Tag: Surgical outcomes

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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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Surgical outcomes for spinal arachnoid cysts and webs: a case series

Acta Neurochirurgica (2025) 167:248

This retrospective case series found that surgical treatment for spinal arachnoid cysts (SAC) and webs (SAW) resulted in favorable outcomes (mMC I-II) in 90% and 83% of patients, respectively, with low complication and recurrence rates. Surgery should be considered for symptomatic patients.

• Spinal arachnoid cysts (SAC) and spinal arachnoid webs (SAW) are rare intradural pathologies causing pain and myelopathic symptoms.

• MRI is the main diagnostic tool, but distinguishing between SAC and SAW can be difficult; both may show the “scalpel sign”.

• This retrospective study reviewed 35 patients (29 SAC, 6 SAW) treated surgically from 2011–2023.

• Most patients presented with pain, gait disturbance, sensory, or motor deficits; preoperative neurological status was often not severe.

• Surgical treatment (fenestration or resection) led to favorable outcomes (mMC I-II) in 90% of SAC and 83% of SAW patients.

• Complications occurred in 14.7% of SAC cases but resolved without lasting deficits; no complications in SAW group.

• Recurrence was rare (2.7% in SAC, none in SAW) during short-term follow-up.

• Surgery is recommended for symptomatic patients, with generally favorable short-term results, but larger and longer-term studies are needed.

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Factors affecting outcomes following burr hole drainage of chronic subdural hematoma

J Neurosurg 142:1606–1615, 2025

This large single-center retrospective study of 1226 patients found that preoperative factors—age under 80, independence, higher GCS motor score, fewer medications, and lower ASA grade—predict better outcomes after burr hole drainage for chronic subdural hematoma. Surgical drain use and shorter bed rest improved discharge outcomes, but recurrence was not linked to modifiable factors.

• Chronic subdural hematoma (CSDH) is a common neurosurgical condition, especially in elderly patients, and burr hole craniostomy (BHC) is the main surgical treatment.

• This large single-center retrospective study (n=1226) analyzed predictors of outcomes, complications, recurrence, and hospital length of stay (LOS) after BHC for CSDH.

• Favorable short-term outcomes were associated with age <80, preadmission independence, preoperative GCS motor score of 6, fewer than 5 regular medications, and ASA grades I–II.

• Use of a subdural drain and shorter postoperative bed rest (1 day vs 2 days) were linked to better outcomes and higher odds of discharge home.

• No modifiable or nonmodifiable factors, including surgical technique, were significantly associated with CSDH recurrence.

• Polypharmacy (>4 medications) and older age were associated with higher risk of complications and longer hospital LOS.

• Antithrombotic use was not significantly associated with clinical outcomes, recurrence, complications, or LOS.

• Long-term survival was mainly influenced by baseline patient factors (age, independence, GCS-M, ASA grade), not surgical variables.

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Patients May Return to Work Sooner After Laminoplasty: Occupational Outcomes of the Cervical Spondylotic Myelopathy Surgical Trial

Neurosurgery 96:131–141, 2025

Return-to-work (RTW) is an important outcome for employed patients considering surgery for cervical spondylotic myelopathy (CSM). We conducted a post hoc analysis of patients as-treated in the Cervical Spondylotic Myelopathy Surgical Trial, a prospective, randomized trial comparing surgical approaches for CSM to evaluate factors associated with RTW.

METHODS: In the trial, patients were randomized (2:3) to either anterior surgery (anterior cervical decompression/fusion [ACDF]) or posterior surgery (laminoplasty [LP], or posterior cervical decompression/fusion [PCDF], at surgeon’s discretion). Work status was recorded at 1, 3, 6, and 12 months postoperatively. For patients working full-time or part-time on enrollment, time to RTW was compared across as-treated surgical groups using discrete-time survival analysis. Multivariate logistic regression was used to assess predictors of RTW. Clinical outcomes were compared using a linear mixed-effects model. RESULTS: A total of 68 (42%) of 163 patients were working preoperatively and were analyzed. In total, 27 patients underwent ACDF, 29 underwent PCDF, and 12 underwent LP. 45 (66%) of 68 patients returned to work by 12 months. Median time to RTW differed by surgical approach (LP = 1 month, ACDF = 3 months, PCDF = 6 months; P = .02). Patients with longer length-of-stay were less likely to be working at 1 month (odds ratio 0.51; 95% CI, 0.29-0.91; P = .022) and 3 months (odds ratio 0.39; 95% CI, 0.16-0.96; P = .04). At 3 months, PCDF was associated with lower Short-Form 36 physical component summary scores than ACDF (estimated mean difference [EMD]: 6.42; 95% CI, 1.4-11.4; P = .007) and LP (EMD: 7.98; 95% CI, 2.7-13.3; P = .003), and higher Neck Disability Index scores than ACDF (EMD: 12.48; 95% CI, 2.3-22.7; P = .01) and LP (EMD: 15.22; 95% CI, 2.3-28.1; P = .014), indicating worse perceived physical functioning and greater disability, respectively.

