Study Design:Retrospective cohort.Objective:This study aims to evaluate the relationship between the cervical levels fused and the degree of subsidence following anterior cervical discectomy and fusion (ACDF) procedures.Background:Subsidence following ACDF may worsen clinical outcomes. Previous studies have linked lower cervical levels with higher rates of subsidence, but none have quantified the relative degree of subsidence between levels.Materials and Methods:Patients who underwent ACDF from 2016 to 2021 at a tertiary medical center were included in this study. Lateral cervical radiographs from the immediate postoperative period and the final follow-ups were used to calculate subsidence. Analysis of variance was used to examine the association between cervical levels fused and subsidence. Multivariable linear regression analysis controlled for age, sex, smoking status, osteopenia/osteoporosis, number of fused levels, cage-to-body ratio, and cage type while examining the relationship between the cervical level fused and subsidence.Results:This study includes 122 patients who underwent 227 levels fused. There were 16 (7.0%) C3-C4 fusions, 55 (24.2%) C4-C5 fusions, 97 (42.7%) C5-C6 fusions, and 59 (26.0%) C6-C7 fusions. There was a significant difference in the degree of anterior subsidence between cervical levels fused (P = 0.013) with a mean subsidence of 1.0 mm (SD: 1.6) for C3-C4, 1.1 mm (SD: 1.4) for C4-C5, 1.8 mm (SD: 1.5) for C5-C6, and 1.8 mm (SD: 1.6) for C6-C7 fusions. Relative to C6-C7 fusions, C4-C5 (P = 0.016), and C3-C4 (P = 0.014) fusions were associated with decreased anterior subsidence, whereas C5-C6 (P = 0.756) fusions were found to have similar degrees of anterior subsidence in the multivariable analysis.Conclusion:We found upper cervical levels experienced a smaller degree of anterior subsidence than lower levels, after controlling for demographic and implant characteristics. Surgeons can consider using larger cages at lower cervical levels to minimize these risks.

CASE:We report a case of adolescent-onset idiopathic scoliosis of the lumbar spine in a 43-year-old woman treated with nonfusion vertebral body tethering (VBT), a controversial and unreported technique in this age group. At 6-year follow-up, clinical and radiographic improvements are maintained. She continues to live an active lifestyle and reports being pain free. CONCLUSION:We demonstrate intermediate term safety and efficacy of VBT in a single adult patient. Careful ongoing assessment of this patient is needed to determine if this procedure will have a durable outcome and lend support for adequately powered prospective multicenter studies.

STUDY DESIGN:An experimental study. PURPOSE:To explore the concordance of ChatGPT responses with established national guidelines for the management of cervical spine and spinal cord injuries. OVERVIEW OF LITERATURE:ChatGPT-4.0 is an artificial intelligence model that can synthesize large volumes of data and may provide surgeons with recommendations for the management of spinal cord injuries. However, no available literature has quantified ChatGPT's capacity to provide accurate recommendations for the management of cervical spine and spinal cord injuries. METHODS:Referencing the "Management of acute cervical spine and spinal cord injuries" guidelines published by the Congress of Neurological Surgeons (CNS), a total of 36 questions were formulated. Questions were stratified into therapeutic, diagnostic, or clinical assessment categories as seen in the guidelines. Questions were secondarily grouped according to whether the corresponding recommendation contained level I evidence (highest quality) versus only level II/III evidence (moderate and low quality). ChatGPT-4.0 was prompted with each question, and its responses were assessed by two independent reviewers as "concordant" or "nonconcordant" with the CNS clinical guidelines. "Nonconcordant" responses were rationalized into "insufficient" and "contradictory" categories. RESULTS:In this study, 22/36 (61.1%) of ChatGPT's responses were concordant with the CNS guidelines. ChatGPT's responses aligned with 17/24 (70.8%) therapeutic questions and 4/7 (57.1%) diagnostic questions. ChatGPT's response aligned with only one of the five clinical assessment questions. Notably, the recommendations supported by level I evidence were the least likely to be replicated by ChatGPT. ChatGPT's responses agreed with 80.8% of the recommendations supported exclusively by level II/III evidence. CONCLUSIONS:ChatGPT-4 was moderately accurate when generating recommendations that aligned with the clinical guidelines. The model frequently aligned with low evidence and therapeutic recommendations but exhibited inferior performance on topics that contained high-quality evidence or pertained to diagnostic and clinical assessment strategies. Medical practitioners should monitor its usage until further models can be rigorously trained on medical data.

