Publications by authors named "Bobby Tay"

60 Publications

Reoperation and Mortality Rates Following Elective 1 to 2 Level Lumbar Fusion: A Large State Database Analysis.

Global Spine J 2021 Jan 21:2192568220986148. Epub 2021 Jan 21.

Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA.

Study Design: Retrospective cohort.

Objective: Reoperation to lumbar spinal fusion creates significant burden on patient quality of life and healthcare costs. We assessed rates, etiologies, and risk factors for reoperation following elective 1 to 2 level lumbar fusion.

Methods: Patients undergoing elective 1 to 2 level lumbar fusion were identified using the Health Care Utilization Project (HCUP) state inpatient databases from Florida and California. Patients were tracked for 5 years for any subsequent lumbar fusion. Cox proportional hazard analyses for reoperation were assessed using the following covariates: fusion approach type, age, race, Charlson comormidity index, gender, and length of stay. Distribution of etiologies for reoperation was then assessed.

Results: 71, 456 patients receiving elective 1 to 2 level lumbar fusion were included. A 5-year reoperation rate of 13.53% and mortality rate of 2.22% was seen. Combined anterior-posterior approaches (HR = 0.904, p < 0.05) and TLIF (HR = 0.867, p < 0.001) were associated with reduced risk of reoperation compared to stand-alone anterior approaches and non-TLIF posterior approaches. Age, gender, and number of comorbidities were not associated with risk of reoperation. From 1 to 5 years, degenerative disease rose from 43.50% to 50.31% of reoperations; mechanical failure decreased from 37.65% to 29.77%.

Conclusions: TLIF and combined anterior-posterior approaches for 1 to 2 level lumbar fusion are associated with the lowest rate of reoperation. Number of comorbidities and age are not predictive of reoperation. Primary etiologies leading to reoperation were degenerative disease and mechanical failure. Mortality rate is not increased from baseline following 1 to 2 level lumbar fusion.
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http://dx.doi.org/10.1177/2192568220986148DOI Listing
January 2021

Reducing Time to Surgery for Hip Fragility Fracture Patients: A Resident Quality Improvement Initiative.

J Healthc Qual 2020 Nov 24. Epub 2020 Nov 24.

As part of an institutional quality improvement (QI) initiative for the 2018-2019 academic year, orthopedic residents at our tertiary center were incentivized to bring over 75% of hip fracture patients with American Society of Anesthesiologists (ASA) Class 2 or less to surgery in under 24 hours, compared to the baseline rate of 55.9%. The time between admission and surgery for hip fracture patients with ASA class 2 or less was prospectively recorded. At the end of the study period, a retrospective comparison was performed between patients treated before and after the resident QI initiative. The percentage of patients who underwent surgery within 24 hours of admission increased significantly in the Study Cohort compared to the Baseline Cohort (78.6% vs. 55.9%, p = .037). Length of stay was shorter in the Study Cohort compared to the Baseline Cohort (3 days vs. 4 days, p = .01), whereas readmissions (3.6% vs. 4.4%, p = .85) and discharges to skilled nursing facilities (60.7% vs. 57.4%, p = .76) were comparable between both cohorts. A goal-directed, resident-led QI initiative was associated with a significantly increased percentage of hip fragility fracture patients who underwent surgery in less than 24 hours.
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http://dx.doi.org/10.1097/JHQ.0000000000000288DOI Listing
November 2020

The impact of increasing interbody fusion levels at the fractional curve on lordosis, curve correction, and complications in adult patients with scoliosis.

J Neurosurg Spine 2020 Nov 13:1-10. Epub 2020 Nov 13.

Departments of1Neurosurgery and.

Objective: Radiculopathy from the fractional curve, usually from L3 to S1, can create severe disability. However, treatment methods of the curve vary. The authors evaluated the effect of adding more levels of interbody fusion during treatment of the fractional curve.

Methods: A single-institution retrospective review of adult patients treated for scoliosis between 2006 and 2016 was performed. Inclusion criteria were as follows: fractional curves from L3 to S1 > 10°, ipsilateral radicular symptoms concordant on the fractional curve concavity side, patients who underwent at least 1 interbody fusion at the level of the fractional curve, and a minimum 1-year follow-up. Primary outcomes included changes in fractional curve correction, lumbar lordosis change, pelvic incidence - lumbar lordosis mismatch change, scoliosis major curve correction, and rates of revision surgery and postoperative complications. Secondary analysis compared the same outcomes among patients undergoing posterior, anterior, and lateral approaches for their interbody fusion.

Results: A total of 78 patients were included. There were no significant differences in age, sex, BMI, prior surgery, fractional curve degree, pelvic tilt, pelvic incidence, pelvic incidence - lumbar lordosis mismatch, sagittal vertical axis, coronal balance, scoliotic curve magnitude, proportion of patients undergoing an osteotomy, or average number of levels fused among the groups. The mean follow-up was 35.8 months (range 12-150 months). Patients undergoing more levels of interbody fusion had more fractional curve correction (7.4° vs 12.3° vs 12.1° for 1, 2, and 3 levels; p = 0.009); greater increase in lumbar lordosis (-1.8° vs 6.2° vs 13.7°, p = 0.003); and more scoliosis major curve correction (13.0° vs 13.7° vs 24.4°, p = 0.01). There were no statistically significant differences among the groups with regard to postoperative complications (overall rate 47.4%, p = 0.85) or need for revision surgery (overall rate 30.7%, p = 0.25). In the secondary analysis, patients undergoing anterior lumbar interbody fusion (ALIF) had a greater increase in lumbar lordosis (9.1° vs -0.87° for ALIF vs transforaminal lumbar interbody fusion [TLIF], p = 0.028), but also higher revision surgery rates unrelated to adjacent-segment pathology (25% vs 4.3%, p = 0.046). Higher ALIF revision surgery rates were driven by rod fracture in the majority (55%) of cases.

Conclusions: More levels of interbody fusion resulted in increased lordosis, scoliosis curve correction, and fractional curve correction. However, additional levels of interbody fusion up to 3 levels did not result in more postoperative complications or morbidity. ALIF resulted in a greater lumbar lordosis increase than TLIF, but ALIF had higher revision surgery rates.
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http://dx.doi.org/10.3171/2020.6.SPINE20256DOI Listing
November 2020

Anterior Lumbar Interbody Fusion With Cage Retrieval for the Treatment of Pseudarthrosis After Transforaminal Lumbar Interbody Fusion: A Single-Institution Case Series.

Oper Neurosurg (Hagerstown) 2021 01;20(2):164-173

Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.

Background: The treatment of pseudarthrosis after transforaminal lumbar interbody fusion (TLIF) can be challenging, particularly when anterior column reconstruction is required. There are limited data on TLIF cage removal through an anterior approach.

Objective: To assess the safety and efficacy of anterior lumbar interbody fusion (ALIF) as a treatment for pseudarthrosis after TLIF.

Methods: ALIFs performed at a single academic medical center were reviewed to identify cases performed for the treatment of pseudarthrosis after TLIF. Patient demographics, surgical characteristics, perioperative complications, and 1-yr radiographic data were collected.

Results: A total of 84 patients were identified with mean age of 59 yr and 37 women (44.0%). A total of 16 patients (19.0%) underwent removal of 2 interbody cages for a total of 99 implants removed with distribution as follows: 1 L2/3 (0.9%), 6 L3/4 (5.7%), 37 L4/5 (41.5%), and 55 L5/S1 (51.9%). There were 2 intraoperative venous injuries (2.4%) and postoperative complications were as follows: 7 ileus (8.3%), 5 wound-related (6.0%), 1 rectus hematoma (1.1%), and 12 medical complications (14.3%), including 6 pulmonary (7.1%), 3 cardiac (3.6%), and 6 urinary tract infections (7.1%). Among 58 patients with at least 1-yr follow-up, 56 (96.6%) had solid fusion. There were 5 cases of subsidence (6.0%), none of which required surgical revision. Two patients (2.4%) required additional surgery at the level of ALIF for pseudarthrosis.

