Post-operative nerve injuries after cervical spine surgery

Although relatively rare, post-operative nerve injuries may occur after cervical spine procedures. The most common post-operative neural disorder is C5 nerve palsy. The risk factors for C5 nerve palsy are male gender, OPLL, and posterior cervical approaches. It generally presents with deltoid and/or biceps weakness, and may present immediately or several days after surgery. Treatment is generally conservative due to transient duration of symptoms, but evaluation of residual compression at C4-5 is essential. PTS (Parsonage-Turner syndrome) is an idiopathic plexopathy generally presenting with severe neuropathic pain in the shoulder, neck, and arms, followed by neurological deficits involving the upper brachial plexus. The deficits typically present in a delayed fashion after the onset of pain. Once residual nerve compression is ruled out, initial treatment is based on pain control and physical therapy. Post-operative C8-T1 nerve palsies occur with weakness of the five intrinsic muscles of the hand innervated by the medial nerve, with sensory symptoms in the territory innervated by the ulnar nerve (ulnar two digits of the hand), and also the medial forearm. The risk factors for C8-T1 nerve injuries after surgery are C7 pedicle subtraction osteotomies and posterior fixation of the cervico-thoracic junction, especially in patients with preoperative C7-T1 stenosis. A wide foraminal decompression at C7-T1 region is necessary to minimize risk of this complication. Finally, Horner's syndrome can occur post-operatively, especially after anterolateral approaches to the middle and lower levels of the cervical spine. It is characterized by ipsilateral papillary miosis, facial anhydrosis, and ptosis secondary to injury of the cervical sympathetic nerves. Avoid using the cautery on the lateral border of the longus colli muscle, where the sympathetic chain lies and place the retractors properly underneath the muscle to decrease the chance of sympathetic injuries. It can also occur from iatrogenic compression or injury to the T1 nerve root, as the sympathetic chain gets some of its fibers from that level. Understanding the most common potential nerve injuries after cervical spine procedures is helpful in prevention, early diagnosis, and appropriate management.4379179

Evidence-based use of arthroplasty in cervical degenerative disc disease

Cervical disc arthroplasty (CDA) was developed to decrease the rate of symptomatic adjacent-level disease while preserving motion in the cervical spine. The objectives of this paper are to provide criteria for proper patient selection as well as to present a comprehensive literature review of the current evidence for CDA, including randomized studies, the most recent meta-analysis findings, and long-term follow-up clinical trials as well.ResultsCurrently, there are several prospective randomized controlled studies of level I of evidence attesting to the safety and efficacy of CDA in the management of cervical spondylotic disease (CSD) for one- or two-level degenerative diseases. These as well as recent meta-analyses suggest that CDA is potentially similar or even superior to anterior cervical discectomy and fusion (ACDF) when considering several outcomes, including dysphagia and re-operation rate over medium-term follow-up. Less robust studies have also reported satisfactory clinical and radiological outcomes of CDA for hybrid procedures (ACDF combined with CDA), non-contiguous disease, and even for multilevel disease (more than 2 levels). Based on this evidence we conclude that CDA is a safe and effective alternative to ACDF in properly selected patients for one- or two-level diseases. Defining superiority of specific implants and detailing optimal surgical indications will require further well-designed long-term studies.4376777

Patient-Reported Outcomes Measurement Information System physical function instruments compare favorably to legacy patient reported outcome measures in spine patients: a systematic review of the literature

BACKGROUND CONTEXT: Preliminary evidence has suggested favorable correlation between National Institutes of Health (NIH) Patient-Reported Outcomes Measurement Information System (PROMIS) assessments and traditional ( legacy ) patient reported outcome measures (PROMs) in spine surgery. There has been a significant increase in PROMIS research with regards to spinal conditions. PURPOSE: The purpose of this systematic review is to provide an assessment of PROMIS Physical Function (PF) measures in this patient population. STUDY DESIGN/SETTING: Systematic review. METHODS: A systematic search of the PubMed/MEDLINE and Embase databases was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify published articles that referenced the various PROMIS PF measures. Two authors independently reviewed selected studies. The search returned 1,060 studies, 124 of which were selected for independent review by two authors. Of these, 37 were selected for inclusion. Mixed linear models were performed to assess for differences between legacy PROMs and PROMIS measures. RESULTS: The combined sample size of all included studies yielded 10,296 total patients. Overall, PROMIS Physical Function (PF) measures demonstrated strong correlations with legacy PROMs when evaluating spine patients (weighted Pearson correlation, 0.589, standard error [SE] = 0.023; weighted Spearman correlation, 0.702, SE = 0.028). PROMIS questionnaires had significantly fewer questions than did legacy PROMs (4.2 ± 0.30 vs 9.53 ± 0.82, P = 0.015). In spine studies, the PROMIS PF forms were completed in significantly less time than legacy PROMs (48.1 ± 2.9 vs 174.7 ± 12.6 seconds, P \u3c 0.001). The differences for the reliability measures and the floor and ceiling effects were not significant. CONCLUSIONS: Patient-Reported Outcomes Measurement Information System PF forms compare favorably with legacy PROMs with regard to correlations, ease of use, and quality criteria in the field of spine surgery. PROMIS PF scores correlate strongly with commonly used legacy PROMs, particularly in spine patients. Patient-Reported Outcomes Measurement Information System PF forms can be administered efficiently and to a broad patient population while remaining highly reliable

Online access to spine care: do institutions advertise themselves as multidisciplinary?

