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STUDY DESIGN: Prospective multicenter cohort study. OBJECTIVE: To explore the association between operative level and postoperative dysphagia after anterior cervical discectomy and fusion (ACDF). BACKGROUND: Dysphagia is common after ACDF and has several risk factors, including soft tissue edema. The degree of prevertebral soft tissue edema varies based on the operative cervical level. However, the operative level has not been evaluated as a source of postoperative dysphagia. PATIENTS AND METHODS: Adult patients undergoing elective ACDF were prospectively enrolled at 3 academic centers. Dysphagia was assessed using the Bazaz Questionnaire, Dysphagia Short Questionnaire, and Eating Assessment Tool-10 (EAT-10) preoperatively and at 2, 6, 12, and 24 weeks postoperatively. Patients were grouped based on the inclusion of specific surgical levels in the fusion construct. Multivariable regression analyses were performed to evaluate the independent effects of the number of surgical levels and the inclusion of each particular level on dysphagia symptoms. RESULTS: A total of 130 patients were included. Overall, 24 (18.5%) patients had persistent postoperative dysphagia at 24 weeks and these patients were older, female, and less likely to drink alcohol. There was no difference in operative duration or dexamethasone administration. Patients with persistent dysphagia were significantly more likely to have C4-C5 included in the fusion construct (62.5% vs . 34.9%, P = 0.024) but there were no differences based on the inclusion of other levels. On multivariable regression, the inclusion of C3-C4 or C6-C7 was associated with more severe EAT-10 (ß: 9.56, P = 0.016 and ß: 8.15, P = 0.040) and Dysphagia Short Questionnaire (ß: 4.44, P = 0.023 and (ß: 4.27, P = 0.030) at 6 weeks. At 12 weeks, C3-C4 fusion was also independently associated with more severe dysphagia (EAT-10 ß: 4.74, P = 0.024). CONCLUSION: The location of prevertebral soft tissue swelling may impact the duration and severity of patient-reported dysphagia outcomes at up to 24 weeks postoperatively. In particular, the inclusion of C3-C4 and C4-C5 into the fusion may be associated with dysphagia severity.

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STUDY DESIGN: Systematic literature review. OBJECTIVE: It is estimated that one third of the world population is overweight and 20% of adults have some low back symptoms at some point of their lives. The association of obesity and low back pain and physical deterioration has been well established. We designed this study to evaluate the role of bariatric surgery (BS) for lumbar spine symptoms in obese patients. METHODS: A systematic literature review was performed using the PubMed database identifying lumbar spine symptoms (pain, functional status, disability index) and/or complications of lumbar spine surgery before and after BS. Study quality was assessed according to the Oxford Centre for Evidence-Based Medicine. RESULTS: Ten studies were identified. Nine evaluated the role of BS in low back pain and/or functional status before and after surgery: all reported that bariatric surgery had a positive impact in improving low back pain symptoms and decreasing disability in severely obese patients. One study evaluated the role of posterior lumbar surgery in patients who were obese at the time of surgery and those who had a previous bariatric procedure: bariatric surgery decreased postoperative surgical complications. The level of the evidence was low (III and IV). CONCLUSIONS: Bariatric surgery in severely obese patients decreases the intensity of low back symptoms and also decreases disability secondary to back problems. Additionally, bariatric surgery may be advantageous for patients who need a posterior lumbar surgery and are severely obese. Prospective studies with longer follow-up are necessary to confirm this conclusion.

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BACKGROUND: The new AOSpine Upper Cervical Classification System (UCCS) was recently proposed by the AOSpine Knowledge Forum Trauma team to standardize the treatment of upper cervical traumatic injuries (UCI). In this context, evaluating its reliability is paramount prior to clinical use. OBJECTIVE: To evaluate the reliability of the new AOSpine UCCS. METHODS: A total of 32 patients with UCI treated either nonoperatively or with surgery by one of the authors were included in the study. Injuries were classified based on the new AO UCCS according to site and injury type using computed tomography scan images in 3 planes by 8 researchers at 2 different times, with a minimum interval of 4 wk between assessments. Intra- and interobserver reliability was assessed using the kappa index (K). Treatment options suggested by the evaluators were also assessed. RESULTS: Intraobserver agreement for sites ranged from 0.830 to 0.999, 0.691 to 0.983 for types, and 0.679 to 0.982 for the recommended treatment. Interobserver analysis at the first assessment was 0.862 for injury sites, 0.660 for types, and 0.585 for the treatment, and at the second assessment, it was 0.883 for injury sites, 0.603 for types, and 0.580 for the treatment. These results correspond to a high level of agreement of answers for the site and type analysis and a moderate agreement for the recommended treatment. CONCLUSION: This study reported an acceptable reproducibility of the new AO UCCS and safety in recommending the treatment. Further clinical studies with a larger patient sample, multicenter and international, are necessary to sustain the universal and homogeneity quality of the new AO UCCS.

