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Kevin T. Huang, Michael A. Silva, Alfred P. See, Kyle C. Wu, Troy Gallerani, Hasan A. Zaidi, Yi Lu, John H. Chi, Michael W. Groff and Omar M. Arnaout

vision in neurosurgery is automated identification of spinal hardware. As many as 15%–20% of patients undergoing anterior cervical discectomy and fusion (ACDF) require revision surgery. 2 , 5 , 8 , 18 Removal of the previously implanted hardware is frequently required to accomplish the goals of the revision. Unfortunately, information on which hardware system was previously implanted is frequently missing from the medical records, especially for patients whose prior surgery was at another institution. Although universal hardware removal kits exist, they are often

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Michael G. Kaiser, Jason C. Eck, Michael W. Groff, Zoher Ghogawala, William C. Watters III, Andrew T. Dailey, Daniel K. Resnick, Tanvir F. Choudhri, Alok Sharan, Jeffrey C. Wang, Sanjay S. Dhall and Praveen V. Mummaneni

demonstrated a positive impact on fusion rate; however, there is insufficient evidence regarding its impact on clinical outcome (single Level III study/multiple Level IV studies). Grade I There is insufficient evidence to recommend for or against the use of PEMFS as a treatment alternative to revision surgery in patients presenting with pseudarthrosis following posterior lumbar fusion (single Level IV study). Rationale Since the publication of the original “Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine,” 16 the

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Michael W. Groff, Andrew T. Dailey, Zoher Ghogawala, Daniel K. Resnick, William C. Watters III, Praveen V. Mummaneni, Tanvir F. Choudhri, Jason C. Eck, Alok Sharan, Jeffrey C. Wang, Sanjay S. Dhall and Michael G. Kaiser

The utilization of pedicle screw fixation as an adjunct to posterolateral lumbar fusion (PLF) has become routine, but demonstration of a definitive benefit remains problematic. The medical evidence indicates that the addition of pedicle screw fixation to PLF increases fusion rates when assessed with dynamic radiographs. More recent evidence, since publication of the 2005 Lumbar Fusion Guidelines, suggests a stronger association between radiographic fusion and clinical outcome, although, even now, no clear correlation has been demonstrated. Although several reports suggest that clinical outcomes are improved with the addition of pedicle screw fixation, there are conflicting findings from similarly classified evidence. Furthermore, the largest contemporary, randomized, controlled study on this topic failed to demonstrate a significant clinical benefit with the use of pedicle screw fixation in patients undergoing PLF for chronic low-back pain. This absence of proof should not, however, be interpreted as proof of absence. Several limitations continue to compromise these investigations. For example, in the majority of studies the sample size is insufficient to detect small increments in clinical outcome that may be observed with pedicle screw fixation. Therefore, no definitive statement regarding the efficacy of pedicle screw fixation as a means to improve functional outcomes in patients undergoing PLF for chronic low-back pain can be made. There appears to be consistent evidence suggesting that pedicle screw fixation increases the costs and complication rate of PLF. High-risk patients, including (but not limited to) patients who smoke, patients who are undergoing revision surgery, or patients who suffer from medical conditions that may compromise fusion potential, may appreciate a greater benefit with supplemental pedicle screw fixation. It is recommended, therefore, that the use of pedicle screw fixation as a supplement to PLF be reserved for those patients in whom there is an increased risk of nonunion when treated with only PLF.

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Michael G. Kaiser, Praveen V. Mummaneni, Paul G. Matz, Paul A. Anderson, Michael W. Groff, Robert F. Heary, Langston T. Holly, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic and Daniel K. Resnick

radiographs. Clinical results were based on patients' self-assessment of pain relief, discontinuation of pain medication, & return to normal activities. 16 of the 23 patients underwent revision surgery, 14 through a repeated anterior approach & 2 via a posterior approach. 7 patients w/ persistent neck pain declined surgery. 81% of patients achieved a solid arthrodesis & 69.2% a successful outcome. There was no mention of surgical complications. The authors concluded that their series supports the hypothesis that a good clinical outcome is dependent on a solid arthrodesis

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Michael G. Kaiser, Praveen V. Mummaneni, Paul G. Matz, Paul A. Anderson, Michael W. Groff, Robert F. Heary, Langston T. Holly, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic and Daniel K. Resnick

