Publications by authors named "Sheeraz A Qureshi"

127 Publications

Combining Expandable Interbody Cage Technology With a Minimally Invasive Technique to Harvest Iliac Crest Autograft Bone to Optimize Fusion Outcomes in Minimally Invasive Transforaminal Lumbar Interbody Fusion Surgery.

Clin Spine Surg 2021 Jul 1. Epub 2021 Jul 1.

Hospital for Special Surgery Weill Cornell Medical College, New York, NY Weill Cornell Medical College, Doha, Qatar Ichan School of Medicine at Mount Sinai, New York, NY.

Study Design: This was a retrospective cohort review.

Objective: The objective of this study was to determine the rate of fusion associated with an expandable cage and iliac crest bone graft in minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) surgery.

Summary Of Background Data: MI-TLIF is a commonly performed procedure, but challenges inherent in MI-TLIF technique can make achieving an interbody fusion difficult.

Methods: A retrospective review was performed on consecutive patients treated with an MI-TLIF for degenerative lumbar pathology. Patients that completed patient-reported outcome measures and 1-year computed tomography (CT)-scans for fusion analysis were included. Fusion morphology was analyzed by evaluating CT scans for location of bridging trabecular bone in relation to the cage. Patients with bridging bone were considered fused. Preoperative and postoperative health-related quality of life scores were compared. A Kolmogrov-Smirnoff test was used to determine normality of health-related outcome scores. A Friedman 2-way analysis of variance by ranks with pairwise comparisons to determine statistical significance of differences between the date of a follow-up examination and preoperative examination was done.

Results: Of 75 patients evaluated 23 patients were excluded due to loss to follow-up, adjacent segment degeneration, inability to obtain a CT scan, or reoperation for nonfusion related symptoms. Of 61 disk spaces that were included, 55 had bridging bone through the intervertebral cage, resulting in an overall fusion rate of 90.2%. There was a higher rate of fusion at L5-S1 as compared to L4-L5. There was mean improvement in patient-reported outcome measures for Oswestry Disability Index, Short Form-12 Physical Component Score, Visual Analog Scale Back/Leg pain, and Patient-Reported Outcome Measurement Information System Physical Function. There were no complications associated with iliac crest bone graft harvesting.

Conclusion: Combining an expandable cage with iliac crest autograft bone harvested through a minimally invasive technique can allow for improved fusion rates without graft-site complications in MI-TLIF surgery.
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http://dx.doi.org/10.1097/BSD.0000000000001228DOI Listing
July 2021

Cervical Steroid Injections Are Not Effective for Prevention of Surgical Treatment of Degenerative Cervical Myelopathy.

Global Spine J 2021 Jul 5:21925682211024573. Epub 2021 Jul 5.

Hospital for Special Surgery, New York, NY, USA.

Study Design: Retrospective cohort study.

Objective: The objective of this study is to determine how often patients with degenerative cervical myelopathy (DCM) and initially treated with cervical steroid injections (CSI) and to determine whether these injections provide any benefit in delaying ultimate surgical treatment.

Methods: All patients with a new diagnosis of DCM, without previous cervical spine surgery or steroid injections, were identified in PearlDiver, a large insurance database. Steroid injection and surgery timing was identified using Current Procedural Terminology (CPT) codes. Multivariate logistic regression identified associations with surgical treatment.

Results: A total of 686 patients with DCM were identified. Pre-surgical cervical spine steroid injections were utilized in 244 patients (35.6%). All patients underwent eventual surgical treatment. Median time from initial DCM diagnosis to surgery was 75.5 days (mean 351.6 days; standard deviation 544.9 days). Cervical steroid injections were associated with higher odds of surgery within 1 year (compared to patients without injections, OR = 1.44, .001) and at each examined time point through 5 years (OR = 2.01, .001). In multivariate analysis comparing injection types, none of the 3 injection types were associated with decreased odds of surgery within 1 month of diagnosis.

Conclusions: While cervical steroid injections continue to be commonly performed in patients with DCM, there is an overall increased odds of surgery after any type of cervical injection. Therefore injections should not be used to prevent surgical management of DCM.
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http://dx.doi.org/10.1177/21925682211024573DOI Listing
July 2021

Computer-Assisted Navigation Is Associated With Decreased Rates of Hardware-Related Revision After Instrumented Posterior Lumbar Fusion.

Global Spine J 2021 Jun 23:21925682211019696. Epub 2021 Jun 23.

Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA.

Study Design: Retrospective cohort study.

Objective: To (1) define utilization trends for navigated instrumented posterior lumbar fusion (PLF), (2) compare reasons and rates of revision at 30-day, 60-day, 90-day, and 1-year follow-up, and (3) compare 90-day perioperative complications between navigated versus conventional instrumented PLF.

Methods: Patients who underwent navigated or conventional instrumented PLF were identified from the Humana insurance database using the PearlDiver Patient Records between 2007-2017. Usage of navigation was characterized. Patient demographics and operative characteristics (number of levels fused, interbody usage) were compared between the 2 treatment groups. Propensity score matching was done and comparisons were made for revision rates at different follow-up periods (categorized by reasons) and other 90-day perioperative complications.

Results: This study included 1,648 navigated and 23 429 conventional instrumented PLF. Navigated cases increased over the years studied to approximately 10% in 2017. Statistical analysis after propensity score matching revealed significantly lower rates of hardware-related revision at 90-day follow-up in the navigated cohort (0.49% versus 1.15%, = .033). At 1-year follow-up, the navigated cohort continued to have significantly lower rates of hardware-related revision (1.70% versus 2.73%, = .044) as well as all cause revision (2.67% versus 4.00%, = .032). There were no statistical differences between the 2 cohorts in any of the 90-day perioperative complications studied, such as cellulitis and blood transfusion ( > .05 for all).

Conclusions: These findings suggest that navigation is associated with reductions in hardware-related revisions after instrumented PLF. However, these results should be interpreted cautiously in the setting of potential confounding by other unmeasured variables.
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http://dx.doi.org/10.1177/21925682211019696DOI Listing
June 2021

Does loss of spondylolisthesis reduction impact clinical and radiographic outcomes after minimally invasive transforaminal lumbar interbody fusion.

Spine J 2021 Jun 10. Epub 2021 Jun 10.

Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA; Weill Cornell Medical College, 1300 York Ave, New York, NY, 10065, USA. Electronic address:

Background Context: Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) is a common operative approach to address degenerative lumbar stenosis and spondylolisthesis which has failed nonoperative care. Compared to open TLIF, MI-TLIF relies to a greater extent on indirect decompression resulting in a heightened awareness of spondylolisthesis reduction among MI surgeons. To what extent intraoperative reduction is achieved as well as the rate and clinical impact of loss or reduction and slip recurrence remain unknown.