Objective: To understand parent and child perception of spaces experienced during outpatient procedures and to measure their anxiety in these spaces. Background:Same-day procedures are becoming prevalent among children in the United States. While studies conducted in different types of healthcare settings show that the physical environment influences healthcare experiences of patients, there is a lack of research on patient and family perceptions of the physical environment of the outpatient centers where such procedures are conducted. Methods: This study used ecological momentary assessment to collect patient experience and anxiety data at different points during the patient's journey through an ambulatory surgical center where pediatric gastrointestinal (GI) procedures were performed. Objective and subjective measures of anxiety were collected. A Qualtrics survey asked participants' perceptions about four spaces-waiting, preprocedure, procedure, and recovery. Results: Child participants reported liking murals, double chairs, patient beds, wall color, and access to a television. They disliked medical equipment and lack of child-friendly furniture. Most parents liked the murals, access to a television, and nature photos, while disliking the lack of privacy, lack of toys in waiting areas, and lack of child-friendly furniture. On average, both children and parents experienced the highest anxiety levels before and during the procedure and the lowest during recovery. Between the four spaces, no significant differences were observed in the heart rate variability and skin conductance responses for both groups. Conclusions: Despite the outpatient nature of the procedures, participants experienced anxiety before the GI procedure. Comfortable design features that provide distractions are preferred by children and their parents.

AimThe study aims to evaluate the impact of exposure to a highly realistic virtual facility tour prior to the on-site visit on patients and their parent/care partner's self-reported anxiety and physiological measures on the day of the procedure.BackgroundPreoperative anxiety impacts pediatric surgical outcomes; therefore, it is important for healthcare providers to address and manage preoperative anxiety in pediatric patients to promote better outcomes and overall wellbeing. Providing patients with a preview of the care setting before the actual procedure can be highly beneficial in mitigating preoperative anxiety.MethodologyIn this pilot randomized experimental study, sixteen patient-care partner dyads scheduled to undergo a gastrointestinal procedure either received a virtual tour identical to the places experienced on the day of the procedure (experimental group) or received no virtual tour (control group). Self-reported measures of anxiety were collected from participants before and on the day of the procedure. Physiological measures of heart rate variability and skin conductance were collected on the day of the procedure from both groups.ResultsThere were no significant differences between the self-reported and physiological measures of anxiety between the child groups. However, parents in the control group reported lower levels of anxiety and demonstrated lower levels of stress based on their physiological measures.ConclusionExposure to virtual facility tours days before the surgery was not helpful in positively impacting the psychological measures related to preoperative anxiety levels for the participants.

Professional athletes are prone to spinal injuries, and the treatment of this distinct patient population involves additional medicolegal challenges that must be considered. Catastrophic complications and delay in treatment of complications are linked with plaintiff verdicts in legal claims. Clear communication, thorough informed consent, and prompt disclosure of errors or complications can mitigate litigation risks. Effective collaboration with the athletic team is important in optimizing a safe return to competitive play.

Eosinophilic esophagitis (EoE) is a disease marked by a surplus of eosinophils, a type of white blood cell that causes inflammation and irritation. The current diagnostic and monitoring procedure for EoE is endoscopy with biopsy, which is invasive, expensive, and leads to tissue tearing in patients. A biomarker in plasma would offer a much less invasive form of disease monitoring for patients with EoE. Eosinophils have been shown to make eosinophil peroxidase, an enzyme that produces hypobromous acid, reacts with primary amines, and forms bromoamides. One product of this biochemical reaction is 3-bromotyrosine. We have optimized a selective, sensitive, and reproducible method to detect and quantify L-tyrosine and 3-bromotyrosine in human plasma using high-pressure liquid chromatography and tandem mass spectrometry (HPLC-MS/MS). Our sample preparation and analysis method requires fewer steps and provides a faster analysis than previous methods. Method validation yielded limits of quantification of 50 ng mL-1 for L-tyrosine and 10 ng mL-1 for 3-bromotyrosine. Calibration curves for quantification were linear from 50 to 500 ng mL-1 with an R2 value of 0.9995 for L-tyrosine and 10 to 300 ng mL-1 with an R2 value of 0.9998 for 3-bromotyrosine. Method variability was assessed resulting in relative standard deviations of 0.98-4.6% for 3-bromotyrosine (n = 18) and 0.20-0.58% for L-tyrosine (n = 18). Method applicability was tested with patients with a confirmed diagnosis of EoE, initially suggesting little to no correlation between eosinophil count and 3-bromotyrosine concentration in plasma. However, we do observe a relationship between eosinophil count and esophageal deformities. More research must be conducted to determine a more definitive correlation.