BACKGROUND: The primary aim of our study is to assess the extent to which healthcare systems advertise their spine care programs as multidisciplinary and furthermore clarify whether these institutions accurately reflect this description in their online access to spine care. The secondary aim of our study is to determine what proportion of institutions enable patients to self-schedule appointments online and select providers. METHODS: Newsweek\u27s 2021 list entitled Best Hospitals 2021-United States was utilized to obtain an extensive list of top-rated hospitals in the country. Institutions were considered to be advertising themselves as multidisciplinary if they used this term or similar wording (such as care encompassing broad range of specialties , interdisciplinary , multidisciplinary ). Each institution\u27s website was additionally assessed for the existence of: (I) a standard overview website or multiple individual sites for respective spine-focused divisions (i.e., orthopaedic surgery, neurosurgery, physical medicine and rehabilitation, anesthesiology); (II) online self-scheduling; (III) triage questions prior to requesting appointments; and (IV) selection choice for specific providers. RESULTS: In total, 334 institutions were included in analysis, with 66% utilizing multidisciplinary terminology in describing their institution on their website. However, most institutions only had a standard overview website with no separate websites for respective divisions (54%). Institutions described as multidisciplinary were more likely to have a link on a central page to each division (31% vs. 4%, P\u3c0.001). No significant differences were found between institutions described as multidisciplinary and those not described as such when considering triage questions, online self-scheduling, and choice of provider. CONCLUSIONS: Though the majority of spine care centers are described as multidisciplinary, the patient experience when navigating websites online does not always meet this standard. Further progress in website design, automated triaging, and online scheduling are needed to truly achieve multidisciplinary care

Neurologic Deficit During Halo-Gravity Traction in the Treatment of Severe Thoracic Kyphoscoliotic Spinal Deformity.

Correction of severe spinal deformity is a significant challenge for spinal surgeons. Although halo-gravity traction (HGT) has been shown to be well-tolerated and safe, we report here a case of neurologic decline during treatment. A 24-year-old male presents with severe thoracic kyphoscoliosis with > 180° of 3-dimensional deformity. Magnetic resonance imaging showed his thoracic spinal cord draped across his T7-9 apex. His neurologic exam showed lower extremity myelopathy. During week 7 at a goal traction weight of 18.1 kg, his distal lower extremity exam declined from 4+/5 to 2/5. His traction weight was lowered to 11.3 kg. He subsequently sustained a ground-level fall and became paraparetic with a motor exam of 1-2/5. He subsequently underwent a T1-L4 posterior spinal instrumentation and fusion with a T7-9 vertebral column resection. Postoperatively, he was noted to have a complete return to his baseline neurologic exam. At his 4-month postoperative visit, he was now full strength in his lower extremities with complete resolution of his myelopathy. We present here a case of neurologic decline in a patient with severe kyphoscoliosis who underwent HGT and discuss the management decisions associated with this challenging scenario

Dual S2 Alar-Iliac Screw Technique With a Multirod Construct Across the Lumbosacral Junction: Obtaining Adequate Stability at the Lumbosacral Junction in Spinal Deformity Surgery

To illustrate the safe placement of a 5-screw/5-rod construct across the spinopelvic junction in a complex revision case utilizing 4 S2 alar-iliac (S2AI) screws as well as an iliac screw for a kickstand rod. The S2AI screws are often used for lumbosacral fixation at the base of long spinal deformity constructs. In severe spinal deformities, additional pelvic fixation beyond the standard 2 screws may help achieve and maintain correction, and also increase the rigidity of the construct. With a thorough understanding of pelvic anatomy, multiple pelvic screws, such as bilateral dual S2AI screws, may be placed safely to achieve stability and accommodate additional rods to perform powerful correction techniques. We illustrate the safe use of multiple rods across the lumbosacral junction in this case, by using both a hook rod construct and domino connectors – ultimately though these additional rods rely on the integrity of the pelvic fixation to provide their support. We recommend at least 3 rods across the lumbosacral junction in any adult spinal deformity case requiring pelvic fixation, and would recommend considering more than 3 rods, especially across 3-column osteotomy sites. For long spinal constructs in patients with significant adult spinal deformity, we believe the use of multiple pelvic screws to a multirod construct is a safe and effective way to provide long-term correction and clinical success

Telemedicine in research and training : spine surgeon perspectives and practices worldwide

Purpose: To utilize a global survey to elucidate spine surgeons’ perspectives towards research and resident education within telemedicine. Methods: A cross-sectional, anonymous email survey was circulated to the members of AO Spine, an international organization consisting of spine surgeons from around the world. Questions were selected and revised using a Delphi approach. A major portion of the final survey queried participants on experiences with telemedicine in training, the utility of telemedicine for research, and the efficacy of telemedicine as a teaching tool. Responses were compared by region. Results: A total of 485 surgeons completed the survey between May 15, 2020 and May 31, 2020. Though most work regularly with trainees (83.3%) and 81.8% agreed that telemedicine should be incorporated into clinical education, 61.7% of respondents stated that trainees are not present during telemedicine visits. With regards to the types of clinical education that telemedicine could provide, only 33.9% of respondents agreed that interpretation of physical exam maneuvers can be taught (mean score = − 0.28, SD = ± 1.13). The most frequent research tasks performed over telehealth were follow-up of imaging (28.7%) and study group meetings (26.6%). Of all survey responses provided by members, there were no regional differences (p > 0.05 for all comparisons). Conclusions: Our study of spine surgeons worldwide noted high agreement among specialists for the implantation of telemedicine in trainee curricula, underscoring the global acceptance of this medium for patient management going forward. A greater emphasis towards trainee participation as well as establishing best practices in telemedicine are essential to equip future spine specialists with the necessary skills for navigating this emerging platform.publishedVersionPeer reviewe