When Can You Drive Again After 4 Level Cervical Fusion

Global Spine J. 2015 Aug; v(4): 274–281.

When Is It Safe to Render to Driving After Spinal Surgery?

Trevor P. Scott

¹Department of Orthopaedic Surgery, University of California at Los Angeles, Los Angeles, California, United States

William Pannel

²Department of Orthopaedic Surgery, Academy of Southern California, Los Angeles, California, United states

David Savin

^threeDepartment of Orthopaedic Surgery, University of Illinois at Chicago, Chicago, Illinois, United States

Stephanie S. Ngo

²Department of Orthopaedic Surgery, Academy of Southern California, Los Angeles, California, United States

Jessica Ellerman

^ivSection of Emergency Medicine, Academy of California at Los Angeles, Los Angeles, California, United States

Kristin Toy

¹Department of Orthopaedic Surgery, University of California at Los Angeles, Los Angeles, California, United States

Michael D. Daubs

⁵Department of Orthopaedic Surgery, University of Nevada, Las Vegas, United States

Daniel Lu

⁶Department of Neurological Surgery, University of California at Los Angeles, Los Angeles, California, U.s.

Jeffrey C. Wang

²Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California, United States

Received 2014 Jun 8; Accepted 2014 Dec 4.

Abstract

Report Design Prospective study.

Objective Surgeons' recommendations for a rubber return to driving post-obit cervical and lumbar surgery vary and are based on empirical data. Commuter reaction time (DRT) is an objective measure of the ability to bulldoze safely. There are express information most the effect of cervical and lumbar surgery on DRT. The purpose of our report was to use the DRT to determine when the patients undergoing a spinal surgery may safely render to driving.

Methods We tested 37 patients' DRT using computer software. Xx-three patients (mean fifty.5 ± 17.seven years) received lumbar surgery, and 14 patients had cervical surgery (mean 56.seven ± 10.nine years). Patients were compared with 14 healthy male controls (mean 32 ± 5.19 years). The patients having cervical surgery were subdivided into the inductive versus posterior approach and myelopathic versus nonmyelopathic groups. Patients having lumbar spinal surgery were subdivided by decompression versus fusion with or without decompression and single-level versus multilevel surgery. The patients were tested preoperatively and at ii to 3, 6, and 12 weeks following the surgery. The employ of opioids was noted.

Results Overall, the patients having cervical and lumbar surgery showed no significant differences between pre- and postoperative DRT (cervical p = 0.49, lumbar p = 0.196). Only the patients having single-level procedures had a pregnant improvement from a preoperative DRT of 0.951 seconds (standard deviation 0.255) to 0.794 seconds (standard divergence 0.152) at two to 3 weeks (p = 0.012). None of the other subgroups had a deviation in the DRT.

Conclusions Based on these findings, information technology may exist acceptable to allow patients having a single-level lumbar fusion who are not taking opioids to return to driving as early on as 2 weeks following the spinal surgery.

Keywords: return to driving, lumbar surgery, cervical surgery, driver reaction time

Introduction

A question oft asked of surgeons is when a patient may return to driving later a given process.^{1 two} The safety of the patient and the public must be weighed against the impact that an extended period of being unable to drive would have on the quality of life of the patient.^three

A patient's cognitive country, sensory motor coordination, experience, and fatigue and the local environs all contribute to driving power. However, ane gene universally agreed upon is the ability to terminate in an emergency; this can be measured as driver reaction time (DRT).⁴ The DRT has been studied for many dissimilar orthopedic procedures of the lower extremity.^{5 6 7 eight nine 10} Nevertheless, there are few studies about DRTs in patients afterwards spinal surgery. This lack of data makes it hard for surgeons to provide patients with authentic data virtually when they may return to driving.

Al-khayer et al performed a prospective written report of patients receiving nervus blocks of the lumbar spinal nerves and showed a small increase in DRTs at two weeks postoperatively, which resolved by 6 weeks postoperatively.^four Also, Liebensteiner et al performed a prospective study of patients who had lumbar fusion surgery and establish that the DRT was not significantly increased at i week after the surgery.¹¹ Thaler and colleagues demonstrated that patients who had lumbar disk surgery for radiculopathy showed a significant comeback in DRT at discharge compared with preoperatively; the same researchers also showed similar comeback in DRT on discharge later on anterior cervical decompression and fusion (ACDF) for cervical radiculopathy.^{12 13} Finally, in a recent postal service hoc analysis of information from a big prospective study, Kelly et al found that patients undergoing either ACDF or cervical unmarried-level arthroplasty had no difficulty with driving based on a neck disability questionnaire past postoperative 6 weeks.¹⁴

