Faculty Bibliography

BACKGROUND CONTEXT: Patients with cervical disc herniations resulting in radiculopathy ormyelopathy fromsingle level disease have traditionally been treated with Anterior Cervical Discectomy and Fusion (ACDF) with excellent results. Cervical Disc Arthroplasty (CDA) has been shown to result in similar clinical outcomes. Expert suggestion of reduced adjacent segment degeneration is a promising future result.ACost-UtilityAnalysis of these procedures with long-term follow-up has not been previously reported. PURPOSE: To compare the cost-utility of ACDF vs. CDA in single level cervical disc disease. To structure future research of the cost-utility over a long term follow-up for these alternative surgical options. STUDY DESIGN/SETTING: Single institution review of a randomized controlled trial comparing ACDF to CDA in the setting of single level cervical disc disease with the performance of a cost-utility analysis. PATIENT SAMPLE: 28 patients (ACDF n510, CDA n518) who underwent surgery as part of a randomized controlled trial. OUTCOME MEASURES: Clinical outcome scores (neck disability index, SF-36) and direct treatment costs. METHODS: We reviewed single institution prospective data from a randomized trial comparing single-level ACDF and CDA in cervical disc disease. Data collected included demographics, outcome scores (NDI and SF-36), and utility scores. Procedural cost was estimated via medicare reimbursement based on DRG and physician CPT codes. QALYs were calculated at 1 and 2 years after surgery, allowing for cost/QALYassessments. RESULTS: Patients included ACDF (n510) and CDA (n518) with no significant difference in demographic data. Both groups showed improvement in NDI. Both groups showed improvement in all domains of SF-36 except general health (GH), which remained stable. ACDF patients recorded significantly higher scores in the mental health (MH) domain at 1 and 2 years (p<.05). At two years, total QALYs gained were 0.42 and 0.26 for ACDF and CDA respectively. The average cost of ACDF was <=16,162, while CDA averaged <=13,187. Cost/QALY was <=38,480 and <=50,719 for ACDF and CDA at 2 years. The incremental cost effectiveness ratio (ICER) of ACDF vs CDA was <=18,593. CONCLUSIONS: We confirm the efficacy of ACDF and CDA in the treatment of cervical disc disease. Our results suggest similar clinical outcomes at one and two year follow-up. Both modalities demonstrate cost-effectiveness. However, the additional QALYs gained by ACDF in this study demonstrate a potentially more cost-effective profile at two years. The ICER suggests that the added benefit via ACDF comes at a reasonable cost. Long term follow-up may illustrate greater cost effectiveness via CDA due to reduced cost and potential economic treatment dominance over ACDF

BACKGROUND CONTEXT: Cervical Spondylotic Myelopathy (CSM) is a common disorder, which may lead to neurologic deficits, kyphotic deformity and neck pain. Cervical laminoplasty (CL) and posterior cervical laminectomy and fusion (PCLF) are well established surgical procedures used in the treatment of CSM. There are cases of CSM with surgical equipoise regarding which procedure is most appropriate. A comparative analysis of the peri-operative costs and charges pertaining to this population of patients may assist surgeons in a decision-making algorithm. PURPOSE: To compare and analyze total cost and hospital charges pertaining to patients undergoing cervical laminoplasty or posterior cervical laminectomy and fusion for the treatment of cervical spondylotic myelopathy. STUDY DESIGN/SETTING: Retrospective review and cost analysis at a single institution. PATIENT SAMPLE: Consecutive cases of cervical spondylotic myelopathy patients undergoing cervical laminoplasty and posterior cervical laminectomy and fusion between 2006 and 2008. OUTCOME MEASURES: Total cost (TC), hospital cost (HC), hospital charges (HCh), and hospital reimbursements. METHODS: A retrospective review of 81 consecutive patients from a single institution was performed: 55 were treated with CL and 26 with PCLF for CSM by six surgeons between 2006 and 2008. We analyzed 10,682 individual costs (hospital expenditures) and charges (hospital charge to payer) for surgically treated cases. The hospital cost (HC) was derived from direct costs (eg. hospitalization) and indirect costs (eg. administrative). The total cost (TC) included physicians' fees, obtained via current procedural terminology (CPT) codes, and hospital cost (TC5CPT+HC). Hospital charges (HCh) were derived directly from accounting data. RESULTS: The TC mean was <=18,403 for CL and <=38,257 for PCLF, (p<.01). Mean HCh was <=37,065 for CL and <=88,111 for PCLF, (p<.01); the main contributor was operating room fee (mean <=10,006). Mean HC was <=15,426 for CL and <=32,125 for PCLF, (p<.01); the main contributor was implant cost (mean <=2,582). Mean hospital reimbursement for CL was <=17,312 and <=35,827 for PCLF, (p<.01). The mean length of stay was 3.7 days for CL and 5.9 days for PCLF (p<.01). There were no significant differences between the groups with respect to age, gender, previous surgical history, and type of medical insurance. CONCLUSIONS: Our study demonstrates, in clinically similar populations, that cervical laminoplasty results in a shorter length of stay, reduced TC and HCh. In CSM cases requiring posterior decompression with surgical equipoise for PCLF or CL, we demonstrate CL to be a more cost-effective procedure. In the presence of neck pain, kyphotic deformity or gross instability, this procedure may not be sufficient and PCLF may be required

