The technique of S2-alar-iliac screw fixation: a literature review

The distal fixation in thoracolumbar deformity surgery can be challenging for spine surgeons. When isolated S1-pedicle screws are utilized as the sole distal fixation in long thoracolumbar posterior constructs, there is a high rate of failure, due to loosening, breakage, and pseudarthrosis. Unfortunately, with iliac screw fixation the entry point at the posterior superior iliac spine requires considerable soft tissue dissection and may potentially increase the likelihood of wound complications. S2-alar-iliac (S2AI) screw fixation technique was developed recently to provide increased fixation with a lower profile screw and rod construct. These screws can be inserted with percutaneous or free hand techniques. This fixation also has comparable biomechanical properties to the S1 iliac screw. This technique may provide advantages such as decreased rates of reoperation, surgical site infection, wound dehiscence and symptomatic screw prominence as compared to traditional iliac screw fixation. The purpose of this manuscript is to review the S2AI screw fixation literature including anatomy, technique, biomechanics, and clinical outcomes

Iliac Crest Bone Graft for Minimally Invasive Transforaminal Lumbar Interbody Fusion: A Prospective Analysis of Inpatient Pain, Narcotics Consumption, and Costs

BACKGROUND CONTEXT Iliac crest bone grafting (ICBG) has been associated with enhanced fusion rates. However, concerns have been raised in regard to increased operative time and postoperative pain. The advantages of ICBG compared to other spinal fusion adjuncts have been debated. However, little is known regarding this technique in the setting of a minimally invasive transforaminal lumbar interbody fusion (MIS TLIF). STUDY DESIGN/SETTING Prospective cohort. PATIENT SAMPLE Ninety-eight patients who underwent a MIS TLIF procedure with ICBG or BMP-2, 49 in each cohort. OUTCOME MEASURES Inpatient narcotics consumption in oral morphine equivalents (OME), Visual Analog Scale (VAS) pain, and direct hospital costs. METHODS Prospective, consecutive analysis of patients undergoing primary, single-level MIS TLIF with ICBG were compared to a historical cohort of consecutive patients that received BMP-2. Operative characteristics were compared between groups using chi square analysis or independent t test for categorical and continuous variables, respectively. Postoperative inpatient pain was measured using the VAS, and inpatient narcotics consumption was quantified as OMEs for both groups. Outcomes were compared between groups using multivariate regression controlling for preoperative characteristics. Statistical significance was set at p\u3c.05. RESULTS A total of 98 patients were included in this analysis, 49 in each cohort. No significant differences were noted between cohorts except in regard to gender (more males in the BMP cohort, 67.35% vs. 46.94%, p=.041). There was a significant increase in operative time (14.53 minutes, p=.006) and estimated blood loss (16.64 mL, p=.014) in the ICBG cohort. No significant differences were identified for inpatient length of stay or VAS scores. Narcotics consumption was similar between groups on postoperative days 0 and 1. ICBG was associated with decreased total direct costs ($19,315 vs.$21,645, p\u3c.001) as compared to BMP-2. CONCLUSIONS Patients undergoing MIS TLIF who underwent ICBG experienced increases in operative time and estimated blood loss that were not clinically significant. Furthermore, iliac crest harvesting did not result in either an increase in acute pain or narcotics consumption. Further follow-up is necessary to determine the associated arthrodesis rates and long term outcomes between each cohort. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs

Risk Factors for Medical and Surgical Complications After 1–2-Level Anterior Cervical Discectomy and Fusion Procedures

Background Postoperative complications after anterior cervical discectomy and fusion (ACDF) have a significant impact on clinical outcomes and health care resource use. Identifying predictive factors for complications after ACDF may allow for the modification of care protocols to mitigate complication risk. The purpose of this study is to determine risk factors for the incidence of medical and surgical complications up to 2 years postoperatively after ACDF procedures. Methods A prospectively maintained surgical registry of patients who underwent primary, 1–2-level ACDF was retrospectively reviewed. The incidence of medical and surgical complications up to 2 years postoperatively was determined. Patients were classified according to demographic, comorbidity, and procedural characteristics. Bivariate Poisson regression with robust error variance was used to determine if an association existed between the incidence of medical or surgical complications and patient characteristics. A final multivariate model including all patient and procedural characteristics as controls was created using backwards, stepwise regression until only those variables with P \u3c .05 remained. Results A total of 310 patients were included. Upon bivariate analysis, age \u3e50 years was identified as a risk factor for medical complications after ACDF procedures. Additionally, bivariate analysis identified ageless Charlson comorbidity index ≥2, operative duration \u3e60 minutes, and 2-level procedures as risk factors for surgical complications after ACDF. Upon multivariate analysis, age \u3e50 years was identified as an independent risk factor for medical complications (relative risk [RR] = 3.6, P = .005), while operative time \u3e60 minutes was identified as an independent risk factor for surgical complications after ACDF (RR = 4.5, P = .017). Conclusions The results of this study demonstrate that older age and longer operative time were independent risk factors for medical and surgical complications, respectively, following ACDF. Patients with these risk factors should be counseled regarding their increased risk of postoperative complications and should undergo more vigilant monitoring to aid in complication avoidance. Level of Evidence 3. Clinical Relevance Surgeons should consider the elevated risk of postoperative complications in \u3e50 years old patients and \u3e60 min procedures