Purpose: To determine the rate and clinical impact of slip recurrence after MI-TLIF with expandable cage technology STUDY DESIGN/SETTING: Retrospective Cohort Study PATIENT SAMPLE: Patients undergoing MI-TLIF for degenerative spondylolisthesis using an articulating, expandable cage OUTCOME MEASURES: Patient-reported outcome measures (PROMs), including the Oswestry Disability Index (ODI), visual analog scale (VAS) for back/leg pain, Short Form-12 (SF-12), and PROMIS Physical Function (PF) METHODS: Patients undergoing MI-TLIF for degenerative spondylolisthesis using articulating, expandable cages from 2017 to 2019 were retrospectively studied. Lateral radiographs were reviewed and evaluated for the presence or absence of spondylolisthesis preoperatively, intraoperatively, and at follow-up times including 2 weeks, 6 weeks, 12 weeks, 6 months, and 1 year postoperatively. Spondylolisthesis was measured from the posterior inferior corner of the cephalad vertebra to the posterior superior corner of the caudal vertebra, with any measurement >1 mm classified as spondylolisthesis, and Meyerding grade was noted. Intraoperative reduction was measured, and loss of reduction was defined as >1 mm increase in spondylolisthesis comparing follow-up imaging to intraoperative films. PROMs were recorded at the preoperative and follow-up time points. Fusion was assessed at 1 year postoperatively via CT.

Results: A total of 63 patients and 70 levels were included, with mean age 59.8 years (SD,13.8). 19 levels (27.1%) had complete reduction intraoperatively, 40 (57.1%) had partial reduction, and 11 (15.7%) had no reduction. Of the 30 levels with loss of reduction (50.8%), 20 (66.7%) occurred by 2 weeks postoperatively and 28 (93.3%) occurred by 12 weeks postoperatively. At 6 months, there were significant differences between those who had loss of reduction and those who did not in VAS back pain (3.0 vs. 0.9, p = .017) and SF-12 PCS (41.5 vs. 50.0, p = .035), but no differences were found between the groups for any instruments at any other time points. The overall fusion rate was 82.1% (32/39) at 1 year postoperatively. There was no significant difference in fusion rate between the loss of reduction (16/20) and no loss of reduction (20/23) groups. Patients with loss of reduction had no difference in reoperation rate (1/28) compared to those without loss of reduction (2/24).

Conclusions: While a majority of patients demonstrated reduction intraoperatively, 51% had loss of reduction, most commonly in the acute postoperative period. There were few differences in PROMs between patients who had loss of reduction and those who did not, suggesting that radiographic loss of reduction after MI-TLIF in the setting of degenerative spondylolisthesis may not be clinically meaningful.
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http://dx.doi.org/10.1016/j.spinee.2021.06.009DOI Listing
June 2021

A Primer on the Use of Artificial Intelligence in Spine Surgery.

Clin Spine Surg 2021 May 28. Epub 2021 May 28.

Adventist Health Howard Memorial Hospital, Willits, CA Department of Orthopedic Surgery, University of Tennessee College of Medicine in Chattanooga, Chattanooga, TN School of Medicine and Public Health, University of Wisconsin, Madison, WI Hospital for Special Surgery Weill Cornell Medical College, New York, NY.

Design: This was a narrative review.

Purpose: Summarize artificial intelligence (AI) fundamentals as well as current and potential future uses in spine surgery.

Summary Of Background Data: Although considered futuristic, the field of AI has already had a profound impact on many industries, including health care. Its ability to recognize patterns and self-correct to improve over time mimics human cognitive function, but on a much larger scale.

Methods: Review of literature on AI fundamentals and uses in spine pathology.

Results: Machine learning (ML), a subset of AI, increases in hierarchy of complexity from classic ML to unsupervised ML to deep leaning, where Language Processing and Computer Vision are possible. AI-based tools have been developed to segment spinal structures, acquire basic spinal measurements, and even identify pathology such as tumor or degeneration. AI algorithms could have use in guiding clinical management through treatment selection, patient-specific prognostication, and even has the potential to power neuroprosthetic devices after spinal cord injury.

Conclusion: While the use of AI has pitfalls and should be adopted with caution, future use is promising in the field of spine surgery and medicine as a whole.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1097/BSD.0000000000001211DOI Listing
May 2021

Indirect Lumbar Decompression Combined With or Without Additional Direct Posterior Decompression: A Systematic Review.

Global Spine J 2021 May 20:21925682211013011. Epub 2021 May 20.

Hospital for Special Surgery, New York, NY, USA.

Study Design: Systematic review.

Objective: Indirect decompression via lateral lumbar interbody fusion (LLIF) can ameliorate central and foraminal lumbar stenosis. In severe central stenosis, additional posterior direct decompression is utilized. The aim of this review is to synthesize existing literature on these 2 techniques and identify significant differences in outcomes between isolated indirect decompression via LLIF and combined indirect decompression supplemented with direct posterior decompression.

Methods: A database search algorithm was utilized to query MEDLINE, COCHRANE, and EMBASE to identify literature reporting adult decompression study groups that involved an oblique or lateral fusion approach through September 2020. Improvement in outcomes measures and complication rates were pooled and tested for significance.

Results: A total of 110 publications were assessed with 15 studies meeting inclusion criteria, including 557 patients and 1008 levels. Mean age was 63.1 years with BMI of 27.5 kg/m. For the combined indirect and direct decompression cohort, lumbar lordosis (LL) increased 133.9%, from 22.8 to 48.7, while the indirect decompression cohort LL increased 8.9%, from 41.9 to 45.5. Difference in LL improvement between cohorts was insignificant ( > .05). Oswestry Disability Index (ODI) decreased from 36.5 to 19.4 in the combined indirect and direct decompression cohort, and from 44.4 to 23.1 in the indirect decompression cohort. ODI reduction was insignificant ( = .053).

Conclusions: Prior studies of both indirect decompression as well as combined indirect and direct decompression of lumbar spine stenosis are limited by small samples, heterogeneous populations, and lack of direct comparisons. Both procedures result in improved function and pain postoperatively with direct decompression restoring more lordosis in patients with worse preoperative alignment.
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http://dx.doi.org/10.1177/21925682211013011DOI Listing
May 2021

Inferior Articular Process Fracture in a Collegiate Athlete Causing Back Pain: A Case Report of Surgical Treatment.

JBJS Case Connect 2021 04 19;11(2). Epub 2021 Apr 19.

Hospital for Special Surgery, New York, New York.

Case: A 20-year-old male athlete presented with 8 months of low back pain. Conservative management had been unsuccessful. He noted lumbar spine pain with extension, and imaging showed features of an L4-5 inferior articular facet tip fracture. The fragment was excised, he returned to college lacrosse and is without symptoms at the 9-month follow-up.

