The Burden of Clostridium difficile after Cervical Spine Surgery.

PubMed

Guzman, Javier Z; Skovrlj, Branko; Rothenberg, Edward S; Lu, Young; McAnany, Steven; Cho, Samuel K; Hecht, Andrew C; Qureshi, Sheeraz A

2016-06-01

Study Design Retrospective database analysis. Objective The purpose of this study is to investigate incidence, comorbidities, and impact on health care resources of Clostridium difficile infection after cervical spine surgery. Methods A total of 1,602,130 cervical spine surgeries from the Nationwide Inpatient Sample database from 2002 to 2011 were included. Patients were included for study based on International Classification of Diseases Ninth Revision, Clinical Modification procedural codes for cervical spine surgery for degenerative spine diagnoses. Baseline patient characteristics were determined. Multivariable analyses assessed factors associated with increased incidence of C. difficile and risk of mortality. Results Incidence of C. difficile infection in postoperative cervical spine surgery hospitalizations is 0.08%, significantly increased since 2002 (p < 0.0001). The odds of postoperative C. difficile infection were significantly increased in patients with comorbidities such as congestive heart failure, renal failure, and perivascular disease. Circumferential cervical fusion (odds ratio [OR] = 2.93, p < 0.0001) increased the likelihood of developing C. difficile infection after degenerative cervical spine surgery. C. difficile infection after cervical spine surgery results in extended length of stay (p < 0.0001) and increased hospital costs (p < 0.0001). Mortality rate in patients who develop C. difficile after cervical spine surgery is nearly 8% versus 0.19% otherwise (p < 0.0001). Moreover, multivariate analysis revealed C. difficile to be a significant predictor of inpatient mortality (OR = 3.99, p < 0.0001). Conclusions C. difficile increases the risk of in-hospital mortality and costs approximately $6,830,695 per year to manage in patients undergoing elective cervical spine surgery. Patients with comorbidities such as renal failure or congestive heart failure have increased probability of developing infection after surgery. Accepted antibiotic guidelines in this population must be followed to decrease the risk of developing postoperative C. difficile colitis.

Positioning patients for spine surgery: Avoiding uncommon position-related complications

PubMed Central

Kamel, Ihab; Barnette, Rodger

2014-01-01

Positioning patients for spine surgery is pivotal for optimal operating conditions and operative-site exposure. During spine surgery, patients are placed in positions that are not physiologic and may lead to complications. Perioperative peripheral nerve injury (PPNI) and postoperative visual loss (POVL) are rare complications related to patient positioning during spine surgery that result in significant patient disability and functional loss. PPNI is usually due to stretch or compression of the peripheral nerve. PPNI may present as a brachial plexus injury or as an isolated injury of single nerve, most commonly the ulnar nerve. Understanding the etiology, mechanism and pattern of injury with each type of nerve injury is important for the prevention of PPNI. Intraoperative neuromonitoring has been used to detect peripheral nerve conduction abnormalities indicating peripheral nerve stress under general anesthesia and to guide modification of the upper extremity position to prevent PPNI. POVL usually results in permanent visual loss. Most cases are associated with prolonged spine procedures in the prone position under general anesthesia. The most common causes of POVL after spine surgery are ischemic optic neuropathy and central retinal artery occlusion. Posterior ischemic optic neuropathy is the most common cause of POVL after spine surgery. It is important for spine surgeons to be aware of POVL and to participate in safe, collaborative perioperative care of spine patients. Proper education of perioperative staff, combined with clear communication and collaboration while positioning patients in the operating room is the best and safest approach. The prevention of uncommon complications of spine surgery depends primarily on identifying high-risk patients, proper positioning and optimal intraoperative management of physiological parameters. Modification of risk factors extrinsic to the patient may help reduce the incidence of PPNI and POVL. PMID:25232519

The impact of the 2006 Massachusetts health care reform law on spine surgery patient payer-mix status and age.

PubMed

Villelli, Nicolas W; Yan, Hong; Zou, Jian; Barbaro, Nicholas M

2017-12-01

OBJECTIVE Several similarities exist between the Massachusetts health care reform law of 2006 and the Affordable Care Act (ACA). The authors' prior neurosurgical research showed a decrease in uninsured surgeries without a significant change in surgical volume after the Massachusetts reform. An analysis of the payer-mix status and the age of spine surgery patients, before and after the policy, should provide insight into the future impact of the ACA on spine surgery in the US. METHODS Using the Massachusetts State Inpatient Database and spine ICD-9-CM procedure codes, the authors obtained demographic information on patients undergoing spine surgery between 2001 and 2012. Payer-mix status was assigned as Medicare, Medicaid, private insurance, uninsured, or other, which included government-funded programs and workers' compensation. A comparison of the payer-mix status and patient age, both before and after the policy, was performed. The New York State data were used as a control. RESULTS The authors analyzed 81,821 spine surgeries performed in Massachusetts and 248,757 in New York. After 2008, there was a decrease in uninsured and private insurance spine surgeries, with a subsequent increase in the Medicare and "other" categories for Massachusetts. Medicaid case numbers did not change. This correlated to an increase in surgeries performed in the age group of patients 65-84 years old, with a decrease in surgeries for those 18-44 years old. New York showed an increase in all insurance categories and all adult age groups. CONCLUSIONS After the Massachusetts reform, spine surgery decreased in private insurance and uninsured categories, with the majority of these surgeries transitioning to Medicare. Moreover, individuals who were younger than 65 years did not show an increase in spine surgeries, despite having greater access to health insurance. In a health care system that requires insurance, the decrease in private insurance is primarily due to an increasing elderly population. The Massachusetts model continues to show that this type of policy is not causing extreme shifts in the payer mix, and suggests that spine surgery will continue to thrive in the current US health care system.

Use of an operating microscope during spine surgery is associated with minor increases in operating room times and no increased risk of infection.

PubMed

Basques, Bryce A; Golinvaux, Nicholas S; Bohl, Daniel D; Yacob, Alem; Toy, Jason O; Varthi, Arya G; Grauer, Jonathan N

2014-10-15

Retrospective database review. To evaluate whether microscope use during spine procedures is associated with increased operating room times or increased risk of infection. Operating microscopes are commonly used in spine procedures. It is debated whether the use of an operating microscope increases operating room time or confers increased risk of infection. The American College of Surgeons National Surgical Quality Improvement Program database, which includes data from more than 370 participating hospitals, was used to identify patients undergoing elective spinal procedures with and without the use of an operating microscope for the years 2011 and 2012. Bivariate and multivariate linear regressions were used to test the association between microscope use and operating room times. Bivariate and multivariate logistic regressions were similarly conducted to test the association between microscope use and infection occurrence within 30 days of surgery. A total of 23,670 elective spine procedures were identified, of which 2226 (9.4%) used an operating microscope. The average patient age was 55.1±14.4 years. The average operative time (incision to closure) was 125.7±82.0 minutes.Microscope use was associated with minor increases in preoperative room time (+2.9 min, P=0.013), operative time (+13.2 min, P<0.001), and total room time (+18.6 min, P<0.001) on multivariate analysis.A total of 328 (1.4%) patients had an infection within 30 days of surgery. Multivariate analysis revealed no significant difference between the microscope and nonmicroscope groups for occurrence of any infection, superficial surgical site infection, deep surgical site infection, organ space infection, or sepsis/septic shock, regardless of surgery type. We did not find operating room times or infection risk to be significant deterrents for use of an operating microscope during spine surgery. 3.

Use of an operating microscope during spine surgery is associated with minor increases in operating room times and no increased risk of infection

PubMed Central

Basques, Bryce A.; Golinvaux, Nicholas S.; Bohl, Daniel D.; Yacob, Alem; Toy, Jason O.; Varthi, Arya G.; Grauer, Jonathan N.

2014-01-01

Study Design Retrospective database review. Objective To evaluate whether microscope use during spine procedures is associated with increased operating room times or increased risk of infection. Summary of Background Data Operating microscopes are commonly used in spine procedures. It is debated whether the use of an operating microscope increases operating room time or confers increased risk of infection. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, which includes data from over 370 participating hospitals, was used to identify patients undergoing elective spinal procedures with and without an operating microscope for the years 2011 and 2012. Bivariate and multivariate linear regressions were used to test the association between microscope use and operating room times. Bivariate and multivariate logistic regressions were similarly conducted to test the association between microscope use and infection occurrence within 30 days of surgery. Results A total of 23,670 elective spine procedures were identified, of which 2,226 (9.4%) used an operating microscope. The average patient age was 55.1 ± 14.4 years. The average operative time (incision to closure) was 125.7 ± 82.0 minutes. Microscope use was associated with minor increases in preoperative room time (+2.9 minutes, p=0.013), operative time (+13.2 minutes, p<0.001), and total room time (+18.6 minutes, p<0.001) on multivariate analysis. A total of 328 (1.4%) patients had an infection within 30 days of surgery. Multivariate analysis revealed no significant difference between the microscope and non-microscope groups for occurrence of any infection, superficial surgical site infection (SSI), deep SSI, organ space infection, or sepsis/septic shock, regardless of surgery type. Conclusions We did not find operating room times or infection risk to be significant deterrents for use of an operating microscope during spine surgery. PMID:25188600

Surgery for failed cervical spine reconstruction.

PubMed

Helgeson, Melvin D; Albert, Todd J

2012-03-01

Review article. To review the indications, operative strategy, and complications of revision cervical spine reconstruction. With many surgeons expanding their indications for cervical spine surgery, the number of patients being treated operatively has increased. Unfortunately, the number of patients requiring revision procedures is also increasing, but very little literature exists reviewing changes in the indications or operative planning for revision reconstruction. Narrative and review of the literature. In addition to the well-accepted indications for primary cervical spine surgery (radiculopathy, myelopathy, instability, and tumor), we have used the following indications for revision surgery: pseudarthrosis, adjacent segment degeneration, inadequate decompression, iatrogenic instability, and deformity. Our surgical goal for pseudarthrosis is obviously to obtain a fusion, which can usually be performed with an approach not done previously. Our surgical goals for instability and deformity are more complex, with a focus on decompression of any neurologic compression, correction of deformity, and stability. Revision cervical spine reconstruction is safe and effective if performed for the appropriate indications and with proper planning.

Vertebral artery injury in cervical spine surgery: anatomical considerations, management, and preventive measures.

PubMed

Peng, Chan W; Chou, Benedict T; Bendo, John A; Spivak, Jeffrey M

2009-01-01

Vertebral artery (VA) injury can be a catastrophic iatrogenic complication of cervical spine surgery. Although the incidence is rare, it has serious consequences including fistulas, pseudoaneurysm, cerebral ischemia, and death. It is therefore imperative to be familiar with the anatomy and the instrumentation techniques when performing anterior or posterior cervical spine surgeries. To provide a review of VA injury during common anterior and posterior cervical spine procedures with an evaluation of the surgical anatomy, management, and prevention of this injury. Comprehensive literature review. A systematic review of Medline for articles related to VA injury in cervical spine surgery was conducted up to and including journal articles published in 2007. The literature was then reviewed and summarized. Overall, the risk of VA injury during cervical spine surgery is low. In anterior cervical procedures, lateral dissection puts the VA at the most risk, so sound anatomical knowledge and constant reference to the midline are mandatory during dissection. With the development and rise in popularity of posterior cervical stabilization and instrumentation, recognition of the dangers of posterior drilling and insertion of transarticular screws and pedicle screws is important. Anomalous vertebral anatomy increases the risk of injury and preoperative magnetic resonance imaging and/or computed tomography (CT) scans should be carefully reviewed. When the VA is injured, steps should be taken to control local bleeding. Permanent occlusion or ligation should only be attempted if it is known that the contralateral VA is capable of providing adequate collateral circulation. With the advent of endovascular repair, this treatment option can be considered when a VA injury is encountered. VA injury during cervical spine surgery is a rare but serious complication. It can be prevented by careful review of preoperative imaging studies, having a sound anatomical knowledge and paying attention to surgical landmarks intraoperatively. When a VA injury occurs, prompt recognition and management are important.

Rib-based Distraction Surgery Maintains Total Spine Growth.

PubMed

El-Hawary, Ron; Samdani, Amer; Wade, Jennie; Smith, Melissa; Heflin, John A; Klatt, Joshua W; Vitale, Michael G; Smith, John T

2016-12-01

For children undergoing treatment of early onset scoliosis (EOS) using spine-based distraction, recently published research would suggest that total spine length (T1-S1) achieved after the initial lengthening procedure decreases with each subsequent lengthening. Our purpose was to evaluate the effect of rib-based distraction on spine growth in children with EOS. This was a retrospective multi-center review of 35 patients treated with rib-based distraction (minimum 5 y follow-up). Radiographs were analyzed at initial implantation and just before each subsequent lengthening. The primary outcome was T1-S1 height, which was also analyzed as: Change in T1-S1 height per lengthening procedure, percent of expected age-based T1-S1 growth per lengthening time interval, percent increase in T1-S1 height as compared with postimplantation total spine height, and percent of expected T1-S1 growth based upon patient age at time of lengthening procedure. Thirty-five patients with a mean age of 2.6 years at initial surgery were studied. Diagnoses included congenital (n=18), syndromic (n=7), idiopathic (n=5), and neuromuscular (n=5). Major Cobb angle was 63.5 degrees and kyphosis was 40.5 degree. Four postoperative time periods were compared: L1 (preoperative first lengthening surgery), L2-L5 (preoperative second lengthening to preoperative fifth lengthening), L6-L10 (preoperative sixth lengthening to preoperative 10th lengthening), L11-L15 (preoperative 11th lengthening to preoperative 15th lengthening). Cobb angle stayed relatively constant for each lengthening period while maximum kyphosis increased. Total spine height was 19.9 cm pre-implantation, 22.1 cm postimplantation, and 28.0 cm by the 15th lengthening (P<0.05). Percent expected T1-S1 growth per lengthening was 62% for L2-L5, 95% for L6-L10, and 52% for L11-L15. As compared with postimplantation spine height, over the course of 15 lengthening procedures, a further 27% increase in spine height was observed. When lengthening procedures were performed when children were under age 5 years, 82% of expected growth was observed; between ages 6 and 10 years, 76% of expected growth was observed; and beyond age 10 years, 14% of expected growth was observed. Patients treated with rib-based distraction surgery had an increase in total spine height from 20 cm preimplantation to 28 cm by the 15th lengthening. They maintained greater than 75% of expected age-matched spine growth until age 10 years and lengthening procedures did not appear to follow a law of diminishing returns. Rib-based distraction is an effective means of maintaining spine growth which is likely beneficial for pulmonary development as compared with the natural history of EOS. Level IV-Therapeutic study, case series.

Impact of the Economic Downturn on Elective Cervical Spine Surgery in the United States: A National Trend Analysis, 2003-2013.

PubMed

Bernstein, David N; Jain, Amit; Brodell, David; Li, Yue; Rubery, Paul T; Mesfin, Addisu

2016-12-01

To analyze overall trends of elective cervical spine surgery in the United States from 2003 to 2013 with the goal of determining whether the economic downturn had an impact. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification were used to identify elective cervical spine surgery procedures in the Nationwide Inpatient Sample from 2003 to 2013. National Health Expenditure, gross domestic product, and S&P 500 Index were used as measures of economic performance. The economic downturn was defined as 2008-2009. Confidence intervals were determined using subgroup analysis techniques. Linear regressions were completed to determine the association between surgery trends and economic conditions. From 2003 to 2013, posterior cervical fusions saw a 102.7% increase. During the same time frame, there was a 7.4% and 14.7% decrease in the number of anterior cervical diskectomy and fusions (ACDFs) and posterior decompressions, respectively. The trend of elective cervical spine surgeries per 100,000 persons in the U.S. population may have been affected by the economic downturn from 2008 to 2009 (-0.03% growth). The percentage of procedures paid for by private insurance decreased from 2003 to 2013 for all ACDFs, posterior cervical fusions, and posterior decompressions. The linear regression coefficients (β) and R 2 values between the number of surgeries and each of the macroeconomic factors analyzed were not statistically significant. The overall elective cervical spine surgery trend was not likely impacted by the economic downturn. Posterior cervical fusions grew significantly from 2003 to 2013, whereas ACDFs and posterior decompressions decreased. Copyright © 2016 Elsevier Inc. All rights reserved.

The Arrival of Robotics in Spine Surgery: A Review of the Literature.

PubMed

Ghasem, Alexander; Sharma, Akhil; Greif, Dylan N; Alam, Milad; Maaieh, Motasem Al

2018-04-18

Systematic Review. The authors aim to review comparative outcome measures between robotic and free-hand spine surgical procedures including: accuracy of spinal instrumentation, radiation exposure, operative time, hospital stay, and complication rates. Misplacement of pedicle screws in conventional open as well as minimally invasive surgical procedures has prompted the need for innovation and allowed the emergence of robotics in spine surgery. Prior to incorporation of robotic surgery in routine practice, demonstration of improved instrumentation accuracy, operative efficiency, and patient safety is required. A systematic search of the PubMed, OVID-MEDLINE, and Cochrane databases was performed for papers relevant to robotic assistance of pedicle screw placement. Inclusion criteria were constituted by English written randomized control trials, prospective and retrospective cohort studies involving robotic instrumentation in the spine. Following abstract, title, and full-text review, 32 articles were selected for study inclusion. Intrapedicular accuracy in screw placement and subsequent complications were at least comparable if not superior in the robotic surgery cohort. There is evidence supporting that total operative time is prolonged in robot assisted surgery compared to conventional free-hand. Radiation exposure appeared to be variable between studies; radiation time did decrease in the robot arm as the total number of robotic cases ascended, suggesting a learning curve effect. Multi-level procedures appeared to tend toward earlier discharge in patients undergoing robotic spine surgery. The implementation of robotic technology for pedicle screw placement yields an acceptable level of accuracy on a highly consistent basis. Surgeons should remain vigilant about confirmation of robotic assisted screw trajectory, as drilling pathways have been shown to be altered by soft tissue pressures, forceful surgical application, and bony surface skiving. However, the effective consequence of robot-assistance on radiation exposure, length of stay, and operative time remains unclear and requires meticulous examination in future studies. 4.

Impact of the Economic Downturn on Elective Lumbar Spine Surgery in the United States: A National Trend Analysis, 2003 to 2013

PubMed Central

Bernstein, David N.; Brodell, David; Li, Yue; Rubery, Paul T.

2017-01-01

Study Design: Retrospective database analysis. Objective: The impact of the 2008-2009 economic downtown on elective lumbar spine surgery is unknown. Our objective was to investigate the effect of the economic downturn on the overall trends of elective lumbar spine surgery in the United States. Methods: The Nationwide Inpatient Sample (NIS) was used in conjunction with US Census and macroeconomic data to determine historical trends. The economic downturn was defined as 2008 to 2009. Codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), were used in order to identify appropriate procedures. Confidence intervals were determined using subgroup analysis techniques. Results: From 2003 to 2012, there was a 19.8% and 26.1% decrease in the number of lumbar discectomies and laminectomies, respectively. Over the same time period, there was a 56.4% increase in the number of lumbar spinal fusions. The trend of elective lumbar spine surgeries per 100 000 persons in the US population remained consistent from 2008 to 2009. The number of procedures decreased by 4.5% from 2010 to 2011, 7.6% from 2011 to 2012, and 3.1% from 2012 to 2013. The R 2 value between the number of surgeries and the S&P 500 Index was statistically significant (P ≤ .05). Conclusions: The economic downturn did not affect elective lumbar fusions, which increased in total from 2003 to 2013. The relationship between the S&P 500 Index and surgical trends suggests that during recessions, individuals may utilize other means, such as insurance, to cover procedural costs and reduce out-of-pocket expenditures, accounting for no impact of the economic downturn on surgical trends. These findings can assist multiple stakeholders in better understanding the interconnectedness of macroeconomics, policy, and elective lumbar spine surgery trends. PMID:28660102

Predicting complication risk in spine surgery: a prospective analysis of a novel risk assessment tool.

PubMed

Veeravagu, Anand; Li, Amy; Swinney, Christian; Tian, Lu; Moraff, Adrienne; Azad, Tej D; Cheng, Ivan; Alamin, Todd; Hu, Serena S; Anderson, Robert L; Shuer, Lawrence; Desai, Atman; Park, Jon; Olshen, Richard A; Ratliff, John K

2017-07-01

OBJECTIVE The ability to assess the risk of adverse events based on known patient factors and comorbidities would provide more effective preoperative risk stratification. Present risk assessment in spine surgery is limited. An adverse event prediction tool was developed to predict the risk of complications after spine surgery and tested on a prospective patient cohort. METHODS The spinal Risk Assessment Tool (RAT), a novel instrument for the assessment of risk for patients undergoing spine surgery that was developed based on an administrative claims database, was prospectively applied to 246 patients undergoing 257 spinal procedures over a 3-month period. Prospectively collected data were used to compare the RAT to the Charlson Comorbidity Index (CCI) and the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator. Study end point was occurrence and type of complication after spine surgery. RESULTS The authors identified 69 patients (73 procedures) who experienced a complication over the prospective study period. Cardiac complications were most common (10.2%). Receiver operating characteristic (ROC) curves were calculated to compare complication outcomes using the different assessment tools. Area under the curve (AUC) analysis showed comparable predictive accuracy between the RAT and the ACS NSQIP calculator (0.670 [95% CI 0.60-0.74] in RAT, 0.669 [95% CI 0.60-0.74] in NSQIP). The CCI was not accurate in predicting complication occurrence (0.55 [95% CI 0.48-0.62]). The RAT produced mean probabilities of 34.6% for patients who had a complication and 24% for patients who did not (p = 0.0003). The generated predicted values were stratified into low, medium, and high rates. For the RAT, the predicted complication rate was 10.1% in the low-risk group (observed rate 12.8%), 21.9% in the medium-risk group (observed 31.8%), and 49.7% in the high-risk group (observed 41.2%). The ACS NSQIP calculator consistently produced complication predictions that underestimated complication occurrence: 3.4% in the low-risk group (observed 12.6%), 5.9% in the medium-risk group (observed 34.5%), and 12.5% in the high-risk group (observed 38.8%). The RAT was more accurate than the ACS NSQIP calculator (p = 0.0018). CONCLUSIONS While the RAT and ACS NSQIP calculator were both able to identify patients more likely to experience complications following spine surgery, both have substantial room for improvement. Risk stratification is feasible in spine surgery procedures; currently used measures have low accuracy.

[Patient management in polytrauma with injuries of the cervical spine].

PubMed

Kohler, A; Friedl, H P; Käch, K; Stocker, R; Trentz, O

1994-04-01

Complex unstable cervical spine injuries in polytraumatized patients are stabilized ventro-dorsally in a two-stage procedure. The ventral stabilization is a day-one surgery with the goal to get primary stability for intensive care, early spinal decompression and protection against secondary damage of the spinal cord. The additional dorsal stabilization allows early functional treatment or in case of spinal cord lesions early neurorehabilitation. The combination of severe brain injury and unstable cervical spine injury is especially demanding concerning diagnostic and therapeutic procedures.

The case for restraint in spinal surgery: does quality management have a role to play?

PubMed Central

Mirza, Sohail K.

2009-01-01

Most quality improvement efforts in surgery have focused on the technical quality of care provided, rather than whether the care was indicated, or could have been provided with a safer procedure. Because risk is inherent in any procedure, reducing the number of unnecessary operations is an important issue in patient safety. In the case of lumbar spine surgery, several lines of evidence suggest that, in at least some locations, there may be excessively high surgery rates. This evidence comes from international comparisons of surgical rates; study of small area variations within countries; increasing surgical rates in the absence of new indications; comparisons of surgical outcomes between geographic areas with high or low surgical rates; expert opinion; the preferences of well-informed patients; and increasing rates of repeat surgery. From a population perspective, reducing unnecessary surgery may have a greater impact on complication rates than improving the technical quality of surgery that is performed. Evidence suggests this may be true for coronary bypass surgery in the US and hysterectomy rates in Canada. Though similar studies have not been done for spine surgery, wide geographic variations in surgical rates suggest that this could be the case for spine surgery as well. We suggest that monitoring geographic variations in surgery rates may become an important aspect of quality improvement, and that rates of repeat surgery may bear special attention. Patient registries can help in this regard, if they are very complete and rigorously maintained. They can provide data on surgical rates; offer post-marketing surveillance for new surgical devices and techniques; and help to identify patient subgroups that may benefit most from certain procedures. PMID:19266220

The case for restraint in spinal surgery: does quality management have a role to play?

PubMed

Deyo, Richard A; Mirza, Sohail K

2009-08-01

Most quality improvement efforts in surgery have focused on the technical quality of care provided, rather than whether the care was indicated, or could have been provided with a safer procedure. Because risk is inherent in any procedure, reducing the number of unnecessary operations is an important issue in patient safety. In the case of lumbar spine surgery, several lines of evidence suggest that, in at least some locations, there may be excessively high surgery rates. This evidence comes from international comparisons of surgical rates; study of small area variations within countries; increasing surgical rates in the absence of new indications; comparisons of surgical outcomes between geographic areas with high or low surgical rates; expert opinion; the preferences of well-informed patients; and increasing rates of repeat surgery. From a population perspective, reducing unnecessary surgery may have a greater impact on complication rates than improving the technical quality of surgery that is performed. Evidence suggests this may be true for coronary bypass surgery in the US and hysterectomy rates in Canada. Though similar studies have not been done for spine surgery, wide geographic variations in surgical rates suggest that this could be the case for spine surgery as well. We suggest that monitoring geographic variations in surgery rates may become an important aspect of quality improvement, and that rates of repeat surgery may bear special attention. Patient registries can help in this regard, if they are very complete and rigorously maintained. They can provide data on surgical rates; offer post-marketing surveillance for new surgical devices and techniques; and help to identify patient subgroups that may benefit most from certain procedures.

Laminoplasty for Cervical Myelopathy

PubMed Central

Ito, Manabu; Nagahama, Ken

2012-01-01

This article reviews cervical laminoplasty. The origin of cervical laminoplasty dates back to cervical laminectomy performed in Japan ~50 years ago. To overcome poor surgical outcomes of cervical laminectomy, many Japanese orthopedic spine surgeons devoted their lives to developing better posterior decompression procedures for the cervical spine. Thanks to the development of a high-speed surgical burr, posterior decompression procedures for the cervical spine showed vast improvement from the 1970s to the 1980s, and the original form of cervical laminoplasty was determined. Since around 2000, surgeons performing cervical laminoplasty have been adopting less invasive procedures for the posterior cervical muscle structures so as to minimize postoperative axial neck pain and obtain better functional outcomes of the cervical spine. This article covers the history of cervical laminoplasty, surgical procedures, the benefits and limitation of this procedure, and surgery-related complications. PMID:24353967

Carotid Artery Injury in Anterior Cervical Spine Surgery: Multicenter Cohort Study and Literature Review.

PubMed

Härtl, Roger; Alimi, Marjan; Abdelatif Boukebir, Mohamed; Berlin, Connor D; Navarro-Ramirez, Rodrigo; Arnold, Paul M; Fehlings, Michael G; Mroz, Thomas E; Riew, K Daniel

2017-04-01

Retrospective study and literature review. To provide more comprehensive data about carotid artery injury (CAI) or cerebrovascular accident (CVA) related to anterior cervical spine surgery. We conducted a retrospective, multicenter, case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network. Medical records of 17 625 patients who went through cervical spine surgery (levels from C2 to C7) between January 1, 2005, and December 31, 2011, were analyzed. Also, we performed a literature review using Medline and PubMed databases. The following terms were used alone, and in combination, to search for relevant articles: cervical, spine, surgery, complication, iatrogenic, carotid artery, injury, cerebrovascular accident, CVA, and carotid stenosis. Among 17 625 patients that were analyzed, no cases were reported to experienced CAI or CVA after cervical spine surgery. Nevertheless, in our PubMed search we found 157 articles, but only 5 articles matched our study objective criteria; 2 cases were reported to present CAI and 3 cases presented CVA. CAI and CVA related to anterior cervical spine surgeries are extremely rare. We were not able to find neither in our retrospective study nor in our literature research a correlation between the type or length of anterior cervical spine procedure with CVA or CAI complications. However, surgeons should be aware of the possibility of vascular complications and minimize intraoperative direct vascular manipulations or retraction. Preoperative screening for underlying vascular pathology and risk factors is also important.

Cost Analysis of Spinal Versus General Anesthesia for Lumbar Diskectomy and Laminectomy Spine Surgery.

PubMed

Agarwal, Prateek; Pierce, John; Welch, William C

2016-05-01

Lumbar spine surgery can be performed using various anesthetic modalities, most notably general or spinal anesthesia. Because data comparing the cost of these anesthetic modalities in spine surgery are scarce, this study asks whether spinal anesthesia is less costly than general anesthesia. A total of 542 patients who underwent elective lumbar diskectomy or laminectomy spine surgery between 2007 and 2011 were retrospectively identified, with 364 having received spinal anesthesia and 178 having received general anesthesia. Mean direct operating cost, indirect cost (general support staff, insurance, taxes, floor space, facility, and administrative costs), and total cost were compared among patients who received general and spinal anesthesia. Linear multiple regression analysis was used to identify the effect of anesthesia type on cost and determine the factors underlying this effect, while controlling for patient and procedure characteristics. When controlling for patient and procedure characteristics, use of spinal anesthesia was associated with a 41.1% lower direct operating cost (-$3629 ± $343, P < 0.001), 36.6% lower indirect cost (-$1603 ± $168, P < 0.001), and 39.6% lower total cost (-$5232 ± $482, P < 0.001) compared with general anesthesia. Shorter hospital stay, shorter duration of anesthesia, shorter duration of operation, and lower estimated blood loss contributed to lower costs for spinal anesthesia, but other factors beyond these were also responsible for lower direct operating and total costs. When comparing the benefits of spinal and general anesthesia, spinal anesthesia is less costly when used in patients undergoing lumbar diskectomy and laminectomy spine surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Lack of Consensus in Physician Recommendations Regarding Return to Driving After Cervical Spine Surgery.

PubMed

Moses, Michael J; Tishelman, Jared C; Hasan, Saqib; Zhou, Peter L; Zevgaras, Ioanna; Smith, Justin S; Buckland, Aaron J; Kim, Yong; Razi, Afshin; Protopsaltis, Themistocles S

2018-03-09

Cross-Sectional Study. The goal of this study is to investigate how surgeons differ in collar and narcotic use, as well as return to driving recommendations following cervical spine surgeries and the associated medico-legal ramifications of these conditions. Restoration of quality of life is one of the main goals of cervical spine surgery. Patients frequently inquire when they may safely resume driving after cervical spine surgery. There is no consensus regarding post-operative driving restrictions. This study addresses how surgeons differ in their recommendations concerning cervical immobilization, narcotic analgesia, and suggested timeline of return to driving following cervical spine surgery. Surgeons at the Cervical Spine Research Society annual meeting completed anonymous surveys assessing postoperative patient management following fusion and non-fusion cervical spine surgeries. 70% of surgeons returned completed surveys (n = 71). 80.3% were orthopaedic surgeons and 94.2% completed a spine fellowship. Experienced surgeons (>15y in practice) were more likely to let patients return to driving within 2 weeks than less experienced surgeons (47.1% vs 24.3%, p = .013) for multi-level ACDF and laminectomy with fusion procedures. There were no differences between surgeons practicing inside and outside the USA for prescribing collars or return to driving time. Cervical collars were used more for fusions than non-fusions (57.7% vs 31.0%, p = .001). Surgeons reported 75.3% of patients ask when they may resume driving. For cervical fusions, 31.4% of surgeons allowed their patients to resume driving while restricting them with collars for longer durations. Furthermore, 27.5% of surgeons allowed their patients to resume driving while taking narcotics post-operatively. This survey-based study highlights the lack of consensus regarding patient 'fitness to drive' following cervical spine surgery. The importance of establishing evidence-based guidelines is critical as recommendations for driving in the post-operative period may have significant medical, legal, and financial implications. 5.

Carotid Artery Injury in Anterior Cervical Spine Surgery: Multicenter Cohort Study and Literature Review

PubMed Central

Alimi, Marjan; Abdelatif Boukebir, Mohamed; Berlin, Connor D.; Navarro-Ramirez, Rodrigo; Arnold, Paul M.; Fehlings, Michael G.; Mroz, Thomas E.; Riew, K. Daniel

2017-01-01

Study Design: Retrospective study and literature review. Objective: To provide more comprehensive data about carotid artery injury (CAI) or cerebrovascular accident (CVA) related to anterior cervical spine surgery. Methods: We conducted a retrospective, multicenter, case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network. Medical records of 17 625 patients who went through cervical spine surgery (levels from C2 to C7) between January 1, 2005, and December 31, 2011, were analyzed. Also, we performed a literature review using Medline and PubMed databases. The following terms were used alone, and in combination, to search for relevant articles: cervical, spine, surgery, complication, iatrogenic, carotid artery, injury, cerebrovascular accident, CVA, and carotid stenosis. Results: Among 17 625 patients that were analyzed, no cases were reported to experienced CAI or CVA after cervical spine surgery. Nevertheless, in our PubMed search we found 157 articles, but only 5 articles matched our study objective criteria; 2 cases were reported to present CAI and 3 cases presented CVA. Conclusions: CAI and CVA related to anterior cervical spine surgeries are extremely rare. We were not able to find neither in our retrospective study nor in our literature research a correlation between the type or length of anterior cervical spine procedure with CVA or CAI complications. However, surgeons should be aware of the possibility of vascular complications and minimize intraoperative direct vascular manipulations or retraction. Preoperative screening for underlying vascular pathology and risk factors is also important. PMID:28451496

30-Day Readmission After Spine Surgery: An Analysis of 1400 Consecutive Spine Surgery Patients.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Han, Jing L; Karikari, Isaac O; Cheng, Joseph; Bagley, Carlos A

2017-04-01

Retrospective cohort review. To identify the rates, causes, and risk factors for 30-day unplanned readmissions in after elective spine surgery at our institution. Early readmission after spine surgery is being used as a proxy for quality of care. One-fifth of patients are rehospitalized within 30 days after spine surgery. Nearly 60% of these readmissions are unplanned, which translates into billions of dollars in healthcare costs. A total of 1400 patients undergoing elective spine surgery at Duke University Hospital between 2008 and 2010 were included in the study. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient records were reviewed to determine the cause of readmission and the length of hospital stay. A total of 132 (9.4%) unplanned early readmissions were identified. The mean ± SD age was 58.6 ± 15.1 years. Lumbar decompression and fusion was the most common procedure The most common causes for readmission were infection or a concern for infection (34.8%) and pain (19.7%), and 26.5% of readmissions required a return to the operating room. The majority of patients that were readmitted presented to the emergency department from home (58.0%) whereas 25.2% were readmitted from a skilled nursing facility. The mean ± SD number of days from discharge to readmission was 9.8 ± 7.9 days and the average length of hospital stay for the readmissions was 7.5 days. This study suggests that infection and refractory pain were the most common primary reasons for unplanned readmission. Efforts at reducing unplanned early readmission after elective spine surgery should be focused on more effective post discharge care.

New generation intraoperative three-dimensional imaging (O-arm) in 100 spine surgeries: does it change the surgical procedure?

PubMed

Sembrano, Jonathan N; Santos, Edward Rainier G; Polly, David W

2014-02-01

The O-arm (Medtronic Sofamor Danek, Inc., Memphis, TN, USA), an intraoperative CT scan imaging system, may provide high-quality imaging information to the surgeon. To our knowledge, its impact on spine surgery has not been studied. We reviewed 100 consecutive spine surgical procedures which utilized the new generation mobile intraoperative CT imaging system (O-arm). The most common diagnoses were degenerative conditions (disk disease, spondylolisthesis, stenosis and acquired kyphosis), seen in 49 patients. The most common indication for imaging was spinal instrumentation in 81 patients (74 utilized pedicle screws). In 52 (70%) of these, the O-arm was used to assess screw position after placement; in 22 (30%), it was coupled with Stealth navigation (Medtronic Sofamor Danek, Inc.) to guide screw placement. Another indication was to assess adequacy of spinal decompression in 38 patients; in 19 (50%) of these, intrathecal contrast material was used to obtain an intraoperative CT myelogram. In 20 patients O-arm findings led to direct surgeon intervention in the form of screw removal/repositioning (n=13), further decompression (n=6), interbody spacer repositioning (n=1), and removal of kyphoplasty trocar (n=1). In 20% of spine surgeries, the procedure was changed based on O-arm imaging findings. We found the O-arm to be useful for assessment of instrumentation position, adequacy of spinal decompression, and confirmation of balloon containment and cement filling in kyphoplasty. When used with navigation for image-guided surgery, it obviated the need for registration. Published by Elsevier Ltd.

A medico-legal review of cases involving quadriplegia following cervical spine surgery: Is there an argument for a no-fault compensation system?

PubMed

Epstein, Nancy E

2010-04-07

To determine whether patients who become quadriplegic following cervical spine surgery are adequately compensated by our present medico-legal system. The outcomes of malpractice suits obtained from Verdict Search (East Islip, NY, USA), a medico-legal journal, were evaluated over a 20-year period. Although the present malpractice system generously rewards many quadriplegic patients with substantial settlements/ Plaintiffs' verdicts, a subset receive lesser reimbursements (verdicts/settlements], while others with defense verdicts receive no compensatory damages. Utilizing Verdict Search, 54 cases involving quadriplegia following cervical spine surgery were reviewed for a 20-year interval (1988-2008). The reason(s) for the suit, the defendants, the legal outcome, and the time to outcome were identified. Operations included 25 anterior cervical procedures, 22 posterior cervical operations, 1 circumferential cervical procedure, and 6 cases in which the cervical operations were not defined. The four most prominent legal allegations for suits included negligent surgery (47 cases), lack of informed consent (23 cases), failure to diagnose/treat (33 cases), and failure to brace (15 cases). Forty-four of the 54 suits included spine surgeons. There were 19 Plaintiffs' verdicts (average US $5.9 million, range US $540,000-US $18.4 million), and 20 settlements (average US $2.8 million, range US $66,500-US $12.0 million). Fifteen quadriplegic patients with defense verdicts received no compensatory damages. The average time to verdicts/settlements was 4.3 years. For 54 patients who were quadriplegic following cervical spine surgery, 15 (28%) with defense verdicts received no compensatory damages. Under a No-Fault system, quadriplegic patients would qualify for a "reasonable" level of compensation over a "shorter" time frame.

Minimally Invasive versus Open Spine Surgery: What Does the Best Evidence Tell Us?

PubMed

McClelland, Shearwood; Goldstein, Jeffrey A

2017-01-01

Spine surgery has been transformed significantly by the growth of minimally invasive surgery (MIS) procedures. Easily marketable to patients as less invasive with smaller incisions, MIS is often perceived as superior to traditional open spine surgery. The highest quality evidence comparing MIS with open spine surgery was examined. A systematic review of randomized controlled trials (RCTs) involving MIS versus open spine surgery was performed using the Entrez gateway of the PubMed database for articles published in English up to December 28, 2015. RCTs and systematic reviews of RCTs of MIS versus open spine surgery were evaluated for three particular entities: Cervical disc herniation, lumbar disc herniation, and posterior lumbar fusion. A total of 17 RCTs were identified, along with six systematic reviews. For cervical disc herniation, MIS provided no difference in overall function, arm pain relief, or long-term neck pain. In lumbar disc herniation, MIS was inferior in providing leg/low back pain relief, rehospitalization rates, quality of life improvement, and exposed the surgeon to >10 times more radiation in return for shorter hospital stay and less surgical site infection. In posterior lumbar fusion, MIS transforaminal lumbar interbody fusion (TLIF) had significantly reduced 2-year societal cost, fewer medical complications, reduced time to return to work, and improved short-term Oswestry Disability Index scores at the cost of higher revision rates, higher readmission rates, and more than twice the amount of intraoperative fluoroscopy. The highest levels of evidence do not support MIS over open surgery for cervical or lumbar disc herniation. However, MIS TLIF demonstrates advantages along with higher revision/readmission rates. Regardless of patient indication, MIS exposes the surgeon to significantly more radiation; it is unclear how this impacts patients. These results should optimize informed decision-making regarding MIS versus open spine surgery, particularly in the current advertising climate greatly favoring MIS.

Preoperative MRSA Screening in Pediatric Spine Surgery: A Helpful Tool or a Waste of Time and Money?

PubMed

Luhmann, Scott J; Smith, June C

2016-07-01

To review the use of preoperative screening for Staphylococcus aureus for all pediatric spine procedures that was instituted at our facility in a multimodal approach to decrease the frequency of postoperative wound infections. Four years ago at our facility, a multimodal approach to decrease the frequency of postoperative infections after pediatric spine surgery was instituted. A single-center, single-surgeon pediatric spine surgery database was queried to identify all patients who had preoperative S. aureus nasal swab screening. Data collected included demographic data, diagnoses, methicillin-resistant S. aureus (MRSA) swab findings, bacterial antibiotic sensitivities, and outcome of the spine surgery. A total of 339 MRSA screenings were performed. Twenty (5.9%) were MRSA positive, and 55 (16.2%) were methicillin-sensitive S. aureus (MSSA) positive. In the MRSA-positive group, 13 were neuromuscular, 5 were adolescent idiopathic scoliosis (AIS), 1 congenital, and 1 infantile idiopathic scoliosis. Of the MRSA-positive screenings, 13 (65.0% of MRSA-positive screenings; 3.8% of entire cohort) of were newly identified cases (9 neuromuscular, 3 AIS, and 1 congenital diagnoses). In the 55 MSSA-positive, 6 documented resistance to either cefazolin or clindamycin. Hence, in up to 22 of the preoperative screenings (6.5% of entire cohort; 16 MRSA and 6 MSSA showed antibiotic resistance), the preoperative antibiotic regimen could be altered to appropriately cover the identified bacterial resistances. During the study period, there were 11 patients who were diagnosed with a postoperative deep wound infection, none of them having positive screenings. The use of preoperative nasal swab MRSA screening permitted adjustment of the preoperative antibiotic regimen in up to 6.5% of patients undergoing pediatric spine surgery. This inexpensive, noninvasive tool can be used in preoperative surgical planning for all patients undergoing spinal procedures. Level IV. Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.

Return to Play in Athletes Receiving Cervical Surgery: A Systematic Review

PubMed Central

Molinari, Robert W.; Pagarigan, Krystle; Dettori, Joseph R.; Molinari, Robert; Dehaven, Kenneth E.

2016-01-01

Study Design Systematic review. Clinical Questions Among athletes who undergo surgery of the cervical spine, (1) What proportion return to play (RTP) after their cervical surgery? (2) Does the proportion of those cleared for RTP depend on the type of surgical procedure (artificial disk replacement, fusion, nonfusion foraminotomies/laminoplasties), number of levels (1, 2, or more levels), or type of sport? (3) Among those who return to their presurgery sport, how long do they continue to play? (4) Among those who return to their presurgery sport, how does their postoperative performance compare with their preoperative performance? Objectives To evaluate the extent and quality of published literature on the topic of return to competitive athletic completion after cervical spinal surgery. Methods Electronic databases and reference lists of key articles published up to August 19, 2015, were searched to identify studies reporting the proportion of athletes who RTP after cervical spine surgery. Results Nine observational, retrospective series consisting of 175 patients were included. Seven reported on professional athletes and two on recreational athletes. Seventy-five percent (76/102) of professional athletes returned to their respective sport following surgery for mostly cervical herniated disks. Seventy-six percent of recreational athletes (51/67) age 10 to 42 years RTP in a variety of sports following surgery for mostly herniated disks. No snowboarder returned to snowboarding (0/6) following surgery for cervical fractures. Most professional football players and baseball pitchers returned to their respective sport at their presurgery performance level. Conclusions RTP decisions after cervical spine surgery remain controversial, and there is a paucity of existing literature on this topic. Successful return to competitive sports is well described after single-level anterior cervical diskectomy and fusion surgery for herniated disk. RTP outcomes involving other cervical spine diagnoses and surgical procedures remain unclear. Additional quality research is needed on this topic. PMID:26835207

Prevalence, Comorbidities, and Risk of Perioperative Complications in Human Immunodeficiency Virus-Positive Patients Undergoing Cervical Spine Surgery.

PubMed

Lovy, Andrew J; Guzman, Javier Z; Skovrlj, Branko; Cho, Samuel K; Hecht, Andrew C; Qureshi, Sheeraz A

2015-11-01

Retrospective database analysis. To evaluate outcomes of human immunodeficiency virus (HIV) positive patients after cervical spine surgery. Highly active antiretroviral medications have qualitatively altered the natural history of HIV, thus increasing the number of HIV-positive patients seeking treatment for chronic degenerative conditions. Minimal data exist on HIV patients undergoing degenerative cervical spine surgery. The Nationwide Inpatient Sample was examined from 2002 to 2011. Hospitalizations were identified using International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9-CM) procedural codes for cervical spine surgery and diagnoses codes for degenerative conditions of the cervical spine, and HIV. Statistical analysis was conducted to evaluate associations between HIV status and perioperative complications. A total of 1,602,129 patients underwent degenerative cervical spine surgery, of which 3700 patients (0.23%) had HIV. The prevalence of HIV increased over the study period from 0.19% to 0.33% (P < 0.001). Patients with HIV were younger (48.6 yrs vs. 53.4 yrs, P < 0.001) and more likely to be male (P < 0.001). HIV patients had significantly greater odds of having chronic pulmonary disease, liver disease, and drug abuse. Unadjusted analysis did not reveal increased rate of acute complications among HIV-positive patients compared with negative controls (3.8% vs. 3.7%, P = 0.62). Multivariate analysis did not identify HIV as a significant predictor of complication (odds ratio = 1.04, P = 0.84). HIV was associated with a 1.5 day increased length of stay AND 1.29 fold increase in median costs compared with controls ($14,551 vs. 18,846, P < 0.001). The prevalence of HIV patients undergoing degenerative cervical spine surgery is increasing. A diagnosis of HIV was not associated with an increased risk of perioperative complication among patients undergoing degenerative cervical spine surgery. Further clinical studies are needed to evaluate predictors of complications among HIV patients and long-term outcomes. 4.

Incidence of intraoperative seizures during motor evoked potential monitoring in a large cohort of patients undergoing different surgical procedures.

PubMed

Ulkatan, Sedat; Jaramillo, Ana Maria; Téllez, Maria J; Kim, Jinu; Deletis, Vedran; Seidel, Kathleen

2017-04-01

OBJECTIVE The purpose of this study was to investigate the incidence of seizures during the intraoperative monitoring of motor evoked potentials (MEPs) elicited by electrical brain stimulation in a wide spectrum of surgeries such as those of the orthopedic spine, spinal cord, and peripheral nerves, interventional radiology procedures, and craniotomies for supra- and infratentorial tumors and vascular lesions. METHODS The authors retrospectively analyzed data from 4179 consecutive patients who underwent surgery or an interventional radiology procedure with MEP monitoring. RESULTS Of 4179 patients, only 32 (0.8%) had 1 or more intraoperative seizures. The incidence of seizures in cranial procedures, including craniotomies and interventional neuroradiology, was 1.8%. In craniotomies in which transcranial electrical stimulation (TES) was applied to elicit MEPs, the incidence of seizures was 0.7% (6/850). When direct cortical stimulation was additionally applied, the incidence of seizures increased to 5.4% (23/422). Patients undergoing craniotomies for the excision of extraaxial brain tumors, particularly meningiomas (15 patients), exhibited the highest risk of developing an intraoperative seizure (16 patients). The incidence of seizures in orthopedic spine surgeries was 0.2% (3/1664). None of the patients who underwent surgery for conditions of the spinal cord, neck, or peripheral nerves or who underwent cranial or noncranial interventional radiology procedures had intraoperative seizures elicited by TES during MEP monitoring. CONCLUSIONS In this largest such study to date, the authors report the incidence of intraoperative seizures in patients who underwent MEP monitoring during a wide spectrum of surgeries such as those of the orthopedic spine, spinal cord, and peripheral nerves, interventional radiology procedures, and craniotomies for supra- and infratentorial tumors and vascular lesions. The low incidence of seizures induced by electrical brain stimulation, particularly short-train TES, demonstrates that MEP monitoring is a safe technique that should not be avoided due to the risk of inducing seizures.

Experience with 161 cases of anterior exposure of the thoracic and lumbar spine in an acute care surgery model: impact of exposure level and underlying pathology on morbidity.