Neurosurgeons and orthopedists commonly perform cervical fusions in an effort to treat degenerative spine disease. In addition to assessment of neurological outcome, surgeons often use the presence or absence of a solid arthrodesis as a measure of operative success. Although definitive data correlating clinical outcome to successful arthrodesis is lacking, there are reports indicating a possible relationship and that patients improve after revision surgery of a failed fusion. 10 , 14 , 21 , 23 Therefore, it is useful to be able to diagnose with accuracy the presence or

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Paul G. Matz, Langston T. Holly, Michael W. Groff, Edward J. Vresilovic, Paul A. Anderson, Robert F. Heary, Michael G. Kaiser, Praveen V. Mummaneni, Timothy C. Ryken, Tanvir F. Choudhri and Daniel K. Resnick

. Good or better results in 64–70% depending upon Worker's Compensation status. 87% returned to work. Spontaneous fusion in only 4%. III Anterior cervical decompression results in a good outcome w/ minimal complication. Class III due to case series. Hacker & Miller, 2003 23 patients w/ cervical radiculopathy under-went ACF w/ 3-mo min FU. 7 patients (30%) underwent revision surgery: 4 due to recurrent disc & 3 due to intractable neck pain. Good or better outcome in 12 (52%). III ACF for decompression is associated w/ a high-revision rate w/ worse out

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Zoher Ghogawala, Robert G. Whitmore, William C. Watters III, Alok Sharan, Praveen V. Mummaneni, Andrew T. Dailey, Tanvir F. Choudhri, Jason C. Eck, Michael W. Groff, Jeffrey C. Wang, Daniel K. Resnick, Sanjay S. Dhall and Michael G. Kaiser

rhBMP-2 or ICBG. Outcomes &costs were assessed at 2 yrs. SF-6D was used for utility measurements. Follow-up was 96%. Nosensitivity analysis. The cost of fusion using rhBMP-2 was $39,967. Fusion w/ ICBG cost $42,286. In the ICBG group, there were 5 revision surgeries; in the rhBMP-2 cohort, 1 revision surgery. The 2 cohorts had similar improvement in SF-6D scores. The cost of using rhBMP-2 is comparable to the cost of autograft for lumbar fusion surgery pts. Glassman et al., 2008 IV 106 pts >60 yrs old randomized to either rhBMP-2 vs ICBG for anterior 1-level

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Daniel K. Resnick, Tanvir F. Choudhri, Andrew T. Dailey, Michael W. Groff, Larry Khoo, Paul G. Matz, Praveen Mummaneni, William C. Watters III, Jeffrey Wang, Beverly C. Walters and Mark N. Hadley

analysis of patients who do and do not suffer from postoperative chronic low-back pain (case control study) could potentially provide Class II medical evidence to support the use of fusion in the subgroup of patients in whom there is likely to be a benefit. Abbreviation used in this paper PLF = posterolateral fusion . References 1. Baba H , Chen Q , Kamitani K , et al : Revision surgery for lumbar disc herniation. An analysis of 45 patients. Int Orthop 19 : 98 – 102 , 1995 Baba H, Chen Q, Kamitani

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Sanjay S. Dhall, Tanvir F. Choudhri, Jason C. Eck, Michael W. Groff, Zoher Ghogawala, William C. Watters III, Andrew T. Dailey, Daniel K. Resnick, Alok Sharan, Praveen V. Mummaneni, Jeffrey C. Wang and Michael G. Kaiser

. of levels = 2). Heterogeneous: variable no. of levels, half w/ degenerative spondylolisthesis, some had previous surger, some smokers, age range 44–82 yrs. Used SF-36 & dynamic radiographs; 100% follow-up. Pseudarthrosis in 13 pts, leading to revision surgery in 1. Reports “nearly identical maximum improvement on SF-36” & no correlation btwn fusion & clinical outcome. Found no correlation btwn pseudarthrosis & clinical results. The lesser quality prospective study was downgraded to Level III because of the heterogeneous pt population. Djurasovic et al., 2011

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Jeffrey C. Wang, Andrew T. Dailey, Praveen V. Mummaneni, Zoher Ghogawala, Daniel K. Resnick, William C. Watters III, Michael W. Groff, Tanvir F. Choudhri, Jason C. Eck, Alok Sharan, Sanjay S. Dhall and Michael G. Kaiser

of Odom's criteria. Patients undergoing a fusion demonstrated significantly better outcomes with respect to low-back pain. The frequency of revision surgery was significantly higher in patients who did not receive a fusion, but met the criteria for fusion. Interestingly, those patients who did not fulfill the criteria for fusion but had a fusion surgery also had significantly better results in terms of low-back pain scores compared with those without fusions. The authors concluded with this Level IV study that patients with disc herniations and instability or