1
|
Chung MS, Patel N, Abdelmalek G, Coban D, Changoor S, Elali F, Sinha K, Hwang K, Emami A. The 5-factor modified frailty index (mFI-5) predicts adverse outcomes after elective anterior cervical discectomy and fusion (ACDF). N Am Spine Soc J 2024; 18:100318. [PMID: 38618000 PMCID: PMC11015525 DOI: 10.1016/j.xnsj.2024.100318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 02/15/2024] [Accepted: 02/16/2024] [Indexed: 04/16/2024]
Abstract
Background Anterior cervical discectomy and fusion (ACDF) is a reliable procedure commonly performed in older patients with degenerative diseases of the cervical spine. Over 130,000 procedures are performed every year with an annual increase of 5%, and overall morbidity rates can reach as high as 19.3%, indicating a need for surgeons to gauge their patients' risk for adverse outcomes. Frailty is an age-associated decline in functioning of multiple organ systems and has been shown to predict adverse outcomes following various spine procedures. There have been several proposed frailty indices of various factors including the 11-factor modified frailty index (mFI-11), which has been shown to be an effective tool for predicting complications in patients undergoing ACDF. However, there is a paucity of literature assessing the utility of the 5-factor modified frailty index (mFI-5) as a risk stratification tool for patients undergoing ACDF. The purpose of this study was to analyze the predictive capability of the mFI-5 score for 30-day postoperative adverse events following elective ACDF. Methods A retrospective review was performed using the National Surgical Quality Improvement Program (NSQIP) database from 2010 through 2019. Patients older than 50 years of age who underwent elective ACDF were identified using Current Procedural Terminology ([CPT] codes 22554, 22551, 22552, and 63075). Exclusion criteria removed patients under the age of 51, as well as those with fractures, sepsis, disseminated cancer, a prior operation in the last 30 days, ascites, wound infection, or an emergency surgery. Patients were grouped using mFI scores of 1, 2, and 3+. Univariate analysis, using chi-squared and one-way analysis of variance (ANOVA) tests, was conducted to compare demographics, comorbidities, and postoperative complications across the varying cohorts based on mFI-5 scores. Multivariate logistic regression, including patient demographics and preoperative comorbidities as covariates, was performed to evaluate if mFI-5 scores were independent predictors of 30-day postoperative adverse events. Covariates including race, BMI, sex, ASA, and comorbidities were included in regression models. Results The 45,991 patients were identified and allocated in cohorts based on mFI-5 score. Rates for superficial surgical site infection (SSI), organ/deep space SSI, pneumonia, progressive renal insufficiency, acute renal failure (ARF), urinary tract infection (UTI), stroke/cardiovascular accident (CVA), cardiac arrest requiring cardiopulmonary resuscitation (CPR), myocardial infarction, bleeding requiring transfusions, deep vein thrombosis/thrombophlebitis, sepsis, septic shock, readmissions, reoperation, and mortality incrementally increased with mFI-5 scores from 0 to 3+. Multivariate regression analysis revealed that mFI-5 scores 1 to 3+ increased the odds, in a stepwise manner, of total complications, cardiac arrest requiring CPR, pneumonia and mortality. MFI-5 scores of 2 and 3+ were independent predictors of readmission (2: OR=1.5, p<.001; 3+: OR=2.0, p<.001) and myocardial infarction (2: OR=3.4, p=.001; 3+: OR=6.9, p<.001). A score of 3+ increased the odds of ARF (OR=9.7, p=.022), septic shock (OR=3.6, p=.036), UTI (OR=2.1, p=.007), bleeding requiring transfusions (OR=2.1, p=.016), and reoperations (OR=1.7, p=.004). Conclusion mFI-5 score is a quick and viable option for surgeons to use as an assessment tool to stratify high risk patients undergoing elective ACDF, as increasing mFI-5 scores showed significantly higher rates of all adverse outcomes accounted for in this study, except for deep incisional SSI, wound disruption, and PE. Additionally, moderate to severe mFI-5 scores of 2 or 3+ were independent predictors for 30-day postoperative ARF, UTI, MI, bleeding requiring transfusions, septic shock, reoperation, and readmissions following elective ACDF surgery in adults over 50 years old.
