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Scott A. Meyer and Praveen V. Mummaneni

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Scott A. Meyer and Praveen V. Mummaneni

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Scott A. Meyer, Jau-Ching Wu, and Praveen V. Mummaneni

Object

Two common causes of cervical myelopathy include degenerative stenosis and ossification of the posterior longitudinal ligament (OPLL). It has been postulated that patients with OPLL have more complications and worse outcomes than those with degenerative stenosis. The authors sought to compare the surgical results of laminoplasty in the treatment of cervical stenosis with myelopathy due to either degenerative changes or segmental OPLL.

Methods

The authors conducted a retrospective review of 40 instrumented laminoplasty cases performed at a single institution over a 4-year period to treat cervical myelopathy without kyphosis. Twelve of these patients had degenerative cervical stenotic myelopathy ([CSM]; degenerative group), and the remaining 28 had segmental OPLL (OPLL group). The 2 groups had statistically similar demographic characteristics and number of treated levels (mean 3.9 surgically treated levels; p > 0.05). The authors collected perioperative and follow-up data, including radiographic results.

Results

The overall clinical follow-up rate was 88%, and the mean clinical follow-up duration was 16.4 months. The mean radiographic follow-up rate was 83%, and the mean length of radiographic follow-up was 9.3 months. There were no significant differences in the estimated blood loss (EBL) or length of hospital stay (LOS) between the groups (p > 0.05). The mean EBL and LOS for the degenerative group were 206 ml and 3.7 days, respectively. The mean EBL and LOS for the OPLL group were 155 ml and 4 days, respectively. There was a statistically significant improvement of more than one grade in the Nurick score for both groups following surgery (p < 0.05). The Nurick score improvement was not statistically different between the groups (p > 0.05). The visual analog scale (VAS) neck pain scores were similar between groups pre- and postoperatively (p > 0.05). The complication rates were not statistically different between groups either (p > 0.05). Radiographically, both groups lost extension range of motion (ROM) following laminoplasty, but this change was not statistically significant (p > 0.05).

Conclusions

Patients with CSM due to either degenerative disease or segmental OPLL have similar perioperative results and neurological outcomes with laminoplasty. The VAS neck pain scores did not improve significantly with laminoplasty for either group. Laminoplasty may limit extension ROM.

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Scott A. Wallace, R. Michael Meyer, Michael J. Cirivello, and Raymond I. Cho

Authors of this report describe a Fukushima Type D(b) or Kawase Type ME2 trigeminal schwannoma involving the right maxillary division in a 59-year-old woman who presented with intermittent right-sided facial numbness and pain. This tumor was successfully resected via a right lateral orbitotomy without the need for craniotomy. This novel approach to a lesion of this type has not yet been described in the scientific literature. The outcome in this case was good, and the patient's intra- and postoperative courses proceeded without complication. The epidemiology of trigeminal schwannomas and some technical aspects of lateral orbitotomy, including potential advantages of this approach over traditional transcranial as well as fully endoscopic dissections in appropriately selected cases, are also briefly discussed.

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Gurpreet Gandhoke, Jau-Ching Wu, Nathan C. Rowland, Scott A. Meyer, Camilla Gupta, and Praveen V. Mummaneni

Object

Both anterior cervical corpectomy and fusion (ACCF) and laminoplasty are effective treatments for selected cases of cervical stenosis. Postoperative C-5 palsies may occur with either anterior or posterior decompressive procedures; however, a direct comparison of C-5 palsy rates between the 2 approaches is not present in the literature. The authors sought to compare the C-5 palsy rate of ACCF versus laminoplasty.

Methods

The authors conducted a retrospective review of 31 ACCF (at C-4 or C-5) and 31 instrumented laminoplasty cases performed to treat cervical stenosis. The demographics of the groups were similar except for age (ACCF group mean age 53 years vs laminoplasty group mean age 62 years, p = 0.002). The mean number of levels treated was greater in the laminoplasty cohort (3.87 levels) than in the ACCF cohort (2.74 levels, p < 0.001). The mean preoperative Nurick grade of the laminoplasty cohort (2.61) was higher than the mean preoperative Nurick grade of the ACCF cohort (1.10, p < 0.001).

Results

The overall clinical follow-up rate was 100%. The mean overall clinical follow-up was 15 months. There were no significant differences in the estimated blood loss or length of stay between the 2 groups (p > 0.05). There was no statistical difference between the complication or reoperation rates between the 2 groups (p = 0.184 and p = 0.238). There were 2 C-5 nerve root pareses in each group. Three of the 4 patients recovered full deltoid function, and the fourth patient recovered nearly full deltoid function at final follow-up. There was no statistical difference in the rate of deltoid paresis (6.5%) between the 2 groups (p = 1).

