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Kalil G. Abdullah, Edward C. Benzel and Thomas E. Mroz

Comparative effectiveness research (CER) has impending significance for the field of spine surgery. This article outlines the rationale for comparative effectiveness research and reviews recommended priorities of spinal surgery emphasis. It also examines recent key studies of CER in the spine surgery literature and associated cost-effectiveness studies. It concludes with a discussion of the direction of CER in the spine surgery community.

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Matthew J. Grosso, Roy Hwang, Thomas Mroz, Edward Benzel and Michael P. Steinmetz

Object

Reversal of the normal cervical spine curvature, as seen in cervical kyphosis, can lead to mechanical pain, neurological dysfunction, and functional disabilities. Surgical intervention is warranted in patients with sufficiently symptomatic deformities in an attempt to correct the deformed cervical spine. In theory, improved outcomes should accompany a greater degree of correction toward lordosis, although there are few data available to test this relationship. The purpose of this study is to determine if the degree of deformity correction correlates with improvement in neurological symptoms following surgery for cervical kyphotic deformity.

Methods

A retrospective review of 36 patients with myelopathic symptoms who underwent cervical deformity correction surgery between 2001 and 2009 was performed. Preoperative and postoperative radiographic findings related to the degree of kyphosis were collected and compared with functional outcome measures. The minimum follow-up time was 2 years.

Results

A significant relationship was observed between a greater degree of focal kyphosis correction and improved neurological outcomes according to the modified Japanese Orthopaedic Association (mJOA) score (r = −0.46, p = 0.032). For patients with severe neurological symptoms (mJOA score < 12) a trend toward improved outcomes with greater global kyphosis correction was observed (r = −0.56, p = 0.057). Patients with an mJOA score less than 16 who attained lordosis postoperatively had a significantly greater improvement in total mJOA score than patients who maintained a kyphotic position (achieved lordosis: 2.7 ± 2.0 vs maintained kyphosis: 1.1 ± 2.1, p = 0.044).

Conclusions

The authors' results suggest that the degree of correction of focal kyphosis deformity correlates with improved neurological outcomes. The authors also saw a positive relationship between attainment of global lordosis and improved mJOA scores. With consideration for the risks involved in correction surgery, this information can be used to help guide surgical strategy decision making.

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Matthew D. Alvin, Daniel Lubelski, Edward C. Benzel and Thomas E. Mroz

Cervical spondylotic myelopathy (CSM) often can be surgically treated by either ventral or dorsal decompression and fusion. However, there is a lack of high-level evidence on the relative advantages and disadvantages for these treatments of CSM. The authors' goal was to provide a comprehensive review of the relative benefits of ventral versus dorsal fusion in terms of quality of life (QOL) outcomes, complications, and costs. They reviewed 7 studies on CSM published between 2003 and 2013 and summarized the findings for each category. Both procedures have been shown to lead to statistically significant improvement in clinical outcomes for patients. Ventral fusion surgery has been shown to yield better QOL outcomes than dorsal fusion surgery. Complication rates for ventral fusion surgery range from 11% to 13.6%, whereas those for dorsal fusion surgery range from 16.4% to 19%. Larger randomized controlled trials are needed, with particular emphasis on QOL and minimum clinically important differences.

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Kene T. Ugokwe, Iain H. Kalfas, Thomas E. Mroz and Michael P. Steinmetz

Object

Pseudarthrosis and construct failure following single-level anterior cervical discectomy, fusion, and plate placement (ACDFP) rarely occur. Routine postoperative anteroposterior and lateral radiographs may be an inconvenience to patients and expose them to additional and potentially unnecessary radiation. No standard exists to define when patients should obtain radiographs following an ACDFP. The authors hypothesize that routinely obtaining static anteroposterior and lateral radiographs in patients who recently underwent a single-level ACDFP without new axial neck pain or other neurological complaints or symptoms is unwarranted and does not alter the long-term treatment of the patient.

