Rex A. W. Marco

Study Design: Systematic review. Objective: To perform a systematic review that investigates the incidence and risk factors for cervical postlaminectomy kyphosis. Summary of Background Data: There is a wide range of incidences and risk factors for cervical postlaminectomy kyphosis reported within the literature. Definitive recommendations on indications and technical considerations to minimize this complication remain elusive. Methods: A systematic review was registered with PROSPERO and conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. All level I–III evidence studies investigating radiologic outcomes after cervical laminectomy for compressive pathology of the cervical spine were included. Results: Twenty studies with 1538 patients (1007 males, 531 females) were included. Extensive laminectomy (≥4 laminae) was performed in 746 patients (48.5%), selective laminectomy (P P <0.001). Conclusions: The incidence of cervical postlaminectomy kyphosis varies widely, and the risk factors are multifactorial. Performing selective laminectomies and maximally preserving the attachments of the interspinales and/or semispinalis cervicis may be important considerations for preventing this complication. Levels of Evidence: Level III—systematic review of level I–III studies.

Study Design: Scoping Literature Review. Objective: The aim of this literature review is to examine the results of both skip laminectomy and oblique corpectomy in the setting of degenerative cervical myelopathy (DCM). Methods: A scoping review of the relevant literature examining the efficacy of cervical skip laminectomy and oblique corpectomy in patients with DCM was conducted using the Medline database. Our review strategy aimed at answering two research questions. #1: Do clinical outcomes differ between patients undergoing cervical laminoplasty vs skip laminectomy in the setting of myelopathy. #2: Which outcomes can oblique corpectomy provide, and how its related complication profile differs from other motion preserving procedures? What is the incidence of persistent myelopathy requiring reoperation following oblique corpectomy? Results: Our query identified 43 potentially relevant articles. For questions 1, 3 were deemed relevant to the research question posed. For question 2, 6 articles were deemed relevant to the research question posed. Both cervical skip laminectomy and cervical oblique corpectomy are viable options for the treatment of DCM. Skip laminectomy compared to laminoplasty resulted in at least equivalent results in regard to functional outcomes and retained range of motion. Oblique corpectomy in appropriately indicated patients results in improved functional outcomes. It carries the unique increased risk of temporary and permanent Horner’s syndrome compared to other motion preserving cervical procedures. Conclusion: Additional well designed comparative studies are required to draw firm conclusions in the treatment of cervical myelopathy with these alternative motion preserving techniques.

Background: Shame is an emotional experience in health professions education, often contributing to burnout, isolation, and threats to professional identity. Self-compassion has been identified as a protective factor against shame. This study describes the development and evaluation of an elective designed to foster shame resilience and cultivate self-compassion among health professions students. Methods: A 6-h elective, Fostering Connection and Shame Resilience Through Self-Compassion , was offered over 3 monthly 2-h sessions. Each session included a shared meal, abbreviated large-group conceptual learning, reflective writing, guided self-compassion practices, and small-group discussions. Participants completed the Self-Compassion Scale-Short Form (SCS-SF) at the beginning and end of the course and the Shame Frequency Questionnaire in Medical Students (SFQ-MS) at the end. A control group of nonparticipating medical students completed the SFQ-MS for comparison. An anonymous program evaluation survey was also conducted. Results: Of 21 learners who completed both pre and post SCS-SF scales, statistically significant improvements were observed in 7 of 12 items and in 4 of 6 subscales (Self-Kindness, Self-Judgment, Common Humanity, and Mindfulness). The total self-compassion score increased from mild to moderate. On the SFQ-MS, 6 of 12 items showed statistically significant differences between the postelective group and matched controls. Program evaluation data indicated that 62% reported significantly greater awareness of shame, and 57% reported significantly increased openness to practicing self-compassion. Conclusions: This elective represents an innovative approach to improving emotional resilience in learners, integrating experiential learning, interpersonal connection, and small-group learning. Findings suggest that even brief interventions can positively impact learners’ self-compassion and aspects of shame resilience. Curricula addressing these affective domains may offer valuable tools for enhancing well-being and professional identity formation in health professions education.