Conclusion: ALIF is a safe and effective technique for the treatment of TLIF cage pseudarthrosis with a favorable risk profile.
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http://dx.doi.org/10.1093/ons/opaa303DOI Listing
January 2021

The effect of anterior lumbar interbody fusion staging order on perioperative complications in circumferential lumbar fusions performed within the same hospital admission.

Neurosurg Focus 2020 09;49(3):E6

Departments of1Neurological Surgery.

Objective: Anterior lumbar interbody fusion (ALIF) is a powerful technique that provides wide access to the disc space and allows for large lordotic grafts. When used with posterior spinal fusion (PSF), the procedures are often staged within the same hospital admission. There are limited data on the perioperative risk profile of ALIF-first versus PSF-first circumferential fusions performed within the same hospital admission. In an effort to understand whether these procedures are associated with different perioperative complication profiles, the authors performed a retrospective review of their institutional experience in adult patients who had undergone circumferential lumbar fusions.

Methods: The electronic medicals records of patients who had undergone ALIF and PSF on separate days within the same hospital admission at a single academic center were retrospectively analyzed. Patients carrying a diagnosis of tumor, infection, or traumatic fracture were excluded. Demographics, surgical characteristics, and perioperative complications were collected and assessed.

Results: A total of 373 patients, 217 of them women (58.2%), met the inclusion criteria. The mean age of the study cohort was 60 years. Surgical indications were as follows: degenerative disease or spondylolisthesis, 171 (45.8%); adult deformity, 168 (45.0%); and pseudarthrosis, 34 (9.1%). The majority of patients underwent ALIF first (321 [86.1%]) with a mean time of 2.5 days between stages. The mean number of levels fused was 2.1 for ALIF and 6.8 for PSF. In a comparison of ALIF-first to PSF-first cases, there were no major differences in demographics or surgical characteristics. Rates of intraoperative complications including venous injury were not significantly different between the two groups. The rates of postoperative ileus (11.8% vs 5.8%, p = 0.194) and ALIF-related wound complications (9.0% vs 3.8%, p = 0.283) were slightly higher in the ALIF-first group, although the differences did not reach statistical significance. Rates of other perioperative complications were no different.

Conclusions: In patients undergoing staged circumferential fusion with ALIF and PSF, there was no statistically significant difference in the rate of perioperative complications when comparing ALIF-first to PSF-first surgeries.
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http://dx.doi.org/10.3171/2020.6.FOCUS20296DOI Listing
September 2020

Immediate Voice and Swallowing Complaints Following Revision Anterior Cervical Spine Surgery.

Otolaryngol Head Neck Surg 2020 Oct 2;163(4):778-784. Epub 2020 Jun 2.

Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA.

Objective: To report on the incidence of dysphagia, dysphonia, and acute vocal fold motion impairment (VFMI) following revision anterior cervical spine surgery, as well as to identify risk factors associated with acute VFMI in the immediate postoperative period.

Study Design: Retrospective cohort study.

Setting: Tertiary care center.

Subjects And Methods: All patients who underwent 2-team reoperative anterior cervical discectomy and fusion (ACDF) were retrospectively reviewed. Incidence of dysphonia, dysphagia, and acute VFMI was noted. Patient and operative factors were evaluated for association with risk of acute VFMI.

Results: The incidence of postoperative dysphonia and dysphagia was 25% (18/72) and 52% (37/72), respectively. The incidence of immediate VFMI was 21% (15/72). Subjective postoperative dysphonia (odds ratio, [OR] 8; 95% CI, 2.2-28; = .001) and dysphagia (OR, 22; 95% CI, 2.5-168; = .005) were significantly associated with increased risk of VFMI. Three patients with VFMI required temporary injection medialization for voice complaints and/or aspiration. Infection (OR, 14; 95% CI, 1.4-147, = .025) and level C7/T1 (OR, 5.5; 95% CI, 1.3-23, = .02) were significantly associated with an increased risk of acute VFMI on multivariate logistic regression analysis. Number of prior surgeries, laterality of approach, side of approach relative to prior operations, and number of levels exposed were not significant.

Conclusion: Early involvement of an otolaryngologist in the care of a patient undergoing revision ACDF can be helpful to the patient in anticipation of voice and swallowing changes in the postoperative period. This may be particularly important in those being treated at C7/T1 or those with spinal infections.
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http://dx.doi.org/10.1177/0194599820926133DOI Listing
October 2020

The impact of obesity on perioperative complications in patients undergoing anterior lumbar interbody fusion.

J Neurosurg Spine 2020 Apr 24:1-10. Epub 2020 Apr 24.

1Department of Neurological Surgery, University of California, San Francisco.

Objective: Anterior approaches to the lumbar spine provide wide exposure that facilitates placement of large grafts with high fusion rates. There are limited data on the effects of obesity on perioperative complications.

Methods: Data from consecutive patients undergoing anterior lumbar interbody fusion (ALIF) from 2007 to 2016 at a single academic center were analyzed. The primary outcome was any perioperative complication. Complications were divided into those occurring intraoperatively and those occurring postoperatively. Multivariate logistic regression was used to assess the association of obesity and other variables with these complications. An estimation table was used to identify a body mass index (BMI) threshold associated with increased risk of postoperative complication.

Results: A total of 938 patients were identified, and the mean age was 57 years; 511 were females (54.5%). The mean BMI was 28.7 kg/m2, with 354 (37.7%) patients classified as obese (BMI ≥ 30 kg/m2). Forty patients (4.3%) underwent a lateral transthoracic approach, while the remaining 898 (95.7%) underwent a transabdominal retroperitoneal approach. Among patients undergoing transabdominal retroperitoneal ALIF, complication rates were higher for obese patients than for nonobese patients (37.0% vs 28.7%, p = 0.010), a difference that was driven primarily by postoperative complications (36.1% vs 26.0%, p = 0.001) rather than intraoperative complications (3.2% vs 4.3%, p = 0.416). Obese patients had higher rates of ileus (11.7% vs 7.2%, p = 0.020), wound complications (11.4% vs 3.4%, p < 0.001), and urinary tract infections (UTI) (5.0% vs 2.5%, p = 0.049). In a multivariate model, age, obesity, and number of ALIF levels fused were associated with an increased risk of postoperative complication. An estimation table including 19 candidate cut-points, odds ratios, and adjusted p values found a BMI ≥ 31 kg/m2 to have the highest association with postoperative complication (p = 0.012).

Conclusions: Obesity is associated with increased postoperative complications in ALIF, including ileus, wound complications, and UTI. ALIF is a safe and effective procedure. However, patients with a BMI ≥ 31 kg/m2 should be counseled on their increased risks and warrant careful preoperative medical optimization and close monitoring in the postoperative setting.
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http://dx.doi.org/10.3171/2020.2.SPINE191418DOI Listing
April 2020

Outcomes and Quality of Life Improvement After Multilevel Spinal Fusion in Elderly Patients.

Global Spine J 2020 Apr 19;10(2):153-159. Epub 2019 May 19.

University of California-San Francisco, San Francisco, CA, USA.

Study Design: Retrospective case series.

Objectives: Both the rate and complexity of spine surgeries in elderly patients has increased. This study reports the outcomes of multilevel spine fusion in elderly patients and provides evidence on the appropriateness of complex surgery in elderly patients.

Methods: We identified 101 patients older than70 years who had ≥5 levels of fusion. Demographic, medical, and surgical data, and change between preoperative and >500 days postoperative health survey scores were collected. Health surveys were visual analogue scale (VAS), EuroQoL 5 Dimensions (EQ-5D), Oswestry Disability Index (ODI), Scoliosis Research Society questionnaire (SRS-30), and Short Form health survey (SF-12) (physical composite score [PCS] and mental composite score [MCS]). Minimal clinically important differences (MCIDs) were defined for each survey.

Results: Complications included dural tears (19%), intensive care unit admission (48%), revision surgery within 2 to 5 years (24%), and death within 2 to 5 years (16%). The percentage of patients who reported an improvement in health-related quality of life (HRQOL) of at least an MCID was: VAS Back 69%; EQ-5D 41%; ODI 58%; SRS-30 45%; SF-12 PCS 44%; and SF-12 MCS 48%. Improvement after a primary surgery, as compared with a revision, was on average 13 points higher in ODI ( = .007). Patients who developed a surgical complication averaged an improvement 11 points lower on ODI ( = .042). Patients were more likely to find improvement in their health if they had a lower American Society of Anesthesiologists or Charlson Comorbidity Index score or a higher metabolic equivalent score.