BACKGROUND CONTEXT: The use of a postoperative spinal drain for spine surgery patients is widely thought to increase the risk of postoperative infection. While antibiotics are commonly given postoperatively to decrease bacterial seeding of the hematoma, the duration of postoperative antibiotics is more debatable, and protocols may vary. PURPOSE: To determine if the continuation of postoperative antibiotics for the duration of the timea spinal drain is in place reduces the risk of acute surgical site infection, in comparison with postoperative antibiotics given for 24 hours only. STUDY DESIGN/SETTING: Prospective, randomized double-blind study. PATIENT SAMPLE: Patients undergoing multilevel thoracolumbar spine surgery in which a drain is used. OUTCOME MEASURES: Surgical site infections were defined as purulent drainage; organisms obtained from an aseptically obtained culture; pain, swelling and redness; and/or diagnosis of infection by a surgeon. METHODS: 315 patients who underwent multilevel thoracolumbar spine surgery requiring a postoperative drain were enrolled and randomized into two groups: one group receiving 24 hours of perioperative antibiotics and one group receiving antibiotics for the duration that the drain was in place. Data collected included demographics, medical co-morbidities, type of spine surgery and surgical site infection. RESULTS: 13/170 (7.6%) in the 24 hours of antibiotic group developed a surgical site infection while 21/145 (14.5%) in the antibiotic for the duration of the drain were found to have a surgical site infection. The differences between each group were significant (p<.05). There were no significant differences between the groups with respect to demographics, surgical time, type of surgery, drain output or length of stay. CONCLUSIONS: Continuing postoperative antibiotics for the entire duration a drain is in place after spine surgery does not decrease the rate of surgical site infections

BACKGROUND: Traditional surgical treatment of isthmic spondylolisthesis is posterior-lateral fusion, but the addition of anterior surgery has been explored. The purpose of this study was to evaluate the surgical and clinical outcomes of anterior-posterior surgical treatment for low-grade isthmic spondylolisthesis. METHODS: Retrospectively, we enrolled 23 consecutive patients (mean age of 50) who underwent surgical treatment for low grade isthmic spondylolisthesis. The mean follow-up was 10 months. Basic demographic and radiographic data was collected. Pre- and post-surgical clinical surveys (VAS, ODI, and SF-36) were collected. RESULTS: All 23 patients underwent anterior interbody fusion with a femoral ring allograft or ICBG in combination with posterior lumbar decompression and fusion with instrumentation. The average slip percentage decreased from 23.2% to 19.0% (p = 0.24) while slip angle increased from 9.8 degrees to 17.9 degrees (p < 0.001) and average disc height decreased from 1.9 cm to 0.80 cm (p < 0.001). VAS scores decreased from 7.1 to 2.4 (p < 0.001), ODI scores decreased from 52.5 to 28.1 (p < 0.001), and SF-36 scores increased in the Physical Component Scale (PCS) from 29.5 to 42.6 (p < 0.001). CONCLUSION: In our study, patients demonstrated an improvement in the ODI as well the physical component scores of the SF-36, thus having a good clinical outcome.

