Tag: Cervical spine

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Randomized controlled trials comparing cervical disc arthroplasty and anterior cervical discectomy and fusion outcomes in degenerative spine disease: a systematic review and meta-analysis

J Neurosurg Spine 43:703–716, 2025

This systematic review and meta-analysis synthesizes randomized controlled trials comparing cervical disc arthroplasty (CDA) with anterior cervical discectomy and fusion (ACDF) for degenerative cervical disc disease. Across 25 RCTs (4530 patients), CDA demonstrated higher overall and neurological success, reduced adjacent-segment disease and fewer reoperations, but increased heterotopic ossification and longer operative times.

The authors performed multilevel meta-analysis and meta-regression to explore heterogeneity, finding myelopathy inclusion and follow-up completeness influenced results; sensitivity analyses excluding industry-funded trials showed consistent findings. Conclusions emphasize CDA’s potential benefits for selected patients while recommending longer-term and subgroup-specific trials.

Cervical Disc Arthroplasty (CDA) vs. Anterior Cervical Discectomy and Fusion (ACDF): CDA shows comparable or potentially greater overall and neurological success rates compared to ACDF for degenerative cervical spine disease.

Motion Preservation: CDA preserves cervical spine range of motion at the operated level, while ACDF is associated with loss of motion and potentially increased risk of adjacent segment degeneration (ASD).

Adjacent Segment Disease (ASD): CDA is associated with a significantly lower rate of ASD compared to ACDF, suggesting a protective effect against degeneration of adjacent spinal segments.

Reoperation Rates: CDA results in lower total reoperation rates compared to ACDF, indicating fewer subsequent surgical interventions.

Heterotopic Ossification (HO): CDA has a significantly higher rate of HO, a complication where bone forms in soft tissue, which can potentially reduce the motion-preserving benefit of the procedure.

Operative Time: CDA procedures are associated with significantly longer operative times than ACDF, with no significant difference in blood loss or hospital length of stay between the two techniques.

Pain and Disability Outcomes: No significant differences were found between CDA and ACDF in terms of improvement in arm pain, neck pain, or disability scores (Neck Disability Index) as measured by patient-reported outcomes.

Patient Selection: The benefits of CDA over ACDF are most applicable to patients with 1-2 level degenerative disease, preserved cervical alignment, and no significant instability or deformity; findings may not generalize to more complex cases.

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Management strategies for cervical schwannomas: a comprehensive review

J Neurosurg Spine 42:650–658, 2025

The review discusses cervical schwannomas, focusing on their pathophysiology, clinical presentation, and management strategies, including surgical resection and stereotactic body radiation therapy (SBRT). It emphasizes the importance of a multidisciplinary approach for optimal patient outcomes and highlights the need for ongoing research.

• Cervical schwannomas are benign tumors originating from Schwann cells, often occurring in the intradural, extramedullary space of the cervical spine.

• MRI is the primary imaging modality for diagnosing schwannomas, characterized by avid Gd uptake and specific radiographic features.

• Surgical resection is the main treatment approach, with gross-total resection preferred to minimize recurrence. Various surgical techniques are available depending on tumor location.

• Stereotactic body radiation therapy (SBRT) is a viable alternative for patients who are not surgical candidates, offering good local control and symptomatic relief.

• Histological analysis distinguishes schwannomas through specific features such as Antoni A and B areas and Verocay bodies. Immunohistochemical stains like S100 and SOX10 aid in diagnosis.

• Multidisciplinary management is crucial, integrating surgical and nonsurgical options to optimize patient outcomes and quality of life.

• Observation may be suitable for asymptomatic patients with slow-growing lesions, with regular monitoring to assess progression.

• Malignant transformation into peripheral nerve sheath tumors is rare but possible, particularly in patients with NF1.

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Current concepts in adult cervical spine deformity surgery

J Neurosurg Spine 40:439–452, 2024

Cervical spine deformity surgery has significantly evolved over recent decades. There has been substantial work performed, which has furthered the true understanding of alignment and advancements in surgical technique and instrumentation.

Concomitantly, understanding of cervical spine pathology and the contributing drivers have also improved, which have influenced the development of classification systems for cervical spine deformity and the development of treatment-guiding algorithms.

This article aims to provide a synopsis of the current knowledge surrounding cervical spine deformity to date, with particular focus on preoperative expected alignment targets, perioperative optimization, and the whole operative strategy.

