Background: The study design was a prospective clinical cohort study. The aim of this study was to assess the patient-reported outcome measures (PROMs), patient satisfaction, as well as complication and reoperation rate of cervical hybrid procedures for symptomatic cervical multilevel degenerative disc disease (MLDDD). Cervical total disc replacement (CTDR) has been shown to be safe and effective for the treatment of degenerative pathologies. However, there is minimal PROMs data on the outcomes of combined CTDR and anterior cervical decompression and fusion procedures, commonly referred to as cervical hybrid surgery. Methods: Prospectively collected PROMs were analyzed from patients receiving cervical hybrid surgery for symptomatic cervical MLDDD. Between 2004 and 2016, data were collected preoperatively and postoperatively at 3, 6, and 12 months, then yearly thereafter. Patient reported outcome measures included patient satisfaction, visual analog score for neck and arm, and Neck Disability Index. Complication and reoperation rates were also assessed. Results: A total of 151 patients (80 males, 71 females) who had a minimum of 12 months follow up were included. The mean age was 53 years (range ¼ 24-81), and median follow up was 2 years (range ¼ 1-10). The median number of levels treated was 3, with 29.8%, 49.0%, and 21.2% of patients having 2, 3, and 4 levels treated, respectively. The most common indication for surgery was multilevel cervical spondylotic radiculopathy (52.8%), followed by combined cervical spondylotic radiculomyelopathy (16.7%), axial neck pain (16%), and cervical spondylotic myelopathy (13.9%). Improvement in pain and disability scores were both clinically and statistically significant (P , .001), and these improvements were sustained throughout the course of follow up. There was a 16% incidence of minor adverse events, and 3 (1.9%) reoperations. Conclusions: Cervical hybrid surgery for cervical MLDDD demonstrates favorable and sustained clinical outcomes at short-term to midterm follow up. Level of Evidence: 4. Clinical Relevance: Statistically and substantial clinical benefits can be achieved by cervical hybrid surgery, in the treatment of cervical pathologies including radiculopathy and myelopathy. The key principles is to follow strict indications, and to match technology with the pathology.

Study Design.A prospective study.Objective.The aim of this study was to evaluate clinical and patient outcomes post combined total disc arthroplasty (TDA) and anterior lumbar interbody fusion (ALIF), known as hybrid surgery for the treatment of multilevel symptomatic degenerative disc disease (DDD).Summary of Background Data.Class I studies comparing the treatment of one-level lumbar DDD with TDA and ALIF have confirmed the effectiveness of those treatments through clinical and patient outcomes. Although the success of single-level disease is well documented, the evidence relating to the treatment of multilevel DDD with these modalities is emerging. With the evolution of the TDA technology, a combined approach to multilevel disease has developed in the form of the hybrid procedure.Methods.A total of 617 patients underwent hybrid surgery for chronic back pain between July 1998 and February 2012. Visual Analog Pain Scale for the back and leg were recorded along with the Oswestry Disability Index and Roland Morris Disability Questionnaire.Results.Both statistically and clinically significant (p < 0.005) reductions were seen in back and leg pain, which were sustained for at least 8 years postsurgery. In addition, significant improvements (P < 0.001) in self-rated disability and function were also maintained for at least 8 years. Patient satisfaction was rated as good or excellent in >90% of cases.Conclusion.The results of this research indicate that improvements in both back and leg pain and function can be achieved using the hybrid lumbar reconstructive technique.Level of Evidence: 4