PubMed

Seoudi, Hani; Laporta, Matthew; Griffen, Margaret; Rizzo, Anne; Pullarkat, Ranjit

2013-08-15

Retrospective chart review. To evaluate the outcomes of anterior exposure of the thoracic and lumbar spine by an acute care surgery service. Spine surgeons typically require an "approach surgeon" to provide anterior exposure of the thoracic and lumbar spine. We hypothesized that a dedicated acute care surgery service can perform those operations with acceptable morbidity and mortality. A retrospective review of 161 trauma and nontrauma patients was performed. All cases were performed at a level I trauma center with a dedicated acute care surgery service. In-hospital morbidity and mortality were evaluated. A brief description of the operative techniques used by our group is also provided. Of the 161 patients, 59 (37%) were trauma patients. Ninety-three patients (58%) had anterolateral retroperitoneal exposure of the thoracic and lumbar spine. Sixty-eight patients (42%) had anterior retroperitoneal midline exposure of the lumbar and lumbosacral spine. Total morbidity was 9.3% (7.4% for trauma patients and 1.8% for non trauma patients). Morbidity was highest in patients who had anterolateral exposure of the thoracic and lumbar spine (6.8%). Morbidity in patients who had midline exposure of L4 to S1 was 0%. Total mortality was 1.2% (3.3% for trauma patients and 0% for nontrauma patients). The acute care surgery service gained 3141 physician work relative value units (RVU) by performing those operations. Anterior exposure of the thoracic and lumbar spine both for trauma and nontrauma related indications can be performed with acceptable morbidity and mortality by a dedicated acute care surgery service. Morbidity and mortality were higher in trauma patients and in those who underwent thoracolumbar procedures. Patients who had midline exposure of L4 to S1 for degenerative disc disease had the lowest morbidity. 4.

Anterior cervical spine surgery-associated complications in a retrospective case-control study.

PubMed

Tasiou, Anastasia; Giannis, Theofanis; Brotis, Alexandros G; Siasios, Ioannis; Georgiadis, Iordanis; Gatos, Haralampos; Tsianaka, Eleni; Vagkopoulos, Konstantinos; Paterakis, Konstantinos; Fountas, Kostas N

2017-09-01

Anterior cervical spine procedures have been associated with satisfactory outcomes. However, the occurrence of troublesome complications, although uncommon, needs to be taken into consideration. The purpose of our study was to assess the actual incidence of anterior cervical spine procedure-associated complications and identify any predisposing factors. A total of 114 patients undergoing anterior cervical procedures over a 6-year period were included in our retrospective, case-control study. The diagnosis was cervical radiculopathy, and/or myelopathy due to degenerative disc disease, cervical spondylosis, or traumatic cervical spine injury. All our participants underwent surgical treatment, and complications were recorded. The most commonly performed procedure (79%) was anterior cervical discectomy and fusion (ACDF). Fourteen patients (12.3%) underwent anterior cervical corpectomy and interbody fusion, seven (6.1%) ACDF with plating, two (1.7%) odontoid screw fixation, and one anterior removal of osteophytes for severe Forestier's disease. Mean follow-up time was 42.5 months (range, 6-78 months). The overall complication rate was 13.2%. Specifically, we encountered adjacent intervertebral disc degeneration in 2.7% of our cases, dysphagia in 1.7%, postoperative soft tissue swelling and hematoma in 1.7%, and dural penetration in 1.7%. Additionally, esophageal perforation was observed in 0.9%, aggravation of preexisting myelopathy in 0.9%, symptomatic recurrent laryngeal nerve palsy in 0.9%, mechanical failure in 0.9%, and superficial wound infection in 0.9%. In the vast majority anterior cervical spine surgery-associated complications are minor, requiring no further intervention. Awareness, early recognition, and appropriate management, are of paramount importance for improving the patients' overall functional outcome.

Is Intraoperative Local Vancomycin Powder the Answer to Surgical Site Infections in Spine Surgery?

PubMed

Hey, Hwee Weng Dennis; Thiam, Desmond Wei; Koh, Zhi Seng Darren; Thambiah, Joseph Shantakumar; Kumar, Naresh; Lau, Leok-Lim; Liu, Ka-Po Gabriel; Wong, Hee-Kit

2017-02-15

This is a retrospective cohort comparative study of all patients who underwent instrumented spine surgery at a single institution. To compare the rate of surgical site infection (SSI) between the treatment (vancomycin) and the control group (no vancomycin) in patients undergoing instrumented spine surgery. SSI after spine surgery is a dreaded complication associated with increased morbidity and mortality. Prophylactic intraoperative local vancomycin powder to the wound has been recently adopted as a strategy to reduce SSI but results have been variable. In the present study, there were 117 (30%) patients in the treatment group and 272 (70%) patients in the comparison cohort. All patients received identical standard operative and postoperative care procedures based on protocolized department guidelines. The present study compared the rate of SSI with and without the use of prophylactic intraoperative local vancomycin powder in patients undergoing various instrumented spine surgery, adjusted for confounders. The overall rate of SSI was 4.7% with a decrease in infection rate found in the treatment group (0.9% vs. 6.3%). This was statistically significant (P = 0.049) with an odds ratio of 0.13 (95% confidence interval 0.02-0.99). The treatment group had a significantly shorter onset of infection (5 vs. 16.7 days; P < 0.001) and shorter duration of infection (8.5 vs. 26.8 days; P < 0.001). The most common causative organism was Pseudomonas aeruginosa (35.2%). Patient diagnosis, surgical approach, and intraoperative blood loss were significant risk factors for SSI after multivariable analysis. Prophylactic Intraoperative local vancomycin powder reduces the risk and morbidity of SSI in patients undergoing instrumented spine surgery. P. aeruginosa infection is common in the treatment arm. Future prospective randomized controlled trials in larger populations involving other spine surgeries with a long-term follow-up duration are recommended. 3.

Predicting Occurrence of Spine Surgery Complications Using "Big Data" Modeling of an Administrative Claims Database.

PubMed

Ratliff, John K; Balise, Ray; Veeravagu, Anand; Cole, Tyler S; Cheng, Ivan; Olshen, Richard A; Tian, Lu

2016-05-18

Postoperative metrics are increasingly important in determining standards of quality for physicians and hospitals. Although complications following spinal surgery have been described, procedural and patient variables have yet to be incorporated into a predictive model of adverse-event occurrence. We sought to develop a predictive model of complication occurrence after spine surgery. We used longitudinal prospective data from a national claims database and developed a predictive model incorporating complication type and frequency of occurrence following spine surgery procedures. We structured our model to assess the impact of features such as preoperative diagnosis, patient comorbidities, location in the spine, anterior versus posterior approach, whether fusion had been performed, whether instrumentation had been used, number of levels, and use of bone morphogenetic protein (BMP). We assessed a variety of adverse events. Prediction models were built using logistic regression with additive main effects and logistic regression with main effects as well as all 2 and 3-factor interactions. Least absolute shrinkage and selection operator (LASSO) regularization was used to select features. Competing approaches included boosted additive trees and the classification and regression trees (CART) algorithm. The final prediction performance was evaluated by estimating the area under a receiver operating characteristic curve (AUC) as predictions were applied to independent validation data and compared with the Charlson comorbidity score. The model was developed from 279,135 records of patients with a minimum duration of follow-up of 30 days. Preliminary assessment showed an adverse-event rate of 13.95%, well within norms reported in the literature. We used the first 80% of the records for training (to predict adverse events) and the remaining 20% of the records for validation. There was remarkable similarity among methods, with an AUC of 0.70 for predicting the occurrence of adverse events. The AUC using the Charlson comorbidity score was 0.61. The described model was more accurate than Charlson scoring (p < 0.01). We present a modeling effort based on administrative claims data that predicts the occurrence of complications after spine surgery. We believe that the development of a predictive modeling tool illustrating the risk of complication occurrence after spine surgery will aid in patient counseling and improve the accuracy of risk modeling strategies. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.

Periscopic Spine Surgery.

DTIC Science & Technology

2000-02-01

radiation medicine, the neurosurgery intensive care unit (ICU), and the pediatrics ICU [Geary 1999a]. The major procedures impacted are spine tumor...radiation medicine, and the pediatric intensive care unit . Hardware and software problems addressed included modifications of patient positioning...planning. Attempts have been made to link mechanical tissue properties to cellular interaction through electrical impedance [7] and to Hounsfield units

Epidural Hematoma Following Cervical Spine Surgery.

PubMed

Schroeder, Gregory D; Hilibrand, Alan S; Arnold, Paul M; Fish, David E; Wang, Jeffrey C; Gum, Jeffrey L; Smith, Zachary A; Hsu, Wellington K; Gokaslan, Ziya L; Isaacs, Robert E; Kanter, Adam S; Mroz, Thomas E; Nassr, Ahmad; Sasso, Rick C; Fehlings, Michael G; Buser, Zorica; Bydon, Mohamad; Cha, Peter I; Chatterjee, Dhananjay; Gee, Erica L; Lord, Elizabeth L; Mayer, Erik N; McBride, Owen J; Nguyen, Emily C; Roe, Allison K; Tortolani, P Justin; Stroh, D Alex; Yanez, Marisa Y; Riew, K Daniel

2017-04-01

A multicentered retrospective case series. To determine the incidence and circumstances surrounding the development of a symptomatic postoperative epidural hematoma in the cervical spine. Patients who underwent cervical spine surgery between January 1, 2005, and December 31, 2011, at 23 institutions were reviewed, and all patients who developed an epidural hematoma were identified. A total of 16 582 cervical spine surgeries were identified, and 15 patients developed a postoperative epidural hematoma, for a total incidence of 0.090%. Substantial variation between institutions was noted, with 11 sites reporting no epidural hematomas, and 1 site reporting an incidence of 0.76%. All patients initially presented with a neurologic deficit. Nine patients had complete resolution of the neurologic deficit after hematoma evacuation; however 2 of the 3 patients (66%) who had a delay in the diagnosis of the epidural hematoma had residual neurologic deficits compared to only 4 of the 12 patients (33%) who had no delay in the diagnosis or treatment ( P = .53). Additionally, the patients who experienced a postoperative epidural hematoma did not experience any significant improvement in health-related quality-of-life metrics as a result of the index procedure at final follow-up evaluation. This is the largest series to date to analyze the incidence of an epidural hematoma following cervical spine surgery, and this study suggest that an epidural hematoma occurs in approximately 1 out of 1000 cervical spine surgeries. Prompt diagnosis and treatment may improve the chance of making a complete neurologic recovery, but patients who develop this complication do not show improvements in the health-related quality-of-life measurements.

Technical Aspects on the Use of Ultrasonic Bone Shaver in Spine Surgery: Experience in 307 Patients

PubMed Central

Hazer, Derya Burcu; Yaşar, Barış; Rosberg, Hans-Eric; Akbaş, Aytaç

2016-01-01

Aim. We discuss technical points, the safety, and efficacy of ultrasonic bone shaver in various spinal surgeries within our own series. Methods. Between June 2010 and January 2014, 307 patients with various spinal diseases were operated on with the use of an ultrasonic bone curette with microhook shaver (UBShaver). Patients' data were recorded and analyzed retrospectively. The technique for the use of the device is described for each spine surgery procedure. Results. Among the 307 patients, 33 (10.7%) cases had cervical disorder, 17 (5.5%) thoracic disorder, 3 (0.9%) foramen magnum disorder, and 254 (82.7%) lumbar disorders. Various surgical techniques were performed either assisted or alone by UBShaver. The duration of the operations and the need for blood replacement were relatively low. The one-year follow-up with Neck Disability Index (NDI) and Oswestry Disability Index (ODI) scores were improved. We had 5 cases of dural tears (1.6%) in patients with lumbar spinal disease. No neurological deficit was found in any patients. Conclusion. We recommend this device as an assistant tool in various spine surgeries and as a primary tool in foraminotomies. It is a safe device in spine surgery with very low complication rate. PMID:27195299

Posterior corrective surgery for moderate to severe focal kyphosis in the thoracolumbar spine: 57 cases with minimum 3 years follow-up.

PubMed

Zeng, Yan; Qu, Xiaochen; Chen, Zhongqiang; Yang, Xiaoxi; Guo, Zhaoqing; Qi, Qiang; Li, Weishi; Sun, Chuiguo

2017-07-01

To evaluate the radiological and clinical outcomes of the corrective surgery for patients with moderate to severe focal kyphosis in thoracolumbar spine. Fifty-seven patients with moderate to severe focal kyphosis of the thoracolumbar spine underwent apical segmental resection osteotomy with dual axial rotation correction at our hospital. There were 30 male and 27 female patients. The mean age was 34.3 years. The kyphosis level radiographs were obtained from each patient before surgery, immediately after surgery and at follow-up. Local kyphosis and scoliosis Cobb angles were measured. Full-spine standing radiographs were obtained before surgery and at follow-up, and the spine sagittal and coronal balance were evaluated. The height of patients, the Frankel grading system for neurological functions, the Oswestry disability index for life quality, the visual analogue score for back pain and the patient satisfactory index for satisfaction to surgery were applied before surgery and at follow-up. The radiological and clinical outcomes were further analyzed in different sub-groups of patients according to etiology, severity of kyphosis, age, level of kyphosis apex, Frankel grade before surgery, and complications. The average follow-up time of patients was 46.1 months. The average kyphosis angle reduced from 94.6° before surgery to 31.0° immediately after surgery, and remained at 34.4° at follow-up. The sagittal balance of the spine, height of patients, Frankel grading, Oswestry disability index and visual analogue score were improved. The patient satisfactory index (PSI) showed a satisfied rate of 91.2%. The correction rate was significantly higher in patients with kyphosis angle less than 95° and age less than 35 years. The clinical improvement rate was significantly higher in patient with kyphosis apex at lower thoracic spine or thoracolumbar segment, Frankel grade E before surgery and no complication group. The incidence of intra-operative and early stage complications was 38.6%, and the incidence of instrumentation failure was 10.5%. The most severe complication was transient spinal cord injury, and the incidence was 7.0%. All complications got good relief after appropriate intervention. Apical segmental resection osteotomy with dual axial rotation correction is an effective procedure to treat moderate to severe focal kyphosis, the prevention of serious neurological complications is fundamental to achieve the ideal clinical results.

Minimally Invasive Direct Lateral Interbody Fusion (MIS-DLIF): Proof of Concept and Perioperative Results.

PubMed

Abbasi, Hamid; Abbasi, Ali

2017-01-14

Minimally invasive direct lateral interbody fusion (MIS-DLIF) is a novel approach for fusions of the lumbar spine. In this proof of concept study, we describe the surgical technique and report our experience and the perioperative outcomes of the first nine patients who underwent this procedure. In this study we establish the safety and efficacy of this approach. MIS-DLIF was performed on 15 spinal levels in nine patients who failed to respond to conservative therapy for the treatment of a re-herniated disk, spondylolisthesis, or other severe disk disease of the lumbar spine. We recorded surgery time, blood loss, fluoroscopy time, patient-reported pain, and complications. Throughout the MIS-DLIF procedure, the surgeon is aided by biplanar fluoroscopic imaging to place an interbody graft or cage into the disc space through the interpleural space. A discectomy is performed in the same minimally invasive fashion. The procedure is usually completed with posterior pedicle screw fixation. MIS-DLIF took 44/85 minutes, on average, for 1/2 levels, with 54/112 ml of blood loss, and 0.3/1.7 days of hospital stay. Four of nine patients did not require overnight hospitalization and were discharged two to four hours after surgery. We did not encounter any clinically significant complications. At more than ninety days post surgery, the patients reported a statistically significant reduction of 4.5 points on a 10-point sliding pain scale. MIS-DLIF with pedicle screw fixation is a safe and clinically effective procedure for fusions of the lumbar spine. The procedure overcomes many of the limitations of the current minimally invasive approaches to the lumbar spine and is technically straightforward. MIS-DLIF has the potential to improve patient outcomes and reduce costs relative to the current standard of care and therefore warrants further investigation. We are currently expanding this study to a larger cohort and documenting long-term outcome data.

A review of medicolegal malpractice suits involving cervical spine: what can we learn or change?

PubMed

Epstein, Nancy E

2011-02-01

Utilizing Verdict Search (East Islip, New York), a medicolegal research service for civil and criminal court cases, 78 cervical spine surgical malpractice suits were identified (10-year period). Factors leading to cervical spine surgical litigation may represent an untapped source of risks/complications associated with these operations. Data with fewer adverse events are submitted to and/or published in spine journals, as they are discoverable in a court of law. Cervical spine surgery in 68 patients included 48 anterior operations (1 to 4 level anterior diskectomy/fusions, 1-level corpectomy/fusion). Twenty patients had posterior surgery (7 fusions, 13 laminectomies with/without fusions). Two patients had other operations/procedures, whereas 8 had no surgery. Four major questions were asked; (1) What were the operations/neurologic deficits that led to the suits?, (2) Who was sued?, (3) What purported and/or alleged "malpractice" events prompted the suits?, and (4) What were the outcomes of these suits? Postoperative neurologic deficits that led to suits included quadriplegia in 41 patients (21 anterior, 20 posterior operations). Other injuries/lesser postoperative deficits were observed in 15 patients, whereas 22 had pain alone. Malpractice suits involved 63 spine surgeons, whereas 15 did not. The 3 most common malpractice events prompting cervical suits, and typical for most surgery-related suits, included negligent surgery, lack of informed consent, and failure to diagnose/treat; the fourth unanticipated factor was failure to brace. Outcomes for these suits included 30 defense verdicts (10 quadriplegic patients), 22 plaintiffs' verdicts (average payout $4.0 million dollars), and 26 settlements (average $2.4 million dollars). Data gleaned from medicolegal suits may provide additional information regarding the morbidity associated with cervical surgery. These data may lessen patients' expectations, and limit spine surgeons' liability. In the future, consideration may be given to tort reform, or a No-Fault malpractice system.

COMPARISON OF INTRAOPERATIVE KETAMINE VS. FENTANYL USE DECREASES POSTOPERATIVE OPIOID REQUIREMENTS IN TRAUMA PATIENTS UNDERGOING CERVICAL SPINE SURGERY.

PubMed

Berkowitz, Aviva C; Ginsburg, Aryeh M; Pesso, Raymond M; Angus, George L D; Kang, Amiee; Ginsburg, Dov B

2016-02-01

Postoperative airway compromise following cervical spine surgery is a potentially serious adverse event. Residual effects of anesthesia and perioperative opioids that can cause both sedation and respiratory depression further increase this risk. Ketamine is an N-methyl-d-aspartate (NMDA) receptor antagonist that provides potent analgesia without noticeable respiratory depression. We investigated whether intraoperative ketamine administration could decrease perioperative opioid requirements in trauma patients undergoing cervical spine surgery. We retrospectively reviewed anesthesia records identifying cervical spine surgeries performed between March 2014 and February 2015. All patients received a balanced anesthetic technique utilizing sevoflurane 0.5 minimum alveolar concentration (MAC) and propofol infusion (50-100 mcg/kg/min). For intraoperative analgesia, one group of patients received ketamine (N=25) and a second group received fentanyl (N=27). Cumulative opioid doses in the recovery room and until 24 hours postoperatively were recorded. Fewer patients in the ketamine group (11/25 [44%] vs. 20/27 [74%], respectively; p = 0.03) required analgesics in the recovery room. Additionally, the total cumulative opioid requirements in the ketamine group decreased postoperatively at both 3 and 6 hours (p = 0.01). Ketamine use during cervical spine surgery decreased opioid requirements in both the recovery room and in the first 6 hours postoperatively. This may have the potential to minimize opioid induced respiratory depression in a population at increased risk of airway complications related to the surgical procedure.

Optimization of spine surgery planning with 3D image templating tools

NASA Astrophysics Data System (ADS)

Augustine, Kurt E.; Huddleston, Paul M.; Holmes, David R., III; Shridharani, Shyam M.; Robb, Richard A.

2008-03-01

The current standard of care for patients with spinal disorders involves a thorough clinical history, physical exam, and imaging studies. Simple radiographs provide a valuable assessment but prove inadequate for surgery planning because of the complex 3-dimensional anatomy of the spinal column and the close proximity of the neural elements, large blood vessels, and viscera. Currently, clinicians still use primitive techniques such as paper cutouts, pencils, and markers in an attempt to analyze and plan surgical procedures. 3D imaging studies are routinely ordered prior to spine surgeries but are currently limited to generating simple, linear and angular measurements from 2D views orthogonal to the central axis of the patient. Complex spinal corrections require more accurate and precise calculation of 3D parameters such as oblique lengths, angles, levers, and pivot points within individual vertebra. We have developed a clinician friendly spine surgery planning tool which incorporates rapid oblique reformatting of each individual vertebra, followed by interactive templating for 3D placement of implants. The template placement is guided by the simultaneous representation of multiple 2D section views from reformatted orthogonal views and a 3D rendering of individual or multiple vertebrae enabling superimposition of virtual implants. These tools run efficiently on desktop PCs typically found in clinician offices or workrooms. A preliminary study conducted with Mayo Clinic spine surgeons using several actual cases suggests significantly improved accuracy of pre-operative measurements and implant localization, which is expected to increase spinal procedure efficiency and safety, and reduce time and cost of the operation.

Anterior cervical spine surgery-associated complications in a retrospective case-control study

PubMed Central

Giannis, Theofanis; Brotis, Alexandros G.; Siasios, Ioannis; Georgiadis, Iordanis; Gatos, Haralampos; Tsianaka, Eleni; Vagkopoulos, Konstantinos; Paterakis, Konstantinos; Fountas, Kostas N.

2017-01-01

Anterior cervical spine procedures have been associated with satisfactory outcomes. However, the occurrence of troublesome complications, although uncommon, needs to be taken into consideration. The purpose of our study was to assess the actual incidence of anterior cervical spine procedure-associated complications and identify any predisposing factors. A total of 114 patients undergoing anterior cervical procedures over a 6-year period were included in our retrospective, case-control study. The diagnosis was cervical radiculopathy, and/or myelopathy due to degenerative disc disease, cervical spondylosis, or traumatic cervical spine injury. All our participants underwent surgical treatment, and complications were recorded. The most commonly performed procedure (79%) was anterior cervical discectomy and fusion (ACDF). Fourteen patients (12.3%) underwent anterior cervical corpectomy and interbody fusion, seven (6.1%) ACDF with plating, two (1.7%) odontoid screw fixation, and one anterior removal of osteophytes for severe Forestier’s disease. Mean follow-up time was 42.5 months (range, 6–78 months). The overall complication rate was 13.2%. Specifically, we encountered adjacent intervertebral disc degeneration in 2.7% of our cases, dysphagia in 1.7%, postoperative soft tissue swelling and hematoma in 1.7%, and dural penetration in 1.7%. Additionally, esophageal perforation was observed in 0.9%, aggravation of preexisting myelopathy in 0.9%, symptomatic recurrent laryngeal nerve palsy in 0.9%, mechanical failure in 0.9%, and superficial wound infection in 0.9%. In the vast majority anterior cervical spine surgery-associated complications are minor, requiring no further intervention. Awareness, early recognition, and appropriate management, are of paramount importance for improving the patients’ overall functional outcome. PMID:29057356

The effect of blood transfusion on short-term, perioperative outcomes in elective spine surgery.

PubMed

Seicean, Andreea; Alan, Nima; Seicean, Sinziana; Neuhauser, Duncan; Weil, Robert J

2014-09-01

Studies in various surgical procedures have shown that transfusion of red blood cells (RBC) increases the risk of postoperative morbidity and mortality. Impact of blood transfusion in patients undergoing spine surgery is not well-described. We assessed the impact of intra and postoperative transfusion on postoperative morbidity and mortality in patients undergoing elective spine surgery. We used the American College of Surgeons' National Surgical Quality Improvement Program to identify a retrospective cohort of 36,901 adult patients who underwent elective spine surgery between 2006 and 2011. Patients who received intra or postoperative transfusion (n=3262) were matched to those who did not using propensity scores. Logistic regression predicted adverse postoperative outcomes. We conducted sensitivity analysis in a subset of patients in whom the number of intraoperatively transfused units of RBC or whole blood was known. Upon matching, preoperative hematocrit, length of surgery, and percentage of spinal fusion surgery were not significantly different between transfused and non-transfused patients. After matching, transfusion remained adversely associated with prolonged length of stay (LOS) in hospital (odds ratio [OR] 2.6, 95% confidence interval [CI] 2.3-2.9), postoperative complications (OR 1.6, 95% CI 1.4-1.9), and an increased 30 day return to operation room (OR 1.7, 95% CI 1.3-2.2). Transfusion of even one unit of blood intraoperatively was associated with prolonged LOS (OR 2.0, 95% CI 1.5-2.6) and minor complications (OR 2.4, 95% CI 1.3-4.3). Therefore, transfusion of RBC or whole blood, even a single unit, increased LOS and postoperative morbidity in patients undergoing elective spine surgery, independent of preoperative hematocrit level and patient comorbidities. Copyright © 2014 Elsevier Ltd. All rights reserved.

Is minimal access spine surgery more cost-effective than conventional spine surgery?

PubMed

Lubelski, Daniel; Mihalovich, Kathryn E; Skelly, Andrea C; Fehlings, Michael G; Harrop, James S; Mummaneni, Praveen V; Wang, Michael Y; Steinmetz, Michael P

2014-10-15

Systematic review. To summarize and critically review the economic literature evaluating the cost-effectiveness of minimal access surgery (MAS) compared with conventional open procedures for the cervical and lumbar spine. MAS techniques may improve perioperative parameters (length of hospital stay and extent of blood loss) compared with conventional open approaches. However, some have questioned the clinical efficacy of these differences and the associated cost-effectiveness implications. When considering the long-term outcomes, there seem to be no significant differences between MAS and open surgery. PubMed, EMBASE, the Cochrane Collaboration database, University of York, Centre for Reviews and Dissemination (NHS-EED and HTA), and the Tufts CEA Registry were reviewed to identify full economic studies comparing MAS with open techniques prior to December 24, 2013, based on the key questions established a priori. Only economic studies that evaluated and synthesized the costs and consequences of MAS compared with conventional open procedures (i.e., cost-minimization, cost-benefit, cost-effectiveness, or cost-utility) were considered for inclusion. Full text of the articles meeting inclusion criteria were reviewed by 2 independent investigators to obtain the final collection of included studies. The Quality of Health Economic Studies instrument was scored by 2 independent reviewers to provide an initial basis for critical appraisal of included economic studies. The search strategy yielded 198 potentially relevant citations, and 6 studies met the inclusion criteria, evaluating the costs and consequences of MAS versus conventional open procedures performed for the lumbar spine; no studies for the cervical spine met the inclusion criteria. Studies compared MAS tubular discectomy with conventional microdiscectomy, minimal access transforaminal lumbar interbody fusion versus open transforaminal lumbar interbody fusion, and multilevel hemilaminectomy via MAS versus open approach. Overall, the included cost-effectiveness studies generally supported no significant differences between open surgery and MAS lumbar approaches. However, these conclusions are preliminary because there was a paucity of high-quality evidence. Much of the evidence lacked details on methodology for modeling, related assumptions, justification of economic model chosen, and sources and types of included costs and consequences. The follow-up periods were highly variable, indirect costs were not frequently analyzed or reported, and many of the studies were conducted by a single group, thereby limiting generalizability. Prospective studies are needed to define differences and optimal treatment algorithms. 3.

Clostridium difficile colitis in patients undergoing lumbar spine surgery.

PubMed

Skovrlj, Branko; Guzman, Javier Z; Silvestre, Jason; Al Maaieh, Motasem; Qureshi, Sheeraz A

2014-09-01

Retrospective database analysis. To investigate incidence, comorbidities, and impact on health care resources of Clostridium difficile infection after lumbar spine surgery. C. difficile colitis is reportedly increasing in hospitalized patients and can have a negative impact on patient outcomes. No data exist on estimates of C. difficile infection rates and its consequences on patient outcomes and health care resources among patients undergoing lumbar spine surgery. The Nationwide Inpatient Sample was examined from 2002 to 2011. Patients were included for study based on International Classification of Diseases, Ninth Revision, Clinical Modification, procedural codes for lumbar spine surgery for degenerative diagnoses. Baseline patient characteristics were determined and multivariable analyses assessed factors associated with increased incidence of C. difficile and risk of mortality. The incidence of C. difficile infection in patients undergoing lumbar spine surgery is 0.11%. At baseline, patients infected with C. difficile were significantly older (65.4 yr vs. 58.9 yr, P<0.0001) and more likely to have diabetes with chronic complications, neurological complications, congestive heart failure, pulmonary disorders, coagulopathy, and renal failure. Lumbar fusion (P=0.0001) and lumbar fusion revision (P=0.0003) were associated with increased odds of postoperative infection. Small hospital size was associated with decreased odds (odds ratio [OR], 0.5; P<0.001), whereas urban hospitals were associated with increased odds (OR, 2.14; P<0.14) of acquiring infection. Uninsured (OR, 1.62; P<0.0001) and patients with Medicaid (OR, 1.33; P<0.0001) were associated with higher odds of acquiring postoperative infection. C. difficile increased hospital length of stay by 8 days (P<0.0001), hospital charges by 2-fold (P<0.0001), and inpatient mortality to 4% from 0.11% (P<0.0001). C. difficile infection after lumbar spine surgery carries a 36.4-fold increase in mortality and costs approximately $10,658,646 per year to manage. These data suggest that great care should be taken to avoid C. difficile colitis in patients undergoing lumbar spine surgery because it is associated with longer hospital stays, greater overall costs, and increased inpatient mortality. 3.

Minimally Invasive Spine Surgery: Analyzing Internet-based Education Material.

PubMed

Bryant, Jessica; Mohan, Rohith; Koottappillil, Brian; Wong, Kevin; Yi, Paul H

2018-04-01

This is a cross-sectional study. The purpose of this study is to evaluate the content of information available on the Internet regarding minimally invasive spine surgery (MISS). Patients look to the Internet for quick and accessible information on orthopedic procedures to help guide their personal decision making process regarding the care they receive. However, the quality of internet-based orthopedic education material varies significantly with respect to accuracy and readability. The top 50 results were generated from each of 3 search engines (Google, Yahoo!, and Bing) using the search term "minimally invasive spine surgery." Results were categorized by authorship type and evaluated for their description of key factors such as procedural benefits, risks, and techniques. Comparisons between search engines and between authorship types were done using the Freeman-Halton extension for the Fisher exact test. The content of websites certified by Health on the Net Foundation (HONcode) was compared with those not HONcode certified. Of the 150 websites and videos, only 26% were authored by a hospital or university, whereas 50% were by a private physician or clinic. Most resources presented some benefits of MISS (84%, 126/150), but only 17% presented risks of the procedure (26/150). Almost half of all resources described the technique of MISS, but only 27% had thorough descriptions that included visual representations while 26% failed to describe the procedure. Only 12 results were HONcode certified, and 10 (83%) of these were authored by a medical industry company. Internet-based resources on MISS provide inconsistent content and tend to emphasize benefits of MISS over risks.

Impact of robot-assisted spine surgery on health care quality and neurosurgical economics: A systemic review.

PubMed

Fiani, Brian; Quadri, Syed A; Farooqui, Mudassir; Cathel, Alessandra; Berman, Blake; Noel, Jerry; Siddiqi, Javed

2018-04-03

Whenever any new technology is introduced into the healthcare system, it should satisfy all three pillars of the iron triangle of health care, which are quality, cost-effectiveness, and accessibility. There has been quite advancement in the field of spine surgery in the last two decades with introduction of new technological modalities such as CAN and surgical robotic devices. MAZOR SpineAssist/Renaissance was the first robotic system to be approved for the use in spine surgeries in the USA in 2004. In this review, the authors sought to determine if the current literature supports this technology to be cost-effective, accessible, and improve the quality of care for individuals and populations by increasing the likelihood of desired health outcomes. Robotic-assisted surgery seems to provide perfection in surgical ergonomics and surgical dexterity, consequently improving patient outcomes. A lot of data is present on the accuracy, effectiveness, and safety of the robotic-guided technology which reflects remarkable improvements in quality of care, making its utility convincingly undisputable. The technology has been claimed to be cost-effective but there seems to be lack of data in the literature on this topic to validate this claim. Apart from just the outcome parameters, there is an immense need of studies on real-time cost-efficacy, patient perspective, surgeon and resident learning curve, and their experience with this new technology. Furthermore, new studies looking into increased utilities of this technology, such as brain and spine tumor resection, deep brain stimulation procedures, and osteotomies in deformity surgery, might authenticate the cost of the equipment.

Analysis of intraoperative difficulties and management of operative complications in revision anterior exposure of the lumbar spine: a report of 25 consecutive cases.

PubMed

Flouzat-Lachaniette, Charles-Henri; Delblond, William; Poignard, Alexandre; Allain, Jérôme

2013-04-01

After a first anterior approach to the lumbar spine, formation of adhesions of soft tissues to the spine increases the surgical difficulties and potential for iatrogenic injury during the revision exposure. The objective of this study was to identify the intraoperative difficulties and postoperative complications associated with revision anterior lumbar spine procedures in a single institution. This is a retrospective review of 25 consecutive anterior revision lumbar surgeries in 22 patients (7 men and 15 women) operated on between 1998 and 2011. Patients with trauma or malignancies were excluded. The mean age of the patients at the time of revision surgery was 56 years (range 20-80 years). The complications were analyzed depending on the operative level and the time between the index surgery and the revision. Six major complications (five intraoperatively and one postoperatively) occurred in five patients (20 %): three vein lacerations (12 %) and two ureteral injuries (8 %), despite the presence of a double-J ureteral stent. The three vein damages were repaired or ligated by a vascular surgeon. One of the two ureteral injuries led to a secondary nephrectomy after end-to-end anastomosis failure; the other necessitated secondary laparotomy for small bowel obstruction. Anterior revision of the lumbar spine is technically challenging and is associated with a high rate of vascular or urologic complications. Therefore, the potential complications of the procedure must be weighted against its benefits. When iterative anterior lumbar approach is mandatory, exposure should be performed by an access surgeon in specialized centers that have ready access to vascular and urologic surgeons.

Motor/Prefrontal Transcranial Direct Current Stimulation (tDCS) Following Lumbar Surgery Reduces Postoperative Analgesia Use.

PubMed

Glaser, John; Reeves, Scott T; Stoll, William David; Epperson, Thomas I; Hilbert, Megan; Madan, Alok; George, Mark S; Borckardt, Jeffrey J

2016-05-01

Randomized, controlled pilot trial. The present study is the first randomized, double-blind, sham-controlled pilot clinical trial of transcranial direct current stimulation (tDCS) for pain and patient-controlled analgesia (PCA) opioid usage among patients receiving spine surgery. Lumbar spinal surgeries are common, and while pain is often a complaint that precedes surgical intervention, the procedures themselves are associated with considerable postoperative pain lasting days to weeks. Adequate postoperative pain control is an important factor in determining recovery and new analgesic strategies are needed that can be used adjunctively to existing strategies potentially to reduce reliance on opioid analgesia. Several novel brain stimulation technologies including tDCS are beginning to demonstrate promise as treatments for a variety of pain conditions. Twenty-seven patients undergoing lumbar spine procedures at Medical University of South Carolina were randomly assigned to receive four 20-minute sessions of real or sham tDCS during their postsurgical hospital stay. Patient-administered hydromorphone usage was tracked along with numeric rating scale pain ratings. The effect of tDCS on the slope of the cumulative PCA curve was significant (P < 0.001) and tDCS was associated with a 23% reduction in PCA usage. In the real tDCS group a 31% reduction was observed in pain-at-its-least ratings from admission to discharge (P = 0.027), but no other changes in numeric rating scale pain ratings were significant in either group. The present pilot trial is the first study to demonstrate an opioid sparing effect of tDCS after spine surgical procedures. Although this was a small pilot trial in a heterogeneous sample of spinal surgery patients, a moderate effect-size was observed for tDCS, suggesting that future work in this area is warranted. 2.

A Retrospective Study of Cervical Spine MRI Findings in Children with Abusive Head Trauma.

PubMed

Governale, Lance S; Brink, Farah W; Pluto, Charles P; Schunemann, Victoria A; Weber, Rachel; Rusin, Jerome; Fischer, Beth A; Letson, Megan M

2018-01-01

Increasing attention has been given to the possible association of cervical spine (c-spine) injuries with abusive head trauma (AHT). The aims of this study were to describe c-spine MRI findings in hospitalized AHT patients. This is a retrospective study of children under the age of 5 years with AHT admitted to hospital in 2004-2013. Those with c-spine MRI were identified, and the images were reviewed. 250 AHT cases were identified, with 34 (14%) undergoing c-spine MRI. Eleven patients (32%) had 25 findings, including hematoma in 2, occiput-C1-C2 edema in 3, prevertebral edema in 6, facet edema in 2, and interspinous and/or muscular edema in 10. No patients had a clinically evident c-spine injury, a clinically unstable c-spine, or required c-spine surgery. C-spine MRI may identify abnormalities not apparent upon physical examination and the procedure should therefore be considered in cases of suspected AHT. © 2017 S. Karger AG, Basel.

Surgical apgar score in patients undergoing lumbar fusion for degenerative spine diseases.

PubMed

Ou, Chien-Yu; Hsu, Shih-Yuan; Huang, Jian-Hao; Huang, Yu-Hua

2017-01-01

Lumbar fusion is a procedure broadly performed for degenerative diseases of spines, but it is not without significant morbidities. Surgical Apgar Score (SAS), based on intraoperative blood loss, blood pressure, and heart rate, was developed for prognostic prediction in general and vascular operations. We aimed to examine whether the application of SAS in patients undergoing fusion procedures for degeneration of lumbar spines predicts in-hospital major complications. One hundred and ninety-nine patients that underwent lumbar fusion operation for spine degeneration were enrolled in this retrospective study. Based on whether major complications were present (N=16) or not (N=183), the patients were subdivided. We identified the intergroup differences in SAS and clinical parameters. The incidence of in-hospital major complications was 8%. The duration of hospital stay for the morbid patents was significantly prolonged (p=0.04). In the analysis of multivariable logistic regression, SAS was an independent predicting factor of the complications after lumbar fusion for degenerative spine diseases [p=0.001; odds ratio (95% confidence interval)=0.35 (0.19-0.64)]. Lower scores were accompanied with higher rates of major complications, and the area was 0.872 under the receiver operating characteristic curve. SAS is an independent predicting factor of major complications in patients after fusion surgery for degenerative diseases of lumbar spines, and provides good risk discrimination. Since the scoring system is relatively simple, objective, and practical, we suggest that SAS be included as an indicator in the guidance for level of care after lumbar fusion surgery. Copyright © 2016 Elsevier B.V. All rights reserved.

The medicolegal landscape of spine surgery: how do surgeons fare?

PubMed

Makhni, Melvin C; Park, Paul J; Jimenez, Jesus; Saifi, Comron; Caldwell, Jon-Michael; Ha, Alex; Figueroa-Santana, Bianca; Lehman, Ronald A; Weidenbaum, Mark

2018-02-01

Because of the limited and confidential nature of most legal data, scarce literature is available to physicians about reasons for litigation in spine surgery. To optimally compensate patients while protecting physicians, further understanding of the medicolegal landscape is needed for high-risk procedures such as spine surgery. Based on these, surgeons can explore ways to better protect both their patients and themselves. To characterize the current medicolegal environment of spine surgery by analyzing a recent dataset of malpractice litigation. A retrospective study. All malpractice cases involving spine surgery available to public query between the years of 2010 and 2014. Case outcome for spine surgery malpractice cases between the years of 2010 and 2014. WestlawNext was used to analyze spine surgery malpractice cases at the state and federal level between the years 2010 and 2014. WestlawNext is a subscription-based, legal search engine that contains publicly available federal and state court records. All monetary values were inflation adjusted for 2016. One hundred three malpractice cases were categorized by case descriptors and outcome measures. Claims were categorized as either intraoperative complaints or preoperative complaints. Rulings in favor of the defendant (surgeon) were noted in 75% (77 of 103) of the cases. Lack of informed consent was cited in 34% of cases. For the 26 cases won by the plaintiff, the average amount in settlement was $2,384,775 versus $3,945,456 in cases brought before a jury. Cases involving consent averaged a compensation of $2,029,884, whereas cases involving only intraoperative complaints averaged a compensation of $3,667,530. A significant correlation was seen between increased compensation for plaintiffs and cases involving orthopedic surgeons (p=.020) or nerve injury (p=.005). Wrong-level surgery may be associated with lower plaintiff compensation (p=.055). The length of cases resulting in defense verdicts averaged 5.51 years, which was significantly longer than the 4.34 years average length of settlements or verdicts in favor of plaintiffs (p=.016). Spine surgeons successfully defended themselves in 75% of lawsuits, although the cases won by physicians lingered significantly longer than those settled. Better understanding of these cases may help surgeons to minimize litigation. More than one third of cases involved a claim of insufficient informed consent. Surgeons can protect themselves and optimize care of patients through clear and documented patient communication, education, and intraoperative vigilance to avoid preventable complications. Copyright © 2017 Elsevier Inc. All rights reserved.

Cost-effectiveness analysis in minimally invasive spine surgery.

PubMed

Al-Khouja, Lutfi T; Baron, Eli M; Johnson, J Patrick; Kim, Terrence T; Drazin, Doniel

2014-06-01

Medical care has been evolving with the increased influence of a value-based health care system. As a result, more emphasis is being placed on ensuring cost-effectiveness and utility in the services provided to patients. This study looks at this development in respect to minimally invasive spine surgery (MISS) costs. A literature review using PubMed, the Cost-Effectiveness Analysis (CEA) Registry, and the National Health Service Economic Evaluation Database (NHS EED) was performed. Papers were included in the study if they reported costs associated with minimally invasive spine surgery (MISS). If there was no mention of cost, CEA, cost-utility analysis (CUA), quality-adjusted life year (QALY), quality, or outcomes mentioned, then the article was excluded. Fourteen studies reporting costs associated with MISS in 12,425 patients (3675 undergoing minimally invasive procedures and 8750 undergoing open procedures) were identified through PubMed, the CEA Registry, and NHS EED. The percent cost difference between minimally invasive and open approaches ranged from 2.54% to 33.68%-all indicating cost saving with a minimally invasive surgical approach. Average length of stay (LOS) for minimally invasive surgery ranged from 0.93 days to 5.1 days compared with 1.53 days to 12 days for an open approach. All studies reporting EBL reported lower volume loss in an MISS approach (range 10-392.5 ml) than in an open approach (range 55-535.5 ml). There are currently an insufficient number of studies published reporting the costs of MISS. Of the studies published, none have followed a standardized method of reporting and analyzing cost data. Preliminary findings analyzing the 14 studies showed both cost saving and better outcomes in MISS compared with an open approach. However, more Level I CEA/CUA studies including cost/QALY evaluations with specifics of the techniques utilized need to be reported in a standardized manner to make more accurate conclusions on the cost effectiveness of minimally invasive spine surgery.

Use of an ultrasonic osteotome device in spine surgery: experience from the first 128 patients.

PubMed

Hu, Xiaobang; Ohnmeiss, Donna D; Lieberman, Isador H

2013-12-01

The ultrasonic BoneScalpel is a tissue-specific device that allows the surgeon to make precise osteotomies while protecting collateral or adjacent soft tissue structures. The device is comprised of a blunt ultrasonic blade that oscillates at over 22,500 cycles/s with an imperceptible microscopic amplitude. The recurring impacts pulverize the noncompliant crystalline structure resulting in a precise cut. The more compliant adjacent soft tissue is not affected by the ultrasonic oscillation. The purpose of this study is to report the experience and safety of using this ultrasonic osteotome device in a variety of spine surgeries. Data were retrospectively collected from medical charts and surgical reports for each surgery in which the ultrasonic scalpel was used to perform any type of osteotomy (facetectomy, laminotomy, laminectomy, en bloc resection, Smith Petersen osteotomy, pedicle subtraction osteotomy, etc.). The majority of patients had spinal stenosis, degenerative or adolescent scoliosis, pseudoarthrosis, adjacent segment degeneration, and spondylolisthesis et al. Intra-operative complications were also recorded. A total of 128 consecutive patients (73 female, 55 male) beginning with our first case experience were included in this study. The mean age of the patients was 58 years (range 12-85 years). Eighty patients (62.5 %) had previous spine surgery and/or spinal deformity. The ultrasonic scalpel was used at all levels of the spine and the average levels operated on each patient were 5. The mean operation time (skin to skin) was 4.3 h and the mean blood loss was 425.4 ml. In all cases, the ultrasonic scalpel was used to create the needed osteotomies to facilitate the surgical procedure without any percussion on the spinal column or injury to the underlying nerves. There was a noticeable absence of bleeding from the cut end of the bone consistent with the ultrasonic application. There were 11 instances of dural injuries (8.6 %) and two of which were directly associated with the use of ultrasonic device. In no procedure was the use of the ultrasonic scalpel abandoned for use of another instrument due to difficulty in using the device or failure to achieve the desired osteotomy. Overall, the ultrasonic scalpel was safe and performed as desired when used as a bone cutting device to facilitate osteotomies in a variety of spine surgeries. However, caution should be taken to avoid potential thermal injury and dural tear. If used properly, this device may decrease the risk of soft tissue injury associated with the use of high speed burrs and oscillating saws during spine surgery.

Cervical bracing practices after degenerative cervical surgery: a survey of cervical spine research society members.

PubMed

Lunardini, David J; Krag, Martin H; Mauser, Nathan S; Lee, Joon Y; Donaldson, William H; Kang, James D

2018-05-21

Context: Prior studies have shown common use of post-operative bracing, despite advances in modern day instrumentation rigidity and little evidence of brace effectiveness. To document current practice patterns of brace use after degenerative cervical spine surgeries among members of the Cervical Spine Research Society (CSRS), to evaluate trends, and to identify areas of further study. A questionnaire survey METHODS: A 10 question survey was sent to members of the Cervical Spine Research Society to document current routine bracing practices after various common degenerative cervical spine surgical scenarios, including fusion and non-fusion procedures. The overall bracing rate was 67%. This included 8.4% who used a hard collar in each scenario. Twenty-two percent of surgeons never used a hard collar, while 34% never used a soft collar, and 3.6% (3 respondents) did not use a brace in any surgical scenario. Bracing frequency for specific surgical scenarios varied from 39% after foraminotomy to 88% after multi-level corpectomy with anterior & posterior fixation. After one, two and three level anterior cervical discectomy & fusion (ACDF), bracing rates were 58%, 65% and 76% for an average of 3.3, 4.3 and 5.3 weeks, respectively. After single level corpectomy, 77% braced for an average of 6.2 weeks. After laminectomy and fusion, 72% braced for an average of 5.4 weeks. Significant variation persists among surgeons on the type and length of post-operative brace usage after cervical spine surgeries. Overall rates of bracing have not changed significantly with time. Given the lack evidence in the literature to support bracing, reconsidering use of a brace after certain surgeries may be warranted. Copyright © 2018. Published by Elsevier Inc.

Feasibility Study of Utilization of Action Camera, GoPro Hero 4, Google Glass, and Panasonic HX-A100 in Spine Surgery.

PubMed

Lee, Chang Kyu; Kim, Youngjun; Lee, Nam; Kim, Byeongwoo; Kim, Doyoung; Yi, Seong

2017-02-15

Study for feasibility of commercially available action cameras in recording video of spine. Recent innovation of the wearable action camera with high-definition video recording enables surgeons to use camera in the operation at ease without high costs. The purpose of this study is to compare the feasibility, safety, and efficacy of commercially available action cameras in recording video of spine surgery. There are early reports of medical professionals using Google Glass throughout the hospital, Panasonic HX-A100 action camera, and GoPro. This study is the first report for spine surgery. Three commercially available cameras were tested: GoPro Hero 4 Silver, Google Glass, and Panasonic HX-A100 action camera. Typical spine surgery was selected for video recording; posterior lumbar laminectomy and fusion. Three cameras were used by one surgeon and video was recorded throughout the operation. The comparison was made on the perspective of human factor, specification, and video quality. The most convenient and lightweight device for wearing and holding throughout the long operation time was Google Glass. The image quality; all devices except Google Glass supported HD format and GoPro has unique 2.7K or 4K resolution. Quality of video resolution was best in GoPro. Field of view, GoPro can adjust point of interest, field of view according to the surgery. Narrow FOV option was the best for recording in GoPro to share the video clip. Google Glass has potentials by using application programs. Connectivity such as Wi-Fi and Bluetooth enables video streaming for audience, but only Google Glass has two-way communication feature in device. Action cameras have the potential to improve patient safety, operator comfort, and procedure efficiency in the field of spinal surgery and broadcasting a surgery with development of the device and applied program in the future. N/A.

Development and Validation of a Prediction Model for Pain and Functional Outcomes After Lumbar Spine Surgery.