Our purpose was to perform a prospective study of patients receiving cervical or lumbar spinal surgery and measure their DRTs preoperatively and at starting time (two to 3 weeks), second (6 weeks), and 3rd (12 weeks) follow-up visits to determine when DRT returned to preoperative levels. We hypothesized that the patients would take an increase in DRTs at ii to iii weeks postoperatively, which would return to normal by 6 to 12 weeks postoperatively. We planned to clarify subgroups of these patients based on anterior or posterior surgical approach and on myelopathic or nonmyelopathic groups. The lumbar spine surgery group was divided into multi- or single-level surgery and past decompression alone or those who had had fusion with or without decompression. We expected the subgroups receiving multilevel fusion and those patients who were myelopathic would have a larger and longer-lasting increase in DRTs.

Methods

Participants

Between September 2008 and July 2011, 14 patients receiving cervical spine surgery and 23 patients receiving lumbar surgery were enrolled in the report. Patients were excluded from the study if they did not take a valid driver'southward license, were no longer operating a vehicle, or had a prior surgery within the previous year. The participation was voluntary, and no incentives were given to patients. The experiment was conducted nether the approving of the UCLA Institutional Review Lath. The surgeries were performed by one of the two senior surgeons.

In all, 17 men and six women (mean age fifty.five ± 17.7 years) received lumbar surgery, for a total of 23 patients. 9 patients received unmarried-level surgery and 14 received a multilevel surgery. In full, eleven patients underwent surgery involving decompression alone and 12 received fusion with or without decompression surgery (Table 1). Eight women and 6 men had cervical surgery (mean age 56.7 ± 10.9 years), and 5 patients had inductive cervical surgeries. 9 patients had the surgery via a posterior arroyo. One patient had both anterior and posterior surgeries and was included in the posterior surgery group. There were 11 patients with myelopathy and 3 without (Tabular array ane). Using Chile's modified Japanese Orthopaedic Association myelopathy scale, the average score was 15.45 ± 0.69. All the patients in the cervical group completed the pre- and postoperative DRT testing (100%). However, merely 6 patients completed the DRT testing at 6 weeks (42%), and five patients completed the testing at 12 weeks (36%). In the lumbar grouping, 21 of 23 patients completed the postoperative testing at 2 weeks (91%), 8 patients completed the testing at 6 weeks (35%), and 15 patients completed the testing at 12 weeks (65%). The patients were compared with a control group of fourteen healthy men (mean age 32 ± 5.nineteen years).

Table ane

Demographic data

	Cervical	Lumbar
Mean age (y)	56.7 ± 10.9	50.5 ± 17.7
Male:female	6:8	17:6
Single level:multilevelsurgery	NA	9:fourteen
Decompression:fusion with or without decompression	NA	eleven:12
Inductive:posterior	5:nine	NA
Myelopathic:nonmyelopathic	xi:iii	NA
Total	fourteen	23

Procedure

DRT was measured using commercial estimator instrumentation and software (Vericom Reaction Timer; Rogers, Minnesota, United States).^fifteen The patients were given instructions and the risk to practice on the simulator. The patients then performed 15 divide successful simulations where they responded to a stimulus and reacted appropriately. A successful simulation meant the patient responded correctly. The simulation started with the patient belongings the gas pedal down a predetermined amount, which was represented on the system by the speedometer measuring betwixt 35 and 65 mph. The software and then recorded the response time to five different stimuli: left turn, correct plow, brake, brake + left plough, restriction + correct plow. The patients were tested preoperatively and then postoperatively at ii to 3, 6, and 12 weeks following the surgery. At the postoperative visits, the patients were given the opportunity to do upwards to five practice simulations. The control group was tested once using the same protocol.

Statistical Analysis

The paired t exam was used to compare the preoperative and ii- to 3-calendar week postoperative reaction times. In the case of nonparametric data, Wilcoxon signed rank test was substituted. Linear mixed-effects regression modeling was used to compare the preoperative reaction times through 12-week postoperative values. This method was called over analysis of variance considering the information were not causeless to be independent across a given patient's successive reaction times and because it allowed the authors to clarify the information with missing values. The preoperative times of all the groups and subgroups were compared with the control group using unpaired t exam assay, and the Isle of mann-Whitney test was used for the nonparametric data. The contained sample t test was used to assess for the correlations betwixt opioid use and reaction time. In the case of nonparametric information, the Wilcoxon-Mann-Whitney exam was substituted. The Spearman correlation was used to the compare reaction times and visual analog scale (VAS) scores. All data analysis was performed using STATA (StataCorp, College Station, Texas, United States).