Collapse
Affiliation(s)
- Matthew S. Chung
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203, United States
| | - Neil Patel
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, 703 Main Street, Paterson, NJ 07503, United States
| | - George Abdelmalek
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, 703 Main Street, Paterson, NJ 07503, United States
| | - Daniel Coban
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, 703 Main Street, Paterson, NJ 07503, United States
| | - Stuart Changoor
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, 703 Main Street, Paterson, NJ 07503, United States
| | - Faisal Elali
- Department of Orthopaedic Surgery and Rehabilitation Medicine, The State University of New York (SUNY) Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY 11203, United States
| | - Kumar Sinha
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, 703 Main Street, Paterson, NJ 07503, United States
| | - Ki Hwang
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, 703 Main Street, Paterson, NJ 07503, United States
| | - Arash Emami
- Department of Orthopaedic Surgery, St. Joseph's University Medical Center, 703 Main Street, Paterson, NJ 07503, United States
| |
Collapse
|
2
|
Guo L, Li J, Zhang F, Sun Y, Zhang W. Posterior endoscopic decompression combined with anterior cervical discectomy and fusion versus posterior laminectomy and fusion for multilevel cervical spondylotic myelopathy: a retrospective case-control study. BMC Musculoskelet Disord 2023; 24:578. [PMID: 37454072 DOI: 10.1186/s12891-023-06713-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 07/10/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE To compare the clinical efficacy of surgical treatment for multilevel cervical spondylotic myelopathy (MCSM) between the hybrid procedure, posterior endoscopic decompression (PED) combined with anterior cervical discectomy fusion (ACDF), and posterior cervical laminectomy and fusion (PCLF). METHODS A retrospective analysis was performed on 38 patients who received surgical treatment for MCSM from January 2018 to December 2021, including 19 cases in hybrid procedure group (13 males and 6 females), followed up for 10 to 22 (12.8 ± 10.3) months, and 19 cases in PCLF group (15 males and 4 females), followed up for 10 to 21 (11.7 ± 8.9) months. Perioperative information, including operation time, intraoperative blood loss, length of hospitalization, and complications, were compared between two groups. Visual analogue scale (VAS) of pain, neck disability index (NDI) and Japanese Orthopaedic Association (JOA) score were recorded to evaluate clinical efficacy. Cervical lordosis was calculated by radiographic examination. RESULTS Intraoperative blood loss, length of hospital stay were less in hybrid group than PCLF group, while operation time is longer in hybrid group, with a statistically significant difference (p < 0.05). Increased lordosis was better in hybrid group. There was no significant difference in preoperative VAS, JOA and NDI at pre-operation and final follow-up between two groups. But at post-operation and final follow-up, VAS was less in hybrid group than PCLF group (p < 0.05). There were 2 cases of neurostimulation symptoms in hybrid group, 2 cases of C5 nerve root palsy, 2 cases of subcutaneous fat necrosis and 1 case of dural tear in PCLF group, and all patients relieved with symptomatic treatment. CONCLUSION The hybrid procedure of PED combined with ACDF showed satisfied clinical outcome, with less intraoperative blood loss, shorter length of hospitalization and lower post-operative neck pain than PCLF. It is an effective surgical treatment for MCSM.
Collapse
Affiliation(s)
- Lei Guo
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Hebei, China
| | - Jiaqi Li
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Hebei, China
| | - Fei Zhang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Hebei, China
| | - Yapeng Sun
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Hebei, China
| | - Wei Zhang
- Department of Spine Surgery, The Third Hospital of Hebei Medical University, Hebei, China.
| |
Collapse
|
3
|
Molfenter SM, Amin MR, Balou M, Herzberg EG, Frempong-Boadu A. A scoping review of the methods used to capture dysphagia after anterior cervical discectomy and fusion: the need for a paradigm shift. Eur Spine J 2023; 32:969-976. [PMID: 36625955 PMCID: PMC10805127 DOI: 10.1007/s00586-022-07515-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 12/02/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Dysphagia is the most commonly reported complication of annterior cervical discectomy and fusion (ACDF) surgery. However, the incidence of dysphagia post-ACDF varies widely-partly attributable to differing outcome measures used to capture dysphagia. Our objective was to conduct a scoping review of the literature to quantify which dysphagia outcome measures have been employed post-ACDF and examine trends by study design, year, and location. METHODS After removing duplicates, 2396 abstracts were screened for inclusion. A total of 480 studies were eligible for full-text review. After applying exclusion criteria, data was extracted from 280 studies. We extracted the dysphagia outcome measure(s), study design (prospective vs retrospective), year, and location (country). Approximately 10% of studies were repeated for intra-rater agreement. RESULTS In total, 317 dysphagia outcome measures were reported in 280 studies (primarily retrospective-63%). The largest proportion of outcome measures were categorized as "unvalidated patient-reported outcome measures" (46%), largely driven by use of the popular Bazaz scale. The next most common categories were "insufficient detail" and "validated patient-reported outcome measures" (both 16%) followed by "chart review/database" (13%) and instrumental assessment (7%). Studies examining dysphagia post-ACDF steadily increased over the years and the use of validated measures increased in the past 10 years. CONCLUSIONS This scoping review of the literature highlights that nearly half of the ACDF dysphagia literature relies on unvalidated patient-reported outcome measures. The current understanding of the mechanism, timeline, and presentation of dysphagia post-ACDF are likely limited due to the metrics that are most commonly reported in the literature.
Collapse
Affiliation(s)
- Sonja M Molfenter
- Department of Communicative Sciences and Disorders, NYU Steinhardt, 665 Broadway, Room 622, New York, NY, 10012, USA.