Study Design: Retrospective database study. Objectives: The goal of this study was to assess the influence of weekend admission on patients undergoing elective thoracolumbar spinal fusion by investigating hospital readmission outcomes and analyzing differences in demographics, comorbidities, and postoperative factors. Methods: The 2016-2018 Nationwide Readmission Database was used to identify adult patients who underwent elective thoracolumbar spinal fusion. The sample was divided into weekday and weekend admission patients. Demographics, comorbidities, complications, and discharge status data were compiled. The primary outcomes were 30-day and 90-day readmission. Univariate logistic regression analyzed the relationship between weekday or weekend admission and 30- or 90-day readmission, and multivariate regression determined the impact of covariates. Results: 177,847 patients were identified in total, with 176,842 in the weekday cohort and 1005 in the weekend cohort. Multivariate regression analysis found that 30-day readmissions were significantly greater for the weekend cohort after adjusting for sex, age, Medicare or Medicaid status, and comorbidity status (OR 2.00, 95% CI: 1.60-2.48; P < .001), and 90-day readmissions were also greater for the weekend cohort after adjustment (OR 2.01, 95% CI: 1.68-2.40, P < .001). Conclusions: Patients undergoing elective thoracolumbar spinal fusion surgery who are initially admitted on weekends are more likely to experience hospital readmission. These patients have increased incidence of deep vein thrombosis, postoperative infection, and non-routine discharge status. These factors are potential areas of focus for reducing the impact of the "weekend effect" and improving outcomes for elective thoracolumbar spinal fusion.

Predict nonhome discharge (NHD) following elective anterior cervical discectomy and fusion (ACDF) using an explainable machine learning model. 2227 patients undergoing elective ACDF from 2008 to 2019 were identified from a single institutional database. A machine learning model was trained on preoperative variables, including demographics, comorbidity indices, and levels fused. The validation technique was repeated stratified K-Fold cross validation with the area under the receiver operating curve (AUROC) statistic as the performance metric. Shapley Additive Explanation (SHAP) values were calculated to provide further explainability regarding the model’s decision making. The preoperative model performed with an AUROC of 0.83 ± 0.05. SHAP scores revealed the most pertinent risk factors to be age, medicare insurance, and American Society of Anesthesiology (ASA) score. Interaction analysis demonstrated that female patients over 65 with greater fusion levels were more likely to undergo NHD. Likewise, ASA demonstrated positive interaction effects with female sex, levels fused and BMI. We validated an explainable machine learning model for the prediction of NHD using common preoperative variables. Adding transparency is a key step towards clinical application because it demonstrates that our model’s “thinking” aligns with clinical reasoning. Interactive analysis demonstrated that those of age over 65, female sex, higher ASA score, and greater fusion levels were more predisposed to NHD. Age and ASA score were similar in their predictive ability. Machine learning may be used to predict NHD, and can assist surgeons with patient counseling or early discharge planning.