Conclusions: In multilevel surgery in patients older than 70 years, complications are common, and on average 77% of patients attain some improvement, with 51% reaching an MCID. Physiological status is a stronger predictor of outcomes than chronological age.
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http://dx.doi.org/10.1177/2192568219849393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7076597PMC
April 2020

Cost Analysis of Single-Level Lumbar Fusions.

Global Spine J 2020 Feb 24;10(1):39-46. Epub 2019 Jun 24.

University of California San Francisco, San Francisco, CA, USA.

Study Design: Cost analysis of a retrospectively identified cohort of patients who had undergone primary single-level lumbar fusion at a single institution's orthopedic or neurosurgery department.

Objective: The purpose of this article is to analyze the determinants of direct costs for single-level lumbar fusions and identify potential areas for cost reduction.

Methods: Adult patients who underwent primary single-level lumbar fusion from fiscal years 2008 to 2012 were identified via administrative and departmental databases and were eligible for inclusion. Patients were excluded if they underwent multiple surgeries, had previous surgery at the same anatomic region, underwent corpectomy, kyphectomy, disc replacement, surgery for tumor or infection, or had incomplete cost data. Demographic data, surgical data, and direct cost data in the categories of supplies, services, room and care, and pharmacy, was collected for each patient.

Results: The cohort included 532 patients. Direct costs ranged from $8286 to $73 727 (median = $21 781; mean = $22 890 ± $6323). Surgical approach was an important determinant of cost. The mean direct cost was highest for the circumferential approach and lowest for posterior instrumented spinal fusions without an interbody cage. The difference in mean direct cost between transforaminal lumbar interbody fusions, anterior lumbar interbody fusions, and lateral transpsoas fusions was not statistically significant. Surgical supplies accounted for 44% of direct costs. Spinal implants were the primary component of supply costs (84.9%). Services accounted for 38% of direct costs and were highly dependent on operative time. Comorbidities were an important contributor to variance in the cost of care as evidenced by high variance in pharmacy costs and length of stay related to their management.

Conclusion: The costs of spinal surgeries are highly variable. Important cost drivers in our analysis included surgical approach, implants, operating room time, and length of hospital stay. Areas of high cost and high variance offer potential targets for cost savings and quality improvements.
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http://dx.doi.org/10.1177/2192568219853251DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6963351PMC
February 2020

Local Application of Vancomycin in Spine Surgery Does Not Result in Increased Vancomycin-Resistant Bacteria-10-Year Data.

Spine Deform 2019 09;7(5):696-701

Department of Orthopaedic Surgery, Stanford University, 450 Broadway St., Redwood City, CA 94063, USA. Electronic address:

Study Design: Case-control study.

Objectives: To analyze the microbial flora in surgical spine infections and their antibiotic resistance patterns across time and determine the correlation between vancomycin application in the wound and vancomycin-resistant microbes.

Summary Of Background Data: Prior studies show a reduction in surgical site infections with intrawound vancomycin placement. No data are available on the potential negative effects of this intervention, in particular, whether there would be a resultant increase in vancomycin-resistant organisms or bacterial resistance profiles.

Methods: All culture-positive surgical site infections at a single institution were analyzed from 2007 to 2017. Each bacterium was assessed independently for resistance patterns. The two-tailed Fisher exact test was used to determine the correlation between vancomycin application and the presence of vancomycin-resistant bacteria, polymicrobial infections, or gram-negative bacterial infections.

Results: One hundred and eight bacteria were isolated from 113 surgical site infections from 2007 to 2017. The most common organisms were staphylococcus with varying resistance patterns and Escherichia coli. Vancomycin-resistant Enterococcus faecium was isolated in three infections. Out of the 4,878 surgical cases from 2011 to 2017, vancomycin was placed in 48.3%, and no vancomycin in 51.7%. There were 33 infections (1.4%) in the vancomycin group and 20 infections (0.8%) in the no-vancomycin group (χ = 0.0521). There was no correlation between vancomycin application in the wound and vancomycin-resistant microbes (χ = 0.2334) and polymicrobial infections (χ = 0.1328). There was an increased rate of gram-negative organisms in infections after vancomycin application in the wound versus no vancomycin (χ = 0.0254).

Conclusions: Topical vancomycin within the surgical site is not correlated with vancomycin-resistant bacteria. However, there was an increased incidence of gram-negative organisms in infections after vancomycin application in the wound versus no vancomycin. Continued surveillance with prospectively collected randomized data is necessary to better understand bacterial evolution against current antimicrobial techniques.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jspd.2019.01.005DOI Listing
September 2019

Treatment of only the fractional curve for radiculopathy in adult scoliosis: comparison to lower thoracic and upper thoracic fusions.

J Neurosurg Spine 2019 Feb 1:1-9. Epub 2019 Feb 1.

Departments of1Neurological Surgery and.

OBJECTIVEMany options exist for the surgical management of adult spinal deformity. Radiculopathy and lumbosacral pain from the fractional curve (FC), typically from L4 to S1, is frequently a reason for scoliosis patients to pursue surgical intervention. The purpose of this study was to evaluate the outcomes of limited fusion of the FC only versus treatment of the entire deformity with long fusions.METHODSAll adult scoliosis patients treated at the authors' institution in the period from 2006 to 2016 were retrospectively analyzed. Patients with FCs from L4 to S1 > 10° and radiculopathy ipsilateral to the concavity of the FC were eligible for study inclusion and had undergone three categories of surgery: 1) FC only (FC group), 2) lower thoracic to sacrum (LT group), or 3) upper thoracic to sacrum (UT group). Primary outcomes were the rates of revision surgery and complications. Secondary outcomes were estimated blood loss, length of hospital stay, and discharge destination. Spinopelvic parameters were measured, and patients were stratified accordingly.RESULTSOf the 99 patients eligible for inclusion in the study, 27 were in the FC group, 46 in the LT group, and 26 in the UT group. There were no significant preoperative differences in age, sex, smoking status, prior operation, FC magnitude, pelvic tilt (PT), sagittal vertical axis (SVA), coronal balance, pelvic incidence-lumbar lordosis (PI-LL) mismatch, or proportion of well-aligned spines (SVA < 5 cm, PI-LL mismatch < 10°, and PT < 20°) among the three treatment groups. Mean follow-up was 30 (range 12-112) months, with a minimum 1-year follow-up. The FC group had a lower medical complication rate (22% [FC] vs 57% [LT] vs 58% [UT], p = 0.009) but a higher rate of extension surgery (26% [FC] vs 13% [LT] vs 4% [UT], p = 0.068). The respective average estimated blood loss (592 vs 1950 vs 2634 ml, p < 0.001), length of hospital stay (5.5 vs 8.3 vs 8.3 days, p < 0.001), and rate of discharge to acute rehabilitation (30% vs 46% vs 85%, p < 0.001) were all lower for FC and highest for UT.CONCLUSIONSTreatment of the FC only is associated with a lower complication rate, shorter hospital stay, and less blood loss than complete scoliosis treatment. However, there is a higher associated rate of extension of the construct to the lower or upper thoracic levels, and patients should be counseled when considering their options.
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http://dx.doi.org/10.3171/2018.9.SPINE18505DOI Listing
February 2019

Contribution of Lateral Interbody Fusion in Staged Correction of Adult Degenerative Scoliosis.

J Korean Neurosurg Soc 2018 Nov 30;61(6):716-722. Epub 2018 Oct 30.

Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA, USA.

Objective: Lateral interbody fusion (LIF) is attractive as a less invasive technique to address anterior spinal pathology in the treatment of adult spinal deformity. Its own uses and benefits in treatment of adult degenerative scoliosis are undefined. To investigate the radiographic and clinical outcomes of LIF, and staged LIF and posterior spinal fusion (PSF) for the treatment of adult degenerative scoliosis patients, we analyzed radiographic and clinical outcomes of adult degenerative scoliosis patients who underwent LIF and posterior spinal fusion.