Methods

The authors retrospectively reviewed the charts and radiographs of patients who underwent a single-level ACDFP between January 1, 2000, and December 31, 2005. All patients underwent a single-level ACDFP and had routine cervical radiographs obtained at various intervals after surgery.

Results

Twenty-one patients underwent ACDFP at C5–6, 14 patients underwent surgery at C6–7, 11 patients at C4–5, and 7 patients at C3–4. None of the intraoperative radiographs demonstrated malposition of the graft or instrumentation. Based on subjective reporting by the patients, the vast majority (49 of 53) showed improvement in neck and arm pain, and/or neurological dysfunction following surgery. Overall, 5 patients (9%) demonstrated abnormalities on their postoperative radiographs. No patients were returned to the operating room as a result of postoperative radiographic findings. The sensitivity of plain radiographs in this patient series or the percentage of patients with new symptoms that had an abnormality related to the construct on plain radiography was 50%. The specificity of plain radiographs or the percentage of patients who were asymptomatic and had normal radiographs was 94%. The positive predictive value was 25%; that is, there was a 25% chance that patients with symptoms would have a construct abnormality on postoperative radiographs. The negative predictive value was 98%; that is, 98% of patients without symptoms will have normal radiographs.

Conclusions

Pseudarthrosis and construct failure following single-level ACDFP occur rarely, and patients with new symptoms following surgery are as likely to have normal radiographic findings as they are to have abnormalities identified on their postoperative plain radiographs. Routinely obtaining postoperative radiographs at regular intervals in asymptomatic patients following single-level ACDFP does not appear to be warranted.

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Syed K. Mehdi, Vincent J. Alentado, Bryan S. Lee, Thomas E. Mroz, Edward C. Benzel and Michael P. Steinmetz

OBJECTIVE

Ossification of the posterior longitudinal ligament (OPLL) is a pathological calcification or ossification of the PLL, predominantly occurring in the cervical spine. Although surgery is often necessary for patients with symptomatic neurological deterioration, there remains controversy with regard to the optimal surgical treatment. In this systematic review and meta-analysis, the authors identified differences in complications and outcomes after anterior or posterior decompression and fusion versus after decompression alone for the treatment of cervical myelopathy due to OPLL.

METHODS

A MEDLINE, SCOPUS, and Web of Science search was performed for studies reporting complications and outcomes after decompression and fusion or after decompression alone for patients with OPLL. A meta-analysis was performed to calculate effect summary mean values, 95% CIs, Q statistics, and I2 values. Forest plots were constructed for each analysis group.

RESULTS

Of the 2630 retrieved articles, 32 met the inclusion criteria. There was no statistically significant difference in the incidence of excellent and good outcomes and of fair and poor outcomes between the decompression and fusion and the decompression-only cohorts. However, the decompression and fusion cohort had a statistically significantly higher recovery rate (63.2% vs 53.9%; p < 0.0001), a higher final Japanese Orthopaedic Association score (14.0 vs 13.5; p < 0.0001), and a lower incidence of OPLL progression (< 1% vs 6.3%; p < 0.0001) compared with the decompression-only cohort. There was no statistically significant difference in the incidence of complications between the 2 cohorts.

CONCLUSIONS

This study represents the only comprehensive review of outcomes and complications after decompression and fusion or after decompression alone for OPLL across a heterogeneous group of surgeons and patients. Based on these results, decompression and fusion is a superior surgical technique compared with posterior decompression alone in patients with OPLL. These results indicate that surgical decompression and fusion lead to a faster recovery, improved postoperative neurological functioning, and a lower incidence of OPLL progression compared with posterior decompression only. Furthermore, decompression and fusion did not lead to a greater incidence of complications compared with posterior decompression only.