Conclusion: In similar cases with facet fragments, we would recommend a full workup and attempt nonoperative therapy. If not improved and a diagnostic injection provides near-complete relief, then resection of the facet fragment can be discussed as a potentially effective and conservative surgical option.
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http://dx.doi.org/10.2106/JBJS.CC.20.00173DOI Listing
April 2021

The Feasibility of 3D Intraoperative Navigation in Lateral Lumbar Interbody Fusion: Perioperative Outcomes, Accuracy of Cage Placement and Radiation Exposure.

Global Spine J 2021 Apr 28:21925682211006700. Epub 2021 Apr 28.

25062Hospital for Special Surgery, New York, NY, USA.

Study Design: Retrospective cohort study.

Objectives: To evaluate perioperative outcomes, accuracy of cage placement and radiation exposure in lateral lumbar interbody fusion (LLIF) using 3D intraoperative navigation (ION), compared to conventional 2D fluoroscopy only.

Methods: The perioperative outcomes and accuracy of cage placement were examined in all patients who underwent LLIF using ION (ION group) or fluoroscopy only (non-ION group) by a single surgeon. The radiation exposure was examined in patients who underwent stand-alone LLIF.

Results: A total of 87 patients with 154 levels (ION 49 patients with 79 levels/ non-ION 38 patients with 75 levels) were included. There were no significant differences in operative time (ION 143.5 min vs. non-ION 126.0 min, = .406), time from induction end to surgery start (ION 31.0 min vs. non-ION 31.0 min, = .761), estimated blood loss (ION 37.5 ml vs. non-ION 50.0 ml, = .351), perioperative complications (ION 16.3% vs. non-ION 7.9%, = .335) and length of stay (ION 50.6 hours vs. non-ION 41.7 hours, = .841). No significant difference was found in the accuracy of cage placement ( = .279). ION did not significantly increase total radiation dose (ION 51.0 mGy vs. non-ION 47.4 mGy, = .237) and tended to reduce radiation dose during the procedure (ION 32.2 mGy vs. non-ION 47.4 mGy, = .932).

Conclusions: The perioperative outcomes, accuracy of cage placement and radiation exposure in LLIF using ION were comparable to those using fluoroscopy only. The use of ION in LLIF was feasible, safe and accurate and may reduce radiation dose to the surgeon and surgical team.
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http://dx.doi.org/10.1177/21925682211006700DOI Listing
April 2021

Response to the letter to the Editor: "The necessity and risk factors of subsequent fusion after decompression alone for lumbar spinal stenosis with lumbar spondylolisthesis: 5 years follow-up in two different large populations".

Spine J 2021 04;21(4):725

Weill Cornell Medical College, New York, NY, USA; Department of Orthopedic Surgery, Hospital for Special Surgery, 535 E. 70th St, New York, NY 10021, USA. Electronic address:

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http://dx.doi.org/10.1016/j.spinee.2021.01.005DOI Listing
April 2021

The association between spondylolisthesis and decreased muscle health throughout the lumbar spine for patients with operative lumbar spinal stenosis.

Eur Spine J 2021 Apr 24. Epub 2021 Apr 24.

Hospital for Special Surgery, 535 E. 70th St., New York, NY, 10021, USA.

Purpose: There are data underlining the relationship between muscle health and spine related pathology, but little data regarding changes in paralumbar muscle associated with lumbar spondylolisthesis. We aimed to define changes in paralumbar muscle health associated with spondylolisthesis.

Methods: A retrospective review was performed on consecutive patients with lumbar spine pathology requiring an operation. A pre-operative lumbar MRI was analysed for muscle health measurements including lumbar indentation value (LIV), paralumbar cross-sectional area divided by body mass index (PL-CSA/BMI), and Goutallier classification of fatty atrophy. All measurements were taken from an axial slice of a T2-weighted image at lumbar disc spaces. Baseline health-related quality of life scores (HRQOLs), narcotic use and areas of stenosis were tracked. We performed Chi-square analyses and student's t test to determine statistically significant differences between cohorts.

Results: There were 307 patients (average age 56.1 ± 16.7 years, 141 females) included within our analysis. 112 patients had spondylolisthesis. There were no differences in baseline HRQOLs between the spondylolisthesis cohort (SC) and non-spondylolisthesis cohort (non-SC). There were significantly worse PL-CSA/BMI at L2-L3 (p = 0.03), L3-L4 (p = 0.04) and L4-L5 (p = 0.02) for the SC. Goutallier classification of paralumbar muscle was worse for SC at L1-L2 (p = 0.04) and at L4-L5 (p < 0.001). Increased grade of spondylolisthesis was associated with worse PL-CSA at L1-L2 (p = 0.02), L2-L3 (p = 0.03) and L3-L4 (p = 0.05). Similarly, there were worse Goutallier classification scores associated with higher-grade spondylolisthesis at all levels (p < 0.05).

Conclusion: There are significant detrimental changes to paralumbar muscle health throughout the lumbar spine associated with spondylolisthesis.
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http://dx.doi.org/10.1007/s00586-021-06832-1DOI Listing
April 2021

Time-demand, Radiation Exposure and Outcomes of Minimally Invasive Spine Surgery With the Use of Skin-Anchored Intraoperative Navigation: The Effect of the Learning Curve.

Clin Spine Surg 2021 Mar 23. Epub 2021 Mar 23.

Hospital for Special Surgery Weill Cornell Medical College, New York, NY.

Study Design: Retrospective review.

Objective: The aim was to evaluate the learning curve of skin-anchored intraoperative navigation (ION) for minimally invasive lumbar surgery.

Summary Of Background Data: ION is increasingly being utilized to provide better visualization, improve accuracy, and enable less invasive procedures. The use of noninvasive skin-anchored trackers for navigation is a novel technique, with the few reports on this technique demonstrating safety, feasibility, and significant reductions in radiation exposure compared with conventional fluoroscopy. However, a commonly cited deterrent to wider adoption is the learning curve.

Methods: Retrospective review of patients undergoing 1-level minimally invasive lumbar surgery was performed. Outcomes were: (1) time for ION set-up and image-acquisition; (2) operative time; (3) fluoroscopy time; (4) radiation dose; (5) operative complications; (6) need for repeat spin; (7) incorrect localization.Chronologic case number was plotted against each outcome. Derivative of the nonlinear curve fit to the dataset for each outcome was solved to find plateau in learning.

Results: A total of 270 patients [114 microdiscectomy; 79 laminectomy; 77 minimally invasive transforaminal lumbar interbody fusion (MI-TLIF)] were included. (1) ION set-up and image-acquisition: no learning curve for microdiscectomy. Proficiency at 23 and 31 cases for laminectomy and MI-TLIF, respectively. (2) Operative time: no learning curve for microdiscectomy. Proficiency at 36 and 31 cases for laminectomy and MI-TLIF, respectively. (3) Fluoroscopy time: no learning curve. (4) Radiation dose: proficiency at 42 and 33 cases for microdiscectomy and laminectomy, respectively. No learning curve for MI-TLIF. (5) Operative complications: unable to evaluate for microdiscectomy and MI-TLIF. Proficiency at 29 cases for laminectomy. (6) Repeat spin: unable to evaluate for microdiscectomy and laminectomy. For MI-TLIF, chronology was not associated with repeat spins. (7) Incorrect localization: none.