Results

Cervical

The fourteen patients who had cervical surgery had a hateful preoperative DRT of 0.976 seconds (standard deviation [SD] 0.242); the DRT at the offset postoperative visit was slightly college at 1.007 seconds (SD 0.312; p = 0.49). There was meaning patient attrition at the six- and 12-calendar week postoperative appointments. Of the 6 patients who followed up at 6 weeks, the DRT decreased to 0.908 seconds (SD 0.234), though at 12 weeks, it increased to 0.936 seconds (SD 0.303). The mixed-furnishings regression assay through the 12-week postoperative visit showed that in that location was no change in the DRT (p = 0.851; Tabular array ii, Fig. 1).

The mean driver reaction time (DRT) of patients having cervical surgery at the preoperative and first postoperative visit (ii to iii weeks afterwards surgery). There was no significant difference in pre- and postoperative DRT for the entire cervical group or any of the inductive approach, posterior arroyo, myelopathic, or nonmyelopathic groups.

Table ii

Mean driver reaction time (in seconds) after cervical surgery

Patients	Reaction time
	Preoperative	Postoperativea	6 wk postoperative	12 wk postoperativeb
Overall	0.976 ± 0.242	1.007 ± 0. 312 (p = 0.490)	0.908 ± 0.234	0.936 ± 0.303 (p = 0.851)
Myelopathic	0.993 ± 0.267	1.021 ± 0. 340 (p = 0.554)	–	– (p = 0.908)
Nonmyleopathic	0.917 ± 0.127	0.957 ± 0. 227 (p = 0.697)	–	– (p = 0.582)
Inductive	0.814 ± 0.125	0.818 ± 0. 119 (p = 0.893)	–	– (p = 0.899)
Posterior	1.067 ± 0.248	1.112 ± 0. 341 (p = 0.423)	–	– (p = 0.824)

When broken downward by patients with myelopathy and patients without myelopathy, in that location was withal no difference between the pre- and postoperative mean DRT for either group. There was a general trend for increased DRTs; however, those changes were small. The DRT of the myelopathic group was 0.993 seconds (SD 0.267) preoperatively and one.021 seconds (SD 0.340) postoperatively (p = 0.554). The mean DRT of the nonmyelopathic group was 0.917 seconds (SD 0.127) preoperatively and 0.957 seconds (SD 0.227) postoperatively (p = 0.697). The mixed-effects regression analysis showed no difference in the DRT across the 12-calendar week period for the myelopathic (p = 0.908) or nonmyelopathic groups (p = 0.582; Table 2, Fig. 1).

The analysis of anterior and posterior surgeries besides showed no deviation between the pre- and postoperative reaction time for either grouping, though there continued to be a tendency for slight increase in the DRT postoperatively at ii to 3 weeks. The mean DRT for the anterior group increased slightly from 0.814 seconds (SD 0.125) preoperatively to 0.818 seconds (SD 0.119) postoperatively (p = 0.893). The mean DRT for the posterior group was i.067 seconds (SD 0.248) preoperatively and 1.112 seconds (SD 0.341) postoperatively (p = 0.423). The mixed-effects analysis of the DRT revealed no significant difference beyond all visits for either the anterior (p = 0.899) or the posterior groups (p = 0.824; Table 2, Fig. i).

To assess whether hurting played any role in the changes in DRT, we compared the preoperative and postoperative DRTs to the patient's self-reported VAS score but found no correlation. The preoperative Spearman rho was 0.218 (p = 0.472), and the postoperative Spearman rho was 0.125 (p = 0.684; Fig. ii). Nosotros also plant no relationship between the DRT and opioid utilise either pre- (p = 0.089) or postoperatively (p = 0.199; Fig. 3).

Visual analog calibration (VAS) score correlation with driver reaction time after cervical spine surgery. Spearman correlation was used to compare reaction times and VAS scores of patients afterwards cervical spine surgery. In that location was no statistical relationship either earlier (p = 0.474) or after surgery (p = 0.684) between VAS and driver reaction time.

Opioid use and driver reaction time (DRT) in cervical spine surgery. We used an unpaired t exam analysis to examine whether in that location was a relationship between patient opioid use and DRT. We found no human relationship either preoperatively (p = 0.089) or postoperatively (p = 0.199).