PubMed

Khor, Sara; Lavallee, Danielle; Cizik, Amy M; Bellabarba, Carlo; Chapman, Jens R; Howe, Christopher R; Lu, Dawei; Mohit, A Alex; Oskouian, Rod J; Roh, Jeffrey R; Shonnard, Neal; Dagal, Armagan; Flum, David R

2018-03-07

Functional impairment and pain are common indications for the initiation of lumbar spine surgery, but information about expected improvement in these patient-reported outcome (PRO) domains is not readily available to most patients and clinicians considering this type of surgery. To assess population-level PRO response after lumbar spine surgery, and develop/validate a prediction tool for PRO improvement. This statewide multicenter cohort was based at 15 Washington state hospitals representing approximately 75% of the state's spine fusion procedures. The Spine Surgical Care and Outcomes Assessment Program and the survey center at the Comparative Effectiveness Translational Network prospectively collected clinical and PRO data from adult candidates for lumbar surgery, preoperatively and postoperatively, between 2012 and 2016. Prediction models were derived for PRO improvement 1 year after lumbar fusion surgeries on a random sample of 85% of the data and were validated in the remaining 15%. Surgical candidates from 2012 through 2015 were included; follow-up surveying continued until December 31, 2016, and data analysis was completed from July 2016 to April 2017. Functional improvement, defined as a reduction in Oswestry Disability Index score of 15 points or more; and back pain and leg pain improvement, defined a reduction in Numeric Rating Scale score of 2 points or more. A total of 1965 adult lumbar surgical candidates (mean [SD] age, 61.3 [12.5] years; 944 [59.6%] female) completed baseline surveys before surgery and at least 1 postoperative follow-up survey within 3 years. Of these, 1583 (80.6%) underwent elective lumbar fusion procedures; 1223 (77.3%) had stenosis, and 1033 (65.3%) had spondylolisthesis. Twelve-month follow-up participation rates for each outcome were between 66% and 70%. Improvements were reported in function, back pain, and leg pain at 12 months by 306 of 528 surgical patients (58.0%), 616 of 899 patients (68.5%), and 355 of 464 patients (76.5%), respectively, whose baseline scores indicated moderate to severe symptoms. Among nonoperative patients, 35 (43.8%), 47 (53.4%), and 53 (63.9%) reported improvements in function, back pain, and leg pain, respectively. Demographic and clinical characteristics included in the final prediction models were age, sex, race, insurance status, American Society of Anesthesiologists score, smoking status, diagnoses, prior surgery, prescription opioid use, asthma, and baseline PRO scores. The models had good predictive performance in the validation cohort (concordance statistic, 0.66-0.79) and were incorporated into a patient-facing, web-based interactive tool (https://becertain.shinyapps.io/lumbar_fusion_calculator). The PRO response prediction tool, informed by population-level data, explained most of the variability in pain reduction and functional improvement after surgery. Giving patients accurate information about their likelihood of outcomes may be a helpful component in surgery decision making.

Can Fan-Beam Interactive Computed Tomography Accurately Predict Indirect Decompression in Minimally Invasive Spine Surgery Fusion Procedures?

PubMed

Janssen, Insa; Lang, Gernot; Navarro-Ramirez, Rodrigo; Jada, Ajit; Berlin, Connor; Hilis, Aaron; Zubkov, Micaella; Gandevia, Lena; Härtl, Roger

2017-11-01

Recently, novel mobile intraoperative fan-beam computed tomography (CT) was introduced, allowing for real-time navigation and immediate intraoperative evaluation of neural decompression in spine surgery. This study sought to investigate whether intraoperatively assessed neural decompression during minimally invasive spine surgery (MISS) has a predictive value for clinical and radiographic outcome. A retrospective study of patients undergoing intraoperative CT (iCT)-guided extreme lateral interbody fusion or transforaminal lumbar interbody fusion was conducted. 1) Preoperative, 2) intraoperative (after cage implantation, 3) postoperative, and 4) follow-up radiographic and clinical parameters obtained from radiography or CT were quantified. Thirty-four patients (41 spinal segments) were analyzed. iCT-based navigation was successfully accomplished in all patients. Radiographic parameters showed significant improvement from preoperatively to intraoperatively after cage implantation in both MISS procedures (extreme lateral interbody fusion/transforaminal lumbar interbody fusion) (P ≤ 0.05). Radiologic parameters for both MISS fusion procedures did not show significant differences to the assessed radiographic measures at follow-up (P > 0.05). Radiologic outcome values did not decrease when compared intraoperatively (after cage implantation) to latest follow-up. Intraoperative fan-beam CT is capable of assessing neural decompression intraoperatively with high accuracy, allowing for precise prediction of radiologic outcome and earliest possible feedback during MISS fusion procedures. These findings are highly valuable for routine practice and future investigations toward finding a threshold for neural decompression that translates into clinical improvement. If sufficient neural decompression has been confirmed with iCT imaging studies, additional postoperative and/or follow-up imaging studies might no longer be required if patients remain asymptomatic. Copyright © 2017 Elsevier Inc. All rights reserved.

Analysis of complications and perioperative data after open or percutaneous dorsal instrumentation following traumatic spinal fracture of the thoracic and lumbar spine: a retrospective cohort study including 491 patients.

PubMed

Kreinest, Michael; Rillig, Jan; Grützner, Paul A; Küffer, Maike; Tinelli, Marco; Matschke, Stefan

2017-05-01

The aim of the current study is to analyze perioperative data and complications of open vs. percutaneous dorsal instrumentation after dorsal stabilization in patients suffering from fractures of the thoracic or lumbar spine. In the time period from 01/2007 to 06/2009, open surgical approach was used for dorsal stabilization. The percutaneous surgical approach was used from 05/2009 to 03/2014. In every time period, all types of fractures were treated only by open or by percutaneous approach, respectively, to avoid any selection bias. Retrospectively, epidemiological data, complications and perioperative data were documented and statistically analyzed. A total of 491 patients met the inclusion criteria. Open surgery procedure was carried out on 169 patients, and percutaneous surgery procedure was carried out on 322 patients. Fracture level ranged from T1 to L5, and fractures were classified types A, B, and C. In 91.4% of all patients, no complication occured following dorsal stabilization after traumatic spine fracture during their hospital stay. However, 42 complications related to dorsal stabilization have been documented during the hospital stay. The complication rate was 14.8% if open surgical approach has been used and was significantly reduced to 5.3% using percutaneous surgical approach. Post-operative hospital stay was also reduced significantly using the percutaneous surgical approach. According to the current study, percutaneous dorsal stabilization of the spine could also be safely used in trauma cases and is not restricted to degenerative spinal surgery.

Autonomic dysreflexia triggered by an unstable lumbar spine in a quadriplegic patient.

PubMed

Wu, Katie P; Lai, Po-Liang; Lee, Li-Fang; Hsu, Chih-Chin

2005-07-01

A 40 year-old man with C5 complete quadriplegia, had L2-L3 pyogenic spondylitis treated with debridement and fusion of the lumbar spine with left iliac bone graft. Three months later he developed symptoms of autonomic dysreflexia, including headache, cold sweating, and hypertension whenever he was in an upright position. These symptoms resolved after lying down. Roentgenograms of the lumbar spine revealed absorption of the bone graft at the L2-L3 level. A spinal stabilization procedure was done after eight weeks of antibiotic therapy under the impression of unstable spine caused by pyogenic spondylitis. Symptoms were relieved immediately following the surgery. This report may be helpful for physicians caring for quadriplegic patients with autonomic dysreflexia induced by an unstable spine.

Design-Based Comparison of Spine Surgery Simulators: Optimizing Educational Features of Surgical Simulators.

PubMed

Ryu, Won Hyung A; Mostafa, Ahmed E; Dharampal, Navjit; Sharlin, Ehud; Kopp, Gail; Jacobs, W Bradley; Hurlbert, R John; Chan, Sonny; Sutherland, Garnette R

2017-10-01

Simulation-based education has made its entry into surgical residency training, particularly as an adjunct to hands-on clinical experience. However, one of the ongoing challenges to wide adoption is the capacity of simulators to incorporate educational features required for effective learning. The aim of this study was to identify strengths and limitations of spine simulators to characterize design elements that are essential in enhancing resident education. We performed a mixed qualitative and quantitative cohort study with a focused survey and interviews of stakeholders in spine surgery pertaining to their experiences on 3 spine simulators. Ten participants were recruited spanning all levels of training and expertise until qualitative analysis reached saturation of themes. Participants were asked to perform lumbar pedicle screw insertion on 3 simulators. Afterward, a 10-item survey was administrated and a focused interview was conducted to explore topics pertaining to the design features of the simulators. Overall impressions of the simulators were positive with regards to their educational benefit, but our qualitative analysis revealed differing strengths and limitations. Main design strengths of the computer-based simulators were incorporation of procedural guidance and provision of performance feedback. The synthetic model excelled in achieving more realistic haptic feedback and incorporating use of actual surgical tools. Stakeholders from trainees to experts acknowledge the growing role of simulation-based education in spine surgery. However, different simulation modalities have varying design elements that augment learning in distinct ways. Characterization of these design characteristics will allow for standardization of simulation curricula in spinal surgery, optimizing educational benefit. Copyright © 2017 Elsevier Inc. All rights reserved.

The effect of prone position on respiratory mechanics during spinal surgery.

PubMed

Manna, Essam M; Ibraheim, Osama A; Samarkandi, Abdulhamid H; Alotaibi, Wadha M; Elwatidy, Sherif M

2005-10-01

To study the effect of prone position on respiratory mechanics during spine surgery. Prospective study. Elective spine surgery at a university hospital. 12 ASA physical I & II with no coexisting cardiorespiratory disease undergoing cervical or lumbar laminectomy under general anesthesia in prone position. Ten min after induction of general anesthesia and endotracheal intubation, while patients were in supine position, the following measurements were taken using anesthesia delivery unit (Datex Ohmeda type A_Elec, Promma, Sweden): peak airway pressure (Ppeak), peak plataeu pressure (Pplat), peak mean pressure (Pmean) and dynamic lung compliance (DLC). The same measurements were recorded 10 min after placing patients into prone position. At the end of surgery and 5 min after turning the patients supine and before tracheal extubation, the same measurements were again recorded. The results expressed as means +/- sd. One way ANOVA was used for analysis of differences in the data before, during prone position and after turning patients supine at the end of the procedure. For all comparisons p < 0.05 was considered significant. During prone position there was significant reduction in DLC and significant increase in airway pressures. We conclude that turning the patients form supine to prone position during anesthesia for spine surgery caused significant decrease of DLC and significant increase of airway pressure.

A comparative analysis of minimally invasive and open spine surgery patient education resources.

PubMed

Agarwal, Nitin; Feghhi, Daniel P; Gupta, Raghav; Hansberry, David R; Quinn, John C; Heary, Robert F; Goldstein, Ira M

2014-09-01

The Internet has become a widespread source for disseminating health information to large numbers of people. Such is the case for spine surgery as well. Given the complexity of spinal surgeries, an important point to consider is whether these resources are easily read and understood by most Americans. The average national reading grade level has been estimated to be at about the 7th grade. In the present study the authors strove to assess the readability of open spine surgery resources and minimally invasive spine surgery resources to offer suggestions to help improve the readability of patient resources. Online patient education resources were downloaded in 2013 from 50 resources representing either traditional open back surgery or minimally invasive spine surgery. Each resource was assessed using 10 scales from Readability Studio Professional Edition version 2012.1. Patient education resources representing traditional open back surgery or minimally invasive spine surgery were all found to be written at a level well above the recommended 6th grade level. In general, minimally invasive spine surgery materials were written at a higher grade level. The readability of patient education resources from spine surgery websites exceeds the average reading ability of an American adult. Revisions may be warranted to increase quality and patient comprehension of these resources to effectively reach a greater patient population.

Synframe: a preliminary report.

PubMed

Aebi, M; Steffen, T

2000-02-01

Both endoscopic lumbar spinal surgery and the non-standardized and unstable retractor systems for the lumbar spine presently on the market have disadvantages and limitations in relation to the minimally invasive surgical concept, which have been gradually recognized in the last few years. In an attempt to resolve some of these issues, we have developed a highly versatile retractor system, which allows access to and surgery at the lumbar, thoracic and even cervical spine. This retractor system - Synframe - is based on a ring concept allowing 360 degrees access to a surgical opening in anterior as well as posterior surgery. The ring is concentrically laid over the surgical opening for the approach and is used as a carrier for retractor arms, which are instrumented with either different sizes or types of blades and/or different sizes of Hohmann hooks. In posterior surgery, nerve root retractors can also be installed. This ring also functions as a carrier for fiberoptic illumination devices and different sizes of endoscopes, used to transmit the surgical procedure out of the depth of the surgical exposure for both teaching purposes and for the surgical team when it has no longer direct visual access to the procedure. The ring is stable, being fixed onto the operating table, allowing precise minimally open approaches and surgical procedures under direct vision with optimal illumination. This ring system also opens perspectives for an integrated minimally open surgical concept, where the ring may be used as a reference platform in computer-navigated surgery.

Interest of intra-operative 3D imaging in spine surgery: a prospective randomized study.

PubMed

Ruatti, Sébastien; Dubois, C; Chipon, E; Kerschbaumer, G; Milaire, M; Moreau-Gaudry, A; Tonetti, J; Merloz, Ph

2016-06-01

We report a single-center, prospective, randomized study for pedicle screw insertion in opened and percutaneous spine surgeries, using a computer-assisted surgery (CAS) technique with three-dimensional (3D) intra-operative images intensifier (without planification on pre-operative CT scan) vs conventional surgical procedure. We included 143 patients: Group C (conventional, 72 patients) and Group N (3D Fluoronavigation, 71 patients). We measured the pedicle screw running time, and surgeon's radiation exposure. All pedicle runs were assessed according to Heary by two independent radiologists on a post-operative CT scan. 3D Fluoronavigation appeared less accurate in percutaneous procedures (24 % of misplaced pedicle screws vs 5 % in Group C) (p = 0.007), but more accurate in opened surgeries (5 % of misplaced pedicle screws vs 17 % in Group C) (p = 0.025). For one vertebra, the average surgical running time reached 8 min in Group C vs 21 min in Group N for percutaneous surgeries (p = 3.42 × 10(-9)), 7.33 min in Group C vs 16.33 min in Group N (p = 2.88 × 10(-7)) for opened surgeries. The 3D navigation device delivered less radiation in percutaneous procedures [0.6 vs 1.62 mSv in Group C (p = 2.45 × 10(-9))]. For opened surgeries, it was twice higher in Group N with 0.21 vs 0.1 mSv in Group C (p = 0.022). The rate of misplaced pedicle screws with conventional techniques was nearly the same as most papers and a little bit higher with CAS. Surgical running time and radiation exposure were consistent with many studies. Our work hypothesis is partially confirmed, depending on the type of surgery (opened or closed procedure).

Biomechanical analysis of the upper thoracic spine after decompressive procedures.

PubMed

Healy, Andrew T; Lubelski, Daniel; Mageswaran, Prasath; Bhowmick, Deb A; Bartsch, Adam J; Benzel, Edward C; Mroz, Thomas E

2014-06-01

Decompressive procedures such as laminectomy, facetectomy, and costotransversectomy are routinely performed for various pathologies in the thoracic spine. The thoracic spine is unique, in part, because of the sternocostovertebral articulations that provide additional strength to the region relative to the cervical and lumbar spines. During decompressive surgeries, stability is compromised at a presently unknown point. To evaluate thoracic spinal stability after common surgical decompressive procedures in thoracic spines with intact sternocostovertebral articulations. Biomechanical cadaveric study. Fresh-frozen human cadaveric spine specimens with intact rib cages, C7-L1 (n=9), were used. An industrial robot tested all spines in axial rotation (AR), lateral bending (LB), and flexion-extension (FE) by applying pure moments (±5 Nm). The specimens were first tested in their intact state and then tested after each of the following sequential surgical decompressive procedures at T4-T5 consisting of laminectomy; unilateral facetectomy; unilateral costotransversectomy, and subsequently instrumented fusion from T3-T7. We found that in all three planes of motion, the sequential decompressive procedures caused no statistically significant change in motion between T3-T7 or T1-T12 when compared with intact. In comparing between intact and instrumented specimens, our study found that instrumentation reduced global range of motion (ROM) between T1-T12 by 16.3% (p=.001), 12% (p=.002), and 18.4% (p=.0004) for AR, FE, and LB, respectively. Age showed a negative correlation with motion in FE (r = -0.78, p=.01) and AR (r=-0.7, p=.04). Thoracic spine stability was not significantly affected by sequential decompressive procedures in thoracic segments at the level of the true ribs in all three planes of motion in intact thoracic specimens. Age appeared to negatively correlate with ROM of the specimen. Our study suggests that thoracic spinal stability is maintained immediately after unilateral decompression at the level of the true ribs. These preliminary observations, however, do not depict the long-term sequelae of such procedures and warrant further investigation. Copyright © 2014 Elsevier Inc. All rights reserved.

Desktop-based computer-assisted orthopedic training system for spinal surgery.

PubMed

Rambani, Rohit; Ward, James; Viant, Warren

2014-01-01

Simulation and surgical training has moved on since its inception during the end of the last century. The trainees are getting more exposed to computers and laboratory training in different subspecialties. More needs to be done in orthopedic simulation in spinal surgery. To develop a training system for pedicle screw fixation and validate its effectiveness in a cohort of junior orthopedic trainees. Fully simulated computer-navigated training system is used to train junior orthopedic trainees perform pedicle screw insertion in the lumbar spine. Real patient computed tomography scans are used to produce the real-time fluoroscopic images of the lumbar spine. The training system was developed to simulate pedicle screw insertion in the lumbar spine. A total of 12 orthopedic senior house officers performed pedicle screw insertion in the lumbar spine before and after the training on training system. The results were assessed based on the scoring system, which included the amount of time taken, accuracy of pedicle screw insertion, and the number of exposures requested to complete the procedure. The result shows a significant improvement in amount of time taken, accuracy of fixation, and the number of exposures after the training on simulator system. This was statistically significant using paired Student t test (p < 0.05). Fully simulated computer-navigated training system is an efficient training tool for young orthopedic trainees. This system can be used to augment training in the operating room, and trainees acquire their skills in the comfort of their study room or in the training room in the hospital. The system has the potential to be used in various other orthopedic procedures for learning of technical skills in a manner aimed at ensuring a smooth escalation in task complexity leading to the better performance of procedures in the operating theater. Copyright © 2014 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.

Feasibility of a Modified E-PASS and POSSUM System for Postoperative Risk Assessment in Patients with Spinal Disease.

PubMed

Chun, Dong Hyun; Kim, Do Young; Choi, Sun Kyu; Shin, Dong Ah; Ha, Yoon; Kim, Keung Nyun; Yoon, Do Heum; Yi, Seong

2018-04-01

This retrospective case control study aimed to evaluate the feasibility of using Estimation of Physiological Ability and Surgical Stress (E-PASS) and Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) systems in patients undergoing spinal surgical procedures. Degenerative spine disease has increased in incidence in aging societies, as has the number of older adult patients undergoing spinal surgery. Many older adults are at a high surgical risk because of comorbidity and poor general health. We retrospectively reviewed 217 patients who had undergone spinal surgery at a single tertiary care. We investigated complications within 1 month after surgery. Criteria for both skin incision in E-PASS and operation magnitude in the POSSUM system were modified to fit spine surgery. We calculated the E-PASS and POSSUM scores for enrolled patients, and investigated the relationship between postoperative complications and both surgical risk scoring systems. To reinforce the predictive ability of the E-PASS system, we adjusted equations and developed modified E-PASS systems. The overall complication rate for spinal surgery was 22.6%. Forty-nine patients experienced 58 postoperative complications. Nineteen major complications, including hematoma, deep infection, pleural effusion, progression of weakness, pulmonary edema, esophageal injury, myocardial infarction, pneumonia, reoperation, renal failure, sepsis, and death, occurred in 17 patients. The area under the receiver operating characteristic curve (AUC) for predicted postoperative complications after spine surgery was 0.588 for E-PASS and 0.721 for POSSUM. For predicted major postoperative complications, the AUC increased to 0.619 for E-PASS and 0.842 for POSSUM. The AUC of the E-PASS system increased from 0.588 to 0.694 with the Modified E-PASS equation. The POSSUM system may be more useful than the E-PASS system for estimating postoperative surgical risk in patients undergoing spine surgery. The preoperative risk scores of E-PASS and POSSUM can be useful for predicting postoperative major complications. To enhance the predictability of the scoring systems, using of modified equations based on spine surgery-specific factors may help ensure surgical outcomes and patient safety. Copyright © 2017. Published by Elsevier Inc.

Perioperative care for lumbar microdiscectomy: a survey of Australasian neurosurgeons

PubMed Central

Lim, Kai Zheong; Ghosh, Peter; Goldschlager, Tony

2018-01-01

Background Lumbar microdiscectomy is the most commonly performed spine surgery procedure. Over time it has evolved to a minimally invasive procedure. Traditionally patients were advised to restrict activity following lumbar spine surgery. However, post-operative instructions are heterogeneous. The purpose of this report is to assess, by survey, the perioperative care practices of Australasian neurosurgeons in the minimally invasive era. Methods A survey was conducted by email invitation sent to all full members of the Neurosurgical Society of Australasia (NSA). This consisted of 11 multi-choice questions relating to operative indications, technique, and post-operative instructions for lumbar microdiscectomy answered by an electronically distributed anonymized online survey. Results The survey was sent to all Australasian Neurosurgeons. In total, 68 complete responses were received (28.9%). Most surgeons reported they would consider a period of either 4 to 8 weeks (42.7%) or 8 to 12 weeks (32.4%) as the minimum duration of radicular pain adequate to offer surgery. Unilateral muscle dissection with unilateral discectomy was practiced by 76.5%. Operative microscopy was the most commonly employed method of magnification (76.5%). The majority (55.9%) always refer patients to undergo inpatient physiotherapy. Sitting restrictions were advised by 38.3%. Lifting restrictions were advised by 83.8%. Conclusions Australasian neurosurgical lumbar microdiscectomy perioperative care practices are generally consistent with international practices and demonstrate a similar degree of heterogeneity. Recommendation of post-operative activity restrictions by Australasian neurosurgeons is still common. This suggests a role for the investigation of the necessity of such restrictions in the era of minimally invasive spine surgery. PMID:29732417

Spinal surgery fellowship education in Canada: evaluation of trainee and supervisor perspectives on cognitive and procedural competencies.

PubMed

Malempati, Harsha; Wadey, Veronica M R; Paquette, Scott; Kreder, Hans J; Massicotte, Eric M; Rampersaud, Raja; Fisher, Charles; Dvorak, Marcel F; Fehlings, Michael G; Backstein, David; Yee, Albert

2013-01-01

A cross-sectional survey of spine surgery fellowship educators and trainees. To determine educator and trainee perspectives on the relative importance of core cognitive and procedural competencies in fellowship training. To determine perceptions of confidence in competencies by trainees near the end of their fellowship. Finally, to determine potential differences comparing surgeons by background specialty training (neurosurgical or orthopedic) of their views on competencies. Spine surgery is a growing subspecialty with increasing collaboration among specialists of varied specialty backgrounds involved in education. With the recent implementation of competency-based curricula during specialty training, opportunities may exist in enhancing fellowship education. A questionnaire on cognitive and procedural competencies was administered (online and paper) to fellowship educators and trainees across Canada. A follow-up questionnaire was administered to nonresponders 3 months later. Survey results were summarized using qualitative and descriptive statistics with comparative analyses performed. Of the identified respondents, the response rate was 91%, (15/17 fellow trainees; 47/51 educators). Twelve of the 13 core cognitive skill categories were rated as being important to acquire by the end of fellowship. Trainees were not comfortable performing, and requested additional training in 8 of the 29 less common and technically demanding procedural skills. There were different perceptions on the relative importance of competencies comparing trainees by specialty background as well as different perceptions on the types of competencies where additional training was desired to achieve competency (P < 0.05). Fellowship educators and trainees possessed similar perceptions on the relative importance of core cognitive and procedural competencies required for successful training. Background specialty influenced the perceptions of both fellowship educators and trainees. This study identified potential gaps or perceived deficiencies in the competency of current fellows. Improvements in spine fellowship education should target these areas through developing evidence-based curriculum changes.

Is surgical case order associated with increased infection rate after spine surgery?

PubMed

Gruskay, Jordan; Kepler, Christopher; Smith, Jeremy; Radcliff, Kristen; Vaccaro, Alexander

2012-06-01

Retrospective database review. To determine whether surgical site infections are associated with case order in spinal surgery. Postoperative wound infection is the most common complication after spinal surgery, with incidence varying from 0.5% to 20%. The addition of instrumentation, use of preoperative prophylactic antibiotics, length of procedure, and intraoperative blood loss have all been found to influence infection rate. No previous study has attempted to correlate case order with infection risk after surgery. A total of 6666 spine surgery cases occurring between January 2005 and December 2009 were studied. Subjects were classified into 2 categories: fusion and decompression. Case order was determined, with each procedure labeled 1 to 5 depending on the number of previous cases in the room. Variables such as the American Society of Anesthesiologists score, number of operative levels, wound class, age, sex, and length of surgery were also tracked. A step-down binary regression was used to analyze each variable as a potential risk factor for infection. Decompression cases had a 2.4% incidence of infection. Longer surgical time and higher case order were found to be significant risk factors for lumbar decompressions. Fusion cases had a 3.5% incidence of infection. Posterior approach and revision cases were significant risk factors for infection in cervical cases. For lumbar fusion cases, longer surgical time, higher American Society of Anesthesiologists score, and older age were all significant risk factors for infection. Decompressive procedures performed later in the day carry a higher risk for postoperative infection. No similar trend was shown for fusion procedures. Our results identify potential modifiable risk factors contributing to infection rates in spinal procedures. Specific risk factors, although not defined in this study, might be related to contamination of the operating room, cross-contamination between health care providers during the course of the day, use of flash sterilization, and mid-day shift changes.

What is the role of autologous blood transfusion in major spine surgery?

PubMed

Kumar, Naresh; Chen, Yongsheng; Nath, Chinmoy; Liu, Eugene Hern Choon

2012-06-01

Major spine surgery is associated with significant blood loss, which has numerous complications. Blood loss is therefore an important concern when undertaking any major spine surgery. Blood loss can be addressed by reducing intraoperative blood loss and replenishing perioperative blood loss. Reducing intraoperative blood loss helps maintain hemodynamic equilibrium and provides a clearer operative field during surgery. Homologous blood transfusion is still the mainstay for replenishing blood loss in major spine surgery across the world, despite its known adverse effects. These significant adverse effects can be seen in up to 20% of patients. Autologous blood transfusion avoids the risks associated with homologous blood transfusion and has been shown to be cost-effective. This article reviews the different methods of autologous transfusion and focuses on the use of intraoperative cell salvage in major spine surgery. Autologous blood transfusion is a proven alternative to homologous transfusion in major spine surgery, avoiding most, if not all of these adverse effects. However, autologous blood transfusion rates in major spine surgery remain low across the world. Autologous blood transfusion may obviate the need for homologous transfusion completely. We encourage spine surgeons to consider autologous blood transfusion wherever feasible.

The role of C2-C7 and O-C2 angle in the development of dysphagia after cervical spine surgery.

PubMed

Tian, Wei; Yu, Jie

2013-06-01

Dysphagia is a known complication of cervical surgery and may be prolonged or occasionally serious. A previous study showed that dysphagia after occipitocervical fusion was caused by oropharyngeal stenosis resulting from O-C2 (upper cervical lordosis) fixation in a flexed position. However, there have been few reports analyzing the association between the C2-C7 angle (middle-lower cervical lordosis) and postoperative dysphagia. The aim of this study was to analyze the relationship between cervical lordosis and the development of dysphagia after anterior and posterior cervical spine surgery (AC and PC). Three hundred fifty-four patients were reviewed in this retrospective clinical study, including 172 patients who underwent the AC procedure and 182 patients who had the PC procedure between June 2007 and May 2010. The presence and duration of postoperative dysphagia were recorded via face-to-face questioning or telephone interview performed at least 1 year after the procedure. Plain cervical radiographs before and after surgery were collected. The O-C2 angle and the C2-C7 angle were measured. Changes in the O-C2 angle and the C2-C7 angle were defined as dO-C2 angle = postoperative O-C2 angle - preoperative O-C2 angle and dC2-C7 angle = postoperative C2-C7 angle - preoperative C2-C7 angle. The association between postoperative dysphagia with dO-C2 angle and dC2-C7 angle was studied. Results showed that 12.8 % of AC and 9.4 % of PC patients reported dysphagia after cervical surgery. The dC2-C7 angle has considerable impact on postoperative dysphagia. When the dC2-C7 angle is greater than 5°, the chance of developing postoperative dysphagia is significantly greater. The dO-C2 angle, age, gender, BMI, operative time, blood loss, procedure type, revision surgery, most cephalic operative level, and number of operative levels did not significantly influence the incidence of postoperative dysphagia. No relationship was found between the dC2-C7 angle and the degree of dysphagia. We conclude that postoperative dysphagia is common after cervical surgery. The dC2-C7 angle may play an important role in the development of dysphagia in both anterior and posterior cervical spine surgery. Intraoperative measurement of the dC2-C7 angle is practical and essential in avoiding inadvertent postoperative dysphagia.

Pharyngoesophageal perforation 3 years after anterior cervical spine surgery: a rare case report and literature review.

PubMed

Yin, Dan-Hui; Yang, Xin-Ming; Huang, Qi; Yang, Mi; Tang, Qin-Lai; Wang, Shu-Hui; Wang, Shuang; Liu, Jia-Jia; Yang, Tao; Li, Shi-Sheng

2015-08-01

Pharyngoesophageal perforation after anterior cervical spine surgery is rare and the delayed cases were more rarely reported but potentially life-threatening. We report a case of pharyngoesophageal perforation 3 years after anterior cervical spine surgery. The patient presented with dysphagia, fever, left cervical mass and developing dyspnea 3 years after cervical spine surgery for trauma. After careful examinations, he underwent an emergency tracheostomy, neck exploration, hardware removal, abscess drainage and infected tissue debridement. 14 days after surgery, CT of the neck with oral contrast demonstrated no contrast extravasation from the esophagus. Upon review of literature, only 14 cases of pharyngoesophageal perforation more than 1 year after anterior cervical spine surgery were found. We discussed possible etiology, diagnosis and management and concluded that in cases of dysphagia, dyspnea, cervical pain, swelling and edema of the cervical area even long time after anterior cervical spine surgery, potential pharyngoesophageal damage should be considered.

The future of spine surgery: New horizons in the treatment of spinal disorders

PubMed Central

Kazemi, Noojan; Crew, Laura K.; Tredway, Trent L.

2013-01-01

Background and Methods: As with any evolving surgical discipline, it is difficult to predict the future of the practice and science of spine surgery. In the last decade, there have been dramatic developments in both the techniques as well as the tools employed in the delivery of better outcomes to patients undergoing such surgery. In this article, we explore four specific areas in spine surgery: namely the role of minimally invasive spine surgery; motion preservation; robotic-aided surgery and neuro-navigation; and the use of biological substances to reduce the number of traditional and revision spine surgeries. Results: Minimally invasive spine surgery has flourished in the last decade with an increasing amount of surgeries being performed for a wide variety of degenerative, traumatic, and neoplastic processes. Particular progress in the development of a direct lateral approach as well as improvement of tubular retractors has been achieved. Improvements in motion preservation techniques have led to a significant number of patients achieving arthroplasty where fusion was the only option previously. Important caveats to the indications for arthroplasty are discussed. Both robotics and neuro-navigation have become further refined as tools to assist in spine surgery and have been demonstrated to increase accuracy in spinal instrumentation placement. There has much debate and refinement in the use of biologically active agents to aid and augment function in spine surgery. Biological agents targeted to the intervertebral disc space could increase function and halt degeneration in this anatomical region. Conclusions: Great improvements have been achieved in developing better techniques and tools in spine surgery. It is envisaged that progress in the four focus areas discussed will lead to better outcomes and reduced burdens on the future of both our patients and the health care system. PMID:23653885

Prophylaxis of surgical site infection in adult spine surgery: A systematic review.

PubMed

Yao, Reina; Tan, Terence; Tee, Jin Wee; Street, John

2018-06-01

Surgical site infection (SSI) remains a significant source of morbidity in spine surgery, with reported rates varying from 0.7 to 16%. To systematically review and evaluate the evidence for strategies for prophylaxis of SSI in adult spine surgery in the last twenty years. Two independent systematic searches were conducted, at two international spine centers, encompassing PubMed, ClinicalTrials.gov, Cochrane Database, EBSCO Medline, ScienceDirect, Ovid Medline, EMBASE (Ovid), and MEDLINE. References were combined and screened, then distilled to 69 independent studies for final review. 11 randomized controlled trials (RCTs), 51 case-controlled studies (CCS), and 7 case series were identified. Wide variation exists in surgical indications, approaches, procedures, and even definitions of SSI. Intra-wound vancomycin powder was the most widely studied intervention (19 studies, 1 RCT). Multiple studies examined perioperative antibiotic protocols, closed-suction drainage, povidone-iodine solution irrigation, and 2-octyl-cyanoacrylate skin closure. 18 interventions were examined by a single study only. There is limited evidence for the efficacy of intra-wound vancomycin. There is strong evidence that closed-suction drainage does not affect SSI rates, while there is moderate evidence for the efficacy of povidone-iodine irrigation and that single-dose preoperative antibiotics is as effective as multiple doses. Few conclusions can be drawn about other interventions given the paucity and poor quality of studies. While a small body of evidence underscores a select few interventions for SSI prophylaxis in adult spine surgery, most proposed measures have not been investigated beyond a single study. Further high level evidence is required to justify SSI preventative treatments. Copyright © 2018 Elsevier Ltd. All rights reserved.

Emergence of Three-Dimensional Printing Technology and Its Utility in Spine Surgery.

PubMed

Gadia, Akshay; Shah, Kunal; Nene, Abhay

2018-04-01

In the last decade, spine surgery has advanced tremendously. Tissue engineering and three-dimensional (3D) printing/additive manufacturing have provided promising new research avenues in the fields of medicine and orthopedics in recent literature, and their emergent role in spine surgery is encouraging. We reviewed recent articles that highlighted the role of 3D printing in medicine, orthopedics, and spine surgery and summarized the utility of 3D printing. 3D printing has shown promising results in various aspects of spine surgery and can be a useful tool for spine surgeons. The growing research on tissue bioengineering and its application in conjunction with additive manufacturing has revealed great potential for tissue bioengineering in the treatment of spinal ailments.

Emergence of Three-Dimensional Printing Technology and Its Utility in Spine Surgery

PubMed Central

Gadia, Akshay; Nene, Abhay

2018-01-01

In the last decade, spine surgery has advanced tremendously. Tissue engineering and three-dimensional (3D) printing/additive manufacturing have provided promising new research avenues in the fields of medicine and orthopedics in recent literature, and their emergent role in spine surgery is encouraging. We reviewed recent articles that highlighted the role of 3D printing in medicine, orthopedics, and spine surgery and summarized the utility of 3D printing. 3D printing has shown promising results in various aspects of spine surgery and can be a useful tool for spine surgeons. The growing research on tissue bioengineering and its application in conjunction with additive manufacturing has revealed great potential for tissue bioengineering in the treatment of spinal ailments. PMID:29713420

Clinical acceptance and accuracy assessment of spinal implants guided with SpineAssist surgical robot: retrospective study.

PubMed

Devito, Dennis P; Kaplan, Leon; Dietl, Rupert; Pfeiffer, Michael; Horne, Dale; Silberstein, Boris; Hardenbrook, Mitchell; Kiriyanthan, George; Barzilay, Yair; Bruskin, Alexander; Sackerer, Dieter; Alexandrovsky, Vitali; Stüer, Carsten; Burger, Ralf; Maeurer, Johannes; Donald, Gordon D; Gordon, Donald G; Schoenmayr, Robert; Friedlander, Alon; Knoller, Nachshon; Schmieder, Kirsten; Pechlivanis, Ioannis; Kim, In-Se; Meyer, Bernhard; Shoham, Moshe

2010-11-15

Retrospective, multicenter study of robotically-guided spinal implant insertions. Clinical acceptance of the implants was assessed by intraoperative radiograph, and when available, postoperative computed tomography (CT) scans were used to determine placement accuracy. To verify the clinical acceptance and accuracy of robotically-guided spinal implants and compare to those of unguided free-hand procedures. SpineAssist surgical robot has been used to guide implants and guide-wires to predefined locations in the spine. SpineAssist which, to the best of the authors' knowledge, is currently the sole robot providing surgical assistance in positioning tools in the spine, guided over 840 cases in 14 hospitals, between June 2005 and June 2009. Clinical acceptance of 3271 pedicle screws and guide-wires inserted in 635 reported cases was assessed by intraoperative fluoroscopy, where placement accuracy of 646 pedicle screws inserted in 139 patients was measured using postoperative CT scans. Screw placements were found to be clinically acceptable in 98% of the cases when intraoperatively assessed by fluoroscopic images. Measurements derived from postoperative CT scans demonstrated that 98.3% of the screws fell within the safe zone, where 89.3% were completely within the pedicle and 9% breached the pedicle by up to 2 mm. The remaining 1.4% of the screws breached between 2 and 4 mm, while only 2 screws (0.3%) deviated by more than 4 mm from the pedicle wall. Neurologic deficits were observed in 4 cases yet, following revisions, no permanent nerve damage was encountered, in contrast to the 0.6% to 5% of neurologic damage reported in the literature. SpineAssist offers enhanced performance in spinal surgery when compared to free-hand surgeries, by increasing placement accuracy and reducing neurologic risks. In addition, 49% of the cases reported herein used a percutaneous approach, highlighting the contribution of SpineAssist in procedures without anatomic landmarks.

Unskilled unawareness and the learning curve in robotic spine surgery.

PubMed

Schatlo, Bawarjan; Martinez, Ramon; Alaid, Awad; von Eckardstein, Kajetan; Akhavan-Sigari, Reza; Hahn, Anina; Stockhammer, Florian; Rohde, Veit

2015-10-01

Robotic assistance for the placement of pedicle screws has been established as a safe technique. Nonetheless rare instances of screw misplacement have been reported.The aim of the present retrospective study is to assess whether experience and time affect the accuracy of screws placed with the help of the SpineAssist™ robot system. Postoperative computed tomography (CT) scans of 258 patients requiring thoracolumbar pedicle screw instrumentation from 2008 to 2013 were reviewed. Overall, 13 surgeons performed the surgeries. A pedicle breach of >3 mm was graded as a misplacement. Surgeons were dichotomised into an early and experienced period in increments of five surgeries. In 258 surgeries, 1,265 pedicle screws were placed with the aid of the robot system. Overall, 1,217 screws (96.2 %) were graded as acceptable. When displayed by surgeon, the development of percent misplacement rates peaked between 5 and 25 surgeries in 12 of 13 surgeons. The overall misplacement rate in the first five surgeries was 2.4 % (6/245). The misplacement rate rose to 6.3 % between 11 and 15 surgeries (10/158; p = 0.20), and reached a significant peak between 16 and 20 surgeries with a rate of 7.1 % (8/112; p = 0.03). Afterwards, misplacement rates declined. A major peak in screw inaccuracies occurred between cases 10 and 20, and a second, smaller one at about 40 surgeries. One potential explanation could be a transition from decreased supervision (unskilled but aware) to increased confidence of a surgeon (unskilled but unaware) who adopts this new technique prior to mastering it (skilled). We therefore advocate ensuring competent supervision for new surgeons at least during the first 25 procedures of robotic spine surgery to optimise the accuracy of robot-assisted pedicle screws.

Neurosurgery: A profession or a technical trade?

PubMed Central

Watts, Clark

2014-01-01

The American Association of Neurological Surgeons (AANS), 11 years ago converted its Internal Revenue Code (IRC) tax status from a 501 (c) (3) to a 501 (c) (6) entity. By doing so, the professional medical association, now a trade association, was able to more aggressively lobby, support political campaigns, and pursue business opportunities for its members. In the following decade, major changes were seen in the practice of neurosurgery, especially as it relates to spine surgery. With the majority of neurosurgeons limiting themselves to a spine practice, an increased number of spinal procedures, most noted in the Medicare population, was recorded. For example, a 15-fold increase in complex spinal fusions for spinal stenosis was seen between 2002 and 2007. While the basis for this increase was not readily apparent, it was associated with a reduction in reimbursement per case of about 50%, fueling the belief that the increase in complexity of surgery permitted recovery of fees in complex cases to off-set the loss of reimbursement for simpler cases. Considering the growth of spinal surgery within neurosurgery, and decrease funding for spine surgery, in the future there may be too many surgeons chasing too few dollars. There appears to be within neurosurgery a crisis developing where future manpower projections do not realistically match future anticipated specialty funding. PMID:25558426

Patient perceptions of physician reimbursement for spine surgery.

PubMed

Badlani, Neil; Foran, Jared R; Phillips, Frank M; Pelton, Miguel; Singh, Kern; Garfin, Steven R; Allen, R Todd

2013-07-01

Anonymous patient survey. To determine what patients think surgeons should be paid to perform elective spine surgical procedures, and gauge awareness of actual Medicare reimbursement. With increasing transparency, the public may become aware of physician reimbursements and may be a part of the debate regarding appropriate reimbursement. It is unknown what patients perceive that spinal surgeons deserve to be, or are actually, paid to perform spinal procedures. Two hundred anonymous surveys were given to consecutive patients in an outpatient office setting by means of convenience sampling. Patients were asked how much they think physicians are and should be reimbursed for typical spine procedures; and they were asked about their opinions of the actual reimbursement amount for these procedures. It was made explicit that the fee in question included only the surgeon's reimbursement and not that of the hospital. Data were tabulated, statistical comparisons were made, and results were correlated with demographic information. On average, respondents thought that surgeons should be paid $21,299 for performing a lumbar discectomy and estimated that Medicare actually pays $12,336 (actual average reimbursement $971). Similar disparities were seen for the other procedures.The vast majority of respondents thought that the average Medicare reimbursement for spine procedures was too low. For example, 92.2% of patients thought that $971 for a lumbar discectomy was "too low," 6.1% thought it was "about right," and only 1.6% thought that $971 was "too high." Patients think that orthopedic spine surgeons should be compensated over 10 to 20 times more than current Medicare reimbursement rates. Patients overestimate the actual amount that Medicare reimburses by a factor of approximately 7 to 10. Less than 10% of patients think that the current Medicare payment is about right, and less than 2% think that surgeons are overpaid.

Research articles published by Korean spine surgeons: Scientific progress and the increase in spine surgery.

PubMed

Lee, Soo Eon; Jahng, Tae-Ahn; Kim, Ki-Jeong; Hyun, Seung-Jae; Kim, Hyun Jib; Kawaguchi, Yoshiharu

2017-02-01

There has been a marked increase in spine surgery in the 21st century, but there are no reports providing quantitative and qualitative analyses of research by Korean spine surgeons. The study goal was to assess the status of Korean spinal surgery and research. The number of spine surgeries was obtained from the Korean National Health Insurance Service. Research articles published by Korean spine surgeons were reviewed by using the Medline/PubMed online database. The number of spine surgeries in Korea increased markedly from 92,390 in 2004 to 164,291 in 2013. During the 2000-2014 period, 1982 articles were published by Korean spine surgeons. The annual number of articles increased from 20 articles in 2000 to 293 articles in 2014. There was a positive correlation between the annual spine surgery and article numbers (p<0.001). There were 1176 original studies published, and there was an annual increase in articles with Oxford levels of evidence 1, 2, and 3. The mean five-year impact factor (IF) for article quality was 1.79. There was no positive correlation between the annual IF and article numbers. Most articles (65.9%) were authored by neurosurgical spine surgeons. But spinal deformity-related topics were dominant among articles authored by orthopedics. The results show a clear quantitative increase in Korean spinal surgery and research over the last 15years. The lack of a correlation between annual IF and published article numbers indicate that Korean spine surgeons should endeavor to increase research value. Copyright © 2016 Elsevier Ltd. All rights reserved.

Comparing Angiographic Devascularization with Histologic Penetration after Preoperative Tumor Embolization with Onyx: What Indicates an Effective Procedure?

PubMed

Grandhi, Ramesh; Hunnicutt, Christopher T; Harrison, Gillian; Zwagerman, Nathan T; Snyderman, Carl H; Gardner, Paul A; Hartman, Douglas J; Horowitz, Michael

2015-07-01

To assess Onyx (Covidien, Irvine, California, United States) efficacy as a preoperative embolic agent for neoplasms of the head, neck, and spine, and to compare angiographic and histologic evidence of tumor penetration as predictors of intraoperative blood loss. Retrospective analysis of preoperative Onyx embolization procedures for treatment of head, neck, and spine tumors from 2009 to 2011. Patient demographics and information relating to the embolization procedure and operation were recorded. Measures of Onyx efficacy included intraoperative blood loss and length of surgery. Angiographic and histologic penetration, in addition to percentage of tumor devascularization, were assessed as predictors of efficacy. A total of 22 patients with 17 head or neck and 5 spinal lesions underwent trans-arterial preoperative Onyx embolization. Good angiographic penetration was reported in 41% of tumors and central histologic penetration in 59%, with mean tumor devascularization of 85.3% (standard deviation [SD]: 12.6%). There was no relationship between angiographic and histologic Onyx penetrance. Mean surgical blood loss was 1342 mL (SD: 1327 mL), and length of surgery was 289 minutes (SD: 162 minutes). Neither angiographic, nor histologic Onyx penetration predicted intraoperative blood loss (p = 0.38 and p = 0.32, respectively) or surgical length (p = 0.62 and 0.90, respectively). Devascularization was not associated with blood loss (p = 0.62), but it was a negative predictor of surgical length (p = 0.013). Preoperative Onyx embolization of head, neck, and spine tumors is capable of deep histologic tumor penetration, even when not visualized on angiography. The lack of association between measures of procedural adequacy suggests that using angiographic devascularization as a measure of procedural efficacy may be of limited utility. Georg Thieme Verlag KG Stuttgart · New York.

Complications in pediatric spine surgery using the vertical expandable prosthetic titanium rib: the French experience.

PubMed

Lucas, Grégory; Bollini, Gérard; Jouve, Jean-Luc; de Gauzy, Jérome Sales; Accadbled, Franck; Lascombes, Pierre; Journeau, Pierre; Karger, Claude; Mallet, Jean François; Neagoe, Petre; Cottalorda, Jérome; De Billy, Benoit; Langlais, Jean; Herbaux, Bernard; Fron, Damien; Violas, Philippe

2013-12-01

Multicenter retrospective study of 54 children. To describe the complication rate of the French vertical expandable prosthetic titanium rib (VEPTR) series involving patients treated between August 2005 and January 2012. Congenital chest wall and spine deformities in children are complex entities. Most of the affected patients have severe scoliosis often associated with a thoracic deformity. Orthopedic treatment is generally ineffective, and surgical treatment is very challenging. These patients are good candidates for VEPTR expansion thoracoplasty. The aim of this study was to evaluate the potential complications of VEPTR surgery. Of the 58 case files, 54 were available for analysis. The series involved 33 girls and 21 boys with a mean age of 7 years (range, 20 mo-14 yr and 2 mo) at primary VEPTR surgery. During the follow-up period, several complications occurred. Mean follow-up was 22.5 months (range, 6-64 mo). In total, 184 procedures were performed, including 56 VEPTR implantations, 98 expansions, and 30 nonscheduled procedures for different types of complications: mechanical complications (i.e., fracture, device migration), device-related and infectious complications, neurological disorders, spine statics disturbances. Altogether, there were 74 complications in 54 patients: a complication rate of 137% per patient and 40% per surgery. Comparison of the complications in this series with those reported in the literature led the authors to suggest solutions that should help decrease their incidence. The complication rate is consistent with that reported in the literature. Correct determination of the levels to be instrumented, preoperative improvement of nutritional status, and better evaluation of the preoperative and postoperative respiratory function are important factors in minimizing the potential complications of a technique that is used in weak patients with complex deformities.

Analysis of Incident and Accident Reports and Risk Management in Spine Surgery.