- Rusk Rehabilitation, NYU Langone Health, New York, NY, USA.
| | - Milan R Amin
- Department of Otolaryngology, Head & Neck Surgery, NYU Langone Health, New York, NY, USA
| | - Matina Balou
- Department of Otolaryngology, Head & Neck Surgery, NYU Langone Health, New York, NY, USA
| | | | | |
Collapse
|
4
|
Song KS, Lee J, Ham DW, Jung CW, Kang H, Park SW, Chang DG, Kim YB. Postoperative Segmental Motion up to 1 Year Following Single-Level Anterior Cervical Discectomy and Fusion: Plate versus Non-plate. Asian Spine J 2023:asj.2022.0192. [PMID: 36775832 DOI: 10.31616/asj.2022.0192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 08/30/2022] [Indexed: 02/14/2023] Open
Abstract
Study Design Retrospective observational study. Purpose This study aimed to investigate the impact of plating on postoperative serial segmental motion and its correlation with clinical outcomes in single-level anterior cervical discectomy and fusion (ACDF) for up to 1 year. Overview of Literature The advantages and disadvantages of using cervical plating in ACDF have been well discussed; however, few studies compared the early serial segmental motions at the postoperative level between plating and non-plating. Methods In retrospectively collected data, 149 patients who underwent single-level ACDF for degenerative disease were enrolled and divided into non-plating (n=66) and plating (n=83). Interspinous motion (ISM) at the arthrodesis segment, Numeric Rating Scale (NRS) for neck pain, and Neck Disability Index (NDI) were serially evaluated at 3, 6, and 12 months postoperatively. Predictable factors for fusion, including age, sex, plating, diabetes, smoking, and type of grafts, were investigated, and fusion was defined as ISM <1 mm. Results In both groups, ISM was the highest at 3 months and gradually decreased thereafter, and the plating group showed significantly lower serial ISM than the non-plating group at 12 months. The plating group had lower NRS and NDI scores than the nonplating group at 12 months, and the difference in the NRS scores was statistically significant, particularly at 3 and 6 months, although that of the NDI scores was not. In a multivariate analysis, plating was the most powerful predictor for fusion. Conclusions Plating significantly decreases the serial ISM compared with non-plating in single-level ACDF, and such decreased motion is correlated with decreased neck pain until 12 months postoperatively, particularly at 3 and 6 months. Given that plating was the most predictive factor for fusion, we recommend plating even in single-level ACDF for better early clinical outcomes.
Collapse
Affiliation(s)
- Kwang-Sup Song
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jeongik Lee
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Dae Woong Ham
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Chan-Woo Jung
- Department of Orthopaedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Seung Won Park
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Dong-Gune Chang
- Department of Orthopaedic Surgery, Inje University Sanggye Paik Hospital, College of Medicine, Inje University, Seoul, Korea
| | - Youngbae B Kim
- Department of Orthopaedic Surgery, VHS Medical Center, Seoul, Korea
| |
Collapse
|
5
|
Chambers JS, Kropp RG, Gardocki RJ. Reoperation rates and patient-reported outcomes of single and two-level anterior cervical discectomy and fusion. Arch Orthop Trauma Surg 2023; 143:265-268. [PMID: 34244874 DOI: 10.1007/s00402-021-04056-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 07/02/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purposes of this study were to identify the 2 year rate of reoperation and determine patient-reported outcomes after elective one- and two-level anterior cervical discectomy and fusion (ACDF) with structural allograft and anterior plating using indications similar to cervical disc arthroplasty. MATERIALS AND METHODS A retrospective chart review was performed on 116 consecutive one- and two-level primary ACDF for adult degenerative disease with structural allograft and anterior plating in one surgeon's practice. Patient-reported visual analog score (VAS), Oswestry disability index (ODI) and radiographs, collected prospectively on all operative patients preoperatively and postoperatively at 6 weeks, 3 months, 6 months, 1 year, and 2 years were reviewed. Patient demographics and reoperation rates were obtained from the chart. RESULTS One hundred and four patients were identified with a final reoperation rate of 2.9% at a mean final follow-up 2 years (95% CI 17.2-29.0). No reoperations occurred within 90 days. After 1 year, three patients required reoperation. The mean patient-reported outcomes improved (VAS, 6.6 preoperatively to 3.0 at final follow-up and ODI, 24.3 preoperatively to 12.3 at final follow-up). These improvements were statistically significant (p < 0.01). No significant patient risk factors for reoperation were found. CONCLUSIONS The rate of reoperation for one- and two-level anterior cervical discectomy and fusion at follow-up was found to be lower than those previously published in the literature quoted for CDA. Arthrodesis continues to demonstrate improvements in patient-reported outcomes.
