Background: Anterior cervical discectomy and fusion (ACDF) for cervical degenerative disease is an accepted treatment for symptomatic cervical radiculopathy and myelopathy. One-and two-level fusions are much more common and more widely studied. Outcomes and revision rates for three-and four-level ACDF have not been well described. The purpose of this study is to report on clinical outcomes and revision rates following multilevel ACDF. Methods: Patients who underwent three-or four-level anterior cervical discectomy with plate fixation between 2006 and 2011 from a single-center multi-surgeon practice for symptomatic cervical degenerative disease were identified. Improvements in neck disability index (NDI), neck and arm pain scores two years after surgery and revision rates were analyzed. Results: Forty-six patients with a mean age of 55.9 years were included in the analysis. Twenty-one (46%) were male, 10 (22%) were smokers. Forty-one (89%) underwent three-level fusion and 5 (11%) underwent four-level fusion. NDI improved from 34.46 at baseline to 25.47 at 2 years. Neck pain improved from 7.04 at baseline to 3.95 and arm pain improved from 6.24 to 3.09 at 2 year follow up. Sixteen patients (35%) returned to surgery within 2 years with 11 of these patients (24%) returning for non-union. The average number of days to revision surgery was 750.6±570.3 days. Conclusions: Patients undergoing three-and four-level ACDF for multilevel cervical disease demonstrate substantial improvement in outcomes. However, the two-year revision rate is relatively high at 35% with the majority of these patients returning due to non-union.

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OBJECTIVEThe goal of this study was to determine efficacy and cost-effectiveness of Cell Saver in 2- and 3-level lumbar decompression and fusion.METHODSPatients seen at a tertiary care spine center who were undergoing a posterior 2- or 3-level lumbar decompression and fusion were randomized to have Cell Saver used during their surgery (CS group, n = 48) or not used (No Cell Saver [NCS] group, n = 47). Data regarding preoperative and postoperative hemoglobin and hematocrit, estimated blood loss, volume of Cell Saver blood reinfused, number of units and volume of allogeneic blood transfused intraoperatively and postoperatively, complications, and costs were collected. Costs associated with Cell Saver use were calculated based on units of allogeneic blood transfusions averted.RESULTSDemographics and surgical parameters were similar in both groups. The mean estimated blood loss was similar in both groups: 612 ml in the CS group and 742 ml in the NCS group. There were 53 U of allogeneic blood transfused in 29 patients in the NCS group at a total blood product cost of $67,688; and 38 U of allogeneic blood transfused in 16 patients in the CS group at a total blood cost of $113,162, resulting in a cost of $3031 per allogeneic blood transfusion averted using Cell Saver.CONCLUSIONSCell Saver use produced lower rates of allogeneic transfusion but was found to be more expensive than using only allogeneic blood for 2- and 3-level lumbar degenerative fusions. This increased cost may be reasonable to patients who perceive that the risks associated with allogeneic transfusions are unacceptable.■ CLASSIFICATION OF EVIDENCE Type of question: therapeutic; study design: randomized controlled trial; evidence: class III.

OBJECTIVE Studies have shown that anxious or depressed patients may have poorer outcomes after lumbar fusion. These conclusions were drawn from questionnaires specifically designed to measure anxiety and depression. The objective of this study is to determine if responses to the EQ-5D anxiety/depression domain or the items used to calculate the 36-Item Short-Form Health Survey (SF-36) Mental Component Summary (MCS) can predict outcomes after lumbar fusion surgery. METHODS Patients enrolled in the National Neurosurgery Quality and Outcomes Database from a single center with 1-year follow-up were identified. The outcomes collected include the Oswestry Disability Index (ODI), EQ-5D, SF-36, and the back- and leg-pain numeric rating scales (range 0–10). Linear regression modeling was performed to predict the 1-year ODI scores using the EQ-5D anxiety/depression domain and the 14 items used to calculate SF-36 MCS. RESULTS Complete data were available for 312 (88%) of 353 eligible patients. The mean patient age was 58.5 years, 175 (56%) patients were women, and 52 patients were smokers. After controlling for other factors, the item in the SF-36 that asks “Have you felt downhearted and depressed?” is the strongest predictor of the 1-year ODI score (r2 = 0.191; p = 0.000) and 1-year EQ-5D score (r2 = 0.205; p = 0.000). Neither the EQ-5D anxiety/depression domain nor the diagnoses of anxiety or depression were predictors of 1-year outcomes. CONCLUSIONS Patient responses to SF-36 item “Have you felt downhearted and depressed?” account for 20% of the variability of the 1-year ODI and EQ-5D scores and can be used by clinicians to screen for anxiety or depression in patients prior to lumbar fusion surgery. Clinicians may offer psychological support to these patients preoperatively in order to improve treatment outcomes.