Study Design: Literature review of key topics related to degenerative cervical myelopathy (DCM) with critical appraisal and clinical recommendations. Objective: This article summarizes several key current topics related to the management of DCM. Methods: Recent literature related to the management of DCM was reviewed. Four articles were selected and critically appraised. Recommendations were graded as Strong or Conditional. Results: Article 1: The Relationship Between pre-operative MRI Signal Intensity and outcomes. Conditional recommendation to use diffusion-weighted imaging MR signal changes in the cervical cord to evaluate prognosis following surgical intervention for DCM. Article 2: Efficacy and Safety of Surgery for Mild DCM. Conditional recommendation that surgery is a valid option for mild DCM with favourable clinical outcomes. Article 3: Effect of Ventral vs Dorsal Spinal Surgery on Patient-Reported Physical Functioning in Patients With Cervical Spondylotic Myelopathy: A Randomized Clinical Trial. Strong recommendation that there is equipoise in the outcomes of anterior vs posterior surgical approaches in cases where either technique could be used. Article 4: Machine learning-based cluster analysis of DCM phenotypes. Conditional recommendation that clinicians consider pain, medical frailty, and the impact on health-related quality of life when counselling patients. Conclusions: DCM requires a multidimensional assessment including neurological dysfunction, pain, impact on health-related quality of life, medical frailty and MR imaging changes in the cord. Surgical treatment is effective and is a valid option for mild DCM. In patients where either anterior or posterior surgical approaches can be used, both techniques afford similar clinical benefit albeit with different complication profiles.

Study Design: Clinical practice guideline development. Objectives: Acute spinal cord injury (SCI) can result in devastating motor, sensory, and autonomic impairment; loss of independence; and reduced quality of life. Preclinical evidence suggests that early decompression of the spinal cord may help to limit secondary injury, reduce damage to the neural tissue, and improve functional outcomes. Emerging evidence indicates that “early” surgical decompression completed within 24 hours of injury also improves neurological recovery in patients with acute SCI. The objective of this clinical practice guideline (CPG) is to update the 2017 recommendations on the timing of surgical decompression and to evaluate the evidence with respect to ultra-early surgery (in particular, but not limited to, <12 hours after acute SCI). Methods: A multidisciplinary, international, guideline development group (GDG) was formed that consisted of spine surgeons, neurologists, critical care specialists, emergency medicine doctors, physical medicine and rehabilitation professionals, as well as individuals living with SCI. A systematic review was conducted based on accepted methodological standards to evaluate the impact of early (within 24 hours of acute SCI) or ultra-early (in particular, but not limited to, within 12 hours of acute SCI) surgery on neurological recovery, functional outcomes, administrative outcomes, safety, and cost-effectiveness. The GRADE approach was used to rate the overall strength of evidence across studies for each primary outcome. Using the “evidence-to-recommendation” framework, recommendations were then developed that considered the balance of benefits and harms, financial impact, patient values, acceptability, and feasibility. The guideline was internally appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool. Results: The GDG recommended that early surgery (≤24 hours after injury) be offered as the preferred option for adult patients with acute SCI regardless of level. This recommendation was based on moderate evidence suggesting that patients were 2 times more likely to recover by ≥ 2 ASIA Impairment Score (AIS) grades at 6 months (RR: 2.76, 95% CI 1.60 to 4.98) and 12 months (RR: 1.95, 95% CI 1.26 to 3.18) if they were decompressed within 24 hours compared to after 24 hours. Furthermore, patients undergoing early surgery improved by an additional 4.50 (95% 1.70 to 7.29) points on the ASIA Motor Score compared to patients undergoing surgery after 24 hours post-injury. The GDG also agreed that a recommendation for ultra-early surgery could not be made on the basis of the current evidence because of the small sample sizes, variable definitions of what constituted ultra-early in the literature, and the inconsistency of the evidence. Conclusions: It is recommended that patients with an acute SCI, regardless of level, undergo surgery within 24 hours after injury when medically feasible. Future research is required to determine the differential effectiveness of early surgery in different subpopulations and the impact of ultra-early surgery on neurological recovery. Moreover, further work is required to define what constitutes effective spinal cord decompression and to individualize care. It is also recognized that a concerted international effort will be required to translate these recommendations into policy.