Collapse
Affiliation(s)
- James S Chambers
- Department of Orthopaedic Surgery and Biomedical Engineering, University of Tennessee/Campbell Clinic, Memphis, TN, USA
| | - Robert G Kropp
- University of Tennessee Health Science Center, 1211 Union Avenue, Suite 500, Memphis, TN, 38104, USA
| | - Raymond J Gardocki
- University of Tennessee Health Science Center, 1211 Union Avenue, Suite 500, Memphis, TN, 38104, USA.
| |
Collapse
|
6
|
Gutierrez S, Iwanaga J, Pekala P, Yilmaz E, Clifton WE, Dumont AS, Tubbs RS. The pharyngeal plexus: an anatomical review for better understanding postoperative dysphagia. Neurosurg Rev 2020; 44:763-772. [PMID: 32318923 DOI: 10.1007/s10143-020-01303-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/30/2020] [Accepted: 04/06/2020] [Indexed: 01/22/2023]
Abstract
The pharyngeal plexus is an essential anatomical structure, but the contributions from the glossopharyngeal and vagus nerves and the superior cervical ganglion that give rise to the pharyngeal plexus are not fully understood. The pharyngeal plexus is likely to be encountered during various anterior cervical surgical procedures of the neck such as anterior cervical discectomy and fusion. Therefore, a detailed understanding of its anatomy is essential for the surgeon who operates in and around this region. Although the pharyngeal plexus is an anatomical structure that is widely mentioned in literature and anatomy books, detailed descriptions of its structural nuances are scarce; therefore, we provide a comprehensive review that encompasses all the available data from this critical structure. We conducted a narrative review of the current literature using databases like PubMed, Embase, Ovid, and Cochrane. Information was gathered regarding the pharyngeal plexus to improve our understanding of its anatomy to elucidate its involvement in postoperative spine surgery complications such as dysphagia. The neural contributions of the cranial nerves IX, X, and superior sympathetic ganglion intertwine to form the pharyngeal plexus that can be injured during ACDF procedures. Factors like surgical retraction time, postoperative hematoma, surgical hardware materials, and profiles and smoking are related to postoperative dysphagia onset. Thorough anatomical knowledge and lateral approaches to ACDF are the best preventing measures.
Collapse
Affiliation(s)
| | - Joe Iwanaga
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA.
| | | | - Emre Yilmaz
- Department of Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | | | - Aaron S Dumont
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA
| | - R Shane Tubbs
- Department of Neurosurgery, Tulane Center for Clinical Neurosciences, Tulane University School of Medicine, 131 S. Robertson St. Suite 1300, New Orleans, LA, 70112, USA.,Department of Anatomical Sciences, St. George's University, St. George's, West Indies, Grenada.,Department of Neurosurgery, Ochsner Health System, Ochsner Neuroscience Institute, New Orleans, LA, USA.,Department of Structural and Cellular Biology, Tulane University School of Medicine, New Orleans, LA, USA
| |
Collapse
|
7
|
Goedmakers CMW, Janssen T, Yang X, Arts MP, Bartels RHMA, Vleggeert-Lankamp CLA. Cervical radiculopathy: is a prosthesis preferred over fusion surgery? A systematic review. Eur Spine J 2020; 29:2640-54. [PMID: 31641906 DOI: 10.1007/s00586-019-06175-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 07/17/2019] [Accepted: 10/05/2019] [Indexed: 12/27/2022]
Abstract
BACKGROUND Meta-analyses on the comparison between fusion and prosthesis in the treatment of cervical radiculopathy mainly analyse studies including mixed patient populations: patients with radiculopathy with and without myelopathy. The outcome for patients with myelopathy is different compared to those without. Furthermore, apart from decompression of the spinal cord, restriction of motion is one of the cornerstones of the surgical treatment of spondylotic myelopathy. From this point of view, the results for arthroplasty might be suboptimal for this category of patients. Comparing clinical outcome in patients exclusively suffering from radiculopathy is therefore a more valid method to compare the true clinical effect of the prosthesis to that of fusion surgery. AIM The objective of this study was to compare clinical outcome of cervical arthroplasty (ACDA) to the clinical outcome of fusion (ACDF) after anterior cervical discectomy in patients exclusively suffering from radiculopathy, and to evaluate differences with mixed patient populations. METHODS A literature search was completed in PubMed, EMBASE, Web of Science, COCHRANE, CENTRAL and CINAHL using a sensitive search strategy. Studies were selected by predefined selection criteria (i.a.) patients exclusively suffering from cervical radiculopathy), and risk of bias was assessed using a validated Cochrane Checklist adjusted for this purpose. An additional overview of results was added from articles considering a mix of patients suffering from myelopathy with or without radiculopathy. RESULTS Eight studies were included that exclusively compared intervertebral devices in radiculopathy patients. Additionally, 29 articles concerning patients with myelopathy with or without radiculopathy were studied in a separate results table. All articles showed intermediate to high risk of bias. There was neither a difference in decrease in mean NDI score between the prosthesis (20.6 points) and the fusion (20.3 points) group, nor was there a clinically important difference in neck pain (VAS). Comparing these data to the mixed population data demonstrated comparable mean values, except for the 2-year follow-up NDI values in the prosthesis group: mixed group patients that received a prosthesis reported a mean NDI score of 15.6, indicating better clinical outcome than the radiculopathy patients that received a prosthesis though not reaching clinical importance. CONCLUSIONS ACDF and ACDA are comparably effective in treating cervical radiculopathy due to a herniated disc in radiculopathy patients. Comparing the 8 radiculopathy with the 29 mixed population studies demonstrated that no clinically relevant differences were present in clinical outcome between the two types of patients. These slides can be retrieved under Electronic Supplementary Material.