STUDY DESIGN: Retrospective study of patients enrolled in a prospective randomized Food and Drug Administration trial with single level cervical disc replacement (CDR) with the ProDisc-C (Synthes, Paoli, PA). OBJECTIVE: Evaluate the segmental range of motion (ROM) in the cervical spine pre- and postoperative after CDR. SUMMARY OF BACKGROUND INFORMATION: Each cervical level is believed to have its own biomechanical characteristics, ultimately leading to different sagittal and lateral ROM. Our understanding of the factors that influence motion after CDR continues to change and expand. METHODS: One hundred sixty-four patients with single level ProDisc-C arthroplasty were evaluated radiographically using Medical Metrics (QMATM, Medical Metrics, Inc., Houston, TX). Pre- and postoperative disc height and ROM were measured from standing lateral and flexion-extension radiographs. Of these 164 patients, 44 had a CDR at C6/C7, 96 at C5/C6, 18 at C4/C5, and 6 at C3/C4. The mean follow-up was of 24 months. Statistical analysis evaluated the difference in mean ROM between the groups. RESULTS: Before surgery, C4/C5 had more sagittal ROM compared with C3/C4, C5/C6, and C6/C7 (P < 0.001.) Before surgery, C4/C5 also had more lateral ROM compared with C3/C4, C5/C6, and C6/C7 (P = 0.015). After surgery, there were no significant differences in sagittal and lateral ROM between C3/C4, C4/C5, C5/C6, and C6/C7. The delta (difference between pre- and postoperative) proved that the C4/C5 CDR actually lost sagittal ROM (-2.5 degrees ) compared with the other levels, which gained sagittal ROM, C3/C4 (0.9 degrees ), C5/C6 (1.8 degrees ), and C6/C7 (1.6 degrees ); P = 0.037. There was no significant difference in the delta lateral ROM between the segments: C3/C4, C4/C5, C5/C6, and C6/C7. CONCLUSION: CDR approximates the different segmental sagittal and lateral ROM. Although C4/C5 had negative delta ROM in the sagittal and lateral planes, it provided a satisfactory final ROM. Long-term clinical outcome studies are needed to properly evaluate if these differences could ultimately affect the patients everyday life

STUDY DESIGN.: Systematic review of cohort studies comparing surgical treatment options for cervical spondylotic myelopathy. OBJECTIVE.: Compare results of major surgical treatments. SUMMARY OF BACKGROUND DATA.: Controversy exists between various surgical options for the treatment of multilevel cervical spondylotic myelopathy, including multilevel corpectomy (CORP) and fusion, anterior cervical discectomy and fusion, laminoplasty (LAMP), and laminectomy and fusion (LAMI). A systematic review was done in order to compare results and complications among these procedures. METHODS.: Systematic review of retrospective cohort studies comparing anterior cervical discectomy and fusion (ACDF), CORP, LAMP, and LAMI from 1980 to January 2008. Separately, a review was performed of case series with greater than 10-year follow-up. RESULTS.: About 1735 articles found initially, 591 abstracts screened, 36 articles retrieved in full, 11 studies included in review. All comparison studies are retrospective cohort studies. Four studies compared multilevel CORP versus LAMP, 1 study compared LAMI with LAMP, and 2 studies compared ACDF with LAMP. There were 3 case studies with greater than 10-year follow-up. CONCLUSION.: All approaches yield similar neuro recovery rates. Laminoplasty has a significant incidence of neck pain compared with multilevel CORP. ACDFs increase the rate of adjacent secondary spondylosis compared with LAMP. Multilevel CORP and laminectomy with fusion have a significantly higher rate of graft, instrumentation, and approach related complications. Multilevel CORP and laminectomy with fusion have a significant decrease in range of motion of neck compared with LAMP

