Background: Degenerative cervical myelopathy is a spinal disorder resulting in progressive spinal cord compression and consequent neurological deficits that can be assessed and tracked using the modified Japanese Orthopedic Association (mJOA) questionnaire. However, it is difficult to predict which patients will recover neurological function after surgery, making it difficult for clinicians to set reliable postoperative patient expectations. Methods: Sixty-eight operative myelopathy patients (50 male, 14 female) consented to complete the mJOA questionnaire both preoperatively and 6-months postoperatively. Fifteen of these patients had mild, twenty-three had moderate, and thirty had severe preoperative disease. Results: We found that in mild myelopathy, sensation and strength recover in similar proportions. In moderate myelopathy, a greater proportion of patients recover in each domain except for sensation. Recovery in severe myelopathy was comparable to moderate disease, but showed more dramatic recovery in sensation and sphincter function. Conclusions: This study shows that the severity of myelopathic disease influences the pattern of postoperative recovery. Though limited in sample size, the recovery patterns identified above are an important first step in recognizing myelopathy as a disease that patients experience heterogeneously both pre- and post-operatively. Our results will aid clinicians in goals-of-surgery discussions and assist with managing postoperative patient expectations.

Background: Degenerative cervical myelopathy is a debilitating condition of the spinal column resulting in a progressive, clinically measurable loss of motor and sensory function secondary to spinal cord compression. We sought to correlate the patient’s subjective experience of specific myelopathic impairments with components of the objective clinical exam, to determine if the latter provides any clinically-relevant information postoperatively. Methods: Thirty-eight myelopathy patients consented to complete the mJOA questionnaire and receive a physical exam preoperatively, and 6-weeks and 6-months postoperatively. mJOA components were correlated with the physical exam using Spearman correlations with an alpha of 0.05. Results: mJOA scores for sensation and lower limb motor function correlated with the sensory and lower limb motor exams respectively, both preoperatively and 6-weeks postoperatively. mJOA scores for upper limb motor function did not correlate with the upper limb motor exam at either timepoint. Conclusions: At baseline and immediately postoperatively, patients self-report sensation and lower limb motor function accurately. However, the patients’ subjective experience of upper limb motor function does not align with clinical exam findings, suggesting either a continued need for this component of the physical exam or a need for tools that better correlate with the patient’s experience of upper limb motor impairment.

Background: Spinal instrumentation is commonly utilized to mechanically stabilize the spine in trauma, oncology and degenerative disease. Although several complications have been reported, this is the first case of screw penetration of the pulmonary artery. Methods: We present a case of a 74-year old gentleman who suffered from a thoracic spine chordoma. He underwent a T8 resection with T8-T12 instrumented fusion with subsequent radiation. Recurrence of his disease led to resection of his 3rd and 4th ribs and repeat radiation. He presented 6 years later with 2 episodes of massive hemoptysis. Review of the literature was conducted to search for similar complications. Results: A Chest Computed Tomography scan demonstrated the presence of a pedicle screw tip in the right pulmonary artery. Angiogram revealed no evidence of active arterial extravasation. In the operating room, the patient had a right lower lobectomy, with segmental pulmonary artery sacrifice, as well as replacement of the spinal fixation hardware. Literature review revealed multiple aortic injuries following spinal instrumentation. However, this was the first case of pulmonary artery erosion. Conclusions: Spinal instrumentation has been associated with screw migration and penetration of nearby tissues and vessels. A high incidence of suspicion is required when patients present with delayed and unusual complications.

Background: Prolonged length of stay (LOS) is associated with increased resource utilization and worse outcomes. The goal of this study is identifying patient, surgical and systemic factors associated with prolonged LOS overall and per diagnostic category for adults admitted to a quaternary spinal care center. Methods: We performed a retrospective analysis on 13,493 admissions from 2006 to 2019. Factors analyzed included patient age, sex, emergency vs elective admission, diagnostic category (degenerative, deformity, oncology, trauma), presence of neurological deficits in trauma patients, ASIA score, operative management and duration, blood loss, and adverse events (AEs). Univariate and multivariate analyses determined factors associated with prolonged LOS. Results: Overall mean LOS (±SD) was 15.80 (±34.03) days. Through multivariate analyses, predictors of prolonged LOS were advanced age (p<0.001), emergency admission (p<0.001), advanced ASIA score (p<0.001), operative management (p=0.043), and presence of AEs (p<0.001), including SSI (p=0.001), other infections (systemic and UTI) (p<0.001), delirium (p=0.006), and pneumonia (p<0.001). The effects of age, emergency admission, and AEs on LOS differed by diagnostic category. Conclusions: Understanding patient and disease factors that affect LOS provides opportunities for QI intervention and allows for an informed preoperative discussion with patients. Future interventions can be targeted to maximize patient outcomes, optimize care quality, and decrease costs.