Collapse
|
8
|
Arshi A, Wang C, Park HY, Blumstein GW, Buser Z, Wang JC, Shamie AN, Park DY. Ambulatory anterior cervical discectomy and fusion is associated with a higher risk of revision surgery and perioperative complications: an analysis of a large nationwide database. Spine J 2018; 18:1180-1187. [PMID: 29155340 PMCID: PMC6291305 DOI: 10.1016/j.spinee.2017.11.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2017] [Revised: 10/02/2017] [Accepted: 11/07/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT With the changing landscape of health care, outpatient spine surgery is being more commonly performed to reduce cost and to improve efficiency. Anterior cervical discectomy and fusion (ACDF) is one of the most common spine surgeries performed and demand is expected to increase with an aging population. PURPOSE The objective of this study was to determine the nationwide trends and relative complication rates associated with outpatient ACDF. STUDY DESIGN/SETTING This is a large-scale retrospective case control study. PATIENT SAMPLE The patient sample included Humana-insured patients who underwent one- to two-level ACDF as either outpatients or inpatients from 2011 to 2016 OUTCOME MEASURES: The outcome measures included incidence and the adjusted odds ratio (OR) of postoperative medical and surgical complications within 1 year of the index surgery. MATERIALS AND METHODS A retrospective review was performed of the PearlDiver Humana insurance records database to identify patients undergoing one- to two-level ACDF (Current Procedural Terminology [CPT]-22551 and International Classification of Diseases [ICD]-9-816.2) as either outpatients or inpatients from 2011 to 2016. The incidence of perioperative medical and surgical complications was determined by querying for relevant ICD and CPT codes. Multivariate logistic regression adjusting for age, gender, and Charlson Comorbidity Index was used to calculate ORs of complications among outpatients relative to inpatients undergoing ACDF. RESULTS Cohorts of 1,215 patients who underwent outpatient ACDF and 10,964 patients who underwent inpatient ACDF were identified. The median age was in the 65-69 age group for both cohorts. The annual relative incidence of outpatient ACDF increased from 0.11 in 2011 to 0.22 in 2016 (R2=0.82, p=.04). Adjusting for age, gender, and comorbidities, patients undergoing outpatient ACDF were more likely to undergo revision surgery for posterior fusion at both 6 months (OR 1.58, confidence interval [CI] 1.27-1.96, p<.001) and 1 year (OR 1.79, CI 1.51-2.13, p<.001) postoperatively. Outpatient ACDF was also associated with a higher likelihood of revision anterior fusion at 1 year postoperatively (OR 1.46, CI 1.26-1.70, p<.001). Among medical complications, postoperative acute renal failure was more frequently associated with outpatient ACDF than inpatient ACDF (OR 1.25, CI 1.06-1.49, p=.010). Adjusted rates of all other queried surgical and medical complications were comparable. CONCLUSIONS Outpatient ACDF is increasing in frequency nationwide over the past several years. Nationwide data demonstrate a greater risk of perioperative surgical complications, including revision anterior and posterior fusion, as well as a higher risk of postoperative acute renal failure. Candidates for outpatient ACDF should be counseled and carefully selected to reduce these risks.