The mean DRT of the control group was 0.762 seconds (SD 0.091). That was significantly faster than every cervical grouping at both pre- and postoperative visits except the anterior cervical approach group (presurgical p = 0.521; postsurgical p = 0.3).

Lumbar

Overall, the 23 patients who received lumbar surgery showed a trend toward decreased DRT. For all the lumbar patients, the mean DRT was i.012 seconds (SD 0.222) preoperatively and 0.953 seconds (SD 0.222) at the get-go 2- to 3-week follow-upwardly visit (p = 0.196). At 6 weeks, the mean DRT was 0.842 seconds (SD 0.071) and at 12 weeks information technology was 0.946 seconds (SD 0.133) The mixed-effects assay revealed no significant difference in the DRT across all visits (p = 0.110; Table 3, Fig. 4). The Spearman rho analysis of the VAS scores revealed no correlation of pain and DRT. The preoperative Spearman rho was −0.199 (p = 0.364) and the postoperative Spearman rho was 0.011 (p = 0.964; Fig. five). Likewise, there was no detectable effect of opioid use on the preoperative (p = 0.327) or postoperative (p = 0.353) reaction times (Fig. six).

The mean driver reaction time (DRT) of patients having lumbar surgery at the preoperative and first postoperative visit (two to 3 weeks after surgery). In that location was no significant difference in pre- and postoperative DRT for the unabridged lumbar group or any of the subgroups, except the single-level surgical group, which was improved.

Correlation of visual analog calibration (VAS) hurting scale and driver reaction time after lumbar spine surgery. We used Spearman correlation to compare reaction times and VAS scores of patients after lumbar spine surgery. There was no statistical relationship either before (p = 0.364) or later surgery (p = 0.964).

Opioid use and driver reaction time (DRT) in lumbar spine surgery. Unpaired t testing was used to decide if in that location was a relationship between patient opioid use and driver reaction time in lumbar surgery. In that location was no relationship either preoperatively (p = 0.327) or postoperatively (p = 0.353) betwixt opioid employ and DRT.

Table 3

Mean driver reaction time (in seconds) after lumbar surgery

Patients	Reaction time
	Preoperative	Postoperativea	six wk postoperative	12 wk postoperativeb
Overall	i.012 ± 0.222	0.953 ± 0. 222 (p = 0.196)	0.841 ± 0.071	0.945 ± 0.133 (p = 0.110)
Single level	0.951 ± 0.255	0.794 ± 0. 152 (p = 0.012)	–	– (p = 0.008)
Multilevel	1.051 ± 0.197	1.052 ± 0.204 (p = 0.950)	–	– (p = 0.123)
Fusion	1.077 ± 0.136	one.046 ± 0. 232 (p = 0.713)	–	– (p = 0.229)
Decompression	0.952 ± 0.270	0.884 ± 0. 198 (p = 0.117)	–	– (p = 0.275)

Patients in the lumbar group were then further analyzed by single- versus multilevel surgery. The unmarried-level group had a mean preoperative DRT of 0.951 seconds (SD 0.255) and a mean postoperative DRT of 0.794 seconds (SD 0.152), which reached statistical significance (p = 0.012). Conversely, the mean DRT of the multilevel group was ane.051 seconds (SD 0.197) preoperatively and i.052 seconds (SD 0.204) postoperatively (p = 0.950). For the unmarried-level surgeries, the mixed-furnishings regression analysis had a p value of 0.008, indicating decreased DRT across the postoperative visits. Conversely, the multilevel surgery group mixed-furnishings analysis revealed no postoperative difference across all four visits (p = 0.123; Tabular array three, Fig. 4).

When the lumbar grouping was broken down into the patients who had received fusion with or without decompression and the patients who had received decompression alone, the fusion group's mean DRT was 1.077 seconds (SD 0.136) preoperatively and 1.046 seconds (SD 0.232) postoperatively (p = 0.713). The decompression-but grouping'south mean preoperative DRT was 0.952 seconds (SD 0.270), which decreased to 0.884 seconds (SD = 0.198) at the first postoperative visit (p = 0.117). The mixed-effects regression analysis of the fusion grouping (p = 0.229) and the decompression group (p = 0.275) showed no meaning change beyond all postoperative visits (p = 0.229; Table 3, Fig. iv).