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Midpoint of C7 Lateral Mass Serves as an Accurate Reference Point for the Placement of T1 Pedicle Screws: An Anatomic Study

Operative Neurosurgery 26:323–329, 2024

Free-hand placement of T1 pedicle screws can often be challenging. A reliable freehand technique for placement of T1 pedicle screws can overcome some of the difficulties associated with poor fluoroscopy in this region. The purpose of this study was to propose a novel anatomic landmark for accurate identification of the T1 entry point using the midpoint of the C7 lateral mass as a reference point. Our hypothesis is that the midpoint of the C7 lateral mass is within 1–2 mm of the center of the T1 pedicle.

METHODS: Using 3-dimensional reconstruction software, the pedicle of T1 and the lateral mass of C7 were isolated to assess the location of the T1 pedicle relative to the C7 lateral mass. Specifically, the distance between the center of the T1 pedicle and the center of the C7 lateral mass was measured on 40 computed tomography scans. Furthermore, a clinical validation of this technique was performed by assessing the postoperative computed tomography scans of 53 patients undergoing cervicothoracic instrumentation. The Gertzbein and Robbins classification system was used to grade the accuracy of T1 pedicle screw placements in all patients using this technique.

RESULTS: The average horizontal deviation + SD from centers of the T1 pedicle and the C7 lateral mass was 0.398 mm ± 0.953 mm. The T1 pedicle on average was slightly medial to the center of the C7 lateral mass. A total of 98.1% of T1 pedicle screws placed in vivo using the free-hand technique were of Grade A.

CONCLUSION: In this article, we demonstrate that the center of the C7 lateral mass overlays the T1 pedicle and the optimal entry point is immediately below the midpoint of the C7 lateral mass. This approach provides a practical and accurate landmark in posterior cervicothoracic spine procedures that reduce the need for additional radiation exposure or increased operative time with image-guided techniques.

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Long-Term Results After Surgery for Degenerative Cervical Myelopathy

Neurosurgery 94:454–460, 2024

Degenerative cervical myelopathy (DCM) is a frequent cause of spinal cord dysfunction, and surgical treatment is considered safe and effective. Long-term results after surgery are limited. This study investigated long-term clinical outcomes through data from the Norwegian registry for spine surgery.

METHODS: Patients operated at the university hospitals serving Central and Northern Norway were approached for long-term follow-up after 3 to 8 years. The primary outcome was change in the Neck Disability Index, and the secondary outcomes were changes in the European Myelopathy Scale score, quality of life (EuroQoL EQ-5D); numeric rating scales (NRS) for headache, neck pain, and arm pain; and perceived benefit of surgery assessed by the Global Perceived Effect scale from 1 year to long-term follow-up.

RESULTS: We included 144 patients operated between January 2013 and June 2018. In total, 123 participants (85.4%) provided patient-reported outcome measures (PROMs) at long-term follow-up. There was no significant change in PROMs from 1 year to long-term follow-up, including Neck Disability Index (mean 1.0, 95% CI À2.1-4.1, P = .53), European Myelopathy Scale score (mean À0.3, 95% CI À0.7-0.1, P = .09), EQ-5D index score (mean À0.02, 95% CI À0.09-0.05, P = .51), NRS neck pain (mean 0.3 95% CI À0.2-0.9, P = .22), NRS arm pain (mean À0.1, 95% CI À0.8-0.5, P = .70), and NRS headache (mean 0.4, 95% CI À0.1-0.9, P = .11). According to Global Perceived Effect assessments, 106/121 patients (87.6%) reported to be stable or improved (“complete recovery,” “much better,” “slightly better,” or “unchanged”) at long-term follow-up compared with 88.1% at 1 year. Dichotomizing the outcome data based on severity of DCM did not demonstrate significant changes either.

CONCLUSION: Long-term follow-up of patients undergoing surgery for DCM demonstrates persistence of statistically significant and clinically meaningful improvement across a wide range of PROMs.

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Effect of workers’ compensation status on pain, disability, quality of life, and return to work after anterior cervical discectomy and fusion: a 1-year propensity score–matched analysis

J Neurosurg Spine 39:822–830, 2023

Patients with workers’ compensation (WC) claims are reported to demonstrate poorer surgical outcomes after lumbar spine surgery. However, outcomes after anterior cervical discectomy and fusion (ACDF) in WC patients remain debatable. The authors aimed to compare outcomes between a propensity score–matched population of WC and non-WC patients who underwent ACDF.