Collapse
Affiliation(s)
- Armin Arshi
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St., Santa Monica, CA 90404
| | - Christopher Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, 1450 San Pablo St., Suite 5400, Los Angeles, CA, 90033
| | - Howard Y. Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St., Santa Monica, CA 90404
| | - Gideon W. Blumstein
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St., Santa Monica, CA 90404
| | - Zorica Buser
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, 1450 San Pablo St., Suite 5400, Los Angeles, CA, 90033
| | - Jeffrey C. Wang
- Department of Orthopaedic Surgery, Keck School of Medicine of USC, 1450 San Pablo St., Suite 5400, Los Angeles, CA, 90033
| | - Arya N. Shamie
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St., Santa Monica, CA 90404
| | - Don Y. Park
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St., Santa Monica, CA 90404,Corresponding author. Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, 1250 16th St. Suite 3142, Santa Monica, CA 90404. Tel.: (424) 259-9829., (D.Y. Park)
| |
Collapse
|
9
|
Grasso G, Landi A. Long-term clinical and radiological outcomes following anterior cervical discectomy and fusion by zero-profile anchored cage. J Craniovertebr Junction Spine 2018; 9:87-92. [PMID: 30008525 PMCID: PMC6024738 DOI: 10.4103/jcvjs.jcvjs_36_18] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Objectives: The purpose of this study was to extend the results of our previous study providing a minimum of 4-year follow-up results of a prospective study following implantation of a cervical cage with an integrated fixation system. Summary of Background Data: The use of cervical intersomatic cages with an integrated fixation system for anterior cervical discectomy and fusion (ACDF) has increased rapidly in this last decade. In addition to immediate stabilization, these implants allow avoidance of anterior plating and iliac crest bone-grafting. Methods: Patients were studied prospectively, and data were collected and analyzed. Intersomatic cages with an integrated fixation system were used in consecutive 100 patients operated on for ACDF. Intraoperative parameters, clinical, and outcome scores were recorded. Radiographs were taken to evaluate implant positioning and fusion rate, disc height (DH), and changes in adjacent disc spaces. All the patients had a minimum 4-year follow-up. Results: A total of 127 cages were implanted in the 100 patients. Compared to preoperatively, the visual analog scale, 36-item short-form health survey, the Japanese Orthopedic Association, and the Neck Disability Index scores were significantly improved at 1-year follow-up without change during subsequent follow-up. At 4 years, the fusion rate was 97%. Two patients complained about minor dysphagia-related symptoms, which resolved rapidly. DH index and cervical Cobb angle were significantly restored after surgery, and the results were maintained during the whole follow-up. Conclusions: This is a prospective, independently conducted study on cages with an integrated fixation system with 4-year long follow-up. Findings of this study seem to be interesting regarding outcomes and low complications rates compared to recent series using other implants with integrated fixation system. Larger, randomized controlled trials are warranted.
Collapse
Affiliation(s)
- Giovanni Grasso
- Department of Experimental Biomedicine and Clinical Neurosciences, Neurosurgical Clinic, School of Medicine, University of Palermo, Palermo, Italy
| | - Alessandro Landi
- Department of Neurology and Psychiatry, Neurosurgery, Sapienza University of Rome, Rome, Italy
| |
Collapse
|
10
|
Yu J, Ha Y, Shin JJ, Oh JK, Lee CK, Kim KN, Yoon DH. Influence of plate fixation on cervical height and alignment after one- or two-level anterior cervical discectomy and fusion. Br J Neurosurg 2017; 32:188-195. [PMID: 29069938 DOI: 10.1080/02688697.2017.1394980] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To evaluate the efficacy of plate fixation on cervical alignment after anterior cervical discectomy and fusion (ACDF) using a stand-alone cage (ACDF-CA), compared to ACDF performed using a cage and plate fixation (ACDF-CP) and ACDF using autologous iliac bone graft and plate fixation (ACDF-AP), for the treatment of one- or two-level cervical degenerative disease. A second objective was to assess the clinical and radiological outcomes between the groups. METHODS A total of 247 patients underwent ACDF and were divided into three groups: those who underwent ACDF-CA (n = 76), ACDF-CP (n = 82) or ACDF-AP (n = 89). Fusion rate and time-to-fusion, global cervical and segmental angle, fused segment height, subsidence rate, and clinical outcomes, were measured using the visual analogue scale (VAS), Oswestry Neck Disability Index (NDI), and Robinson's criteria, assessed preoperatively, immediately postoperatively, and at least 24 months, postoperatively. RESULTS ACDF-AP was associated with the shortest mean time-to-fusion, followed by ACDF-CP and ACDF-CA. Compared to the preoperative status, the fused segment height and segmental angle increased in all groups immediately postoperatively, being well-maintained in patients who underwent ACDF-AP, while decreasing in those who underwent ACDF-CP and ACDF-CA procedures. Global cervical lordosis increased with ACDF-AP, but decreased immediately postoperatively with ACDF-CP and ACDF-CA, and at the final follow-up. Univariate analysis confirmed that a change in fused segment height was positively associated with a change in both segmental and global cervical angles. Clinical outcomes, namely VAS and NDI scores, as well as Robinson's criteria, were comparable among the three techniques. CONCLUSIONS Supplementation with plate fixation, especially using autologous iliac bone graft, is beneficial for maintaining the fused segment height and cervical spine curvature, as well as reducing time-to-fusion and subsidence rate.