Background Anterior vertebral body tethering (AVBT) has been approved for skeletally immature (IM) adolescent idiopathic scoliosis patients, but the role of AVBT in patients with minimal remaining skeletal growth is controversial. The purpose of this study was to compare minimum 2-year (YR2) outcomes in skeletally IM patients vs those with minimal remaining skeletal growth. Methods Patients with single thoracic AVBT were grouped by their preoperative (PR) skeletal maturity: IM (n = 16, Risser 0–2) vs mature (M, n = 19, Risser 3–5). Outcomes were assessed at PR, first erect (FE), and YR2. Median (range) was compared with nonparametric tests (P < 0.05). Results The PR age was 12.5 (9–16) vs 15 (12–18) years with major Cobb 51° (36°–69°) and 49° (40°–69°) for IM and M, respectively. At FE, there was no difference in correction; however, at YR2, the IM group yielded a lower residual curve (15° [−16° to 38°] vs 29° [12°–42°], P = 0.008). Thoracolumbar/lumbar curves were corrected without group differences. Clinically successful correction (<35°) (15 [94%] vs 15 [79%]) and suspected cord breakages (2 [13%] vs 2 [12%]) were similar at YR2. Two overcorrections occurred, both in IM patients. Scoliosis Research Society-22 outcomes at final follow-up were similar between groups. No revision reoperations or conversions to spinal fusion were needed. Conclusions Skeletally IM patients benefit from greater growth-modulated curve correction than M patients, however, at the increased risk of overcorrection. M patients maintained clinically significant correction at latest follow-up. Longer-term follow-up is required to determine durability of outcomes for patients undergoing AVBT who have minimal remaining growth at the time of index surgery. Clinical Relevance This study is relevant to spine surgeons, spine physiotherapists, and patients with idiopathic scoliosis. It offers evidence of clinical correction of scoliosis in mature patients. Level of Evidence 3.

STUDY DESIGN:A retrospective database study of patients at an urban academic medical center undergoing an Anterior Cervical Discectomy and Fusion (ACDF) surgery between 2008 and 2019. OBJECTIVE:ACDF is one of the most common spinal procedures. Old age has been found to be a common risk factor for postoperative complications across a plethora of spine procedures. Little is known about how this risk changes among elderly cohorts such as the difference between elderly (60+) and octogenarian (80+) patients. This study seeks to analyze the disparate rates of complications following elective ACDF between patients aged 60-69 or 70-79 and 80+ at an urban academic medical center. METHODS:We identified patients who had undergone ACDF procedures using CPT codes 22,551, 22,552, and 22,554. Emergent procedures were excluded, and patients were subdivided on the basis of age. Then each cohort was propensity matched for univariate and univariate logistic regression analysis. RESULTS:The propensity matching resulted in 25 pairs in both the 70-79 and 80+ y.o. cohort comparison and 60-69 and 80+ y.o. cohort comparison. None of the cohorts differed significantly in demographic variables. Differences between elderly cohorts were less pronounced: the 80+ y.o. cohort experienced only significantly higher total direct cost (P = .03) compared to the 70-79 y.o. cohort and significantly longer operative time (P = .04) compared to the 60-69 y.o. cohort. CONCLUSIONS:Octogenarian patients do not face much riskier outcomes following elective ACDF procedures than do younger elderly patients. Age alone should not be used to screen patients for ACDF.

Background: The gold standard for percutaneous pedicle screw placement is 2-dimensional (2D) fluoroscopy. Data are sparse on the accuracy of 3-dimensional (3D) navigation percutaneous screw placement in minimally invasive spine procedures. Objective: We sought to compare a single surgeon's percutaneous pedicle screw placement accuracy using 2D fluoroscopy versus 3D navigation, as well as to investigate the effect of facet orientation on facet violation when using 2D fluoroscopy. Methods: We conducted a retrospective radiographic study of consecutive cohort of patients who underwent percutaneous lumbar instrumentation using either 2D fluoroscopy or 3D navigation. All procedures were performed by a single surgeon at 2 academic institutions between 2011 and 2018. Radiographic measurement of screw accuracy was assessed using a postoperative computed tomographic scan. The primary outcome was facet violation, and secondary outcomes were endplate/tip breaches, the Gertzbein-Robbins classification for cortical breaches, and the Simplified Screw Accuracy grade. Statistical comparisons were made between screws placed using 2D fluoroscopy versus 3D navigation. Axial facet angles were also measured to correlate with facet violation rates. Results: In the 138 patients included, 376 screws were placed with fluoroscopy and 193 with navigation. Superior (unfused) level facet violation was higher with 2D fluoroscopy than with 3D navigation (9% vs 0.5%), which comprises the main cause for poor screw placement. Axial facet angles exceeding 45° at L4 and 60° at L5 were correlated with facet violations. Conclusion: This retrospective study found that 3D navigation is associated with lower facet violation rates in percutaneous lumbar pedicle screw placement when compared with 2D fluoroscopy. These findings suggest that 3D navigation may be of particular value when facet joints are coronally oriented.

