Laminectomy alone versus laminectomy with fusion for degenerative cervical myelopathy: a long-term study of a national cohort

Purpose To compare patient-reported 5-year clinical outcomes between laminectomy alone versus laminectomy with instrumented fusion in patients with degenerative cervical myelopathy in a population-based cohort. Methods All patients in the national Swedish Spine Register (Swespine) from January 2006 until March 2019, with degenerative cervical myelopathy, were assessed. Multiple imputation and propensity score matching based on clinicodemographic and radiographic parameters were used to compare patients treated with laminectomy alone with patients treated with laminectomy plus posterior-lateral instrumented fusion. The primary outcome measure was the European Myelopathy Score, a validated patient-reported outcome measure. The scale ranges from 5 to 18, with lower scores reflecting more severe myelopathy. Results Among 967 eligible patients, 717 (74%) patients were included. Laminectomy alone was performed on 412 patients (mean age 68 years; 149 women [36%]), whereas instrumented fusion was added for 305 patients (mean age 68 years; 119 women [39%]). After imputation, the propensity for smoking, worse myelopathy scores, spondylolisthesis, and kyphosis was slightly higher in the fusion group. After imputation and propensity score matching, there were on average 212 pairs patients with a 5-year follow-up in each group. There were no important differences in patient-reported clinical outcomes between the methods after 5 years. Due to longer hospitalization times and implant-related costs, the mean cost increase per instrumented patient was approximately $4700 US. Conclusions Instrumented fusions generated higher costs and were not associated with superior long-term clinical outcomes. These findings are based on a national cohort and can thus be regarded as generalizable.

Concurrent and overlapping surgery: perspectives from surgeons on spinal posterior instrumented fusion for adolescent idiopathic scoliosis

Purpose The purpose of this study was to determine perspectives of surgeons regarding simultaneous surgery in patients undergoing posterior spine instrumentation and fusion (PSIF) for adolescent idiopathic scoliosis (AIS). Methods A survey was administered to orthopaedic trainees and faculty regarding simultaneous surgery for primary PSIF for AIS. A five-point Likert scale (1: ‘Strongly Disagree’ to 5: ‘Strongly Agree’) was used to assess agreement with statements about simultaneous surgery. We divided simultaneous surgery into concurrent, when critical portions of operations occur at the same time, and overlapping, when noncritical portions occur at the same time. Results The 72 respondents (78.3% of 92 surveyed) disagreed with concurrent surgery for ‘one of my patients’ (response mean 1.76 (sd 1.03)) but were more accepting of overlapping surgery (mean 3.94 (sd 0.99); p < 0.0001). The rating difference between concurrent and overlapping surgery was smaller for paediatric and spine surgeons (-1.25) than for residents or those who did not identify a subspecialty (-2.17; p = 0.0246) or other subspecialty surgeons (-2.57; p = 0.0026). Respondents were more likely to agree with explicit informed consent for concurrent surgery compared with overlapping (mean 4.32 (sd 0.91) versus 3.44 (sd 1.14); p < 0.001). Conclusion Orthopaedic surgeons disagreed with concurrent but were more accepting of overlapping surgery and anaesthesia for PSIF for AIS. Respondents were in greater agreement that patients should be explicitly informed of concurrence than of overlap. The surgical community’s evidence and position regarding simultaneous surgery, in particular overlapping, must be more effectively presented to the public in order to bridge the gap in perspectives. Level of Evidence IV

Subaxial cervical Castleman’s disease: A rare cause of myelopathy

Background: Castleman’s disease (CD) is a rare lymphoproliferative disease of unknown origin which rarely affects the spine. Here, we present CD involving a lytic, destructive C3 lesion with extension into the spinal canal contributing to upper cervical cord compression. Notably, the lesion mimicked other primary bone lesions, metastatic tumors, and/or lymphoma. Case Description: A 52-year-old male presented with progressive quadriparesis (i.e. weakness, instability of gait) and loss of dexterity in both hands over 2 weeks. The MRI, X-ray, and CT scans revealed a destructive lytic lesion involving the C3 vertebral body (i.e. including both anterior and posterior elements). The patient underwent a C3 total and C4 partial laminectomy followed by a C2-C4/5 instrumented fusion (i.e. included C2 pedicle screws/laminar screws, and C4/C5 lateral mass fixation). Histopathology showed a lymphoproliferative disorder with follicles of different sizes, central abnormal germinal structures, and a Mantle zone (i.e. expanded germinal centre with concentric layering with an “onionskin” appearance). These findings were all consistent with the diagnosis of CD (i.e. hyaline-vascular type). Conclusion: CD, a rare lymphoproliferative disease of unknown origin rarely affects the spine. Here, we presented a 52-year-old male with a C3 lytic lesion resulting in C3/4 cord compression that favorably responded to a C3/4 laminectomy with posterior instrumented fusion.

Spinal anesthesia in contemporary and complex lumbar spine surgery: experience with 343 cases

OBJECTIVE Spinal anesthesia (SA) is an alternative to general anesthesia (GA) for lumbar spine surgery, including complex instrumented fusion, although there are relatively few outcome data available. The authors discuss their experience using SA in a modern complex lumbar spine surgery practice to describe its utility and implementation. METHODS Data from patients receiving SA for lumbar spine surgery by one surgeon from March 2017 to December 2020 were collected via a retrospective chart review. Cases were divided into nonfusion and fusion procedure categories and analyzed for demographics and baseline medical status; pre-, intra-, and postoperative events; hospital course, including Acute Pain Service (APS) consults; and follow-up visit outcome data. RESULTS A total of 345 consecutive lumbar spine procedures were found, with 343 records complete for analysis, including 181 fusion and 162 nonfusion procedures and spinal levels from T11 through S1. The fusion group was significantly older (mean age 65.9 ± 12.4 vs 59.5 ± 15.4 years, p < 0.001) and had a significantly higher proportion of patients with American Society of Anesthesiologists (ASA) Physical Status Classification class III (p = 0.009) than the nonfusion group. There were no intraoperative conversions to GA, with infrequent need for a second dose of SA preoperatively (2.9%, 10/343) and rare preoperative conversion to GA (0.6%, 2/343) across fusion and nonfusion groups. Rates of complications during hospitalization were comparable to those seen in the literature. The APS was consulted for 2.9% (10/343) of procedures. An algorithm for the integration of SA into a lumbar spine surgery practice, from surgical and anesthetic perspectives, is also offered. CONCLUSIONS SA is a viable, safe, and effective option for lumbar spine surgery across a wide range of age and health statuses, particularly in older patients and those who want to avoid GA. The authors’ protocol, based in part on the largest set of data currently available describing complex instrumented fusion surgeries of the lumbar spine completed under SA, presents guidance and best practices to integrate SA into contemporary lumbar spine practices.