Methods: Forty consecutive adult degenerative scoliosis patients who underwent LIF followed by staged PSF at a single institution were retrospectively reviewed. Long-standing 36" anterior-posterior and lateral radiographs were taken preoperatively, at inter-stage, 3 months, 1 year, and 2 years after surgery were reviewed. Outcomes were assessed through the visual analogue scale (VAS), 36-Item Short Form Health Survey (SF-36), and Oswestry Disability Index (ODI).

Results: Forty patients with a mean age of 66.3 (range, 49-79) met inclusion criteria. A mean of 3.8 levels (range, 2-5) were fused using LIF, while a mean of 9.0 levels (range, 3-16) were fused during the posterior approach. The mean time between stages was 1.4 days (range, 1-6). The mean follow-up was 19.6 months. Lumbar lordosis was significantly restored from 36.4º preoperatively up to 48.9º (71.4% of total correction) after LIF and 53.9º after PSF. Lumbar coronal Cobb was prominently improved from 38.6º preoperatively to 24.1º (55.8% of total correction) after LIF, 12.6º after PSF respectively. The mean pelvic incidence-lumbar lordosis mismatch was markedly improved from 22.2º preoperatively to 8.1º (86.5% of total correction) after LIF, 5.9º after PSF. Correction of coronal imbalance and sagittal vertebral axis did not reach significance. The rate of perioperative complication was 37.5%. Five patients underwent revision surgery due to wound infection. No major perioperative medical complications occurred. At last followup, there were significant improvements in VAS, SF-36 Physical Component Summary and ODI scores.

Conclusion: LIF provides significant corrections in the coronal and sagittal plane in the patients with adult degenerative scoliosis. However, LIF combined with staged PSF provides more excellent radiographic and clinical outcomes, with reduced perioperative risk in the treatment of adult degenerative scoliosis.
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http://dx.doi.org/10.3340/jkns.2017.0275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6280057PMC
November 2018

An Analysis of Implant Retention and Antibiotic Suppression in Instrumented Spine Infections: A Preliminary Data Set of 67 Patients.

Int J Spine Surg 2018 Aug 31;12(4):490-497. Epub 2018 Aug 31.

Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California.

Background: It is unclear whether patients can be taken off suppressive antibiotics with infected retained instrumentation. This study aimed to retrospectively analyze the perioperative course and antibiotic regimen that led to the clinical intervention of patients with infected spinal instrumentation.

Methods: Consecutive adult patients with spine instrumentation who suffered surgical site infections (SSI) requiring debridement were retrospectively analyzed. The patients were grouped into 4 cohorts based on their clinical intervention: removal of instrumentation, reinstrumentation, retention of instrumentation with continued antibiotic suppression, and retention of instrumentation with no antibiotic suppression. Patient factors, infection factors, debridement, and antibiosis were compared.

Results: Of the 67 patients with SSI after spine surgery and instrumentation, 19 (28%) had their instrumentation removed, 6 (9%) had their instrumentation exchanged, 25 (37%) had their instrumentation retained and were on antibiotic suppression, and 17 (25%) had their instrumentation retained without any suppression. Those who had their instrumentation removed had a later presentation of their infection averaging 85 days (range 6-280 days) postoperatively. There was an earlier presentation for those who retained their implants, with suppression averaging 19 days (range 9-39) and no suppression averaging 29 days (range 6-90 days) post operatively ( < .001).

Conclusions: None of the patients with retained instrumentation without suppression had recurrence of infections after long-term follow-up. Lifelong antibiotic suppression may not be required with SSI that present early after early aggressive debridement. Patients with infections detected later are difficult to treat without removal of their original instrumentation.

Clinical Relevance: This study presents the outcomes of surgical and antibiotic factors in patients with infected spinal instrumentation.
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http://dx.doi.org/10.14444/5060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159739PMC
August 2018

Comparison of Stand-Alone, Transpsoas Lateral Interbody Fusion at L3-4 and Cranial vs Transforaminal Interbody Fusion at L3-4 and L4-5 for the Treatment of Lumbar Adjacent Segment Disease.

Int J Spine Surg 2018 Aug 31;12(4):469-474. Epub 2018 Aug 31.

Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California.

Study Design: Retrospective cohort study.

Objective: To compare outcomes and complications of stand-alone minimally invasive lateral interbody fusion (LIF) vs revision posterior surgery for the treatment of lumbar adjacent segment disease.

Methods: Adults who underwent LIF or transforaminal lumbar interbody fusion (TLIF) for adjacent segment disease were compared. Exclusion criteria: >grade 1 spondylolisthesis, posterior approach after LIF, and L5/S1 surgery. Patient demographics, estimated blood loss, hospital length of stay, complications, reoperations, health-related quality of life measures, and radiographs were examined. Data were analyzed with the χ, Wilcoxon signed rank, and Mann-Whitney tests.

Results: A total of 17 LIF and 16 TLIF patients were included. Demographics were similar. Follow up was similar (LIF: 22.9 ± 11.8 months vs TLIF: 22.0 ± 4.6 months;  = .86). The LIF patients had significantly less blood loss (LIF: 36 ± 16 mL vs TLIF: 700 ± 767 mL;  < .001) and shorter length of stay (LIF: 2.6 ± 2.9 days vs TLIF: 3.3 ± 0.9 days;  = .001). There were no intraoperative complications. Revision rate was 4 of 17 in LIF and 3 of 16 in TLIF ( = .73). Baseline health-related quality of life and radiographic measurements were similar. In both groups, back and leg pain scores significantly improved, and in LIF, the Owestry Disability Index, and EuroQol-5D significantly improved. The LIF had a significant increase in intervertebral height (LIF: 4.8 ± 2.9 mm,  < .001, TLIF: 1.3 ± 3.4 mm,  = .37), which was significantly greater for LIF than TLIF ( = .002). Similarly, LIF had a significant increase in segmental lordosis (LIF: 5.6° ± 4.9°,  < .001, TLIF: 3.6° ± 8.6°,  = .16), which was not significantly different between groups.

Conclusions: Patients with adjacent segment disease may receive significant benefit from stand-alone LIF or TLIF. The LIF offers advantages of less blood loss and a shorter hospital stay.

Level Of Evidence: 3.
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http://dx.doi.org/10.14444/5056DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6159729PMC
August 2018

Quantitative Assessment of the Anatomical Footprint of the C1 Pedicle Relative to the Lateral Mass: A Guide for C1 Lateral Mass Fixation.

Global Spine J 2018 Aug 10;8(5):507-511. Epub 2017 Dec 10.

University of California at San Francisco, San Francisco, CA, USA.

Study Design: Anatomic study.

Objectives: To determine the relationship of the anatomical footprint of the C1 pedicle relative to the lateral mass (LM).

Methods: Anatomic measurements were made on fresh frozen human cadaveric C1 specimens: pedicle width/height, LM width/height (minimum/maximum), LM depth, distance between LM's medial aspect and pedicle's medial border, distance between LM's lateral aspect to pedicle's lateral border, distance between pedicle's inferior aspect and LM's inferior border, distance between arch's midline and pedicle's medial border. The percentage of LM medial to the pedicle and the distance from the center of the LM to the pedicle's medial wall were calculated.

Results: A total of 42 LM were analyzed. The C1 pedicle's lateral aspect was nearly confluent with the LM's lateral border. Average pedicle width was 9.0 ± 1.1 mm, and average pedicle height was 5.0 ± 1.1 mm. Average LM width and depth were 17.0 ± 1.6 and 17.2 ± 1.6 mm, respectively. There was 6.9 ± 1.5 mm of bone medial to the medial C1 pedicle, which constituted 41% ± 9% of the LM's width. The distance from C1 arch's midline to the medial pedicle was 13.5 ± 2.0 mm. The LM's center was 1.6 ± 1 mm lateral to the medial pedicle wall. There was on average 3.5 ± 0.6 mm of the LM inferior to the pedicle inferior border.