BACKGROUND CONTEXT: Symptomatic Adult Lumbar Scoliosis (ALS) has a multitude of potential pain and disability generators such as neural compression, discogenic pain, facet degeneration, spinal instability, and spinal malalignment. Depending on the treating physician, patients with ALS may receive a spectrum of surgical treatments from limited decompression to long-spanning fusion with instrumentation and spinal realignment. PURPOSE: This study aims to investigate the differences in operative planning between two groups of spine surgeons based on fellowship experience and practice composition. STUDY DESIGN/SETTING: A comparative pre-operative planning analysis between 2 groups of surgeons: degenerative spine surgeons (Group 1, n56) and spinal deformity surgeons (Group 2, n56). Deformity surgeons were defined by the percentage of deformity surgery in their practice (>50%). PATIENT SAMPLE: The sample consisted of 7 patients with symptomatic lumbar scoliosis. METHODS: 12 Surgeons; 6 Degenerative Spine (Group 1) and 6 Spinal Deformity (Group 2) surgeons were shown 7 cases of a symptomatic adult degenerative scoliosis patient with radiculopathy. Each case consisted of patients with the following inclusion criteria: lumbar curve between 25degree- 40degree, Thoracic Kyphosis (T2-T12) between 20degree-50degree, Lumbar Lordosis (L1-S1) between 30degree-65degree, and Sagittal Vertical Axis (C7 Plumbline to posterior- superior S1) between 0-80 mm. Patients with olithesis OGrade 1, cauda equina syndrome or prior thoracic or lumbar instrumentation and fusion were excluded. Each case was presented with a brief history, physical exam findings, 36 in PA and lateral radiographs, MRI and CT scans. Surgeons completed a questionnaire detailing their fellowship and practice deformity experience and their planned operative intervention including the number of fusion levels if any, the approach (anterior vs. posterior), choice of bone graft and interbody device. Pearson Correlation was used to investigate the association between fellowship training, practice composition, number of fusion levels and the other variables. Intraclass correlation (ICC) analysis was used to investigate the internal consistency among the degenerative and deformity surgeons. RESULTS: Fellowship and Practice: Group 1 surgeons had a mean 33% deformity cases in fellowship (range 10%-75%) while Group 2 surgeons had a mean of 65% (range 50%-80%). The mean deformity pathology in their practice was 18% (range 10%-25%) for group 1 surgeons and 67% (range 50%-90%) for group 2 surgeons. Correlation between fellowship and practice spinal deformity composition was r=0.62, p<0.01. Fusion Levels: Group 1 surgeons fused a mean 4.5 vertebral levels (range 2.8- 6.2 levels) while Group 2 surgeons fused a mean 11.8 vertebral levels (range 5.3-17.7 levels). Deformity surgeons fused a significantly greater number of levels for each case than degenerative surgeons on paired student t-test (p=0.003). Pearson correlation between % practice spinal deformity and number of fusion levels was r=0.87, p<0.01). ICC analysis for the agreement among deformity surgeons for the number of levels fused per case was r=0.327, 95% Confidence Interval: 0.07-0.76, p=0.004). ICC for Degenerative Surgeons was r=0.01 (95% Confidence Interval: -0.16-0.18, p=0.842). CONCLUSIONS: Findings from this investigation demonstrate the association between practice composition and deformity experience during fellowship training. In the setting of patients with ALS without significant sagittal malalignment, fellowship and practice composition have a significant influence on the physician's surgical planning. Deformity surgeons had significantly higher group consistency and planned a greater number of fusion levels than degenerative surgeons in these ALS cases