Conclusions: Skin-anchored ION did not result in any wrong level surgeries. Learning curve for other parameters varied by surgery type, but was achieved at 25-35 cases for a majority of outcomes.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1097/BSD.0000000000001167DOI Listing
March 2021

Multimodality Intraoperative Neuromonitoring in Lateral Lumbar Interbody Fusion: A Review of Alerts in 628 Patients.

Global Spine J 2021 Mar 18:21925682211000321. Epub 2021 Mar 18.

25062Hospital for Special Surgery, New York, NY, USA.

Study Design: Retrospective review of private neuromonitoring databases.

Objectives: To review neuromonitoring alerts in a large series of patients undergoing lateral lumbar interbody fusion (LLIF) and determine whether alerts occurred more frequently when more lumbar levels were accessed or more frequently at particular lumbar levels.

Methods: Intraoperative neuromonitoring (IONM) databases were reviewed and patients were identified undergoing LLIF between L1 and L5. All cases in which at least one IONM modality was used (motor evoked potentials (MEP), somatosensory evoked potentials (SSEP), evoked electromyography (EMG)) were included in this study. The type of IONM used and incidence of alerts were collected from each IONM report and analyzed. The incidence of alerts for each IONM modality based on number of levels at which at LLIF was performed and the specific level an LLIF was performed were compared.

Results: A total of 628 patients undergoing LLIF across 934 levels were reviewed. EMG was used in 611 (97%) cases, SSEP in 561 (89%), MEP in 144 (23%). The frequency of IONM alerts for EMG, SSEP and MEPs did not significantly increase as the number of LLIF levels accessed increased. No EMG, SSEP, or MEP alerts occurred at L1-L2. EMG alerts occurred in 2-5% of patients at L2-L3, L3-L4, and L4-L5 and did not significantly vary by level ( = .34). SSEP and MEP alerts occurred more frequently at L4-L5 versus L2-L3 and L3-L4 ( < .03).

Conclusions: IONM may provide the greatest utility at L4-L5, particularly MEPs, and may not be necessary for more cephalad LLIF procedures such as at L1-L2.
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http://dx.doi.org/10.1177/21925682211000321DOI Listing
March 2021

Technique, Time Demand, Radiation Exposure, and Outcomes of Skin-anchored Intraoperative 3D Navigation in Minimally Invasive Posterior Cervical Laminoforaminotomy.

Clin Spine Surg 2021 Feb 25. Epub 2021 Feb 25.

Hospital for Special Surgery Weill Cornell Medical College, New York, NY.

Study Design: This was a retrospective review.

Objective: The objective of this study was to describe our technique and evaluate the time demand, radiation exposure, and outcomes of minimally invasive posterior cervical laminoforaminotomy (MI-PCLF) using skin-anchored intraoperative navigation (ION).

Background: Although bone-anchored trackers are most commonly used for ION, a novel technique utilizing noninvasive skin-anchored trackers has recently been described for lumbar surgery and has shown favorable results. There are currently no reports on the use of this technology for cervical surgery.

Methods: Time demand, radiation exposure, and perioperative outcomes of MI-PCLF using skin-anchored ION were evaluated.

Results: Twenty-one patients with 36 operative levels were included. Time for ION setup and operative time were a median of 34 and 62 minutes, respectively. Median radiation to the patient was 2.5 mGy from 10 seconds of fluoroscopy time. Radiation exposure to operating room personnel was negligible because they are behind a protective lead shield during ION image acquisition. There were no intraoperative complications or wrong-level surgeries. One patient required a repeat ION spin, and in 2 patients, ION was abandoned and standard fluoroscopy was used.

Conclusions: Skin-anchored ION for MI-PCLF is feasible, safe, and accurate. It results in short operative times, minimal complications, low radiation to the patient, and negligible radiation to operating room personnel.
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http://dx.doi.org/10.1097/BSD.0000000000001143DOI Listing
February 2021

Early Catastrophic Failure of Cervical Disc Arthroplasty: A Case Report.

JBJS Case Connect 2021 Feb 11;11(1):e20.00185. Epub 2021 Feb 11.

Department of Orthopaedic Surgery Hospital for Special Surgery, New York, New York.

Case: A 47-year-old healthy man underwent cervical disc arthroplasty (CDA) for a C6 radiculopathy. Two-week radiographs showed a well-positioned implant. At the 6-week postoperative visit, the inferior portion of the implant had displaced ventrally, with C6 anterior vertebral body collapse. The next day, the implant was removed and converted to a C5/6 anterior cervical discectomy and fusion. Bone biopsy was unremarkable.

Conclusions: This is the first reported case of early catastrophic failure of a well-positioned CDA in a healthy patient with good bone quality. Possible contributing mechanisms include hypermobility and anterior bone loss, factors previously associated with CDA.
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http://dx.doi.org/10.2106/JBJS.CC.20.00185DOI Listing
February 2021

Minimally Invasive Scoliosis Surgery Is a Feasible Option for Management of Idiopathic Scoliosis and Has Equivalent Outcomes to Open Surgery: A Meta-Analysis.

Global Spine J 2021 Feb 9:2192568220988267. Epub 2021 Feb 9.

Hospital for Special Surgery, New York, NY, USA.

Study Design: Meta-analysis.

Objective: To compare outcomes between minimally invasive scoliosis surgery (MISS) and traditional posterior instrumentation and fusion in the correction of adolescent idiopathic scoliosis (AIS).

Methods: A literature search was performed using MEDLINE, PubMed, EMBASE, Google scholar and Cochrane databases, including studies reporting outcomes for both MISS and open correction of AIS. Study details, demographics, and outcomes, including curve correction, estimated blood loss (EBL), operative time, postoperative pain, length of stay (LOS), and complications, were collected and analyzed.

Results: A total of 4 studies met the selection criteria and were included in the analysis, totaling 107 patients (42 MIS and 65 open) with a mean age of 16 years. Overall there was no difference in curve correction between MISS (73.2%) and open (76.7%) cohorts. EBL was significantly lower in the MISS (271 ml) compared to the open (527 ml) group, but operative time was significantly longer (380 min for MISS versus 302 min for open). There were no significant differences between the approaches in pain, LOS, complications, or reoperations.

Conclusion: MISS was associated with less blood loss but longer operative times compared to traditional open fusion for AIS. There was no difference in curve correction, postoperative pain, LOS, or complications/reoperations. While MISS has emerged as a feasible option for the surgical management of AIS, further research is warranted to compare these 2 approaches.
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http://dx.doi.org/10.1177/2192568220988267DOI Listing
February 2021

Narrative review of intraoperative image guidance for transforaminal lumbar interbody fusion.