PubMed

Kobayashi, Kazuyoshi; Imagama, Shiro; Ando, Kei; Hida, Tetsuro; Ito, Kenyu; Tsushima, Mikito; Ishikawa, Yoshimoto; Matsumoto, Akiyuki; Morozumi, Masayoshi; Nishida, Yoshihiro; Nagao, Yoshimasa; Ishiguro, Naoki

2017-08-01

A review of accident and incident reports. To analyze prevalence, characteristics, and details of perioperative incidents and accidents in patients receiving spine surgery. In our institution, a clinical error that potentially results in an adverse event is usually submitted as an incident or accident report through a web database, to ensure anonymous and blame-free reporting. All reports are analyzed by a medical safety management group. These reports contain valuable data for management of medical safety, but there have been no studies evaluating such data for spine surgery. A total of 320 incidents and accidents that occurred perioperatively in 172 of 415 spine surgeries were included in the study. Incidents were defined as events that were "problematic, but with no damage to the patient," and accidents as events "with damage to the patient." The details of these events were analyzed. There were 278 incidents in 137 surgeries and 42 accidents in 35 surgeries, giving prevalence of 33% (137/415) and 8% (35/415), respectively. The proportion of accidents among all events was significantly higher for doctors than non-doctors [68.0% (17/25) vs. 8.5% (25/295), P < 0.01] and in the operating room compared with outside the operating room [40.5% (15/37) vs. 9.5% (27/283), P < 0.01]. There was no significant difference in years of experience among personnel involved in all events. The major types of events were medication-related, line and tube problems, and falls and slips. Accidents also occurred because of a long-term prone position, with complications such as laryngeal edema, ulnar nerve palsy, and tooth damage. Surgery and procedures in the operating room always have a risk of complications. Therefore, a particular effort is needed to establish safe management of this environment and to provide advice on risk to the doctor and medical care team. 4.

The profit motive and spine surgery.

PubMed

Weiner, Bradley K; Levi, Benjamin H

2004-11-15

The profit motive and market medicine have had a significant impact on clinical practice and research in the field of spine surgery. An overview of current concerns is presented. The objective of this study was to provide those involved in the study and treatment of spinal disorders with a critical overview of the effects of the profit motive on our practices. Historically, the profit motive has been viewed as eroding the standards of spine surgery, encouraging surgeons to operate aggressively and researchers to bias their results. Although there are legitimate concerns regarding the role played by such market forces, the profit motive exerts several quite positive effects on spine surgery as well. Negative and positive aspects of the profit motive in spine surgery are explored along with alternative approaches. The profit motive in spine surgery can result in unnecessary surgery, as well as the push to market of unproven technologies. Yet, without a robust profit motive, it is unclear where sufficient funding could be found to support research and education, and to underwrite the advancement of new technologies. The profit motive significantly influences the way we practice and conduct research in spine surgery. To minimize the negative aspects of the profit motive, spine surgeons and researchers must refrain from being used by companies to rush products to market and/or compromising patient care out of self-interest.

A post-market surveillance analysis of the safety of hydroxyapatite-derived products as bone graft extenders or substitutes for spine fusion.

PubMed

Barbanti Brodano, G; Griffoni, C; Zanotti, B; Gasbarrini, A; Bandiera, S; Ghermandi, R; Boriani, S

2015-10-01

Iliac crest bone graft (ICBG) is considered the gold standard for spine surgical procedures to achieve a successful fusion, because of its known osteoinductive and osteoconductive properties. Considering its autogenous origin, the use of ICBG has not been associated to an increase of intraoperative or postoperative complications directly related to the surgery. However, complications related to the harvesting procedure and to the donor site morbidity have been largely reported in the literature, favoring the development of a wide range of alternative products to be used as bone graft extenders or substitutes for spine fusion. The family of ceramic-based bone grafts has been widely used and studied during the last years for spine surgical procedures in order to reduce the need for iliac crest bone grafting and the consequent morbidity associated to the harvesting procedures. We report here the results of a post-market surveillance analysis performed on four independent cohorts of patients (115 patients) to evaluate the safety of three different formulations of hydroxyapatite-derived products used as bone graft extenders/substitutes for lumbar arthrodesis. No intraoperative or post-operative complications related to the use of hydroxyapatite-derived products were detected, during medium and long follow up period (minimum 12 months-maximum 5 years). This post-market surveillance analysis evidenced the safety of ceramic products as bone graft extenders or substitutes for spine fusion. Moreover, the evidence of the safety of hydroxyapatite-derived products allows to perform clinical studies aimed at evaluating the fusion rates and the clinical outcomes of these materials as bone graft extenders/substitutes, in order to support their use as an alternative to ICBG for spine fusion.

Low-invasive reconstruction of spine discs under thermo-mechanical effect of fiber laser

NASA Astrophysics Data System (ADS)

Sobol, Emil; Baskov, Andrey; Borshchenko, Igor; Shekhter, Anatoly

2018-02-01

The paper considers physical processes and mechanisms of laser reparation of spine cartilage, presents results of investigations aimed to optimize laser settings and to develop feedback control system for laser reconstruction of spine discs. Possible mechanisms of laser-induced regeneration include: (1) Space and temporary modulated laser beam induces non-homogeneous and pulse repetitive thermal expansion and stress in the irradiated zone of cartilage. Mechanical effect due to controllable thermal expansion of the tissue and micro and nano gas bubbles formation in the course of the moderate (up to 50 °C) heating of the NP activate biological cells (chondrocytes) and promote cartilage regeneration. (2) Non-destructive laser radiation leads to the formation of nano and micro-pores in cartilage matrix in the in the immediate vicinity of chondrocytes. That promotes water permeability and increases the feeding of biological cells. Results provide the scientific and engineering basis for the novel low-invasive laser procedures to be used in neurosurgery and orthopedics for the treatment cartilages of spine. The technology and equipment for laser reconstruction of spine discs have been tested first on animals, and then in a clinical trial. Since 2001 the laser reconstruction of intervertebral discs have been performed (i) for more than 3,200 patients with chronic symptoms of low back or neck pain who failed to improve with non-operative care; and (ii) for 1100 patients underwent hernia removal surgery. Substantial relief of back pain was obtained in 92.5% of patients treated who returned to their daily activities. LRD allowed also to decrease secondary surgeries more than three times. Optical fiber technique based on light scattering measurements have been used to promote safety and efficacy of the laser procedures.

Scoliosis Screening in Schools.

ERIC Educational Resources Information Center

New York State Education Dept., Albany. Div. of Pupil Personnel Services.

The booklet outlines New York state school policy and procedures for screening students for scoliosis, lateral curvature of the spine. It is explained that screening is designed to discover spinal deformities early enough to prevent surgery. Planning aspects, including organizing a planning team for the school district, are discussed. Among…

Risk factors for unavoidable removal of instrumentation after surgical site infection of spine surgery

PubMed Central

Tominaga, Hiroyuki; Setoguchi, Takao; Kawamura, Hideki; Kawamura, Ichiro; Nagano, Satoshi; Abematsu, Masahiko; Tanabe, Fumito; Ishidou, Yasuhiro; Yamamoto, Takuya; Komiya, Setsuro

2016-01-01

Abstract Surgical site infection (SSI) after spine instrumentation is difficult to treat, and often requires removal of instrumentation. The removal of instrumentation after spine surgery is a severe complication that can lead to the deterioration of activities of daily living and poor prognosis. Although there are many reports on SSI after spine surgery, few reports have investigated the risk factors for the removal of instrumentation after spine surgery SSI. This study aimed to identify the risk factors for unavoidable removal of instrumentation after SSI of spine surgery. We retrospectively reviewed 511 patients who underwent spine surgery with instrumentation at Kagoshima University Hospital from January 2006 to December 2014. Risk factors associated with SSI were analyzed via multiple logistic regression analysis. Parameters of the group that needed instrumentation removal were compared with the group that did not require instrumentation removal using the Mann–Whitney U and Fisher's exact tests. The posterior approach was used in most cases (453 of 511 cases, 88.6%). SSI occurred in 16 of 511 cases (3.14%) of spine surgery with instrumentation. Multivariate logistic regression analysis identified 2 significant risk factors for SSI: operation time, and American Society of Anesthesiologists physical status classification ≥ 3. Twelve of the 16 patients with SSI (75%) were able to keep the instrumentation after SSI. Pseudarthrosis occurred in 2 of 4 cases (50%) after instrumentation removal. Risk factors identified for instrumentation removal after spine SSI were a greater number of past surgeries, low preoperative hemoglobin, high preoperative creatinine, high postoperative infection treatment score for the spine, and the presence of methicillin-resistant Staphylococcus aureus. In these high risk cases, attempts should be made to decrease the risk factors preoperatively, and careful postoperative monitoring should be conducted. PMID:27787365

Risk factors for unavoidable removal of instrumentation after surgical site infection of spine surgery: A retrospective case-control study.

PubMed

Tominaga, Hiroyuki; Setoguchi, Takao; Kawamura, Hideki; Kawamura, Ichiro; Nagano, Satoshi; Abematsu, Masahiko; Tanabe, Fumito; Ishidou, Yasuhiro; Yamamoto, Takuya; Komiya, Setsuro

2016-10-01

Surgical site infection (SSI) after spine instrumentation is difficult to treat, and often requires removal of instrumentation. The removal of instrumentation after spine surgery is a severe complication that can lead to the deterioration of activities of daily living and poor prognosis. Although there are many reports on SSI after spine surgery, few reports have investigated the risk factors for the removal of instrumentation after spine surgery SSI. This study aimed to identify the risk factors for unavoidable removal of instrumentation after SSI of spine surgery. We retrospectively reviewed 511 patients who underwent spine surgery with instrumentation at Kagoshima University Hospital from January 2006 to December 2014. Risk factors associated with SSI were analyzed via multiple logistic regression analysis. Parameters of the group that needed instrumentation removal were compared with the group that did not require instrumentation removal using the Mann-Whitney U and Fisher's exact tests. The posterior approach was used in most cases (453 of 511 cases, 88.6%). SSI occurred in 16 of 511 cases (3.14%) of spine surgery with instrumentation. Multivariate logistic regression analysis identified 2 significant risk factors for SSI: operation time, and American Society of Anesthesiologists physical status classification ≥ 3. Twelve of the 16 patients with SSI (75%) were able to keep the instrumentation after SSI. Pseudarthrosis occurred in 2 of 4 cases (50%) after instrumentation removal. Risk factors identified for instrumentation removal after spine SSI were a greater number of past surgeries, low preoperative hemoglobin, high preoperative creatinine, high postoperative infection treatment score for the spine, and the presence of methicillin-resistant Staphylococcus aureus. In these high risk cases, attempts should be made to decrease the risk factors preoperatively, and careful postoperative monitoring should be conducted.

Usefulness of three-dimensional full-scale modeling of surgery for a giant cell tumor of the cervical spine.

PubMed

Yamazaki, M; Akazawa, T; Okawa, A; Koda, M

2007-03-01

Case report. To report a case with giant cell tumor (GCT) of C6 vertebra, in which three-dimensional (3-D) full-scale modeling of the cervical spine was useful for preoperative planning and intraoperative navigation. A university hospital in Japan. A 27-year-old man with a GCT involving the C6 vertebra presented with severe neck pain. The C6 vertebra was collapsed and the tumor had infiltrated around both vertebral arteries (VAs). A single-stage operation combining anterior and posterior surgical procedures was scheduled to resect the tumor and stabilize the spine. To evaluate the anatomic structures within the surgical fields, we produced a 3-D full-scale model from the computed tomography angiography data. The 3-D full-scale model clearly showed the relationships between the destroyed C6 vertebra and the deviations in the courses of both VAs. Using the model, we were able to identify the anatomic landmarks around the VAs during anterior surgery and to successfully resect the tumor. During the posterior surgery, we were able to determine accurate starting points for the pedicle screws. Anterior iliac bone graft from C5 to C7 and posterior fixation with a rod and screw system from C4 to T2 were performed without any complications. Postoperatively, the patient experienced relief of his neck pain. The 3-D full-scale model was useful for simultaneously evaluating the destruction of the vertebral bony structures and the deviations in the courses of the VAs during surgery for GCT involving the cervical spine.

Robotics and the spine: a review of current and ongoing applications.

PubMed

Shweikeh, Faris; Amadio, Jordan P; Arnell, Monica; Barnard, Zachary R; Kim, Terrence T; Johnson, J Patrick; Drazin, Doniel

2014-03-01

Robotics in the operating room has shown great use and versatility in multiple surgical fields. Robot-assisted spine surgery has gained significant favor over its relatively short existence, due to its intuitive promise of higher surgical accuracy and better outcomes with fewer complications. Here, the authors analyze the existing literature on this growing technology in the era of minimally invasive spine surgery. In an attempt to provide the most recent, up-to-date review of the current literature on robotic spine surgery, a search of the existing literature was conducted to obtain all relevant studies on robotics as it relates to its application in spine surgery and other interventions. In all, 45 articles were included in the analysis. The authors discuss the current status of this technology and its potential in multiple arenas of spinal interventions, mainly spine surgery and spine biomechanics testing. There are numerous potential advantages and limitations to robotic spine surgery, as suggested in published case reports and in retrospective and prospective studies. Randomized controlled trials are few in number and show conflicting results regarding accuracy. The present limitations may be surmountable with future technological improvements, greater surgeon experience, reduced cost, improved operating room dynamics, and more training of surgical team members. Given the promise of robotics for improvements in spine surgery and spine biomechanics testing, more studies are needed to further explore the applicability of this technology in the spinal operating room. Due to the significant cost of the robotic equipment, studies are needed to substantiate that the increased equipment costs will result in significant benefits that will justify the expense.

A novel index for quantifying the risk of early complications for patients undergoing cervical spine surgeries.

PubMed

Passias, Peter G; Diebo, Bassel G; Marascalchi, Bryan J; Jalai, Cyrus M; Horn, Samantha R; Zhou, Peter L; Paltoo, Karen; Bono, Olivia J; Worley, Nancy; Poorman, Gregory W; Challier, Vincent; Dixit, Anant; Paulino, Carl; Lafage, Virginie

2017-11-01

OBJECTIVE It is becoming increasingly necessary for surgeons to provide evidence supporting cost-effectiveness of surgical treatment for cervical spine pathology. Anticipating surgical risk is critical in accurately evaluating the risk/benefit balance of such treatment. Determining the risk and cost-effectiveness of surgery, complications, revision procedures, and mortality rates are the most significant limitations. The purpose of this study was to determine independent risk factors for medical complications (MCs), surgical complications (SCs), revisions, and mortality rates following surgery for patients with cervical spine pathology. The most relevant risk factors were used to structure an index that will help quantify risk and anticipate failure for such procedures. METHODS The authors of this study performed a retrospective review of the National Inpatient Sample (NIS) database for patients treated surgically for cervical spine pathology between 2001 and 2010. Multivariate models were performed to calculate the odds ratio (OR) of the independent risk factors that led to MCs and repeated for SCs, revisions, and mortality. The models controlled for age (< and > 65 years old), sex, race, revision status (except for revision analysis), surgical approach, number of levels fused/re-fused (2-3, 4-8, ≥ 9), and osteotomy utilization. ORs were weighted based on their predictive category: 2 times for revision surgery predictors and 4 times for mortality predictors. Fifty points were distributed among the predictors based on their cumulative OR to establish a risk index. RESULTS Discharges for 362,989 patients with cervical spine pathology were identified. The mean age was 52.65 years, and 49.47% of patients were women. Independent risk factors included medical comorbidities, surgical parameters, and demographic factors. Medical comorbidities included the following: pulmonary circulation disorder, coagulopathy, metastatic cancer, renal failure, congestive heart failure, alcohol abuse, neurological disorder, nonmetastatic cancer, liver disease, rheumatoid arthritis/collagen vascular diseases, and chronic blood loss/anemia. Surgical parameters included posterior approach to fusion/re-fusion, ≥ 9 levels fused/re-fused, corpectomy, 4-8 levels fused/re-fused, and osteotomy; demographic variables included age ≥ 65 years. These factors increased the risk of at least 1 of MC, SC, revision, or mortality (risk of death). A total of 50 points were distributed among the factors based on the cumulative risk ratio of every factor in proportion to the total risk ratios. CONCLUSIONS This study proposed an index to quantify the potential risk of morbidity and mortality prior to surgical intervention for patients with cervical spine pathology. This index may be useful for surgeons in patient counseling efforts as well as for health insurance companies and future socioeconomics studies in assessing surgical risks and benefits for patients undergoing surgical treatment of the cervical spine.

Neurosurgical procedures in Jehovah's Witnesses: the Tema experience.

PubMed

Andrews, N B

2009-05-01

On account of religious reasons, Jehovah Witnesses do not accept blood or blood products; occasionally, they accept reinfusion of autologous blood via a cell saver during surgery. The aim of this study was to document the demographics of Jehovah Witnesses undergoing neurosurgical procedures, the neurosurgical procedures undertaken in Jehovah Witnesses and to evaluate the complications of the procedures. A retrospective audit of the medical records of all Jehovah's Witnesses who underwent neurosurgical procedures at our institution, from January 1st 2000 to December 31st 2006, was carried out. The parameters investigated included demographics, pre and post operative diagnosis, type of neurosurgical procedure and complications. Nineteen patients (fifteen male, four female; male/female 3.8:1) constituted the series. The mean age was 45.8 (range: 20-65) years. A total of 21 procedures were performed; intracranial surgery (33%), spinal surgery (67%). No autotransfusion of blood was given. Lumbar laminectomy for stenosis was the commonest spine procedure, ten (71.4%); craniotomy for tumor excision was the commonest intracranial procedure, six (85.7%). With respect to the whole series, the morbidity rate was 4.7% and the mortality rate was 4.7%; both were from intracranial surgery. It is possible to perform certain types of neurosurgical procedures in Jehovah's Witnesses without increasing the mortality and morbidity rate.

Most Cited Publications in Cervical Spine Surgery

PubMed Central

Brooks, Francis; Sandler, Simon; Yau, Yun-Hom; Selby, Michael; Freeman, Brian

2017-01-01

Purpose The purpose of this study is to perform a citation analysis on the most frequently cited articles in the topic of cervical spine surgery and report on the top 100 most cited publication in this topic. Methods We used the Thomson Reuters Web of Science to search citations of all articles from 1945 to 2015 relevant to cervical spine surgery and ranked them according to the number of citations. The 100 most cited articles that matched the search criteria were further analyzed by number of citations, first author, journal, year of publication, country and institution of origin. Results The top 100 cited articles in the topic of cervical spine surgery were published from 1952-2011. The number of citations ranged from 106 times for the 100th paper to 1206 times for the top paper. The decade of 1990-1999 saw the most publications. The Journal of Spine published the most articles, followed by Journal of Bone and Joint Surgery America. Investigators from America authored the most papers and The University of California contributed the most publications. Cervical spine fusion was the most common topic published with 36 papers, followed by surgical technique and trauma. Conclusion This article identifies the 100 most cited articles in cervical spine surgery. It has provided insight to the history and development in cervical spine surgery and many of which have shaped the way we practice today. PMID:28765803

The Role of Multimodal Analgesia in Spine Surgery.

PubMed

Kurd, Mark F; Kreitz, Tyler; Schroeder, Gregory; Vaccaro, Alexander R

2017-04-01

Optimal postoperative pain control allows for faster recovery, reduced complications, and improved patient satisfaction. Historically, pain management after spine surgery relied heavily on opioid medications. Multimodal regimens were developed to reduce opioid consumption and associated adverse effects. Multimodal approaches used in orthopaedic surgery of the lower extremity, especially joint arthroplasty, have been well described and studies have shown reduced opioid consumption, improved pain and function, and decreased length of stay. A growing body of evidence supports multimodal analgesia in spine surgery. Methods include the use of preemptive analgesia, NSAIDs, the neuromodulatory agents gabapentin and pregabalin, acetaminophen, and extended-action local anesthesia. The development of a standard approach to multimodal analgesia in spine surgery requires extensive assessment of the literature. Because a substantial number of spine surgeries are performed annually, a standardized approach to multimodal analgesia may provide considerable benefits, particularly in the context of the increased emphasis on accountability within the healthcare system.

Incidence of Postoperative Hematomas Requiring Surgical Treatment in Neurosurgery: A Retrospective Observational Study.

PubMed

Lillemäe, Kadri; Järviö, Johanna Annika; Silvasti-Lundell, Marja Kaarina; Antinheimo, Jussi Juha-Pekka; Hernesniemi, Juha Antero; Niemi, Tomi Tapio

2017-12-01

We aimed to characterize the occurrence of postoperative hematoma (POH) after neurosurgery overall and according to procedure type and describe the prevalence of possible confounders. Patient data between 2010 and 2012 at the Department of Neurosurgery in Helsinki University Hospital were retrospectively analyzed. A data search was performed according to the type of surgery including craniotomies; shunt procedures, spine surgery, and spinal cord stimulator implantation. We analyzed basic preoperative characteristics, as well as data about the initial intervention, perioperative period, revision operation and neurologic recovery (after craniotomy only). The overall incidence of POH requiring reoperation was 0.6% (n = 56/8783) to 0.6% (n = 26/4726) after craniotomy, 0% (n = 0/928) after shunting procedure, 1.1% (n = 30/2870) after spine surgery, and 0% (n = 0/259) after implantation of a spinal cord stimulator. Craniotomy types with higher POH incidence were decompressive craniectomy (7.9%, n = 7/89), cranioplasty (3.6%, n = 4/112), bypass surgery (1.7%, n = 1/60), and epidural hematoma evacuation (1.6%, n = 1/64). After spinal surgery, POH was observed in 1.1% of cervical and 2.1% of thoracolumbar operations, whereas 46.7% were multilevel procedures. 64.3% of patients with POH and 84.6% of patients undergoing craniotomy had postoperative hypertension (systolic blood pressure >160 mm Hg or lower if indicated). Poor outcome (Glasgow Outcome Scale score 1-3), whereas death at 6 months after craniotomy was detected in 40.9% and 21.7%. respectively, of patients with POH who underwent craniotomy. POH after neurosurgery was rare in this series but was associated with poor outcome. Identification of risk factors of bleeding, and avoiding them, if possible, might decrease the incidence of POH. Copyright © 2017 Elsevier Inc. All rights reserved.

Esophageal Perforation Following Anterior Cervical Spine Surgery: Case Report and Review of the Literature

PubMed Central

Hershman, Stuart H.; Kunkle, William A.; Kelly, Michael P.; Buchowski, Jacob M.; Ray, Wilson Z.; Bumpass, David B.; Gum, Jeffrey L.; Peters, Colleen M.; Singhatanadgige, Weerasak; Kim, Jin Young; Smith, Zachary A.; Hsu, Wellington K.; Nassr, Ahmad; Currier, Bradford L.; Rahman, Ra’Kerry K.; Isaacs, Robert E.; Smith, Justin S.; Shaffrey, Christopher; Thompson, Sara E.; Wang, Jeffrey C.; Lord, Elizabeth L.; Buser, Zorica; Arnold, Paul M.; Fehlings, Michael G.; Mroz, Thomas E.

2017-01-01

Study Design: Multicenter retrospective case series and review of the literature. Objective: To determine the rate of esophageal perforations following anterior cervical spine surgery. Methods: As part of an AOSpine series on rare complications, a retrospective cohort study was conducted among 21 high-volume surgical centers to identify esophageal perforations following anterior cervical spine surgery. Staff at each center abstracted data from patients’ charts and created case report forms for each event identified. Case report forms were then sent to the AOSpine North America Clinical Research Network Methodological Core for data processing and analysis. Results: The records of 9591 patients who underwent anterior cervical spine surgery were reviewed. Two (0.02%) were found to have esophageal perforations following anterior cervical spine surgery. Both cases were detected and treated in the acute postoperative period. One patient was successfully treated with primary repair and debridement. One patient underwent multiple debridement attempts and expired. Conclusions: Esophageal perforation following anterior cervical spine surgery is a relatively rare occurrence. Prompt recognition and treatment of these injuries is critical to minimizing morbidity and mortality. PMID:28451488

Esophageal Perforation Following Anterior Cervical Spine Surgery: Case Report and Review of the Literature.

PubMed

Hershman, Stuart H; Kunkle, William A; Kelly, Michael P; Buchowski, Jacob M; Ray, Wilson Z; Bumpass, David B; Gum, Jeffrey L; Peters, Colleen M; Singhatanadgige, Weerasak; Kim, Jin Young; Smith, Zachary A; Hsu, Wellington K; Nassr, Ahmad; Currier, Bradford L; Rahman, Ra'Kerry K; Isaacs, Robert E; Smith, Justin S; Shaffrey, Christopher; Thompson, Sara E; Wang, Jeffrey C; Lord, Elizabeth L; Buser, Zorica; Arnold, Paul M; Fehlings, Michael G; Mroz, Thomas E; Riew, K Daniel

2017-04-01

Multicenter retrospective case series and review of the literature. To determine the rate of esophageal perforations following anterior cervical spine surgery. As part of an AOSpine series on rare complications, a retrospective cohort study was conducted among 21 high-volume surgical centers to identify esophageal perforations following anterior cervical spine surgery. Staff at each center abstracted data from patients' charts and created case report forms for each event identified. Case report forms were then sent to the AOSpine North America Clinical Research Network Methodological Core for data processing and analysis. The records of 9591 patients who underwent anterior cervical spine surgery were reviewed. Two (0.02%) were found to have esophageal perforations following anterior cervical spine surgery. Both cases were detected and treated in the acute postoperative period. One patient was successfully treated with primary repair and debridement. One patient underwent multiple debridement attempts and expired. Esophageal perforation following anterior cervical spine surgery is a relatively rare occurrence. Prompt recognition and treatment of these injuries is critical to minimizing morbidity and mortality.

Historical contributions from the Harvard system to adult spine surgery.

PubMed

Schoenfeld, Andrew J

2011-10-15

Literature review. To document the historical contributions from the Harvard Medical School system to the field of adult spine surgery. Despite the fact that significant contributions to the discipline of spinal surgery have derived from the Harvard system, no prior study documents the history of the Harvard spine services in a cohesive narrative. This historical perspective reviews the history of adult spine surgery within the Harvard system and outlines the significant contributions made by orthopedic and neurosurgical practitioners to the field. Literature reviews were performed from historical works, as well as scientific publications to fashion a cohesive review covering the history of spine surgery at Harvard from the early 19th century to the present. The development of the spine surgical services at the three main Harvard hospitals, and significant spine surgical personalities within the system, are discussed, including W. Jason Mixter, MD, Joseph S. Barr Sr., MD, and Marius N. Smith-Petersen, MD. Substantial developments that have arisen from the Harvard teaching hospitals include the recognition of disc herniation as the cause of radicular symptoms in the lower extremities, the description of lumbar discectomy as a surgical treatment for radicular pain, osteotomy for the correction of spinal deformity, and the first attempt to create a systematic algorithm capable of informing treatment for cervical spine trauma. Despite humble beginnings, the surgeons and scientists at Harvard have influenced nearly every facet of spine surgery over the course of the last two centuries.

Goal-Directed Fluid Therapy Based on Stroke Volume Variation in Patients Undergoing Major Spine Surgery in the Prone Position: A Cohort Study.

PubMed

Bacchin, Maria Renata; Ceria, Chiara Marta; Giannone, Sandra; Ghisi, Daniela; Stagni, Gaetano; Greggi, Tiziana; Bonarelli, Stefano

2016-09-15

A retrospective observational study. The aim of this study was to test whether a goal-directed fluid therapy (GDFT) protocol, based on stroke volume variation (SVV), applied in major spine surgery performed in the prone position, would be effective in reducing peri-operative red blood cells transfusions. Recent literature shows that optimizing perioperative fluid therapy is associated with lower complication rates and faster recovery. Data from 23 patients who underwent posterior spine arthrodesis surgery and whose intraoperative fluid administration were managed with the GDFT protocol were retrospectively collected and compared with data from 23 matched controls who underwent the same surgical procedure in the same timeframe, and who received a liberal intraoperative fluid therapy. Patients in the GDFT group received less units of transfused red blood cells (primary endpoint) in the intra (0 vs. 2.0, P = 0.0 4) and postoperative period (2.0 vs. 4.0, P = 0.003). They also received a lower amount of intraoperative crystalloids, had fewer blood losses, and lower intraoperative peak lactate. In the postoperative period, patients in the GDFT group had fewer pulmonary complications and blood losses from surgical drains, needed less blood product transfusions, had a shorter intensive care unit stay, and a faster return of bowel function. We found no difference in the total length of stay among the two groups. Our study shows that application of a GDFT based on SVV in major spine surgery is feasible and can lead to reduced blood losses and transfusions, better postoperative respiratory performance, shorter ICU stay, and faster return of bowel function. 3.

Does the Type of Metal Instrumentation Affect the Risk of Surgical Site Infection in Pediatric Scoliosis Surgery?

PubMed

Wright, Margaret L; Skaggs, David L; Matsumoto, Hiroko; Woon, Regina P; Trocle, Ashley; Flynn, John M; Vitale, Michael G

2016-05-01

Retrospective cohort study. To determine the association of implant metal composition with the risk of surgical site infection (SSI) following pediatric spine surgery. SSI is a well-described complication following pediatric spine surgery. Many risk factors have been identified in the literature, but controversy remains regarding metal composition as a risk factor. This was a retrospective study of patients who underwent posterior spinal instrumentation procedures between January 1, 2006, and December 31, 2008, at three large children's hospitals for any etiology of scoliosis and had at least 1 year of postoperative follow-up. Procedures included posterior spinal fusion, growth-friendly instrumentation, and revision of spinal instrumentation. The Centers for Disease Control and Prevention definition of SSI was used. A chi-squared test was performed to determine the relationship between type of metal instrumentation and development of an SSI. The study included 874 patients who underwent 1,156 total procedures. Overall, 752 (65%) procedures used stainless steel instrumentation, 238 (21%) procedures used titanium instrumentation, and the remaining 166 (14%) procedures used cobalt chrome and titanium hybrid instrumentation. The overall risk of infection was 6.1% (70/1,156) per procedure, with 5.9% (44/752) for stainless steel, 6.7% (12/238) for titanium, and 6.0% (10/166) for cobalt chrome. The multiple regression analysis found no significant differences in the metal type used between patients with and without infection (p = .886) adjusting for etiology, instrumentation to pelvis, and type of procedures. When stratified based on etiology, the multiple regression analyses also found no significant difference in SSI between two metal type groups. This study found no difference in risk of infection with stainless steel, titanium, or cobalt chrome/titanium instrumentation and is adequately powered to detect a true difference in risk of SSI. Level II, prognostic. Copyright © 2016 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.

Advantages and disadvantages of nonfusion technology in spine surgery.

PubMed

Huang, Russel C; Girardi, Federico P; Lim, Moe R; Cammisa, Frank P

2005-07-01

Nonfusion technology in spine surgery may improve outcomes by reducing surgical morbidity and the incidence of adjacent level degeneration; however, new technologies also introduce new short- and long-term complications. There is currently no evidence that nonfusion implants are superior to fusion in mid- to long-term follow-up. Understanding the potential risks and benefits of nonfusion technology is essential for spine surgeons and their patients. This article reviews the current evidence relating to the potential risks and benefits of nonfusion technology in spine surgery.

The top 100 classic papers in lumbar spine surgery.

PubMed

Steinberger, Jeremy; Skovrlj, Branko; Caridi, John M; Cho, Samuel K

2015-05-15

Bibliometric review of the literature. To analyze and quantify the most frequently cited papers in lumbar spine surgery and to measure their impact on the entire lumbar spine literature. Lumbar spine surgery is a dynamic and complex field. Basic science and clinical research remain paramount in understanding and advancing the field. While new literature is published at increasing rates, few studies make long-lasting impacts. The Thomson Reuters Web of Knowledge was searched for citations of all papers relevant to lumbar spine surgery. The number of citations, authorship, year of publication, journal of publication, country of publication, and institution were recorded for each paper. The most cited paper was found to be the classic paper from 1990 by Boden et al that described magnetic resonance imaging findings in individuals without back pain, sciatica, and neurogenic claudication showing that spinal stenosis and herniated discs can be incidentally found when scanning patients. The second most cited study similarly showed that asymptomatic patients who underwent lumbar spine magnetic resonance imaging frequently had lumbar pathology. The third most cited paper was the 2000 publication of Fairbank and Pynsent reviewing the Oswestry Disability Index, the outcome-measure questionnaire most commonly used to evaluate low back pain. The majority of the papers originate in the United States (n=58), and most were published in Spine (n=63). Most papers were published in the 1990s (n=49), and the 3 most common topics were low back pain, biomechanics, and disc degeneration. This report identifies the top 100 papers in lumbar spine surgery and acknowledges those individuals who have contributed the most to the advancement of the study of the lumbar spine and the body of knowledge used to guide evidence-based clinical decision making in lumbar spine surgery today. 3.

Impact of the 2006 Massachusetts health care insurance reform on neurosurgical procedures and patient insurance status.

PubMed

Villelli, Nicolas W; Das, Rohit; Yan, Hong; Huff, Wei; Zou, Jian; Barbaro, Nicholas M

2017-01-01

OBJECTIVE The Massachusetts health care insurance reform law passed in 2006 has many similarities to the federal Affordable Care Act (ACA). To address concerns that the ACA might negatively impact case volume and reimbursement for physicians, the authors analyzed trends in the number of neurosurgical procedures by type and patient insurance status in Massachusetts before and after the implementation of the state's health care insurance reform. The results can provide insight into the future of neurosurgery in the American health care system. METHODS The authors analyzed data from the Massachusetts State Inpatient Database on patients who underwent neurosurgical procedures in Massachusetts from 2001 through 2012. These data included patients' insurance status (insured or uninsured) and the numbers of procedures performed classified by neurosurgical procedural codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Each neurosurgical procedure was grouped into 1 of 4 categories based on ICD-9-CM codes: 1) tumor, 2) other cranial/vascular, 3) shunts, and 4) spine. Comparisons were performed of the numbers of procedures performed and uninsured patients, before and after the implementation of the reform law. Data from the state of New York were used as a control. All data were controlled for population differences. RESULTS After 2008, there were declines in the numbers of uninsured patients who underwent neurosurgical procedures in Massachusetts in all 4 categories. The number of procedures performed for tumor and spine were unchanged, whereas other cranial/vascular procedures increased. Shunt procedures decreased after implementation of the reform law but exhibited a similar trend to the control group. In New York, the number of spine surgeries increased, as did the percentage of procedures performed on uninsured patients. Other cranial/vascular procedures decreased. CONCLUSIONS After the Massachusetts health care insurance reform, the number of uninsured individuals undergoing neurosurgical procedures significantly decreased for all categories, but more importantly, the total number of surgeries performed did not change dramatically. To the extent that trends in Massachusetts can predict the overall US experience, we can expect that some aspects of reimbursement may be positively impacted by the ACA. Neurosurgeons, who often treat patients with urgent conditions, may be affected differently than other specialists.

Anterior debridement may not be necessary in the treatment of tuberculous spondylitis of the thoracic and lumbar spine in adults: a retrospective study.

PubMed

Wang, S-T; Ma, H-L; Lin, C-P; Chou, P-H; Liu, C-L; Yu, W-K; Chang, M-C

2016-06-01

Many aspects of the surgical treatment of patients with tuberculosis (TB) of the spine, including the use of instrumentation and the types of graft, remain controversial. Our aim was to report the outcome of a single-stage posterior procedure, with or without posterior decompression, in this group of patients. Between 2001 and 2010, 51 patients with a mean age of 62.5 years (39 to 86) underwent long posterior instrumentation and short posterior or posterolateral fusion for TB of the thoracic and lumbar spines, followed by anti-TB chemotherapy for 12 months. No anterior debridement of the necrotic tissue was undertaken. Posterior decompression with laminectomy was carried out for the 30 patients with a neurological deficit. The mean kyphotic angle improved from 26.1° (- 1.8° to 62°) to 15.2° (-25° to 51°) immediately after the operation. At a mean follow-up of 68.8 months (30 to 144) the mean kyphotic angle was 16.9° (-22° to 54°), with a mean loss of correction of 1.6° (0° to 10°). There was a mean improvement in neurological status of 1.2 Frankel grades in those with a neurological deficit. Bony union was achieved in all patients, without recurrent infection. Long posterior instrumentation with short posterior or posterolateral fusion is effective in the treatment of TB spine. It controls infection, corrects the kyphosis, and maintains correction and neurological improvement over time. With effective anti-TB chemotherapy, a posterior only procedure without debridement of anterior lesion is effective in the treatment of TB spondylitis, and an anterior procedure can be reserved for those patients who have not improved after posterior surgery. Cite this article: Bone Joint J 2016;98-B:834-9. ©2016 The British Editorial Society of Bone & Joint Surgery.

Cost analysis of incidental durotomy in spine surgery.

PubMed

Nandyala, Sreeharsha V; Elboghdady, Islam M; Marquez-Lara, Alejandro; Noureldin, Mohamed N B; Sankaranarayanan, Sriram; Singh, Kern

2014-08-01

Retrospective database analysis. To characterize the consequences of an incidental durotomy with regard to perioperative complications and total hospital costs. There is a paucity of data regarding how an incidental durotomy and its associated complications may relate to total hospital costs. The Nationwide Inpatient Sample database was queried from 2008 to 2011. Patients who underwent cervical or lumbar decompression and/or fusion procedures were identified, stratified by approach, and separated into cohorts based on a documented intraoperative incidental durotomy. Patient demographics, comorbidities (Charlson Comorbidity Index), length of hospital stay, perioperative outcomes, and costs were assessed. Analysis of covariance and multivariate linear regression were used to assess the adjusted mean costs of hospitalization as a function of durotomy. The incidental durotomy rate in cervical and lumbar spine surgery is 0.4% and 2.9%, respectively. Patients with an incidental durotomy incurred a longer hospitalization and a greater incidence of perioperative complications including hematoma and neurological injury (P < 0.001). Regression analysis demonstrated that a cervical durotomy and its postoperative sequelae contributed an additional adjusted $7638 (95% confidence interval, 6489-8787; P < 0.001) to the total hospital costs. Similarly, lumbar durotomy contributed an additional adjusted $2412 (95% confidence interval, 1920-2902; P < 0.001) to the total hospital costs. The approach-specific procedural groups demonstrated similar discrepancies in the mean total hospital costs as a function of durotomy. This analysis of the Nationwide Inpatient Sample database demonstrates that incidental durotomies increase hospital resource utilization and costs. In addition, it seems that a cervical durotomy and its associated complications carry a greater financial burden than a lumbar durotomy. Further studies are warranted to investigate the long-term financial implications of incidental durotomies in spine surgery and to reduce the costs associated with this complication. 3.

More nerve root injuries occur with minimally invasive lumbar surgery, especially extreme lateral interbody fusion: A review

PubMed Central

Epstein, Nancy E.

2016-01-01

Background: In the lumbar spine, do more nerve root injuries occur utilizing minimally invasive surgery (MIS) techniques versus open lumbar procedures? To answer this question, we compared the frequency of nerve root injuries for multiple open versus MIS operations including diskectomy, laminectomy with/without fusion addressing degenerative disc disease, stenosis, and/or degenerative spondylolisthesis. Methods: Several of Desai et al. large Spine Patient Outcomes Research Trial studies showed the frequency for nerve root injury following an open diskectomy ranged from 0.13% to 0.25%, for open laminectomy/stenosis with/without fusion it was 0%, and for open laminectomy/stenosis/degenerative spondylolisthesis with/without fusion it was 2%. Results: Alternatively, one study compared the incidence of root injuries utilizing MIS transforaminal lumbar interbody fusion (TLIF) versus posterior lumbar interbody fusion (PLIF) techniques; 7.8% of PLIF versus 2% of TLIF patients sustained root injuries. Furthermore, even higher frequencies of radiculitis and nerve root injuries occurred during anterior lumbar interbody fusions (ALIFs) versus extreme lateral interbody fusions (XLIFs). These high frequencies were far from acceptable; 15.8% following ALIF experienced postoperative radiculitis, while 23.8% undergoing XLIF sustained root/plexus deficits. Conclusions: This review indicates that MIS (TLIF/PLIF/ALIF/XLIF) lumbar surgery resulted in a higher incidence of root injuries, radiculitis, or plexopathy versus open lumbar surgical techniques. Furthermore, even a cursory look at the XLIF data demonstrated the greater danger posed to neural tissue by this newest addition to the MIS lumbar surgical armamentariu. The latter should prompt us as spine surgeons to question why the XLIF procedure is still being offered to our patients? PMID:26904372

Red Blood Cell Transfusion Need for Elective Primary Posterior Lumbar Fusion in A High-Volume Center for Spine Surgery

PubMed Central

Ristagno, Giuseppe; Beluffi, Simonetta; Tanzi, Dario; Belloli, Federica; Carmagnini, Paola; Croci, Massimo; D’Aviri, Giuseppe; Menasce, Guido; Pastore, Juan C.; Pellanda, Armando; Pollini, Alberto; Savoia, Giorgio

2018-01-01

(1) Background: This study evaluated the perioperative red blood cell (RBC) transfusion need and determined predictors for transfusion in patients undergoing elective primary lumbar posterior spine fusion in a high-volume center for spine surgery. (2) Methods: Data from all patients undergoing spine surgery between 1 January 2014 and 31 December 2016 were reviewed. Patients’ demographics and comorbidities, perioperative laboratory results, and operative time were analyzed in relation to RBC transfusion. Multivariate logistic regression analysis was performed to identify the predictors of transfusion. (3) Results: A total of 874 elective surgeries for primary spine fusion were performed over the three years. Only 54 cases (6%) required RBC transfusion. Compared to the non-transfused patients, transfused patients were mainly female (p = 0.0008), significantly older, with a higher ASA grade (p = 0.0002), and with lower pre-surgery hemoglobin (HB) level and hematocrit (p < 0.0001). In the multivariate logistic regression, a lower pre-surgery HB (OR (95% CI) 2.84 (2.11–3.82)), a higher ASA class (1.77 (1.03–3.05)) and a longer operative time (1.02 (1.01–1.02)) were independently associated with RBC transfusion. (4) Conclusions: In the instance of elective surgery for primary posterior lumbar fusion in a high-volume center for spine surgery, the need for RBC transfusion is low. Factors anticipating transfusion should be taken into consideration in the patient’s pre-surgery preparation. PMID:29385760

Early Predictors of Lumbar Spine Surgery after Occupational Back Injury: Results from a Prospective Study of Workers in Washington State

PubMed Central

Keeney, Benjamin J.; Fulton-Kehoe, Deborah; Turner, Judith A.; Wickizer, Thomas M.; Chan, Kwun Chuen Gary; Franklin, Gary M.

2014-01-01

Study Design Prospective population-based cohort study Objective To identify early predictors of lumbar spine surgery within 3 years after occupational back injury Summary of Background Data Back injuries are the most prevalent occupational injury in the United States. Little is known about predictors of lumbar spine surgery following occupational back injury. Methods Using Disability Risk Identification Study Cohort (D-RISC) data, we examined the early predictors of lumbar spine surgery within 3 years among Washington State workers with new worker’s compensation temporary total disability claims for back injuries. Baseline measures included worker-reported measures obtained approximately 3 weeks after claim submission. We used medical bill data to determine whether participants underwent surgery, covered by the claim, within 3 years. Baseline predictors (P < 0.10) of surgery in bivariate analyses were included in a multivariate logistic regression model predicting lumbar spine surgery. The model’s area under the receiver operating characteristic curve (AUC) was used to determine the model’s ability to identify correctly workers who underwent surgery. Results In the D-RISC sample of 1,885 workers, 174 (9.2%) had a lumbar spine surgery within 3 years. Baseline variables associated with surgery (P < 0.05) in the multivariate model included higher Roland Disability Questionnaire scores, greater injury severity, and surgeon as first provider seen for the injury. Reduced odds of surgery were observed for those under age 35, women, Hispanics, and those whose first provider was a chiropractor. 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. The multivariate model’s AUC was 0.93 (95% CI 0.92–0.95), indicating excellent ability to discriminate between workers who would versus would not have surgery. Conclusion Baseline variables in multiple domains predicted lumbar spine surgery. There was a very strong association between surgery and first provider seen for the injury, even after adjustment for other important variables. PMID:23238486

Early predictors of lumbar spine surgery after occupational back injury: results from a prospective study of workers in Washington State.

PubMed

Keeney, Benjamin J; Fulton-Kehoe, Deborah; Turner, Judith A; Wickizer, Thomas M; Chan, Kwun Chuen Gary; Franklin, Gary M

2013-05-15

Prospective population-based cohort study. To identify early predictors of lumbar spine surgery within 3 years after occupational back injury. Back injuries are the most prevalent occupational injury in the United States. Few prospective studies have examined early predictors of spine surgery after work-related back injury. Using Disability Risk Identification Study Cohort (D-RISC) data, we examined the early predictors of lumbar spine surgery within 3 years among Washington State workers, with new workers compensation temporary total disability claims for back injuries. Baseline measures included worker-reported measures obtained approximately 3 weeks after claim submission. We used medical bill data to determine whether participants underwent surgery, covered by the claim, within 3 years. Baseline predictors (P < 0.10) of surgery in bivariate analyses were included in a multivariate logistic regression model predicting lumbar spine surgery. The area under the receiver operating characteristic curve of the model was used to determine the model's ability to identify correctly workers who underwent surgery. In the D-RISC sample of 1885 workers, 174 (9.2%) had a lumbar spine surgery within 3 years. Baseline variables associated with surgery (P < 0.05) in the multivariate model included higher Roland-Morris Disability Questionnaire scores, greater injury severity, and surgeon as first provider seen for the injury. Reduced odds of surgery were observed for those younger than 35 years, females, Hispanics, and those whose first provider was a chiropractor. Approximately 42.7% of workers who first saw a surgeon had surgery, in contrast to only 1.5% of those who saw a chiropractor. The area under the receiver operating characteristic curve of the multivariate model was 0.93 (95% confidence interval, 0.92-0.95), indicating excellent ability to discriminate between workers who would versus would not have surgery. Baseline variables in multiple domains predicted lumbar spine surgery. There was a very strong association between surgery and first provider seen for the injury even after adjustment for other important variables.

Outcomes of Corpectomy in Patients with Metastatic Cancer.

PubMed

Guzik, Grzegorz

2017-01-26

The objective of surgical management of spinal metastases is to reduce pain and improve the patient's quality of life. The operation should restore spinal stability and decompress neural structures. One surgical technique is corpectomy followed by vertebral body reconstruction and stabilisation of the spine. The procedure may be performed in patients in overall good health and a good survival prognosis. The aim of this paper is to present the outcomes of surgical management of spinal metastases in patients who underwent corpectomy followed by vertebral body reconstruction and stabilisation of the spine. The aim of the study was achieved by analysing medical histories of 124 patients with spinal metastases treated in the Oncological Orthopaedics Department in Brzozów in the period 2010-2015. The majority of patients in the group were women, who represented 64% of all the subjects. The average age was 63 years for women and 67 for men. The metastases were most frequently produced by breast cancer (36%) and myeloma (22%). A total of 87% of the group were diagnosed with pathologic fractures and 92% had spinal instability. Stenosis of the spinal canal was found in 78% of the patients. The surgeries were performed in 18 persons with metastases to the cervical spine, 69 patients with metastases to the thoracic spine and 37 participants with metastases to the lumbar spine. Single-level corpectomies were performed in 83 patients and multilevel corpectomies in 41 persons. Parameters analysed comprised overall health condition, neurological function (the Frankel Grade) and performance status (the Karnofsky score) of the patients. A VAS was used to assess the intensity of pain. The course of the operation and complications were also analysed. Following the surgeries, the average VAS pain score decreased from 7.2 to 3.8. Performance improved from a Karnofsky score of 50.26 to 68.65. Neurological function improved in 21 out of 34 patients with pareses. The average duration of the surgery was 67 minutes for the cervical spine, 123 minutes for the thoracic spine and 112 minutes for the lumbar spine. The loss of blood was strongest for lumbar spine surgeries, amounting on average to 580 ml. 62% of patients required transfusion ofblood substitutes after the operation. The average hospitalisation time was 14 days, with a minimum and maximum duration of 7 and 24 days, respectively. The most common complication was damage to the endplate of the vertebra adjacent to the prosthesis (11%). Two patients developed complete and irreversible paralysis of lower limbs. 1. Corpectomy followed by vertebral body reconstruction should be used in patients with a good prognosis. 2. Therapeutic outcomes are good. The surgery produced a considerable reduction in pain and improvement in performance in the majority of patients. 3. Complications are not frequent. The most common complication is intrusion of the implant into the endplate of the adjacent vertebrae. 4. A high survival rate at one year after the surgery, exceeding 90% of the patients, is evidence of effectiveness of the treatment and appropriate qualification of patients for the operation.

Postoperative occipital neuralgia in posterior upper cervical spine surgery: a systematic review.