CONCLUSION: Most employed patients returned to work within 1 year. LP patients resumed employment earliest, while PCDF patients returned to work latest, with greater disability at follow-up, suggesting that choice of surgical intervention may influence occupational outcomes.

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Posterolateral approaches to the thoracic spine for calcific disc herniation: is wider exposure always better?

Objective To compare the costotransversectomy (CTV) and transpedicular (TP) approaches versus the transfacet (TF) approach for the surgical treatment of calcific thoracic spine herniations (cTDH), in terms of surgical and clinical outcomes.

Background Surgical approaches for cTDH are debated. Anterior approaches are recommended, while posterolateral approaches are preferred for non-calcific, paramedian, and lateral hernias. Currently, there is limited evidence about the superiority of a more invasive surgical approach, such as CTV or TP, over TF, a relatively less invasive approach, in terms of neurological outcome, pain, and surgical complications, for the treatment of cTDH.

Methods A retrospective, observational, monocentric study was conducted on patients who underwent posterolateral thoracic approaches for symptomatic cTDH, between 2010 and 2023, at our institute. Three groups were drafted, based on the surgical approach used: TF, TP, and CTV. All procedures were assisted by intraoperative CT scan, spinal neuronavigation, and intraoperative neuromonitoring. Analyzed factors include duration of surgery, amount of bone removal, intraoperative blood loss, CSF leak, need of instrumentation for iatrogenic instability, degree of disc herniation removal, myelopathy recovery. Afterwards, a statistical analysis was performed to investigate the bony resection of the superior posterior edge of the vertebral soma. The primary outcome was the partial or total herniation removal.

Results This study consecutively enrolled 65 patients who underwent posterolateral thoracic surgery for cTDH. The TF approach taking the least, and the CTV the longest time (p < 0.01). No statistical difference was observed between the three mentioned approaches, in terms of intraoperative blood loss, dural leakage, post-resection instrumentation, total herniation removal, or myelopathy recovery. An additional somatic bony resection was successful in achieving total herniation removal (p < 0.01), and the extent of bony resection was directly proportional to the extent of hernia removal (p < 0.01).

Conclusions No statistically significant differences were highlighted between the TP, TF, and CTV regarding the extent of cTDH removal, the postoperative complications, and the neurological improvement. The described somatic bone resection achieved significant total herniation removal and was directly proportional to the preop against postop anteroposterior diameter difference.

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Mechanical complications and patient-reported outcome measures associated with high pelvic incidence and persistent pelvic retroversion: the Roussouly “false type 2” profile

J Neurosurg Spine May 12, 2023

OBJECTIVE The objective of this paper was to report mechanical complications and patient-reported outcome measures (PROMs) for adult spinal deformity (ASD) patients with a Roussouly “false type 2” (FT2) profile.

METHODS ASD patients treated from 2004 to 2014 at a single center were identified. Inclusion criteria were pelvic incidence ≥ 60° and a minimum 2-year follow-up. FT2 was defined as a high postoperative pelvic tilt (PT), as defined by the Global Alignment and Proportion target, and thoracic kyphosis < 30°. Mechanical complications, defined as proximal junctional kyphosis (PJK) and/or instrumentation failure, were determined and compared. Scoliosis Research Society22r (SRS-22r) scores were compared between groups.

RESULTS Ninety-five patients (normal PT [NPT] group 49, FT2 group 46) who met the inclusion criteria were identified and studied. Most surgeries were revisions (NPT group 30 [61%], FT2 group 30 [65%]), and most were performed via a posterior-only approach (86%) (mean ± SD 9.6 ± 5 levels). Proximal junctional angles increased after surgery in both groups, without differences between groups. Neither rates of radiographic PJK (p = 0.10), revision for PJK (p = 0.45), nor revision for pseudarthrosis (p = 0.66) were different between groups. There were no differences between groups for SRS-22r domain scores or subscores.

CONCLUSIONS In this single-center experience, patients with high pelvic incidence fixed with persistent lumbopelvic parameter mismatch and engaged compensatory mechanisms (Roussouly FT2) had mechanical complications and PROMs not different from those with normalized alignment parameters. Compensatory PT may be acceptable in some cases of ASD surgery.