Ann Transl Med 2021 Jan;9(1):89

Hospital for Special Surgery Department of Orthopedic Surgery, New York, NY, USA.

Recent advancements in imaging technology have changed the landscape of transforaminal lumbar interbody fusion (TLIF) with the objective of improving safety and efficacy for the patient and surgical team. Spine surgery, and specifically TLIFs, involve challenging anatomy and command precise surgical accuracy, creating an essential role for intraoperative imaging, navigation, and robotics. Traditionally, surgeons have relied upon fluoroscopy for pedicle screw and interbody placement. More recently, intraoperative 3-dimensional navigation (ION) has risen in popularity in TLIF surgery. This technology utilizes intra-operative advanced imaging, such as computed tomography (CT) and 3D-fluroscopy, to accurately track instruments and implants in relation to the patient's anatomy. ION has demonstrated improved accuracy of pedicle screw placement, decreased operating room times, and lower radiation exposure to the surgeon and staff. However, conventional fluoroscopy, 3D fluoroscopy, intraoperative CT, image-guided navigation, and robot-assisted surgery all have a role in TLIF surgery. Numerous studies have been published regarding the benefits and pitfalls of these intraoperative tools in spine surgery, but there is a relative lack of research regarding some of the newer technologies surrounding TLIF. As future studies are published, and technology continues to evolve, surgeons must stay abreast of novel techniques to maximize patient safety and outcomes. Over the coming decade, we can expect intraoperative navigation and robotics to play a more significant role in spine surgery.
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http://dx.doi.org/10.21037/atm-20-1971DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859762PMC
January 2021

Association of Duration of Preoperative Opioid Use with Reoperation After One-level Anterior Cervical Discectomy and Fusion in Nonmyelopathic Patients.

Spine (Phila Pa 1976) 2021 Jul;46(13):E719-E725

Hospital for Special Surgery, New York, NY.

Study Design: Retrospective cohort study.

Objective: The aim of this study was to determine that rates of preoperative opioid use in patients undergoing single-level anterior discectomy and fusion (ACDF) without myelopathy and determine the association with reoperations over 5 years.

Summary Of Background Data: Preoperative opioid use before cervical spine surgery has been linked to worse postoperative outcomes. However, no studies have determined the association of duration and type of opioid used with reoperations after ACDF.

Methods: Patients undergoing single-level ACDF without myelopathy between 2007 and 2016 with at least 5-year follow-up were identified in one private insurance administrative database. Preoperative opiate use was divided into acute (within 3 months), subacute (acute use and use between 3 and 6 months), and chronic (subacute use and use before 6 months) and by the opiate medication prescribed (tramadol, oxycodone, and hydrocodone). Postoperative rates of additional cervical spine surgery were determined at 5 years and multivariate logistic regression was used to determine the association of preoperative opiates with additional surgery.

Results: Of 445 patients undergoing single-level ACDF without myelopathy, 66.3% were taking opioid medications before surgery. The most commonly used preoperative opioid was hydrocodone (50.3% acute use, 24.7% chronic use). Opioid-naïve patients had a 5-year reoperation rate of 4.7%, compared to 25.0%, 15.5%, and 23.3% with chronic preoperative use of tramadol, hydrocodone, and oxycodone. In multivariate analysis, controlling for age, sex, and Charlson Comorbidity Index, chronic use of hydrocodone (odds ratio [OR] = 2.08, P = 0.05), oxycodone (OR = 4.46, P < 0.01), and tramadol (OR = 4.01, P = 0.01) were all associated with increased reoperations. However, acute use of hydrocodone, oxycodone, and tramadol was not associated with reoperations (P > 0.05).

Conclusion: Both subacute and chronic use of common lower-dose opioid medications is associated with increased reoperations after single-level ACDF in nonmyelopathic patients. This information is critical when counseling patients preoperatively and developing preoperative opioid cessation programs.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003861DOI Listing
July 2021

Use of Higher-strength Opioids has a Dose-Dependent Association With Reoperations After Lumbar Decompression and Interbody Fusion Surgery.

Spine (Phila Pa 1976) 2021 Feb;46(3):E203-E212

Hospital for Special Surgery.

Study Design: A retrospective cohort study.

Objective: The aim of this study was to identify an association between preoperative opioid use and reoperations rates.

Summary Of Background Data: Chronic opioid use is a public health crisis in the United States and has been linked to worse outcomes after lumbar spine surgery. However, no studies have identified an association between preoperative opioid use and reoperations rates.

Methods: A retrospective cohort study was conducted using patients from one private insurance database who underwent primary lumbar decompression/discectomy (LDD) or posterior/transforaminal lumbar interbody fusion (PLIF/TLIF). Preoperative use of five specific opioid medications (tramadol, hydromorphone, oxycodone, hydromorphone, and extended-release oxycodone) was categorized as acute (within 3 months), subacute (acute use and use between 3 and 6 months), or chronic (subacute use and use before 6 months). Multivariate regression, controlling for multilevel surgery, age, sex, and Charlson Comorbidity Index, was used to determine the association of each medication on reoperations within 5 years.

Results: A total of 11,551 patients undergoing LDD and 3291 patients undergoing PLIF/TLIF without previous lumbar spine surgery were identified. In the LDD group, opioid-naïve patients had a 5-year reoperation rate of 2.8%, compared with 25.0% and 8.0 with chronic preoperative use of hydromorphone and oxycodone, respectively. In multivariate analysis, any preoperative use of oxycodone was associated with increased reoperations (odds ratios [OR] = 1.4, 2.0, and 2.3, for acute, subacute, and chronic use; P < 0.01). Chronic use of hydromorphone was also associated with increased reoperations (OR = 7.5, P < 0.01).In the PLIF/TLIF group, opioid-naïve patients had a 5-year reoperation rate of 11.3%, compared with 66.7% and 16.8% with chronic preoperative use of hydromorphone and oxycodone, respectively. In multivariate analysis, any preoperative use of hydromorphone was associated with increased reoperations (OR = 2.9, 4.0, and 14.0, for acute, subacute, and chronic use; P < 0.05).

Conclusion: Preoperative use of the higher-potency opioid medications is associated with increased reoperations after LDD and PLIF/TLIF in a dose-dependent manner. Surgeons should use this data for preoperative opioid cessation counseling and individualized risk stratification.Level of Evidence: 3.
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http://dx.doi.org/10.1097/BRS.0000000000003751DOI Listing
February 2021

Radiographic Evaluation of Cervical Disk Replacement: The Impact of Preoperative Arthrosis and Implant Positioning on Patient-report Outcomes.

Clin Spine Surg 2020 11;33(9):370-377

Hospital for Special Surgery, New York, NY.

Study Design: This was a retrospective review.

Objective: Provide a validated method of radiographic evaluation of cervical disk replacement (CDR) patients linked to outcomes.