Background: Hallux valgus is a common cause of pain and dysfunction of the foot, sometimes requiring surgical correction when conservative measures fail. Although there are many methods of correction, one of the newer techniques is minimally invasive chevron-Akin (MICA). The aim of the current study is to evaluate clinical and radiographic effectiveness of MICA and narcotic use in a large patient cohort. Methods: All patients in this retrospective study were treated by a single fellowship-trained foot and ankle orthopaedic surgeon. Patient demographics were collected for all cases. Preoperative and postoperative intermetatarsal angle (IMA) and hallux valgus angle (HVA) were measured in all patients on weightbearing 3-views radiographs. The Foot Function Index (FFI) was obtained pre- and postoperatively at each visit. All patients were prescribed regular use of ibuprofen for 3 days with acetaminophen and oxycodone reserved for breakthrough pain. Use of narcotic pain medication was recorded. Results: A total of 274 feet in 248 patients were included in the study. Overall, 87.9% were female and 12.1% were male. The mean preoperative IMA and HVA were 13.4 and 29.1 degrees, respectively. The postoperative IMA and HVA were 4.9 and 8.9 degrees, respectively. The mean FFI score part A was 92 preoperatively and 43 postoperatively. Patient satisfaction was 91.6%. The mean postoperative 5 mg oxycodone pill consumption was 2.2. Conclusion: MICA is good method to correct hallux valgus deformity with low postoperative narcotic use. Level of Evidence: Level III, restrospective cohort study of a single surgeon practice.

BACKGROUND AND AIMS:The incidence and prevalence of eosinophilic esophagitis (EoE) and inflammatory bowel disease (IBD) are rising with similar patterns. Co-occurrence of both diseases in the same patient has been increasingly reported. We sought to examine the pediatric population with both EoE and IBD to better understand the epidemiology and clinical implications of this overlap. METHODS:We conducted a retrospective case-control study at 2 tertiary care children's hospitals. Subjects with both EoE and IBD were identified and compared with randomly selected controls with EoE and IBD alone in terms of: demographics, atopic conditions, IBD classification, location and phenotype of Crohn disease (CD), IBD medications, endoscopic findings, and histopathology. Descriptive statistics summarized the data. RESULTS:Sixty-seven subjects with dual-diagnosis were identified across both institutions. The prevalence of IBD in the EoE population was 2.2% and EoE in IBD was 1.5%. Subjects with both diseases were more likely to have IgE-mediated food allergy compared with IBD alone (36% vs 7%, P < 0.001). Subjects with CD-EoE were less likely to have perianal disease than CD alone (2% vs 20%, P = 0.004). There was no difference in fibrostenotic EoE between the dual-diagnosis group and EoE alone. Treatment with a TNF-alpha inhibitor (anti-TNF) for management of preexisting IBD was protective against development of EoE with a relative risk of 0.314 [95% confidence interval [CI] 0.159-0.619]. CONCLUSIONS:This is a unique population in whom the underlying pathway leading to dual-diagnosis is unclear. Concomitant atopic conditions, especially IgE-mediated food allergy, and medication exposures, particularly anti-TNFs, may help predict likelihood of developing dual-diagnosis.