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Context: It is well established that traumatic spinal dislocations (AO Type C injuries) should be surgically treated. However, no recent comparative study of surgical versus non-surgical management of type C injuries was found attesting the superiority of surgical treatment.Objective: Due to the lack of information about the natural history of non-surgical management of type C injuries, we evaluated the outcome of historical conservative treatment of type C injuries.Methods: An extensive manual search of articles was performed in the Pubmed Database. We included articles that reported the clinical and/ or the radiological outcome of non-surgical management of thoracic and/ or lumbar spinal fracture-dislocations.Results: Three well described retrospective studies where fracture-dislocations of the thoracolumbar spine were managed non-surgically were included. Non-surgical management typically consisted in postural reduction and prolonged bed rest (about 10-13 weeks on average). Residual deformity was common, and some studies reported a high rate of post treatment pain syndromes. Some studies reported surgery for gibbus deformity after conservative treatment or persistent instability requiring further bed rest. Neurological deterioration was rare, and some patients had some improvement, although the vast majority of the patients had persistent, severe neurological deficits.Conclusions: Compared with historical non-surgical care, surgery for type C injuries decreases the chances of post-operative pain, late spinal deformity and also allowed early rehabilitation, once no bed restriction is necessary. Ethical issues based on this historical analysis may preclude performing a comparative study of non-surgical versus surgical management of these injuries in the modern spine era.

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STUDY DESIGN: Systematic literature review. OBJECTIVES: To evaluate risk factors, diagnosis, and management of sacral and pelvic fractures (SPFs) after instrumented fusions. METHODS: A systematic review following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed using the PubMed database. Articles with patients with an SPF after a lumbar instrumented fusion were included. The articles addressing specifically proximal junctional kyphosis were excluded. Eleven small cases series (level of evidence IV) were reviewed. RESULTS: The incidence of SPF was 1.86% in one study. The risk factors reported were elderly patients, multilevel surgery, long fusions stopping at L5 or S1 instead of the ilium, osteoporosis, obesity, and sagittal imbalance. Computed tomography scan was the preferential image modality for diagnosing. Nonsurgical treatment may be used in patients with tolerable pain and nondisplaced fracture. Persistent pain was an indication for surgery, as well as fracture displacement. The most common surgical treatment reported was an extension of the fusion to the iliac using iliac screws. CONCLUSION: SPFs after lumbar instrumented fusion are rare but clinically meaningful complications. The risk factors, diagnosis, and management of SPFs are described in our review.

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STUDY DESIGN: Systematic literature review. OBJECTIVES: Many studies have provided evidence that short-segment posterior fixation (SSPF-1 level above and 1 below) with screws at the fracture level (SFL) are enough to achieve stability in some injury patterns, such as burst fractures, avoiding the need for circumferential reconstruction and long-segment instrumented fusion (LSIF-at least 2 levels above and 2 below). Given the potential benefits of avoiding unnecessary fusion in mobile healthy spinal segments, we performed a systematic review of biomechanical studies comparing different spinal reconstruction techniques for fractures of the thoracolumbar spine. METHODS: A systematic literature review was performed in the PubMed and OVID databases of biomechanical studies comparing biomechanical differences between techniques of spine reconstructions. RESULTS: Eight studies were included and evaluated. Five of 6 studies reported stiffness improvement with SSPF and SFL, even comparable to circumferential fusion for a burst fracture. Two studies reported that LSPF has higher stiffness and restricts range of motion better than SSPF, but inclusion of screws in the fracture level is similar to LSPF (1 study). Finally, although SSPF is less stiff than anterior reconstruction, adding a SFL in SSPF results in similar stiffness than circumferential fusion for unstable burst fractures. CONCLUSIONS: Biomechanical studies analyzed generally suggested that SFL in SSPF may improve construction stiffness, and can even be compared with long-segment fixation or circumferential reconstruction in some scenarios. This construct option may be used to enhance stiffness in selected injury patterns, avoiding the needs of an additional anterior approach.

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CONTEXT: Current treatment of TLST should consider injury morphology, neurological status, clinical status (pain and disability) and also multimodal radiological evaluation (MMRE) with CT, MRI and dynamic/ standing plain radiographs. METHODS: A narrative literature review was performed to propose a treatment algorithm to guide the management of thoracolumbar spinal trauma (TLST). In order to classify injuries and surgical indications, we utilized the two most recent classification systems (TLICS and new AO spine classification) and related recent literature. RESULTS: Injuries were categorized into three groups according to stability: 1) Stable injuries, 2) Potentially unstable injuries/ delayed instability or 3) Clearly unstable injuries. Stable injuries included most of AO type A fractures without neurological deficit, mild clinical symptoms and without risk factors for late deformity. Potentially unstable injuries generally included patients without neurological deficits but with some risk factors for late deformity or with severe clinical symptoms. Surgery may be recommended in this group. Finally, clearly unstable injuries are those with spinal dislocations and/ or with neurological deficits, especially in the setting of persistent neural tissue compression, requiring early surgical treatment. CONCLUSIONS: The proposed treatment algorithm is intended to help surgeons select the best treatment modality for their patients, categorizing injuries according to their main characteristics into one of these three groups. Further studies addressing the reliability and safety of this algorithm are necessary.