STUDY DESIGN: Prospective inter-rater and intrarater reliability analysis. OBJECTIVE: To compare the inter-rater and intrarater reliability of magnetic resonance imaging (MRI) and computed tomography (CT) for grading of facet arthropathy as well as determining whether there is a contraindication to total disc replacement (TDR). SUMMARY OF BACKGROUND DATA: Several classifications attempted to evaluate lumbar facet joints and their degree of arthropathy. The Fujiwara-MRI and Pathrea-CT classifications remain the most commonly used. METHODS: A total of 10 fellowship-trained orthopedic spine surgeons and 3 orthopedic spine fellows evaluated 50 levels from L3-L4 through L5-S1 on parallel axial MRI (T1 and T2) and CT images. The degree of osteoarthritis was graded on a 4-point scale (Fujiwara-MRI and Pathrea-CT). Surgeons evaluated whether the degree of facet disease represented a contraindication to TDR. Grading was performed during 2 sessions. Weighted kappa statistics were used to describe inter- and intraobserver agreement. RESULTS: The inter-rater reliability for MRI was 0.21 and 0.07 (fair to slight) among attendings and fellows, respectively. inter-rater reliability for CT was 0.33 and 0.27 (fair), respectively. The mean intrarater reliability for MRI was fair, 0.36 (attendings) and 0.26 (fellows). The mean intrarater reliability for CT was moderate, 0.52 (attendings) and 0.51 (fellows). For possible TDR contraindication, the inter-rater reliability for MRI was 0.22 and 0.01 (fair to slight) among attendings and fellows, respectively. Inter-rater reliability for CT was 0.33 and 0.45 (fair), respectively. The mean intrarater reliability for MRI was fair, 0.36 (attendings) and 0.26 (fellows). The mean intrarater reliability for CT was moderate, 0.52 (attendings) and 0.51 (fellows). CONCLUSION: The current grading system for facet arthropathy has only fair agreement. CT is slightly more reliable for grading. Intrarater reliability was only fair for MRI and moderate for CT. Only limited agreement existed between surgeons as to the extent of facet disease that would pose as a contraindication for TDR

BACKGROUND CONTEXT: Anterior lumbar surgery is a common procedure for anterior lumbar interbody fusion and disc replacement but the impact of obesity on this procedure has not been determined. PURPOSE: To assess the perioperative outcomes of anterior retroperitoneal lumbar surgery in obese versus non-obese patients. STUDY DESIGN/SETTING: Prospective review of patients with anterior retroperitoneal lumbar disc procedures PATIENT SAMPLE: Seventy-four patients with anterior retroperitoneal lumbar disc procedures performed were evaluated. OUTCOME MEASURES: Access-related parameters included tissue depth (skin-to-fascia and fascia-to-spine depths), length of incision, estimated blood loss during the anterior procedure, the duration of the anterior exposure, and the duration of the entire anterior procedure. Outcome measures included complications attributable to the anterior procedure, analgesic use, length of time to ambulation, and length of hospitalization. METHODS: Seventy-four anterior retroperitoneal lumbar disc procedures were prospectively analyzed. Patient age, sex, body mass index, comorbidities, diagnosis, and operative parameters were collected. Access-related parameters and outcome measures were compared between obese and non-obese patients. Obesity was defined as body mass index greater than or equal to 30. RESULTS: There were 35 males and 39 females. Mean age was 46.6 years. The main diagnosis (63.5%) was discogenic back pain. Forty-one (55%) patients were non-obese and 33 were obese. The two patient groups were comparable in terms of age, sex, diagnosis, mean number of anterior levels operated, and previous abdominal surgery (all p>.05). In obese patients, there were two iliac vein lacerations (major complication rate, 6.1%), one superficial infection, and one urinary tract infection (minor complication rate, 6.1%). In non-obese patients, there were two iliac vein lacerations, one intestinal serosal tear (major complication rate, 7.3%), and two urinary tract infections (minor complication rate, 4.9%). There was no significant difference in the complication rates between obese and non-obese patients (p=.6). Obese patients have significantly longer duration of anterior exposure, duration of entire anterior surgery, longer length of anterior incision, and more depth from skin to fascia and from fascia to spine compared with non-obese patients. However, obesity does not affect blood loss, analgesic use, length of time to ambulation, and length of hospitalization. CONCLUSION: Perioperative outcomes in obese and non-obese patients were comparable and obesity is not related to an increased risk of morbidity in anterior lumbar surgery