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Spinal Intradural Arachnoid Cysts in Adults

Neurosurgery 92:450–463, 2023

Adult spinal intradural arachnoid cysts are rare pathologic entities with an unclear etiopathogenesis. These lesions can be dichotomized into primary (idiopathic) or secondary (related to inflammation, intradural surgery, or trauma) etiologies. Limited series have depicted optimal management strategies and clinical outcomes.

OBJECTIVE: To illustrate our experience with spinal intradural arachnoid cysts and to present a literature review of surgically treated cysts to elucidate the clinical and anatomic differences between etiologies.

METHODS: Institutional review revealed 29 patients. Various data were extracted from the medical record. Initial and follow-up symptomatologies of the surgical cohort were compared. The literature review included case series describing cysts managed surgically.

RESULTS: From patients treated surgically at our institution (22), there was a significant reduction in thoracic back pain postoperatively (P = .034). A literature review yielded 271 additional cases. Overall, primary and secondary lesions accounted for 254 and 39 cases, respectively. Cysts of secondary origin were more likely localized ventral to the spinal cord (P = .013). The rate of symptomatic improvement after surgical intervention for primary cysts was more than double than that of secondary cysts (P < .001). Compared with primary etiologies, the rates of radiographic progression (P = .032) and repeat surgery (P = .041) were each more than double for secondary cysts.

CONCLUSION: Surgical intervention for spinal intradural arachnoid cysts improves thoracic back pain. The literature supports surgical intervention for symptomatic primary spinal intradural arachnoid cysts with improved clinical outcomes. Surgery should be cautiously considered for secondary cysts given worse outcomes.

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Thirty-Day Hospital Readmission and Surgical Complication Rates for Shunting in Normal Pressure Hydrocephalus: A Large National Database Analysis

Neurosurgery 86:843–850, 2020

Research on age-related complications secondary to shunts in normal pressure hydrocephalus (NPH) is primarily limited to single-center studies and small cohorts.

OBJECTIVE: To determine the rates of hospital readmission and surgical complications, and factors that predict them, following shunt surgery for NPH in a large healthcare network.

METHODS: Surgical procedures, complications, and readmissions for adults undergoing ventricular shunting for NPH were determined using de-identified claims from a privately insured United States healthcare network in years 2007-2014. Univariate and multivariate statistics were used to determine factors that predict poor surgical outcomes. The primary outcome variable was surgical complications or readmissions (composite variable for any major perioperative complication or 30-d readmission).

RESULTS: The 30-d readmission rate for 974 patients with NPH who underwent ventricular shunting was 7.29%; the most common reasons for readmission were shunt-related complications, infection, hemorrhage, altered mental status, and cardiopulmonary and musculoskeletal problems. The perioperative complication rate was 21.15%, including intraparenchymal hemorrhage (5.85%) and extra-axial (subdural or epidural) hematoma (5.54%). The overall rate of having a surgical complication or 30-d readmission was 25.15%. Age did not predict surgical complication or 30-d readmission. Preoperative comorbidities independently associated with poor outcome were myocardial infarction within 1 yr (OR = 3.984, 95% CI = 1.105-14.368); existing cerebrovascular disease (odds ratio [OR] = 2.206, 95% CI = 1.544-3.152); and moderate/severe renal disease (OR = 2.000, 95% CI = 1.155-3.464).

CONCLUSION: The rate of complications or readmission within 30 d of ventricular shunting for NPH is 25.15%. Preoperative comorbidities of myocardial infarction within 1 yr, cerebrovascular disease, and moderate/severe renal disease are independent risk factors for poor outcome.

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Association between payer status and patient-reported outcomes in adult patients with lumbar spinal stenosis treated with decompression surgery

J Neurosurg Spine 30:198–210, 2019

Insurance disparities can have relevant effects on outcomes after elective lumbar spinal surgery. The aim of this study was to evaluate the association between private/public payer status and patient-reported outcomes in adult patients who underwent decompression surgery for lumbar spinal stenosis.

METHODS A sample of 100 patients who underwent surgery for lumbar spinal stenosis from 2012 to 2014 was evaluated as part of the prospectively collected Quality Outcomes Database at a single institution. Outcome measures were evaluated at 3 months and 12 months, analyzed in regard to payer status (private insurance vs Medicare/Veterans Affairs insurance), and adjusted for potential confounders.

