, Charlson Comorbidity Index>0=0.6%). There was no significant difference in emergency department visit rate, inpatient readmission rate, or reoperation rates within 30 days of the index procedure between outpatient or inpatient ADR. Outpatient ADR is noninferior to inpatient ADR in all clinical outcomes. The direct cost was significantly lower in the outpatient ADR group ($11,059 vs. 17,033; P<0.001). The 90-day cumulative charges were significantly lower in the outpatient ADR group (mean $46,404.03 vs. $80,055; P<0.0001). Conclusions: ADR can be performed in an ambulatory setting with comparable morbidity, readmission rates, and lower costs, to inpatient ADR.