Background: Length of stay (LOS) is a surrogate for care complexity and a determinant of occupancy and service provision. Our primary goal was to assess changes in and determinants of LOS at a quaternary spinal care center. Secondary goals included identifying opportunities for improvement and determinants of future service planning. Methods: This is a prospective study of patients admitted from 2006 to 2019. Data included demographics, diagnostic category (degenerative, oncology, deformity, trauma, other), LOS (mean, median, interquartile range, standard deviation) and in-hospital adverse events (AEs). Results: 13,493 admissions were included. Mean age has increased from 48.4 (2006) to 58.1 years (2019) (p=<0.001). Mean age increased overtime for patients treated for deformity (p=<0.001), degenerative pathology (p=<0.001) and trauma (p=<0.001), but not oncology (p=0.702). Overall LOS has not changed over time (p=0.451). LOS increased in patients with degenerative pathology (p=0.019) but not deformity (p=0.411), oncology (p=0.051) or trauma (p=0.582). Emergency admissions increased overtime for degenerative pathologies (p=<0.001). AEs and SSIs have decreased temporally (p=<0.001). Conclusions: This is the first North American study to analyze temporal trends in LOS for spine surgery in an academic center. Understanding temporal trends in LOS and patient epidemiology can provide opportunities for intervention, targeted at the geriatric populations, to reduce LOS.

Background: Mean arterial pressure augmentation is one current established practice for management of patients with SCI. We present the first data investigating the effectiveness of Intrathecal Pressure (ITP) reduction through CSF drainage (CSFD) in managing patients with acute traumatic SCI at a large academic center. Methods: Data from 6 patients with acute traumatic SCI were included. A lumbar intrathecal catheter was used to monitor ITP and volume of CSFD. CSFD was performed and recorded hourly. ITP recordings were collected hourly and the change in ITP was calculated (hour after minus before CSFD). 369 data points were collected and change in ITP was plotted against volume of CSFD. Results: Data across all patients showed variability in the ITP over time without a significant trend (slope=0.016). We found no significant change in ITP with varying amounts of CSFD (slope=0.007, r2=0.00, p=0.88). Changes in ITP were not significantly different across groups of CSFD but the variation in the data decreased with increasing levels of CSFD. Conclusions: We present the first known data on changes in ITP with varying degrees of CSFD in patients with acute traumatic SCI. These results may provide insight into the complexity of ITP changes in patients post-injury and help inform future SCI management.

Background: Despite the inherent importance of physical reserve and ability to tolerate surgery, pre-operative patient-specific surrogate markers of frailty that may improve accuracy of outcome prognostication following surgery for SMD are not well described. Methods: A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, Scopus, EMBASE, Cochrane Registry of Controlled Trials, CINAHL, and Web of Science were searched. Quality of evidence was scored using the Oxford CEBM Scoring Tool. Results: Forty studies accounted for 8,364 patients. Surgical indications included neurological dysfunction, intractable pain, and spinal instability. Tumor histology varied across and within studies. Age, gender, performance status, neurologic function, comorbidities, and biochemical abnormalities were the most frequently analyzed pre-operative surrogate markers of frailty. The most commonly assessed outcomes were overall and progression-free survival; few studies examined health-related quality of life, peri-operative adverse events, and post-operative complications. Conclusions: This study highlights the need for objective measures of frailty in order to improve risk stratification and outcome prognostication among patients receiving surgery for metastatic spinal disease. Future studies should address identified knowledge gaps pertaining to peri-operative adverse events, post-operative complications, and health-related quality of life outcomes.