Summary Of Background Data: Preoperative radiographic criteria for CDRs and the impact of intraoperative positioning remain without formalized guidelines. The association between preexisting degenerative changes, optimal implant positioning, and patient-reported outcome measures (PROMs) are not well understood. Our study establishes a systematic radiographic evaluation of preoperative spondylosis, implant placement, and associated clinical outcomes.

Methods: Preoperative radiographs for CDR patients were evaluated for disk height, facet arthrosis, and uncovertebral joint degeneration. Postoperative radiographs were scored based on the position of the CDR implant on anterior-posterior (AP) and lateral radiographs. PROMs including Visual Analogue Scale (VAS) arm pain, VAS neck pain, Neck Disability Index (NDI), Short Form 12 physical health (SF12-PCS) and mental health (SF12-M) were collected preoperatively, at early follow, and at late follow-up.

Results: A total of 115 patients were included. Preoperative disk height had the highest reliability, intraclass correlation coefficient of 0.798). Facet arthrosis had the lowest intraclass correlation coefficient at 0.563. Preoperative disk height scores showed a significant correlation with AP radiographs and implant positioning score. Patients with more advanced uncovertebral degenerative changes showed less improvement 6 months postoperatively, based on SF-12 PCS scores (R=0.446, P=0.025). Postoperative implant position on lateral radiograph showed a significant correlation with SF-12 MCS scores at follow-up beyond 6 months (R=0.385, P=0.011). Overall postoperative implant position scores demonstrated significant correlation with SF-12 PCS (R=0.350, P=0.046) scores.

Conclusion: This study provides a systematic method of evaluation of preoperative and intraoperative radiographs that can optimize outcomes. On the basis of our study, spine surgeons performing cervical disk replacement surgery should consider: (a) the presence of preexisting uncovertebral joint degeneration can negatively impact outcomes, (b) achieving optimal implant positioning can be increasingly difficult with more severe loss of disk height, and (c) overall implant position as judged on AP and lateral fluoroscopy can impact outcomes.
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http://dx.doi.org/10.1097/BSD.0000000000001091DOI Listing
November 2020

Impact of Nonlordotic Sagittal Alignment on Short-term Outcomes of Cervical Disc Replacement.

Neurospine 2020 Sep 30;17(3):588-602. Epub 2020 Sep 30.

Weill Cornell Medical College, New York, NY, USA.

Objective: To evaluate outcomes of cervical disc replacement (CDR) in patients with nonlordotic alignment.

Methods: Patients who underwent CDR were retrospectively reviewed and divided into 3 cohorts: (1) neutral/lordotic segmental and C2-7 Cobb angle (L), (2) nonlordotic segmental Cobb angle, lordotic C2-7 Cobb angle (NL-S), and (3) nonlordotic segmental and C2-7 Cobb angle (NL-SC). Radiographic and patient-reported outcomes (PROMs) were compared.

Results: One-hundred five patients were included (L: 37, NL-S: 30, NL-SC: 38). A significant gain in segmental lordosis was seen in all cohorts at < 6 months (L: -1.90° [p = 0.007]; NL-S: -5.16° [p < 0.0001]; NL-SC: -6.00° [p < 0.0001]) and ≥ 6 months (L: -2.07° [p = 0.031; NL-S: -6.04° [p < 0.0001]; NL-SC: -6.74° [p < 0.0001]), with greater lordosis generated in preoperatively nonlordotic cohorts (p < 0.0001). C2-7 lordosis improved in the preoperatively nonlordotic cohort (NL-SC: 8.04°) at follow-up of < 6 months (-4.15°, p = 0.003) and ≥ 6 months (-6.40°, p = 0.003), but not enough to create lordotic alignment (< 6 months: 3.89°; ≥ 6 months: 4.06°). All cohorts showed improvement in Neck Disability Index, visual analogue scale (VAS) neck, and VAS arm, without significant difference among groups in the amount of improvement ( ≥ 6-month PROMs follow-up = 69%).

Conclusion: In patients without major kyphotic deformity, CDR has the potential to generate and maintain lordosis and improve PROMs in the short-term, and can be an effective treatment option for patients with nonlordotic alignment.
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http://dx.doi.org/10.14245/ns.2040398.199DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7538348PMC
September 2020

Early Peri-operative Outcomes Were Unchanged in Patients Undergoing Spine Surgery During the COVID-19 Pandemic in New York City.

HSS J 2020 Sep 15:1-8. Epub 2020 Sep 15.

Department of Orthopaedic Surgery, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA.

Background: Healthcare resources have been greatly limited by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic halting non-essential surgical cases without clear service expansion protocols.

Questions/purposes: We sought to compare the peri-operative outcomes of patients undergoing spine surgery during the SARS-CoV-2 pandemic to a matched cohort prior to the pandemic.

Methods: We identified a consecutive sample of 127 adult patients undergoing spine surgery between March 9, 2020, and April 10, 2020, corresponding with the state of emergency declared in New York and the latest possible time for 1-month surgical follow-up. The study group was matched one-to-one based on age, gender, and body mass index with eligible control patients who underwent similar spine procedures prior to the SARS-CoV-2 outbreak. Surgeries performed for infectious or oncologic indications were excluded. Intra- and post-operative complication rates, re-operations, hospital length of stay, re-admissions, post-operative visit format, development of post-operative fever and/or respiratory symptoms, and SAR-CoV2 testing.

Results: A total of 254 patients (127 SARS-CoV-2 pandemic, 127 matched controls) were included. One hundred fifty-eight were male (62%), and 96 were female (38%). The mean age in the pandemic group was 59.8 ± 13.4 years; that of the matched controls was 60.3 ± 12.3. All patients underwent general anesthesia and did not require re-intubation. There were no significant differences in 1-month post-operative complication rates (16.5% pandemic vs. 12.6% control). There was one death in the pandemic group. No patients tested positive for the virus.

Conclusion: This study represents the first report of post-operative outcomes in a large group of spine surgical patients in an area heavily affected by the SARS-CoV-2 pandemic.
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http://dx.doi.org/10.1007/s11420-020-09797-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491022PMC
September 2020

Does interbody cage lordosis impact actual segmental lordosis achieved in minimally invasive lumbar spine fusion?

Neurosurg Focus 2020 09;49(3):E17

1Hospital for Special Surgery, New York, New York.

Objective: In an effort to prevent loss of segmental lordosis (SL) with minimally invasive interbody fusions, manufacturers have increased the amount of lordosis that is built into interbody cages. However, the relationship between cage lordotic angle and actual SL achieved intraoperatively remains unclear. The purpose of this study was to determine if the lordotic angle manufactured into an interbody cage impacts the change in SL during minimally invasive surgery (MIS) for lumbar interbody fusion (LIF) done for degenerative pathology.