METHODS Patients who underwent 1- to 4-level ACDF were retrospectively reviewed from the prospectively maintained Quality Outcomes Database (QOD). After propensity score matching, 1-year patient satisfaction, physical disability (Neck Disability Index [NDI]), pain (visual analog scale [VAS]), EQ-5D, and return to work were compared between WC and non-WC cohorts.

RESULTS A total of 9957 patients were included (9610 non-WC and 347 WC patients). Patients in the WC cohort were significantly younger (50 ± 9.1 vs 56 ± 11.4 years, p < 0.001), less educated, and were more frequently male, non-Caucasian, and active smokers (29.1% vs 18.1%, p < 0.001), with greater baseline VAS and NDI scores and poorer quality of life (p < 0.001). One-year postoperative improvements in VAS, NDI, EQ-5D, and return-to-work rates and satisfaction were all significantly worse for WC compared with non-WC patients. After adjusting for baseline differences via propensity score matching, WC versus non-WC patients continued to demonstrate worse 3- and 12-month VAS neck pain and NDI (p = 0.010), satisfaction (χ 2 = 4.03, p = 0.045), and delayed return to work (9.3 vs 5.7 weeks, p < 0.001).

CONCLUSIONS WC status was associated with greater 1-year residual disability and axial pain along with delayed return to work, without any difference in quality of life despite having fewer comorbidities and being a younger population. Further studies are needed to determine the societal impact that WC claims have on healthcare delivery in the setting of ACDF.

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Comparison of Clinical Outcomes of Cervical Laminoplasty for Cervical Spondylotic Myelopathy: Double-Door With Lamina Staple, Single-Door With Miniplate, and Double-Door With Spacer—A 2-Year Follow-Up Study

Neurosurgery 92:1259–1268, 2023

There were few studies to compare the outcomes of different types of cervical laminoplasties.

OBJECTIVE: To compare the clinical outcomes of double-door cervical laminoplasty with lamina staple (double-door staple), single-door cervical laminoplasty with miniplate (singledoor miniplate), and double-door cervical laminoplasty with spacer (double-door spacer).

METHODS: The study involved 166 patients with cervical spondylotic myelopathy (CSM). Fifty-two patients underwent double-door staple, 63 patients underwent single-door miniplate, and 51 patients underwent double-door spacer. The clinical outcomes were measured.

RESULTS: There was no significant difference in Japanese Orthopedic Association score among the 3 groups (P > .05). The operation time was significantly shorter in double-door staple and single-door miniplate groups than in the double-door spacer group (P < .005). The estimated blood loss was significantly more in the single-door miniplate group than in double-door staple and double-door spacer groups (P < .005). The expansion ratio of cervical intraspinal cross-sectional area decreased in the order of double-door staple > double-door spacer > single-door miniplate. There were no significant differences in the expansion ratio of dural sac cross-sectional area among the 3 groups.

CONCLUSION: Double-door staple, double-door spacer, and single-door miniplate can achieve favorable clinical outcomes for CSM. The blood loss of double-door staple is less than that of single-door miniplate, and the operation time of double-door staple is shorter than that of double-door spacer. The mean expansion ratio of cervical intraspinal cross-sectional area decreased in the order of double-door staple > double-door spacer > single-door miniplate. Overall, double-door staple is a safe and innovative alternative choice for treatment of CSM.

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Ideal entry point and trajectory for C2 pedicle screw placement in children: a 3D computed tomography study

European Spine Journal (2022) 31:3426–3432

Purpose To identify the ideal entry point for pediatric C2 pedicle screw and to obtain parameters of it for the indication of pediatric atlantoaxial fusion arthrodesis.

Methods The pediatric cervical CT images were reconstructed into the 3D digital models and the C2 vertebrae were separated. The location of ideal entry point and screw placement related linear and angular parameters were assessed on the 3D digital models.