Background: Many studies have demonstrated improved arm pain (AP) following surgery for degenerative cervical radiculopathy (DCR); however, axial neck pain (NP) is generally not felt to improve. The purpose of this study was to determine whether surgery for DCR improves NP. Methods: A ambispective cohort study of the Canadian Spine Outcomes Research Network (CSORN) registry for patients

who received 1-level, 2-level, 3-level ADCF (anterior cervical discectomy and fusion) or cervical disc arthroplasty (CDA) for DCR. Outcomes: 12-month post-operative Visual Analogue Scale for NP (VAS-NP), Neck Disability Index (NDI), VAS for AP (VAS-AP), Short-Form Physical Health Composite Scale (SF36-PCS), and Mental Health Composite Scale (SF36-MCS). Results: We identified 603 patients with DCR. CDA patients were the youngest (ANOVA; p<0.001). Patients reported similar pre-operative AP, NP, disability, and health-related quality of life, regardless of procedure (ANOVA; all P>0.05). All procedures offered a statistically significant reduction in VAS-NP, VAS-AP, and NDI (ANOVA; all P<0.001). Mean change from baseline in NP, AP, and disability, were similar across procedures. At 12 months, mean reduction in VAS-AP, VAS-NP, and NDI exceeded minimal clinically important differences for nearly all procedures. Conclusions: Patients undergoing surgery for DCR can expect a clinically significant, approximate 50% reduction in NP, AP, and neck-related disability.

Background: Lumbar disc herniation (LDH) is a risk factor for Modic change (MC) development on spinal MRI. MC has been associated with worse pre- and post-operative pain, disability, and health-related quality of life (HRQoL). We examined the relationship between pre-operative MC and post-operative assessment scores for patients receiving discectomy (LD) or transforaminal interbody fusion (TLIF) for LDH. Methods: We reviewed 285 primary single-level surgeries. Pre-operative and 12-month post-operative assessment scores: Visual Analog Scale Leg-Pain (VAS-LP), Oswestry Disability Index (ODI), and Short-Form-36 Physical Component Summary (SF-36-PCS). MC subgroup on pre-operative MRI was recorded by a single neuroradiologist. Results: 179 patients were included. The sample prevalence of MC on pre-operative MRI was 62%; MC2 was most common (35%). No differences in pre-operative scores were identified, regardless of present or absent MC. For the overall cohort, improvement in assessment scores were observed: SF-36 improved an average of 8.2 points (95% CI: [5.8, 10.7]), ODI by 11.3 points (95% CI: [8.7, 14.0]), and VAS by 2.8 points (95% CI: [2.1, 3.5]). In nearly all cases, MCID values were met. Conclusions: Clinically significant improvement in post-operative pain, disability, and HRQoL was observed for both procedures. Modic change on pre-operative MRI was not associated with worse clinical assessment scores.

Background: The Degenerative lumbar Spondylolisthesis Instability Classification (DSIC) system categorizes spondylolisthesis (stable, potentially unstable, unstable) based on surgeon impression. It does not contain objective criteria. Objective-1: Develop a quantitative-DSIC system from predetermined radiographic/clinical variables. Objective-2: Compare qualitative (surgeon-assigned) and quantitative (objective) DSIC Types. Objective-3: Determine proportion of patients receiving more invasive surgery than warranted based on the objective system. Methods: Patients from 8 centers were enrolled prospectively (2015–2020). Radiographic/clinical variables were collected and included/excluded from the quantitative DSIC system based on prior systematic review. Scores were converted to DSIC Types: 0-2 points (“Stable”; Type 1), 3 points (“Potentially Unstable”; Type 2), 4-5 points (“Unstable”; Type 3). Surgical procedures performed were compared to those suggested by the objective system. Results: Quantitative DSIC scores were calculated (309 patients). The score includes five variables: facet effusion, disc height, translation, disc angle, and low back pain. Quantitatively, 57% were stable, 34% potentially unstable, and 9% unstable patients. Qualitatively, 30% were stable, 53% potentially unstable, and 17% unstable patients. Surgeons assigned more instability than the objective scoring system in 42% of cases. More invasive surgery was performed in 57% of cases. Conclusions: Surgeons are more likely to categorize greater degrees of spinal instability than what is objectively scored.

