Erik Edström

Objective: Adjacent segment disease (ASD) is a recognized long-term complication after anterior cervical discectomy and fusion (ACDF). Cervical disc arthroplasty (CDA) was introduced as a motion-preserving alternative, thought to reduce stress at adjacent levels and lower ASD risk. This study aimed to compare the risk of ASD requiring reoperation after ACDF and CDA and identify factors associated with ASD.Methods: This retrospective cohort study used prospectively collected data from the Swedish Spine Registry (Swespine) and included adult patients undergoing anterior cervical surgery for degenerative cervical disease between 2006 and 2026. ASD was defined as a secondary operation at an adjacent level ≥12 months after the index procedure. Cumulative incidence was estimated using Kaplan-Meier analysis, and associations with ASD were evaluated using multivariable Cox proportional hazards regression. Radiological or conservatively treated ASD were not assessed.Results: A total of 9,338 patients were included (ACDF, n=9,005; CDA, n=333). During 45,666 person-years follow-up, 509 ASD events occurred (incidence rate 11.1 per 1,000 person-years). Cumulative incidence was 4.9% at 5 years and 10.4% at 10 years. CDA was associated with lower ASD hazard than ACDF (hazard ratio [HR], 0.61) though this association was not significant after propensity score matching (HR, 0.88). Multilevel procedures (HR, 0.61), increasing age (HR, 0.96 per year), and radiculopathy were associated with lower risk, while myelopathy or stenosis was associated with higher risk (HR, 1.22).Conclusion: The long-term risk of ASD requiring reoperation was lower than previously reported. After adjustment, CDA was associated with lower ASD risk compared to ACDF, although the absolute difference was small, and the clinical significance remains uncertain.

Instability of the craniocervical junction is a potentially life-threatening condition requiring surgical stabilization. Traditional occipital plate fixation carries risks of construct loosening and intracranial complications due to variable skull thickness, particularly after posterior fossa decompression where plate fixation is challenging. Occipital condyle screws (OCS) provide direct fixation into the occipital condyles (OCs). However, comprehensive outcome data remains sparse. This systematic review and meta-analysis evaluated anatomical parameters, technical aspects, and surgical outcomes of OCS fixation in craniocervical stabilization. Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, PubMed/MEDLINE, Embase, and Scopus were searched for studies reporting techniques and outcomes of occipitocervical fixation using OCS. Two reviewers independently extracted data, and study quality was assessed using the Newcastle-Ottawa Scale, when possible. Random-effects meta-analysis was performed. The primary endpoint was to characterize the technical aspects of craniocervical fixation using OCS and to ascertain its overall feasibility, defined by morphometric suitability, technical success rates, and complication rates. Thirty studies met inclusion: 12 cadaveric (618 specimens), 10 imaging (1,604 participants), and 8 surgical (284 patients). Morphometry consistently showed larger OC in male populations. Bicortical screw placement achieved 100% technical success. Standard 3.5-mm screws (18–24 mm) were commonly used. Recommended trajectories varied (sagittal with 18°–28° angulation; axial with 22°–37° angulation). No major symptomatic vascular or permanent neurological complications occurred. Meta-analytic data revealed significant differences in morphometric measurements of the OC and differences in the OCS length and angulation parameters. OCS fixation appears to be an anatomically feasible and technically promising fixation strategy in selected patients when anatomy and technique are carefully evaluated. Population-specific morphometric variability mandates individualized preoperative assessment. Future comparative studies should define long-term outcomes, fusion rates, and optimize region-specific surgical parameters.

BACKGROUND AND OBJECTIVES: External ventricular drainage (EVD) care bundle approaches are associated with reduced infection rates after EVD insertion. However, awareness and standardization of such protocols remain limited, and the current literature is sparse and has a high variability in analysis. We conducted a systematic review and meta-analysis of appropriate studies to identify the key components of an effective EVD care bundle for reducing EVD-related infections (ERIs). METHODS: A systematic review of the literature was conducted to identify any studies presenting patient cohorts undergoing EVD placement and reporting the introduction of bundle care protocols including postoperative infection rates. Major scientific databases (PubMed/MEDLINE, EMBASE, and Scopus) were systematically searched for studies published up to December 31, 2024. Studies were screened, and data were extracted independently by 2 authors. RESULTS: Twenty-eight studies were included for analysis. ERI rates before and after the implementation of care bundle protocols were observed. Different care bundles were identified and categorized as follows: insertion bundles, manipulation bundles, dressing bundles, and others. Although the literature concerning the implementation of care bundles for ERI is deemed poor, our results show a significant reduction in the postoperative ERI rates; a meta-analysis of the studies comparing cohorts before and after the implementation of care bundle protocols reveals significant differences in the postoperative infection rate after EVD placement (odds ratio 3.70, 95% CI 2.89-4.74, P < .0001 for the overall effect, heterogeneity I ² = 46%). CONCLUSION: Implementation of care bundle approaches for EVD insertion is associated with a significant reduction in ERIs. The implementation of care bundle approaches and the strict knowledge, training, and adherence to these protocols permit a standardization of the procedure and a better postoperative management diminishing complication rates. The available evidence supports the broader adoption of care bundle protocols as a new standard of care in clinical practice.