Results A total of 214 pedicles from 107 C2 digital models were analyzed. The average entry point for C2 was 3.80 ± 2.78 mm medial to the lateral notch (LN) and 2.57 ± 1.70 mm superior to the LN. The average pedicle diameter (PD) was 6.02 ± 1.31 mm, and the average pedicle screw length (PSL) was 25.63 ± 3.46 mm. Statistical differences were found between different sex for PD and PSL (P < 0.05). As patient age increases, using the most lateral and inferior edge of the lateral mass as a reference marker, the entry point tends to move medial and cephalad, when using the LN as a reference marker, the entry point tends to move medial and slightly caudad. Univariate linear regression analysis suggested that these linear parameters were associated with age (P < 0.01).

Conclusion In this study, we found that the measurement results of C2 pedicle screw varied based on sex, laterality, and ages for children younger than 18 years. The entry point of the screws facilitating ideal trajectory tends to change in a linear way as a function of age. This information helps the surgeon to establish the specific anatomy related to C2 pedicle screw placement to facilitate fixation in the pediatric patients.

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Longitudinal assessment of segmental motion of the cervical spine following total disc arthroplasty: a comparative analysis of devices

J Neurosurg Spine 37:556–562, 2022

Total disc arthroplasty (TDA) has been shown to be an effective and safe treatment for cervical degenerative disc disease at short- and midterm follow-up. However, there remains a paucity of literature reporting the differences between individual prosthesis designs with regard to device performance. In this study, the authors evaluated the longterm maintenance of segmental range of motion (ROM) at the operative cervical level across a diverse range of TDA devices.

METHODS In this study, the authors retrospectively evaluated all consecutive patients who underwent 1- or 2-level cervical TDA between 2005 and 2020 at a single institution. Patients with a minimum of 6 months of follow-up and lateral flexion/extension radiographs preoperatively, 2 months postoperatively, and at final follow-up were included. Radiographic measurements included static segmental lordosis, segmental range of motion (ROM) on flexion/extension, global cervical (C2–7) ROM on flexion/extension, and disc space height. The paired t-test was used to evaluate improvement in radiographic parameters. Subanalysis between devices was performed using one-way ANCOVA. Significance was determined at p < 0.05.

RESULTS A total of 85 patients (100 discs) were included, with a mean patient age of 46.01 ± 8.82 years and followup of 43.56 ± 39.36 months. Implantations included 22 (22.00%) M6-C, 51 (51.00%) Mobi-C, 14 (14.00%) PCM, and 13 (13.00%) ProDisc-C devices. There were no differences in baseline radiographic parameters between groups. At 2 months postoperatively, PCM provided significantly less segmental lordosis (p = 0.037) and segmental ROM (p = 0.039). At final follow-up, segmental ROM with both the PCM and ProDisc-C devices was significantly less than that with the M6-C and Mobi-C devices (p = 0.015). From preoperatively to 2 months postoperatively, PCM implantation led to a significant loss of lordosis (p < 0.001) and segmental ROM (p = 0.005) relative to the other devices. Moreover, a significantly greater decline in segmental ROM from 2 months postoperatively to final follow-up was seen with ProDiscC, while segmental ROM increased significantly over time with Mobi-C (p = 0.049).

CONCLUSIONS Analysis by TDA device brand demonstrated that motion preservation differs depending on disc design. Certain devices, including M6-C and Mobi-C, improve ROM on flexion/extension from preoperatively to postoperatively and continue to increase slightly at final follow-up. On the other hand, devices such as PCM and ProDisc-C contributed to greater segmental stiffness, with a gradual decline in ROM seen with ProDisc-C. Further studies are needed to understand how much segmental ROM is ideal after TDA for preservation of physiological cervical kinematics.

 

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Artificial intelligence in predicting early‑onset adjacent segment degeneration following anterior cervical discectomy and fusion

European Spine Journal (2022) 31:2104–2114

Anterior cervical discectomy and fusion (ACDF) is a common surgical treatment for degenerative disease in the cervical spine. However, resultant biomechanical alterations may predispose to early-onset adjacent segment degeneration (EO-ASD), which may become symptomatic and require reoperation. This study aimed to develop and validate a machine learning (ML) model to predict EO-ASD following ACDF.

Methods Retrospective review of prospectively collected data of patients undergoing ACDF at a quaternary referral medical center was performed. Patients > 18 years of age with > 6 months of follow-up and complete pre- and postoperative X-ray and MRI imaging were included. An ML-based algorithm was developed to predict EO-ASD based on preoperative demographic, clinical, and radiographic parameters, and model performance was evaluated according to discrimination and overall performance.