Collapse
Affiliation(s)
- Jaecheon Yu
- a Department of Neurosurgery , Sanggye Paik Hospital, Inje University College of Medicine , Seoul , Korea
| | - Yoon Ha
- b Department of Neurosurgery , Yonsei University College of Medicine , Seoul , Korea
| | - Jun Jae Shin
- a Department of Neurosurgery , Sanggye Paik Hospital, Inje University College of Medicine , Seoul , Korea
| | - Jae Keun Oh
- c Department of Neurosurgery , Spine Center, Hallym University Sacred Heart Hospital , Seoul , Korea
| | - Chang Kyu Lee
- d Department of Neurosurgery , Keimyung University Dongsan Medical Center , Daegu , Korea
| | - Keung Nyun Kim
- b Department of Neurosurgery , Yonsei University College of Medicine , Seoul , Korea
| | - Do Heum Yoon
- b Department of Neurosurgery , Yonsei University College of Medicine , Seoul , Korea
| |
Collapse
|
11
|
Jang SR, Lee SB, Cho KS. A Comparison of Anterior Cervical Discectomy and Fusion versus Fusion Combined with Artificial Disc Replacement for Treating 3-Level Cervical Spondylotic Disease. J Korean Neurosurg Soc 2017; 60:676-683. [PMID: 29142627 PMCID: PMC5678057 DOI: 10.3340/jkns.2016.1010.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/05/2017] [Accepted: 01/31/2017] [Indexed: 11/27/2022] Open
Abstract
Objective The purpose of this study is to evaluate the efficacy and safety of 3-level hybrid surgery (HS), which combines fusion and cervical disc replacement (CDR), compared to 3-level fusionin patient with cervical spondylosis involving 3 levels. Methods Patients in the anterior cervical discectomy and fusion (ACDF) group (n=30) underwent 3-level fusion and the HS group (n=19) underwent combined surgery with fusion and CDR. Clinical outcomes were evaluated using the visual analogue scale for the arm, the neck disability index (NDI), Odom criteria and postoperative complications. The cervical range of motion (ROM), fusion rate and adjacent segments degeneration were assessed with radiographs. Results Significant improvements in arm pain relief and functional outcome were observed in ACDF and HS group. The NDI in the HS group showed better improvement 6 months after surgery than that of the ACDF group. The ACDF group had a lower fusion rate, higher incidence of device related complications and radiological changes in adjacent segments compared with the HS group. The better recovery of cervical ROM was observed in HS group. However, that of the ACDF group was significantly decreased and did not recover. Conclusion The HS group was better than the ACDF group in terms of NDI, cervical ROM, fusion rate, incidence of postoperative complications and adjacent segment degeneration.
Collapse
Affiliation(s)
- Seo-Ryang Jang
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University, Uijeongbu, Korea
| | - Sang-Bok Lee
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University, Uijeongbu, Korea
| | - Kyoung-Suok Cho
- Department of Neurosurgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University, Uijeongbu, Korea
| |
Collapse
|
12
|
Abstract
PURPOSE OF REVIEW Cervical disc replacement (CDR) has emerged as a motion-preserving alternative to anterior cervical discectomy and fusion in selected cases. Despite favorable literature, CDR is not universally accepted because of concerns regarding bias in the existing literature. The purpose of this review is to identify the possible biases in the disc replacement literature. RECENT FINDINGS Recent studies that compare CDR and ACDF have demonstrated equivalent or superior outcomes, lower rates of secondary surgery, and equivalent safety at medium- and long-term follow-up. In our review, we identified four types of bias that may affect the CDR literature: publication bias, external validity, confounding bias, and financial conflicts of interest. Bias, whether intentional or unintentional, can impact the interpretation and outcome of CDR studies. Recognition of this issue is critical when utilizing the existing literature to determine the efficacy of CDR and designing future studies.
Collapse
|
13
|
Zou S, Gao J, Xu B, Lu X, Han Y, Meng H. Anterior cervical discectomy and fusion (ACDF) versus cervical disc arthroplasty (CDA) for two contiguous levels cervical disc degenerative disease: a meta-analysis of randomized controlled trials. Eur Spine J 2017; 26:985-97. [PMID: 27314663 DOI: 10.1007/s00586-016-4655-5] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 06/05/2016] [Accepted: 06/05/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) has been considered as a gold standard for symptomatic cervical disc degeneration (CDD), which may result in progressive degeneration of the adjacent segments. The artificial cervical disc was designed to reduce the number of lesions in the adjacent segments. Clinical studies have demonstrated equivalence of cervical disc arthroplasty (CDA) for anterior cervical discectomy and fusion in single segment cervical disc degeneration. But for two contiguous levels cervical disc degeneration (CDD), which kind of treatment method is better is controversial. PURPOSE To evaluate the clinical effects requiring surgical intervention between anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (CDA) at two contiguous levels cervical disc degeneration. METHODS We conducted a comprehensive search in multiple databases, including PubMed, Cochrane Central Register of Controlled Trials, EBSCO and EMBASE. We identified that six reports meet inclusion criteria. Two independent reviewers performed the data extraction from archives. Data analysis was conducted with RevMan 5.3. RESULTS After applying inclusion and exclusion criteria, six papers were included in meta-analyses. The overall sample size at baseline was 650 patients (317 in the TDR group and 333 in the ACDF group). The results of the meta-analysis indicated that the CDA patients had significant superiorities in mean blood loss (P < 0.00001, standard mean differences (SMD) = -0.85, 95 % confidence interval (CI) = -1.22 to -0.48); reoperation (P = 0.0009, risk ratio (RR) = 0.28, 95 % confidence interval (CI) = 0.13-0.59), adjacent segment degeneration (P < 0.00001, risk ratio (RR) = 0.48, 95 % confidence interval (CI) = 0.40-0.58) and Neck Disability Index (P = 0.002, SMD = 0.31, 95 % CI = 0.12-0.50). No significant difference was identified between the two groups regarding mean surgical time (P = 0.84, SMD = -0.04, 95 % CI = -0.40 to 0.32), neck and arm pain scores (P = 0.52, SMD = 0.06, 95 % CI = -0.13 to 0.25) reported on a visual analog scale and rate of postoperative complications [risk ratio (RR) = 0.79; 95 % CI = 0.50-1.25; P = 0.31]. The CDA group of sagittal range of motion (ROM) of the operated and adjacent levels, functional segment units (FSU) and C2-7 is superior to ACDF group by radiographic data of peroperation, postoperation and follow-up. CONCLUSION We can learn from this meta-analysis that the cervical disc arthroplasty (CDA) group is equivalent and in some aspects has more significant clinical outcomes than the ACDF group at two contiguous levels CDD.