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Michael F. Shriver, Valerie Zeer, Vincent J. Alentado, Thomas E. Mroz, Edward C. Benzel and Michael P. Steinmetz

OBJECT

There are a variety of surgical positions that provide optimal exposure of the dorsal lumbar spine. These include the prone, kneeling, knee-chest, knee-elbow, and lateral decubitus positions. All are positions that facilitate exposure of the spine. Each position, however, is associated with an array of unique complications that result from excessive pressure applied to the torso or extremities. The authors reviewed clinical studies reporting complications that arose from positioning of the patient during dorsal exposures of the lumbar spine.

METHODS

MEDLINE, Scopus, and Web of Science database searches were performed to find clinical studies reporting complications associated with positioning during lumbar spine surgery. For articles meeting inclusion criteria, the following information was obtained: publication year, study design, sample size, age, operative time, type of surgery, surgical position, frame or table type, complications associated with positioning, time to first observed complication, long-term outcomes, and evidence-based recommendations for complication avoidance.

RESULTS

Of 3898 articles retrieved from MEDLINE, Scopus, and Web of Science, 34 met inclusion criteria. Twenty-four studies reported complications associated with use of the prone position, and 7 studies investigated complications after knee-chest positioning. Complications associated with the knee-elbow, lateral decubitus, and supine positions were each reported by a single study. Vision loss was the most commonly reported complication for both prone and knee-chest positioning. Several other complications were reported, including conjunctival swelling, Ischemic orbital compartment syndrome, nerve palsies, thromboembolic complications, pressure sores, lower extremity compartment syndrome, and shoulder dislocation, highlighting the assortment of possible complications following different surgical positions. For prone-position studies, there was a relationship between increased operation time and position complications. Only 3 prone-position studies reported complications following procedures of less than 120 minutes, 7 studies reported complications following mean operative times of 121–240 minutes, and 9 additional studies reported complications following mean operative times greater than 240 minutes. This relationship was not observed for knee-chest and other surgical positions.

CONCLUSIONS

This work presents a systematic review of positioning-related complications following prone, knee-chest, and other positions used for lumbar spine surgery. Numerous evidence-based recommendations for avoidance of these potentially severe complications associated with intraoperative positioning are discussed. This investigation may serve as a framework to educate the surgical team and decrease rates of intraoperative positioning complications.

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Michael F. Shriver, Jack J. Xie, Erik Y. Tye, Benjamin P. Rosenbaum, Varun R. Kshettry, Edward C. Benzel and Thomas E. Mroz

OBJECT

Lumbar microdiscectomy and its various minimally invasive surgical techniques are seeing increasing popularity, but a systematic review of their associated complications has yet to be performed. The authors sought to identify all prospective clinical studies reporting complications associated with lumbar open microdiscectomy, microendoscopic discectomy (MED), and percutaneous microdiscectomy.

METHODS

The authors conducted MEDLINE, Scopus, Web of Science, and Embase database searches for randomized controlled trials and prospective cohort studies reporting complications associated with open, microendoscopic, or percutaneous lumbar microdiscectomy. Studies with fewer than 10 patients and published before 1990 were excluded. Overall and interstudy median complication rates were calculated for each surgical technique. The authors also performed a meta-analysis of the reported complications to assess statistical significance across the various surgical techniques.

RESULTS

Of 9504 articles retrieved from the databases, 42 met inclusion criteria. Most studies screened were retrospective case series, limiting the number of studies that could be included. A total of 9 complication types were identified in the included studies, and these were analyzed across each of the surgical techniques. The rates of any complication across the included studies were 12.5%, 13.3%, and 10.8% for open, MED, and percutaneous microdiscectomy, respectively. New or worsening neurological deficit arose in 1.3%, 3.0%, and 1.6% of patients, while direct nerve root injury occurred at rates of 2.6%, 0.9%, and 1.1%, respectively. Hematoma was reported at rates of 0.5%, 1.2%, and 0.6%, respectively. Wound complications (infection, dehiscence, orseroma) occurred at rates of 2.1%, 1.2%, and 0.5%, respectively. The rates of recurrent disc complications were 4.4%, 3.1%, and 3.9%, while reoperation was indicated in 7.1%, 3.7%, and 10.2% of operations, respectively. Meta-analysis calculations revealed a statistically significant higher rate of intraoperative nerve root injury following percutaneous procedures relative to MED. No other significant differences were found.