Impact of Body Mass Index on Surgical Outcomes, Narcotics Consumption, and Hospital Costs Following Anterior Cervical Discectomy and Fusion

OBJECTIVE Given the increasing prevalence of obesity, more patients with a high body mass index (BMI) will require surgical treatment for degenerative spinal disease. In previous investigations of lumbar spine pathology, obesity has been associated with worsened postoperative outcomes and increased costs. However, few studies have examined the association between BMI and postoperative outcomes following anterior cervical discectomy and fusion (ACDF) procedures. Thus, the purpose of this study was to compare surgical outcomes, postoperative narcotics consumption, complications, and hospital costs among BMI stratifications for patients who have undergone primary 1- to 2-level ACDF procedures. METHODS The authors retrospectively reviewed a prospectively maintained surgical database of patients who had undergone primary 1- to 2-level ACDF for degenerative spinal pathology between 2008 and 2015. Patients were stratified by BMI as follows: normal weight (\u3c 25.0 kg/m2), overweight (25.0–29.9 kg/m2), obese I (30.0–34.9 kg/m2), or obese II–III (≥ 35.0 kg/m2). Differences in patient demographics and preoperative characteristics were compared across the BMI cohorts using 1-way ANOVA or chi-square analysis. Multivariate linear or Poisson regression with robust error variance was used to determine the presence of an association between BMI category and narcotics utilization, improvement in visual analog scale (VAS) scores, incidence of complications, arthrodesis rates, reoperation rates, and hospital costs. Regression analyses were controlled for preoperative demographic and procedural characteristics. RESULTS Two hundred seventy-seven patients were included in the analysis, of whom 20.9% (n = 58) were normal weight, 37.5% (n = 104) were overweight, 24.9% (n = 69) were obese I, and 16.6% (n = 46) were obese II–III. A higher BMI was associated with an older age (p = 0.049) and increased comorbidity burden (p = 0.001). No differences in sex, smoking status, insurance type, diagnosis, presence of neuropathy, or preoperative VAS pain scores were found among the BMI cohorts (p \u3e 0.05). No significant differences were found among these cohorts as regards operative time, intraoperative blood loss, length of hospital stay, and number of operative levels (p \u3e 0.05). Additionally, no significant differences in postoperative narcotics consumption, VAS score improvement, complication rates, arthrodesis rates, reoperation rates, or total direct costs existed across BMI stratifications (p \u3e 0.05). CONCLUSIONS Patients with a higher BMI demonstrated surgical outcomes, narcotics consumption, and hospital costs comparable to those of patients with a lower BMI. Thus, ACDF procedures are both safe and effective for all patients across the entire BMI spectrum. Patients should be counseled to expect similar rates of postoperative complications and eventual clinical improvement regardless of their BMI

Swallowing Function Following Anterior Cervical Discectomy and Fusion With and Without Anterior Plating: A SWAL-QOL (Swallowing-Quality of Life) and Radiographic Assessment

Objective Anterior cervical plating in anterior cervical discectomy and fusion (ACDF) procedures are associated with improved outcomes compared to stand-alone cages. However, concerns exist regarding increased rates of postoperative dysphagia following an ACDF. This study aims to quantify the effect of anterior plating on swallowing-quality of life (SWAL-QOL) scores and radiographic swelling assessments following a primary, single-level ACDF. Methods Patients retrospectively reviewed. Patients grouped into those receiving a cage or anterior plate. SWAL-QOL scores were recorded preoperatively and 6 weeks and 12 weeks postoperatively. Lateral radiographs were used to create a swelling index with a ratio of the prevertebral swelling distance to the anterior-posterior diameter of each involved vertebral body. An air index was created using the same methodology. Statistical analysis was performed using chi-square analysis and independent t-tests for categorical and continuous variables. Results Sixty-eight primary, single-level ACDF patients were included. Forty-one (60.3%) received a stand-alone cage and 27 (39.7%) received a cage with anterior plating. No differences in demographics, comorbidities, operative time, estimated blood loss, or length of hospital stay were identified between Cage and Plate cohorts. Finally, no differences were observed in postoperative SWAL-QOL scores or swelling and air indices between groups. Conclusion The results demonstrate that patients undergoing a primary, single-level ACDF with or without anterior plating experience similar operative times and lengths of stay. Patients that receive a cage with anterior plating did not experience significant increases in dysphagia as measured by the SWAL-QOL questionnaire compared to patients that received a stand-alone cage. Furthermore, radiographic assessments of swelling are comparable

