Two-Year Clinical and Radiological Outcomes in Patients With Diabetes Undergoing Single-Level Anterior Cervical Discectomy and Fusion

Cervical Radiculopathy: Focus on Factors for Better Surgical Outcomes and Operative Techniques

For patients with cervical radiculopathy, most studies have recommended conservative treatment as the first-line treatment; however, when conventional treatment fails, surgery is considered. A better understanding of the prognosis of cervical radiculopathy is essential to provide accurate information to the patients. If the patients complain of persistent and recurrent arm pain/numbness not respond to conservative treatment, or exhibit neurologic deficits, surgery is performed using anterior or posterior approaches. Anterior cervical discectomy and fusion (ACDF) has historically been widely used and has proven to be safe and effective. To improve surgical outcomes of ACDF surgery, many studies have been conducted on types of spacers, size/height/position of cages, anterior plating, patients' factors, surgical techniques, and so forth. Cervical disc replacement (CDR) is designed to reduce the incidence of adjacent segment disease during long-term follow-up by maintaining cervical spine motion postoperatively. Many studies on excellent indications for the CDR, proper type/size/shape/height of the implants, and surgical techniques were performed. Posterior cervical foraminotomy is a safe and effective surgical option to avoid complications associated with anterior approach and fusion surgery. Most recent literature demonstrated that all three surgical techniques for patients with cervical radiculopathy have clear advantages and disadvantages and reveal satisfactory surgical outcomes under a proper selection of patients and application of appropriate surgical methods. For this, it is important to fully understand the factors for better surgical outcomes and to adequately practice the operative techniques for patients with cervical radiculopathy.

Preoperative Cervical Cobb Angle Is a Risk Factor for Postoperative Axial Neck Pain after Anterior Cervical Discectomy and Fusion with Zero-Profile Interbody

OBJECTIVES

Anterior cervical discectomy and fusion (ACDF) with zero-profile interbody has a lower incidence of complications in treating cervical spondylotic myelopathy (CSM). However, postoperative axial neck pain is still commonly occurred, and the factors affecting which is not known. Here, we retrospectively analyze the risk factors for postoperative axial pain after performing ACDF with zero-profile implant in single-level CSM.

METHODS

Patients who suffered from single-level CSM and who received ACDF with zero-profile implant between 2018 January to 2020 December were reviewed. Of 180 single-level CSM patients, 144 patients who passed the inclusion criteria were enrolled. Patients were divided into two groups according to the severity of postoperative axial pain as measured by postoperative neck visual analogue scale (nVAS). Clinical parameters including age, sex, smoking history, symptom duration, body mass index (BMI), the Japanese Orthopaedic Association (JOA) scores, as well as radiological parameters were obtained pre- and post-operatively, and the data were compared between two groups. Pearson's chi-square tests and Mann-Whitney U tests were implemented to identify statistically significant differences between subgroups for categorical and continuous data, respectively; otherwise, the data were tested with Student's t-test. Risk factors were identified using logistic regression.

RESULTS

Of the patients (97.8%) achieved satisfied neurological recovery, and 88.2% of the patients achieved fusion at 1-year follow-up. 33% of the patients (48 patients out of 144) had sustained postoperative axial pain after the surgery. Comparison of different severity groups exhibited no significant differences in terms of the possible risk factors (P > 0.05) except for pre- and post-operative C2-C7 Cobb angles (6.33 ± 6.53 vs. 11.88 ± 7.41, P < 0.05; 13.49 ± 5.31 vs 16.64 ± 7.34, P < 0.05). Furthermore, correlation analysis showed that the preoperative C2-C7 Cobb angle is significantly correlated with the severity of the postoperative axial pain (R²  = 0.83, P < 0.01). In addition, logistic regression analysis demonstrated that the preoperative C2-C7 Cobb angle is an independent predictor of postoperative axial pain (P < 0.01, OR = 0.53). Further receiver operating characteristic (ROC) analysis displayed an area under the curve (AUC) of 0.78 (P < 0.01) for preoperative C2-C7 Cobb angle, and the optimal cutoff was 8.4° (sensitivity 0.77, specificity 0.65).

CONCLUSION

The pre-operative C2-C7 Cobb angle is a risk factor for severe postoperative axial pain after anterior cervical discectomy and fusion with zero-profile interbody, and we should be cautious when poor preoperative C2-C7 Cobb angle is found in myelopathy patients planning to use zero-profile interbody to treat such patients.

A Pre-clinical Standard Operating Procedure for Evaluating Orthobiologics in an In Vivo Rat Spinal Fusion Model

The rat animal model is a cost effective and reliable model used in spinal pre-clinical research. Complications from various surgical procedures in humans often arise that were based on these pre-clinical animal models. Therefore safe and efficacious pre-clinical animal models are needed to establish continuity into clinical trials. A Standard Operating Procedure (SOP) is a validated method that allows researchers to safely and carefully replicate previously successful surgical techniques. Thus, the aim of this study is to describe in detail the procedures involved in a common rat bilateral posterolateral intertransverse spinal fusion SOP used to test the efficacy and safety different orthobiologics using a collagen-soaked sponge as an orthobiologic carrier. Only two orthobiologics are currently FDA approved for spinal fusion surgery which include recombinant bone morphogenetic protein 2 (rhBMP-2), and I-FACTOR. While there are many additional orthobiologics currently being tested, one way to show their safety profile and gain FDA approval, is to use well established pre-clinical animal models. A preoperative, intraoperative, and postoperative surgical setup including specific anesthesia and euthanasia protocols are outlined. Furthermore, we describe different postoperative methods used to validate the spinal fusion SOP, which include μCT analysis, histopathology, biomechanical testing, and blood analysis. This SOP can help increase validity, transparency, efficacy, and reproducibly in future rat spinal fusion surgery procedures.