Conclusions: The center of the lateral mass is 1.6 ± 1 mm lateral to the medial wall of the C1 pedicle and approximately 15 mm from the midline. There is 6.9 ± 1.5 mm of bone medial to the medial C1 pedicle. Thus, the medial aspect of C1 pedicle may be used as an anatomic reference for locating the center of the C1 LM for screw fixation.
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http://dx.doi.org/10.1177/2192568217744530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6149043PMC
August 2018

How Cervical Reconstruction Surgery Affects Global Spinal Alignment.

Neurosurgery 2019 04;84(4):898-907

Department of Neurological Surgery, University of California San Francisco, California, USA.

Background: There have been no reports describing how cervical reconstruction surgery affects global spinal alignment (GSA).

Objective: To elucidate the effects of cervical reconstruction for GSA through a retrospective multicenter study.

Methods: Seventy-eight patients who underwent cervical reconstruction surgery for cervical kyphosis were divided into a Head-balanced group (n = 42) and a Trunk-balanced group (n = 36) according to the values of the C7 plumb line (PL). We also divided the patients into a cervical sagittal balanced group (CSB group, n = 18) and a cervical sagittal imbalanced group (CSI group, n = 60) based on the C2 PL-C7 PL distance. Various sagittal Cobb angles and the sagittal vertical axes were measured before and after surgery.

Results: Cervical alignment was improved to achieve occiput-trunk concordance (the distance between the center of gravity [COG] PL, which is considered the virtual gravity line of the entire body, and C7 PL < 30 mm) despite the location of COG PL and C7PL. A subsequent significant change in thoracolumbar alignment was observed in Head-balanced and CSI groups. However, no such significant change was observed in Trunk-balanced and CSB groups. We observed 1 case of transient and 1 case of residual neurological worsening.

Conclusion: The primary goal of cervical reconstruction surgery is to achieve occiput-trunk concordance. Once it is achieved, subsequent thoracolumbar alignment changes occur as needed to harmonize GSA. Cervical reconstruction can restore both cervical deformity and GSA. However, surgeons must consider the risks and benefits in such challenging cases.
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http://dx.doi.org/10.1093/neuros/nyy141DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6417912PMC
April 2019

Autonomic dysreflexia caused by cervical stenosis.

Spinal Cord Ser Cases 2017 29;3:17102. Epub 2017 Dec 29.

Department of Orthopedic Surgery, University of California, San Francisco, CA 94143 USA.

Introduction: Autonomic dysreflexia (AD) is a well-known sequela of high spinal cord injuries (SCI). The characteristic episodic presentation is one of increased sympathetic tone: diaphoresis, hypertension, tachycardia, or reflex bradycardia. The episodes are triggered by visceral sensations and can last days to weeks.

Case Presentation: This report presents the case of a 73-year-old male with cervical stenosis, with a longstanding history of "hot flashes" accompanied by dizziness, flushing and diaphoresis, and palpitations. The patient was evaluated extensively by cardiology, endocrinology, and neurology with no treatable pathology determined aside from the patient's cervical stenosis. The patient was diagnosed with autonomic dysreflexia caused by cervical spinal stenosis and underwent anterior cervical decompression and fusion (ACDF) at the stenotic C5-C6 level. He found near complete resolution of his autonomic symptoms.

Discussion: We hypothesize that the cervical compression caused a disruption in the regulatory control of the sympathetic preganglionic neurons resulting in the autonomic symptoms. Although numerous studies exist of patients with a traumatic onset of AD, to the best of our knowledge, this is the first case report in the literature of autonomic symptoms that stemmed from cervical stenosis. The purpose of this case report is to alert clinicians to a potential association between AD and spinal stenosis, which may exist outside the realm of SCI.
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http://dx.doi.org/10.1038/s41394-017-0018-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5798920PMC
December 2017

Comparative analysis of 3 surgical strategies for adult spinal deformity with mild to moderate sagittal imbalance.

J Neurosurg Spine 2018 01 3;28(1):40-49. Epub 2017 Nov 3.

Departments of2Orthopaedic Surgery and.

OBJECTIVE Surgical treatment of adult spinal deformity (ASD) is an effective endeavor that can be accomplished using a variety of surgical strategies. Here, the authors assess and compare radiographic data, complications, and health-related quality-of-life (HRQoL) outcome scores among patients with ASD who underwent a posterior spinal fixation (PSF)-only approach, a posterior approach combined with lateral lumbar interbody fusion (LLIF+PSF), or a posterior approach combined with anterior lumbar interbody fusion (ALIF+PSF). METHODS The medical records of consecutive adults who underwent thoracolumbar fusion for ASD between 2003 and 2013 at a single institution were reviewed. Included were patients who underwent instrumentation from the pelvis to L-1 or above, had a sagittal vertical axis (SVA) of < 10 cm, and underwent a minimum of 2 years' follow-up. Those who underwent a 3-column osteotomy were excluded. Three groups of patients were compared on the basis of the procedure performed, LLIF+PSF, ALIF+PSF, and PSF only. Perioperative spinal deformity parameters, complications, and HRQoL outcome scores (Oswestry Disability Index [ODI], Scoliosis Research Society 22-question Questionnaire [SRS-22], 36-Item Short Form Health Survey [SF-36], visual analog scale [VAS] for back/leg pain) from each group were assessed and compared with each other using ANOVA. The minimal clinically important differences used were -1.2 (VAS back pain), -1.6 (VAS leg pain), -15 (ODI), 0.587/0.375/0.8/0.42 (SRS-22 pain/function/self-image/mental health), and 5.2 (SF-36, physical component summary). RESULTS A total of 221 patients (58 LLIF, 91 ALIF, 72 PSF only) met the inclusion criteria. Average deformities consisted of a SVA of < 10 cm, a pelvic incidence-lumbar lordosis (LL) mismatch of > 10°, a pelvic tilt of > 20°, a lumbar Cobb angle of > 20°, and a thoracic Cobb angle of > 15°. Preoperative SVA, LL, pelvic incidence-LL mismatch, and lumbar and thoracic Cobb angles were similar among the groups. Patients in the PSF-only group had more comorbidities, those in the ALIF+PSF group were, on average, younger and had a lower body mass index than those in the LLIF+PSF group, and patients in the LLIF+PSF group had a significantly higher mean number of interbody fusion levels than those in the ALIF+PSF and PSF-only groups. At final follow-up, all radiographic parameters and the mean numbers of complications were similar among the groups. Patients in the LLIF+PSF group had proximal junctional kyphosis that required revision surgery significantly less often and fewer proximal junctional fractures and vertebral slips. All preoperative HRQoL scores were similar among the groups. After surgery, the LLIF+PSF group had a significantly lower ODI score, higher SRS-22 self-image/total scores, and greater achievement of the minimal clinically important difference for the SRS-22 pain score. CONCLUSIONS Satisfactory radiographic outcomes can be achieved similarly and adequately with these 3 surgical approaches for patients with ASD with mild to moderate sagittal deformity. Compared with patients treated with an ALIF+PSF or PSF-only surgical strategy, patients who underwent LLIF+PSF had lower rates of proximal junctional kyphosis and mechanical failure at the upper instrumented vertebra and less back pain, less disability, and better SRS-22 scores.
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http://dx.doi.org/10.3171/2017.5.SPINE161370DOI Listing
January 2018

Perioperative Gabapentin Does Not Reduce Postoperative Delirium in Older Surgical Patients: A Randomized Clinical Trial.

Anesthesiology 2017 10;127(4):633-644

From the Departments of Anesthesia and Perioperative Care (J.M.L., S.K.), Neurosurgery (C.A., D.C., P.W.), Orthopedic Surgery (S. Bergven, S. Burch, V.D., M.R., B.T., T.V.), and Medicine (K.C.) and Memory and Aging Center (J.H.K.), University of California San Francisco, San Francisco, California; Virginia Tech, Blacksburg, Virginia (L.P.S.); Department of Statistics, Purdue University, West Lafayette, Indiana (N.C.); Department of Surgery & Perioperative Care, Dell Medical School, University of Texas at Austin, Austin, Texas (K.B.). participated in patient recruitment, cognitive assessments, data entry, and data management participated in patient recruitment, cognitive assessments, data entry, and data management participated in patient recruitment, cognitive assessments, data entry, and data management participated in patient recruitment, cognitive assessments, data entry, and data management participated in patient recruitment, cognitive assessments, data entry, and data management participated in patient recruitment, cognitive assessments, data entry, and data management.

