Utility of Computed Tomography following Anterior Cervical Diskectomy and Fusion

Expert Panel on Neurological Imaging, Eldaya RW, Parsons MS, Hutchins TA, Avery R, Burns J, Griffith B, Hassankhani A, Khan MA, Ng H, Raizman NM, Reitman C, Shah VN, Sliker C, Soliman H, Timpone VM, Tomaszewski CA, Yahyavi-Firouz-Abadi N, Policeni B. ACR Appropriateness Criteria® Cervical Pain or Cervical Radiculopathy: 2024 Update

Cervical spine pain is one of the most common reasons for seeking medical care as it ranks in the top 5 causes of global years lost to disability. The economic burden of cervical pain is also significant. Imaging is at the center of diagnosis of cervical pain and its causes. However, different symptoms and potential causes of cervical pain require different initial imaging to maximize the benefit of diagnostic usefulness of imaging. In this document we address different cervical pain variants with detailed assessment of the strengths and weaknesses of different modalities for addressing each specific variant. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Postoperative management following degenerative cervical spine surgery: Results from a survey conducted by the French Society of Spine Surgery

OBJECTIVE

To describe and evaluate postoperative care after degenerative cervical spine surgery among spine surgeons in France.

HYPOTHESIS

The postoperative management after degenerative cervical spine surgery varies considerably depending on the team caring for the patient. Based on a national survey, we aimed at providing trends and guidelines regarding the following points: 1/ clinical follow-up and postoperative imaging, 2/ the place and role of bracing after surgery, 3/ driving recommendation and 4/ return to sports activities after such surgery.

METHODS

Data were collected from spinal surgeons using a practice-based online questionnaire (SurveyMonkey Inc.). The survey comprised 15 questions on the current management following degenerative cervical spine surgery in France, especially single or multilevel anterior cervical discectomy fusion (ACDF). The surgeons were asked to answer several questions on 1) patient clinical follow-up, 2) postoperative imaging, 3) postoperative recommendation (e.g., bracing), and 4) time to return to work and sport practice.

RESULTS

A total of 239 surgeons participated in the survey, including 158 (66%) neurosurgeons and 81 (34%) orthopedic surgeons. A total of 218 (96.9%) investigators proposed a face-to-face follow-up consultation within 6 weeks after surgery. A total of 210 (92%) practitioners asked for systematic cervical imaging at the first clinical follow-up. In the latter situation, cervical radiography was requested by 195 (85.2%) surgeons, and cervical CT scans were requested by 15 (6.6%) surgeons. A minority of surgeons recommended bracing after monosegmental cervical surgery (n = 99, 43%), except among orthopedic surgeons (n = 51 (63%), p < 0.0001). 38 (16.6%) surgeons advocated for early postoperative physiotherapy, and 130 (56.8%) for delayed physiotherapy. A prolonged time off work (>1 month) was recommended by 133 (57.8%) practitioners. 139 (62.9%) surgeons agreed on returning to sports without load or constraint during the first postoperative month, although orthopedic surgeons were more conservative than neurosurgeons (p = 0.0019). Conversely, return to sport with load (n = 171, 75.3%) or rotation (n = 219, 98%) was delayed for at least 1 month.

CONCLUSION

This nationwide study reflects the status of current postoperative management strategies after elective degenerative cervical spine surgery among the French spine community. Interestingly, the information provided to the patient may vary depending on the surgeon's specialty. Consensus-based recommendations are needed to homogenize practices.

LEVEL OF EVIDENCE

V.

Clinical Utility of Routine Postoperative Imaging in Spinal Fusion Surgery: A Systematic Review

OBJECTIVE

Following spinal fusion surgery, routine imaging is often obtained in all patients regardless of clinical presentation. Such routine imaging may include x-ray, computed tomography, or magnetic resonance imaging studies in both the immediate postoperative period and after discharge. The clinical utility of this practice is questionable. Our goal is to assess the existing literature for evidence of impact on clinical care from routine radiographic surveillance following spinal fusion.

METHODS

A systematic search of Embase, Scopus, PubMed, Cochrane, and Ovid databases was performed for studies investigating postoperative imaging following spinal fusion surgery. Studies were analyzed for imaging findings and rates of change in management due to imaging.