Methods: The authors performed a retrospective review of a single-surgeon database of adult patients who underwent primary LIF between April 2017 and December 2018. Procedures were performed for 1-2-level lumbar degenerative disease using contemporary MIS techniques, including transforaminal LIF (TLIF), lateral LIF (LLIF), and anterior LIF (ALIF). Surgical levels were classified on lateral radiographs based on the cage lordotic angle (6°-8°, 10°-12°, and 15°-20°) and the position of the cage in the disc space (anterior vs posterior). Change in SL was the primary outcome of interest. Subgroup analyses of the cage lordotic angle within each surgical approach were also conducted.

Results: A total of 116 surgical levels in 98 patients were included. Surgical approaches included TLIF (56.1%), LLIF (32.7%), and ALIF (11.2%). There were no differences in SL gained by cage lordotic angle (2.7° SL gain with 6°-8° cages, 1.6° with 10°-12° cages, and 3.4° with 15°-20° cages, p = 0.581). Subgroup analysis of LLIF showed increased SL with 15° cages only (p = 0.002). The change in SL was highest after ALIF (average increase 9.8° in SL vs 1.8° in TLIF vs 1.8° in LLIF, p < 0.001). Anterior position of the cage in the disc space was also associated with a significantly greater gain in SL (4.2° vs -0.3°, p = 0.001), and was the only factor independently correlated with SL gain (p = 0.016).

Conclusions: Compared with cage lordotic angle, cage position and approach play larger roles in the generation of SL in 1-2-level MIS for lumbar degenerative disease.
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http://dx.doi.org/10.3171/2020.6.FOCUS20393DOI Listing
September 2020

Psychometric Evaluation of Patient-reported Outcomes Measurement Information System Physical Function Computer Adaptive Testing in Minimally Invasive Lumbar Spine Surgery: An Analysis of Responsiveness, Coverage, Discriminant Validity, and Concurrent Validity.

J Am Acad Orthop Surg 2020 Sep;28(17):717-729

From the Department of Orthopaedic Surgery, Hospital for Special Surgery (Dr. Vaishnav, Dr. McAnany, Dr. Iyer, Dr. Albert, Ms. Gang, and Dr. Qureshi), and Weill Cornell Medical College (Dr. McAnany, Dr. Iyer, Dr. Albert, and Dr. Qureshi), New York, NY.

Introduction: Although the Patient-reported Outcomes Measurement Information System (PROMIS) is increasingly being used, there are few studies assessing the psychometric properties of PROMIS in minimally invasive spine (MIS) surgery. Thus, the purpose of this study was to perform a psychometric evaluation of PROMIS Physical Function Computer Adaptive Testing (PROMIS-PF CAT) in MIS lumbar surgery.

Methods: The patient-reported outcome measures collected preoperatively and postoperatively of patients undergoing MIS lumbar surgery were retrospectively analyzed to assess responsiveness, coverage, discriminant validity, and concurrent validity of PROMIS-PF CAT.

Results: Four hundred twenty-one patients were included. The responsiveness of PROMIS Physical Function (PROMIS-PF) was lower than that of the Oswestry Disability Index (ODI) in the decompression subgroup. Although the ODI had a ceiling effect of 16.7% at 1 year, the Short-Form 12 physical health score and PROMIS-PF did not show floor or ceiling effects. PROMIS-PF demonstrated discriminant validity preoperatively and postoperatively and convergent validity with the ODI, as evidenced by a significant strong negative correlation but not with the Short-Form 12 Physical Health Score, as evidenced by the variability in strength of correlation.

Conclusions: Although the PROMIS-PF showed lower responsiveness than the ODI, particularly in the decompression subgroup, it demonstrated discriminant validity preoperatively and postoperatively, convergent validity with ODI, and better coverage than ODI. These findings suggest that the PROMIS-PF CAT demonstrates reasonable psychometric properties and may be a good surrogate for the ODI.
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http://dx.doi.org/10.5435/JAAOS-D-19-00306DOI Listing
September 2020

How do high preoperative pain scores impact the clinical course and outcomes for patients undergoing lumbar microdiscectomy?

J Neurosurg Spine 2020 Aug 7:1-7. Epub 2020 Aug 7.

1Department of Orthopaedic Surgery, Hospital for Special Surgery, New York; and.

Objective: Preoperative pain assessment is often used to gauge the amount of disability in patients with lumbar disc herniation. How high preoperative pain scores impact the clinical course and outcomes of patients after lumbar microdiscectomy is not always clear. Here, the authors aimed to determine whether patients reporting higher preoperative pain scores have worse outcomes after lumbar microdiscectomy than those reporting lower preoperative scores.

Methods: The authors performed a retrospective review of patients with symptomatic lumbar disc herniations that had failed to improve with nonsurgical methods and who had undergone tubular lumbar microdiscectomy. Health-related quality of life (HRQOL) scores had been collected in the preoperative and postoperative period. The anatomical severity of disease was graded based on lumbar disc health (Pfirrmann classification), facet degeneration, thecal sac cross-sectional area, and disc herniation grade. Data on each patient's narcotic consumption and length of stay were collected. A Student t-test and chi-square test were used to compare patients with high preoperative pain scores (HP cohort) and those with lower preoperative scores (non-HP cohort).

Results: One hundred thirty-eight patients were included in this analysis. The 47 patients in the HP cohort had taken more preoperative opioids (12.0 ± 21.2 vs 3.6 ± 11.1 morphine equivalent doses, p = 0.01). However, there was no statistically significant difference in Pfirrmann classification (p > 0.15), facet grade (p > 0.11), thecal sac cross-sectional area (p = 0.45), or disc herniation grade (p = 0.39) between the HP and non-HP cohorts. The latter cohort had statistically significant higher preoperative PROMIS scores (36.5 ± 7.0 vs 29.9 ± 6.4, p < 0.001), SF-12 mental component summary scores (48.7 ± 11.5 vs 38.9 ± 16.1, p < 0.001), and SF-12 physical component summary scores (PCS; 32.4 ± 8.6 vs 27.5 ± 10.0, p = 0.005), but a lower Oswestry Disability Index (56.4 ± 22.1 vs 35.4 ± 15.5, p < 0.001). There were only two time points after microdiscectomy when the HP cohort had worse HRQOL scores: at the 2-week follow-up for SF-12 PCS scores (32.4 ± 8.6 vs 29.3 ± 7.1, p = 0.03) and the 12-week follow-up for PROMIS scores (45.2 ± 9.5 vs 39.5 ± 7.1, p = 0.01). All other postoperative HRQOL measurements were similar between the two cohorts (p > 0.05).

Conclusions: A patient's perceived severity of disease often does not correlate with the actual clinical pathology on imaging. Although patients who report high pain and have a symptomatic lumbar disc herniation may describe their pain as more extreme, they should be counseled that the outcomes of microdiscectomy are positive.
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http://dx.doi.org/10.3171/2020.5.SPINE20373DOI Listing
August 2020

Response to letter to the Editor: "Is the likelihood of dysphagia different in patients undergoing one-level versus two-level anterior cervical discectomy and fusion?"