BACKGROUND:Mutations in ITCH, which encodes an E3 ubiquitin-protein ligase, can result in systemic autoimmunity and immunodeficiency. The clinical phenotype and mechanism of disease have not been fully characterized, resulting in a paucity of therapeutic options for this potentially fatal disease. OBJECTIVE:We aimed to (1) expand the understanding about the phenotype of human ITCH deficiency (2) further characterize the associated immune dysregulation, and (3) report the first successful hematopoietic cell transplant (HCT) in a patient with ITCH deficiency. METHODS:Disease profiling was performed in a patient with multisystem immune dysregulation. Whole exome sequencing with trio analysis and functional validation of candidate disease variants were performed, including mRNA and protein expression. Analyses to further delineate the immunophenotype included quantitative evaluation of lymphoid and myeloid subsets with flow cytometry and mass cytometry. RESULTS:A patient with multisystem immune dysregulation presenting with growth failure, very-early-onset inflammatory bowel disease, arthritis, uveitis, psoriasis, and type 1 diabetes mellitus underwent whole exome sequencing, which identified novel compound heterozygous mutations in ITCH. Reduced expression of ITCH mRNA and absent ITCH protein were found. Abnormalities in both lymphoid and myeloid lineages were identified. The patient underwent HCT. He demonstrated excellent immune reconstitution and resolution of many manifestations of his systemic disease. CONCLUSIONS:Here we report ITCH deficiency with unique clinical features of colonic very-early-onset inflammatory bowel disease, arthritis, and uveitis in the setting of immune dysregulation and further characterize the underlying immune dysregulation. We demonstrate that HCT can be an effective, and potentially curative, therapy for ITCH deficiency.

STUDY DESIGN:This was a retrospective cohort study.OBJECTIVE:Identify the independent risk factors for 30- and 90-day readmission because of surgical site infection (SSI) in patients undergoing elective posterior lumbar fusion (PLF).SUMMARY OF BACKGROUND DATA:SSI is a significant cause of morbidity in the 30- and 90-day windows after hospital discharge. There remains a gap in the literature on independent risk factors for readmission because of SSI after PLF procedures. In addition, readmission for SSI after spine surgery beyond the 30-day postoperative period has not been well studied.METHODS:A retrospective analysis was performed on data from the 2012 to 2014 Healthcare Cost and Utilization Project Nationwide Readmissions Database. The authors identified 65,121 patients who underwent PLF. There were 191 patients (0.30%) readmitted with a diagnosis of SSI in the 30-day readmission window, and 283 (0.43%) patients readmitted with a diagnosis of SSI in the 90-day window. Baseline patient demographics and medical comorbidities were assessed. Bivariate and multivariate analyses were performed to examine the independent risk factors for readmission because of SSI.RESULTS:In the 30-day window after discharge, this study identified patients with liver disease, uncomplicated diabetes, deficiency anemia, depression, psychosis, renal failure, obesity, and Medicaid or Medicare insurance as higher risk patients for unplanned readmission with a diagnosis of SSI. The study identified the same risk factors in the 90-day window with the addition of diabetes with chronic complications, chronic pulmonary disease, and pulmonary circulation disease.CONCLUSIONS:Independent risk factors for readmission because of SSI included liver disease, uncomplicated diabetes, obesity, and Medicaid insurance status. These findings suggest that additional intervention in the perioperative workup for patients with these risk factors may be necessary to lower unplanned readmission because of SSI after PLF surgery.

BACKGROUND:A high prevalence (9.5-30%) of eosinophilic esophagitis (EoE) in patients with esophageal atresia (EA) has been reported. The application of the EoE criteria to EA patients might be problematic. To date, only studies using a "routine" biopsy approach, even in asymptomatic patients, have been performed. The aim of the study was to establish the prevalence of EoE among symptomatic EA patients (EA/EoE group) without anastomotic stricture (AS) and to compare their characteristics with those of EoE patients from general population (EoE group). METHODS:From 2005 to 2018, we reviewed charts of children with EA and EoE. "Selective" biopsy approach only in EA children without AS and/or endoscopic feature of EoE was performed. Characteristics of EA/EoE and EoE groups were compared. RESULTS:Among 370 EA and 118 EoE, 15 EA/EoE patients were detected (4.0% of EA patients). Male predominance and a high prevalence of allergy without differences between EA/EoE and EoE groups was observed. EA/EoE children were significantly younger (p < 0.0001). PPI-responder patients were significantly more prevalent in EA/EoE group (p = 0.045). CONCLUSION:Our data confirm that EA patients are at high risk for developing EoE. High incidence, early onset, and high prevalence of PPI-responders might suggest that esophageal motility disorders interact to increase propensity to EoE in EA patients. However, our study also suggests that overdiagnosis of EoE may occur in EA and that adapted criteria for EoE diagnosis should be developed for EA patients. TRIAL REGISTRATION:Not applicable for this retrospective study.