PubMed

Guan, Qing; Xing, Fei; Long, Ye; Xiang, Zhou

2017-11-07

Postoperative occipital neuralgia (PON) after upper cervical spine surgery can cause significant morbidity and may be overlooked. The causes, presentation, diagnosis, management, prognosis, and prevention of PON were reviewed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. English-language studies and case reports published from inception to 2017 were retrieved. Data on surgical procedures, incidence, cause of PON, management, outcomes, and preventive technique were extracted. Sixteen articles, including 591 patients, were selected; 93% of the patients with PON underwent C1 lateral mass screw (C1LMS) fixation, with additional 7% who underwent occipitocervical fusion without C1 fixation. PON had an incidence that ranged from 1 to 35% and was transient in 34%, but persistent in 66%. Five articles explained the possible causes. The primary presentation was constant or paroxysmal burning pain located mainly in the occipital and upper neck area and partially extending to the vertical, retroauricular, retromandibular, and forehead zone. Treatment included medications, nerve block, revision surgery, and nerve stimulation. Two prospective studies compared the effect of C2 nerve root transection on PON. PON in upper cervical spine surgery is a debilitating complication and was most commonly encountered by patients undergoing C1LMS fixation. The etiology of PON is partially clear, and the pain could be persistent and hard to cure. Reducing the incidence of PON can be realized by improving technique. More high-quality prospective studies are needed to define the effect of C2 nerve root transection on PON.

Does Minimally Invasive Spine Surgery Minimize Surgical Site Infections?

PubMed

Kulkarni, Arvind Gopalrao; Patel, Ravish Shammi; Dutta, Shumayou

2016-12-01

Retrospective review of prospectively collected data. To evaluate the incidence of surgical site infections (SSIs) in minimally invasive spine surgery (MISS) in a cohort of patients and compare with available historical data on SSI in open spinal surgery cohorts, and to evaluate additional direct costs incurred due to SSI. SSI can lead to prolonged antibiotic therapy, extended hospitalization, repeated operations, and implant removal. Small incisions and minimal dissection intrinsic to MISS may minimize the risk of postoperative infections. However, there is a dearth of literature on infections after MISS and their additional direct financial implications. All patients from January 2007 to January 2015 undergoing posterior spinal surgery with tubular retractor system and microscope in our institution were included. The procedures performed included tubular discectomies, tubular decompressions for spinal stenosis and minimal invasive transforaminal lumbar interbody fusion (TLIF). The incidence of postoperative SSI was calculated and compared to the range of cited SSI rates from published studies. Direct costs were calculated from medical billing for index cases and for patients with SSI. A total of 1,043 patients underwent 763 noninstrumented surgeries (discectomies, decompressions) and 280 instrumented (TLIF) procedures. The mean age was 52.2 years with male:female ratio of 1.08:1. Three infections were encountered with fusion surgeries (mean detection time, 7 days). All three required wound wash and debridement with one patient requiring unilateral implant removal. Additional direct cost due to infection was $2,678 per 100 MISS-TLIF. SSI increased hospital expenditure per patient 1.5-fold after instrumented MISS. Overall infection rate after MISS was 0.29%, with SSI rate of 0% in non-instrumented MISS and 1.07% with instrumented MISS. MISS can markedly reduce the SSI rate and can be an effective tool to minimize hospital costs.

Philosophy and concepts of modern spine surgery.

PubMed

José-Antonio, Soriano-Sánchez; Baabor-Aqueveque, Marcos; Silva-Morales, Francisco

2011-01-01

The main goal of improving pain and neurological deficit in the practice of spine surgery is changing for a more ambitious goal, namely to improve the overall quality of life and the future of patients through three major actions (1) preserving the vertebral anatomical structures; (2) preserving the paravertebral anatomical structures; and (3) preserving the functionality of the segment. Thus, three new concepts have emerged (a) minimal surgery; (b) minimal access surgery; and (c) motion preservation surgery. These concepts are covered in a new term, minimally invasive spine surgery (MISS) The term "MISS" is not about one or several particular surgical techniques, but a new way of thinking, a new philosophy. Although the development of minimally invasive spine surgery is recent, its application includes all spine segments and almost all the existing conditions, including deformities.Evidence-based medicine (EBM), a term coined by Alvan Feinstein in the 1960s (Feinstein A (1964) Annals of Internal Medicine 61: 564-579; Feinstein A (1964) Annals of Internal Medicine 61: 757-781; Feinstein A (1964) Annals of Internal Medicine 61: 944-965; Feinstein A (1964) Annals of Internal Medicine 61: 1162-1193.), emphasizes the possibility of combining art and science following the strict application of scientific methods in the treatment of patients (Feinstein A (1964) Annals of Internal Medicine 61: 944-965; Feinstein A (1964) Annals of Internal Medicine 61: 1162-1193.), which may represent the advantages of objectivity and rationality in the use of different treatments (Fig. 11). However, EBM has many obvious defects, especially in spine surgery it is almost impossible to develop double-blind protocols (Andersson G, Bridwell K, Danielsson A, et al (2007) Spine 32: S64-S65.). In most cases, the only evidence one can find in the literature is the lack of evidence (Resnick D (2007) Spine 32:S15-S19.), however, the lack of evidence does not mean its absence. Only then, with a rigorous self-analysis, we may take a clear path towards a new philosophy in spine surgery. Of course, feedback from patients through satisfaction and clinical scales can guide our direction and provide the energy needed to maintain the enthusiasm (Fig. 12).

Surgical Site Infections in Pediatric Spine Surgery: Comparative Microbiology of Patients with Idiopathic and Nonidiopathic Etiologies of Spine Deformity.

PubMed

Maesani, Matthieu; Doit, Catherine; Lorrot, Mathie; Vitoux, Christine; Hilly, Julie; Michelet, Daphné; Vidal, Christophe; Julien-Marsollier, Florence; Ilharreborde, Brice; Mazda, Keyvan; Bonacorsi, Stéphane; Dahmani, Souhayl

2016-01-01

Surgical site infections (SSIs) are a concern in pediatric spine surgery with unusually high rates for a clean surgery and especially for patients with deformity of nonidiopathic etiology. Microbiologic differences between etiologies of spine deformities have been poorly investigated. We reviewed all cases of SSI in spinal surgery between 2007 and 2011. Characteristics of cases and of bacteria according to the etiology of the spine disease were investigated. Of 496 surgeries, we identified 51 SSIs (10.3%) in 49 patients. Staphylococcus aureus was the most frequent pathogen whatever the etiology (n = 31, 61% of infection cases). The second most frequent pathogens vary according to the etiology of the spine deformity. It was Gram-negative bacilli (GNB) in nonidiopathic cases (n = 19, 45% of cases) and anaerobe in idiopathic cases (n = 8, 38% of cases), particularly Gram-positive anaerobic cocci (n = 5, 24% of cases). Infection rate was 6.8% in cases with idiopathic spine disease (n = 21) and 15.9% in cases with nonidiopathic spine disease (n = 30). Nonidiopathic cases were more frequently male with lower weight. American Society of Anesthesiologists score was more often greater than 2, they had more frequently sacral implants and postoperative intensive care unit stay. GNB were significantly associated with a nonidiopathic etiology, low weight, younger age and sacral fusion. SSIs were polymicrobial in 31% of cases with a mean of 1.4 species per infection cases. S. aureus is the first cause of SSI in pediatric spine surgery. However, Gram-positive anaerobic cocci should be taken into account in idiopathic patients and GNB in nonidiopathic patients when considering antibiotic prophylaxis and curative treatment.

Predicting surgical site infection after spine surgery: a validated model using a prospective surgical registry.

PubMed

Lee, Michael J; Cizik, Amy M; Hamilton, Deven; Chapman, Jens R

2014-09-01

The impact of surgical site infection (SSI) is substantial. Although previous study has determined relative risk and odds ratio (OR) values to quantify risk factors, these values may be difficult to translate to the patient during counseling of surgical options. Ideally, a model that predicts absolute risk of SSI, rather than relative risk or OR values, would greatly enhance the discussion of safety of spine surgery. To date, there is no risk stratification model that specifically predicts the risk of medical complication. The purpose of this study was to create and validate a predictive model for the risk of SSI after spine surgery. This study performs a multivariate analysis of SSI after spine surgery using a large prospective surgical registry. Using the results of this analysis, this study will then create and validate a predictive model for SSI after spine surgery. The patient sample is from a high-quality surgical registry from our two institutions with prospectively collected, detailed demographic, comorbidity, and complication data. An SSI that required return to the operating room for surgical debridement. Using a prospectively collected surgical registry of more than 1,532 patients with extensive demographic, comorbidity, surgical, and complication details recorded for 2 years after the surgery, we identified several risk factors for SSI after multivariate analysis. Using the beta coefficients from those regression analyses, we created a model to predict the occurrence of SSI after spine surgery. We split our data into two subsets for internal and cross-validation of our model. We created a predictive model based on our beta coefficients from our multivariate analysis. The final predictive model for SSI had a receiver-operator curve characteristic of 0.72, considered to be a fair measure. The final model has been uploaded for use on SpineSage.com. We present a validated model for predicting SSI after spine surgery. The value in this model is that it gives the user an absolute percent likelihood of SSI after spine surgery based on the patient's comorbidity profile and invasiveness of surgery. Patients are far more likely to understand an absolute percentage, rather than relative risk and confidence interval values. A model such as this is of paramount importance in counseling patients and enhancing the safety of spine surgery. In addition, a tool such as this can be of great use particularly as health care trends toward pay for performance, quality metrics (such as SSI), and risk adjustment. To facilitate the use of this model, we have created a Web site (SpineSage.com) where users can enter patient data to determine likelihood for SSI. Copyright © 2014 Elsevier Inc. All rights reserved.

Predicting medical complications after spine surgery: a validated model using a prospective surgical registry.

PubMed

Lee, Michael J; Cizik, Amy M; Hamilton, Deven; Chapman, Jens R

2014-02-01

The possibility and likelihood of a postoperative medical complication after spine surgery undoubtedly play a major role in the decision making of the surgeon and patient alike. Although prior study has determined relative risk and odds ratio values to quantify risk factors, these values may be difficult to translate to the patient during counseling of surgical options. Ideally, a model that predicts absolute risk of medical complication, rather than relative risk or odds ratio values, would greatly enhance the discussion of safety of spine surgery. To date, there is no risk stratification model that specifically predicts the risk of medical complication. The purpose of this study was to create and validate a predictive model for the risk of medical complication during and after spine surgery. Statistical analysis using a prospective surgical spine registry that recorded extensive demographic, surgical, and complication data. Outcomes examined are medical complications that were specifically defined a priori. This analysis is a continuation of statistical analysis of our previously published report. Using a prospectively collected surgical registry of more than 1,476 patients with extensive demographic, comorbidity, surgical, and complication detail recorded for 2 years after surgery, we previously identified several risk factor for medical complications. Using the beta coefficients from those log binomial regression analyses, we created a model to predict the occurrence of medical complication after spine surgery. We split our data into two subsets for internal and cross-validation of our model. We created two predictive models: one predicting the occurrence of any medical complication and the other predicting the occurrence of a major medical complication. The final predictive model for any medical complications had a receiver operator curve characteristic of 0.76, considered to be a fair measure. The final predictive model for any major medical complications had receiver operator curve characteristic of 0.81, considered to be a good measure. The final model has been uploaded for use on SpineSage.com. We present a validated model for predicting medical complications after spine surgery. The value in this model is that it gives the user an absolute percent likelihood of complication after spine surgery based on the patient's comorbidity profile and invasiveness of surgery. Patients are far more likely to understand an absolute percentage, rather than relative risk and confidence interval values. A model such as this is of paramount importance in counseling patients and enhancing the safety of spine surgery. In addition, a tool such as this can be of great use particularly as health care trends toward pay-for-performance, quality metrics, and risk adjustment. To facilitate the use of this model, we have created a website (SpineSage.com) where users can enter in patient data to determine likelihood of medical complications after spine surgery. Copyright © 2014 Elsevier Inc. All rights reserved.

Bony ankylosis of the facet joint of the cervical spine in rheumatoid arthritis: Its characteristics and relationship to the clinical findings.

PubMed

Iizuka, Haku; Iizuka, Yoichi; Okamura, Koichi; Yonemoto, Yukio; Mieda, Tokue; Takagishi, Kenji

2017-09-01

The purpose of this study was to clarify the characteristics of bony ankylosis of the facet joint of the cervical spine in rheumatoid arthritis (RA) patients who required cervical spine surgery, and its relationship to the clinical findings. Eighty consecutive RA patients with cervical spine disorder who received initial surgery were reviewed. The occurrence of bony ankylosis of the facet joint of the cervical spine was investigated using computed tomography (CT) before surgery. We also evaluated the severity of neurological symptoms and the plain wrist radiographs taken before surgery; furthermore, we evaluated each patient's medical history for total knee arthroplasty (TKA) or hip arthroplasty (THA). The preoperative CT imaging demonstrated bony ankylosis of the facet joint of the cervical spine in 45 facet levels of 19 cases (BA + group). In all patients, responsible instability or stenosis was demonstrated just caudal or on the cranial side of those bony ankylosis. Before surgery, the BA + group included significantly more patients showing severe cervical myelopathy (p < 0.05), and significantly more cases showing progressed ankylosis in the wrist joint bilaterally (p < 0.01). There were also significantly more patients who received two or more TKA or THA before the cervical spine surgery in the BA + group (p < 0.01). Bony ankylosis of the facet joint of the cervical spine may be a risk factor of instability or stenosis at the adjacent disc level and severe cervical myelopathy. Furthermore, its ankylosis was demonstrated in RA patients with severe destroyed joints.

Risk Factors and Independent Predictors of 30-Day Readmission for Altered Mental Status After Elective Spine Surgery for Spine Deformity: A Single-Institutional Study of 1090 Patients.

PubMed

Elsamadicy, Aladine A; Adogwa, Owoicho; Reddy, Gireesh B; Sergesketter, Amanda; Warwick, Hunter; Jones, Terrell; Cheng, Joseph; Bagley, Carlos A; Karikari, Isaac O

2017-05-01

Altered mental status (AMS) has been associated with inferior surgical outcomes. The factors leading to AMS after spine surgery are unknown. The aim of this study is to determine the risk factors and independent predictors of 30-day readmission for AMS in patients with spine deformity after undergoing elective spine surgery. The medical records of 1090 adult (≥18 years old) patients with spine deformity undergoing elective spine surgery at a major academic institution from 2005 to 2015 were reviewed. We identified 18 patients (1.65%) who had AMS as the primary driver for 30-day readmission after surgery. Patient demographics, comorbidities, and intraoperative and postoperative complication rates were collected for each patient. The primary outcome investigated in this study was risk factors associated with 30-day readmission for AMS. Patient demographics and comorbidities were similar between both groups, with the AMS cohort being significantly older than the no-AMS cohort (70.11 vs. 61.93; P = 0.003). There were no significant differences in intraoperative variables and complication rates within the cohorts. The AMS cohort had a significantly higher proportion of patients transferred to the intensive care unit (AMS, 61.11% vs. no-AMS, 19.76%; P = 0.0002) and rate of pulmonary embolism (AMS, 11.11 vs. no-AMS, 0.93; P = 0.02) after surgery. Other postoperative complication rates were similar between the cohorts. In a multivariate stepwise regression analysis, age (P = 0.013) and ICU transfer (P = 0.0002) were independent predictors of 30-day readmission for AMS. Our study suggests that increasing age and intensice care unit transfer are independent predictors of 30-day readmission for AMS after spine surgery in patients with spine deformity. Copyright © 2017 Elsevier Inc. All rights reserved.

Swespine: the Swedish spine register : the 2012 report.

PubMed

Strömqvist, Björn; Fritzell, Peter; Hägg, Olle; Jönsson, Bo; Sandén, Bengt

2013-04-01

Swespine, the Swedish National Spine Register, has existed for 20 years and is in general use within the country since over 10 years regarding degenerative lumbar spine disorders. Today there are protocols for registering all disorders of the entire spinal column. Patient-based pre- and postoperative questionnaires, completed before surgery and at 1, 2, 5 and 10 years postoperatively. Among patient-based data are VAS pain, ODI, SF-36 and EQ-5D. Postoperatively evaluation of leg and back pain as compared to preoperatively ("global assessment"), overall satisfaction with outcome and working conditions are registered in addition to the same parameters as preoperatively evaluation. A yearly report is produced including an analytic part of a certain topic, in this issue disc prosthesis surgery. More than 75,000 surgically treated patients are registered to date with an increasing number yearly. The present report includes 7,285 patients; 1-, 2- and 5-year follow-up data of previously operated patients are also included for lumbar disorders as well as for disc prosthesis surgery. For the degenerative lumbar spine disorders (disc herniation, spinal stenosis, spondylolisthesis and DDD) significant improvements are seen in all aspects as exemplified by pronounced improvement regarding EQ-5D and ODI. Results seem to be stable over time. Spinal stenosis is the most common indication for spine surgery. Disc prosthesis surgery yields results on a par with fusion surgery in disc degenerative pain. The utility of spine surgery is well documented by the results. Results of spine surgery as documented on a national basis can be utilized for quality assurance and quality improvement as well as for research purposes, documenting changes over time and bench marking when introducing new surgical techniques. A basis for international comparisons is also laid.

Use of a life-size three-dimensional-printed spine model for pedicle screw instrumentation training.

PubMed

Park, Hyun Jin; Wang, Chenyu; Choi, Kyung Ho; Kim, Hyong Nyun

2018-04-16

Training beginners of the pedicle screw instrumentation technique in the operating room is limited because of issues related to patient safety and surgical efficiency. Three-dimensional (3D) printing enables training or simulation surgery on a real-size replica of deformed spine, which is difficult to perform in the usual cadaver or surrogate plastic models. The purpose of this study was to evaluate the educational effect of using a real-size 3D-printed spine model for training beginners of the free-hand pedicle screw instrumentation technique. We asked whether the use of a 3D spine model can improve (1) screw instrumentation accuracy and (2) length of procedure. Twenty life-size 3D-printed lumbar spine models were made from 10 volunteers (two models for each volunteer). Two novice surgeons who had no experience of free-hand pedicle screw instrumentation technique were instructed by an experienced surgeon, and each surgeon inserted 10 pedicle screws for each lumbar spine model. Computed tomography scans of the spine models were obtained to evaluate screw instrumentation accuracy. The length of time in completing the procedure was recorded. The results of the latter 10 spine models were compared with those of the former 10 models to evaluate learning effect. A total of 37/200 screws (18.5%) perforated the pedicle cortex with a mean of 1.7 mm (range, 1.2-3.3 mm). However, the latter half of the models had significantly less violation than the former half (10/100 vs. 27/100, p < 0.001). The mean length of time to complete 10 pedicle screw instrumentations in a spine model was 42.8 ± 5.3 min for the former 10 spine models and 35.6 ± 2.9 min for the latter 10 spine models. The latter 10 spine models had significantly less time than the former 10 models (p < 0.001). A life-size 3D-printed spine model can be an excellent tool for training beginners of the free-hand pedicle screw instrumentation.

Management of sciatica due to lumbar disc herniation in the Netherlands: a survey among spine surgeons.

PubMed

Arts, Mark P; Peul, Wilco C; Koes, Bart W; Thomeer, Ralph T W M

2008-07-01

Although clinical guidelines for sciatica have been developed, various aspects of lumbar disc herniation remain unclear, and daily clinical practice may vary. The authors conducted a descriptive survey among spine surgeons in the Netherlands to obtain an overview of routine management of lumbar disc herniation. One hundred thirty-one spine surgeons were sent a questionnaire regarding various aspects of different surgical procedures. Eighty-six (70%) of the 122 who performed lumbar disc surgery provided usable questionnaires. Unilateral transflaval discectomy was the most frequently performed procedure and was expected to be the most effective, whereas percutaneous laser disc decompression was expected to be the least effective. Bilateral discectomy was expected to be associated with the most postoperative low-back pain. Recurrent disc herniation was expected to be lowest after bilateral discectomy and highest after percutaneous laser disc decompression. Complications were expected to be highest after bilateral discectomy and lowest after unilateral transflaval discectomy. Nearly half of the surgeons preferentially treated patients with 8-12 weeks of disabling leg pain. Some consensus was shown on acute surgery in patients with short-lasting drop foot and those with a cauda equina syndrome, and nonsurgical treatment in patients with long-lasting, painless drop foot. Most respondents allowed postoperative mobilization within 24 hours but advised their patients not to resume work until 8-12 weeks postoperatively. Unilateral transflaval discectomy was the most frequently performed procedure. Minimally invasive techniques were expected to be less effective, with higher recurrence rates but less postoperative low-back pain. Variety was shown between surgeons in the management of patients with neurological deficit. Most responding surgeons allowed early mobilization but appeared to give conservative advice in resumption of work.

Four-point bending as a method for quantitatively evaluating spinal arthrodesis in a rat model.

PubMed

Robinson, Samuel T; Svet, Mark T; Kanim, Linda A; Metzger, Melodie F

2015-02-01

The most common method of evaluating the success (or failure) of rat spinal fusion procedures is manual palpation testing. Whereas manual palpation provides only a subjective binary answer (fused or not fused) regarding the success of a fusion surgery, mechanical testing can provide more quantitative data by assessing variations in strength among treatment groups. We here describe a mechanical testing method to quantitatively assess single-level spinal fusion in a rat model, to improve on the binary and subjective nature of manual palpation as an end point for fusion-related studies. We tested explanted lumbar segments from Sprague-Dawley rat spines after single-level posterolateral fusion procedures at L4-L5. Segments were classified as 'not fused,' 'restricted motion,' or 'fused' by using manual palpation testing. After thorough dissection and potting of the spine, 4-point bending in flexion then was applied to the L4-L5 motion segment, and stiffness was measured as the slope of the moment-displacement curve. Results demonstrated statistically significant differences in stiffness among all groups, which were consistent with preliminary grading according to manual palpation. In addition, the 4-point bending results provided quantitative information regarding the quality of the bony union formed and therefore enabled the comparison of fused specimens. Our results demonstrate that 4-point bending is a simple, reliable, and effective way to describe and compare results among rat spines after fusion surgery.

Eliminating log rolling as a spine trauma order.

PubMed

Conrad, Bryan P; Rossi, Gianluca Del; Horodyski, Mary Beth; Prasarn, Mark L; Alemi, Yara; Rechtine, Glenn R

2012-01-01

Currently, up to 25% of patients with spinal cord injuries may experience neurologic deterioration during the initial management of their injuries. Therefore, more effective procedures need to be established for the transportation and care of these to reduce the risk of secondary neurologic damage. Here, we present more acceptable methods to minimize motion in the unstable spine during the management of patients with traumatic spine injuries. This review summarizes more than a decade of research aimed at evaluating different methods of caring for patients with spine trauma. The most commonly utilized technique to transport spinal cord injured patients, the log rolling maneuver, produced more motion than placing a patient on a spine board, removing a spine board, performing continuous lateral therapy, and positioning a patient prone for surgery. Alternative maneuvers that produced less motion included the straddle lift and slide, 6 + lift and slide, scoop stretcher, mechanical kinetic therapy, mechanical transfers, and the use of the operating table to rotate the patient to the prone position for surgical stabilization. The log roll maneuver should be removed from the trauma response guidelines for patients with suspected spine injuries, as it creates significantly more motion in the unstable spine than the readily available alternatives. The only exception is the patient who is found prone, in which case the patient should then be log rolled directly on to the spine board utilizing a push technique.

Ten-Step Minimally Invasive Spine Lumbar Decompression and Dural Repair Through Tubular Retractors.

PubMed

Boukebir, Mohamed Abdelatif; Berlin, Connor David; Navarro-Ramirez, Rodrigo; Heiland, Tim; Schöller, Karsten; Rawanduzy, Cameron; Kirnaz, Sertaç; Jada, Ajit; Härtl, Roger

2017-04-01

Minimally invasive spine (MIS) surgery utilizing tubular retractors has become an increasingly popular approach for decompression in the lumbar spine. However, a better understanding of appropriate indications, efficacious surgical techniques, limitations, and complication management is required to effectively teach the procedure and to facilitate the learning curve. To describe our experience and recommendations regarding tubular surgery for lumbar disc herniations, foraminal compression with unilateral radiculopathy, lumbar spinal stenosis, synovial cysts, and dural repair. We reviewed our experience between 2008 and 2014 to develop a step-by-step description of the surgical techniques and complication management, including dural repair through tubes, for the 4 lumbar pathologies of highest frequency. We provide additional supplementary videos for dural tear repair, laminotomy for bilateral decompression, and synovial cyst resection. Our overview and complementary materials document the key technical details to maximize the success of the 4 MIS surgical techniques. The review of our experience in 331 patients reveals technical feasibility as well as satisfying clinical results, with no postoperative complications associated with cerebrospinal fluid leaks, 1 infection, and 17 instances (5.1%) of delayed fusion. MIS surgery through tubular retractors is a safe and effective alternative to traditional open or microsurgical techniques for the treatment of lumbar degenerative disease. Adherence to strict microsurgical techniques will allow the surgeon to effectively address bilateral pathology while preserving stability and minimizing complications. Copyright © 2017 by the Congress of Neurological Surgeons

Work domain constraints for modelling surgical performance.

PubMed

Morineau, Thierry; Riffaud, Laurent; Morandi, Xavier; Villain, Jonathan; Jannin, Pierre

2015-10-01

Three main approaches can be identified for modelling surgical performance: a competency-based approach, a task-based approach, both largely explored in the literature, and a less known work domain-based approach. The work domain-based approach first describes the work domain properties that constrain the agent's actions and shape the performance. This paper presents a work domain-based approach for modelling performance during cervical spine surgery, based on the idea that anatomical structures delineate the surgical performance. This model was evaluated through an analysis of junior and senior surgeons' actions. Twenty-four cervical spine surgeries performed by two junior and two senior surgeons were recorded in real time by an expert surgeon. According to a work domain-based model describing an optimal progression through anatomical structures, the degree of adjustment of each surgical procedure to a statistical polynomial function was assessed. Each surgical procedure showed a significant suitability with the model and regression coefficient values around 0.9. However, the surgeries performed by senior surgeons fitted this model significantly better than those performed by junior surgeons. Analysis of the relative frequencies of actions on anatomical structures showed that some specific anatomical structures discriminate senior from junior performances. The work domain-based modelling approach can provide an overall statistical indicator of surgical performance, but in particular, it can highlight specific points of interest among anatomical structures that the surgeons dwelled on according to their level of expertise.

The Michigan Spine Surgery Improvement Collaborative: a statewide Collaborative Quality Initiative.

PubMed

Chang, Victor; Schwalb, Jason M; Nerenz, David R; Pietrantoni, Lisa; Jones, Sharon; Jankowski, Michelle; Oja-Tebbe, Nancy; Bartol, Stephen; Abdulhak, Muwaffak

2015-12-01

OBJECT Given the scrutiny of spine surgery by policy makers, spine surgeons are motivated to demonstrate and improve outcomes, by determining which patients will and will not benefit from surgery, and to reduce costs, often by reducing complications. Insurers are similarly motivated. In 2013, Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network (BCN) established the Michigan Spine Surgery Improvement Collaborative (MSSIC) as a Collaborative Quality Initiative (CQI). MSSIC is one of the newest of 21 other CQIs that have significantly improved-and continue to improve-the quality of patient care throughout the state of Michigan. METHODS MSSIC focuses on lumbar and cervical spine surgery, specifically indications such as stenosis, disk herniation, and degenerative disease. Surgery for tumors, traumatic fractures, deformity, scoliosis, and acute spinal cord injury are currently not within the scope of MSSIC. Starting in 2014, MSSIC consisted of 7 hospitals and in 2015 included another 15 hospitals, for a total of 22 hospitals statewide. A standardized data set is obtained by data abstractors, who are funded by BCBSM/BCN. Variables of interest include indications for surgery, baseline patient-reported outcome measures, and medical history. These are obtained within 30 days of surgery. Outcome instruments used include the EQ-5D general health state score (0 being worst and 100 being the best health one can imagine) and EQ-5D-3 L. For patients undergoing lumbar surgery, a 0 to 10 numeric rating scale for leg and back pain and the Oswestry Disability Index for back pain are collected. For patients undergoing cervical surgery, a 0 to 10 numeric rating scale for arm and neck pain, Neck Disability Index, and the modified Japanese Orthopaedic Association score are collected. Surgical details, postoperative hospital course, and patient-reported outcome measures are collected at 90-day, 1-year, and 2-year intervals. RESULTS As of July 1, 2015, a total of 6397 cases have been entered into the registry. This number reflects 4824 eligible cases with confirmed surgery dates. Of these 4824 eligible cases, 3338 cases went beyond the 120-day window and were considered eligible for the extraction of surgical details, 90-day outcomes, and adverse events. Among these 3338 patients, there are a total of 2469 lumbar cases, 862 cervical cases, and 7 combined procedures that were entered into the registry. CONCLUSIONS In addition to functioning as a registry, MSSIC is also meant to be a platform for quality improvement with the potential for future initiatives and best practices to be implemented statewide in order to improve quality and lower costs. With its current rate of recruitment and expansion, MSSIC will provide a robust platform as a regional prospective registry. Its unique funding model, which is supported by BCBSM/BCN, will help ensure its longevity and viability, as has been observed in other CQIs that have been active for several years.

Bilateral vertebral artery lesion after dislocating cervical spine trauma. A case report.

PubMed

Wirbel, R; Pistorius, G; Braun, C; Eichler, A; Mutschler, W

1996-06-01

This case report illustrates the problems associated with diagnosis and management of vertebral artery injuries resulting from dislocating cervical spine trauma. Treatment involved the principles of anterior stabilization of dislocating cervical spine fracture as well as the diagnostic procedures and therapeutic modalities appropriate for vertebral artery lesions. Because vertebral artery injuries with cervical spine trauma are rarely symptomatic, they can easily be overlooked. Bilateral or dominant vertebral artery occlusion, however, may cause fatal ischemic damage to the brain stem and cerebellum. Cervical spine dislocation was stabilized immediately after admission using internal fixation by ventral plate and corticocancellous bone graft. Immediate angiography was performed when brain stem neurologic dysfunction manifested 36 hours after surgery. The patient was treated with anticoagulation, osmotherapy, and controlled hypertension. A fatal outcome resulted in this case of dominant left vertebral artery occlusion. Necropsy even revealed bilateral vertebral artery damage at the level of the osseous lesion. The possibility of the complication of a vertebral artery lesion should be kept in mind when examining patients with cervical spine trauma, especially in patients with fracture-dislocation. Immediate identification by vertebral angiography, magnetic resonance imaging, or thin-slice computed tomography scan is necessary for optimal management of this injury.

[Surgical management of ankylosing spondylitis (Bechterew's disease)].

PubMed

Allouch, H; Shousha, M; Böhm, H

2017-12-01

Ankylosing spondylitis is an inflammatory rheumatic disease that is often associated with back pain and restricted spinal movement. In the later stages of the disease, complete ossification of the entire spine and severe deformity can occur, often resulting in a marked reduction in quality of life and an increased risk of loss of independence due to diminished visual field. Patients with ankylosing spondylitis are at greater risk of spinal fractures. These are generally complex fractures associated with high morbidity and mortality; in addition, neurological deficits are not unusual. Conventional radiological diagnosis is often insufficient to establish a diagnosis. Conservative treatment of fractures of the spine in this patient group is unsatisfactory. Surgical procedures, if necessary combined with decompression, are often the preferred treatment of choice in the fractured or malaligned ankylosed spine. Rebalancing of the sagittal profile with normalization of the visual axis and an improvement of quality of life is achieved through corrective osteotomies. Despite the high rate of complications, long-term results following spinal surgery in patients with ankylosing spondylitis are good. Minimally invasive surgery is appropriate for a further reduction in the complication rate. Meticulous preoperative planning is essential in the treatment of patients with ankylosing spondylitis.

History of computer-assisted orthopedic surgery (CAOS) in sports medicine.

PubMed

Jackson, Douglas W; Simon, Timothy M

2008-06-01

Computer-assisted orthopedic surgery and navigation applications have a history rooted in the desire to link imaging technology with real-time anatomic landmarks. Although applications are still evolving in the clinical and research setting, computer-assisted orthopedic surgery has already demonstrated in certain procedures its potential for improving the surgeon's accuracy, reproducibility (once past the learning curve), and in reducing outlier outcomes. It is also being used as an educational tool to assist less experienced surgeons in interpreting measurements and precision placements related to well defined anatomic landmarks. It also can assist experienced surgeons, in real-time, plan their bony cuts, tunnel placement, and with ligament balancing. Presently, the additional time, the expense to acquire the needed software and hardware, and restricted reimbursement have slowed the widespread use of navigation. Its current applications have been primarily in joint replacement surgery, spine surgery, and trauma. It has not been widely used in the clinical setting for sports medicine procedures. Sports medicine applications such as individualizing tunnel placement in ligament surgery, opening wedge osteotomy with and without accompanying ligament reconstruction, and balancing and tensioning of the ligaments during the procedure (allowing real-time corrections if necessary) are currently being evaluated and being used on a limited clinical basis.

Drivers of 30-Day Readmission in Elderly Patients (>65 Years Old) After Spine Surgery: An Analysis of 500 Consecutive Spine Surgery Patients.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Han, Jing; Karikari, Isaac O; Cheng, Joseph; Bagley, Carlos A

2017-01-01

Early readmission after spine surgery is being used as a proxy for quality of care. One-fifth of patients are rehospitalized within 30 days after spine surgery, and more than one-third within 90 days; however, there is a paucity of data about the cause of early readmissions in elderly patients after elective spine surgery. A total of 500 elderly patients (>65 years old) undergoing elective spine surgery at a major academic hospital were included in the study. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient records were reviewed to determine the cause of readmission and the length of hospital stay. A total of 50 (10%) unplanned early readmissions were identified. The mean ± SD age was 72.54 ± 5.84 years. The mean ± SD number of days from discharge to readmission was 11.02 ± 7.25 days, and the average length of hospital stay for the readmissions was 7.7 days. The majority of patients that were readmitted presented to the emergency department from home (46%), whereas 38% were readmitted from a skilled nursing facility. The most common causes for readmission were infection or a concern for infection (42%) and pain (14%), with 32% of readmissions requiring a return to the operating room. Our study suggests that in elderly patients undergoing elective spine surgery, infection or a concern for infection, pain, and altered mental status were the most common primary reasons for unplanned readmission. Copyright © 2016 Elsevier Inc. All rights reserved.

Current applications of robotics in spine surgery: a systematic review of the literature.

PubMed

Joseph, Jacob R; Smith, Brandon W; Liu, Xilin; Park, Paul

2017-05-01

OBJECTIVE Surgical robotics has demonstrated utility across the spectrum of surgery. Robotics in spine surgery, however, remains in its infancy. Here, the authors systematically review the evidence behind robotic applications in spinal instrumentation. METHODS This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Relevant studies (through October 2016) that reported the use of robotics in spinal instrumentation were identified from a search of the PubMed database. Data regarding the accuracy of screw placement, surgeon learning curve, radiation exposure, and reasons for robotic failure were extracted. RESULTS Twenty-five studies describing 2 unique robots met inclusion criteria. Of these, 22 studies evaluated accuracy of spinal instrumentation. Although grading of pedicle screw accuracy was variable, the most commonly used method was the Gertzbein and Robbins system of classification. In the studies using the Gertzbein and Robbins system, accuracy (Grades A and B) ranged from 85% to 100%. Ten studies evaluated radiation exposure during the procedure. In studies that detailed fluoroscopy usage, overall fluoroscopy times ranged from 1.3 to 34 seconds per screw. Nine studies examined the learning curve for the surgeon, and 12 studies described causes of robotic failure, which included registration failure, soft-tissue hindrance, and lateral skiving of the drill guide. CONCLUSIONS Robotics in spine surgery is an emerging technology that holds promise for future applications. Surgical accuracy in instrumentation implanted using robotics appears to be high. However, the impact of robotics on radiation exposure is not clear and seems to be dependent on technique and robot type.

Delayed lymphocele formation following lateral lumbar interbody fusion of the spine.

PubMed

Hey, Hwee Weng Dennis; Wong, Keng Lin; Gatam, Asrafi Rizki; Lim, Joel Louis; Wong, Hee-Kit

2017-05-01

This paper aims to describe the rare post-operative complication of a lymphocele formation after lateral lumbar interbody fusion. The patient in this case was a 76-year-old lady with a 10 year history of low back pain and neurogenic claudication. She had previously underwent multiple spine surgeries for her condition. She presented to our institution for a recurrence of her low back pain and right anterior thigh pain. She then underwent surgery in two stages; first, a mini-open lateral interbody fusion at L3/4 and L4/5; second, posterior instrumentation of T3 to S1 with sagittal spinal deformity correction. The patient recovered uneventfully in the initial post op period and was discharged within 8 days. However, she developed abdominal distension and discomfort 6 months after surgery. MRI and CT scan of her abdomen showed a retroperitoneal fluid collection compressing her left ureter, resulting in hydroureter and hydronephrosis. She was managed with a CT-guided drainage of the fluid collection. Fluid analysis was consistent with a lymphocele. Since the procedure, the patient has been asymptomatic for 2 years. Delayed lymphocele formation is a potential complication of lateral lumbar interbody fusion. When present, it can be managed conservatively with good results. This case suggests that surgeons should have a low threshold to investigate for a lymphocele development post-anterior or lateral lumbar spine surgery. The authors recommend the placement of a post surgical retroperitoneal drain, as it might assist in the early detection of a lymphocele formation.

Role of prospective registries in defining the value and effectiveness of spine care.

PubMed

McGirt, Matthew J; Parker, Scott L; Asher, Anthony L; Norvell, Dan; Sherry, Ned; Devin, Clinton J

2014-10-15

Literature review and case example. Describe methodological considerations of spine surgery registries. Review existing spine surgery registries. Describe the Vanderbilt Prospective Spine Registry (VPSR) as a case example and demonstrate its impact on comparative effectiveness research, value analysis, quality improvement, and practice-based learning. To bend the cost curve and ultimately achieve sustainability in health care, medical providers and surgical treatments of the highest quality and effectiveness must be preferentially used and purchased. As the current US health care environment continues to evolve, it will be essential for all spine clinicians to understand and be facile with the principles of evidence-based health care reform. We describe the methodological considerations of spine surgery registries, review the literature to describe existing spine surgery registries, and discuss the VPSR as a case example. We were able to obtain detailed information on 13 existing spine surgery registries through various internet-based resources. Of the 13, 2 registries had start dates before 2000, 3 between 2001 and 2005, 5 starting in 2006, and 3 were indeterminate. Follow-up rates were in the range from 22% to 79%, with longer follow-up times consistently producing lower follow-up rates. Prospective, longitudinal, patient-reported outcomes registries are powerful tools that allow measurement of cost, safety, effectiveness, and health care value across clinically meaningful episodes of care. Registries entirely based on claims or billing data, safety measures alone, process measures, or other proxies of outcome offer valuable insights, but do not provide comprehensive data to drive patient-centered value-based reform. As more spine-focused registries emerge and their integration into the US health care delivery evolve, the evidence to power value-based reform will be enabled.

Artificial Cervical Vertebra and Intervertebral Complex Replacement through the Anterior Approach in Animal Model: A Biomechanical and In Vivo Evaluation of a Successful Goat Model

PubMed Central

Qin, Jie; He, Xijing; Wang, Dong; Qi, Peng; Guo, Lei; Huang, Sihua; Cai, Xuan; Li, Haopeng; Wang, Rui

2012-01-01

This was an in vitro and in vivo study to develop a novel artificial cervical vertebra and intervertebral complex (ACVC) joint in a goat model to provide a new method for treating degenerative disc disease in the cervical spine. The objectives of this study were to test the safety, validity, and effectiveness of ACVC by goat model and to provide preclinical data for a clinical trial in humans in future. We designed the ACVC based on the radiological and anatomical data on goat and human cervical spines, established an animal model by implanting the ACVC into goat cervical spines in vitro prior to in vivo implantation through the anterior approach, and evaluated clinical, radiological, biomechanical parameters after implantation. The X-ray radiological data revealed similarities between goat and human intervertebral angles at the levels of C2-3, C3-4, and C4-5, and between goat and human lordosis angles at the levels of C3-4 and C4-5. In the in vivo implantation, the goats successfully endured the entire experimental procedure and recovered well after the surgery. The radiological results showed that there was no dislocation of the ACVC and that the ACVC successfully restored the intervertebral disc height after the surgery. The biomechanical data showed that there was no significant difference in range of motion (ROM) or neural zone (NZ) between the control group and the ACVC group in flexion-extension and lateral bending before or after the fatigue test. The ROM and NZ of the ACVC group were greater than those of the control group for rotation. In conclusion, the goat provides an excellent animal model for the biomechanical study of the cervical spine. The ACVC is able to provide instant stability after surgery and to preserve normal motion in the cervical spine. PMID:23300816

Infection rate after transoral approach for the upper cervical spine.

PubMed

Shousha, Mootaz; Mosafer, Azim; Boehm, Heinrich

2014-09-01

A retrospective review of prospectively collected databases of 139 consecutive patients who underwent transoral surgery for lesions of the upper cervical spine. To analyze the incidence and risk factors of local infection after transoral surgery for the craniocervical junction in a single institution and to compare the findings with the literature. One of the primary risks associated with transoral approach for lesions in the upper cervical spine is postoperative surgical wound infection. From April 1994 to December 2012, 139 consecutive transoral surgical procedures were performed at a single referral center. The mean age at presentation was 53.6 years (range: 5-87 yr), and more than half of the patients were males (58.3%). The majority of cases were experiencing rheumatic diseases (43.9%), whereas tumor destruction was the indication for surgery in 23.7% of the cases. A total of 23% had fracture of the upper cervical spine and primary infection was found in 7 patients (5%). The mean follow-up period was 4.5 years. Infection of the pharyngeal wound occurred in 5 patients (3.6%), solely in the rheumatic and tumor groups. The presentation was mostly in the first 4 months. A single patient with cage reconstruction after giant cell tumor C2 presented with a late infection 5 years postoperatively. Debridement and primary closure was possible in 2 patients, whereas flap coverage of the pharyngeal wall was necessary in 3 patients. The presence of implant did not have a statistically significant effect on the occurrence of infection. However, infection in the presence of titanium cage mostly necessitated flap coverage of the pharyngeal wall after removal of the cage. The transoral route has proved to be an invaluable method of approaching pathological lesions in the upper cervical spine. The infection rate in this work was 3.6%. Patients with rheumatic diseases and patients presenting with tumors were more susceptible to postoperative surgical wound infection. 4.

Treatment patterns of children with spine and spinal cord tumors: national outcomes and review of the literature.

PubMed

Shweikeh, Faris; Quinsey, Carolyn; Murayi, Roger; Randle, Ryan; Nuño, Miriam; Krieger, Mark D; Patrick Johnson, J

2017-08-01

Tumors of the spine in children are rare, and further clinical description is necessary. This study investigated epidemiology, interventions, and outcomes of pediatric patients with spine and spinal cord tumors. The National Inpatient Sample and Kids' Inpatient Database were used for the study. Outcomes were studied, and bivariate significant trends were analyzed in a multivariate setting. Analysis of 2870 patients between 2000 and 2009 found a median age of diagnosis of 11 years (Tables 1 and 2). Most were white (65.2%) and had private insurance (62.3%), and 46.8% of procedures were emergent operations. Treatment occurred at teaching (93.6%) and non-children's hospitals (81.1%). Overall mortality rate was 1.7%, non-routine discharges occurred at a rate 19.9%, complications at 21.1%, and average total charges were $66,087. A majority of patients (87.5%) had no intervention, and of those patients receiving treatment, 78.2% underwent surgery and 23.1% had radiotherapy. Treatment with surgery alone increased significantly over time (p < 0.0001). Odds ratio (OR) of mortality was significantly higher in 2006 (OR 3.5) and 2009 (OR 2.6) when compared to 2000. Complications (OR 7.9) and disease comorbidities (OR 1.5) were associated with significantly increased odds of mortality. Hospital characteristics, length of stay, and charges remained relatively unchanged. In recent years, there has been a decreasing incidence of spine and spinal cord tumors in children. Notably, a higher mortality rate is evident over time in addition to an increase in the proportion of patients undergoing surgery. The high percentage of emergent operations suggests a weak recognition of spine tumors in children and should prompt a call for increased awareness of this cancer. In spite of these findings, lack of tumor type identification was a limitation to this study.

The use of presurgical psychological screening to predict the outcome of spine surgery.

PubMed

Block, A R; Ohnmeiss, D D; Guyer, R D; Rashbaum, R F; Hochschuler, S H

2001-01-01

Several previous studies have shown that psychosocial factors can influence the outcome of elective spine surgery. The purpose of the current study was to determine how well a presurgical screening instrument could predict surgical outcome. The study was conducted by staff of a psychologist's office. They performed preoperative screening for spine surgery candidates and collected the follow-up data. Presurgical screening and follow-up data collection was performed on 204 patients who underwent laminectomy/discectomy (n=118) or fusion (n=86) of the lumbar spine. The outcome measures used in the study were visual analog pain scales, the Oswestry Disability Questionnaire, and medication use. A semi-structured interview and psychometric testing were used to identify specific, quantifiable psychological, and "medical" risk factors for poor surgical outcome. A presurgical psychological screening (PPS) scorecard was completed for each patient, assessing whether the patient had a high or low level of risk on these psychological and medical dimensions. Based on the scorecard, an overall surgical prognosis of "good," "fair," or "poor" was generated. Results showed spine surgery led to significant overall improvements in pain, functional ability, and medication use. Medical and psychological risk levels were significantly related to outcome, with the poorest results obtained by patients having both high psychological and medical risk. Further, the accuracy of PPS surgical prognosis in predicting overall outcome was 82%. Only 9 of 53 patients predicted to have poor outcome achieved fair or good results from spine surgery. These findings suggest that PPS should become a more routine part of the evaluation of chronic pain patients in whom spine surgery is being considered.

Predictive modeling of complications.

PubMed

Osorio, Joseph A; Scheer, Justin K; Ames, Christopher P

2016-09-01

Predictive analytic algorithms are designed to identify patterns in the data that allow for accurate predictions without the need for a hypothesis. Therefore, predictive modeling can provide detailed and patient-specific information that can be readily applied when discussing the risks of surgery with a patient. There are few studies using predictive modeling techniques in the adult spine surgery literature. These types of studies represent the beginning of the use of predictive analytics in spine surgery outcomes. We will discuss the advancements in the field of spine surgery with respect to predictive analytics, the controversies surrounding the technique, and the future directions.

Analysis of Reasons for Failure of Surgery for Degenerative Disease of Lumbar Spine.

PubMed

Baranowska, Alicja; Baranowska, Joanna; Baranowski, Paweł

2016-03-23

In the aging society, there is a growing number of patients with advanced degenerative disease of the spine. These patients frequently require surgical treatment. This paper aims to analyse the reasons for failure of surgery for degenerative disease of the lumbar spine. Histories of patients operated on by one group of surgeons in the Neuroorthopaedic Department of "STOCER" in 2014 and 2015 due to degenerative disease of the lumbar spine were analysed retrospectively. Out of the cohort, patients who had undergone a revision surgery were selected for the study and divided into two groups: group A (60) of patients previously operated on in another centre and group B (47) of patients previously operated on in "STOCER". The reasons for failure of the surgery were analysed in detail based on history, physical examination, imaging studies and surgery reports. Surgery was performed in 601 patients, of whom 107 patients had been previously operated on. The most frequent reasons for revision surgery of the same motor segment were recurrent disc herniation, inadequate decompression and inappropriate surgical technique. In the group of patients who had implants inserted to stabilise the spine, the revision surgery in most cases was due to adjacent segment disease. Use of implants and spinal fusion is always associated with a risk of complications and is frequently independent of the surgeon. 2. In order to reduce the rate of revision surgeries, it is important to perform complete decompression and select an adequate surgical technique.

A Technique to Allow Prone Positioning in the Spine Surgery Patient With Unstable Spine Fracture and Flail Segment Rib Fractures.

PubMed

Pennington, Matthew W; Roche, Anthony M; Bransford, Richard J; Zhang, Fangyi; Dagal, Armagan

2016-07-01

Two patients with unstable thoracic spine and flail segment rib fractures initially failed prone positioning on a Jackson spinal table used for posterior spinal instrumentation and fusion surgery. Both patients experienced rapid hemodynamic collapse. We developed a solution using the anterior portions of a thoracolumbosacral orthosis brace as chest supports to use during prone positioning, allowing both patients to undergo uncomplicated posterior spinal instrumentation and fusion surgeries with greater hemodynamic stability.

Microscope sterility during spine surgery.