CONCLUSIONS

This review highlights complication rates among various microdiscectomy techniques, which likely reflect real-world practice and conceptualization of complications among physicians. This investigation sets the framework for further discussions regarding microdiscectomy options and their associated complications during the informed consent process.

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Jay M. Levin, Robert D. Winkelman, Joseph E. Tanenbaum, Edward C. Benzel, Thomas E. Mroz and Michael P. Steinmetz

OBJECTIVE

The Patient Experience of Care, composed of 9 dimensions derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, is being used by the Centers for Medicare & Medicaid Services to adjust hospital reimbursement. Currently, there are minimal data on how scores on the constituent HCAHPS items impact the global dimension of satisfaction, the Overall Hospital Rating (OHR). The purpose of this study was to determine the key drivers of overall patient satisfaction in the setting of inpatient lumbar spine surgery.

METHODS

Demographic and preoperative patient characteristics were obtained. Patients selecting a top-box score for OHR (a 9 or 10 of 10) were considered to be satisfied with their hospital experience. A baseline multivariable logistic regression model was then developed to analyze the association between patient characteristics and top-box OHR. Then, multivariable logistic regression models adjusting for patient-level covariates were used to determine the association between individual components of the HCAHPS survey and a top-box OHR.

RESULTS

A total of 453 patients undergoing lumbar spine surgery were included, 80.1% of whom selected a top-box OHR. Diminishing overall health status (OR 0.63, 95% CI 0.43–0.91) was negatively associated with top-box OHR. After adjusting for potential confounders, the survey items that were associated with the greatest increased odds of selecting a top-box OHR were: staff always did everything they could to help with pain (OR 12.5, 95% CI 6.6–23.7), and nurses were always respectful (OR 11.0, 95% CI 5.3–22.6).

CONCLUSIONS

Patient experience of care is increasingly being used to determine hospital and physician reimbursement. The present study analyzed the key drivers of patient experience among patients undergoing lumbar spine surgery and found several important associations. Patient overall health status was associated with top-box OHR. After adjusting for potential confounders, staff always doing everything they could to help with pain and nurses always being respectful were the strongest predictors of overall satisfaction in this population. These findings highlight opportunities for quality improvement efforts in the spine care setting.

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Yumeng Li, Daniel Lubelski, Kalil G. Abdullah, Thomas E. Mroz and Michael P. Steinmetz

Object

Bertolotti's syndrome consists of low-back pain caused by lumbosacral transitional vertebrae (LSTVs) and LSTV-associated biomechanical spinal changes. There is a lack of consensus regarding the cause, clinical significance, and treatment of this condition. The authors aim to characterize the clinical presentation of patients with Bertolotti's syndrome and describe a minimally invasive surgical treatment for this condition.

Methods

Seven patients who underwent minimally invasive paramedian tubular-based resection of the LSTV for Bertolotti's syndrome were identified over the course of 5 years. Diagnosis was based on patient history of chronic low-back pain, radiographic findings of LSTV, and pain relief on trigger-site injection with steroid and/or anesthetics. Electronic medical records were reviewed to identify demographics, operative data, and outcomes.