Does the use of i-FACTOR bone graft affect bone healing in those undergoing periacetabular osteotomy (PAO) for developmental dysplasia of the hip (DDH)? A retrospective study

The aims of this study were to compare, in patients with and without the use of i-FACTOR bone graft during periacetabular osteotomy (PAO) surgery for developmental dysplasia of the hip (DDH), (i) bone healing at six-weeks post-operatively (ii) rate of complications. This was a retrospective review of case records. Participants were people aged 15-50 years undergoing rectus-sparing minimally invasive PAO surgery for DDH. Group 1: patients with i-FACTOR, Group 2: No i-FACTOR. The primary outcome was the rate of bone healing on radiographs at 6 weeks. The likelihood of bone healing was compared using logistic regression with Generalised Estimating Equations (GEE) and expressed as odds ratios (95% confidence intervals (CIs; P &lt; 0.05)). The occurrence of complications was extracted from surgical records. The i-FACTOR group had 3-times greater odds of partial/full union than those without [adjusted odds ratio (95% CIs, P-value)]: [3.265 (1.032 to 10.330, P = 0.044)]. The i-FACTOR group had 89% partial/full union at 6-weeks, compared to 69% of the non-i-FACTOR group. Half of the patients had leaking of bone graft in the i-FACTOR group versus 10% in the non-i-FACTOR group, 26% of the i-FACTOR group and 12% of the non-i-FACTOR group had neuropraxia of the lateral femoral cutaneous nerve (LFCN). Complication rates were low, and similar between groups. However, the rate of LFCN neuropraxia and bone graft leakage was higher in the i-FACTOR. These findings should be confirmed in a future prospective randomised clinical trial and include outcomes such as pain and quality of life.

Comorbidity Influence on Postoperative Outcomes Following Anterior Cervical Discectomy and Fusion

Objective

This study aims to detail the association between comorbidity burden and achieving minimum clinically important difference (MCID) following anterior cervical discectomy and fusion (ACDF).

Methods

A prospective surgical registry was retrospectively reviewed. Patients with missing preoperative Patient-Reported Outcomes Measurement Information System physical function (PROMIS PF) were excluded. Patients were stratified by Charlson Comorbidity Index (CCI): no comorbidities = 0 point; low CCI = 1–2 points; high CCI = ≥ 3 points. Demographic and perioperative characteristics were collected and evaluated for differences. Visual analogue scale (VAS), 12-item Short Form health survey (SF-12), and PROMIS PF were collected pre- and postoperatively and assessed for differences. Differences in achievement of MCID were compared using established values: VAS neck = 2.6, VAS arm = 4.1, NDI = 8.5, SF-12 physical composite score (SF-12 PCS) = 8.1, PROMIS PF = 4.5.

Results

One hundred twenty-five ACDF patients were included: 37 had no comorbidities, 64 with low CCI, and 24 with high CCI. Higher CCI groups were older, nonsmokers, diabetic, arthritic, hypertensive, and had cancer. Multilevel fusions, operative time, length of stay, and later discharge day were associated with high CCI. VAS neck differed preoperatively by group. SF-12 PCS and PROMIS PF were inversely associated with CCI groups. CCI did not impact achievement of MCID for all outcomes. A lower rate of reaching MCID was demonstrated at 3 months for SF-12 PCS.

Conclusion

Regardless of comorbidity burden, patients undergoing ACDF for cervical pathology demonstrated a similar rate of achieving MCID for VAS neck, VAS arm, NDI, and PROMIS PF. Regardless of CCI score, ACDF can have a significant benefit for patients.

Commercial Bone Grafts Claimed as an Alternative to Autografts: Current Trends for Clinical Applications in Orthopaedics

In the last twenty years, due to an increasing medical and market demand for orthopaedic implants, several grafting options have been developed. However, when alternative bone augmentation materials mimicking autografts are searched on the market, commercially available products may be grouped into three main categories: cellular bone matrices, growth factor enhanced bone grafts, and peptide enhanced xeno-hybrid bone grafts. Firstly, to obtain data for this review, the search engines Google and Bing were employed to acquire information from reports or website portfolios of important competitors in the global bone graft market. Secondly, bibliographic databases such as Medline/PubMed, Web of Science, and Scopus were also employed to analyse data from preclinical/clinical studies performed to evaluate the safety and efficacy of each product released on the market. Here, we discuss several products in terms of osteogenic/osteoinductive/osteoconductive properties, safety, efficacy, and side effects, as well as regulatory issues and costs. Although both positive and negative results were reported in clinical applications for each class of products, to date, peptide enhanced xeno-hybrid bone grafts may represent the best choice in terms of risk/benefit ratio. Nevertheless, more prospective and controlled studies are needed before approval for routine clinical use.