Background: Postoperative pain and opioid use are associated with postoperative delirium. We designed a single-center, randomized, placebo-controlled, parallel-arm, double-blinded trial to determine whether perioperative administration of gabapentin reduced postoperative delirium after noncardiac surgery.

Methods: Patients were randomly assigned to receive placebo (N = 347) or gabapentin 900 mg (N = 350) administered preoperatively and for the first 3 postoperative days. The primary outcome was postoperative delirium as measured by the Confusion Assessment Method. Secondary outcomes were postoperative pain, opioid use, and length of hospital stay.

Results: Data for 697 patients were included, with a mean ± SD age of 72 ± 6 yr. The overall incidence of postoperative delirium in any of the first 3 days was 22.4% (24.0% in the gabapentin and 20.8% in the placebo groups; the difference was 3.20%; 95% CI, 3.22% to 9.72%; P = 0.30). The incidence of delirium did not differ between the two groups when stratified by surgery type, anesthesia type, or preoperative risk status. Gabapentin was shown to be opioid sparing, with lower doses for the intervention group versus the control group. For example, the morphine equivalents for the gabapentin-treated group, median 6.7 mg (25th, 75th quartiles: 1.3, 20.0 mg), versus control group, median 6.7 mg (25th, 75th quartiles: 2.7, 24.8 mg), differed on the first postoperative day (P = 0.04).

Conclusions: Although postoperative opioid use was reduced, perioperative administration of gabapentin did not result in a reduction of postoperative delirium or hospital length of stay.
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http://dx.doi.org/10.1097/ALN.0000000000001804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5605447PMC
October 2017

The Accuracy of Multimodality Intraoperative Neuromonitoring to Predict Postoperative Neurologic Deficits Following Cervical Laminoplasty.

World Neurosurg 2017 Oct 12;106:17-25. Epub 2017 Jun 12.

Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.

Background: Intraoperative neuromonitoring (IONM) has been reported to be sensitive and specific in the detection of neurologic injury during spinal surgery. The purpose of this study was to clarify the incidence of C5 palsy using multimodality IONM and to compare the accuracy of multimodality IONM to predict postoperative C5 palsy with isolated transcranial motor evoked potentials (MEPs).

Methods: We retrospectively reviewed 135 consecutive patients at a single institution with cervical spondylotic myelopathy who underwent open door laminoplasty using MEPs combined with somatosensory evoked potentials and free-running electromyography.

Results: Multimodality IONM was obtained in 131 cases. Ossification of the posterior longitudinal ligament was present in 19 patients (14.1%). Postoperative C5 palsy occurred in 3 patients (2.2%). Significant MEP alerts occurred in 12 patients. Significant somatosensory evoked potential change was not observed. To predict acute-onset C5 palsy, MEP alerts in the deltoid or biceps had 100% sensitivity and 98.4% specificity. Transient or persistent MEP alerts in the deltoid or biceps had same positive predictive value with sensitivity of 50.0% and specificity 99.2%.

Conclusions: Incidence of any neurologic deficit, including C5 palsy, during laminoplasty while using multimodality IONM was relatively low. MEP alerts in the deltoids or biceps had 100% sensitivity and 98.4% specificity for predicting a postoperative deficit. Somatosensory evoked potentials did not appear to be helpful in predicting postoperative deficits.
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http://dx.doi.org/10.1016/j.wneu.2017.06.026DOI Listing
October 2017

Global Spinal Alignment in Cervical Kyphotic Deformity: The Importance of Head Position and Thoracolumbar Alignment in the Compensatory Mechanism.

Neurosurgery 2018 05;82(5):686-694

Department of Neurological Surgery, University of California San Francisco, San Francisco, California.

Background: Previous studies have evaluated cervical kyphosis (C-kypho) using cervical curvature or chin-brow vertical angle, but the relationship between C-kypho and global spinal alignment is currently unknown.

Objective: To elucidate global spinal alignment and compensatory mechanisms in primary symptomatic C-kypho using full-spine radiography.

Methods: In this retrospective multicenter study, symptomatic primary C-kypho patients (Cerv group; n = 103) and adult thoracolumbar deformity patients (TL group; n = 119) were compared. We subanalyzed Cerv subgroups according to sagittal vertical axis (SVA) values of C7 (SVAC7 positive or negative [C7P or C7N]). Various Cobb angles (°) and SVAs (mm) were evaluated.

Results: SVAC7 values were -20.2 and 63.6 mm in the Cerv group and TL group, respectively (P < .0001). Various statistically significant compensatory curvatures were observed in the Cerv group, namely larger lumbar lordosis (LL) and thoracic kyphosis. The C7N group had significantly lower SVACOG (center of gravity of the head) and SVAC7 (32.9 and -49.5 mm) values than the C7P group (115.9 and 45.1 mm). Sagittal curvatures were also different in T4-12, T10-L2, LL4-S, and LL. The value of pelvic incidence (PI)-LL was different (C7N vs C7P; -2.2° vs 9.9°; P < .0003). Compensatory sagittal curvatures were associated with potential for shifting of SVAC7 posteriorly to adjust head position. PI-LL affected these compensatory mechanisms.

Conclusion: Compensation in symptomatic primary C-kypho was via posterior shifting of SVAC7, small T1 slope, and large LL. However, even in C-kypho patients, lumbar degeneration might affect global spinal alignment. Thus, global spinal alignment with cervical kyphosis is characterized as head balanced or trunk balanced.
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http://dx.doi.org/10.1093/neuros/nyx288DOI Listing
May 2018

A Comparison of Implants Used in Open-Door Laminoplasty: Structural Rib Allografts Versus Metallic Miniplates.

Clin Spine Surg 2017 Jun;30(5):E523-E529

*Department of Orthopaedic and Neurological Surgery, University of California, San Francisco, San Francisco, CA †Department of Orthopaedic Surgery, Louisiana State University, Baton Rouge, LA ‡University of Southern California, Los Angeles, CA §Department of Neurological Surgery, Loyola University Medical Center, Maywood, IL ∥Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA.

Study Design: A retrospective case-controlled study.

Summary Of Background Data: Open-door laminoplasty has been successfully used to address cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament. Two common implants include rib allograft struts and metallic miniplates.

Objective: The goals of this study were to compare outcomes, complications, and costs associated with these 2 implants.

Methods: A retrospective review was done on 51 patients with allograft struts and 55 patients with miniplates. Primary outcomes were neck visual analog scale (VAS) pain scores and Nurick scores. Secondary outcomes included length of the procedure, estimated blood loss, rates of complications, and the direct costs associated with the surgery and inpatient hospitalization.

Results: There were no differences in demographic characteristics, diagnoses, comorbidities, and preoperative outcome scores between the 2 treatment groups. Mean follow-up was 27 months. The postoperative neck VAS scores and Nurick scores improved significantly from baseline to final follow-up for both groups, but there was no difference between the 2 groups. The average length of operation (161 vs. 136 min) and number of foraminotomies (2.7 vs. 1.3) were higher for the allograft group (P=0.007 and 0.0001, respectively). Among the miniplate group, there was no difference in complications but a trend for less neck pain for patients treated without hard collar at final follow-up (1.8 vs. 2.3, P=0.52). The mean direct costs of hospitalization for the miniplate group were 15% higher.

Conclusions: Structural rib allograft struts and metallic miniplates result in similar improvements in pain and functional outcome scores with no difference in the rate of complications in short-term follow-up. Potential benefits of using a plate include shorter procedure length and less need for postoperative immobilization. When costs of bracing and operative time are included, the difference in cost between miniplates and allograft struts is negligible.
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http://dx.doi.org/10.1097/BSD.0000000000000139DOI Listing
June 2017

Factors Associated With the Development of and Revision for Proximal Junctional Kyphosis in 440 Consecutive Adult Spinal Deformity Patients.