Outcomes for type C proximal humerus fractures in the adult population: comparison of nonoperative treatment, locked plate fixation, and reverse shoulder arthroplasty

BackgroundThis study compares patient-reported outcomes and range of motion (ROM) between adults with an AO Foundation/Orthopaedic Trauma Association type C proximal humerus fracture managed nonoperatively, with open reduction and internal fixation (ORIF), and with reverse shoulder arthroplasty (RSA).MethodsThis is a retrospective cohort study of patients >60 years of age treated with nonoperative management, ORIF, or RSA for AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures from 2015 to 2018. Visual analog scale pain scores, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, ROM values, and complication and reoperation rates were compared using analysis of variance for continuous variables and chi square analysis for categorical variables.ResultsA total of 88 patients were included: 41 nonoperative, 23 ORIF, and 24 RSA. At the 2-week follow-up, ORIF and RSA had lower visual analog scale scores and lower PROMIS pain interference scores (P < .05) than nonoperative treatment. At the 6-week follow-up, ORIF and RSA had lower visual analog scale, PROMIS pain interference, and PF scores and better ROM (P < .05) than nonoperative treatment. At the 3-month follow-up, ORIF and RSA had better ROM and PROMIS pain interference and PF scores (P < .05) than nonoperative treatment. At the 6-month follow-up, ORIF and RSA had better ROM and PROMIS PF scores (P < .05) than nonoperative treatment. There was a significantly higher complication rate in the ORIF group than in the non-operative and RSA groups (P < .05).ConclusionThe management of AO Foundation/Orthopaedic Trauma Association type 11C proximal humerus fractures in older adults with RSA or ORIF led to early decreased pain and improved physical function and ROM compared to nonoperative management at the expense of a higher complication rate in the ORIF group

Impact of Iliac Crest Bone Grafting on Postoperative Outcomes and Complication Rates Following Minimally Invasive Transforaminal Lumbar Interbody Fusion

Objective The relationship between bone graft technique and postoperative outcomes for minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) has not been well-defined. This study aims to determine the effect of iliac crest bone grafting (ICBG) on patient-reported outcomes (PROs) and complication rates following MIS TLIF. Methods Primary, single-level MIS TLIF patients were consecutively analyzed. Patients that prospectively received a percutaneous technique of ICBG were compared to patients that retrospectively received bone morphogenetic protein-2 (BMP-2). Complication rates were assessed perioperatively and up to 1 year postoperatively. Changes in Oswestry Disability Index (ODI), visual analogue scale (VAS) back, and VAS leg pain were compared. Rates of minimum clinically important difference (MCID) achievement at final follow-up for ODI, VAS back, and VAS leg scores were compared. Results One hundred forty-nine patients were included: 101 in the BMP-2 cohort and 48 in the ICBG cohort. The ICBG cohort demonstrated increases in intraoperative blood loss and shorter lengths of stay. ICBG patients also experienced longer operative times, though this did not reach statistical significance. No significant differences in complication or reoperation rates were identified. The ICBG cohort demonstrated greater improvements in VAS leg pain at 6-week and 12-week follow-up. No other significant differences in PROs or MCID achievement rates were identified. Conclusion Patients undergoing MIS TLIF with ICBG experienced clinically insignificant increases in intraoperative blood loss and did not experience increases in postoperative pain or disability. Complication and reoperation rates were similar between groups. These results suggest that ICBG is a safe option for MIS TLIF

Variation in Spine Surgeon Selection Criteria Between Neurosurgery and Orthopedic Surgery Patients

Study design: A cross-sectional survey study. Objective: The objective of this study is to determine if there are any differences in spine surgeon selection criteria between neurosurgery patients and orthopedic patients. Background information: The evolution of the health care delivery system has allowed for increased patient autonomy in provider selection. However, the process and criteria by which patients choose particular spine surgeons is not well understood. Furthermore, differences in physician selection criteria used by patients who present either to a neurosurgery or orthopedic spine surgeon has not been previously established. Materials and methods: An anonymous questionnaire consisting of 26 questions was administered to 644 patients seeking treatment from either a single neurosurgery-trained or orthopedics-trained spine surgeon at an urban institution. Four questions pertained to demographic variables. Sixteen questions asked patients to rate specific spine surgeon selection criteria in terms of importance (scale, 1-10). Six questions were multiple choice, asking patients to select their preferences towards aspects of a spine surgeon. Patient responses were compared using χ analysis or Fisher exact test for categorical variables. Results: The 3 most important factors for selecting a spine surgeon were the same for neurosurgery and orthopedic surgery patients: board certification (neurosurgery, orthopedic surgery) (9.07±2.35, 9.22±1.79), in-network provider status (8.01±3.15, 8.09±3.03), and surgeon bedside manner (7.88±2.52, 8.07±2.29). When listing their preference regarding surgeon specialty training, 82.74% of neurosurgery patients and 48.81% of orthopedic surgery patients preferred a surgeon who was trained in neurosurgery. Conclusions: The growth in patient autonomy within the current health care system has emphasized the importance of identifying patient preferences in the physician selection process.Board certification, in-network insurance status, and bedside manner may be the most influential factors for patients in spine surgeon selection irrespective of surgical subspecialty. Patients may also be more likely to seek spine surgeons with neurosurgery training over orthopedic surgery training. The present study provides spine surgeons a framework to improve both patient recruitment and patient satisfaction