PubMed

Bible, Jesse E; O'Neill, Kevin R; Crosby, Colin G; Schoenecker, Jonathan G; McGirt, Matthew J; Devin, Clinton J

2012-04-01

Prospective study. Assess the contamination rates of sterile microscope drapes after spine surgery. The use of the operating microscope has become more prevalent in certain spine procedures, providing superior magnification, visualization, and illumination of the operative field. However, it may represent an additional source of bacterial contamination and increase the risk of developing a postoperative infection. This study included 25 surgical spine cases performed by a single spine surgeon that required the use of the operative microscope. Sterile culture swabs were used to obtain samples from 7 defined locations on the microscope drape after its use during the operation. The undraped technician's console was sampled in each case as a positive control, and an additional 25 microscope drapes were swabbed immediately after they were applied to the microscope to obtain negative controls. Swab samples were assessed for bacterial growth on 5% sheep blood Columbia agar plates using a semiquantitative technique. No growth was observed on any of the 25 negative control drapes. In contrast, 100% of preoperative and 96% of postoperative positive controls demonstrated obvious contamination. In the postoperative group, all 7 sites of evaluation were found to be contaminated with rates of 12% to 44%. Four of the 7 evaluated locations were found to have significant contamination rates compared with negative controls, including the shafts of the optic eyepieces on the main surgeon side (24%, P = 0.022), "forehead" portion on both the main surgeon (24%, P = 0.022) and assistant sides (28%, P = 0.010), and "overhead" portion of the drape (44%, P = 0.0002). Bacterial contamination of the operative microscope was found to be significant after spine surgery. Contamination was more common around the optic eyepieces, likely due to inadvertent touching of unsterile portions. Similarly, all regions above the eyepieces also have a propensity for contamination because of unknown contact with unsterile parts of the surgeon. Therefore, we believe that changing gloves after making adjustments to the optic eyepieces and avoid handling any portion of the drape above the eyepieces may decrease the risks of intraoperative contamination and possibly postoperative infection as well.

Vocal cord palsy after anterior cervical spine surgery: a qualitative systematic review.

PubMed

Tan, Tze P; Govindarajulu, Arun P; Massicotte, Eric M; Venkatraghavan, Lashmi

2014-07-01

Vocal cord palsy (VCP) is a known complication of anterior cervical spine surgery. However, the true incidence and interventions to minimize this complication are not well studied. To conduct a systematic review to identify the incidence, risk, and interventions for VCP after anterior cervical spine surgery. This is a qualitative systematic literature review. Prospective and retrospective trials of patients undergoing anterior cervical spine surgery that reported on postoperative VCP or recurrent laryngeal nerve palsy. Primary: incidence of VCP after anterior cervical spine surgery; secondary: risk factors and interventions for prevention of VCP after anterior cervical spine surgery. Electronic searches were conducted on Ovid Medline, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systemic Reviews for clinical studies reporting VCP in anterior cervical spine surgery, limited to studies published between 1995 and June 2013 in English and French languages. After selection of studies independently by two review authors, data on incidence, risk, and interventions were extracted. Qualitative analysis was performed on three domains: quality of studies, strength of evidence, and impact of interventions. Our search has identified 187 abstracts, and 34 studies met our inclusion criteria. The incidence of VCP ranges from 2.3% to 24.2%. Significant heterogeneity in study design and definition of VCP were used in the published studies. There is good evidence that reoperation increases the risk of VCP. One study of moderate strength suggests that operating from the right side may increase the risk of VCP. Among the interventions studied, endotracheal tube (ETT) cuff pressure monitoring with deflation during retraction has shown to reduce the incidence from 6% to 2%, but this result was not confirmed by randomized control trials. Limited evidence exists for other interventions of intraoperative electromyographic monitoring and methylprednisolone. Vocal cord palsy is a significant morbidity after anterior cervical surgery with incidence up to 24.2% in the immediate postoperative period, with a higher risk in reoperation of the anterior cervical spine. Moderate evidence exists for ETT cuff pressure adjustment in preventing this complication. Copyright © 2014 Elsevier Inc. All rights reserved.

Mini-open lateral retroperitoneal lumbar spine approach using psoas muscle retraction technique. Technical report and initial results on six patients.

PubMed

Aghayev, Kamran; Vrionis, Frank D

2013-09-01

The main aim of this paper was to report reproducible method of lumbar spine access via a lateral retroperitoneal route. The authors conducted a retrospective analysis of the technical aspects and clinical outcomes of six patients who underwent lateral multilevel retroperitoneal interbody fusion with psoas muscle retraction technique. The main goal was to develop a simple and reproducible technique to avoid injury to the lumbar plexus. Six patients were operated at 15 levels using psoas muscle retraction technique. All patients reported improvement in back pain and radiculopathy after the surgery. The only procedure-related transient complication was weakness and pain on hip flexion that resolved by the first follow-up visit. Psoas retraction technique is a reliable technique for lateral access to the lumbar spine and may avoid some of the complications related to traditional minimally invasive transpsoas approach.

Stability of cervical spine fractures after gunshot wounds to the head and neck.

PubMed

Medzon, Ron; Rothenhaus, Todd; Bono, Christopher M; Grindlinger, Gene; Rathlev, Niels K

2005-10-15

Retrospective chart review. To determine the frequency of stable and unstable cervical spine fractures after gunshot wounds to the head or neck; to identify potential risk factor(s) for an unstable versus stable cervical spine fracture. Cervical spine fractures after gunshot wounds to the head and neck are common. Because of the nature of their injuries, patients often present with concomitant airway obstruction and large blood vessel injury that can necessitate emergent procedures. In some cases, acute treatment of these problems can be hindered by the presence of a cervical collar or strict adherence to spinal precautions (i.e., patient laying supine). In such situations, information regarding the probability of a stable versus unstable cervical spine fracture would be useful in emergency treatment decision making. A search for patients with gunshot wounds to the head or neck potentially involving the cervical spine over a 13-year period was performed using a trauma registry. Individuals with cervical spine fractures were identified and their records reviewed in detail. Data collected included information about neurologic deficits, mental status, airway treatment, entrance wounds, fracture level/type, initial/definitive fracture treatment, and final disposition at hospital discharge. A total of 81 patients were identified; 19 had cervical spine fractures. There were 5 patients who were not examinable because of altered mental status (severe head trauma, hemorrhagic shock, or intoxication). All 5 patients had stable cervical spine fractures. There were 11 patients who had an acute spinal cord injury, 3 (30%) of whom underwent surgery for an unstable fracture. Of the 65 awake, alert patients without a neurologic deficit, only 3 (5%) had a fracture, none of which were unstable. Gunshot wounds to the head and neck had a high rate of concomitant cervical spine fracture. Neurologically intact patients have a lower rate of fracture than those presenting with a spinal cord injury or altered mental status. In this small series of patients, the only unstable cervical spine injuries were detected in patients with a spinal cord injury. The data suggest that spinal precautions and/or a hard cervical collar should not be maintained at the expense of delaying or hindering emergent life-saving airway or hemodynamically stabilizing procedures, particularly in awake, neurologically intact patients. However, the cervical collar and spinal precautions should be resumed after such procedures are completed and continued until a more definitive evaluation of spinal stability can be performed.

Comparison of hybrid constructs with 2-level artificial disc replacement and 2-level anterior cervical discectomy and fusion for surgical reconstruction of the cervical spine: a kinematic study in whole cadavers.

PubMed

Liu, Baoge; Zeng, Zheng; Hoof, Tom Van; Kalala, Jean Pierre; Liu, Zhenyu; Wu, Bingxuan

2015-04-08

Multi-level cervical degeneration of the spine is a common clinical pathology that is often repaired by anterior cervical discectomy and fusion (ACDF). The aim of this study was to investigate the kinematics of the cervical spine after hybrid surgery compared with 2-level ACDF. Five freshly frozen, unembalmed whole human cadavers were used including 3 males and 2 females with a mean age of 51 ± 8 years. After evaluating the intact spine for range of motion (ROM), sagittal alignment and instantaneous center of rotation (ICR), each cadaver underwent 4 consecutive surgeries: 2-level artificial disc replacement (ADR) from C4 to C6 (ADR surgery); 2-level ACDF from C4 to C6 (ACDF surgery); hybrid C4-5 ACDF and C5-6 ADR (ACDF+ADR surgery); and hybrid C4-5 ADR and C5-6 ACDF (ADR+ACDF surgery). The ROM and ICR of adjacent intact segments (C3-4; C6-7), and whole sagittal alignment were revaluated. Two-level ACDF resulted in increased ROM at C3-4 and C6-7 compared with intact spine. ROM was significantly different to intact spine using ACDF surgery at C3-C4 and C6-C7 and ROM was increased with ACDF+ADR surgery at C6-C7 (all P<0.05). No improvement in sagittal alignment was observed with any approach. The localization of the ICR shifted upwards and anteriorly at C3-C4 after reconstruction. ICR changes at C3-C4 were greatest for ADR+ACDF surgery and were significantly different to ACDF surgery (P<0.05), but not between ADR surgery and ACDF+ADR surgery. At C6-C7, the ICR was more posterior and superior than in the intact condition. The greatest change in ICR was observed in ACDF surgery at the C6-C7 level, significantly different from the other groups (P<0.05). For 2-level reconstruction, hybrid surgery and ADR did not alter ROM and minimally changed ICR at the adjacent-level. The type of surgery had a significant impact on the ICR location. This suggests that hybrid surgery may be a viable option for 2-level cervical surgery.

External validation of a prediction model for surgical site infection after thoracolumbar spine surgery in a Western European cohort.

PubMed

Janssen, Daniël M C; van Kuijk, Sander M J; d'Aumerie, Boudewijn B; Willems, Paul C

2018-05-16

A prediction model for surgical site infection (SSI) after spine surgery was developed in 2014 by Lee et al. This model was developed to compute an individual estimate of the probability of SSI after spine surgery based on the patient's comorbidity profile and invasiveness of surgery. Before any prediction model can be validly implemented in daily medical practice, it should be externally validated to assess how the prediction model performs in patients sampled independently from the derivation cohort. We included 898 consecutive patients who underwent instrumented thoracolumbar spine surgery. To quantify overall performance using Nagelkerke's R 2 statistic, the discriminative ability was quantified as the area under the receiver operating characteristic curve (AUC). We computed the calibration slope of the calibration plot, to judge prediction accuracy. Sixty patients developed an SSI. The overall performance of the prediction model in our population was poor: Nagelkerke's R 2 was 0.01. The AUC was 0.61 (95% confidence interval (CI) 0.54-0.68). The estimated slope of the calibration plot was 0.52. The previously published prediction model showed poor performance in our academic external validation cohort. To predict SSI after instrumented thoracolumbar spine surgery for the present population, a better fitting prediction model should be developed.

Is There Variation in Procedural Utilization for Lumbar Spine Disorders Between a Fee-for-Service and Salaried Healthcare System?

PubMed

Schoenfeld, Andrew J; Makanji, Heeren; Jiang, Wei; Koehlmoos, Tracey; Bono, Christopher M; Haider, Adil H

2017-12-01

Whether compensation for professional services drives the use of those services is an important question that has not been answered in a robust manner. Specifically, there is a growing concern that spine care practitioners may preferentially choose more costly or invasive procedures in a fee-for-service system, irrespective of the underlying lumbar disorder being treated. (1) Were proportions of interbody fusions higher in the fee-for-service setting as opposed to the salaried Department of Defense setting? (2) Were the odds of interbody fusion increased in a fee-for-service setting after controlling for indications for surgery? Patients surgically treated for lumbar disc herniation, spinal stenosis, and spondylolisthesis (2006-2014) were identified. Patients were divided into two groups based on whether the surgery was performed in the fee-for-service setting (beneficiaries receive care at a civilian facility with expenses covered by TRICARE insurance) or at a Department of Defense facility (direct care). There were 28,344 patients in the entire study, 21,290 treated in fee-for-service and 7054 treated in Department of Defense facilities. Differences in the rates of fusion-based procedures, discectomy, and decompression between both healthcare settings were assessed using multinomial logistic regression to adjust for differences in case-mix and surgical indication. TRICARE beneficiaries treated for lumbar spinal disorders in the fee-for-service setting had higher odds of receiving interbody fusions (fee-for-service: 7267 of 21,290 [34%], direct care: 1539 of 7054 [22%], odds ratio [OR]: 1.25 [95% confidence interval 1.20-1.30], p < 0.001). Purchased care patients were more likely to receive interbody fusions for a diagnosis of disc herniation (adjusted OR 2.61 [2.36-2.89], p < 0.001) and for spinal stenosis (adjusted OR 1.39 [1.15-1.69], p < 0.001); however, there was no difference for patients with spondylolisthesis (adjusted OR 0.99 [0.84-1.16], p = 0.86). The preferential use of interbody fusion procedures was higher in the fee-for-service setting irrespective of the underlying diagnosis. These results speak to the existence of provider inducement within the field of spine surgery. This reality portends poor performance for surgical practices and hospitals in Accountable Care Organizations and bundled payment programs in which provider inducement is allowed to persist. Level III, economic and decision analysis.

Surgical Treatment of Congenital Scoliosis Associated With Tethered Cord by Thoracic Spine-shortening Osteotomy Without Cord Detethering.

PubMed

Huang, Jing-Hui; Yang, Wei-Zhou; Shen, Chao; Chang, Michael S; Li, Huan; Luo, Zhuo-Jing; Tao, Hui-Ren

2015-10-15

Retrospective case series. To investigate the safety and efficacy of spine-shortening osteotomy for congenital scoliosis with tethered cord. Conventional surgery for congenital scoliosis associated with tethered cord risks the complications of detethering. Spine-shortening osteotomy holds the potential to correct scoliosis and decrease spinal cord tension simultaneously without an extra detethering procedure, but no data on this issue is available. 21 patients (14 females and 7 males, average age 15.4 yr) underwent spine-shortening osteotomy without detethering. All of the patients had tethered cord. Patients with main curve more than 90° underwent vertebral column resection (VCR), whereas the others had pedicle subtraction osteotomy (PSO) performed. The average postoperative follow-up period was 45.2 months. The mean operation time was 544.5 min with average blood loss of 2769.1 ml. The deformity correction was 61.3% in the coronal plane and 43.9° in the sagittal plane. 10 patients had neurological deficits preoperatively. At the final follow-up, the deficits in 8 (80%) patients were significantly improved, whereas 2 (20%) remained unchanged. At final follow-up, 71.4% (5/7) patients reported improvement in motor function, 100% (3/3) had improved pain scores, and 75% (3/4) reported better sensory function after the spine-shortening osteotomy. Urinary dysfunction and bowel incontinence present preoperatively in 3 patients all recovered by final follow-up. 5 (23.8%) patients incurred complications including temporary neurological deterioration in 1 patient, urinary tract infection in 2 patients, cerebrospinal fluid leakage in 1 patient, and blood loss more than 5000 ml in 1 patient. Spine-shortening osteotomy is a safe and effective procedure for congenital scoliosis associated with tethered cord. Spine-shortening osteotomy at the thoracic apical vertebrae level not only corrects the spine deformity but also simultaneously releases the tension of the tethered cord, resulting in improved neurologic function.

Spine Surgery Outcomes in Elderly Patients Versus General Adult Patients in the United States: A MarketScan Analysis.

PubMed

Lagman, Carlito; Ugiliweneza, Beatrice; Boakye, Maxwell; Drazin, Doniel

2017-07-01

To compare spine surgery outcomes in elderly patients (80-103 years old) versus general adult patients (18-79 years-old) in the United States. Truven Health Analytics MarketScan Research Databases (2000-2012) were queried. Patients with a diagnosis of degenerative disease of the spine without concurrent spinal stenosis, spinal stenosis without concurrent degenerative disease, or degenerative disease with concurrent spinal stenosis and who had undergone decompression without fusion, fusion without decompression, or decompression with fusion procedures were included. Indirect outcome measures included length of stay, in-hospital mortality, in-hospital and 30-day complications, and discharge disposition. Patients (N = 155,720) were divided into elderly (n = 10,232; 6.57%) and general adult (n = 145,488; 93.4%) populations. Mean length of stay was longer in elderly patients versus general adult patients (3.62 days vs. 3.11 days; P < 0.0001). In-hospital mortality was more common in elderly patients versus general adult patients (0.31% vs. 0.06%; P < 0.0001). In-hospital and 30-day complications were more common in elderly patients versus general adult patients (11.3% vs. 7.15% and 17.8% vs. 12.6%; P < 0.0001). Nonroutine discharge was more common in elderly patients versus general adult patients (33.7% vs. 16.2%; P < 0.0001). Our results revealed significantly longer hospital stays, more in-hospital mortalities, and more in-hospital and 30-day complications after decompression without fusion, fusion without decompression, or decompression with fusion procedures in elderly patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Orthobiologics in Pediatric Orthopedics.

PubMed

Murphy, Robert F; Mooney, James F

2017-07-01

Orthobiologics are biologic devices or products used in orthopedic surgery to augment or enhance bone formation. The use of orthobiologics in pediatric orthopedics is less frequent than in other orthopedic subspecialties, mainly due to the naturally abundant healing potential and bone formation in children compared with adults. However, orthobiologics are used in certain situations in pediatric orthopedics, particularly in spine and foot surgery. Other uses have been reported in conjunction with specific procedures involving the tibia and pelvis. The use of bioabsorable implants to stabilize children's fractures is an emerging concept but has limited supporting data. Copyright © 2017 Elsevier Inc. All rights reserved.

Hemothorax caused by the trocar tip of the rod inserter after minimally invasive transforaminal lumbar interbody fusion: case report.

PubMed

Maruo, Keishi; Tachibana, Toshiya; Inoue, Shinichi; Arizumi, Fumihiro; Yoshiya, Shinichi

2016-03-01

Minimally invasive surgery (MIS) for transforaminal lumbar interbody fusion (MIS-TLIF) is widely used for lumbar degenerative diseases. In the paper the authors report a unique case of a hemothorax caused by the trocar tip of the rod inserter after MIS-TLIF. A 61-year-old woman presented with thigh pain and gait disturbance due to weakness in her lower right extremity. She was diagnosed with a lumbar disc herniation at L1-2 and the MIS-TLIF procedure was performed. Immediately after surgery, the patient's thigh pain resolved and she remained stable with normal vital signs. The next day after surgery, she developed severe anemia and her hemoglobin level decreased to 7.6 g/dl, which required blood transfusions. A chest radiograph revealed a hemothorax. A CT scan confirmed a hematoma of the left paravertebral muscle. A chest tube was placed to treat the hemothorax. After 3 days of drainage, there was no active bleeding. The patient was discharged 14 days after surgery without leg pain or any respiratory problems. This complication may have occurred due to injury of the intercostal artery by the trocar tip of the rod inserter. A hemothorax after spine surgery is a rare complication, especially in the posterior approach. The rod should be caudally inserted in the setting of the thoracolumbar spine.

Subsequent, unplanned spine surgery and life survival of patients operated for neuropathic spine deformity.

PubMed

Asher, Marc A; Lai, Sue-Min; Burton, Douglas C

2012-01-01

Retrospective study of a prospectively assembled cohort. To characterize the survival from subsequent spine surgery and the life survival of patients treated surgically for severe spinal deformity due to neuropathic diseases. Survivorship analysis is widely used to study the natural history of disease processes and of treatments provided, but has very seldom been used to study patients' course after surgery for spinal deformity associated with neuropathic diseases. Patients with neuropathic spinal deformity treated with primary posterior instrumentation and arthrodesis from 1989 through 2002 were identified and studied by review of charts and radiographs, and by mail survey. Subsequent spine surgery and death events, and the time interval from surgery were identified. Fifteen variables possibly influencing survivorship were studied. There were no perioperative deaths, spinal cord injuries, or acute wound infections in the 117 eligible patients. Reoperation and life survival statuses were available for 110 patients (94%) at an average follow-up of 11.89 years (±5.3; range: 2-20.9 yr). Twelve patients (11%) had subsequent spine surgery. Survival from subsequent spine surgery was 91% at 5 years, 90% at 10 and 15 years, and 72% at 20 years. Proximal fixation problems occurred in 4 patients. Twenty-two patients (20%) had died from 4 to 20 years postoperative. Life survival was 98% at 5 years, 89% at 10 years, 81% at 15 years, and 56% at 20 years. The only variable associated with life survival was the occurrence of one or more perioperative complications, P = 0.0032. The younger half of the series at operation (<13.75 yr) was significantly more likely to have one or more perioperative complications, P = 0.0068. Spinal deformity type and magnitude were similar for the younger and older halves of the patients. Life survival of the patients with cerebral-palsy and not-cerebral-palsy upper motor neuron disease was not different. One-hundred-two of 105 were at least satisfied or would have the surgery again for the same condition. Survival from subsequent spine operation was similar to adolescent idiopathic scoliosis series studied in the same manner. Life survival decline began at 4 years postoperative and was significantly associated with the occurrence of one or more perioperative complications. Even after successful spine deformity surgery, this population's health status is often precarious.

Incidence of surgical site infection after spine surgery: what is the impact of the definition of infection?

PubMed

Nota, Sjoerd P F T; Braun, Yvonne; Ring, David; Schwab, Joseph H

2015-05-01

Orthopaedic surgical site infections (SSIs) can delay recovery, add impairments, and decrease quality of life, particularly in patients undergoing spine surgery, in whom SSIs may also be more common. Efforts to prevent and treat SSIs of the spine rely on the identification and registration of these adverse events in large databases. The effective use of these databases to answer clinical questions depends on how the conditions in question, such as infection, are defined in the databases queried, but the degree to which different definitions of infection might cause different risk factors to be identified by those databases has not been evaluated. The purpose of this study was to determine whether different definitions of SSI identify different risk factors for SSI. Specifically, we compared the International Classification of Diseases, 9th Revision (ICD-9) coding, Centers for Disease Control and Prevention (CDC) criteria for deep infection, and incision and débridement for infection to determine if each is associated with distinct risk factors for SSI. In this single-center retrospective study, a sample of 5761 adult patients who had an orthopaedic spine surgery between January 2003 and August 2013 were identified from our institutional database. The mean age of the patients was 56 years (± 16 SD), and slightly more than half were men. We applied three different definitions of infection: ICD-9 code for SSI, the CDC criteria for deep infection, and incision and débridement for infection. Three hundred sixty-one (6%) of the 5761 surgeries received an ICD-9 code for SSI within 90 days of surgery. After review of the medical records of these 361 patients, 216 (4%) met the CDC criteria for deep SSI, and 189 (3%) were taken to the operating room for irrigation and débridement within 180 days of the day of surgery. We found the Charlson Comorbidity Index, the duration of the operation, obesity, and posterior surgical approach were independently associated with a higher risk of infection for each of the three definitions of SSI. The influence of malnutrition, smoking, specific procedures, and specific surgeons varied by definition of infection. These elements accounted for approximately 6% of the variability in the risk of developing an infection. The frequency of SSI after spine surgery varied according to the definition of an infection, but the most important risk factors did not. We conclude that large database studies may be better suited for identifying risk factors than for determining absolute numbers of infections. Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Characteristics of Hemorrhagic Stroke following Spine and Joint Surgeries.

PubMed

Yang, Fei; Zhao, Jianning; Xu, Haidong

2017-01-01

Hemorrhagic stroke can occur after spine and joint surgeries such as laminectomy, lumbar spinal fusion, tumor resection, and total joint arthroplasty. Although this kind of stroke rarely happens, it may cause severe consequences and high mortality rates. Typical clinical symptoms of hemorrhagic stroke after spine and joint surgeries include headache, vomiting, consciousness disturbance, and mental disorders. It can happen several hours after surgeries. Most bleeding sites are located in cerebellar hemisphere and temporal lobe. A cerebrospinal fluid (CSF) leakage caused by surgeries may be the key to intracranial hemorrhages happening. Early diagnosis and treatments are very important for patients to prevent the further progression of intracranial hemorrhages. Several patients need a hematoma evacuation and their prognosis is not optimistic.

Cerebrospinal fluid leaks following spinal or posterior fossa surgery: use of fat grafts for prevention and repair.

PubMed

Black, P

2000-01-01

Cerebrospinal fluid (CSF) leaks are relatively common following spinal or posterior fossa surgery. A midline dural tear in the spine is readily repaired by direct application of a suture. However, far-lateral or ventral dural tears are problematic. Fat is an ideal sealant because it is impermeable to water. In this paper the author reports his experience with using fat grafts for the prevention or repair of CSF leaks and proposes a technique in which a large sheet of fat, harvested from the patient's subcutaneous layer, is used to cover not only the dural tear(s) but all of the exposed dura and is tucked into the lateral recess. This procedure prevents CSF from seeping around the fat, which may be tacked to the dura with a few sutures. Fibrin glue is spread on the surface of the fat and is further covered with Surgicel or Gelfoam. For ventral dural tears (associated with procedures in which disc material is excised), fat is packed into the disc space to seal off the ventral dural leak. Leaks in the posterior fossa are managed similarly to those in the spine. Dural suture lines, following suboccipital or spinal intradural exploration, are prophylactically protected from CSF leakage in the same manner. With one exception, 27 dural tears noted during 1650 spinal procedures were successfully repaired using this technique. There was one case of postoperative CSF leakage in 150 cases in which intradural exploration for tumor or other lesions was undertaken. Both postoperative CSF leaks were controlled by applying additional skin sutures. The use of a fat graft is recommended as a rapid, effective means of prevention and repair of CSF leaks following posterior fossa and spinal surgery.

Bone Morphogenetic Protein Usage in Anterior Lumbar Interbody Fusion: What Else Can Go Wrong?

PubMed

Elias, Elias; Nasser, Zeina; Winegan, Lona; Verla, Terence; Omeis, Ibrahim

2018-03-01

Bone morphogenetic protein (BMP) graft showed promising outcome during early phases of its use. However, unreported adverse events and off-label use shattered its safe profile and raised concerns regarding its indication. In 2008 the U.S. Food and Drug Administration prohibited its use in anterior cervical spine procedures due to the possibility of edema, hematoma, and need to intubate. At the molecular level, BMPs act as multifactorial growth factors playing a role in cartilage, heart, and bone formation. However, its unfavorable effect on bone overgrowth or heterotopic ossification post spine surgeries has been described. Reported cases in the literature were limited to epidural bone formation. We present a rare and interesting case of a 59-year-old female, in whom BMP caused intradural bone growth several years after an anterior lumbar interbody fusion surgery. Caution must be exercised while using BMPs because of inadvertent complications. Copyright © 2017 Elsevier Inc. All rights reserved.

Epithelioid sarcoma of the spine: case report and literature review.

PubMed

Chamadoira, Clara; Pereira, Paulo; Silva, Pedro S; Castro, Ligia; Vaz, Rui

2014-01-01

Epithelioid sarcomas are rare mesenchymal neoplasms mainly arising in the limbs of young adults. We report the case of a 24-year-old male presenting low back pain radiating to both lower limbs, constipation and urinary retention. The MRI scan showed an intraspinal lesion extending from L4 to S2. Surgery resulted in gross total removal of the extradural lesion and partial removal of the intradural component. The immunohistological study of the lesion was consistent with an epithelioid sarcoma. The patient was submitted to radiotherapy and chemotherapy, but a local recurrence of the lesion and dissemination along the neuraxis were observed 3 months after surgery. Despite treatment, the patient died 4 months after the surgical procedure due to multiorgan failure. Despite there being isolated reports of epithelioid sarcomas appearing in the spine, this is, to our knowledge, the first case with intradural extension. Copyright © 2013 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.

[Differentiation of coding quality in orthopaedics by special, illustration-oriented case group analysis in the G-DRG System 2005].

PubMed

Schütz, U; Reichel, H; Dreinhöfer, K

2007-01-01

We introduce a grouping system for clinical practice which allows the separation of DRG coding in specific orthopaedic groups based on anatomic regions, operative procedures, therapeutic interventions and morbidity equivalent diagnosis groups. With this, a differentiated aim-oriented analysis of illustrated internal DRG data becomes possible. The group-specific difference of the coding quality between the DRG groups following primary coding by the orthopaedic surgeon and final coding by the medical controlling is analysed. In a consecutive series of 1600 patients parallel documentation and group-specific comparison of the relevant DRG parameters were carried out in every case after primary and final coding. Analysing the group-specific share in the additional CaseMix coding, the group "spine surgery" dominated, closely followed by the groups "arthroplasty" and "surgery due to infection, tumours, diabetes". Altogether, additional cost-weight-relevant coding was necessary most frequently in the latter group (84%), followed by group "spine surgery" (65%). In DRGs representing conservative orthopaedic treatment documented procedures had nearly no influence on the cost weight. The introduced system of case group analysis in internal DRG documentation can lead to the detection of specific problems in primary coding and cost-weight relevant changes of the case mix. As an instrument for internal process control in the orthopaedic field, it can serve as a communicative interface between an economically oriented classification of the hospital performance and a specific problem solution of the medical staff involved in the department management.

Non-opioid analgesics: Novel approaches to perioperative analgesia for major spine surgery.

PubMed

Dunn, Lauren K; Durieux, Marcel E; Nemergut, Edward C

2016-03-01

Perioperative pain management is a significant challenge following major spine surgery. Many pathways contribute to perioperative pain, including nociceptive, inflammatory, and neuropathic sources. Although opioids have long been a mainstay for perioperative analgesia, other non-opioid therapies have been increasingly used as part of a multimodal analgesic regimen to provide improved pain control while minimizing opioid-related side effects. Here we review the evidence supporting the use of novel analgesic approaches as an alternative to intravenous opioids for major spine surgery. Copyright © 2015 Elsevier Ltd. All rights reserved.

Surgical vs Nonoperative Treatment for Lumbar Disk Herniation

PubMed Central

Weinstein, James N.; Tosteson, Tor D.; Lurie, Jon D.; Tosteson, Anna N. A.; Hanscom, Brett; Skinner, Jonathan S.; Abdu, William A.; Hilibrand, Alan S.; Boden, Scott D.; Deyo, Richard A.

2008-01-01

Context Lumbar diskectomy is the most common surgical procedure performed for back and leg symptoms in US patients, but the efficacy of the procedure relative to nonoperative care remains controversial. Objective To assess the efficacy of surgery for lumbar intervertebral disk herniation. Design, Setting, and Patients The Spine Patient Outcomes Research Trial, a randomized clinical trial enrolling patients between March 2000 and November 2004 from 13 multidisciplinary spine clinics in 11 US states. Patients were 501 surgical candidates (mean age, 42 years; 42% women) with imaging-confirmed lumbar intervertebral disk herniation and persistent signs and symptoms of radiculopathy for at least 6 weeks. Interventions Standard open diskectomy vs nonoperative treatment individualized to the patient. Main Outcome Measures Primary outcomes were changes from baseline for the Medical Outcomes Study 36-item Short-Form Health Survey bodily pain and physical function scales and the modified Oswestry Disability Index (American Academy of Orthopaedic Surgeons MODEMS version) at 6 weeks, 3 months, 6 months, and 1 and 2 years from enrollment. Secondary outcomes included sciatica severity as measured by the Sciatica Bothersomeness Index, satisfaction with symptoms, self-reported improvement, and employment status. Results Adherence to assigned treatment was limited: 50% of patients assigned to surgery received surgery within 3 months of enrollment, while 30% of those assigned to nonoperative treatment received surgery in the same period. Intent-to-treat analyses demonstrated substantial improvements for all primary and secondary outcomes in both treatment groups. Between-group differences in improvements were consistently in favor of surgery for all periods but were small and not statistically significant for the primary outcomes. Conclusions Patients in both the surgery and the nonoperative treatment groups improved substantially over a 2-year period. Because of the large numbers of patients who crossed over in both directions, conclusions about the superiority or equivalence of the treatments are not warranted based on the intent-to-treat analysis. Trial Registration clinicaltrials.gov Identifier: NCT00000410 PMID:17119140

Return-to-Duty Rates Following Minimally Invasive Spine Surgery Performed on Active Duty Military Patients in an Ambulatory Surgery Center.

PubMed

Granger, Elder; Prada, Stefan; Bereczki, Zoltan; Weiss, Michael; Wade, Chip; Davis, Reginald

2018-05-21

Low back pain is a primary health care utilization driver in the US population. Health care evaluation visits for low back pain are as common as medical evaluation for the common cold. Low back pain is the most common reason for reductions in activities of daily living and work activity in the general population. Although these statistics are compelling, in the military population, there is arguably a significantly greater economic impact on the military population, as the cost to train, retain, and deploy a service member is a tremendous cost. The current study retrospectively examines surgical outcomes, return to duty, and patient-centric outcomes among 82 active duty or reserve military patients who underwent an outpatient minimally invasive spine surgery Laminotomy Foraminotomy Decompression for the treatment of lumbar spinal stenosis in an ambulatory surgery center. Overall, our results indicate that within the 82 active duty military service members, 100% of the service members return to duty within 3 mo. Additionally, there was a significant reduction in self-reported pain and disability 12 mo postoperative, whereas the average length of surgery was 62 min with an average estimated blood loss of 30.64 mL. The current study indicates that minimally invasive procedures for the treatment of lumbar spinal stenosis in an ambulatory surgery center setting are an effective option for active duty servicemen to reduce return-to-duty rates and symptomatic back-related pain and disability.

Hospital market concentration, pricing, and profitability in orthopedic surgery and interventional cardiology.

PubMed

Robinson, James C

2011-06-01

To examine the association between hospital market concentration and pricing. Hospitals have been merging into systems that potentially wield bargaining power over private health insurers. Concern is growing among policy makers that these systems may respond to provisions of the 2010 health reform legislation by further increasing consolidation and prices. Multivariate statistical methods were used to evaluate the association between hospital market concentration, prices, and profits (contribution margins) for commercially insured patients admitted for any of 6 major cardiac and orthopedic surgery procedures, adjusting for characteristics of the patient (diagnoses, comorbidities,complications) and of the hospital (size, patient volume, teaching status). Data were obtained on 11,330 patients treated in 61 hospitals in 27 markets across 8 states in 2008. Hospital prices for patients in concentrated markets were higher than hospital prices for otherwise-comparable patients in competitive markets by 25.1% for coronary angioplasty, 13.0%for cardiac rhythm management (CRM) device insertion, 19.2% for total knee replacement, 24.1%for total hip replacement, 19.3% for lumbar spine fusion, and 22.7% for cervical spine fusion (P <.05). Contribution margins were higher in concentrated than in competitive hospital markets by $5259 for angioplasty, $3417 for CRM device insertion, $4123 for total knee replacement, $5889 for total hip replacement, $7931 for lumbar spine fusion, and $4663 for cervical spine fusion (P <.05). Hospitals in concentrated markets charge significantly higher prices and earn significantly higher margins from private insurers than do hospitals in competitive markets.

The Effect of Severity of Illness on Spine Surgery Costs Across New York State Hospitals: An Analysis of 69,831 Cases.

PubMed

Kaye, I David; Adrados, Murillo; Karia, Raj J; Protopsaltis, Themistocles S; Bosco, Joseph A

2017-11-01

Observational database review. To determine the effect of patient severity of illness (SOI) on the cost of spine surgery among New York state hospitals. National health care spending has risen at an unsustainable rate with musculoskeletal care, and spine surgery in particular, accounting for a significant portion of this expenditure. In an effort towards cost-containment, health care payers are exploring novel payment models some of which reward cost savings but penalize excessive spending. To mitigate risk to health care institutions, accurate cost forecasting is essential. No studies have evaluated the effect of SOI on costs within spine surgery. The New York State Hospital Inpatient Cost Transparency Database was reviewed to determine the costs of 69,831 hospital discharges between 2009 and 2011 comprising the 3 most commonly performed spine surgeries in the state. These costs were then analyzed in the context of the specific all patient refined diagnosis-related group (DRG) SOI modifier to determine this index's effect on overall costs. Overall, hospital-reported cost increases with the patient's SOI class and patients with worse baseline health incur greater hospital costs (P<0.001). Moreover, these costs are increasingly variable for each worsening SOI class (P<0.001). This trend of increasing costs is persistent for all 3 DRGs across all 3 years studied (2009-2011), within each of the 7 New York state regions, and occurs irrespective of the hospital's teaching status or size. Using the 3M all patient refined-DRG SOI index as a measure of patient's health status, a significant increase in cost for spine surgery for patients with higher SOI index was found. This study confirms the greater cost and variability of spine surgery for sicker patients and illustrates the inherent unpredictability in cost forecasting and budgeting for these same patients.

Morbidity and mortality of complex spine surgery: a prospective cohort study in 679 patients validating the Spine AdVerse Event Severity (SAVES) system in a European population.

PubMed

Karstensen, Sven; Bari, Tanvir; Gehrchen, Martin; Street, John; Dahl, Benny

2016-02-01

Most literature on complications in spine surgery has been retrospective or based on national databases with few variables. The Spine AdVerse Events Severity (SAVES) system has been found reliable and valid in two Canadian centers, providing precise information regarding all adverse events (AEs). This study aimed to determine the mortality and examine the incidence of morbidity in patients undergoing complex spinal surgery, including pediatric patients, and to validate the SAVES system in a European population. A prospective, consecutive cohort study was conducted using the SAVES version 2010 in the period from January 1, 2013 until December 31, 2013. A retrospective analysis was performed on all patients operated from November 1, 2011 until October 31, 2012 for comparison. Patients undergoing spinal surgery at a tertiary referral center comprised the patient sample. Morbidity and mortality were determined according to the newest version of the SAVES system and compared with the Canadian cohort. Other outcomes were length of stay, readmission, unplanned second surgery during index admission, as well as wound infections requiring revision. All patients undergoing spinal surgery at an academic tertiary referral center in the study period were prospectively included. The newest version of SAVES system was used, and a research coordinator collected all intraoperative and perioperative data prospectively. Once a week all patients were reviewed for additional events, validation of the data, and clarification of any questions. Patients were grouped according to the type of admission (elective of emergency) and age, and subgrouped according to a major diagnostic group. The survival status was registered on January 31, 2014 to obtain 30-day survival. A total of 679 consecutive cases were included with 100% data completion. The in-hospital mortality was 1.3% and the 30-day mortality was 2.7%; all occurring after emergency procedures. The number of intraoperative AEs was 162 (overall incidence 20%), and the number of postoperative AEs was 1,415 (overall incidence 77%). Of the patients, 2.2% had postoperative infections requiring surgical revision. A prospective registration improves AE recognition, and our data confirm the generalizability of the SAVES system to pediatric and non-Canadian populations. Copyright © 2015 Elsevier Inc. All rights reserved.

Surgical management of prostate cancer metastatic to the spine.

PubMed

Williams, Brian J; Fox, Benjamin D; Sciubba, Daniel M; Suki, Dima; Tu, Shi Ming; Kuban, Deborah; Gokaslan, Ziya L; Rhines, Laurence D; Rao, Ganesh

2009-05-01

Significant improvements in neurological function and pain relief are the benefits of aggressive surgical management of spinal metastatic disease. However, there is limited literature regarding the management of tumors with specific histological features. In this study, a series of patients undergoing spinal surgery for metastatic prostate cancer were reviewed to identify predictors of survival and functional outcome. The authors retrospectively reviewed the records of all patients who were treated with surgery for prostate cancer metastases to the spine between 1993 and 2005 at a single institution. Particular attention was given to initial presentation, operative management, clinical and neurological outcomes, and factors associated with complications and overall survival. Forty-four patients underwent a total of 47 procedures. The median age at spinal metastasis was 66 years (range 50-84 years). Twenty-four patients had received previous external-beam radiation to the site of spinal involvement, with a median dose of 70 Gy (range 30-74 Gy). Frankel scores on discharge were significantly improved when compared with preoperative scores (p = 0.001). Preoperatively, 32 patients (73%) were walking and 33 (75%) were continent. On discharge, 36 (86%) of 42 patients were walking, and 37 (88%) of 42 were continent. Preoperatively, 40 patients (91%) were taking narcotics, with a median morphine equivalent dose of 21.5 mg/day, and 28 patients (64%) were taking steroids, with a median dose of 16 mg/day. At discharge, the median postoperative morphine equivalent dose was 12 mg/day, and the median steroid dose was 0 mg/day (p < 0.001). Complications occurred in 15 (32%) of 47 procedures, with 9 (19%) considered major, and there were 4 deaths within 30 days of surgery. The median overall survival was 5.4 months. Gleason score (p = 0.002), total number of metastases (p = 0.001), and the degree of spinal canal compression (p = 0.001) were independent predictors of survival. Age > or = 65 years at the time of surgery was an independent predictor of a postoperative complication (p = 0.005). In selected patients with prostate cancer metastases to the spine, aggressive surgical decompression and spinal reconstruction is a useful treatment option. The results show that on average, neurological outcome is improved and use of analgesics is reduced. Gleason score, metastatic burden, and degree of spinal canal compression may be associated with survival following surgery, and thus should be considered carefully prior to opting for surgical management.

Readability of Spine-Related Patient Education Materials From Leading Orthopedic Academic Centers.

PubMed

Ryu, Justine H; Yi, Paul H

2016-05-01

Cross-sectional analysis of online spine-related patient education materials from leading academic centers. To assess the readability levels of spine surgery-related patient education materials available on the websites of academic orthopedic surgery departments. The Internet is becoming an increasingly popular resource for patient education. Yet many previous studies have found that Internet-based orthopedic-related patient education materials from subspecialty societies are written at a level too difficult for the average American; however, no prior study has assessed the readability of spine surgery-related patient educational materials from leading academic centers. All spine surgery-related articles from the online patient education libraries of the top five US News & World Report-ranked orthopedic institutions were assessed for readability using the Flesch-Kincaid (FK) readability test. Mean readability levels of articles amongst the five academic institutions and articles were compared. We also determined the number of articles with readability levels at or below the recommended sixth- or eight-grade levels. Intraobserver and interobserver reliability of readability assessment were assessed. A total of 122 articles were reviewed. The mean overall FK grade level was 11.4; the difference in mean FK grade level between each department varied significantly (range, 9.3-13.4; P < 0.0001). Twenty-three articles (18.9%) had a readability level at or below the eighth grade level, and only one (0.8%) was at or below the sixth grade level. Intraobserver and interobserver reliability were both excellent (intraclass correlation coefficient of 1 for both). Online patient education materials related to spine from academic orthopedic centers are written at a level too high for the average patient, consistent with spine surgery-related patient education materials provided by the American Academy of Orthopaedic Surgeons and spine subspecialty societies. This study highlights the potential difficulties patients might have in reading and comprehending the information in publicly available education materials related to spine. N/A.

Is the use of minimally invasive fusion technologies associated with improved outcomes after elective interbody lumbar fusion? Analysis of a nationwide prospective patient-reported outcomes registry.

PubMed

McGirt, Matthew J; Parker, Scott L; Mummaneni, Praveen; Knightly, John; Pfortmiller, Deborah; Foley, Kevin; Asher, Anthony L

2017-07-01

Over the last decade, clinical investigators and biomedical industry groups have used significant resources to develop advanced technologies that enable less invasive spine fusions. These minimally invasive surgery (MIS) technologies often require increased expenditures by hospitals and payers. Although several small single center studies have suggested MIS technologies decrease surgical morbidity and reduce hospital stay, evidence documenting benefit from a patient perspective remains limited. Furthermore, MIS outcomes have yet to be evaluated from the perspective of multiple practice types representing the broad spectrum of US spine surgery. This study aimed to examine a population of patients who underwent one- or two-level interbody lumbar fusion diagnosed with lumbar stenosis or Grade 1 spondylolisthesis in an observational, prospective national registry for the purposes of determining how MIS and traditional open technologies affect postsurgical and patient-reported outcomes (PROs). This study used observational analysis of prospectively collected data. The sample consisted of cases from the National Neurosurgery Quality and Outcomes Database (N 2 QOD). Numeric rating scale for back and leg pain, Oswestry Disability Index, EuroQol-5D, return to work, and perioperative morbidity were the outcome measures. The N 2 QOD is a prospective PROs registry enrolling patients undergoing elective spine surgery from 60 hospitals in 27 US states via representative sampling. We analyzed the N 2 QOD aggregate dataset (2010-2014) to identify one- and two-level lumbar interbody fusion procedures performed for lumbar stenosis or Grade 1 spondylolisthesis with 12 months' follow-up where surgical instrumentation and implant types were clearly identified. Perioperative and 1-year outcomes were compared between cases performed with MIS enabling technologies versus traditional open technologies before and after propensity matching. There were 467 (24%) patients who underwent elective interbody lumbar fusion using MIS enabling technologies whereas 1,480 (76%) underwent the procedure using traditional open technologies. The MIS patients were slightly healthier (American Society of Anesthesiologists grade), had private insurance more frequently, and underwent two-level fusion less frequently. Unmatched, the MIS cohort was associated with reduced blood loss, a 0.7-day reduction in mean length of hospital stay, and 5% reduced need for post-discharge inpatient rehabilitation, but equivalent 90-day safety measures. After propensity matching, the MIS cohort remained associated with reduced blood loss and a shorter length of stay for one-level fusion (p<.05) but had equivalent length of stay for two-level fusion. Outcomes in all other 90-day safety measures were similar. In both unadjusted and propensity-matched comparison, MIS versus open technologies were associated with equivalent return to work, patient-reported pain, physical disability, and quality of life at 3 and 12 months' follow-up. In a representative sampling registry of elective interbody lumbar spine fusion procedures spanning 27 US states, nearly a quarter of procedures performed from 2010 to 2014 used minimally invasive enabling technologies. Regardless of approach, interbody lumbar fusion was associated with significant and sustained improvements in all measured health domains. When used in everyday care by a wide spectrum of spine surgeons in non-research settings, the use of MIS technologies was associated with reduced intraoperative blood loss but only a half-day reduction in mean length of hospital stay for one-level fusions. Minimally invasive surgery was not associated with any improved perioperative safety measures or 12-month outcomes. Although MIS enabling technologies may increase some in-hospital care efficiencies, MIS clinical outcomes are similar to open surgery for patients undergoing one- and two-level interbody lumbar fusions. Copyright © 2017 Elsevier Inc. All rights reserved.

Narrative review of the in vivo mechanics of the cervical spine after anterior arthrodesis as revealed by dynamic biplane radiography.

PubMed

Anderst, William

2016-01-01

Arthrodesis is the standard of care for numerous pathologic conditions of the cervical spine and is performed over 150,000 times annually in the United States. The primary long-term concern after this surgery is adjacent segment disease (ASD), defined as new clinical symptoms adjacent to a previous fusion. The incidence of adjacent segment disease is approximately 3% per year, meaning that within 10 years of the initial surgery, approximately 25% of cervical arthrodesis patients require a second procedure to address symptomatic adjacent segment degeneration. Despite the high incidence of ASD, until recently, there was little data available to characterize in vivo adjacent segment mechanics during dynamic motion. This manuscript reviews recent advances in our knowledge of adjacent segment mechanics after cervical arthrodesis that have been facilitated by the use of dynamic biplane radiography. The primary observations from these studies are that current in vitro test paradigms often fail to replicate in vivo spine mechanics before and after arthrodesis, that intervertebral mechanics vary among cervical motion segments, and that joint arthrokinematics (i.e., the interactions between adjacent vertebrae) are superior to traditional kinematics measurements for identifying altered adjacent segment mechanics after arthrodesis. Future research challenges are identified, including improving the biofidelity of in vitro tests, determining the natural history of in vivo spine mechanics, conducting prospective longitudinal studies on adjacent segment kinematics and arthrokinematics after single and multiple-level arthrodesis, and creating subject-specific computational models to accurately estimate muscle forces and tissue loading in the spine during dynamic activities. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc.

When Less Is More: The indications for MIS Techniques and Separation Surgery in Metastatic Spine Disease.

PubMed

Zuckerman, Scott L; Laufer, Ilya; Sahgal, Arjun; Yamada, Yoshiya J; Schmidt, Meic H; Chou, Dean; Shin, John H; Kumar, Naresh; Sciubba, Daniel M

2016-10-15

Systematic review. The aim of this study was to review the techniques, indications, and outcomes of minimally invasive surgery (MIS) and separation surgery with subsequent radiosurgery in the treatment of patients with metastatic spine disease. The utilization of MIS techniques in patients with spine metastases is a growing area within spinal oncology. Separation surgery represents a novel paradigm where radiosurgery provides long-term control after tumor is surgically separated from the neural elements. PubMed, Embase, and CINAHL databases were systematically queried for literature reporting MIS techniques or separation surgery in patients with metastatic spine disease. PRISMA guidelines were followed. Of the initial 983 articles found, 29 met inclusion criteria. Twenty-five articles discussed MIS techniques and were grouped according to the primary objective: percutaneous stabilization (8), tubular retractors (4), mini-open approach (8), and thoracoscopy/endoscopy (5). The remaining 4 studies reported separation surgery. Indications were similar across all studies and included patients with instability, refractory pain, or neurologic compromise. Intraoperative variables, outcomes, and complications were similar in MIS studies compared to traditional approaches, and some MIS studies showed a statistically significant improvement in outcomes. Studies of mini-open techniques had the strongest evidence for superiority. Low-quality evidence currently exists for MIS techniques and separation surgery in the treatment of metastatic spine disease. Given the early promising results, the next iteration of research should include higher-quality studies with sufficient power, and will be able to provide higher-level evidence on the outcomes of MIS approaches and separation surgery. N/A.