Once more, every lumbar grouping was significantly slower than the control hateful DRT of 0.762 seconds (SD 0.091) preoperatively. Postoperatively, but the single-level group (p = 0.691) and the decompression groups were non different than the command group (p = 0.128).

Word

The goal of this study was to establish when a patient's DRT returns to baseline afterward a spinal surgery. Although there are many subjective factors that contribute to a patient'southward ability to safely drive, one agreed-upon objective factor is DRT.^xvi There is very express literature on when postal service–spinal surgery DRT returns to preoperative times for the patients having lumbar surgery, and simply two studies, focusing on ACDFs, for cervical surgery. Similarly to Liebensteiner et al and in dissimilarity to Al-khayer et al, nosotros found that lumbar patients' DRT at their first postoperative visit was non different from their preoperative DRT.^{4 11} In that location was a trend for the lumbar surgery group every bit a whole to have improved DRTs between their preoperative and kickoff postoperative visit. In the single-level surgical group, this improved DRT really reached significance. The group that received decompression alone also approached statistical significance for improved DRT postoperatively. This was similar to the results institute by Thaler et al, who showed that the postoperative DRT really improved compared with the preoperative DRT for patients receiving lumbar deejay surgery for radiculopathy.¹² As results were either improved or non statistically different from the preoperative groups, nosotros feel comfy stating that some patients having lumbar surgery, peculiarly single-level surgery or decompression only, may consider render to driving at 2 weeks based on the DRT, although other factors particularly including severity of illness, corporeality of muscular dissection performed, and baseline functional status must be taken into account.

It is not immediately clear why our results differ from that of Al-khayer et al and support Liebensteiner et al and Thaler et al.^{4 11 12} It is possible that the nerve blocks studied past Al-khayer et al had a greater effect on DRT than the fusions studied by Liebensteiner et al or the fusions and/or decompressions in our report because of the direct effect of selective nerve root cake anesthesia on nerve roots. Interestingly, like Al-khayer et al,⁴ we constitute no relationship between the self-reported pain and DRT; nonetheless, Liebensteiner et al did detect a correlation betwixt the pain and DRT. It is possible that the brake used past Liebensteiner et al required greater force to shrink and thus was more than afflicted by the pain.¹¹ In contrast, Thaler et al showed a statistically significant comeback in DRT postoperatively at discharge for the patients receiving surgery for lumbar radiculopathy.¹² Their patient group'southward more than dramatic improvement was likely due to their described minimal surgical dissection and resolution of radicular pain, unlike our more heterogeneous patient population that likely connected to take some effect from chronic pain and the surgery at the kickoff postoperative visit.¹²

To the best of our noesis, only two other studies have addressed DRT after cervical surgery. Lechner et al constitute that the patients receiving ACDF for cervical radiculopathy had significant improvement in DRT at the time of discharge and recommended that it was condom for them to render to driving.^thirteen Kelly et al performed a post hoc assay of patients' self-reported driving disability from neck hurting on patients involved in an investigational device exemption study of ACDF and cervical arthroplasty and found that about patients reported no problem with driving at half dozen weeks afterwards surgery, which was the first postoperative time signal recorded in their report.¹⁴ In our study in dissimilarity to lumbar surgery and in contrast to the results of Lechner's group, in that location was a slight tendency toward an increased DRT later on cervical surgery across all the groups. This is likely because our group was again more than heterogeneous and included more patients with myelopathy and chronic pain who were less likely to have the immediate symptom resolution seen in the report of Lechner et al.¹³ Nonetheless, even in our group the overall departure between the mean preoperative and postoperative DRTs was only 0.031 seconds. At seventy mph, that deviation would increase the total stopping distance by three feet. Given the small real-world effect this would have, it may exist acceptable to let some cervical patients who are non on narcotics to drive after the first postoperative visit, although surgeons should refrain from giving firm recommendations on this topic and factors including the affliction severity must exist considered.