Results In total, 366 ACDF patients were included (50.8% male, mean age 51.4 ± 11.1 years). Over 18.7 ± 20.9 months of follow-up, 97 (26.5%) patients developed EO-ASD. The model demonstrated good discrimination and overall performance according to precision (EO-ASD: 0.70, non-ASD: 0.88), recall (EO-ASD: 0.73, non-ASD: 0.87), accuracy (0.82), F1-score (0.79), Brier score (0.203), and AUC (0.794), with C4/C5 posterior disc bulge, C4/C5 anterior disc bulge, C6 posterior superior osteophyte, presence of osteophytes, and C6/C7 anterior disc bulge identified as the most important predictive features.

Conclusions Through an ML approach, the model identified risk factors and predicted development of EO-ASD following ACDF with good discrimination and overall performance. By addressing the shortcomings of traditional statistics, ML techniques can support discovery, clinical decision-making, and precision-based spine care.

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PEEK versus titanium‑coated PEEK cervical cages: fusion rate

Acta Neurochirurgica (2022) 164:1501–1507

Anterior cervical discectomy and fusion (ACDF) is one of the most commonly performed procedures for degenerative cervical disease. The evaluation of fusion status is still not fully standardized, and a variety of measurement methods are used. This study presents our own evaluation of fusion by comparing two types of implants.

Methods A total of 170 disc spaces were operated on in 104 patients using PEEK (polyetheretherketone) cages and titaniumcoated (TC) PEEK cages. Patients were assigned to a specific implant using a randomisation table. Fusion status was evaluated based on functional radiographs and CT scans obtained at 12 months post-surgery. Multivariate mixed-effects logistic regression models were performed to assess the association of type of implant with different fusion rates.

Results At 12 months post-surgery, CT scans were performed in 86 patients (a total of 144 disc spaces) and conventional radiographs were obtained in 102 (a total of 166 disc spaces). Complete fusion was demonstrated in 101 cases (71.1%), partial fusion in 43 cases (29.9%). There were no cases of absence of fusion. A total of 85 PEEK cages (59%) and 59 TCPEEK cages (41%) were implanted. For PEEK cages, complete fusion was seen in 75 (88.2%) disc spaces, compared to 26 (44.1%) achieved with TC-PEEK cages. A significantly higher proportion of complete fusions (B = 15.58; P < 0.0001) after 12 months was observed with PEEK implants compared to TC-PEEK implants.

Conclusion Complete fusion was noted at 12 months post-surgery significantly more frequently with PEEK implants compared to TC-PEEK implants.

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Failure in cervical total disc arthroplasty

The Spine Journal 22 (2022) 353−369

Cervical total disc arthroplasty (TDA) is an alternative procedure to anterior cervical discectomy and fusion that facilitates neural decompression while both preserving motion of the spinal unit and decreasing the risk for degenerative changes at adjacent segments. However, due to its more recent introduction in clinical practice and low complication rates, the modes by which TDA may fail remain to be described.

PURPOSE: This study sought to identify the modes and frequencies of cervical TDA failure in order to propose a novel classification system.

STUDY DESIGN: Retrospective cohort and systematic review.

PATIENT SAMPLE: Patients who underwent single or two-level TDA for cervical radiculopathy or myelopathy at a single institution and in the literature of medium and large prospective studies. OUTCOME MEASURES: Cervical TDA failure, defined as subsequent surgical intervention at the index segment.

METHODS: This study retrospectively reviewed patients who underwent single or two-level TDA for cervical radiculopathy or myelopathy at a single institution to identify the potential implant failure modes. A systematic review and meta-analysis of prospective data in the literature was then performed to further supplement failure mode identification and to describe the rates at which the various failure types occurred. Statistical analysis included betweengroup comparisons of Non-Failed and Failed patients and frequencies of each failure type among Failed patients.