Spine (Phila Pa 1976) 2017 Nov;42(22):1693-1698

Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), San Francisco, CA.

MINI: Proximal junctional kyphosis (PJK) is a common, yet incompletely understood, complication of surgery for adult spinal deformity. We analyzed 440 consecutive adult spinal deformity patients for trends in development of PJK and need for revision surgery. pelvic tilt and thoracic kyphosis were predictive for developing PJK, while radiographic evidence of proximal junctional failure was predictive for proceeding to revision.

Study Design: Retrospective review of prospectively collected data.

Objective: The aim of this study was to examine which radiographic parameters and surgical strategies are most closely associated with proximal junctional kyphosis (PJK) after adult spinal deformity (ASD) surgery, the need for revision surgery for PJK, and whether these differ based on the upper instrumented vertebra (UIV).

Summary Of Background Data: Multiple parameters are considered when planning correction of ASD. Determining which of these factors contribute to the development of and need for revision surgery for PJK presents a challenging problem.

Methods: Consecutive patients undergoing long fusion to the pelvis with age >18 years, minimum 6-month follow-up, and adequate radiographs for analysis in a single institution between 2003 and 2011 were included. Along with chart review, measurement of proximal junctional angle (PJA), sagittal balance, and pelvic parameters was performed on preoperative, postoperative, and latest follow-up radiographs. Postoperative radiographs were also examined for signs of PJF.

Results: A total of 440 patients with a mean follow-up of 34 months met inclusion criteria, 159 of whom developed PJK (36%), with 65 requiring revision surgery (41%). Higher preoperative pelvic tilt (PT) (P = 0.018) and postoperative thoracic kyphosis (TK) (P ≤ 0.001) were predictive for development of PJK, whereas hooks at UIV were protective (odds ratio [OR] 0.049). In patients who developed PJK, revision was more frequent in younger patients (P = 0.005) with greater postoperative sagittal vertical axis and PJA (P = 0.029, P = 0.018). PJF with spondylolisthesis, fracture, or instrumentation failure at the UIV had the highest ORs for proceeding to a revision (5.1, 1.6, and 2.2, respectively).

Conclusion: TK and PT are important indicators of overall rigidity and reference the ability of the spine to compensate for sagittal plane deformity. Special attention should be paid to these characteristics and to the choice of proximal instrumentation when attempting to prevent PJK. Prevention of radiographically evident PJF may hold the key to reducing the need for revision surgery.

Level Of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000002209DOI Listing
November 2017

Temporary fusionless posterior occipitocervical fixation for a proximal junctional type II odontoid fracture after previous C2-pelvis fusion: case report, description of a new surgical technique, and review of the literature.

Eur Spine J 2017 05 13;26(Suppl 1):243-248. Epub 2017 Apr 13.

Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MU West 3rd Floor, San Francisco, CA, 94143, USA.

Purpose: Axial fractures in patients with a previous C2-pelvis posterior instrumented fusion are rare and may be challenging to manage. Motion preservation in the axial spine for these patients is important, as the C1-2 and Occipit-C1 joints are their only remaining mobile spinal segments. In this unique report, we present for the first time the use of a fusionless occipitocervical operation for the treatment of a type II odontoid fracture and unilateral C2 pars fracture adjacent to a previous C2-pelvis posterior instrumented fusion.

Methods: Case report.

Results: Three years after proximal extension of a T3-pelvis posterior instrumented fusion to C2, the patient sustained a displaced odontoid fracture and unilateral C2 pars fracture after a mechanical fall. She underwent fracture stabilization with extension of instrumentation to the occiput. No attempt at fusion was performed. Post-operatively, she was distraught by severely limited neck range of motion, which was reflected in worsening of health-related quality of life (HRQoL) scores. The fracture healed uneventfully after which the instrumentation from the occiput and C1 were removed, which resulted in improvement of neck range of motion. Two years post-operatively, HRQoL scores showed minimal neck disability (NDI 12), no neck or arm pain (VAS 0), and outstanding general health (EQ-5D 85 out of 100, SF-36 PCS 35.3, SF-36 MCS 41.1).

Conclusion: In this one patient, instrumentation without fusion allowed for successful and timely union of a displaced odontoid fracture in a patient with a previous C2-pelvis fusion. Axial range of motion was preserved after instrumentation removal.
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http://dx.doi.org/10.1007/s00586-017-5093-8DOI Listing
May 2017

The effect of transforaminal epidural steroid injections in patients with spondylolisthesis.

J Back Musculoskelet Rehabil 2017 ;30(4):841-846

Department of Orthopedic Surgery, University of California San Francisco, San Francisco, CA, USA.

Background: Transforaminal epidural steroid injection (TFE) is a widely accepted non-surgical treatment for pain in patients with spondylolisthesis. However, the effectiveness of TFE has not been compared in patients with degenerative (DS) and isthmic spondylolisthesis (IS).

Objective: To compare the effectiveness of bilateral TFEs in DS and IS.

Methods: Patients who underwent bilateral TFEs for spondylolisthesis at University of California San Francisco Orthopaedic Institute from 2009 to 2014 were evaluated retrospectively.

Results: DS patients (120 female, 51 male) were significantly older and had higher comorbidity than those with IS (18 female, 14 male). They had better pain relief after TFE than patients with IS (72.11 ± 27.46% vs 54.39 ± 34.31%; p = 0.009). The number of TFEs, the mean duration of pain relief after TFE, follow-up periods, translation and facet joint widening were similar in DS and IS groups (p > 0.05). DS group had higher successful treatment rate (66.1% vs 46.9%, p = 0.009) and longer duration of pain relief (181.29 ± 241.37 vs 140.07 ± 183.62 days, p = 0.065) compared to IS group.

Conclusions: Bilateral TFEs at the level of spondylolisthesis effectively decreased pain in patients. TFEs provided better pain relief for longer duration in patients with DS than for those with IS.
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http://dx.doi.org/10.3233/BMR-160543DOI Listing
March 2018

Adjacent segment disease after instrumented fusion for adult lumbar spondylolisthesis: Incidence and risk factors.

Clin Neurol Neurosurg 2017 May 27;156:29-34. Epub 2017 Feb 27.

Department of Orthopaedic Surgery, University of California, San Francisco, CA, USA.

Objective: A potential long-term complication of lumbar fusion is the development of adjacent segment disease (ASD), which may necessitate second surgery and adversely affect outcomes. The objective of this is to determine the incidence of ASD following instrumented fusion in adult patients with lumbar spondylolisthesis and to identify the risk factors for this complication.

Patients And Methods: We retrospectively assessed adult patients who had undergone decompression and instrumented fusion for lumbar spondylolisthesis between January 2006 and December 2012. The incidence of ASD was analyzed. Potential risk factors included the patient-related factors, surgery-related factors, and radiographic variables such as sagittal alignment, preexisting disc degeneration and spinal stenosis at the adjacent segment.

Results: A total of 154 patients (mean age, 58.4 years) were included. Mean duration of follow-up was 28.6 months. Eighteen patients (11.7%) underwent a reoperation for ASD; 15 patients had reoperation at cranial ASD and 3 at caudal ASD. The simultaneous decompression at adjacent segment (p=0.002) and preexisting spinal stenosis at cranial adjacent segment (p=0.01) were identified as risk factors for ASD. The occurrence of ASD was not affected by patient-related factors, the types, grades and levels of spondylolisthesis, surgical approach, fusion procedures, levels of fusion, number of levels fused, types of bone graft, use of bone morphogenetic proteins, sagittal alignment, preexisting adjacent disc degeneration and preexisting spinal stenosis at caudal adjacent segments.

Conclusion: Our findings suggest the overall incidence of ASD is 11.7% in adult patients with lumbar spondylolisthesis after decompression and instrumented fusion at a mean follow-up of 28.6 months, the simultaneous decompression at the adjacent segment and preexisting spinal stenosis at cranial adjacent segment are risk factors for ASD.
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http://dx.doi.org/10.1016/j.clineuro.2017.02.020DOI Listing
May 2017

The James A. Rand Young Investigator's Award: Administrative Claims vs Surgical Registry: Capturing Outcomes in Total Joint Arthroplasty.