Comparison of Postoperative Outcomes between Primary MIS TLIF and MIS TLIF as a Revision Procedure to Primary Decompression

Study design: Retrospective cohort. Objective: To compare postoperative improvements in surgical and patient-reported outcomes (PROs) between patients undergoing minimally invasive laminectomy and minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) as a primary procedure to patients undergoing MIS laminectomy and TLIF as a revision to primary lumbar decompression (LD). Summary of background data: MIS TLIF and LD have demonstrated to be effective surgical options for lumbar degenerative disease. However, some patients undergoing LD experience recurrent symptoms and eventually require a revision decompression with fusion. Methods: A prospectively maintained surgical database of patients who underwent a primary or revision one-level MIS TLIF for degenerative spinal pathology between 2014 and 2016 was reviewed. Consecutive patients undergoing primary MIS TLIF and revision lumbar discectomy and/or laminectomy were matched in a one-to-one fashion to primary MIS TLIF patients who had not undergone a previous LD by age and preoperative diagnosis. Differences in patient demographic, comorbidity, and perioperative characteristics between procedure groups were assessed using Pearson chi-squared analysis and Student t test for categorical and continuous variables, respectively. Improvements in PROs from preoperative values were compared between primary and revision cohorts using Student t tests. Pearson chi-squared analysis was used to compare rates of minimum clinically important difference achievement between procedure groups. Statistical significant was set at P \u3c 0.05. Results: A total of 52 patients were included in this analysis. Twenty-six underwent primary MIS laminectomy and TLIF and 26 underwent MIS TLIF with a revision decompression. No differences in baseline or perioperative variables were observed. Revision and primary MIS TLIF patients experienced similar improvements in PROs at all postoperative time points. Conclusion: The results of the present study demonstrate patients undergoing primary MIS TLIF with LD as a revision to a primary decompression experienced similar postoperative improvements in PROs as compared to primary MIS TLIF patients. This indicates a primary decompression does not compromise clinical outcomes in patients undergoing MIS TLIF. As such, patients should not be precluded from undergoing MIS TLIF based on the history of a previous LD. Level of evidence: 3

Does the Day of the Week Affect Length of Stay and Hospital Charges Following Anterior Cervical Discectomy and Fusion?

Background To reduce the economic impact of excessive costs, risk factors for increased length of stay (LOS) must be identified. Previous literature has demonstrated that surgeries later in the week can affect the LOS and costs following joint arthroplasty. However, few investigations regarding the day of surgery have been performed in the spine literature. The present study attempts to identify the association between day of surgery on LOS and hospital charges following anterior cervical discectomy and fusion (ACDF) procedures. Methods A prospectively maintained surgical database of primary, level 1-2 ACDF patients between 2008 and 2015 was retrospectively reviewed. Patients were stratified by surgery day: early week (Tuesday) or late week (Friday) ACDF. Differences in patient demographics and preoperative characteristics were compared between cohorts using chi-square analysis or Student t test for categorical and continuous variables, respectively. Direct hospital costs were obtained using hospital charges for each procedure and subsequent care prior to discharge. Associations between date of surgery and costs were assessed using multivariate linear regression controlled for. Results Two hundred and ninety-five patients were included in the analysis. One hundred and fifty-three patients underwent early week ACDF, and 142 underwent late week ACDF. Surgery day cohorts reported similar baseline characteristics. There were no differences in operative characteristics or hospital LOS between cohorts. Additionally, no differences in total or subcategorical hospital costs were identified between surgery day cohorts. Conclusions Patients undergoing ACDF later in the week exhibit similar LOS and hospital costs compared to those undergoing ACDF early in the week. These results suggest that outpatient procedures with short postoperative stays are likely not affected by the changes in hospital work efficiency that occur during the transition to the weekend. As such, hospitals should not restrict outpatient procedures to specific days of the week. Level of Evidence 3