Conclusions

Both ACCF and laminoplasty are effective treatments for patients with cervical stenosis. The authors found no difference in the rate of deltoid paresis between ACCF and laminoplasty to treat cervical stenosis.

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Connor Berlin, Alexandria C. Marino, Praveen V. Mummaneni, Juan Uribe, Luis M. Tumialán, Jay Turner, Michael Y. Wang, Paul Park, Erica F. Bisson, Mark Shaffrey, Oren Gottfried, Khoi D. Than, Kai-Ming Fu, Kevin Foley, Andrew K. Chan, Mohamad Bydon, Mohammed Ali Alvi, Cheerag Upadhyaya, Domagoj Coric, Anthony Asher, Eric A. Potts, John Knightly, Scott Meyer, and Avery Buchholz

OBJECTIVE

While surgical decompression is an important treatment modality for cervical spondylotic myelopathy (CSM), it remains unclear if the severity of preoperative myelopathy status affects potential benefit from surgical intervention and when maximum postoperative improvement is expected. This investigation sought to determine if retrospective analysis of prospectively collected patient-reported outcomes (PROs) following surgery for CSM differed when stratified by preoperative myelopathy status. Secondary objectives included assessment of the minimal clinically important difference (MCID).

METHODS

A total of 1151 patients with CSM were prospectively enrolled from the Quality Outcomes Database at 14 US hospitals. Baseline demographics and PROs at baseline and 3 and 12 months were measured. These included the modified Japanese Orthopaedic Association (mJOA) score, Neck Disability Index (NDI), quality-adjusted life-years (QALYs) from the EQ-5D, and visual analog scale from the EQ-5D (EQ-VAS). Patients were stratified by preoperative myelopathy severity using criteria established by the AO Spine study group: mild (mJOA score 15–17), moderate (mJOA score 12–14), or severe (mJOA score < 12). Univariate analysis was used to identify demographic variables that significantly varied between myelopathy groups. Then, multivariate linear regression and linear mixed regression were used to model the effect of severity and time on PROs, respectively.

RESULTS

For NDI, EQ-VAS, and QALY, patients in all myelopathy cohorts achieved significant, maximal improvement at 3 months without further improvement at 12 months. For mJOA, moderate and severe myelopathy groups demonstrated significant, maximal improvement at 3 months, without further improvement at 12 months. The mild myelopathy group did not demonstrate significant change in mJOA score but did maintain and achieve higher PRO scores overall when compared with more advanced myelopathy cohorts. The MCID threshold was reached in all myelopathy cohorts at 3 months for mJOA, NDI, EQ-VAS, and QALY, with the only exception being mild myelopathy QALY at 3 months.

CONCLUSIONS

As assessed by statistical regression and MCID analysis, patients with cervical myelopathy experience maximal improvement in their quality of life, neck disability, myelopathy score, and overall health by 3 months after surgical decompression, regardless of their baseline myelopathy severity. An exception was seen for the mJOA score in the mild myelopathy cohort, improvement of which may have been limited by ceiling effect. The data presented here will aid surgeons in patient selection, preoperative counseling, and expected postoperative time courses.

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Domagoj Coric, Ahmad Nassr, Paul K. Kim, William C. Welch, Stephen Robbins, Steven DeLuca, Donald Whiting, Ali Chahlavi, Stephen M. Pirris, Michael W. Groff, John H. Chi, Jason H. Huang, Roland Kent, Robert G. Whitmore, Scott A. Meyer, Paul M. Arnold, Ashvin I. Patel, R. Douglas Orr, Ajit Krishnaney, Peggy Boltes, Yoram Anekstein, and Michael P. Steinmetz

OBJECTIVE

The purpose of this study was to evaluate the safety and efficacy of a posterior facet replacement device, the Total Posterior Spine (TOPS) System, for the treatment of one-level symptomatic lumbar stenosis with grade I degenerative spondylolisthesis. Posterior lumbar arthroplasty with facet replacement is a motion-preserving alternative to lumbar decompression and fusion. The authors report the preliminary results from the TOPS FDA investigational device exemption (IDE) trial.

METHODS

The study was a prospective, randomized controlled FDA IDE trial comparing the investigational TOPS device with transforaminal lumbar interbody fusion (TLIF) and pedicle screw fixation. The minimum follow-up duration was 24 months. Validated patient-reported outcome measures included the Oswestry Disability Index (ODI) and visual analog scale (VAS) for back and leg pain. The primary outcome was a composite measure of clinical success: 1) no reoperations, 2) no device breakage, 3) ODI reduction of ≥ 15 points, and 4) no new or worsening neurological deficit. Patients were considered a clinical success only if they met all four measures. Radiographic assessments were made by an independent core laboratory.