Background: Despite growing evidence for early surgical decompression for traumatic cervical spinal cord injury(tCSCI) patients, controversy surrounds the efficacy of early surgical decompression on patients with a complete (ASIA A) cervical injury. Methods: Patients with ASIA A cervical tCSCI were isolated from 4 prospective, multi-center datasets. Patients who had a Glasgow coma scale of less than 13, were over the age of 70 or under 16 were excluded. Significant gain was defined to include those that recovered more than two muscle groups (greater than 3/5 power) below their level of injury. Analysis of variance (ANOVA) was then done to compare significant gain over the 1 year follow-up period for patients with and without early decompressive surgery (<24hrs). Results: We identified 420 cervical ASIA A tCSCI patients. The mean number of muscle groups gained was 2.69 (SD 2.3.12) for those who had early surgery compared to 2.37 (SD 3.38) for those with late surgery. Of those patients who had early surgery 39.67% had a significant improvement vs. 28.76% of those who did not have early surgery (P = 0.030). Conclusions: For the first time, we have shown a clear therapeutic benefit of early surgical decompression within 24 hrs in ASIA A tCSCI patients.

Background: Enhanced Recovery After Surgery (ERAS) Protocols improve post-surgical outcomes through decreased length of hospital stay, reduced readmission rates, decreased post-operative pain, and greater patient satisfaction. ERAS also has significant benefits to the healthcare system through reduced cost of post-operative care. While ERAS protocols are well established in many surgical fields, a complete guideline for spine surgery is lacking. Early ERAS studies in spine surgery suggest up to a 50% reduction in length of stay (LOS) and decreased cost of care. Methods: Primary literature review followed by multidisciplinary critical appraisal for optimization and redesign of our current system of care for scheduled spine surgery (SSS), including patient experience and team logistics from initial consultation through post-operative care and follow up. Results: An evidence-based guideline, optimizing pre-, intra-, and post-operative phases of care was developed. Specific focus catered to pre-operative education and patient barriers to discharge. Further improvements in pre-admission patient goal setting, introduction of a patient care “passport”, post-operative reduction in narcotic administration, and increased same day post-operative mobilization were means to reduce LOS. Conclusions: A spine ERAS pathway was developed, allowing our care program to better facilitate patient recovery after SSS. Future work will aim to determine economic impact of the pathway.

Background: Occult spinal dysraphism (OSD) may be associated with visible cutaneous manifestations. A common non-pathological mimic of a dermal sinus tract is an incidental sacrococcygeal dimple. Choosing Wisely Canada Guidelines recommend these dimples not be imaged. Methods: This study assessed the appropriateness of spinal ultrasounds performed for the investigation of an OSD. We interrogated our local imaging system to analyze spinal ultrasounds being performed in babies less than 6 months of age, from 2017-2018. Results: 429 children had spinal ultrasounds ordered by pediatricians (55%), family doctors (21%), and neonatologists (20%). 183 children (43%) had imaging indications that was deemed “inappropriate”. Some of this cohort had further MRI imaging (5/183) or neurosurgical referral (8/183). None of these children underwent neurosurgery. 231 (54%) children had appropriate indications for imaging. Within this cohort MRI imaging (23/231), neurosurgical referral (24/231) and neurosurgical intervention occurred (4/231). All four “surgical children” harboured either a dorsal appendage or a subcutaneous lipoma. We estimated, declining inappropriate scans would save $22, 500 annually. Conclusions: A significant portion of local spinal ultrasound requests for OSD are inappropriate. Collaboration with other sites is ongoing to investigate if the Choosing Wisely guidelines for imaging this patient population are being practiced more efficiently.

Background: While the use of neural stem/progenitor cells has been reported as a promising therapeutic approach for spinal cord injury, direct comparison of adult primary animal spinal cord NSPCs have not been compared to human NSPCs under the same conditions to characterize intrinsic differences between human/animal NSPC response to inflammatory/regenerative factors. Methods: To mimic post-injury inflammation, primary-derived NSPCs from adult humans, pigs, and rats were treated with pro-inflammatory factors.To direct regeneration, NSPCs were treated with retinoic acid, platelet-derived growth factor or bone morphogenic protein-(BMP4) to induce neurons, oligodendrocytes or astrocytes, respectively.Cultures were treated for 7 or 14 days and characterized by immunocytochemistry. Results: Pro-inflammatory factors promoted more astrogenesis in rat and pig NSPCs compared to human NSPCs and induced neuronal differentiation in human NSPCs. RA increased neurogenesis of human and rat NSPCs, PDGFα increased oligodendrocyte differentiation of rat NSPCs, and BMP4 increased astrogenesis of human and rat NSPCs Conclusions: For the first time, differences in response of human, pig and rat primary NSPCs to inflammatory and regenerative factors have been identified. Better understanding of these differences is essential to improving the successful translation of regenerative therapies to humans.