RESULTS: A retrospective review at our institution of 169 patients (201 levels) identified eight failures, for a failure rate of 4.7%. Additionally, seven patients were revised who had the primary surgery at an outside institution. The systematic review of 3976 patients (4525 levels) identified 165 (4.1%) additional failures. Using this data, six primary failure types were classified, with several subtypes. These include recurrent or persistent index-level stenosis (Type I); migration (Type II) presenting as gross extrusion (A) or endplate failure with subsidence/acute fracture (B); instability (Type III) due to mechanical loosening (A), septic loosening (B), or device fracture (C); device motion loss (Type IV) such as “locking” of the device in kyphosis; implantation error (Type V) due to malposition (A) or improper sizing (B); and wear (Type VI) either without osteolysis (A) or with wear-particle-induced osteolysis (B). Stenosis (Type I) was the most common mode of failure found both through retrospective review and in the literature.

CONCLUSIONS: Cervical TDA fails through six primary mechanisms. While rates of certain failures requiring subsequent surgical intervention are low, it is possible that these complications may become more prevalent upon further longitudinal observation. Thus, future application and validation of this classification system is warranted to evaluate how failure frequencies change over time and with larger patient samples. © 2021 Elsevier Inc. All rights reserved.

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Workers’ Compensation Association With Clinical Outcomes After Anterior Cervical Diskectomy and Fusion

Neurosurgery 90:322–328, 2022

Research has suggested that workers’ compensation (WC) status can result in poor outcomes after anterior cervical diskectomy and fusion (ACDF).

OBJECTIVE: To determine the influence WC status has on postoperative clinical outcomes after ACDF.

METHODS: A surgical database was reviewed for patients undergoing primary or revision single-level ACDF. Patients were grouped into WC vs Non-WC, and differences in baseline characteristics were assessed. Postoperative improvement was assessed for differences in mean scores between WC subgroups for visual analog scale (VAS) arm, VAS neck, 12-item Short Form Physical Composite Score, Patient-Reported Outcomes Measurement Information System physical function (PF), and Neck Disability Index (NDI) at preoperative and postoperative time points. Minimum clinically important difference (MCID) achievement was compared between groups.

RESULTS: The patient cohort included 44 with WC and 95 without. The cohort was 40% female with an average age of 48 years and mean body mass index of 30. Mean VAS arm, VAS neck, NDI, 12-item Short-Form Physical Composite Score, and Patient-Reported Outcomes Measurement Information System PF scores differed between groups; however, the difference was not sustained at the 1-yr time point. MCID achievement among WC subgroups was different for VAS arm (6 wk through 6 mo, P = .005), VAS neck (3 and 6 mo, P < .01), and NDI (3 and 6 mo, P < .05). No statistically significant difference was noted between cohorts for overall rates of MCID achievement for all patient-reported outcome measures collected.

CONCLUSION: WC patients reported similar preoperative and 1-yr postoperative neck and arm pain compared with non-WC patients after ACDF. One-yr MCID achievement rates were similar between cohorts for disability and PF scores.

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Surgery for Degenerative Cervical Myelopathy: A Nationwide Registry-Based Observational Study With Patient-Reported Outcomes

Neurosurgery 89:704–711, 2021

Indications and optimal timing for surgical treatment of degenerative cervical myelopathy (DCM) remain unclear, and data from daily clinical practice are warranted.

OBJECTIVE: To investigate clinical outcomes following decompressive surgery for DCM.

METHODS: Data were obtained from the Norwegian Registry for Spine Surgery. The primary outcome was change in the neck disability index (NDI) 1 yr after surgery. Secondary endpoints were the European myelopathy score (EMS), quality of life (EuroQoL 5D [EQ- 5D]), numeric rating scales (NRS) for headache, neck pain, and arm pain, complications, and perceived benefit of surgery assessed by the Global Perceived Effect (GPE) scale.

RESULTS: We included 905 patients operated between January 2012 and June 2018. There were significant improvements in all patient-reported outcome measures (PROMs) including NDI (mean −10.0, 95% CI −11.5 to −8.4, P < .001), EMS (mean 1.0, 95% CI 0.8-1.1, P < .001), EQ-5D index score (mean 0.16, 95% CI 0.13-0.19, P < .001), EQ-5D visual analogue scale (mean 13.8, 95% CI 11.7-15.9, P < .001), headache NRS (mean −1.1, 95% CI −1.4 to −0.8, P < .001), neck pain NRS (mean −1.8, 95% CI −2.0 to −1.5, P < .001), and arm pain NRS (mean −1.7, 95% CI −1.9 to −1.4, P < .001). According to GPE scale assessments, 229/513 patients (44.6%) experienced “complete recovery” or felt “much better” at 1 yr. There were signif- icant improvements in all PROMs for both mild and moderate-to-severe DCM. A total of 251 patients (27.7%) experienced adverse effects within 3 mo.