Spine J 2020 08;20(8):1357

Weill Cornell Medical College, New York, NY, USA; Hospital for Special Surgery, New York, NY, USA. Electronic address:

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http://dx.doi.org/10.1016/j.spinee.2020.04.002DOI Listing
August 2020

Early Failures After Lumbar Discectomy Surgery: An Analysis of 62 690 Patients.

Global Spine J 2020 Jul 17:2192568220935404. Epub 2020 Jul 17.

Hospital for Special Surgery, New York, NY, USA.

Study Design: Retrospective cohort study.

Objective: To determine the rate of early failures (readmission or reoperation for new or recurrent pain/neurological symptoms) within 30 days after lumbar discectomy and identify associated risk factors.

Methods: A retrospective cohort study was conducted of patients undergoing lumbar discectomy in the National Surgical Quality Improvement Program database between 2013 and 2017. Rates of readmission for new or recurrent symptoms or reoperation for revision discectomy or fusion within 30 days postoperatively were measured and correlated with risk factors.

Results: In total 62 690 patients were identified; overall rate of readmission within 30 days was 3.3%, including 1.2% for pain or neurological symptoms. Populations at increased risk of readmission were those with 3 or more levels of treatment (2.0%, odds ratio [OR] 2.8%, < .01), age >70 years (1.8%, OR 1.6, < .01), class 3 obesity (1.5%, OR 1.4, = .04), and female gender (1.4%, OR 1.2, = .02). The overall rate of reoperation within 30 days was 2.2%, including 1.2% for revision decompression or lumbar fusion surgery. Populations at increased risk of reoperation were revision discectomies (1.4%, OR 1.7, < .01) and females (1.1%, OR 1.4, < 0.01). Extraforaminal discectomies were associated with lower rates of readmission (0.7%, OR 0.6, = 0.02) and reoperation (0.4%, OR 0.4, = .01).

Conclusions: Early failures after lumbar discectomy surgery are rare. However, certain subpopulations are associated with increased rates of early failure: obesity, multilevel surgery, females, and revision discectomies.
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http://dx.doi.org/10.1177/2192568220935404DOI Listing
July 2020

Fusion rate for stand-alone lateral lumbar interbody fusion: a systematic review.

Spine J 2020 11 11;20(11):1816-1825. Epub 2020 Jun 11.

Hospital for Special Surgery, 535 East 70th St, New York, NY 10021, USA. Electronic address:

Background: Lateral lumbar interbody fusion (LLIF) is used to treat multiple conditions, including spondylolisthesis, degenerative disc disorders, adjacent segment disease, and degenerative scoliosis. Although many advocate for posterior fixation with LLIF, stand-alone LLIF is increasingly being performed. Yet the fusion rate for stand-alone LLIF is unknown.

Purpose: Determine the fusion rate for stand-alone LLIF.

Study Design: Systematic review.

Methods: We queried Cochrane, EMBASE, and MEDLINE for literature on stand-alone LLIF fusion rate with a publication cutoff of April 2020. LLIF surgery was considered stand-alone when not paired with supplemental posterior fixation. Cohort fusion rate differences were calculated and tested for significance (p<0.05). All reported means were pooled.

Results: A total of 2,735 publications were assessed. Twenty-two studies met inclusion criteria, including 736 patients and 1,103 vertebral levels. Mean age was 61.7 years with BMI 26.5 kg/m. Mean fusion rate was 85.6% (range, 53.0%-100.0%), which did not differ significantly by number of levels fused (1-level, 2-level, and ≥3-level). Use of rhBMP-2 was reported in 39.3% of subjects, with no difference in fusion rates between studies using rhBMP-2 (87.7%) and those in which rhBMP-2 was not used (83.9%, odds ratio=1.37, p=0.448). Fusion rate did not differ with the addition of a lateral plate, or by underlying diagnosis. All-complication rate was 42.2% and mean reoperation rate was 11.1%, with 2.3% reoperation due to pseudarthrosis. Of the studies comparing stand-alone to circumferential fusion, pooled fusion rate was found to be 80.4% versus 91.0% (p=0.637).

Conclusions: Stand-alone LLIF yields high fusion rates overall. The wide range of reported fusion rates and lower fusion rates in studies involving subsequent surgical reoperation highlights the importance of proper training in this technique and employing a rigorous algorithm when indicating patients for stand-alone LLIF. Future research should focus on examining risk factors and patient-reported outcomes in stand-alone LLIF.
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http://dx.doi.org/10.1016/j.spinee.2020.06.006DOI Listing
November 2020

Minimally Invasive Spine Lumbar Surgery in Obese Patients: A Systematic Review and Meta-Analysis.

HSS J 2020 Jul 18;16(2):168-176. Epub 2020 Jan 18.

Hospital for Special Surgery, 535 E. 70th St., New York, NY USA.

Background: Transforaminal lumbar interbody fusion (TLIF) is the treatment of choice for lumbar spinal stenosis and spondylolisthesis. The procedure can be performed through a traditional open approach (O-TLIF) or through minimally invasive techniques (MI-TLIF). Spinal surgeries in obese patients can pose risks, including increased rates of infection and thromboembolic events.

Questions/purposes: We sought to systematically review the literature on the differences between MI-TLIF and O-TLIF in the obese patient in terms of complication rate, functional outcomes, blood loss, and length of hospital stay.

Methods: We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to systematically search PubMed, Embase, Web of Science, and the Cochrane Library for studies published through February 2019 and identified those comparing the outcomes of O-TLIF and MI-TLIF in obese patients. The primary outcome was complication rate (total, infections, dural tears); secondary outcomes were blood loss, length of hospital stay, and functional scores. Two authors independently reviewed the studies using the Newcastle-Ottawa Scale, and data were pooled using the Mantel-Haenszel random-effects model.

Results: In the sample of 430 patients, the average age was 53.5 years, there were 153 men and 203 women, and the average body mass index was 33.6. Complications were significantly higher in O-TLIF than in MI-TLIF (OR = 0.420 [95% CI: 0.199, 0.887];  = 45.20%). No difference was detected between the two groups for visual analog scale back pain scores and Oswestry Disability Index scores between the pre-operative and last follow-up visits (SMD = -0.034 [95% CI -0.695, 0.627];  = 62.14% and SMD = 0.617 [95% CI: -1.082, 2.316];  = 25%, respectively). Blood loss was significantly lower in MI-TLIF compared to O-TLIF (SMD = -426.736 [95% CI: -490.720, -362.752];  = 70.53%), as was the duration of hospital stay (SMD = -1.079 [95% CI: -1.591, -0.208];  = 84.3%).

Conclusion: MI-TLIF has equivalent efficacy to O-TLIF in obese patients at long-term follow-up. In addition, complication rate, blood loss, and length of hospital stay were lower in MI-TLIF than in O-TLIF.
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http://dx.doi.org/10.1007/s11420-019-09735-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7253546PMC
July 2020
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