Coccydynia is a painful condition of the coccyx that is frequently misdiagnosed and managed inconsistently. This review summarizes and grades the current evidence on diagnostic strategies and treatment options. We systematically searched the literature and included 42 studies covering conservative, interventional, and surgical management. Based on these data, we propose a current best framework for diagnostic evaluation and therapeutic management. Initial assessment should include detailed history and focused examination with palpation for localized coccygeal tenderness and symptom provocation. Standard anteroposterior and lateral radiographs are recommended mainly to exclude serious pathology, while dynamic sitting-standing radiographs can be considered when mechanical pain is suspected and symptoms persist. Cross-sectional imaging with magnetic resonance imaging or computed tomography (CT) should be reserved for trauma, red-flag features, suspected neoplasm or infection, or inconclusive basic imaging. First-line treatment should consist of education, ergonomic advice, offloading strategies, nonsteroidal anti-inflammatory drugs or other simple analgesics, and physiotherapy, with extracorporeal shock wave therapy having the strongest support. In patients with persistent pain, image-guided diagnostic and therapeutic injections and radiofrequency procedures can provide substantial relief and help select candidates for more invasive treatment. Coccygectomy should be reserved for patients with chronic, function-limiting pain who have failed conservative and interventional care and show concordant findings on assessment, imaging, and diagnostic blocks, while modified incision strategies and minimally invasive techniques may be considered in selected cases.

Surgical navigation and augmented reality (AR) are widely used in neurosurgery, spinal surgery, and orthopedics. However, their use in minimally invasive abdominal and thoracic soft-tissue surgery is limited, as tracking deformable, mobile organs is challenging. Recent advances in AR may address these challenges to improve intraoperative navigation. This systematic review, registered in PROSPERO (2024) and based on PRISMA guidelines, analyzes literature from 2014 to 2024 about AR in minimally invasive abdominal and thoracic soft-tissue surgery. It identifies target organs, describes AR hardware and software, and evaluates accuracy levels, usability outcomes, clinical benefits, technical limitations, and research needs. Searches of PubMed, Web of Science, and Embase for English-language studies found 1297 records, of which only 28 (2%) met the inclusion criteria. Nearly half (n =12; 42%) focused on liver surgery; none on gynecologic surgery. The AR devices varied in tracking methods, image processing, visualization, and display. Overall, AR improved anatomical guidance and procedural planning, especially in complex surgeries. Integration with robotic systems may further boost visualization, precision, and workflow, though challenges remain in standardization, large-cohort validation, and workflow integration.

Background: Cervical spondylosis is a common degenerative condition of the cervical spine that often requires surgical intervention. Obesity is a modifiable risk factor that may influence surgical outcomes, including those in cervical spine procedures. This study aims to examine the relationship between obesity and patient-reported outcomes, including pain, function, and return to work, following anterior surgery for cervical spondylosis. Methods: We conducted a retrospective longitudinal cohort study using data from the Swedish National Spine Register (Swespine) on patients who underwent anterior cervical surgery for cervical spondylosis between 2006 and 2021. We compared preoperative and postoperative pain, function, and quality of life, between obese and non-obese patients. Results: A total of 7,933 patients were included in the analysis. Baseline characteristics differed between obese and non-obese groups, with obese patients reporting lower preoperative baseline health-related quality of life and higher disability scores (p < 0.05). Nonetheless, at 1-year follow-up, both groups showed similar improvements in neck pain, arm pain, disability (NDI), and quality of life (EQ-5D index and EQ VAS). However, obese patients were less likely to experience complete arm pain relief and had slightly poorer recovery in fine motor skills. Additionally, obese patients had lower rates of return to work (33% vs. 28%, p = 0.003). On subgroup analysis, patients with severe or morbid obesity were found to have significantly higher risks of overall complications following surgery when compared to non-obese patients (3.4% vs. 1.4%; p = 0.009). Conclusion: Although obese patients were worse at baseline, they showed similar improvements in pain, function, and quality of life compared to non-obese patients following anterior cervical surgery. Our findings suggest that obesity should not preclude surgical intervention, as obese patients have the potential for significant postoperative recovery, although attention when treating severely or morbidly obese patients is warranted.

