Object To review the cost effectiveness for the management of a unilateral cervical radiculopathy with either posterior cervical foraminotomy (PCF) or anterior cervical discectomy and fusion (ACDF) in military personnel, with a particular focus on time required to return to active-duty service. Methods Following internal review board approval, the authors conducted a retrospective review of 38 cases in which patients underwent surgical management of unilateral cervical radiculopathy. Nineteen patients who underwent PCF were matched for age, treatment level, and surgeon to 19 patients who had undergone ACDF. Successful outcome was determined by return to full, unrestricted active-duty military service. The difference in time of return to active duty was compared between the groups. In addition, a cost analysis consisting of direct and indirect costs was used to compare the PCF group to the ACDF group. Results A total of 21 levels were operated on in each group. There were 17 men and 2 women in the PCF group, whereas all 19 patients in the ACDF group were men. The average age at the time of surgery was 41.5 years (range 27–56 years) and 39.3 years (range 24–52 years) for the PCF and ACDF groups, respectively. There was no statistically significant difference in operating room time, estimated blood loss, or postoperative narcotic refills. Complications included 2 cases of transient recurrent laryngeal nerve palsy in the ACDF group. The average time to return to unrestricted full duty was 4.8 weeks (range 1–8 weeks) in the PCF group and 19.6 weeks (range 12–32 weeks) in the ACDF group, a difference of 14.8 weeks (p < 0.001). The direct costs of each surgery were $3570 for the PCF and $10,078 for the ACDF, a difference of $6508. Based on the 14.8-week difference in time to return to active duty, the indirect cost was calculated to range from $13,586 to $24,045 greater in the ACDF group. Total cost (indirect plus direct) ranged from $20,094 to $30,553 greater in the ACDF group. Conclusions In the management of unilateral posterior cervical radiculopathy for military active-duty personnel, PCF offers a benefit relative to ACDF in immediate short-term direct and long-term indirect costs. The indirect cost of a service member away from full, unrestricted active duty 14.8 weeks longer in the ACDF group was the main contributor to this difference.

Object The introduction of cervical and lumbar arthroplasty has allowed for management of cervical radiculopathy and lumbar degenerative disease in patients with the preservation of motion at the affected segment. While the early clinical outcomes of this technology appear promising, it remains unclear what activity limitations should be imposed after surgery in patients with these implants. This is of particular interest in military personnel, who may be required to return to a rigorous level of activity after surgery. The goals of the FDA trials evaluating various disc arthroplasty devices were to establish safety, efficacy, and equivalency to arthrodesis. Information regarding the level of physical performance attained and restrictions or limitations is lacking, as these were outside the objectives of these trials. Nevertheless, there data are essential for the military surgeon, who is tasked with guiding the postoperative management of patients treated with arthroplasty and returning them to full duty. While there is a single report of clinical results of lumbar arthroplasty in athletes, at this writing, there are no reports of either cervical or lumbar arthroplasty in active duty military personnel. Methods The surgical database at a single, tertiary care military treatment facility was queried for all activeduty patients who underwent placement of either a cervical or lumbar arthroplasty device over a 3-year period. The authors performed a retrospective chart review to collect patient and procedural data including blood loss, length of hospital stay, tobacco use, age, rank, complications, and ability to return to full unrestricted active duty. Arthroplasty cohorts were then compared to historical controls of arthrodesis to ascertain differences in the time required to return to full duty. Results Twelve patients were identified who underwent cervical arthroplasty. All patients returned to unrestricted full duty. This cohort was then compared with 12 patients who had undergone a single-level anterior cervical discectomy and fusion. The average time to return to unrestricted full duty for the arthroplasty group was 10.3 weeks (range 7–13 weeks), whereas that in the fusion group was 16.5 weeks. This difference between these 2 groups was statistically significant (p = 0.008). Twelve patients were identified who underwent lumbar arthroplasty. Ten (83%) of 12 patients in this group returned to unrestricted full duty. In patients who returned to full duty, it took an average of 22.6 weeks (range 12–29 weeks). This cohort was then compared with one in which patients had undergone anterior lumbar interbody fusion. Eight (67%) of 12 patients in the lumbar arthrodesis group returned to unrestricted full duty. In patients who returned to full duty, it took an average of 32.4 weeks (range 25–41 weeks). This difference was not statistically significant (p = 0.156). Conclusions The preliminary experience with cervical and lumbar arthroplasty at the authors' institution indicates that arthroplasty is comparable with arthrodesis and may actually expedite return to active duty. Patients are capable of returning to a high level of rigorous training and physical performance. There are no apparent restrictions or limitations that are required after 3 months in the cervical patient and after 6 months in the lumbar patient. Further prospective studies with long-term follow-up are indicated and will be of value when determining the role of arthroplasty compared to arthrodesis in the active-duty population.

Summary: Targeted muscle reinnervation (TMR) is an evolving technique with promising results for prevention and treatment of neuropathic pain, as well as modulation of control for myoelectric prostheses. The previously described and most commonly used technique for transhumeral TMR combines both an anterior and posterior approach to access the major peripheral nerves of the upper extremity. In this article, we review the literature for transhumeral TMR and describe a more expeditious and efficient anterior-only approach that offers safe access through a single incision.

Fifty-five percent of the service members who underwent a single-level lumbar interbody fusion returned to unrestricted full duty. Older age and higher rank were statistically significant positive predictors of a successful return to active duty.

Both single and 2-level ACDFs have high overall success with an 88% rate of return to full duty.