RESULTS At baseline, patients had similar visual analog scale back and leg pain, Oswestry Disability Index, and EQ- 5D scores. At 3 months postintervention, patients with government-funded insurance reported significantly worse quality of life (mean difference 0.11, p < 0.001) and more leg pain (mean difference 1.26, p = 0.05). At 12 months, patients with government-funded insurance reported significantly worse quality of life (mean difference 0.14, p < 0.001). There were no significant differences at 3 months or 12 months between groups for back pain (p = 0.14 and 0.43) or disability (p = 0.19 and 0.15). Across time points, patients in both groups showed improvement at 3 months and 12 months in all 4 functional outcomes compared with baseline (p < 0.001).

CONCLUSIONS Both private and public insurance patients had significant improvement after elective lumbar spinal surgery. Patients with public insurance had slightly less improvement in quality of life after surgery than those with private insurance but still benefited greatly from surgical intervention, particularly with respect to functional status.

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Classification of middle fossa floor dehiscence syndromes

Classification of middle fossa floor dehiscence syndromes

J Neurosurg 122:557–563, 2015

Middle fossa floor dehiscence (MFFD) can present as multiple syndromes depending on dehiscence location, tissue herniation, and dural integrity. The authors propose a classification system for MFFD with the potential to guide clinical decision making.

Methods A retrospective analysis of the electronic medical records (years 1995–2012) of patients who had undergone temporal craniotomy for the surgical repair of an MFFD syndrome at a single institution was undertaken. Reviewed data included demographic, operative, presentation, and outcome details. Middle fossa floor dehiscence was classified as follows: Class A, bony dehiscence without herniation of the brain and/or meninges; Class B, herniation of the brain and/or meninges through the middle fossa floor without CSF leakage; Class C, dehiscence with CSF leakage without meningitis; or Class D, dehiscence with meningitis.

Results Fifty-one patients, 22 males and 29 females, were included in the analysis. The mean age was 48.7 ± 15.5 years, mean body mass index was 32.65 ± 6.86 kg/m2, and mean symptom duration was 33 ± 42 months. Seven patients underwent repeat surgery for symptomatic recurrence; therefore, there were 58 surgical encounters. Repair included bony reconstruction with hydroxyapatite with or without resection of encephaloceles and/or repair of a dural defect. According to the MFFD classification system described, 15, 8, 27, and 8 cases were categorized as Class A, B, C, and D, respectively. The prevalence of hearing loss was 87%, 63%, and 70% in Classes A, B, and C, respectively. Vestibular symptoms were more prevalent in Class A. Seven patients reported persistent symptoms at the last follow-up. Transient complications were similar in each classification (13%–25%), and a single permanent complication related to anesthesia was observed. There were no mortalities or severe neurological morbidities in the series.

Conclusions Middle fossa floor dehiscence has a spectrum of clinical presentations. A classification system may help to clarify the diagnosis and guide therapy. Surgery, the mainstay of treatment, is safe and well tolerated.

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Outcome After Suboccipital Decompression for Chiari Malformation I in Adults

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Neurosurgery 73:569–581, 2013

To date, there has been no study to comprehensively assess the effectiveness of suboccipital craniectomy (SOC) for Chiari malformation I (CMI) using validated patient-reported outcome measures.

OBJECTIVE: To determine the effectiveness and minimum clinically important difference thresholds of SOC for the treatment of adult patients with CMI using patientreported outcome metrics.

METHODS: Fifty patients undergoing first-time SOC and C1 laminectomy for CMI at a single institution were followed up for 1 year. Baseline and 1-year postoperative pain, disability, quality of life, patient satisfaction, and return to work were assessed. Minimum clinically important difference thresholds were calculated with 2 anchors: the Health Transition Index and North American Spine Society satisfaction questionnaire.

RESULTS: The severity of headaches improved in 37 patients (74%). Improvement in syrinx size was seen in 12 patients (63%) and myelopathy in 12 patients (60%). All patientreported outcomes showed significant improvement 1 year postoperatively (P,.05). Of the 38 patients (76%) employed preoperatively, 29 (76%) returned to work postoperatively at a median time of 6 weeks (interquartile range, 4-12 weeks). Minimum clinically important difference thresholds after SOC for CMI were 4.4 points for numeric rating scale for headache, 0.7 points for numeric rating scale for neck pain, 13.8 percentage points for Headache Disability Index, 14.2 percentage points for Neck Disability Index, 7.0 points for Short Form-12 Physical Component Summary, 6.1 points for Short Form-12 Mental Component Summary, 4.5 points for Zung depression, 1.7 points for modified Japanese Orthopaedic Association, and 0.34 quality-adjusted life-years for Euro-Qol-5D.

CONCLUSION: Surgical management of CMI in adults via SOC provides significant and sustained improvement in pain, disability, general health, and quality of life as assessed by patient-reported outcomes. This patient-centered assessment suggests that suboccipital decompression for CMI in adults is an effective treatment strategy.

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