Study Design: Clinical practice guideline development following the GRADE process. Objectives: Hemodynamic management is one of the only available treatment options that likely improves neurologic outcomes in patients with acute traumatic spinal cord injury (SCI). Augmenting mean arterial pressure (MAP) aims to improve blood perfusion and oxygen delivery to the injured spinal cord in order to minimize secondary ischemic damage to neural tissue. The objective of this guideline was to update the 2013 AANS/CNS recommendations on the hemodynamic management of patients with acute traumatic SCI, acknowledging that much has been published in this area since its publication. Specifically, we sought to make recommendations on 1. The range of mean arterial pressure (MAP) to be maintained by identifying an upper and lower MAP limit; 2. The duration of such MAP augmentation; and 3. The choice of vasopressor. Additionally, we sought to make a recommendation on spinal cord perfusion pressure (SCPP) targets. Methods: A multidisciplinary guideline development group (GDG) was formed that included health care professionals from a wide range of clinical specialities, patient advocates, and individuals living with SCI. The GDG reviewed the 2013 AANS/CNS guidelines and voted on whether each recommendation should be endorsed or updated. A systematic review of the literature, following PRISMA standards and registered in PROSPERO, was conducted to inform the guideline development process and address the following key questions: (i) what are the effects of goal-directed interventions to optimize spinal cord perfusion on extent of neurological recovery and rates of adverse events at any time point of follow-up? and (ii) what are the effects of particular monitoring techniques, perfusion ranges, pharmacological agents, and durations of treatment on extent of neurological recovery and rates of adverse events at any time point of follow-up? The GDG combined the information from this systematic review with their clinical expertise in order to develop recommendations on a MAP target range (specifically an upper and lower limit to target), the optimal duration for MAP augmentation, and the use of vasopressors or inotropes. Using methods outlined by the GRADE working group, recommendations were formulated that considered the balance of benefits and harms, financial impact, acceptability, feasibility and patient preferences. Results: The GDG suggested that MAP should be augmented to at least 75-80 mmHg as the “lower limit,” but not actively augmented beyond an “upper limit” of 90-95 mmHg in order to optimize spinal cord perfusion in acute traumatic SCI. The quality of the evidence around the “target MAP” was very low, and thus the strength of this recommendation is weak. For duration of hemodynamic management, the GDG “suggested” that MAP be augmented for a duration of 3-7 days. Again, the quality of the evidence around the duration of MAP support was very low, and thus the strength of this recommendation is also weak. The GDG felt that a recommendation on the choice of vasopressor or the use of SCPP targets was not warranted, given the dearth of available evidence. Conclusion: We provide new recommendations for blood pressure management after acute SCI that acknowledge the limitations of the current evidence on the relationship between MAP and neurologic recovery. It was felt that the low quality of existing evidence and uncertainty around the relationship between MAP and neurologic recovery justified a greater range of MAP to target, and for a broader range of days post-injury than recommended in previous guidelines. While important knowledge gaps still remain regarding hemodynamic management, these recommendations represent current perspectives on the role of MAP augmentation for acute SCI.

Study Design: Scoping Review. Objective: To review the literature and summarize information on checklists and algorithms for responding to intraoperative neuromonitoring (IONM) alerts and management of intraoperative spinal cord injuries (ISCIs). Methods: MEDLINE® was searched from inception through January 26, 2022 as were sources of grey literature. We attempted to obtain guidelines and/or consensus statements from the following sources: American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), American Academy of Neurology (AAN), American Clinical Neurophysiology Society, NASS (North American Spine Society), and other spine surgery organizations. Results: Of 16 studies reporting on management strategies for ISCIs, two were publications of consensus meetings which were conducted according to the Delphi method and eight were retrospective cohort studies. The remaining six studies were narrative reviews that proposed intraoperative checklists and management strategies for IONM alerts. Of note, 56% of included studies focused only on patients undergoing spinal deformity surgery. Intraoperative considerations and measures taken in the event of an ISCI are divided and reported in three categories of i) Anesthesiologic, ii) Neurophysiological/Technical, and iii) Surgical management strategies. Conclusion: There is a paucity of literature on comparative effectiveness and harms of management strategies in response to an IONM alert and possible ISCI. There is a pressing need to develop a standardized checklist and care pathway to avoid and minimize the risk of postoperative neurologic sequelae.