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OBJECTIVE: The surgical management of high-grade lumbar spondylolisthesis (HGLS) is complex and aims to achieve both a solid fusion that is able to support the high shear forces of the lumbosacral junction, as well as neural decompression. We performed a systematic literature review of the safety and efficacy of posterior transdiscal (PTD) screw fixation from L5S1 for HGLS and its variations. METHODS: A systematic literature review following the PRISMA guidelines was performed in the PubMed database of the studies describing the use of PTD screw fixation for HGLS. Clinical and radiological data were extracted and discussed. Study quality was assessed with the Oxford Centre for Evidence-Based Medicine Levels of Evidence. RESULTS: Seven studies were included and reviewed; all of them were level IV of evidence. Two of them had large case series comparing different surgical techniques: one concluded that PTD was associated with better clinical outcomes when compared with standard screw fixation techniques and the other suggesting that the clinical and radiological outcomes of PTD were similar to those when an interbody fusion (TLIF) technique was performed, but PTD was technically less challenging. The remaining five studies included small case series and case reports. All of them reported the successful useful of PTD with or without technical variations. CONCLUSIONS: Our review concludes, with limited level of evidence that PTD fixation is a safe and efficient technique for treating HGLS patients. It is technically less demanding than a circumferential fusion, even though proper screw insertion is more demanding than conventional pedicle screw fixation.

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SUMMARY OBJECTIVE: The surgical management of high-grade lumbar spondylolisthesis (HGLS) is complex and aims to achieve both a solid fusion that is able to support the high shear forces of the lumbosacral junction, as well as neural decompression. We performed a systematic literature review of the safety and efficacy of posterior transdiscal (PTD) screw fixation from L5S1 for HGLS and its variations. METHODS: A systematic literature review following the PRISMA guidelines was performed in the PubMed database of the studies describing the use of PTD screw fixation for HGLS. Clinical and radiological data were extracted and discussed. Study quality was assessed with the Oxford Centre for Evidence-Based Medicine Levels of Evidence. RESULTS: Seven studies were included and reviewed; all of them were level IV of evidence. Two of them had large case series comparing different surgical techniques: one concluded that PTD was associated with better clinical outcomes when compared with standard screw fixation techniques and the other suggesting that the clinical and radiological outcomes of PTD were similar to those when an interbody fusion (TLIF) technique was performed, but PTD was technically less challenging. The remaining five studies included small case series and case reports. All of them reported the successful useful of PTD with or without technical variations. CONCLUSIONS: Our review concludes, with limited level of evidence that PTD fixation is a safe and efficient technique for treating HGLS patients. It is technically less demanding than a circumferential fusion, even though proper screw insertion is more demanding than conventional pedicle screw fixation.

RESUMO OBJETIVOS: O tratamento cirúrgico das listeses de alto grau da coluna lombar (LAGCL) é complexo, objetivando alcançar uma fusão sólida capaz de suportar o estresse biomecânico da junção lombo-sacra, bem como descompressão do tecido neural. Realizamos revisão sistemática da literatura para avaliar a segurança e a eficácia da fixação transdiscal (FTD) L5S1 em LAGCL e suas variações. MÉTODOS: Realizamos revisão sistemática conforme metodologia Prisma na base de dados PubMed dos estudos que utilizaram FTD no tratamento das LAGCL e suas variações. Dados clínicos e radiológicos foram extraídos dos trabalhos e discutidos. A qualidade dos estudos foi avaliada segundo o Oxford Centre for Evidence-Based Medicine Levels of Evidence. RESULTADOS: Sete estudos foram incluídos e analisados, todos com nível IV de evidência. Dois estudos tinham séries de casos maiores, comparando diferentes técnicas cirúrgicas: um concluiu que a FTD foi associada a melhor prognóstico clínico quando comparada à fixação pedicular tradicional, e o outro sugeriu que os resultados clínicos e radiológicos com a FTD foram semelhantes à fusão intersomática, porém com menor demanda técnica na FTD. Os demais cinco estudos eram pequenas séries ou relatos de casos. Todos reportaram o uso da FTD com sucesso, com e sem variações da técnica. CONCLUSÃO: Concluímos que, embora com evidências limitadas, a FTD é segura e efetiva no tratamento das LAGCL. É tecnicamente mais simples do que a fusão circunferencial (intersomática), porém com maior complexidade que a fixação pedicular convencional.

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