CONCLUSION: Surgery for DCM is associated with significant and clinically meaningful improvement across a wide range of PROMs.

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Poor Fusion Rates Following Cervical Corpectomy Reconstructed With an Expandable Cage

Neurosurgery 89:617–625, 2021

Expandable cages are often used to reconstruct cervical corpectomies but there are few long-term follow-up studies with large numbers.

OBJECTIVE: To analyze the clinical and radiographic results of cervical corpectomy reconstructed with expandable cages for degenerative stenosis.

METHODS: We performed a retrospective analysis of 78 patients with degenerative cervical stenosis treated with a corpectomy reconstructed with an expandable cage. We evaluated the clinical and radiographic outcomes, as well as complications of the procedure at a minimum 2-yr follow-up.

RESULTS: There was a decrease in the visual analog scale pain average from 75 mm to 8.5mm(P=.02); a decrease in the Neck Disability Index average from55% to 12% (P=.009); and improvement in the Japanese Orthopaedic Association average from 12 to 14 points (P = .01). There was a change in cervical lordosis (Cobb method) average from −9.3◦ to −15.1◦ (P = .002), without significant loss of lordosis (P = .63). The fusion rate, by criteria of theCervical Spine Research Society (CSRS), was low: using dynamic X-rays –50%(n=39/78) and using computed tomography (CT) – 47.4% (n = 37/78). A total of 11 patients (14.1%) suffered complications.

CONCLUSION: To our knowledge, this is the largest series (78)with a minimum 2-yr followup in the literature and the first using the dynamic radiographic and CT criteria endorsed by the CSRS. Using these criteria, our fusion rates were much lower than all previous reports in the literature. Despite this, patient-reported outcomes were reasonable. There was a relatively low incidence of perioperative complications, most of which were likely not implant-specific and there was only 1 case of implant failure.

 

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Odontoid screw placement for Anderson type II odontoid fractures: how do duration from injury to surgery and clinical and radiological factors influence the union rate? A multicenter retrospective study

J Neurosurg Spine 34:27–31, 2021

Anderson type II odontoid fractures are severe conditions, mostly affecting elderly people (≥ 70 years old). Surgery can be performed as a primary treatment or in cases of failed conservative management. This study aimed to investigate how duration from injury to surgery, as well as clinical, radiological, and surgical risk factors, may influence the union rate after anterior odontoid screw placement for Anderson type II odontoid fractures.

METHODS The authors conducted a retrospective multicenter study. Demographic, clinical, surgical, and radiological data of patients who underwent anterior odontoid screw placement for Anderson type II fractures were retrieved from institutional databases. Study exclusion criteria were prolonged corticosteroid drug therapy (> 4 weeks), polytraumatic injuries, oncological diagnosis, and prior cervical spine trauma.

RESULTS Eighty-five patients were included in the present investigation. The union rate was 76.5%, and 73 patients (85.9%) did not report residual instability. Age ≥ 70 years (p < 0.001, OR 6), female gender (p = 0.016, OR 3.61), osteoporosis (p = 0.009, OR 4.02), diabetes (p = 0.056, OR 3.35), fracture diastasis > 1 mm (p < 0.001, OR 8.5), and duration from injury to surgery > 7 days (p = 0.002, OR 48) independently influenced union rate, whereas smoking status (p = 0.677, OR 1.24) and odontoid process angulation > 10° (p = 0.885, OR 0.92) did not.

CONCLUSIONS Although many factors have been reported as influencing the union rate after anterior odontoid screw placement for Anderson type II fractures, duration from injury to surgery > 7 days appears to be the most relevant, resulting in a 48 times higher risk for nonunion. Early surgery appears to be associated with better radiological outcomes, as reported by orthopedic surgeons in other districts. Prospective comparative clinical trials are needed to confirm these results.

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Trajectory of Improvement in Myelopathic Symptoms From 3 to 12 Months Following Surgery for Degenerative Cervical Myelopathy

Neurosurgery 86:763–768, 2020

Degenerative cervical myelopathy (DCM) is a progressive disease resulting fromcervical cord compression. The modified JapaneseOrthopaedic Association (mJOA) is commonly used to grade myelopathic symptoms, but its persistent postoperative improvement has not been previously explored.