Study Design: Development of a clinical practice guideline following the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) process. Objective: The objectives of this study were to develop guidelines that outline the utility of intraoperative neuromonitoring (IONM) to detect intraoperative spinal cord injury (ISCI) among patients undergoing spine surgery, to define a subset of patients undergoing spine surgery at higher risk for ISCI and to develop protocols to prevent, diagnose, and manage ISCI. Methods: All systematic reviews were performed according to PRISMA standards and registered on PROSPERO. A multidisciplinary, international Guidelines Development Group (GDG) reviewed and discussed the evidence using GRADE protocols. Consensus was defined by 80% agreement among GDG members. A systematic review and diagnostic test accuracy (DTA) meta-analysis was performed to synthesize pooled evidence on the diagnostic accuracy of IONM to detect ISCI among patients undergoing spinal surgery. The IONM modalities evaluated included somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), electromyography (EMG), and multimodal neuromonitoring. Utilizing this knowledge and their clinical experience, the multidisciplinary GDG created recommendations for the use of IONM to identify ISCI in patients undergoing spine surgery. The evidence related to existing care pathways to manage ISCI was summarized and based on this a novel AO Spine-PRAXIS care pathway was created. Results: Our recommendations are as follows: (1) We recommend that intraoperative neurophysiological monitoring be employed for high risk patients undergoing spine surgery, and (2) We suggest that patients at “high risk” for ISCI during spine surgery be proactively identified, that after identification of such patients, multi-disciplinary team discussions be undertaken to manage patients, and that an intraoperative protocol including the use of IONM be implemented. A care pathway for the prevention, diagnosis, and management of ISCI has been developed by the GDG. Conclusion: We anticipate that these guidelines will promote the use of IONM to detect and manage ISCI, and promote the use of preoperative and intraoperative checklists by surgeons and other team members for high risk patients undergoing spine surgery. We welcome teams to implement and evaluate the care pathway created by our GDG.

We thank the authors for their interest in and commentary on “Preoperative Serum Albumin Level Predicts Length of Stay and Perioperative Adverse Events Following Vertebral Corpectomy and Posterior Stabilization for Metastatic Spine Disease.” We appreciate the opportunity to respond to their comments herein.

Study Design: Retrospective review of a prospectively collected national database Objectives: To determine the association between preoperative serum albumin levels and perioperative adverse events (AEs) following vertebral corpectomy and posterior stabilization for metastatic spine disease. Methods: The 2010 to 2019 American College of Surgeons’ National Surgical Quality Improvement (ACS-NSQIP) database was used to identify all patients undergoing vertebral corpectomy and posterior stabilization for metastatic spine disease. Receiver operative characteristic (ROC) curve analysis was used to determine preoperative serum albumin cut-off values for predicting perioperative AEs. Low preoperative serum albumin was defined as serum albumin below this cut-off value. Results: A total of 301 patients were included in the study. ROC curve analysis demonstrated serum albumin < 3.25 g/dL as a cut-off value for predicting perioperative AEs. The low serum albumin group had a higher overall perioperative AEs ( P = .041), longer post-operative LOS ( P < .001), higher 30-day reoperation rate ( P = .014), and a higher in-hospital mortality rate ( P = .046). Multivariate analysis demonstrated that low preoperative serum albumin was associated with higher perioperative AEs. Conclusions: Low serum albumin level is associated with higher perioperative AEs, longer postoperative LOS, and higher rates of 30-day reoperation and in-hospital mortality among patients undergoing vertebral corpectomy and posterior stabilization for metastatic spine disease. Strategies to improve preoperative nutritional status in patients undergoing this procedure may improve these perioperative outcome measures within this surgical population. Level of Evidence: III