Study Design. Case series Objective. The aim of this study was to assess the patient-reported outcome measures (PROMs) and patient satisfaction of multilevel lumbar total disc arthroplasty (TDA) for symptomatic multilevel degenerative disc disease (MLDDD). Summary of Background Data. TDA has been shown to be safe and effective for the treatment of symptomatic single level degenerative disc disease. There is minimal PROMs data on the mid- to long-term outcomes of multilevel TDA constructs. Methods. Prospectively collected PROMs were analyzed from patients receiving multilevel TDA for symptomatic MLDDD. Data were collected preoperatively and postoperatively at 3, 6, and 12 months, then yearly. PROMs included patient satisfaction, Visual Analog Score back and leg, Oswestry Disability Index, and Roland-Morris Disability Questionnaire. Results. One hundred twenty-two patients (77 men, 45 women) who had preoperative and at least 24-month follow-up data were included. The average age was 42 ± 8.2 years (range 21–61) and mean follow-up 7.8 years (range 2–10). The majority received two-level TDA, except two patients (1.6%) who received three-level TDA. The two- to three-level TDA's were at the levels L3–4, L4–5, and L5-S1, whereas most two levels (n = 110, 90.2%) were at L4–5 and L5-S1; the remainder (n = 10, 8.2%) being at L3–4 and L4–5. Implants used were Charité (DePuy Spine, Raynham, MA) in 119 patients (240 levels) and InMotion (DePuy Spine) in 3 patients (6 levels). Improvement in pain and disability scores were both clinically and statistically significant (P < 0.001), and this improvement was sustained in those patients over the course of their follow-up. Ninety-two percent of patients reported good or excellent satisfaction with treatment at final review. Conclusion. Multilevel TDA constructs for MLDDD demonstrate favorable and sustained clinical outcomes at mid- to long-term follow-up. Level of Evidence: 4

Background: Total disc replacement (TDR) has been shown to be effective for the treatment of lumbar degenerative disc disease (DDD) in carefully selected patients. Previous studies have demonstrated high rates of patient satisfaction and improvement in patient-reported outcome measures (PROMs) compared with preoperative status but most have short-term follow-up or small cohort sizes only.Objective: The aim of this study is to report mid-to long-term PROMs from the treatment of symptomatic single-level lumbar DDD with TDR.Methods: Data collected prospectively concerning single-level TDR performed via an anterior approach were included for analysis. A preoperative assessment was obtained followed by postoperative follow-up assessments at 3, 6, and 12 months, and yearly follow-up thereafter. PROMs included patient satisfaction, visual analog score back and leg, Oswestry Disability Index, and Roland-Morris Disability Questionnaire.Results: A total of 211 patients (118 men, 93 women) operated on between June 1997 and July 2015 were included in this study. Minimum follow-up was 4 years. The average age was 42.2 (range 24-87) years and median follow-up 96 interquartile range 72-132, range 48-120) months. The operative levels were L5-S1 (160, 75.8%) and L4-L5 (61, 24.2%). Both statistically and clinically significant improvements observed postoperatively were maintained at 10 years. In addition, 92% of patients reported either good (n = 29) or excellent satisfaction (n = 155) with treatment at final review.Conclusions: This study shows that single-level lumbar TDR used appropriately in selected patient results in clinically significant improvements in pain and function, well above the minimum clinically important difference, and good to excellent satisfaction in most patients. Further study to define long-term outcomes and survivorship is required.Clinical Relevance: Statistically significant and clinically relevant improvements can be achieved by single-level lumbar TDR, in the treatment of single-level discogenic axial low back pain, with or without radiculopathy. These outcomes are sustained in the mid-to long-term followup periods.Level of Evidence: 4.