OBJECTIVE: To utilize the Quality Outcomes Database (QOD) to evaluate the trajectory of outcomes in those operatively treated for DCM.

METHODS: This study is a retrospective analysis of prospectively collected data. The QOD was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9-13), or severe (<9) categories for their baseline severity of myelopathic symptoms (mJOA scores). A parsimonious multivariable logistic regression model was fitted with 2 points improvement on mJOA from 3- to 12-mo follow-up as the outcome of interest.

RESULTS: A total of 2156 patients who underwent elective surgery for DCM and had complete 3- and 12-mo follow-up were included in our analysis. Patients improved significantly from baseline to 3-mo on their mJOA scores, regardless of their baseline mJOA severity. After adjusting for the relevant preoperative characteristics, the baseline mJOA categories had significant impact on outcome of whether a patient keeps improving in mJOA score from 3 to 12 mo postsurgery. Patient with severe mJOA score at baseline had a higher likelihood of improvement in theirmyelopathic symptoms, compared to patients with mild mJOA score in.

CONCLUSION: Most patients achieve improvement on a shorter follow-up; however, patients with severe symptoms keep on improving until after a longer follow-up. Preoperative identification of such patients helps the clinician settling realistic expectations for each follow-up timepoint.

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Total uncinectomy of the cervical spine with an osteotome

J Neurosurg Spine 31:831–834, 2019

Total uncinate process resection or uncinectomy is often required in the setting of severe foraminal stenosis or cervical kyphosis correction. The proximity of the uncus to the vertebral artery, nerve root, and spinal cord makes this a challenging undertaking. Use of a high-speed burr or ultrasonic bone dissector can be associated with direct injury to the vertebral artery and thermal injury to the surrounding structures. The use of an osteotome is a safe and efficient method of uncinectomy.

Here the authors describe their technique, which is illustrated with an intraoperative video.

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Motorcycle helmets and cervical spine injuries

J Neurosurg Spine 28:607–611, 2018

Motorcycle helmets have been shown to decrease the incidence and severity of traumatic brain injury due to motorcycle crashes. Despite this proven efficacy, some previous reports and speculation suggest that helmet use is associated with a higher likelihood of cervical spine injury (CSI). In this study, the authors examine 1061 cases of motorcycle crash victims who were treated during a 5-year period at a Level 1 trauma center to investigate the association of helmet use with the incidence and severity of CSI. The authors hypothesized that wearing a motorcycle helmet during a motorcycle crash is not associated with an increased risk of CSI and may provide some protective advantage to the wearer.

METHODS The authors performed a retrospective review of all cases in which the patient had been involved in a motorcycle crash and was evaluated at a single Level 1 trauma center in Wisconsin between January 1, 2010, and January 1, 2015. Biometric, clinical, and imaging data were obtained from a trauma registry database. The patients were then divided into 2 distinct groups based on whether or not they were wearing helmets at the time of the accident. Baseline and functional characteristics were compared between the 2 groups. The Student t-test was used for continuous variables, and Pearson’s chi-square analysis was used for categorical variables.

RESULTS In total, 1061 patient charts were examined containing data on 738 unhelmeted (69.6%) and 323 helmeted (30.4%) motorcycle riders. On average, helmeted riders had a much lower Injury Severity Score (p < 0.001). Cervical spine injury occurred in 114 unhelmeted riders (15.4%) compared with only 24 helmeted riders (7.4%) (p < 0.001), with an adjusted odds ratio of 2.3 (95% CI 1.44–3.61, p = 0.0005). In the unhelmeted group, 10.8% of patients were found to have a cervical spine fracture compared with only 4.6% of patients in the helmeted group (p = 0.001). Additionally, ligamentous injury occurred more frequently in unhelmeted riders (1.9% vs 0.3%, p = 0.04). No difference was found in the occurrence of cervical strain, cord contusion, or nerve root injury (all p > 0.05).

CONCLUSIONS The results of this study demonstrate a statistically significant lower likelihood of suffering a CSI among helmeted motorcyclists. Unhelmeted riders sustained a statistically significant higher number of vertebral fractures and ligamentous injuries. The study findings reported here confirm the authors’ hypothesis that helmet use does not increase the risk of developing a cervical spine fracture and may provide some protective advantage.

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