DRT is 1 of many factors that affect a patient's ability to drive. It should be noted that though the medicolegal issues are outside the purview of this commodity, surgeons demand to consider each patient individually and should probably refrain from giving firm recommendations. Although this study showed no significant effect on DRT from narcotic pain medication usage, nosotros exercise non suggest whatever patient on narcotics return to driving, and furthermore, nosotros did non have data about the corporeality of narcotic used by patients, then it remains very possible that patients using high doses of narcotic may have increased DRT. Also, the multilevel lumbar group did not trend toward a faster DRT like the other lumbar groups; besides, the posterior cervical grouping showed the greatest increase in DRT postoperatively. Both these groups underwent more extensive surgeries than the other cohorts and likely had more pre- and postoperative hurting. Hurting may lead to reflex inhibition, which could be the root cause of the high pre- and postoperative DRT for the multilevel grouping.¹⁷ In California, the DMV handbook notes the recommended DRT is 750 milliseconds merely in foreign countries the recommended DRT varies from 700 milliseconds in Peachy Britain to 1,500 milliseconds in Frg. Although various models of driving simulators were used to establish those numbers and therefore they are not straight applicable to the results of this study, in our study the fusion and multilevel lumbar surgery groups and posterior cervical groups were subsets of patients with a hateful DRT that approached that upper limit, so those patients should practice actress caution.^{four 16 18 xix xx} For all drivers, information technology is probably wise to begin by practicing driving on short trips effectually their local neighborhood with a rider who is available to drive.ⁱⁱⁱ

Weakness of our study include that we were unable to recruit any female controls and our controls were younger on average than our patients, both of which may contribute to the faster DRTs in the control grouping. Other potential weaknesses of this written report include the small-scale population size and the high rate of patient attrition in study participation after the first postoperative visit. Furthermore, our study population is relatively heterogenous, a fact that impacts the overall power of our report especially for the groups undergoing more extensive surgery, which may require longer postoperative recovery. Such subgroups were those receiving multilevel lumbar surgery, lumbar fusion, or posterior cervical surgery. In addition, our study only measured the speed at which the patient can compress a pedal and not the strength with which they are able to exercise so, and thus the results may not be generalizable to more than existent-earth weather condition. It is as well cannot exist ruled out that some comeback in the DRT may exist secondary to learning by the patients. Moreover, it is possible that our follow-upward period is too short to evidence the full outcome on DRT of surgeries with longer recovery times, such as with lumbar fusion. To address these issues, we programme to recruit more than patients for a future study with longer time periods in those subgroups with greater DRTs and likely longer postoperative recovery periods required. Specifically we programme to perform another written report with increased participant numbers on patients undergoing lumbar fusion, multilevel lumbar surgery, and cervical surgery via the posterior arroyo equally those groups had both pre- and postoperative DRTs closest to the recommended limit for safety driving and thus well-nigh require further study to elucidate when such patients may safely return to driving. The return to driving in real-world situations is vastly more than circuitous than the driving simulator. Furthermore, the legal implications of driving are beyond the telescopic of this article. The DRT is a reasonable proxy for patients' ability to brake in an emergency, simply it must exist remembered that information technology does not address the many other aspects of real-world driving like baseline functional status and the patients' power to effectively maneuver within their seats to fairly notice their environments—all of which touch on each private patient's power to render safely to driving.

In summary, for patients who have received either cervical or lumbar surgery, there is no measurable change in the DRT between the preoperative visit and the first postoperative visit. The ane exception to this is unmarried-level lumbar surgery, in which the DRT is significantly improved at the start operative visit. This is in contrast to our hypothesis that patients' DRTs would exist elevated at 2 to 3 weeks postoperatively. We believe that these data indicate that some spinal patients, especially those having single-level lumbar surgery and those who have good baseline functional condition, may be able to return to driving subsequently their start postoperative visit. Our information may be useful in developing guidelines regarding render to driving, although further study is needed.

Disclosures Trevor P. Scott, none William Pannel, none David Savin, none Stephanie S. Ngo, none Jessica Ellerman, none Kristin Toy, none Michael D. Daubs, Consultant: Depuy-Synthes; Royalties: Depuy-Synthes Daniel Lu, none Jeffery C. Wang, Lath membership: North American Spine Social club, Cervical Spine Research Society, AOSpine Foundation, Collaborative Spine Research Foundation; Royalties: Stryker, Osprey, Aesculap, Biomet, Amedica, Seaspine, Synthes; Stock/stock options: Fziomed, Promethean Spine, Paradigm Spine, Benevenue, NexGen, Pioneer, Amedica, Vertiflex, Electrocore, Surgitech, Axiomed, VG Innovations, Corespine, Expanding Orthopaedics, Syndicom, Osprey, Bone Biologics, Curative Biosciences, PearlDiver Conflicts of Interest and Source of Funding The submitted manuscript does not contain any data about medical devices or drugs. No funds were received in back up of this work. No benefits in any form accept been or volition be received from a commercial political party related directly or indirectly to the subject of this manuscript.

^*The Institutional Review Board of University of California Los Angeles approved this study protocol (Approval number: #10-001893).

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4516735/

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