RESULTS

In total, the review identified 9 studies that separated data by unique patient or by unique clinic visits. The 4 studies reporting per-patient data totaled 475 patients with 328 (69%) receiving routine imaging. Among these, 28 (8.5%) patients had abnormal routine findings with no patients having a change to their clinical course. Of the 5 studies that reported clinic visit data, 3119 patient visits were included with 2365 (76%) clinic visits accompanied by imaging. Across these 5 studies, 146 (6.2%) visits noted abnormal imaging with only 12 (0.5%) subsequent management changes.

CONCLUSIONS

Our analysis found that routine imaging after spinal fusion surgery had no direct benefit on clinical management. The utility of baseline imaging for long-term comparison and medicolegal concerns were not studied and remain up to the provider's judgment. Further research is necessary to identify optimal imaging criteria following spinal fusion surgery.

Immediate Postoperative Imaging Following Elective Lumbar Fusion Provides Little Clinical Utility

STUDY DESIGN

Retrospective review at a single institution of all adult patients who underwent elective lumbar fusion surgery for degenerative spinal disease from 2013 to 2018. Reoperation rates and change in clinical management due to routine imaging findings were the primary outcomes.

OBJECTIVE

To investigate what effects immediate routine postoperative imaging has on the clinical management of patients following lumbar fusion surgery.

SUMMARY OF BACKGROUND DATA

The clinical utility of routine postoperative imaging following lumbar fusion surgery remains uncertain. Existing studies on the clinical utility of postoperative imaging in lumbar fusion patients have largely focused on imaging obtained post-discharge. We present a retrospective analysis that to our knowledge is the first study reporting on the clinical utility of routine imaging in lumbar fusion patients during the immediate postoperative period.

METHODS

The medical records of patients who had undergone elective lumbar instrumented fusion for degenerative disease from 2013 to 2018 by neurosurgeons across one regional healthcare system were retrospectively analyzed. Inpatient records and imaging orders for patients were reviewed. Routine immediate postoperative imaging was defined by any lumbar spine imaging prior to discharge in the absence of specific indications.

RESULTS

Analysis identified 115 patients who underwent elective lumbar instrumented fusion for degenerative disease. One-hundred-twelve patients received routine postoperative imaging. Routine imaging was abnormal in four patients (4%). There was one instance (<1%) where routine immediate postoperative imaging led to change in clinical management. Abnormal routine imaging was not associated with either reoperation or development of neurological symptoms postoperatively (P = 0.10), however, new or worsening neurologic deficits did predict reoperation (P < 0.01).

CONCLUSION

New neurologic deficit was the only significant predictor of reoperation. Routine imaging, whether normal or abnormal, was not found to be associated with reoperation. The practice of routine imaging prior to discharge following elective lumbar fusion surgery appears to provide little utility to clinical management.Level of Evidence: 3.

Health Care Resource Utilization in Commercially Insured Patients Undergoing Anterior Cervical Discectomy and Fusion for Degenerative Cervical Pathology

STUDY DESIGN

Retrospective review of an administrative database.

OBJECTIVES

The aim of our study was to investigate the distribution of spending for the entire episode of care among nonelderly, commercially insured patients undergoing elective, inpatient anterior cervical discectomy and fusion (ACDF) surgeries for degenerative cervical pathology.

METHODS

Using a private insurance claims database, we identified patients who underwent single-level, inpatient ACDF for degenerative spinal disease. Patients were selected using a combination of Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes. Entire episode of care was defined as 6-months before (preoperative) to 6 months after (postoperative) the surgical admission.

RESULTS

In our cohort containing 33 209 patients, perioperative median spending per patient (MSPP) within the year encompassing surgery totaled $37 020 (interquartile range [IQR] $28 363-$49 206), with preoperative, surgical admission, and postoperative spending accounting for 9.8%, 80.7%, and 9.5% of total spending, respectively. Preoperatively, MSPP was $3109 (IQR $1806-$5215), 48% of patients underwent physical therapy, and 31% underwent injections in the 6 months period prior to surgery. Postoperatively, MSPP was $1416 (IQR $398-$3962), and unplanned hospital readmission (6% incidence) accounted for 33% of the overall postoperative spending. Discharge to a nonhome discharge disposition was associated with higher postoperative spending ($14 216) compared with patients discharged home ($1468) and home with home care ($2903), P < .001.

CONCLUSION

Understanding the elements and distribution of perioperative spending for the episode of care in patients undergoing ACDF surgery for degenerative conditions is important for health care planning and resource allocation.