BACKGROUND CONTEXT While attention to sagittal parameters in the cervical spine is increasing, the relationship between these radiographic measurements and clinical outcomes is less clear. PURPOSE The aim of the present study was to characterize independent associations between cervical spine radiographic parameters and clinical outcomes following anterior cervical discectomy and fusion (ACDF). STUDY DESIGN/SETTING Retrospective cohort analysis. PATIENT SAMPLE Analysis of consecutive patients who underwent a single-level ACDF at an academic institution between 2008 and 2015 for cervical radiculopathy and/or myelopathy, with a minimum of 6 months of clinical and radiographic follow-up. OUTCOME MEASURES Disc height was measured as the anterior vertebral distance (AVD), mid-vertebral distance (MVD), and posterior vertebral distance (PVD) on preoperative and immediate postoperative radiographs. Sagittal parameters were also measured, and included C2-C7 lordosis, T1 angle, fusion segment lordosis, sagittal vertical axis (SVA), proximal and distal adjacent segment lordosis. Preoperative and final visual analog scale (VAS) neck, VAS arm, and Neck Disability Index (NDI) scores were collected. The rates of reoperation, successful fusion, and subsidence (postoperative disc space collapse >2 mm) were determined. METHODS Preoperative, postoperative, and final radiographs were reviewed. Radiographic parameters were tested for association with patient-reported outcomes, reoperation, fusion, and subsidence using multivariate linear regression and multivariate logistic regression for continuous and binary outcomes, respectively. Multivariate regressions controlled for potential confounding variables in order to identify independent risk factors for each outcome. The Šidák-Holm method was used to adjust p-values in order to correct for multiple statistical comparisons. The threshold for statistical significance was set at p <0.05. RESULTS A total of 381 patients met inclusion criteria. Average follow-up length was 28 months, average age was 50.2 years, average body mass index was 28.7, and 49.2% of patients were female. Of these patients, 93.7% achieved successful fusion, 6.6% had graft subsidence, and 4.99% had a reoperation. Preoperative and postoperative radiographic measurements and patient-reported outcomes were collected. Preoperative radiographic measurements poorly predicted clinical outcomes. Increased preoperative lordosis at the adjacent unfused segment proximal to the eventual fusion mass was found to be associated with increased final NDI (corrected p=0.018), and increased final proximal lordosis was associated with increased final NDI (corrected p=0.049). However, no other radiographic parameters were associated with any patient-reported clinical outcomes. Subsidence rates were increased with greater change in proximal lordosis from preoperative to postoperative (OR 1.30, corrected p=0.007) and from preoperative to final follow-up (OR 1.17, corrected p=0.044). Subsidence was negatively associated with increased change in lordosis across the fused segments from preoperative to postoperative (OR 0.88, corrected p=0.032) and from preoperative to final follow-up (OR 0.86, corrected p=0.017). CONCLUSIONS The present study found that sagittal parameters were poorly predictive of clinical outcomes. Increased preoperative lordosis at the adjacent segment proximal to the fusion mass was associated with worse final NDI scores, and was the only preoperative radiographic parameter associated with clinical outcomes. Further research should attempt to identify other preoperative factors or radiographic parameters that are more closely associated with clinical outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs. While attention to sagittal parameters in the cervical spine is increasing, the relationship between these radiographic measurements and clinical outcomes is less clear. The aim of the present study was to characterize independent associations between cervical spine radiographic parameters and clinical outcomes following anterior cervical discectomy and fusion (ACDF). Retrospective cohort analysis. Analysis of consecutive patients who underwent a single-level ACDF at an academic institution between 2008 and 2015 for cervical radiculopathy and/or myelopathy, with a minimum of 6 months of clinical and radiographic follow-up. Disc height was measured as the anterior vertebral distance (AVD), mid-vertebral distance (MVD), and posterior vertebral distance (PVD) on preoperative and immediate postoperative radiographs. Sagittal parameters were also measured, and included C2-C7 lordosis, T1 angle, fusion segment lordosis, sagittal vertical axis (SVA), proximal and distal adjacent segment lordosis. Preoperative and final visual analog scale (VAS) neck, VAS arm, and Neck Disability Index (NDI) scores were collected. The rates of reoperation, successful fusion, and subsidence (postoperative disc space collapse >2 mm) were determined. Preoperative, postoperative, and final radiographs were reviewed. Radiographic parameters were tested for association with patient-reported outcomes, reoperation, fusion, and subsidence using multivariate linear regression and multivariate logistic regression for continuous and binary outcomes, respectively. Multivariate regressions controlled for potential confounding variables in order to identify independent risk factors for each outcome. The Šidák-Holm method was used to adjust p-values in order to correct for multiple statistical comparisons. The threshold for statistical significance was set at p <0.05. A total of 381 patients met inclusion criteria. Average follow-up length was 28 months, average age was 50.2 years, average body mass index was 28.7, and 49.2% of patients were female. Of these patients, 93.7% achieved successful fusion, 6.6% had graft subsidence, and 4.99% had a reoperation. Preoperative and postoperative radiographic measurements and patient-reported outcomes were collected. Preoperative radiographic measurements poorly predicted clinical outcomes. Increased preoperative lordosis at the adjacent unfused segment proximal to the eventual fusion mass was found to be associated with increased final NDI (corrected p=0.018), and increased final proximal lordosis was associated with increased final NDI (corrected p=0.049). However, no other radiographic parameters were associated with any patient-reported clinical outcomes. Subsidence rates were increased with greater change in proximal lordosis from preoperative to postoperative (OR 1.30, corrected p=0.007) and from preoperative to final follow-up (OR 1.17, corrected p=0.044). Subsidence was negatively associated with increased change in lordosis across the fused segments from preoperative to postoperative (OR 0.88, corrected p=0.032) and from preoperative to final follow-up (OR 0.86, corrected p=0.017). The present study found that sagittal parameters were poorly predictive of clinical outcomes. Increased preoperative lordosis at the adjacent segment proximal to the fusion mass was associated with worse final NDI scores, and was the only preoperative radiographic parameter associated with clinical outcomes. Further research should attempt to identify other preoperative factors or radiographic parameters that are more closely associated with clinical outcomes.