Collapse
|
14
|
Thirumala PD, Muralidharan A, Loke YK, Habeych M, Crammond D, Balzer J. Value of intraoperative neurophysiological monitoring to reduce neurological complications in patients undergoing anterior cervical spine procedures for cervical spondylotic myelopathy. J Clin Neurosci 2016; 25:27-35. [PMID: 26677786 DOI: 10.1016/j.jocn.2015.06.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 06/08/2015] [Indexed: 01/23/2023]
Abstract
The primary aim of this study was to conduct a systematic review of reports of patients with cervical spondylotic myelopathy and to assess the value of intraoperative monitoring (IOM), including somatosensory evoked potentials, transcranial motor evoked potentials and electromyography, in anterior cervical procedures. A search was conducted to collect a small database of relevant papers using key words describing disorders and procedures of interest. The database was then shortlisted using selection criteria and data was extracted to identify complications as a result of anterior cervical procedures for cervical spondylotic myelopathy and outcome analysis on a continuous scale. In the 22 studies that matched the screening criteria, only two involved the use of IOM. The average sample size was 173 patients. In procedures done without IOM a mean change in Japanese Orthopaedic Association score of 3.94 points and Nurick score by 1.20 points (both less severe post-operatively) was observed. Within our sub-group analysis, worsening myelopathy and/or quadriplegia was seen in 2.71% of patients for studies without IOM and 0.91% of patients for studies with IOM. Variations persist in the existing literature in the evaluation of complications associated with anterior cervical spinal procedures. Based on the review of published studies, sufficient evidence does not exist to make recommendations regarding the use of different IOM modalities to reduce neurological complications during anterior cervical procedures. However, future studies with objective measures of neurological deficits using a specific IOM modality may establish it as an effective and reliable indicator of injury during such surgeries.
Collapse
|
15
|
Xu R, Ritzl EK, Sait M, Sciubba DM, Wolinsky JP, Witham TF, Gokaslan ZL, Bydon A. A role for motor and somatosensory evoked potentials during anterior cervical discectomy and fusion for patients without myelopathy: Analysis of 57 consecutive cases. Surg Neurol Int 2011; 2:133. [PMID: 22059128 PMCID: PMC3205491 DOI: 10.4103/2152-7806.85606] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 07/31/2011] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Although the usage of combined motor and sensory intraoperative monitoring has been shown to improve the surgical outcome of patients with cervical myelopathy, the role of transcranial electric motor evoked potentials (tceMEP) used in conjunction with somatosensory evoked potentials (SSEP) in patients presenting with radiculopathy but without myelopathy has been less clear. METHODS We retrospectively reviewed all patients (n = 57) with radiculopathy but without myelopathy, undergoing anterior cervical decompression and fusion at a single institution over the past 3 years, who had intraoperative monitoring with both tceMEPs and SSEPs. RESULTS Fifty-seven (100%) patients presented with radiculopathy, 53 (93.0%) with mechanical neck pain, 35 (61.4%) with motor dysfunction, and 29 (50.9%) with sensory deficits. Intraoperatively, 3 (5.3%) patients experienced decreases in SSEP signal amplitudes and 4 (6.9%) had tceMEP signal changes. There were three instances where a change in neuromonitoring signal required intraoperative alteration of the surgical procedure: these were deemed clinically significant events/true positives. SSEP monitoring showed two false positives and two false negatives, whereas tceMEP monitoring only had one false positive and no false negatives. Thus, tceMEP monitoring exhibited higher sensitivity (33.3% vs. 100%), specificity (95.6% vs. 98.1%), positive predictive value (33.3% vs. 75.0%), negative predictive value (97.7% vs. 100%), and efficiency (91.7% vs. 98.2%) compared to SSEP monitoring alone. CONCLUSIONS Here, we present a retrospective series of 57 patients where tceMEP/SSEP monitoring likely prevented irreversible neurologic damage. Though further prospective studies are needed, there may be a role for combined tceMEP/SSEP monitoring for patients undergoing anterior cervical decompression without myelopathy.
Collapse
Affiliation(s)
- Risheng Xu
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | | | | | | |
Collapse
|