Prone position in balloon kyphoplasty leads to no secondary vertebral compression fractures in osteoporotic spine – a MRI study

PubMed Central

Spalteholz, Matthias; Strasser, Evald; Hantel, Torsten; Gahr, Ralf Herbert

2014-01-01

Purpose: Vertebral compression fractures are the most common fractures in the elderly. Long lasting pain and deformity is responsible for consecutive impairment with markedly reduced life quality, increased morbidity and mortality. The beneficial effects of balloon kyphoplasty are verified in many studies. Subsequent fracture risk is not finally clarified, cement related risks and deformity related risks are discussed. There is less knowledge about the risk of bone marrow edema and new fractures during balloon kyphoplasty procedure. The goal of this study is to examine, if prone position during kyphoplasty is an independent risk factor for new fractures in the osteoporotic spine. Methods: Consecutive MRI study of 20 patients with fresh, non-traumatic thoracolumbar vertebral compression fractures and balloon kyphoplasty treatment. MRI Scans of the thoracolumbar spine were obtained after surgery, before patients have been mobilized. Specific MRI changes like new bone marrow edema, signal intensity changes in adjacent and remote segments and new fractures were assessed by specialized neuro-radiologist. Results: 20 MR images were examined within 48 hours after balloon kyphoplasty procedure. 85% did not show bone marrow edema extent changes after kyphoplasty. We found minor increase of bone marrow edema within the augmented vertebral body in 3 cases. We did not find any new bone marrow edema and no new fractures in adjacent and remote segments after balloon kyphoplasty treatment. Conclusion: Prone position leads to no new bone marrow edema and no new fractures in the osteoporotic spine. Accordingly, prone position has no risk for adjacent level fractures in osteoporotic spines. PMID:26504728

Bone substitutes and expanders in Spine Surgery: A review of their fusion efficacies

PubMed Central

Millhouse, Paul W; Kepler, Christopher K; Radcliff, Kris E.; Fehlings, Michael G.; Janssen, Michael E.; Sasso, Rick C.; Benedict, James J.; Vaccaro, Alexander R

2016-01-01

Study Design A narrative review of literature. Objective This manuscript intends to provide a review of clinically relevant bone substitutes and bone expanders for spinal surgery in terms of efficacy and associated clinical outcomes, as reported in contemporary spine literature. Summary of Background Data Ever since the introduction of allograft as a substitute for autologous bone in spinal surgery, a sea of literature has surfaced, evaluating both established and newly emerging fusion alternatives. An understanding of the available fusion options and an organized evidence-based approach to their use in spine surgery is essential for achieving optimal results. Methods A Medline search of English language literature published through March 2016 discussing bone graft substitutes and fusion extenders was performed. All clinical studies reporting radiological and/or patient outcomes following the use of bone substitutes were reviewed under the broad categories of Allografts, Demineralized Bone Matrices (DBM), Ceramics, Bone Morphogenic proteins (BMPs), Autologous growth factors (AGFs), Stem cell products and Synthetic Peptides. These were further grouped depending on their application in lumbar and cervical spine surgeries, deformity correction or other miscellaneous procedures viz. trauma, infection or tumors; wherever data was forthcoming. Studies in animal populations and experimental in vitro studies were excluded. Primary endpoints were radiological fusion rates and successful clinical outcomes. Results A total of 181 clinical studies were found suitable to be included in the review. More than a third of the published articles (62 studies, 34.25%) focused on BMP. Ceramics (40 studies) and Allografts (39 studies) were the other two highly published groups of bone substitutes. Highest radiographic fusion rates were observed with BMPs, followed by allograft and DBM. There were no significant differences in the reported clinical outcomes across all classes of bone substitutes. Conclusions There is a clear publication bias in the literature, mostly favoring BMP. Based on the available data, BMP is however associated with the highest radiographic fusion rate. Allograft is also very well corroborated in the literature. The use of DBM as a bone expander to augment autograft is supported, especially in the lumbar spine. Ceramics are also utilized as bone graft extenders and results are generally supportive, although limited. The use of autologous growth factors is not substantiated at this time. Cell matrix or stem cell-based products and the synthetic peptides have inadequate data. More comparative studies are needed to evaluate the efficacy of bone graft substitutes overall. PMID:27909654

[Orthopedic and trauma surgery in the German DRG System 2007].

PubMed

Franz, D; Kaufmann, M; Siebert, C H; Windolf, J; Roeder, N

2007-03-01

The German Diagnosis-Related Groups (DRG) System was further developed into its 2007 version. For orthopedic and trauma surgery, significant changes were made in terms of the coding of diagnoses and medical procedures, as well as in the DRG structure itself. The German Societies for Trauma Surgery and for Orthopedics and Orthopedic Surgery (Deutsch Gesellschaft für Unfallchirurgie, DGU; and Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie, DGOOC) once again cooperated constructively with the German DRG Institute InEK. Among other innovations, new International Classification of Diseases (ICD) codes for second-degree burns were implemented. Procedure codes for joint operations, endoprosthetic-surgery and spine surgery were restructured. Furthermore, a specific code for septic surgery was introduced in 2007. In addition, the DRG structure was improved. Case allocation of patients with more than one significant operation was established. Further DRG subdivisions were established according to the patients age and the Patient Clinical Complexity Level (PCCL). DRG developments for 2007 have improved appropriate case allocation, but once again increased the system's complexity. Clinicians need an ever growing amount of specific coding know-how. Still, further adjustments to the German DRG system are required to allow for a correct allocation of cases and funds.

Intraoperative Neurophysiological Monitoring in Spine Surgery: A Significant Tool for Neuronal Protection and Functional Restoration.

PubMed

Scibilia, Antonino; Raffa, Giovanni; Rizzo, Vincenzo; Quartarone, Angelo; Visocchi, Massimiliano; Germanò, Antonino; Tomasello, Francesco

2017-01-01

Although there is recent evidence for the role of intraoperative neurophysiological monitoring (IONM) in spine surgery, there are no uniform opinions on the optimal combination of the different tools. At our institution, multimodal IONM (mIONM) approach in spine surgery involves the evaluation of somatosensory evoked potentials (SEPs) and motor evoked potentials (MEPs) with electrical transcranial stimulation, including the use of a multipulse technique with multiple myomeric registration of responses from limbs, and a single-pulse technique with D-wave registration through epi- and intradural recording, and free running and evoked electromyography (frEMG and eEMG) with bilateral recording from segmental target muscles. We analyzed the impact of the mIONM on the preservation of neuronal structures and on functional restoration in a prospective series of patients who underwent spine surgery. We observed an improvement of neurological status in 50 % of the patients. The D-wave registration was the most useful intraoperative tool, especially when MEP and SEP responses were absent or poorly recordable. Our preliminary data confirm that mIONM plays a fundamental role in the identification and functional preservation of the spinal cord and nerve roots. It is highly sensitive and specific for detecting and avoiding neurological injury during spine surgery and represents a helpful tool for achieving optimal postoperative functional outcome.

A short review on a complication of lumbar spine surgery: CSF leak.

PubMed

Menon, Sajesh K; Onyia, Chiazor U

2015-12-01

Cerebrospinal fluid (CSF) leak is a common complication of surgery involving the lumbar spine. Over the past decades, there has been significant advancement in understanding the basis, management and techniques of treatment for post-operative CSF leak following lumbar spine surgery. In this article, we review previous work in the literature on the various factors and technical errors during or after lumbar spine surgery that may lead to this feared complication, the available options of management with focus on the various techniques employed, the outcomes and also to highlight on the current trends. We also discuss the presentation, factors contributing to its development, basic concepts and practical aspects of the management with emphasis on the different techniques of treatment. Different outcomes following various techniques of managing post-operative CSF leak after lumbar spine surgery have been well described in the literature. However, there is currently no most ideal technique among the available options. The choice of which technique to be applied in each case is dependent on each surgeon's cumulative experience as well as a clear understanding of the contributory underlying factors in each patient, the nature and site of the leak, the available facilities and equipment. Copyright © 2015 Elsevier B.V. All rights reserved.

Rheumatoid Arthritis and the Cervical Spine: A Review on the Role of Surgery

PubMed Central

Gillick, John L.; Wainwright, John; Das, Kaushik

2015-01-01

Rheumatoid arthritis (RA) is a chronic systemic inflammatory disease affecting a significant percentage of the population. The cervical spine is often affected in this disease and can present in the form of atlantoaxial instability (AAI), cranial settling (CS), or subaxial subluxation (SAS). Patients may present with symptoms and disability secondary to these entities but may also be neurologically intact. Cervical spine involvement in RA can pose a challenge to the clinician and the appropriate role of surgical intervention is controversial. The aim of this paper is to describe the pathology, pathophysiology, clinical manifestations, and diagnostic evaluation of rheumatoid arthritis in the cervical spine in order to provide a better understanding of the indications and options for surgery. Both the medical and surgical treatment options for RA have improved, so has the prognosis of the cervical spine disease. With the advent of disease modifying antirheumatic drugs (DMARDs), fewer patients are presenting with cervical spine manifestations of RA; however, those that do, now have improved surgical techniques available to them. We hope that, by reading this paper, the clinician is able to better evaluate patients with RA in the cervical spine and determine in which patients surgery is indicated. PMID:26351458

Postoperative 3D spine reconstruction by navigating partitioning manifolds

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kadoury, Samuel, E-mail: samuel.kadoury@polymtl.ca; Labelle, Hubert, E-mail: hubert.labelle@recherche-ste-justine.qc.ca; Parent, Stefan, E-mail: stefan.parent@umontreal.ca

Purpose: The postoperative evaluation of scoliosis patients undergoing corrective treatment is an important task to assess the strategy of the spinal surgery. Using accurate 3D geometric models of the patient’s spine is essential to measure longitudinal changes in the patient’s anatomy. On the other hand, reconstructing the spine in 3D from postoperative radiographs is a challenging problem due to the presence of instrumentation (metallic rods and screws) occluding vertebrae on the spine. Methods: This paper describes the reconstruction problem by searching for the optimal model within a manifold space of articulated spines learned from a training dataset of pathological casesmore » who underwent surgery. The manifold structure is implemented based on a multilevel manifold ensemble to structure the data, incorporating connections between nodes within a single manifold, in addition to connections between different multilevel manifolds, representing subregions with similar characteristics. Results: The reconstruction pipeline was evaluated on x-ray datasets from both preoperative patients and patients with spinal surgery. By comparing the method to ground-truth models, a 3D reconstruction accuracy of 2.24 ± 0.90 mm was obtained from 30 postoperative scoliotic patients, while handling patients with highly deformed spines. Conclusions: This paper illustrates how this manifold model can accurately identify similar spine models by navigating in the low-dimensional space, as well as computing nonlinear charts within local neighborhoods of the embedded space during the testing phase. This technique allows postoperative follow-ups of spinal surgery using personalized 3D spine models and assess surgical strategies for spinal deformities.« less

Lumbar Spine Surgery in Patients with Parkinson Disease.

PubMed

Schroeder, Joshua E; Hughes, Alexander; Sama, Andrew; Weinstein, Joseph; Kaplan, Leon; Cammisa, Frank P; Girardi, Federico P

2015-10-21

Parkinson disease is the second most common neurodegenerative condition. The literature on patients with Parkinson disease and spine surgery is limited, but increased complications have been reported. All patients with Parkinson disease undergoing lumbar spine surgery between 2002 and 2012 were identified. Patients' charts, radiographs, and outcome questionnaires were reviewed. Parkinson disease severity was assessed with use of the modified Hoehn and Yahr staging scale. Complications and subsequent surgeries were analyzed. Risk for reoperation was assessed. Ninety-six patients underwent lumbar spine surgery. The mean patient age was 63.0 years. The mean follow-up duration was 30.1 months. The Parkinson disease severity stage was <2 in thirteen patients, 2 in thirty patients, 2.5 in twenty-three patients, and ≥3 in thirty patients. The primary indication for surgery was spinal stenosis in seventy-two patients, spondylolisthesis in seventeen patients, and coronal and/or sagittal deformity in seven patients. There were nineteen early complications, including postoperative infections requiring surgical irrigation and debridement and long-term antibiotics in ten patients. The visual analog scale for back pain improved from 7.4 cm preoperatively to 1.8 cm postoperatively (p < 0.001). The visual analog scale for lower-limb pain improved from 7.7 cm preoperatively to 2.3 cm postoperatively (p < 0.001). The Oswestry Disability Index score dropped from 54.1 points to 17.7 points at the time of the latest follow-up (p < 0.001). The Short Form-12 Physical Component Summary score improved from 26.6 points preoperatively to 30.5 points postoperatively (p < 0.05). Twenty patients required revision surgery. Risks for further surgery included a Parkinson disease severity stage of ≥3 (p < 0.05), a history of diabetes mellitus, treatment for osteoporosis, and a combined anterior and posterior approach. Despite a higher rate of complications than in the general population, the overall outcome of spine surgery in patients with mild to moderate Parkinson disease is good, with improvement of spine-related pain. A larger prospective study is warranted. Copyright © 2015 by The Journal of Bone and Joint Surgery, Incorporated.

The cost effectiveness of single-level instrumented posterolateral lumbar fusion at 5 years after surgery.

PubMed

Glassman, Steven D; Polly, David W; Dimar, John R; Carreon, Leah Y

2012-04-20

Cost effectiveness analysis for single-level instrumented fusion during a 5-year postoperative interval. To determine the cost/quality-adjusted life year (QALY) gained for single-level instrumented posterolateral lumbar fusion for degenerative lumbar spine conditions during a 5-year period. Cost/QALY has become a standard measure among healthcare economists because it is generic and can be used across medical treatments. Prior studies have reported widely variable estimates of cost/QALY for lumbar spine fusion. This variability may be related to factors including study design, sample population, baseline assumptions, and length of the observation period. To determine QALY, the Short Form 6D (SF-6D), a utility index derived from the Short Form (36) Health Survey (SF-36) was used. Cost analysis was performed based on actual reimbursements from third-party payors, including those for the index surgical procedure, treatment of complications, emergency room outpatient visits, and revision surgery. A second cost analysis using only the contemporaneous Medicare Fee schedule was also performed, in addition to a subanalysis including indirect costs from days off work. The mean SF-6D health utility value showed a gradual increase throughout the follow-up period. The mean health utility value gained in each year postoperatively was 0.12, 0.14, 0.13, 0.15, and 0.15, for a cumulative 0.69 QALY improvement during the 5-year interval. Mean direct medical costs based on actual reimbursements for 5 years after surgery, including the index and revision procedures, was $22,708. The resultant cost per QALY gained at the 5-year postoperative interval was $33,018. The analogous mean direct cost based on Medicare reimbursement for 5 years was $20,669, with a resultant cost per QALY gained of $30,053. The mean total work productivity cost for 5 years was $14,377. The resultant total cost (direct and indirect) per QALY gained ranged from $53,949 to $53,914 at 5 years postoperatively. In the future, surgeons will need to demonstrate cost-effectiveness as well as clinical efficacy in order to justify payment for medical and surgical interventions, including lumbar spine fusion. This study indicates that at 5-year follow-up, single-level instrumented posterolateral spine fusion is both effective and durable, resulting in a favorable cost/QALY gain compared to other widely accepted healthcare interventions.

Do measures of surgical effectiveness at 1 year after lumbar spine surgery accurately predict 2-year outcomes?

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Han, Jing L; Cheng, Joseph; Karikari, Isaac; Bagley, Carlos A

2016-12-01

OBJECTIVE With the recent passage of the Patient Protection and Affordable Care Act, there has been a dramatic shift toward critical analyses of quality and longitudinal assessment of subjective and objective outcomes after lumbar spine surgery. Accordingly, the emergence and routine use of real-world institutional registries have been vital to the longitudinal assessment of quality. However, prospectively obtaining longitudinal outcomes for patients at 24 months after spine surgery remains a challenge. The aim of this study was to assess if 12-month measures of treatment effectiveness accurately predict long-term outcomes (24 months). METHODS A nationwide, multiinstitutional, prospective spine outcomes registry was used for this study. Enrollment criteria included available demographic, surgical, and clinical outcomes data. All patients had prospectively collected outcomes measures and a minimum 2-year follow-up. Patient-reported outcomes instruments (Oswestry Disability Index [ODI], SF-36, and visual analog scale [VAS]-back pain/leg pain) were completed before surgery and then at 3, 6, 12, and 24 months after surgery. The Health Transition Index of the SF-36 was used to determine the 1- and 2-year minimum clinically important difference (MCID), and logistic regression modeling was performed to determine if achieving MCID at 1 year adequately predicted improvement and achievement of MCID at 24 months. RESULTS The study group included 969 patients: 300 patients underwent anterior lumbar interbody fusion (ALIF), 606 patients underwent transforaminal lumbar interbody fusion (TLIF), and 63 patients underwent lateral interbody fusion (LLIF). There was a significant correlation between the 12- and 24-month ODI (r = 0.82; p < 0.0001), SF-36 Physical Component Summary score (r = 0.89; p < 0.0001), VAS-back pain (r = 0.90; p < 0.0001), and VAS-leg pain (r = 0.85; p < 0.0001). For the ALIF cohort, patients achieving MCID thresholds for ODI at 12 months were 13-fold (p < 0.0001) more likely to achieve MCID at 24 months. Similarly, for the TLIF and LLIF cohorts, patients achieving MCID thresholds for ODI at 12 months were 13-fold and 14-fold (p < 0.0001) more likely to achieve MCID at 24 months. Outcome measures obtained at 12 months postoperatively are highly predictive of 24-month outcomes, independent of the surgical procedure. CONCLUSIONS In a multiinstitutional prospective study, patient-centered measures of surgical effectiveness obtained at 12 months adequately predict long-term (24-month) outcomes after lumbar spine surgery. Patients achieving MCID at 1 year were more likely to report meaningful and durable improvement at 24 months, suggesting that the 12-month time point is sufficient to identify effective versus ineffective patient care.

Prevalence and Outcomes in Patients Undergoing Reintubation After Anterior Cervical Spine Surgery: Results From the AOSpine North America Multicenter Study on 8887 Patients.

PubMed

Nagoshi, Narihito; Fehlings, Michael G; Nakashima, Hiroaki; Tetreault, Lindsay; Gum, Jeffrey L; Smith, Zachary A; Hsu, Wellington K; Tannoury, Chadi A; Tannoury, Tony; Traynelis, Vincent C; Arnold, Paul M; Mroz, Thomas E; Gokaslan, Ziya L; Bydon, Mohamad; De Giacomo, Anthony F; Jobse, Bruce C; Massicotte, Eric M; Riew, K Daniel

2017-04-01

A multicenter, retrospective cohort study. To evaluate clinical outcomes in patients with reintubation after anterior cervical spine surgery. A total of 8887 patients undergoing anterior cervical spine surgery were enrolled in the AOSpine North America Rare Complications of Cervical Spine Surgery study. Patients with or without complications after surgery were included. Demographic and surgical information were collected for patients with reintubation. Patients were evaluated using a variety of assessment tools, including the modified Japanese Orthopedic Association scale, Nurick score, Neck Disability Index, and Short Form-36 Health Survey. Nine cases of postoperative reintubation were identified. The total prevalence of this complication was 0.10% and ranged from 0% to 0.59% across participating institutions. The time to development of airway symptoms after surgery was within 24 hours in 6 patients and between 5 and 7 days in 3 patients. Although 8 patients recovered, 1 patient died. At final follow-up, patients with reintubation did not exhibit significant and meaningful improvements in pain, functional status, or quality of life. Although the prevalence of reintubation was very low, this complication was associated with adverse clinical outcomes. Clinicians should identify their high-risk patients and carefully observe them for up to 2 weeks after surgery.

Racial Disparities in 30-Day Readmission Rates After Elective Spine Surgery: A Single Institutional Experience.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Mehta, Ankit I; Cheng, Joseph; Bagley, Carlos A; Karikari, Isaac O

2016-11-01

Retrospective cohort review. The aim of this study is to investigate whether patient race is an independent predictor of unplanned 30-day hospital readmission after elective spine surgery. Racial disparities are known to exist for many aspects of surgical care. However, it is unknown if disparities exist in 30-day readmissions after elective spine surgery, an area that is becoming a prime focus for clinical leaders and policymakers. Records of 600 patients undergoing elective spine surgery at a major academic medical center were reviewed. We identified all unplanned readmissions within 30 days of discharge. Unplanned readmissions were defined to have occurred as a result of either a surgical or a nonsurgical complication. Patient's records were reviewed to determine the cause of readmission and the length of hospital stay. The main outcome measure was risk-adjusted odds of all-cause 30-day readmission. We used multivariate logistic regression to determine if Black patients had an increased likelihood of 30-day readmission compared with White patients. Baseline characteristics were similar between both groups. Black patients had higher readmission rates than White patients (10.56% vs. 7.86%, P = 0.04). In a univariate analysis, race, body mass index, sex, patient age, smoking, diabetes, and fusion levels were associated with increased 30-day readmission rates. However, in a multivariate logistic regression model, race was an independent predictor of 30-day readmission after elective spine surgery. In addition, no significant differences in baseline, 1-year and 2-year patient reported outcomes measures were observed between both groups. This study suggests that Black patients are more likely to be readmitted within 30-days of discharge after elective spine surgery. Efforts at reducing disparities should focus not only on race-based measures but also effective post discharge care. 3.

Variation in payments for spine surgery episodes of care: implications for episode-based bundled payment.

PubMed

Kahn, Elyne N; Ellimoottil, Chandy; Dupree, James M; Park, Paul; Ryan, Andrew M

2018-05-25

OBJECTIVE Spine surgery is expensive and marked by high variation across regions and providers. Bundled payments have potential to reduce unwarranted spending associated with spine surgery. This study is a cross-sectional analysis of commercial and Medicare claims data from January 2012 through March 2015 in the state of Michigan. The objective was to quantify variation in payments for spine surgery in adult patients, document sources of variation, and determine influence of patient-level, surgeon-level, and hospital-level factors. METHODS Hierarchical regression models were used to analyze contributions of patient-level covariates and influence of individual surgeons and hospitals. The primary outcome was price-standardized 90-day episode payments. Intraclass correlation coefficients-measures of variability accounted for by each level of a hierarchical model-were used to quantify sources of spending variation. RESULTS The authors analyzed 17,436 spine surgery episodes performed by 195 surgeons at 50 hospitals. Mean price-standardized 90-day episode payments in the highest spending quintile exceeded mean payments for episodes in the lowest cost quintile by $42,953 (p < 0.001). Facility payments for index admission and post-discharge payments were the greatest contributors to overall variation: 39.4% and 32.5%, respectively. After accounting for patient-level covariates, the remaining hospital-level and surgeon-level effects accounted for 2.0% (95% CI 1.1%-3.8%) and 4.0% (95% CI 2.9%-5.6%) of total variation, respectively. CONCLUSIONS Significant variation exists in total episode payments for spine surgery, driven mostly by variation in post-discharge and facility payments. Hospital and surgeon effects account for relatively little of the observed variation.

A simple method for in vivo measurement of implant rod three-dimensional geometry during scoliosis surgery.

PubMed

Salmingo, Remel A; Tadano, Shigeru; Fujisaki, Kazuhiro; Abe, Yuichiro; Ito, Manabu

2012-05-01

Scoliosis is defined as a spinal pathology characterized as a three-dimensional deformity of the spine combined with vertebral rotation. Treatment for severe scoliosis is achieved when the scoliotic spine is surgically corrected and fixed using implanted rods and screws. Several studies performed biomechanical modeling and corrective forces measurements of scoliosis correction. These studies were able to predict the clinical outcome and measured the corrective forces acting on screws, however, they were not able to measure the intraoperative three-dimensional geometry of the spinal rod. In effect, the results of biomechanical modeling might not be so realistic and the corrective forces during the surgical correction procedure were intra-operatively difficult to measure. Projective geometry has been shown to be successful in the reconstruction of a three-dimensional structure using a series of images obtained from different views. In this study, we propose a new method to measure the three-dimensional geometry of an implant rod using two cameras. The reconstruction method requires only a few parameters, the included angle θ between the two cameras, the actual length of the rod in mm, and the location of points for curve fitting. The implant rod utilized in spine surgery was used to evaluate the accuracy of the current method. The three-dimensional geometry of the rod was measured from the image obtained by a scanner and compared to the proposed method using two cameras. The mean error in the reconstruction measurements ranged from 0.32 to 0.45 mm. The method presented here demonstrated the possibility of intra-operatively measuring the three-dimensional geometry of spinal rod. The proposed method could be used in surgical procedures to better understand the biomechanics of scoliosis correction through real-time measurement of three-dimensional implant rod geometry in vivo.

Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients.

PubMed

Tubaki, Vijay Ramappa; Rajasekaran, S; Shetty, Ajoy Prasad

2013-12-01

A prospective randomized controlled trial. To assess the ability of local vancomycin powder in controlling postoperative infection in spine surgery. Despite improvements through the use of prophylactic systemic antibiotics, surgical site infections remain a significant problem in spine surgical procedures. Various retrospective and prospective studies have reported the efficacy of local application of vancomycin powder in reducing the infection in animal and human studies. However, there were no randomized control trials that reported on its efficacy. Prospective randomized controls of 907 patients with various spinal pathologies were treated surgically during a period of 18 months. The control group received standard systemic prophylaxis only, whereas the treatment group received vancomycin powder in the surgical wound in addition to systemic prophylaxis. Patient demographics, comorbidities, level of spinal pathology, estimated blood loss, nutritional status, and hemoglobin were recorded. Incidence of infection was the primary outcome evaluated. There were 8 infections (1.68%) in the control group (6 instrumented and 2 noninstrumented, 6 deep and 2 superficial) with bacteria cultured in 3 (1 Escherichia coli and 2 Staphylococcus aureus). In the treatment group, 7 infections (1.61%) were observed (6 instrumented and 1 noninstrumented surgical procedures, 6 deep and 1 superficial) with bacteria cultured in 3 (1 Staphylococcus aureus and 2 Klebsiella). No adverse effects were observed from the use of vancomycin powder. Statistically no significant difference was seen in infection rate between the treatment group and control group. The local application of vancomycin powder in surgical wounds did not significantly reduce the incidence of infection in patients with surgically treated spinal pathologies. The use of vancomycin powder may not be effective when incidence of infection is low.

Lumbar stenosis surgery: Spine surgeons not insurance companies should decide when enough is better than too much.

PubMed

Epstein, Nancy E

2017-01-01

Lumbar surgery for spinal stenosis is the most common spine operation being performed in older patients. Nevertheless, every time we want to schedule surgery, we confront the insurance industry. More often than not they demand patients first undergo epidural steroid injections (ESI); clearly they are not aware of ESI's lack of long-term efficacy. Who put these insurance companies in charge anyway? We did. How? Through performing too many unnecessary or overly extensive spinal operations (e.g., interbody fusions and instrumented fusions) without sufficient clinical and/or radiographic indications. Patients with lumbar spinal stenosis with/without degenerative spondylolisthesis (DS) are being offered decompressions alone and/or unnecessarily extensive interbody and/or instrumented fusions. Furthermore, a cursory review of the literature largely demonstrates comparable outcomes for decompressions alone vs. decompressions/in situ fusions vs. interbody/instrumented fusions. Too many older patients are being subjected to unnecessary lumbar spine surgery, some with additional interbody/non instrumented or instrumented fusions, without adequate clinical/neurodiagnostic indications. The decision to perform spine surgery for lumbar stenosis/DS, including decompression alone, decompression with non instrumented or instrumented fusion should be in the hands of competent spinal surgeons with their patients' best outcomes in mind. Presently, insurance companies have stepped into the "void" left by spinal surgeons' failing to regulate when, what type, and why spinal surgery is being offered to patients with spinal stenosis. Clearly, spine surgeons need to establish guidelines to maximize patient safety and outcomes for lumbar stenosis surgery. We need to remove insurance companies from their present roles as the "spinal police."

Addition of instrumented fusion after posterior decompression surgery suppresses thickening of ossification of the posterior longitudinal ligament of the cervical spine.

PubMed

Ota, Mitsutoshi; Furuya, Takeo; Maki, Satoshi; Inada, Taigo; Kamiya, Koshiro; Ijima, Yasushi; Saito, Junya; Takahashi, Kazuhisa; Yamazaki, Masashi; Aramomi, Masaaki; Mannoji, Chikato; Koda, Masao

2016-12-01

Laminoplasty (LMP) is a widely accepted surgical procedure for ossification of the posterior longitudinal ligament (OPLL) of the cervical spine. Progression of OPLL can occur in the long term after LMP. The aim of the present study was to determine whether addition of the instrumented fusion, (posterior decompression with instrumented fusion [PDF]), can suppress progression of OPLL or not. The present study included 50 patients who underwent LMP (n=23) or PDF (n=27) for OPLL of the cervical spine. We performed open door laminoplasty. PDF surgery was performed by double-door laminoplasty followed by instrumented fusion. We observed the non-ossified segment of the OPLL and measured the thickness of the OPLL at the thickest segment with pre- and postoperative sagittal CT multi-planar reconstruction images. Postoperative CT scan revealed fusion of the non-ossified segment of the OPLL was obtained in 4/23 patients (17%) in the LPM group and in 23/27 patients (85%) in the PDF group, showing a significant difference between both groups (p=0.003). Progression of the thickness of the OPLL in the PDF group (-0.1±0.4mm) was significantly smaller than in the LMP group (0.6±0.7mm, p=0.0002). The proportion of patients showing the decrease in thickness of OPLL was significantly larger in the PDF group (6/27 patients; 22%) than in the LMP group (0/23 patients; 0%, p=0.05). In conclusion, PDF surgery can suppress the thickening of OPLL. Copyright © 2016 Elsevier Ltd. All rights reserved.

Readmission Rates, Reasons, and Risk Factors Following Anterior Cervical Fusion for Cervical Spondylosis in Patients Above 65 Years of Age.

PubMed

Puvanesarajah, Varun; Hassanzadeh, Hamid; Shimer, Adam L; Shen, Francis H; Singla, Anuj

2017-01-15

A retrospective database review. The aim of this study was to determine readmission reasons and rates following primary, elective anterior cervical spinal fusion surgery for cervical spondylosis and determine risk factors predicting increased risk of 30-day readmission in an exclusively elderly population. In the United States, there were almost 190,000 cervical spine procedures in 2009. Many cervical spine surgery patients are elderly, a demographic increasingly requiring surgery for degenerative cervical spine pathology. Unfortunately, this patient population is poorly studied, particularly concerning readmission rates. Medicare data from 2005 to 2012 were queried for elderly patients (65-84 years) who underwent primary one to two and ≥three-level anterior cervical spine fusion surgeries for cervical spondylosis. Forty-five thousand two hundred eighty-four patients treated with one to two-level and 12,103 patients with ≥three-level anterior cervical fusion (ACF) were identified and included in two study cohorts. Reasons for and rates of readmission were determined within 30 days, 90 days, and one-year postoperatively. Risk factors for medical, surgical, and all 30-day readmissions were also determined, selecting from various comorbidities, demographics, and surgical variables. Readmission rates of 1.0% to 1.4%, 2.7% to 3.6%, and 13.2% to 14.1% were observed within 30 days, 90 days, and one year. Within 30 days, over 30% of patients from both study cohorts were readmitted for surgical reasons. Of surgical reasons for 30-day readmission, hematoma/seroma diagnoses were the most frequent (11.4%-15.4% of all readmissions). Male gender, diabetes mellitus, chronic pulmonary disease, obesity, and smoking history were all found to be predictive of all-cause readmissions. Unplanned 30-day readmission rates following primary, elective ACF in elderly patients is low and often due to medical reasons. Frequent surgical reasons for 30-day readmission include hematoma/seroma formation. Male gender and various comorbid diagnoses are significant predictors of all-cause readmissions within 30 days. 3.

Idiopathic scoliosis: the tethered spine II: post-surgical pain.

PubMed

Whyte Ferguson, Lucy

2014-10-01

The treatment of severe chronic pain in young people following surgery for the correction of curvatures of idiopathic scoliosis (IS) is presented through two case histories. Effective treatment involved release of myofascial trigger points (TrPs) known to refer pain into the spine, and treatment of related fascia and joint dysfunction. The TrPs found to be contributing to spinal area pain were located in muscles at some distance from the spine rather than in the paraspinal muscles. Referred pain from these TrPs apparently accounted for pain throughout the base of the neck and thoracolumbar spine. Exploratory surgery was considered for one patient to address pain following rod placement but the second surgery became unnecessary when the pain was controlled with treatment of the myofascial pain and joint dysfunction. The other individual had both scoliosis and hyperkyphosis, had undergone primary scoliosis surgery, and subsequently underwent a second surgery to remove hardware in an attempt to address her persistent pain following the initial surgery (and because of dislodged screws). The second surgery did not, however, reduce her pain. In both cases these individuals, with severe chronic pain following scoliosis corrective surgery, experienced a marked decrease of pain after myofascial treatment. As will be discussed below, despite the fact that a significant minority of individuals who have scoliosis corrective surgery are thought to require a second surgery, and despite the fact that pain is the most common reason leading to such revision surgery, myofascial pain syndrome (MPS) had apparently not previously been considered as a possible factor in their pain. Copyright © 2014 Elsevier Ltd. All rights reserved.

Intrawound Vancomycin Decreases the Risk of Surgical Site Infection After Posterior Spine Surgery: A Multicenter Analysis.

PubMed

Devin, Clinton J; Chotai, Silky; McGirt, Matthew J; Vaccaro, Alexander R; Youssef, Jim A; Orndorff, Douglas G; Arnold, Paul M; Frempong-Boadu, Anthony K; Lieberman, Isador H; Branch, Charles; Hedayat, Hirad S; Liu, Ann; Wang, Jeffrey C; Isaacs, Robert E; Radcliff, Kris E; Patt, Joshua C; Archer, Kristin R

2018-01-01

Secondary analysis of data from a prospective multicenter observational study. The aim of this study was to evaluate the occurrence of surgical site infection (SSI) in patients with and without intrawound vancomycin application controlling for confounding factors associated with higher SSI after elective spine surgery. SSI is a morbid and expensive complication associated with spine surgery. The application of intrawound vancomycin is rapidly emerging as a solution to reduce SSI following spine surgery. The impact of intrawound vancomycin has not been systematically studied in a well-designed multicenter study. Patients undergoing elective spine surgery over a period of 4 years at seven spine surgery centers across the United States were included in the study. Patients were dichotomized on the basis of whether intrawound vancomycin was applied. Outcomes were occurrence of SSI within postoperative 30 days and SSI that required return to the operating room (OR). Multivariable random-effect log-binomial regression analyses were conducted to determine the relative risk of having an SSI and an SSI with return to OR. .: A total of 2056 patients were included in the analysis. Intrawound vancomycin was utilized in 47% (n = 966) of patients. The prevalence of SSI was higher in patients with no vancomycin use (5.1%) than those with use of intrawound vancomycin (2.2%). The risk of SSI was higher in patients in whom intrawound vancomycin was not used (relative risk (RR) -2.5, P < 0.001), increased number of levels exposed (RR -1.1, P = 0.01), and those admitted postoperatively to intensive care unit (ICU) (RR -2.1, P = 0.005). Patients in whom intrawound vancomycin was not used (RR -5.9, P < 0.001), increased number of levels were exposed (RR-1.1, P = 0.001), and postoperative ICU admission (RR -3.3, P < 0.001) were significant risk factors for SSI requiring a return to the OR. The intrawound application of vancomycin after posterior approach spine surgery was associated with a reduced risk of SSI and return to OR associated with SSI. 2.

[A transparent, internal complication management concept: results and consequences].

PubMed

Wagner, G; Gritzbach, B; Frank, J; Marzi, I

2010-09-01

The acquisition of data and public discussion of complications after therapeutic procedures and surgeries is a sensitive subject, which is mostly avoided even in department meetings. However, it is evident that the broad discussion and the expression of different opinions and aspects provide useful information for continuous improvements. Therefore, we established a system for the transparent acquisition of complications in our department. Since January 2005, we systematically register operative and non-operative complications at our department, evaluate them and therefore gain a great benefit. All the complications are presented, discussed and evaluated within the weekly morbidity and mortality conferences. In 2005 and 2006, among a total number of 2730 and, respectively, 3124 operations, 102 (3.7 %) and 71 (2.3 %) complications have been registered and analysed according to different criteria. We have distinguished between complications which required surgery and complications which only required conservative treatment. There was a higher number of complications which needed surgery. In this group, the most common complications have been found in vertebral spine surgery. The groups of complications with conservative treatment were mostly related to nerve lesions and deep venous thrombosis. With the aid of the internal department evaluation of the registered data, especially the number of complications in vertebral spine surgery could be clearly reduced in 2006. The described method has created a transparency of occurring complications because each colleague is informed as well as involved in the solution process. Furthermore, it is planned to evaluate the impact of risk factors on the various performed surgeries. © Georg Thieme Verlag KG Stuttgart · New York.

Cervical spine surgery in the ancient and medieval worlds.

PubMed

Goodrich, James Tait

2007-01-01

The early historical literature on cervical spine surgery lacks printed material for review, and we can rely only on pathological material from the prehistoric period that has survived as a result of anthropological investigations. After the introduction of Egyptian and early Hellenic medicine, some written material became available. This paper reviews these materials, from both books and manuscripts, in an effort to understand the development of cervical spine surgery from the perspectives of the personalities involved and the early surgical practices used. The review thus considers the following five eras of medicine: 1) prehistoric; 2) Egyptian and Babylonian; 3) Greek and early Byzantine; 4) Middle Eastern; and 5) medieval.

Determination of the Oswestry Disability Index score equivalent to a "satisfactory symptom state" in patients undergoing surgery for degenerative disorders of the lumbar spine-a Spine Tango registry-based study.

PubMed

van Hooff, Miranda L; Mannion, Anne F; Staub, Lukas P; Ostelo, Raymond W J G; Fairbank, Jeremy C T

2016-10-01

The achievement of a given change score on a valid outcome instrument is commonly used to indicate whether a clinically relevant change has occurred after spine surgery. However, the achievement of such a change score can be dependent on baseline values and does not necessarily indicate whether the patient is satisfied with the current state. The achievement of an absolute score equivalent to a patient acceptable symptom state (PASS) may be a more stringent measure to indicate treatment success. This study aimed to estimate the score on the Oswestry Disability Index (ODI, version 2.1a; 0-100) corresponding to a PASS in patients who had undergone surgery for degenerative disorders of the lumbar spine. This is a cross-sectional study of diagnostic accuracy using follow-up data from an international spine surgery registry. The sample includes 1,288 patients with degenerative lumbar spine disorders who had undergone elective spine surgery, registered in the EUROSPINE Spine Tango Spine Surgery Registry. The main outcome measure was the ODI (version 2.1a). Surgical data and data from the ODI and Core Outcome Measures Index (COMI) were included to determine the ODI threshold equivalent to PASS at 1 year (±1.5 months; n=780) and 2 years (±2 months; n=508) postoperatively. The symptom-specific well-being item of the COMI was used as the external criterion in the receiver operating characteristic (ROC) analysis to determine the ODI threshold equivalent to PASS. Separate sensitivity analyses were performed based on the different definitions of an "acceptable state" and for subgroups of patients. JF is a copyright holder of the ODI. The ODI threshold for PASS was 22, irrespective of the time of follow-up (area under the curve [AUC]: 0.89 [sensitivity {Se}: 78.3%, specificity {Sp}: 82.1%] and AUC: 0.91 [Se: 80.7%, Sp: 85.6] for the 1- and 2-year follow-ups, respectively). Sensitivity analyses showed that the absolute ODI-22 threshold for the two follow-up time-points were robust. A stricter definition of PASS resulted in lower ODI thresholds, varying from 16 (AUC=0.89; Se: 80.2%, Sp: 82.0%) to 18 (AUC=0.90; Se: 82.4%, Sp: 80.4%) depending on the time of follow-up. An ODI score ≤22 indicates the achievement of an acceptable symptom state and can hence be used as a criterion of treatment success alongside the commonly used change score measures. At the individual level, the threshold could be used to indicate whether or not a patient with a lumbar spine disorder is a "responder" after elective surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Risk Factors for Venous Thromboembolism After Spine Surgery

PubMed Central

Tominaga, Hiroyuki; Setoguchi, Takao; Tanabe, Fumito; Kawamura, Ichiro; Tsuneyoshi, Yasuhiro; Kawabata, Naoya; Nagano, Satoshi; Abematsu, Masahiko; Yamamoto, Takuya; Yone, Kazunori; Komiya, Setsuro

2015-01-01

Abstract The efficacy and safety of chemical prophylaxis to prevent the development of deep venous thrombosis (DVT) or pulmonary embolism (PE) following spine surgery are controversial because of the possibility of epidural hematoma formation. Postoperative venous thromboembolism (VTE) after spine surgery occurs at a frequency similar to that seen after joint operations, so it is important to identify the risk factors for VTE formation following spine surgery. We therefore retrospectively studied data from patients who had undergone spinal surgery and developed postoperative VTE to identify those risk factors. We conducted a retrospective clinical study with logistic regression analysis of a group of 80 patients who had undergone spine surgery at our institution from June 2012 to August 2013. All patients had been screened by ultrasonography for DVT in the lower extremities. Parameters of the patients with VTE were compared with those without VTE using the Mann–Whitney U-test and Fisher exact probability test. Logistic regression analysis was used to analyze the risk factors associated with VTE. A value of P < 0.05 was used to denote statistical significance. The prevalence of VTE was 25.0% (20/80 patients). One patient had sensed some incongruity in the chest area, but the vital signs of all patients were stable. VTEs had developed in the pulmonary artery in one patient, in the superficial femoral vein in one patient, in the popliteal vein in two patients, and in the soleal vein in 18 patients. The Mann–Whitney U-test and Fisher exact probability test showed that, except for preoperative walking disability, none of the parameters showed a significant difference between patients with and without VTE. Risk factors identified in the multivariate logistic regression analysis were preoperative walking disability and age. The prevalence of VTE after spine surgery was relatively high. The most important risk factor for developing postoperative VTE was preoperative walking disability. Gait training during the early postoperative period is required to prevent VTE. PMID:25654385

Intra-operative localisation of thoracic spine level: a simple "'K'-wire in pedicle" technique.

PubMed

Thambiraj, Sathya; Quraishi, Nasir A

2012-05-01

To describe a simple and reliable method of intra-operative localisation of thoracic spine in a single surgical setting. Intra-operative localisation of thoracic spine levels can be difficult due to anatomical constraints, such as scapular shadow, patient's size and poor bone quality. This is particularly true in cases of thoracic discectomies in which the vertebral bodies appear normal. There are several methods described in recent literature to address this. Many of them require a separate procedure which was performed often the previous day. We report a technique which addresses the issue of localising thoracic level intra-operatively. After induction of general anaesthesia, the patient was placed prone and the pedicle of interest was identified using fluoroscopy. A K-wire was then inserted percutaneously into this pedicle under image guidance [confirmed in the antero-posterior (AP) and lateral views]. The wire was then cut close to the skin after bending it. The patient was now positioned laterally and the intended procedure performed through an anterior trans-thoracic approach. The 'K' wire was removed at the end of the procedure. We routinely used this technique in all our thoracic discectomies (four cases in 2 years). There were no intra-operative complications. This method is simple, avoids the patient undergoing two procedures and requires no more ability than placing an implant in the pedicle under fluoroscopy. Placing the 'K' wire into a fixed point like the pedicle facilitates rapid intra-operative viewing of the level of interest and is removed easily at the conclusion of surgery.

[Technique and advantages of multimodal intraoperative neuromonitoring for complex spinal interventions in older patients].

PubMed

Campos-Friz, M; Hubbe, U

2018-04-01

Complex spinal surgery in elderly patients mostly treats degenerative spine alterations. The use of multimodal intraoperative neuromonitoring (IONM) has proven to be a useful tool to recognize neural deterioration during such operations. Elderly patients often have preexisting neural impairment, which leads to difficulties in deriving some potentials or can even lead to not obtaining any potentials at all. For reliable benefits from IONM a combined use of monitoring and mapping methods as well as the right choice of methods according to the spine level to be treated and a definition of the neural structures in danger is needed. This article intends to explain IONM methods in procedures treating degenerative spine alterations in a comprehensive way and to show our point of view on pedicle stimulation. Readers should be motivated to deepen their knowledge in these methods and to gain confidence and experience to increase the safety of these operations for the benefit of our patients.

ASA grade and Charlson Comorbidity Index of spinal surgery patients: correlation with complications and societal costs.

PubMed

Whitmore, Robert G; Stephen, James H; Vernick, Coleen; Campbell, Peter G; Yadla, Sanjay; Ghobrial, George M; Maltenfort, Mitchell G; Ratliff, John K

2014-01-01

The Charlson Comorbidity Index (CCI) and the American Society of Anesthesiologists (ASA) Physical Status Classification System (ASA grade) are useful for predicting morbidity and mortality for a variety of disease processes. To evaluate CCI and ASA grade as predictors of complications after spinal surgery and examine the correlation between these comorbidity indices and the cost of care. Prospective observational study. All patients undergoing any spine surgery at a single academic tertiary center over a 6-month period. Direct health-care costs estimated from diagnosis related group and Current Procedural Terminology (CPT) codes. Demographic data, including all patient comorbidities, procedural data, and all complications, occurring within 30 days of the index procedure were prospectively recorded. Charlson Comorbidity Index was calculated from International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and ASA grades determined from the operative record. Diagnosis related group and CPT codes were captured for each patient. Direct costs were estimated from a societal perspective using Medicare rates of reimbursement. A multivariable analysis was performed to assess the association of the CCI and ASA grade to the rate of complication and direct health-care costs. Two hundred twenty-six cases were analyzed. The average CCI score for the patient cohort was 0.92, and the average ASA grade was 2.65. The CCI and ASA grade were significantly correlated, with Spearman ρ of 0.458 (p<.001). Both CCI and ASA grade were associated with increasing body mass index (p<.01) and increasing patient age (p<.0001). Increasing CCI was associated with an increasing likelihood of occurrence of any complication (p=.0093) and of minor complications (p=.0032). Increasing ASA grade was significantly associated with an increasing likelihood of occurrence of a major complication (p=.0035). Increasing ASA grade showed a significant association with increasing direct costs (p=.0062). American Society of Anesthesiologists and CCI scores are useful comorbidity indices for the spine patient population, although neither was completely predictive of complication occurrence. A spine-specific comorbidity index, based on ICD-9-CM coding that could be easily captured from patient records, and which is predictive of patient likelihood of complications and mortality, would be beneficial in patient counseling and choice of operative intervention. Copyright © 2014 Elsevier Inc. All rights reserved.

Building Consensus: Development of Best Practice Guidelines on Wrong Level Surgery in Spinal Deformity.

PubMed

Vitale, Michael; Minkara, Anas; Matsumoto, Hiroko; Albert, Todd; Anderson, Richard; Angevine, Peter; Buckland, Aaron; Cho, Samuel; Cunningham, Matthew; Errico, Thomas; Fischer, Charla; Kim, Han Jo; Lehman, Ronald; Lonner, Baron; Passias, Peter; Protopsaltis, Themistocles; Schwab, Frank; Lenke, Lawrence

Consensus-building using the Delphi and nominal group technique. To establish best practice guidelines using formal techniques of consensus building among a group of experienced spinal deformity surgeons to avert wrong-level spinal deformity surgery. Numerous previous studies have demonstrated that wrong-level spinal deformity occurs at a substantial rate, with more than half of all spine surgeons reporting direct or indirect experience operating on the wrong levels. Nevertheless, currently, guidelines to avert wrong-level spinal deformity surgery have not been developed. The Delphi process and nominal group technique were used to formally derive consensus among 16 fellowship-trained spine surgeons. Surgeons were surveyed for current practices, presented with the results of a systematic review, and asked to vote anonymously for or against item inclusion during three iterative rounds. Agreement of 80% or higher was considered consensus. Items near consensus (70% to 80% agreement) were probed in detail using the nominal group technique in a facilitated group meeting. Participants had a mean of 13.4 years of practice (range: 2-32 years) and 103.1 (range: 50-250) annual spinal deformity surgeries, with a combined total of 24,200 procedures. Consensus was reached for the creation of best practice guidelines (BPGs) consisting of 17 interventions to avert wrong-level surgery. A final checklist consisting of preoperative and intraoperative methods, including standardized vertebral-level counting and optimal imaging criteria, was supported by 100% of participants. We developed consensus-based best practice guidelines for the prevention of wrong-vertebral-level surgery. This can serve as a tool to reduce the variability in preoperative and intraoperative practices and guide research regarding the effectiveness of such interventions on the incidence of wrong-level surgery. Level V. Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.

Elective Thoracolumbar Spine Fusion Surgery in Patients with Parkinson Disease.