Study Design: Retrospective cohort study. Objective: To compare clinical outcomes after anterior cervical discectomy and fusion (ACDF) based on preoperative duration of radiculopathy symptoms. Summary of Background Data: There is no clear indication of when outcomes after ACDF become less effective in the setting of acute versus chronic symptoms from cervical nerve root compression. Materials and Methods: A retrospective cohort study of consecutive patients who underwent an ACDF between 2008 and 2015 for radiculopathy was performed. Patients were divided into 3 groups: radicular symptoms lasting for <6 months, symptoms lasting for 6-12 months, and those with symptoms for >= 12 months. Neck Disability Index (NDI) and Visual Analog Scale (VAS) scores for both the neck and arms were obtained at preoperative and final postoperative visits. Radiographs were assessed for adjacent segment degeneration, fusion, and subsidence. Bivariate and multivariate regressions were subsequently used to compare outcomes between groups. Results: A total of 379 patients were included. Patients with symptoms lasting for 6-12 months and those with symptoms lasting for >= 12 months had worse preoperative VAS neck pain compared with patients with symptoms lasting for < 6 months (P=0.000 and P=0.004, respectively). Patients with symptoms lasting for >= 12 months had worse baseline functional status compared with patients with symptoms lasting for <6 months (P=0.009). At final follow-up, there were no significant differences in VAS neck, VAS arm, or NDI between symptom duration groups. However, differences in outcomes were noted when considering the type of preoperative symptom. Patients with pain symptoms of >= 12 months had worse preoperative VAS neck (P=0.001), VAS arm (P=0.008), and NDI (P<0.001) and had significantly worse final VAS arm (P=0.019) and NDI (P=0.016) compared with patients with preoperative pain symptoms lasting for <6 months. The overall reoperation rate was 4.5%. Fusion was achieved in 97.6% of the patients, and subsidence was observed in 5.5%. There were no significant differences in the risk of adjacent segment degeneration, reoperations, fusion rates, or subsidence rates based on preoperative symptom duration. Conclusions: Despite worse preoperative neck pain and functional status in patients with preoperative duration of symptoms >6 months, there were no differences in final clinical outcomes across groups.