J Arthroplasty 2017 09 6;32(9S):S11-S17. Epub 2017 Feb 6.

Department of Orthopaedic Surgery, University of California, San Francisco, California.

Background: Administrative claims in total joint arthroplasty are used for observational studies and payment adjustments under the Comprehensive Care for Joint Replacement (CJR) legislation. Claims data have not been validated against prospective surgical outcome registries for primary total hip (THA) or knee arthroplasty (TKA). We hypothesized that significant differences in reported comorbidity and adverse event measures exist between administrative claims and prospective registry data relevant to payment adjudication under the CJR reimbursement model.

Methods: Comorbidities and outcomes in primary TKA and THA in the United Healthcare and Medicare Standard Analytical File 5% Sample insurance claims datasets (PearlDiver Technologies, Inc) were compared to age-matched cohorts from the National Surgical Quality Improvement Program (ACS-NSQIP) surgical outcomes data from 2007 to 2011 using comparable International Classification of Diseases, Ninth Revision, Clinical Modification and Current Procedural Terminology codes at 30, 90, and 360 days from index arthroplasty. Pearson's chi-square test was used for statistical analyses.

Results: The total study population included 93,953 primary THA and 176,944 TKA patients. Primary TKA and THA patients in insurance claims cohorts had significantly fewer reported comorbidities, higher rates of surgical site infection, pulmonary embolism, wound dehiscence, thromboembolic events, and neurologic deficits, and lower reported rates of revision surgery than ACS-NSQIP cohorts within 30 days of primary TKA and THA. Cumulative incidence of adverse events increased significantly from 30 to 360 days after primary arthroplasty.

Conclusion: We report significant discordance in the prevalence of patient comorbidities and incidence of adverse events in primary THA and TKA between ACS-NSQIP and the administrative claims data of Medicare and United Healthcare. These disparities have implications for observational outcome studies as well as payment adjudication under the CJR reimbursement model in total joint arthroplasty.
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http://dx.doi.org/10.1016/j.arth.2016.08.041DOI Listing
September 2017

ISSLS PRIZE IN BASIC SCIENCE 2017: Intervertebral disc/bone marrow cross-talk with Modic changes.

Eur Spine J 2017 05 31;26(5):1362-1373. Epub 2017 Jan 31.

Department of Orthopaedic Surgery, University of California San Francisco, 513 Parnassus Ave, S-1164, San Francisco, CA, 94143, USA.

Study Design: Cross-sectional cohort analysis of patients with Modic Changes (MC).

Objective: Our goal was to characterize the molecular and cellular features of MC bone marrow and adjacent discs. We hypothesized that MC associate with biologic cross-talk between discs and bone marrow, the presence of which may have both diagnostic and therapeutic implications.

Background Data: MC are vertebral bone marrow lesions that can be a diagnostic indicator for discogenic low back pain. Yet, the pathobiology of MC is largely unknown.

Methods: Patients with Modic type 1 or 2 changes (MC1, MC2) undergoing at least 2-level lumbar interbody fusion with one surgical level having MC and one without MC (control level). Two discs (MC, control) and two bone marrow aspirates (MC, control) were collected per patient. Marrow cellularity was analyzed using flow cytometry. Myelopoietic differentiation potential of bone marrow cells was quantified to gauge marrow function, as was the relative gene expression profiles of the marrow and disc cells. Disc/bone marrow cross-talk was assessed by comparing MC disc/bone marrow features relative to unaffected levels.

Results: Thirteen MC1 and eleven MC2 patients were included. We observed pro-osteoclastic changes in MC2 discs, an inflammatory dysmyelopoiesis with fibrogenic changes in MC1 and MC2 marrow, and up-regulation of neurotrophic receptors in MC1 and MC2 bone marrow and discs.

Conclusion: Our data reveal a fibrogenic and pro-inflammatory cross-talk between MC bone marrow and adjacent discs. This provides insight into the pain generator at MC levels and informs novel therapeutic targets for treatment of MC-associated LBP.
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http://dx.doi.org/10.1007/s00586-017-4955-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5409869PMC
May 2017

Anterior Versus Posterior Approaches for Odontoid Fracture Stabilization in Patients Older Than 65 Years: 30-day Morbidity and Mortality in a National Database.

Clin Spine Surg 2017 Oct;30(8):E1033-E1038

Department of Orthopaedic Surgery, University of California-San Francisco, San Francisco, CA.

Study Design: Retrospective cohort analysis.

Objective: To compare 30-day perioperative clinical outcomes of surgical odontoid stabilization by an anterior or posterior operative approach in elderly patients.

Summary Of Background Data: Surgical stabilization of odontoid fractures is superior to nonoperative management in geriatric patients. How elderly patients with odontoid fractures fare after anterior and posterior approaches, however, is not well defined.

Materials And Methods: Retrospective review of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database (2005-2013). Elderly patients (≥65 y) with odontoid fractures who underwent odontoid stabilization through anterior or posterior approaches were identified by International Classification of Diseases 9th Revision/Common Procedure Terminology codes. Exclusion criteria included concomitant subaxial spine surgery, instrumentation noncontiguous with the atlantoaxial interval, and combined approaches. Baseline demographics and perioperative details were compared. Adverse events, mortality, reoperation, discharge, and readmission rates within 30 days of operation were compared using bivariate and multivariate generalized linear regressions.

Results: One hundred forty-one patients (male-81; female-60; average age: 77.8±6.5 y; anterior approach-48; posterior approach-93) were analyzed. Patients scheduled to have a posterior approach had significantly more nonunions preoperatively and higher body mass indices. Operative times for posterior surgeries were significantly longer. Age, comorbidities, functional dependence, time to surgery, and length of hospital stay were similar between groups. There were no significant differences in the relative risk (RR) of the composite outcome of "any adverse event" after adjusting for differences in baseline characteristics. Patients who underwent an anterior approach were more likely to have an unplanned hospital readmission (RR=8.95; 95% confidence interval, 2.21-36.29; P=0.002) and have significantly more revision operations (RR=19.51; 95% confidence interval, 2.49-152.62; P=0.005) than patients who had a posterior operation.

Conclusions: An anterior approach for odontoid fracture stabilization in patients ≥65 years old were associated with shorter operative times and greater RRs of unplanned readmissions and revision operations within 30 days of surgery relative to a posterior approach.
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October 2017

Sexual function after cervical spine surgery: Independent predictors of functional impairment.

J Clin Neurosci 2017 Feb 4;36:94-101. Epub 2016 Nov 4.

Department of Neurological Surgery, University of California, San Francisco, 505 Parnassus Avenue, Rm 779M, CA 94143, USA. Electronic address:

Sexual function (SF) is an important component of patient-focused health related quality of life (HRQoL), but it has not been well studied in spine surgery. This study aims to assess SF after cervical spine surgery and identify predictors of SF. This single-center retrospective study evaluates SF of adults who underwent cervical spine surgery 2007-2012. Predictor variables included demographics, medical/surgical history, operative information, HRQoL measures (Neck Disability Index, SF-12), validated SF surveys [Female Sexual Function Index (FSFI) and Brief Sexual Function Inventory (BSFI) for males], and a study-specific SF questionnaire. 59 patients (31M, 28F; mean age=56±8.4) had significantly lower SF scores compared to age-matched peers: average BSFI = 2.26±1.22 (vs. 06±0.74), average FSFI=13.05±11.42 (<26.55 indicating sexual dysfunction). In men, lower mental SF-12 and higher NDI, back pain, and number of operated levels were associated with lower BSFI scores (all p<0.05). In women, higher total number of medications and pain medications were associated with lower FSFI scores (both p<0.05). 46% of patients reported difficulty performing a sexual position after surgery that they had previously enjoyed. 39% of men had difficulty on top during intercourse, and 32% of participants reported difficulty performing oral sex. 39% of patients reported worse SF, while only 5% reported an improvement in postoperative SF. Men and women who underwent cervical spine surgery had lower SF scores than age-matched peers, likely attributable to general mental health, regional neck disability, back pain, and medications. A large portion of patients reported subjectively worsened SF after surgery.
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February 2017
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