RESULTS

A total of 249 patients were evaluated (n = 170 in the TOPS group and n = 79 in the TLIF group). There were no statistically significant differences between implanted levels (L4–5: TOPS, 95% and TLIF, 95%) or blood loss. The overall composite measure for clinical success was statistically significantly higher in the TOPS group (85%) compared with the TLIF group (64%) (p = 0.0138). The percentage of patients reporting a minimum 15-point improvement in ODI showed a statistically significant difference (p = 0.037) favoring TOPS (93%) over TLIF (81%). There was no statistically significant difference between groups in the percentage of patients reporting a minimum 20-point improvement on VAS back pain (TOPS, 87%; TLIF, 64%) and leg pain (TOPS, 90%; TLIF, 88%) scores. The rate of surgical reintervention for facet replacement in the TOPS group (5.9%) was lower than the TLIF group (8.8%). The TOPS cohort demonstrated maintenance of flexion/extension range of motion from preoperatively (3.85°) to 24 months (3.86°).

CONCLUSIONS

This study demonstrates that posterior lumbar decompression and dynamic stabilization with the TOPS device is safe and efficacious in the treatment of lumbar stenosis with degenerative spondylolisthesis. Additionally, decompression and dynamic stabilization with the TOPS device maintains segmental motion.

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Andrew K. Chan, Christopher I. Shaffrey, Oren N. Gottfried, Christine Park, Khoi D. Than, Erica F. Bisson, Mohamad Bydon, Anthony L. Asher, Domagoj Coric, Eric A. Potts, Kevin T. Foley, Michael Y. Wang, Kai-Ming Fu, Michael S. Virk, John J. Knightly, Scott Meyer, Paul Park, Cheerag Upadhyaya, Mark E. Shaffrey, Avery L. Buchholz, Luis M. Tumialán, Jay D. Turner, Giorgos D. Michalopoulos, Brandon A. Sherrod, Nitin Agarwal, Dean Chou, Regis W. Haid Jr., and Praveen V. Mummaneni

OBJECTIVE

The aim of this study was to determine whether multilevel anterior cervical discectomy and fusion (ACDF) or posterior cervical laminectomy and fusion (PCLF) is superior for patients with cervical spondylotic myelopathy (CSM) and high preoperative neck pain.

METHODS

This was a retrospective study of prospectively collected data using the Quality Outcomes Database (QOD) CSM module. Patients who received a subaxial fusion of 3 or 4 segments and had a visual analog scale (VAS) neck pain score of 7 or greater at baseline were included. The 3-, 12-, and 24-month outcomes were compared for patients undergoing ACDF with those undergoing PCLF.

RESULTS

Overall, 1141 patients with CSM were included in the database. Of these, 495 (43.4%) presented with severe neck pain (VAS score > 6). After applying inclusion and exclusion criteria, we compared 65 patients (54.6%) undergoing 3- and 4-level ACDF and 54 patients (45.4%) undergoing 3- and 4-level PCLF. Patients undergoing ACDF had worse Neck Disability Index scores at baseline (52.5 ± 15.9 vs 45.9 ± 16.8, p = 0.03) but similar neck pain (p > 0.05). Otherwise, the groups were well matched for the remaining baseline patient-reported outcomes. The rates of 24-month follow-up for ACDF and PCLF were similar (86.2% and 83.3%, respectively). At the 24-month follow-up, both groups demonstrated mean improvements in all outcomes, including neck pain (p < 0.05). In multivariable analyses, there was no significant difference in the degree of neck pain change, rate of neck pain improvement, rate of pain-free achievement, and rate of reaching minimal clinically important difference (MCID) in neck pain between the two groups (adjusted p > 0.05). However, ACDF was associated with a higher 24-month modified Japanese Orthopaedic Association scale (mJOA) score (β = 1.5 [95% CI 0.5–2.6], adjusted p = 0.01), higher EQ-5D score (β = 0.1 [95% CI 0.01–0.2], adjusted p = 0.04), and higher likelihood for return to baseline activities (OR 1.2 [95% CI 1.1–1.4], adjusted p = 0.002).

CONCLUSIONS

Severe neck pain is prevalent among patients undergoing surgery for CSM, affecting more than 40% of patients. Both ACDF and PCLF achieved comparable postoperative neck pain improvement 3, 12, and 24 months following 3- or 4-segment surgery for patients with CSM and severe neck pain. However, multilevel ACDF was associated with superior functional status, quality of life, and return to baseline activities at 24 months in multivariable adjusted analyses.