Purpose: The decision to cross the cervicothoracic junction (CTJ) during multilevel posterior cervical fusion remains controversial. While constructs extending into the thoracic spine may enhance stability, they may also increase surgical complexity. The clinical relevance of these differences, particularly regarding patient-reported outcomes (PROMs), is still unclear. We hence aimed to determine whether extending fusion across the CTJ impacts PROMs and perioperative complication rates in a nationwide cohort. Methods: This retrospective cohort study used prospectively collected data from the Swedish Spine Registry (Swespine). Adult patients who underwent multilevel posterior cervical fusion were divided into two groups: those ending at C7 and those extending beyond the CTJ. Baseline characteristics, surgical details, complication rates, and PROMs at 1- and 5-years were compared. Results: Baseline characteristics were similar between groups ( p ≥ 0.5). Perioperative complication and reoperation rates did not differ significantly between groups ( p ≥ 0.5). Similarly, at both one- and five-years of follow-up, PROMs, including pain scores, disability indices, and satisfaction, were comparable ( p ≥ 0.5). However, a significant difference was observed in terms of fine motor recovery, with patients whose constructs crossed the CTJ demonstrating a greater degree of improvement ( p = 0.009). Conclusions: Crossing the CTJ in multilevel posterior cervical fusion does not significantly affect complication rates, reoperations, or most PROMs at one and five years. Surgical decisions should prioritize anatomical and clinical factors, rather than expected differences in PROMs.

BACKGROUND AND OBJECTIVES: Degenerative cervical myelopathy (DCM) is a progressive disorder that leads to significant neurological deficits, often requiring surgical decompression to prevent further decline. There are only a handful of studies analyzing return-to-work (RTW) outcomes after cervical spine surgery for DCM. This study seeks to elucidate RTW outcomes and to identify predictors preventing RTW in patients surgically treated for DCM in a nationwide prospective registry. METHODS: A nationwide cohort analysis was conducted using prospectively gathered data from patients surgically treated for DCM, from the Swedish Spine Registry. Patients with documented postoperative outcomes focusing on RTW rates from 1 to 5 years were included. To identify predictive factors affecting RTW at 1 year postoperatively, separate univariable and multivariable logistic regression models were developed, incorporating demographic, functional and clinical, as well as preoperative and postoperative data and occupational characteristics. RESULTS: A total of 789 patients were included with an average age of 52 years, with most patients working in moderate intensity jobs and nearly half were on sick leave before surgery. Most surgeries were elective, using an anterior approach. The RTW rate at 1 year was 76%, separating into 54% who had resumed full-time employment and 23% who had returned to a part-time capacity. In this cohort, 24% had not returned to work at the 1-year mark. Older age, physically demanding work, higher preoperative Neck Disability Index Score, reduced walking distance, and sickness benefits were significant predictors of a lack of RTW. CONCLUSION: 75% of the patients surgically treated for DCM returned to work within 1 year. Higher age, physically demanding work, higher Neck Disability Index Score, and full-time sickness benefits were all associated with a decreased likelihood of RTW. Recognizing these risk factors can help identify patients who may benefit from additional physical therapy, behavioral interventions, counseling, or work-place adjustments to support RTW.

Purpose: Patient involvement and shared decision-making (SDM) are central to patient-centered care and have been linked to improved patient satisfaction and outcomes. However, their implementation in spinal surgery remains limited, and the effect of patient involvement on postoperative outcomes is not well described. Methods: This observational cohort study used data from the Swedish Spine Registry (Swespine) to examine the association between perceived patient involvement in decision-making and postoperative outcomes among adults undergoing cervical spinal surgery between 2006 and 2020. Propensity score-matching was performed at a ratio of 2:1 to minimize baseline differences between groups. Uni- and multivariable analyses were conducted to identify factors associated with patient’s perception of involvement in decision-making. Results: A total of 3,249 patients were included, with 81% (n = 2,640) reporting perceived involvement in decision-making and 19% (n = 609) not. Following matching, patients who were involved in decision-making had significantly greater improvements at one year follow-up regarding neck and arm pain (p < 0.001), disability (p < 0.001), health-related quality of life (p < 0.001), and subjective satisfaction (p < 0.001). Patients with poorer preoperative health status are more likely to feel involved in decision making, while those undergoing minor procedures feel significantly less involved. Positive predictors of perceived patient involvement included number of operated levels (OR 1.13, p = 0.041), unemployment (OR 1.89, p < 0.001), walking less than 100 m at a normal pace (OR 1.45, p = 0.044), and higher preoperative NDI (OR 1.01, p = 0.039). Negative predictors included higher preoperative EQ-5D index (OR 0.64, p = 0.022) and higher preoperative myelopathy score (OR 0.96, p = 0.042). Conclusion: Patients with a higher degree of perceived involvement report better postoperative patient-reported outcomes following cervical spinal surgery. Patients undergoing larger surgeries and with poorer preoperative health status were more likely to perceive involvement than those undergoing minor procedures. Identifying and supporting patients that are susceptible to feel less involved in treatment-related decisions through individualized information or counseling may help optimize outcomes and satisfaction.