Results

All patients presented with severe, chronic low-back pain lasting an average of 8 years that was resistant to nonoperative care. At presentation, 6 (86%) of 7 patients experienced radicular pain that was ipsilateral to the LSTV. Radiographic evidence showed a presence of LSTV in all patients on the left (43%), right (29%), or bilaterally (29%). Degenerative disc changes at the L4–5 level immediately above the anomalous LSTV were observed in 6 of 7 (86%) patients; these changes were not seen at the level below the LSTV. Following pseudo-joint injection, all patients experienced temporary relief of their symptoms. All patients underwent a minimally invasive, paramedian tubular-based approach for resection of the LSTV. Three (43%) of 7 patients reported complete resolution of low-back pain, 2 (29%) of 7 patients had reduced low-back pain, and 2 patients (29%) experienced initial relief but return of low-back pain at 1 and 4 years postoperatively. Three (50%) of the 6 patients with radicular pain had complete relief of this symptom. The median follow-up time was 12 months. No intraoperative complication was reported. Two (29%) of 7 patients developed postoperative complications including one with a wound hematoma and another with new L-5 radiculopathy that resolved 2 years after surgery.

Conclusions

Diagnosis of Bertolotti's syndrome should be considered with adequate patient history, imaging studies, and diagnostic injections. A minimally invasive surgical approach for resection of the LSTV is presented here for symptomatic treatment of select patients with Bertolotti's syndrome whose conditions are refractory to conventional therapy and who have pain that can be attributed to the LSTV. Several short-term complications were noted with this procedure, but overall this procedure is effective for treating symptoms related to Bertolotti's syndrome.

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Andrew T. Healy, Prasath Mageswaran, Daniel Lubelski, Benjamin P. Rosenbaum, Virgilio Matheus, Edward C. Benzel and Thomas E. Mroz

OBJECT

The degenerative process of the spinal column results in instability followed by a progressive loss of segmental motion. Segmental degeneration is associated with intervertebral disc and facet changes, which can be quantified. Correlating this degeneration with clinical segmental motion has not been investigated in the thoracic spine. The authors sought to determine if imaging-determined degeneration would correlate with native range of motion (ROM) or the change in ROM after decompressive procedures, potentially guiding clinical decision making in the setting of spine trauma or following decompressive procedures in the thoracic spine.

METHODS

Multidirectional flexibility tests with image analysis were performed on thoracic cadaveric spines with intact ib cage. Specimens consisted of 19 fresh frozen human cadaveric spines, spanning C-7 to L-1. ROM was obtained for each specimen in axial rotation (AR), flexion-extension (FE), and lateral bending (LB) in the intact state and following laminectomy, unilateral facetectomy, and unilateral costotransversectomy performed at either T4–5 (in 9 specimens) or T8–9 (in 10 specimens). Image grading of segmental degeneration was performed utilizing 3D CT reconstructions. Imaging scores were obtained for disc space degeneration, which quantified osteophytes, narrowing, and endplate sclerosis, all contributing to the Lane disc summary score. Facet degeneration was quantified using the Weishaupt facet summary score, which included the scoring of facet osteophytes, narrowing, hypertrophy, subchondral erosions, and cysts.

RESULTS

The native ROM of specimens from T-1 to T-12 (n = 19) negatively correlated with age in AR (Pearson’s r coefficient = -0.42, p = 0.070) and FE (r = -0.42, p = 0.076). When regional ROM (across 4 adjacent segments) was considered, the presence of disc osteophytes negatively correlated with FE (r = −0.69, p = 0.012), LB (r = −0.82, p = 0.001), and disc narrowing trended toward significance in AR (r = −0.49, p = 0.107). Facet characteristics, scored using multiple variables, showed minimal correlation to native ROM (r range from −0.45 to +0.19); however, facet degeneration scores at the surgical level revealed strong negative correlations with regional thoracic stability following decompressive procedures in AR and LB (Weishaupt facet summary score: r = −0.52 and r = −0.71; p = 0.084 and p = 0.010, respectively). Disc degeneration was not correlated (Lane disc summary score: r = −0.06, p = 0.861).

CONCLUSIONS

Advanced age was the most important determinant of decreasing native thoracic ROM, whereas imaging characteristics (T1–12) did not correlate with the native ROM of thoracic specimens with intact rib cages. Advanced facet degeneration at the surgical level did correlate to specimen stability following decompressive procedures, and is likely indicative of the terminal stages of segmental degeneration.