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Zachary D. Rethorn, Chad E. Cook, Christine Park, Tamara Somers, Praveen V. Mummaneni, Andrew K. Chan, Brenton H. Pennicooke, Erica F. Bisson, Anthony L. Asher, Avery L. Buchholz, Mohamad Bydon, Mohammed Ali Alvi, Domagoj Coric, Kevin T. Foley, Kai-Ming Fu, John J. Knightly, Scott Meyer, Paul Park, Eric A. Potts, Christopher I. Shaffrey, Mark Shaffrey, Khoi D. Than, Luis Tumialan, Jay D. Turner, Cheerag D. Upadhyaya, Michael Y. Wang, and Oren Gottfried

OBJECTIVE

Combinations of certain social risk factors of race, sex, education, socioeconomic status (SES), insurance, education, employment, and one’s housing situation have been associated with poorer pain and disability outcomes after lumbar spine surgery. To date, an exploration of such factors in patients with cervical spine surgery has not been conducted. The objective of the current work was to 1) define the social risk phenotypes of individuals who have undergone cervical spine surgery for myelopathy and 2) analyze their predictive capacity toward disability, pain, quality of life, and patient satisfaction–based outcomes.

METHODS

The Cervical Myelopathy Quality Outcomes Database was queried for the period from January 2016 to December 2018. Race/ethnicity, educational attainment, SES, insurance payer, and employment status were modeled into unique social phenotypes using latent class analyses. Proportions of social groups were analyzed for demonstrating a minimal clinically important difference (MCID) of 30% from baseline for disability, neck and arm pain, quality of life, and patient satisfaction at the 3-month and 1-year follow-ups.

RESULTS

A total of 730 individuals who had undergone cervical myelopathy surgery were included in the final cohort. Latent class analysis identified 2 subgroups: 1) high risk (non-White race and ethnicity, lower educational attainment, not working, poor insurance, and predominantly lower SES), n = 268, 36.7% (class 1); and 2) low risk (White, employed with good insurance, and higher education and SES), n = 462, 63.3% (class 2). For both 3-month and 1-year outcomes, the high-risk group (class 1) had decreased odds (all p < 0.05) of attaining an MCID score in disability, neck/arm pain, and health-related quality of life. Being in the low-risk group (class 2) resulted in an increased odds of attaining an MCID score in disability, neck/arm pain, and health-related quality of life. Neither group had increased or decreased odds of being satisfied with surgery.

CONCLUSIONS

Although 2 groups underwent similar surgical approaches, the social phenotype involving non-White race/ethnicity, poor insurance, lower SES, and poor employment did not meet MCIDs for a variety of outcome measures. This finding should prompt surgeons to proactively incorporate socially conscience care pathways within healthcare systems, as well as to optimize community-based resources to improve outcomes and personalize care for populations at social risk.

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David T. Asuzu, Jonathan J. Yun, Mohammed Ali Alvi, Andrew K. Chan, Cheerag D. Upadhyaya, Domagoj Coric, Eric A. Potts, Erica F. Bisson, Jay D. Turner, Jack J. Knightly, Kai-Ming Fu, Kevin T. Foley, Luis Tumialan, Mark Shaffrey, Mohamad Bydon, Praveen V. Mummaneni, Paul Park, Scott Meyer, Anthony L. Asher, Oren N. Gottfried, Khoi D. Than, Michael Y. Wang, and Avery L. Buchholz

OBJECTIVE

Degenerative cervical myelopathy (DCM) results in significant morbidity. The duration of symptoms prior to surgical intervention may be associated with postoperative surgical outcomes and functional recovery. The authors’ objective was to investigate whether delayed surgical treatment for DCM is associated with worsened postoperative outcomes.

METHODS

Data from 1036 patients across 14 surgical centers in the Quality Outcomes Database were analyzed. Baseline demographic characteristics and findings of preoperative and postoperative symptom evaluations, including duration of symptoms, were assessed. Postoperative functional outcomes were measured using the Neck Disability Index (NDI) and modified Japanese Orthopaedic Association (mJOA) scale. Symptom duration was classified as either less than 12 months or 12 months or greater. Univariable and multivariable regression were used to evaluate for the associations between symptom duration and postoperative outcomes.

RESULTS

In this study, 513 patients (49.5%) presented with symptom duration < 12 months, and 523 (50.5%) had symptoms for 12 months or longer. Patients with longer symptom duration had higher BMI and higher prevalence of anxiety and diabetes (all p < 0.05). Symptom duration ≥ 12 months was associated with higher average baseline NDI score (41 vs 36, p < 0.01). However, improvements in NDI scores from baseline were not significantly different between groups at 3 months (p = 0.77) or 12 months (p = 0.51). Likewise, the authors found no significant differences between groups in changes in mJOA scores from baseline to 3 months or 12 months (both p > 0.05).

CONCLUSIONS

Surgical intervention resulted in improved mJOA and NDI scores at 3 months, and this improvement was sustained in both patients with short and longer initial symptom duration. Patients with DCM can still undergo successful surgical management despite delayed presentation.