Background: Treatment options for aortic-iliac pathology may include endovascular repair and open surgical repair. Treatment options for degenerative disc disease (DDD) are varied but commonly include anterior reconstruction. When both the aortic-iliac and spinal pathologies are significant and surgical intervention is indicated for each pathology, the opportunity exists for concurrent treatment of both the aortic-iliac pathology and DDD in the same operation. The purpose of this case series was to document the safety and feasibility of a surgical strategy whereby a combined elective reconstructive procedure was performed for aortic and anterior lumbar spinal pathologies.Methods: The case histories of 5 patients who were treated for both spinal and vascular pathology are presented. Surgical outcome measures included operative time, blood loss, length of stay, and complications. Spine-specific outcome measures included Oswestry Disability Index, Roland Morris Disability Questionnaire, and visual analogue scores (back and leg).Results: The spinal reconstructions performed included 1 L4-5 total disc replacement (TDR), 1 L4-5, L5-S1 anterior lumbar interbody fusion (ALIF), 1 L5-S1 ALIF, and 2 hybrid procedures (L4-5 TDR with L5-S1 ALIF). Vascular reconstructions included 4 aorto-bi-iliac bypass grafts and 1 aortic tube graft. The average operative time was 365 minutes (ranging between 330 and 510 minutes), the average blood loss was 1699 mL (range between 1160 and 2960 mL), and the average length of hospital stay was 14 days (range from 8 to 22 days). There were no in-hospital complications, and all patients experienced significant improvement in both back and leg pain. One patient developed kinking of the iliac limbs of the vascular graft 1 year postoperatively, which was managed with endovascular stenting of the graft.Conclusions: Aortic-iliac pathology and DDD are significant pathologies often treated in isolation. This study illustrates that, despite its complexity, highly trained individuals in a specialized setting can perform combined surgery to achieve a satisfactory outcome for the patient.Level of Evidence: Level IV evidence. Lumbar SpineKeywords: abdominal aortic aneurysm, total disc arthroplasty, anterior lumbar interbody fusion, aortic iliac occlusive disease, multidisciplinary approach by guest on July 5, 2020 http://ijssurgery.com/ Downloaded from Abbreviations: VAS, visual analogue score; ODI, Oswestry Disability Index; RMDQ, Roland Morris Disability Questionnaire.

Lumbar interbody fusion is an established surgical technique for a variety of conditions affecting the lumbar spine. A large number of interbody fusion devices made of differing materials are now available for use. Approaches for interbody fusion include anterior lumbar interbody fusion, oblique lumbar interbody fusion, lateral lumbar interbody fusion, axial lumbar interbody fusion, transforaminal lumbar interbody fusion, and posterior lumbar interbody fusion. This chapter discusses the biomechanics of lumbar interbody fusion devices and approaches and the clinical rationale and the clinical results of each approach. The advantages and disadvantages of each approach are compared and contrasted. The importance of an appropriate preoperative assessment to determine the best approach for interbody fusion is emphasized, taking into account the condition being treated, sagittal balance, bone quality, and contraindications to a specific approach. The best approach to lumbar interbody fusion by indication and surgical level(s) is discussed.

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Background: The literature reports that index level (IL) revision spine surgery (RSS) and adjacent level (AL) RSS are diminished in lumbar TDR compared with fusion procedures. There is a paucity of PROMs reported after RSS.Objective: To present the incidence of RSS at the IL and AL following single-level lumbar total disc replacement (TDR) and to document patient-related outcome measures (PROMs) associated with RSS.Methods: PROMs and timelines were analyzed for 32 RSS patients from a prospective cohort study of 401 patients treated with TDR for single-level degenerative disc disease. The data collected prospectively are analyzed from baseline (prior to index surgery) to latest follow-up following RSS. PROMs, including visual analog scales for back and leg, Oswestry Disability Index, and Roland-Morris Disability Questionnaire, were collected preoperatively; postoperatively at 3, 6, and 12 months; and annually thereafter until RSS. The time to RSS was recorded, and PROMs for RSS (IL, AL, or both) were documented, analyzed, and compared.Results: The median time to RSS in the IL cohort was 35 months (interquartile range [IQR] = 9-51 months). The median time to RSS cohort was 70 months (IQR = 41.3-105.3 months). Timepoints facilitate PROM discussion for RSS. Patients in both groups achieved thresholds for the minimum clinically important difference for pain and disability scores. The small sample size in each group contributed to the variability demonstrated by the 95% CIs, thereby cautioning definitive conclusions.Conclusions: This study reveals that statistically significant and modest clinical improvements in PROMs can be achieved in RSS for lumbar TDR at IL and AL. The surgical approach and technique are reflective of the pathology and suggest that anterior RSS for AL degeneration and posterior RSS for IL pathology yield similar results.Clinical Relevance: Statistical and clinical improvements can be achieved in IL-RSS and AL-RSS following single level TDR. It is essential for clinicians to understand and verify the underlying IL and/or AL pathology to select an appropriate management strategy and to facilitate balanced informed discussions with patients.Level of Evidence: 4.