PubMed

Puvanesarajah, Varun; Jain, Amit; Qureshi, Rabia; Carstensen, S Evan; Tyger, Rosemarie; Hassanzadeh, Hamid

2016-12-01

Few data are available concerning clinical outcomes in patients with Parkinson disease who undergo elective thoracolumbar spine fusion surgery. The goal of this study is to elucidate complication and revision rates after posterior thoracolumbar fusion surgery in patients with Parkinson disease, with a focus on how Parkinson disease modifies these rates. The PearlDiver database (2005-2012) was queried for patients who underwent posterior approach thoracolumbar fusion from 2006 to 2011. Cohorts of patients with a previous diagnosis of Parkinson disease (n = 4816) and without (n = 280,702) were compared. Multivariate analysis that included various comorbidities and demographics was used to calculate effects of Parkinson disease on development of postoperative infection and major medical complications within 90 days and revision surgery within 1 year. For analyses, significance was set at P < 0.001. Major medical complications were observed in 545 patients (11.3%) for 90 days after the index procedure. Postoperative infection was noted in 91 patients (1.9%) within 90 days, and revision surgeries were performed in 250 patients (5.2%) within 1 year. Multivariate analysis showed that Parkinson disease was significantly associated with an increased risk for medical complications (adjusted odds ratio, 1.22; 95% confidence interval, 1.11-1.34; P < 0.001) and revision surgery (adjusted odds ratio, 1.70; 95% confidence interval, 1.49-1.93; P < 0.001), but not postoperative infection (P = 0.02). Patients with Parkinson disease are more likely to require revision surgery and have higher rates of adverse medical events postoperatively. Patients with Parkinson disease should be appropriately selected to ensure favorable clinical outcomes. Copyright © 2016. Published by Elsevier Inc.

Perils of intraoperative neurophysiological monitoring: analysis of "false-negative" results in spine surgeries.

PubMed

Tamkus, Arvydas A; Rice, Kent S; McCaffrey, Michael T

2018-02-01

Although some authors have published case reports describing false negatives in intraoperative neurophysiological monitoring (IONM), a systematic review of causes of false-negative IONM results is lacking. The objective of this study was to analyze false-negative IONM findings in spine surgery. This is a retrospective cohort analysis. A cohort of 109 patients with new postoperative neurologic deficits was analyzed for possible false-negative IONM reporting. The causes of false-negative IONM reporting were determined. From a cohort of 62,038 monitored spine surgeries, 109 consecutive patients with new postoperative neurologic deficits were reviewed for IONM alarms. Intraoperative neurophysiological monitoring alarms occurred in 87 of 109 surgeries. Nineteen patients with new postoperative neurologic deficits did not have an IONM alarm and surgeons were not warned. In addition, three patients had no interpretable IONM baseline data and no alarms were possible for the duration of the surgery. Therefore, 22 patients were included in the study. The absence of IONM alarms during these 22 surgeries had different origins: "true" false negatives where no waveform changes meeting the alarm criteria occurred despite the appropriate IONM (7); a postoperative development of a deficit (6); failure to monitor the pathway, which became injured (5); the absence of interpretable IONM baseline data which precluded any alarm (3); and technical IONM application issues (1). Overall, the rate of IONM method failing to predict the patient's outcome was very low (0.04%, 22/62,038). Minimizing false negatives requires the application of a proper IONM technique with the limitations of each modality considered in their selection and interpretation. Multimodality IONM provides the most inclusive information, and although it might be impractical to monitor every neural structure that can be at risk, a thorough preoperative consideration of available IONM modalities is important. Delayed development of postoperative deficits cannot be predicted by IONM. Absent baseline IONM data should be treated as an alarm when inconsistent with the patient's preoperative neurologic status. Alarm criteria for IONM may need to be refined for specific procedures and deserves continued study. Copyright © 2017 Elsevier Inc. All rights reserved.

Reversible postoperative blindness caused by bilateral status epilepticus amauroticus following thoracolumbar deformity correction: case report.

PubMed

Ibrahim, Tarik F; Sweis, Rochelle T; Nockels, Russ P

2017-07-01

Postoperative vision loss (POVL) is a devastating complication and has been reported after complex spine procedures. Anterior ischemic optic neuropathy and posterior optic neuropathy are the 2 most common causes of POVL. Bilateral occipital lobe seizures causing complete blindness are rare and have not been reported as a cause of POVL after spine surgery with the patient prone. The authors report the case of a 67-year-old man without a history of seizures who underwent a staged thoracolumbar deformity correction and developed POVL 6 hours after surgery. Imaging, laboratory, and ophthalmological examination results were nonrevealing. Routine electroencephalography study results were negative, but continuous electroencephalography captured bilateral occipital lobe seizures. The patient developed nonconvulsive status epilepticus despite initial treatment with benzodiazepines and loading doses of levetiracetam and lacosamide. He was therefore intubated for status epilepticus amauroticus and received a midazolam infusion. After electrographic seizure cessation for 48 hours, the patient was weaned off midazolam. The patient was maintained on levetiracetam and lacosamide without seizure recurrence and returned to his preoperative visual baseline status.

An evidence-based clinical guideline for the use of antithrombotic therapies in spine surgery.

PubMed

Bono, Christopher M; Watters, William C; Heggeness, Michael H; Resnick, Daniel K; Shaffer, William O; Baisden, Jamie; Ben-Galim, Peleg; Easa, John E; Fernand, Robert; Lamer, Tim; Matz, Paul G; Mendel, Richard C; Patel, Rajeev K; Reitman, Charles A; Toton, John F

2009-12-01

The objective of the North American Spine Society (NASS) Evidence-Based Clinical Guideline on antithrombotic therapies in spine surgery was to provide evidence-based recommendations to address key clinical questions surrounding the use of antithrombotic therapies in spine surgery. The guideline is intended to address these questions based on the highest quality clinical literature available on this subject as of February 2008. The goal of the guideline recommendations was to assist in delivering optimum, efficacious treatment with the goal of preventing thromboembolic events. To provide an evidence-based, educational tool to assist spine surgeons in minimizing the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE). Systematic review and evidence-based clinical guideline. This report is from the Antithrombotic Therapies Work Group of the NASS Evidence-Based Guideline Development Committee. The work group was composed of multidisciplinary spine care specialists, all of whom were trained in the principles of evidence-based analysis. Each member of the group was involved in formatting a series of clinical questions to be addressed by the group. The final questions agreed on by the group are the subject of this report. A literature search addressing each question and using a specific search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based databases. The relevant literature was then independently rated by at least three reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Final grades of recommendation for the answers to each clinical question were arrived at via Web casts among members of the work group using standardized grades of recommendation. When Level I to IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline. Fourteen clinical questions were formulated, addressing issues of incidence of DVT and PE in spine surgery and recommendations regarding utilization of mechanical prophylaxis and chemoprophylaxis in spine surgery. The answers to these 14 clinical questions are summarized in this article. The respective recommendations were graded by the strength of the supporting literature that was stratified by levels of evidence. A clinical guideline addressing the use of antithrombotic therapies in spine surgery has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to assist spine surgeons in minimizing the risk of DVT and PE. The entire guideline document, including the evidentiary tables, suggestions for future research, and all references, is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.

Vertebral artery injuries in cervical spine surgery.

PubMed

Lunardini, David J; Eskander, Mark S; Even, Jesse L; Dunlap, James T; Chen, Antonia F; Lee, Joon Y; Ward, Timothy W; Kang, James D; Donaldson, William F

2014-08-01

Vertebral artery injuries (VAIs) are rare but serious complications of cervical spine surgery, with the potential to cause catastrophic bleeding, permanent neurologic impairment, and even death. The present literature regarding incidence of this complication largely comprises a single surgeon or small multicenter case series. We sought to gather a large sample of high-volume surgeons to adequately characterize the incidence and risk factors for VAI, management strategies used, and patient outcomes after VAI. The study was constructed as a cross-sectional study comprising all cervical spine patients operated on by the members of the international Cervical Spine Research Society (CSRS). All patients who have undergone cervical spine surgery by a current member of CSRS as of the spring of 2012. For each surgeon surveyed, we collected self-reported measures to include the number of cervical cases performed in the surgeon's career, the number of VAIs encountered, the stage of the case during which the injury occurred, the management strategies used, and the overall patient outcome after injury. An anonymous 10-question web-based survey was distributed to the members of the CSRS. Statistical analysis was performed using Student t tests for numerical outcomes and chi-squared analysis for categorical variables. One hundred forty-one CSRS members (of 195 total, 72%) responded to the survey, accounting for a total of 163,324 cervical spine surgeries performed. The overall incidence of VAI was 0.07% (111/163,324). Posterior instrumentation of the upper cervical spine (32.4%), anterior corpectomy (23.4%), and posterior exposure of the cervical spine (11.7%) were the most common stages of the case to result in an injury to the vertebral artery. Discectomy (9%) and anterior exposure of the spine (7.2%) were also common time points for an arterial injury. One-fifth (22/111) of all VAI involved an anomalous course of the vertebral artery. The most common management of VAI was by direct tamponade. The outcomes of VAIs included no permanent sequelae in 90% of patients, permanent neurologic sequelae in 5.5%, and death in 4.5%. Surgeons at academic and private centers had nearly identical rates of VAIs. However, surgeons who had performed 300 or fewer cervical spine surgeries in their career had a VAI incidence of 0.33% compared with 0.06% in those with greater than 300 lifetime cases (p=.028). The overall incidence of VAI during cervical spine surgery reported from this survey was 0.07%. Less experienced surgeons had a higher rate of VAI compared with their more experienced peers. The results of VAI are highly variable, resulting in no permanent harm most of the time; however, permanent neurologic injury or death occur in 10% of cases. Copyright © 2014 Elsevier Inc. All rights reserved.

Prevalence and Outcomes in Patients Undergoing Reintubation After Anterior Cervical Spine Surgery: Results From the AOSpine North America Multicenter Study on 8887 Patients

PubMed Central

Nagoshi, Narihito; Nakashima, Hiroaki; Tetreault, Lindsay; Gum, Jeffrey L.; Smith, Zachary A.; Hsu, Wellington K.; Tannoury, Chadi A.; Tannoury, Tony; Traynelis, Vincent C.; Arnold, Paul M.; Mroz, Thomas E.; Gokaslan, Ziya L.; Bydon, Mohamad; De Giacomo, Anthony F.; Jobse, Bruce C.; Massicotte, Eric M.; Riew, K. Daniel

2017-01-01

Study Design: A multicenter, retrospective cohort study. Objective: To evaluate clinical outcomes in patients with reintubation after anterior cervical spine surgery. Methods: A total of 8887 patients undergoing anterior cervical spine surgery were enrolled in the AOSpine North America Rare Complications of Cervical Spine Surgery study. Patients with or without complications after surgery were included. Demographic and surgical information were collected for patients with reintubation. Patients were evaluated using a variety of assessment tools, including the modified Japanese Orthopedic Association scale, Nurick score, Neck Disability Index, and Short Form-36 Health Survey. Results: Nine cases of postoperative reintubation were identified. The total prevalence of this complication was 0.10% and ranged from 0% to 0.59% across participating institutions. The time to development of airway symptoms after surgery was within 24 hours in 6 patients and between 5 and 7 days in 3 patients. Although 8 patients recovered, 1 patient died. At final follow-up, patients with reintubation did not exhibit significant and meaningful improvements in pain, functional status, or quality of life. Conclusions: Although the prevalence of reintubation was very low, this complication was associated with adverse clinical outcomes. Clinicians should identify their high-risk patients and carefully observe them for up to 2 weeks after surgery. PMID:28451501

The Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF): incremental validity in predicting early postoperative outcomes in spine surgery candidates.

PubMed

Marek, Ryan J; Block, Andrew R; Ben-Porath, Yossef S

2015-03-01

A substantial proportion of individuals who undergo surgical procedures to relieve spine pain continue to report significant pain and dysfunction after recovery. Psychopathology and patient expectations have been linked to poor results, leading to an increasing reliance on presurgical psychological screening (PPS) as part of the surgical diagnostic process. The original Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1943) and the MMPI-2 (Butcher, Graham, Ben-Porath, Tellegen, & Dahlstrom, 2001) were among the measures most commonly used in PPS evaluations and research. This study focuses on the newest version of the test, the MMPI-2-Restructured Form (MMPI-2-RF; Ben-Porath & Tellegen, 2008/2011; Tellegen & Ben-Porath, 2008/2011) as a predictor of outcomes for spine surgery candidates. Using a sample of 172 men and 210 women who underwent a PPS, we examined the ability of MMPI-2-RF scale scores to predict early surgical outcomes independent of other presurgical risk factors identified by other means, as well as patients' presurgical expectations. MMPI-2-RF results accounted for up to 11% of additional variance in measures of early postoperative functioning. MMPI-2-RF scales that assess for emotional/internalizing problems, specifically Demoralization, measures of somatoform dysfunction, and interpersonal problems contributed most to the prediction of diminished outcome. 2015 APA, all rights reserved

Effects of Localized Cold Therapy on Pain in Postoperative Spinal Fusion Patients: A Randomized Control Trial.

PubMed

Quinlan, Patricia; Davis, Jack; Fields, Kara; Madamba, Pia; Colman, Lisa; Tinca, Daniela; Cannon Drake, Regina

Cold therapy used in the sports medicine settings has been found to be effective in reducing postoperative pain; however, there are limited studies that examine the effect of cold therapy on postoperative pain in patients with posterior lumbar spinal fusion. The purpose of this study was to determine the effects of cold on postoperative spine pain and add to the body of knowledge specific to practical application of cold therapy in the spine surgery setting. Researchers used a two-group randomized control design to evaluate the effects of local cold therapy on postoperative pain and analgesia use after lumbar spinal fusion surgery. The primary outcome was postoperative pain. Secondary outcomes included analgesia use and perceived benefit of cold therapy. The intervention (cold) group had a marginally greater reduction in mean Numerical Rating Scale score across all 12 pain checks (M ± SD = -1.1 ± 0.8 points reduction vs. -1.0 ± 0.8 points reduction, p = .589). On average, the intervention group used less morphine equivalents (M ± SD = 12.6 ± 31.5 vs. 23.7 ± 40.0) than the control group across pain checks seven to 12 (p = .042). This study provides additional evidence to support the use of cold therapy as an adjuvant pain management strategy to optimize pain control and reduce opioid consumption following spine fusion surgical procedures.

Experiments on robot-assisted navigated drilling and milling of bones for pedicle screw placement.

PubMed

Ortmaier, T; Weiss, H; Döbele, S; Schreiber, U

2006-12-01

This article presents experimental results for robot-assisted navigated drilling and milling for pedicle screw placement. The preliminary study was carried out in order to gain first insights into positioning accuracies and machining forces during hands-on robotic spine surgery. Additionally, the results formed the basis for the development of a new robot for surgery. A simplified anatomical model is used to derive the accuracy requirements. The experimental set-up consists of a navigation system and an impedance-controlled light-weight robot holding the surgical instrument. The navigation system is used to position the surgical instrument and to compensate for pose errors during machining. Holes are drilled in artificial bone and bovine spine. A quantitative comparison of the drill-hole diameters was achieved using a computer. The interaction forces and pose errors are discussed with respect to the chosen machining technology and control parameters. Within the technological boundaries of the experimental set-up, it is shown that the accuracy requirements can be met and that milling is superior to drilling. It is expected that robot assisted navigated surgery helps to improve the reliability of surgical procedures. Further experiments are necessary to take the whole workflow into account. Copyright 2006 John Wiley & Sons, Ltd.

Airway management in neuroanesthesiology.

PubMed

Aziz, Michael

2012-06-01

Airway management for neuroanesthesiology brings together some key principles that are shared throughout neuroanesthesiology. This article appropriately targets the cervical spine with associated injury and the challenges surrounding airway management. The primary focus of this article is on the unique airway management obstacles encountered with cervical spine injury or cervical spine surgery, and unique considerations regarding functional neurosurgery are addressed. Furthermore, topics related to difficult airway management for those with rheumatoid arthritis or pituitary surgery are reviewed. Copyright © 2012 Elsevier Inc. All rights reserved.

Sexual function after cervical spine surgery: Independent predictors of functional impairment.

PubMed

Keefe, Malla K; Zygourakis, Corinna C; Theologis, Alexander A; Canepa, Emma; Shaw, Jeremy D; Goldman, Lauren H; Burch, Shane; Berven, Sigurd; Chou, Dean; Tay, Bobby; Mummaneni, Praveen; Deviren, Vedat; Ames, Christopher P

2017-02-01

Sexual function (SF) is an important component of patient-focused health related quality of life (HRQoL), but it has not been well studied in spine surgery. This study aims to assess SF after cervical spine surgery and identify predictors of SF. This single-center retrospective study evaluates SF of adults who underwent cervical spine surgery 2007-2012. Predictor variables included demographics, medical/surgical history, operative information, HRQoL measures (Neck Disability Index, SF-12), validated SF surveys [Female Sexual Function Index (FSFI) and Brief Sexual Function Inventory (BSFI) for males], and a study-specific SF questionnaire. 59 patients (31M, 28F; mean age=56±8.4) had significantly lower SF scores compared to age-matched peers: average BSFI = 2.26±1.22 (vs. 06±0.74), average FSFI=13.05±11.42 (<26.55 indicating sexual dysfunction). In men, lower mental SF-12 and higher NDI, back pain, and number of operated levels were associated with lower BSFI scores (all p<0.05). In women, higher total number of medications and pain medications were associated with lower FSFI scores (both p<0.05). 46% of patients reported difficulty performing a sexual position after surgery that they had previously enjoyed. 39% of men had difficulty on top during intercourse, and 32% of participants reported difficulty performing oral sex. 39% of patients reported worse SF, while only 5% reported an improvement in postoperative SF. Men and women who underwent cervical spine surgery had lower SF scores than age-matched peers, likely attributable to general mental health, regional neck disability, back pain, and medications. A large portion of patients reported subjectively worsened SF after surgery. Copyright © 2016 Elsevier Ltd. All rights reserved.

[Controversies about instrumented surgery and pain relief in degenerative lumbar spine pain. Results of scientific evidence].

PubMed

Robaina-Padrón, F J

2007-10-01

Investigation and development of new techniques for intrumented surgery of the spine is not free of conflicts of interest. The influence of financial forces in the development of new technologies an its immediately application to spine surgery, shows the relationship between the published results and the industry support. Even authors who have defend eagerly fusion techniques, it have been demonstrated that them are very much involved in the revision of new articles to be published and in the approval process of new spinal technologies. When we analyze the published results of spine surgery, we must bear in mind what have been call in the "American Stock and Exchange" as "the bubble of spine surgery". The scientific literature doesn't show clear evidence in the cost-benefit studies of most instrumented surgical interventions of the spine compare with the conservative treatments. It has not been yet demonstrated that fusion surgery and disc replacement are better options than the conservative treatment. It's necessary to point out that at present "there are relationships between the industry and back pain, and there is also an industry of the back pain". Nonetheless, the "market of the spine surgery" is growing up because patients are demanding solutions for their back problems. The tide of scientific evidence seams to go against the spinal fusions in the degenerative disc disease, discogenic pain and inespecific back pain. After decades of advances in this field, the results of spinal fusions are mediocre. New epidemiological studies show that "spinal fusion must be accepted as a non proved or experimental method for the treatment of back pain". The surgical literature on spinal fusion published in the last 20 years following the Cochrane's method establish that: 1- this is at least incomplete, not reliable and careless; 2- the instrumentation seems to slightly increase the fusion rate; 3- the instrumentation doesn't improve the clinical results in general, lacking studies in subgroups of patients. We still are needing randomized studies to compare the surgical results with the natural history of the disease, the placebo effect, or the conservative treatment. The European Guidelines for lumbar chronic pain management show a "strong evidence" indicating that complex and demanding spine surgery where different instrumentation is used, is not more effective than a simple, safer and cheaper posterolateral fusion without instrumentation. Recently, the literature published in this field is sending a message to use "minimally invasive techniques", abandon transpedicular fusions and clearly indicating that we must apply the knowledge accumulated at least along the last 20 years based on the scientific evidence. In conclusion, based in recent information, we must recommend the "abandon of the instrumented pathway" in a great number of present indications for degenerative spine surgery, and look for new strategies in the field of rehabilitation and conservative treatments correctly apply, using before the decompressive and instrumented surgery all the interventional and minimally invasive techniques that are presently offer in the field of modem lumbar chronic pain treatment.

Transcranial electric motor evoked potential monitoring during spine surgery: is it safe?

PubMed

Schwartz, Daniel M; Sestokas, Anthony K; Dormans, John P; Vaccaro, Alexander R; Hilibrand, Alan S; Flynn, John M; Li, P Mark; Shah, Suken A; Welch, William; Drummond, Denis S; Albert, Todd J

2011-06-01

Retrospective review. To report on the safety of repetitive transcranial electric stimulation (RTES) for eliciting motor-evoked potentials during spine surgery. Theoretical concerns over the safety of RTES have hindered broader acceptance of transcranial electric motor-evoked potentials (tceMEP), despite successful implementation of spinal cord monitoring with tceMEPs in many large spine centers, as well as their apparent superiority over mixed-nerve somatosensory-evoked potentials (SSEP) for detection of spinal cord injury. The records of 18,862 consecutive patients who met inclusion criteria and underwent spine surgery with tceMEP monitoring were reviewed for RTES-related complications. This large retrospective review identified only 26 (0.14%) cases with RTES-related complications; all but one of these were tongue lacerations, most of which were self-limiting. The results demonstrate that RTES is a highly safe modality for monitoring spinal cord motor tract function intraoperatively.

Virtual estimates of fastening strength for pedicle screw implantation procedures

NASA Astrophysics Data System (ADS)

Linte, Cristian A.; Camp, Jon J.; Augustine, Kurt E.; Huddleston, Paul M.; Robb, Richard A.; Holmes, David R.

2014-03-01

Traditional 2D images provide limited use for accurate planning of spine interventions, mainly due to the complex 3D anatomy of the spine and close proximity of nerve bundles and vascular structures that must be avoided during the procedure. Our previously developed clinician-friendly platform for spine surgery planning takes advantage of 3D pre-operative images, to enable oblique reformatting and 3D rendering of individual or multiple vertebrae, interactive templating, and placement of virtual pedicle implants. Here we extend the capabilities of the planning platform and demonstrate how the virtual templating approach not only assists with the selection of the optimal implant size and trajectory, but can also be augmented to provide surrogate estimates of the fastening strength of the implanted pedicle screws based on implant dimension and bone mineral density of the displaced bone substrate. According to the failure theories, each screw withstands a maximum holding power that is directly proportional to the screw diameter (D), the length of the in-bone segm,ent of the screw (L), and the density (i.e., bone mineral density) of the pedicle body. In this application, voxel intensity is used as a surrogate measure of the bone mineral density (BMD) of the pedicle body segment displaced by the screw. We conducted an initial assessment of the developed platform using retrospective pre- and post-operative clinical 3D CT data from four patients who underwent spine surgery, consisting of a total of 26 pedicle screws implanted in the lumbar spine. The Fastening Strength of the planned implants was directly assessed by estimating the intensity - area product across the pedicle volume displaced by the virtually implanted screw. For post-operative assessment, each vertebra was registered to its homologous counterpart in the pre-operative image using an intensity-based rigid registration followed by manual adjustment. Following registration, the Fastening Strength was computed for each displaced bone segment. According to our preliminary clinical study, a comparison between Fastening Strength, displaced bone volume and mean voxel intensity showed similar results (p < 0.1) between the virtually templated plans and the post-operative outcome following the traditional clinical approach. This study has demonstrated the feasibility of the platform in providing estimates the pedicle screw fastening strength via virtual implantation, given the intrinsic vertebral geometry and bone mineral density, enabling the selection of the optimal implant dimension adn trajectory for improved strength.

Deep Vein Thrombosis After Complex Posterior Spine Surgery: Does Staged Surgery Make a Difference?

PubMed

Edwards, Charles C; Lessing, Noah L; Ford, Lisa; Edwards, Charles C

Retrospective review of a prospectively collected database. To assess the incidence of deep vein thrombosis (DVT) associated with single- versus multistage posterior-only complex spinal surgeries. Dividing the physiologic burden of spinal deformity surgery into multiple stages has been suggested as a potential means of reducing perioperative complications. DVT is a worrisome complication owing to its potential to lead to pulmonary embolism. Whether or not staging affects DVT incidence in this population is unknown. Consecutive patients undergoing either single- or multistage posterior complex spinal surgeries over a 12-year period at a single institution were eligible. All patients received lower extremity venous duplex ultrasonographic (US) examinations 2 to 4 days postoperatively in the single-stage group and 2 to 4 days postoperatively after each stage in the multistage group. Multivariate logistic regression was used to assess the independent contribution of staging to developing a DVT. A total of 107 consecutive patients were enrolled-26 underwent multistage surgery and 81 underwent single-stage surgery. The single-stage group was older (63 years vs. 45 years; p < .01) and had a higher Charlson comorbidity index (2.25 ± 1.27 vs. 1.23 ± 1.58; p < .01). More multistage patients had positive US tests than single-stage patients (5 of 26 vs. 6 of 81; 19% vs. 7%; p = .13). Adjusting for all the above-mentioned covariates, a multistage surgery was 8.17 (95% CI 0.35-250.6) times more likely to yield a DVT than a single-stage surgery. Patients who undergo multistage posterior complex spine surgery are at a high risk for developing a DVT compared to those who undergo single-stage procedures. The difference in DVT incidence may be understated as the multistage group had a lower pre- and intraoperative risk profile with a younger age, lower medical comorbidities, and less per-stage blood loss. Copyright © 2017 Scoliosis Research Society. Published by Elsevier Inc. All rights reserved.

Driving Safety after Spinal Surgery: A Systematic Review

PubMed Central

Alkhalili, Kenan; Hannallah, Jack; Ibeche, Bashar; Bajammal, Sohail; Baco, Abdul Moeen

2017-01-01

This study aimed to assess driving reaction times (DRTs) after spinal surgery to establish a timeframe for safe resumption of driving by the patient postoperatively. The MEDLINE and Google Scholar databases were analyzed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) Statement for clinical studies that investigated changes in DRTs following cervical and lumbar spinal surgery. Changes in DRTs and patients' clinical presentation, pathology, anatomical level affected, number of spinal levels involved, type of intervention, pain level, and driving skills were assessed. The literature search identified 12 studies that investigated postoperative DRTs. Six studies met the inclusion criteria; five studies assessed changes in DRT after lumbar spine surgery and two studies after cervical spina surgery. The spinal procedures were selective nerve root block, anterior cervical discectomy and fusion, and lumbar fusion and/ordecompression. DRTs exhibited variable responses to spinal surgery and depended on the patients' clinical presentation, spinal level involved, and type of procedure performed. The evidence regarding the patients' ability to resume safe driving after spinal surgery is scarce. Normalization of DRT or a return of DRT to pre-spinal intervention level is a widely accepted indicator for safe driving, with variable levels of statistical significance owing to multiple confounding factors. Considerations of the type of spinal intervention, pain level, opioid consumption, and cognitive function should be factored in the assessment of a patient's ability to safely resume driving. PMID:28443178

Driving Safety after Spinal Surgery: A Systematic Review.

PubMed

Alhammoud, Abduljabbar; Alkhalili, Kenan; Hannallah, Jack; Ibeche, Bashar; Bajammal, Sohail; Baco, Abdul Moeen

2017-04-01

This study aimed to assess driving reaction times (DRTs) after spinal surgery to establish a timeframe for safe resumption of driving by the patient postoperatively. The MEDLINE and Google Scholar databases were analyzed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) Statement for clinical studies that investigated changes in DRTs following cervical and lumbar spinal surgery. Changes in DRTs and patients' clinical presentation, pathology, anatomical level affected, number of spinal levels involved, type of intervention, pain level, and driving skills were assessed. The literature search identified 12 studies that investigated postoperative DRTs. Six studies met the inclusion criteria; five studies assessed changes in DRT after lumbar spine surgery and two studies after cervical spina surgery. The spinal procedures were selective nerve root block, anterior cervical discectomy and fusion, and lumbar fusion and/ordecompression. DRTs exhibited variable responses to spinal surgery and depended on the patients' clinical presentation, spinal level involved, and type of procedure performed. The evidence regarding the patients' ability to resume safe driving after spinal surgery is scarce. Normalization of DRT or a return of DRT to pre-spinal intervention level is a widely accepted indicator for safe driving, with variable levels of statistical significance owing to multiple confounding factors. Considerations of the type of spinal intervention, pain level, opioid consumption, and cognitive function should be factored in the assessment of a patient's ability to safely resume driving.

[Impact of obesity in the pathophysiology of degenerative disk disease and in the morbidity and outcome of lumbar spine surgery].

PubMed

Delgado-López, Pedro David; Castilla-Díez, José Manuel

Obesity (BMI>30Kg/m 2 ) is a pandemic with severe medical and financial implications. There is growing evidence that relates certain metabolic processes within the adipose tissue, preferentially abdominal fat, with a low-intensity chronic inflammatory state mediated by adipokines and other substances that favor disk disease and chronic low back pain. Obesity greatly conditions both the preoperative evaluation and the spinal surgical technique itself. Some meta-analyses have confirmed an increase of complications following lumbar spine surgery (mainly infections and venous thrombosis) in obese subjects. However, functional outcomes after lumbar spine surgery are favorable although inferior to the non-obese population, acknowledging that obese patients present with worse baseline function levels and the prognosis of conservatively treated obese cohorts is much worse. The impact of preoperative weight loss in spine surgery has not been prospectively studied in these patients. Copyright © 2017 Sociedad Española de Neurocirugía. Publicado por Elsevier España, S.L.U. All rights reserved.

Variations in cost calculations in spine surgery cost-effectiveness research.

PubMed

Alvin, Matthew D; Miller, Jacob A; Lubelski, Daniel; Rosenbaum, Benjamin P; Abdullah, Kalil G; Whitmore, Robert G; Benzel, Edward C; Mroz, Thomas E

2014-06-01

Cost-effectiveness research in spine surgery has been a prominent focus over the last decade. However, there has yet to be a standardized method developed for calculation of costs in such studies. This lack of a standardized costing methodology may lead to conflicting conclusions on the cost-effectiveness of an intervention for a specific diagnosis. The primary objective of this study was to systematically review all cost-effectiveness studies published on spine surgery and compare and contrast various costing methodologies used. The authors performed a systematic review of the cost-effectiveness literature related to spine surgery. All cost-effectiveness analyses pertaining to spine surgery were identified using the cost-effectiveness analysis registry database of the Tufts Medical Center Institute for Clinical Research and Health Policy, and the MEDLINE database. Each article was reviewed to determine the study subject, methodology, and results. Data were collected from each study, including costs, interventions, cost calculation method, perspective of cost calculation, and definitions of direct and indirect costs if available. Thirty-seven cost-effectiveness studies on spine surgery were included in the present study. Twenty-seven (73%) of the studies involved the lumbar spine and the remaining 10 (27%) involved the cervical spine. Of the 37 studies, 13 (35%) used Medicare reimbursements, 12 (32%) used a case-costing database, 3 (8%) used cost-to-charge ratios (CCRs), 2 (5%) used a combination of Medicare reimbursements and CCRs, 3 (8%) used the United Kingdom National Health Service reimbursement system, 2 (5%) used a Dutch reimbursement system, 1 (3%) used the United Kingdom Department of Health data, and 1 (3%) used the Tricare Military Reimbursement system. Nineteen (51%) studies completed their cost analysis from the societal perspective, 11 (30%) from the hospital perspective, and 7 (19%) from the payer perspective. Of those studies with a societal perspective, 14 (38%) reported actual indirect costs. Changes in cost have a direct impact on the value equation for concluding whether an intervention is cost-effective. It is essential to develop a standardized, accurate means of calculating costs. Comparability and transparency are essential, such that studies can be compared properly and policy makers can be appropriately informed when making decisions for our health care system based on the results of these studies.

Prognostic Factors Influencing the Outcome of 64 Consecutive Patients Undergoing Surgery for Metastatic Melanoma of the Spine.

PubMed

Sellin, Jonathan N; Gressot, Loyola V; Suki, Dima; St Clair, Eric G; Chern, Joshua; Rhines, Laurence D; McCutcheon, Ian E; Rao, Ganesh; Tatsui, Claudio E

2015-09-01

Melanoma metastases to the spine remain a challenge for neurosurgeons. To identify factors associated with survival in a series of patients who underwent spinal surgery for metastatic melanoma. We retrospectively reviewed all patients (n = 64) who received surgical intervention for melanoma metastases to the spine at the University of Texas MD Anderson Cancer Center between July 1993 and March 2012. No patients were excluded from the study, and vital status data were available for all patients. Median overall survival was 5.7 months (95% confidence interval, 2.7-28.7). On univariate survival analysis, diagnosis of spinal metastasis after prior diagnosis of systemic metastasis, higher total spinal disease burden (including but not exclusive to the operative site), presence of progressive systemic disease at the moment of spine surgery, and postoperative complications were associated with poorer overall survival, whereas the presence of only bone metastasis at the moment of surgery was associated with improved overall survival. On multivariate survival analysis, both progressive systemic disease at the moment of spine surgery and total spinal disease burden of ≥3 vertebral levels were significantly associated with worse overall survival (hazard ratio, 6.00; 95% confidence interval, 3.19-11.28; P < .001; and hazard ratio, 2.87; 95% confidence interval, 1.62-5.07; P < .001, respectively). On multivariate analysis, involvement of ≥3 vertebral bodies and progressive systemic disease were associated with worse overall survival. Consideration of these factors should influence surgical decision making in this patient population.

The Top 50 Articles on Minimally Invasive Spine Surgery.

PubMed

Virk, Sohrab S; Yu, Elizabeth

2017-04-01

Bibliometric study of current literature. To catalog the most important minimally invasive spine (MIS) surgery articles using the amount of citations as a marker of relevance. MIS surgery is a relatively new tool used by spinal surgeons. There is a dynamic and evolving field of research related to MIS techniques, clinical outcomes, and basic science research. To date, there is no comprehensive review of the most cited articles related to MIS surgery. A systematic search was performed over three widely used literature databases: Web of Science, Scopus, and Google Scholar. There were four searches performed using the terms "minimally invasive spine surgery," "endoscopic spine surgery," "percutaneous spinal surgery," and "lateral interbody surgery." The amount of citations included was averaged amongst the three databases to rank each article. The query of the three databases was performed in November 2015. Fifty articles were selected based upon the amount of citations each averaged amongst the three databases. The most cited article was titled "Extreme Lateral Interbody Fusion (XLIF): a novel surgical technique for anterior lumbar interbody fusion" by Ozgur et al and was credited with 447, 239, and 279 citations in Google Scholar, Web of Science, and Scopus, respectively. Citations ranged from 27 to 239 for Web of Science, 60 to 279 for Scopus, and 104 to 462 for Google Scholar. There was a large variety of articles written spanning over 14 different topics with the majority dealing with clinical outcomes related to MIS surgery. The majority of the most cited articles were level III and level IV studies. This is likely due to the relatively recent nature of technological advances in the field. Furthermore level I and level II studies are required in MIS surgery in the years ahead. 5.

The role of the vascular surgeon in anterior lumbar spine surgery.

PubMed

Asha, Mohammed Jamil; Choksey, Munchi S; Shad, Amjad; Roberts, Peter; Imray, Chris

2012-08-01

Advances in spinal fusion techniques have led to an increase in the need for safe access to the lumbar spine anteriorly. The aim of this study is to examine the procedure-related complications of anterior lumbar inter-body fusion (ALIF) or anterior lumbar disc replacement (ALDR) when performed jointly by a vascular-surgeon and a neurosurgeon in a single centre. A retrospective cohort analysis was conducted for all patients who underwent ALIF or ALDR between 2004 and 2010. Operative notes were examined to identify any procedure-specific complications. In-hospital postoperative complications were recorded. Outpatients' records were reviewed to record any late-onset postoperative complications. A total of 121 patients (68 female and 53 males) were included. Mean age was 44 years (range of 25-76). Eighty patients (66%) had ALIF while 24 patients (20%) underwent ALDR. The remaining 17 patients (14%) had combined procedure for multilevel disease. In all patients, a transperitoneal approach was performed by vascular surgeon. The main indication (88%) for performing surgery was degenerative lumbar disc disease. No visceral or 'major vascular' complications were reported in any patients. Only three patients had 'minor vascular' injuries. The only significant postoperative complication was self-limiting paralytic ileus affecting 18 patients (14.8%). Hospital stay ranged from 4 to 9 days (median of 5 days). The anterior lumbar approach is not generally favoured by many neurosurgeons, despite its many advantages, due to the significant risk of vascular injuries as reported in the literature. This risk is especially acknowledged by the emerging generation of neurosurgeons with very little general surgical exposure during the training years. Adopting a combined vascular and neurosurgical approach has been reported to reduce the risk of vascular injury in anterior lumbar surgery acceptably low. This team approach provides an excellent opportunity to preserve some key 'general' surgical skills for neurosurgeons and ensure safe outcome for the patients.

Efficacy of tranexamic acid on surgical bleeding in spine surgery: a meta-analysis.

PubMed

Cheriyan, Thomas; Maier, Stephen P; Bianco, Kristina; Slobodyanyuk, Kseniya; Rattenni, Rachel N; Lafage, Virginie; Schwab, Frank J; Lonner, Baron S; Errico, Thomas J

2015-04-01

Spine surgery is usually associated with large amount of blood loss, necessitating blood transfusions. Blood loss-associated morbidity can be because of direct risks, such as hypotension and organ damage, or as a result of blood transfusions. The antifibrinolytic, tranexamic acid (TXA), is a lysine analog that inhibits activation of plasminogen and has shown to be beneficial in reducing surgical blood loss. To consolidate the findings of randomized controlled trials (RCTs) investigating the use of TXA on surgical bleeding in spine surgery. A metaanalysis. Randomized controlled trials investigating the effectiveness of intravenous TXA in reducing blood loss in spine surgery, compared with a placebo/no treatment group. MEDLINE, Embase, Cochrane controlled trials register, and Google Scholar were used to identify RCTs published before January 2014 that examined the effectiveness of intravenous TXA on reduction of blood loss and blood transfusions, compared with a placebo/no treatment group in spine surgery. Metaanalysis was performed using RevMan 5. Weighted mean difference with 95% confidence intervals was used to summarize the findings across the trials for continuous outcomes. Dichotomous data were expressed as risk ratios with 95% confidence intervals. A p<.05 was considered statistically significant. Eleven RCTs were included for TXA (644 total patients). Tranexamic acid reduced intraoperative, postoperative, and total blood loss by an average of 219 mL ([-322, -116], p<.05), 119 mL ([-141, -98], p<.05), and 202 mL ([-299, -105], p<.05), respectively. Tranexamic acid led to a reduction in proportion of patients who received a blood transfusion (risk ratio 0.67 [0.54, 0.83], p<.05) relative to placebo. There was one myocardial infarction (MI) in the TXA group and one deep vein thrombosis (DVT) in placebo. Tranexamic acid reduces surgical bleeding and transfusion requirements in patients undergoing spine surgery. Tranexamic acid does not appear to be associated with an increased incidence of pulmonary embolism, DVT, or MI. Copyright © 2015 Elsevier Inc. All rights reserved.

Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: a randomized, controlled trial.

PubMed

North, Richard B; Kidd, David H; Farrokhi, Farrokh; Piantadosi, Steven A

2005-01-01

Persistent or recurrent radicular pain after lumbosacral spine surgery is often associated with nerve root compression and is treated by repeated operation or, as a last resort, by spinal cord stimulation (SCS). We conducted a prospective, randomized, controlled trial to test our hypothesis that SCS is more likely than reoperation to result in a successful outcome by standard measures of pain relief and treatment outcome, including subsequent use of health care resources. For an average of 3 years postoperatively, disinterested third-party interviewers followed 50 patients selected for reoperation by standard criteria and randomized to SCS or reoperation. If the results of the randomized treatment were unsatisfactory, patients could cross over to the alternative. Success was based on self-reported pain relief and patient satisfaction. Crossover to the alternative procedure was an outcome measure. Use of analgesics, activities of daily living, and work status were self-reported. Among 45 patients (90%) available for follow-up, SCS was more successful than reoperation (9 of 19 patients versus 3 of 26 patients, P <0.01). Patients initially randomized to SCS were significantly less likely to cross over than were those randomized to reoperation (5 of 24 patients versus 14 of 26 patients, P=0.02). Patients randomized to reoperation required increased opiate analgesics significantly more often than those randomized to SCS (P <0.025). Other measures of activities of daily living and work status did not differ significantly. SCS is more effective than reoperation as a treatment for persistent radicular pain after lumbosacral spine surgery, and in the great majority of patients, it obviates the need for reoperation.

Risk factors for postoperative retropharyngeal hematoma after anterior cervical spine surgery.

PubMed

O'Neill, Kevin R; Neuman, Brian; Peters, Colleen; Riew, K Daniel

2014-02-15

Retrospective review of prospective database. To investigate risk factors involved in the development of anterior cervical hematomas and determine any impact on patient outcomes. Postoperative (PO) hematomas after anterior cervical spine surgery require urgent recognition and treatment to avoid catastrophic patient morbidity or death. Current studies of PO hematomas are limited. Cervical spine surgical procedures performed on adults by the senior author at a single academic institution from 1995 to 2012 were evaluated. Demographic data, surgical history, operative data, complications, and neck disability index (NDI) scores were recorded prospectively. Cases complicated by PO hematoma were reviewed, and time until hematoma development and surgical evacuation were determined. Patients who developed a hematoma (HT group) were compared with those that did not (no-HT group) to identify risk factors. NDI outcomes were compared at early (<11 mo) and late (>11 mo) time points. There were 2375 anterior cervical spine surgical procedures performed with 17 occurrences (0.7%) of PO hematoma. In 11 patients (65%) the hematoma occurred within 24 hours PO, whereas 6 patients (35%) presented at an average of 6 days postoperatively. All underwent hematoma evacuation, with 2 patients (12%) requiring emergent cricothyroidotomy. Risk factors for hematoma were found to be (1) the presence of diffuse idiopathic skeletal hyperostosis (relative risk = 13.2, 95% confidence interval = 3.2-54.4), (2) presence of ossification of the posterior longitudinal ligament (relative risk = 6.8, 95% confidence interval = 2.3-20.6), (3) therapeutic heparin use (relative risk 148.8, 95% confidence interval = 91.3-242.5), (4) longer operative time, and (5) greater number of surgical levels. The occurrence of a PO hematoma was not found to have a significant impact on either early (HT: 30, no-HT: 28; P = 0.86) or late average NDI scores (HT: 28, no-HT 31; P = 0.76). With fast recognition and treatment, no long-term detriment from PO anterior cervical hematoma was found. We identified risk factors to be (1) presence of diffuse idiopathic skeletal hyperostosis, (2) presence of ossification of the posterior longitudinal ligament, (3) therapeutic heparin use, (4) longer operative time, and (5) greater number of surgical levels. 4.

Return to golf after spine surgery.

PubMed

Abla, Adib A; Maroon, Joseph C; Lochhead, Richard; Sonntag, Volker K H; Maroon, Adara; Field, Melvin

2011-01-01

no published evidence indicates when patients can resume golfing after spine surgery. The objective of this study is to provide data from surveys sent to spine surgeons. a survey of North American Spine Society members was undertaken querying the suggested timing of return to golf. Of 1000 spine surgeons surveyed, 523 responded (52.3%). The timing of recommended return to golf and the reasons were questioned for college/professional athletes and avid and recreational golfers of both sexes. Responses were tallied for lumbar laminectomy, lumbar microdiscectomy, lumbar fusion, and anterior cervical discectomy with fusion. the most common recommended time for return to golf was 4-8 weeks after lumbar laminectomy and lumbar microdiscectomy, 2-3 months after anterior cervical fusion, and 6 months after lumbar fusion. The results showed a statistically significant increase in the recommended time to resume golf after lumbar fusion than after cervical fusion in all patients (p < 0.01). The same holds true for the return to play after cervical fusion compared with either lumbar laminectomy or lumbar microdiscectomy for all golfer types (p < 0.01). There was a statistically significant shorter recommended time for professional and college golfers compared with noncompetitive golfers after lumbar fusion (p < 0.01), anterior cervical discectomy and fusion (p < 0.01), and lumbar microdiscectomy (p < 0.01). the return to golf after spine surgery depends on many variables, including the general well-being of patients in terms of pain control and comfort when golfing. This survey serves as a guide that can assist medical practitioners in telling patients the average times recommended by surgeons across North America regarding return to golf after spine surgery.

Athletic activity after spine surgery in children and adolescents: results of a survey.

PubMed

Rubery, Paul T; Bradford, David S

2002-02-15

Questionnaire-based survey. To poll the members of the Scoliosis Research Society regarding their opinions and experience with athletic activity after spine surgery performed on children and adolescents. Athletic activity is increasingly important in society. Patients are very concerned about returning to sports and exercise after spinal surgery. There are no generally accepted guidelines for surgeons regarding either appropriate sports or the appropriate time to resume sports after spinal surgery. A survey was designed by the authors and reviewed by a statistical consultant. The form was mailed to the 721 individuals on the Scoliosis Research Society mailing list. Returned surveys were hand scored and entered into an Excel spreadsheet. Of the 316 forms returned, 278 indicated that the respondent performed spinal fusion on children and adolescents. Two hundred sixty-one completed forms, representing approximately 45% of the society's estimated active clinicians, were reviewed. Formal physical therapy was unlikely to be recommended by members of the society regardless of procedure, although postoperative home exercise was used by many after spondylolisthesis fusion. The majority of patients were returned to gym class between 6 months and 1 year (range, immediate to never) after surgery. Most respondents returned patients to noncontact sports between 6 months and 1 year postoperatively. Contact sports were generally withheld until 1 year after surgery. Close to 20% of respondents required, and 35% suggested, that patients never return to collision sports. Twenty percent of respondents for scoliosis and 5% for spondylolisthesis reported having notable adverse outcomes attributed to athletic activity. These survey results show the varying approaches taken by members of the Scoliosis Research Society to postoperative athletic activity, and they provide a starting point for investigations regarding alternative approaches.

Relationship Between Bariatric Surgery and Bone Mineral Density: a Meta-analysis.

PubMed

Ko, Byung-Joon; Myung, Seung Kwon; Cho, Kyung-Hwan; Park, Yong Gyu; Kim, Sin Gon; Kim, Do Hoon; Kim, Seon Mee

2016-07-01

A meta-analysis regarding bone loss after bariatric surgery, designed to compare surgical and nonsurgical groups, has not yet been performed. Therefore, we performed a meta-analysis to compare the differences between bariatric surgical groups and nonoperated controls with regard to bone mineral density. In March 2015, we performed a review of the literature using PubMed, EMBASE, and the Cochrane Library. The search focused on retrospective and prospective studies, including but not limited to randomized studies published in English. Among 1299 studies that were initially screened, ten met the selection criteria. For all types of bariatric surgery, bone density at the femoral neck was lower in the surgical group than in the nonsurgical control group (mean difference [MD] -0.05 g/cm(2); 95 % confidence interval [CI], -0.07 to -0.02; p = 0.001); no difference in bone density was found between the two groups at the lumbar spine (MD -0.01 g/cm(2); 95 % CI -0.07 to 0.05; p = 0.661). The analysis of Roux-en-Y gastric bypass showed similar results. Bone density at the femoral neck decreased after bariatric surgery, compared to that in nonsurgical controls, whereas bone density at the lumbar spine did not show a difference between groups. Further larger scale studies with comparative nonsurgical controls are warranted to overcome the heterogeneity among studies in this analysis and to add evidence of possible bone loss subsequent to bariatric surgical procedures.

Image guided percutaneous spine procedures using an optical see-through head mounted display: proof of concept and rationale.

PubMed

Deib, Gerard; Johnson, Alex; Unberath, Mathias; Yu, Kevin; Andress, Sebastian; Qian, Long; Osgood, Gregory; Navab, Nassir; Hui, Ferdinand; Gailloud, Philippe

2018-05-30

Optical see-through head mounted displays (OST-HMDs) offer a mixed reality (MixR) experience with unhindered procedural site visualization during procedures using high resolution radiographic imaging. This technical note describes our preliminary experience with percutaneous spine procedures utilizing OST-HMD as an alternative to traditional angiography suite monitors. MixR visualization was achieved using the Microsoft HoloLens system. Various spine procedures (vertebroplasty, kyphoplasty, and percutaneous discectomy) were performed on a lumbar spine phantom with commercially available devices. The HMD created a real time MixR environment by superimposing virtual posteroanterior and lateral views onto the interventionalist's field of view. The procedures were filmed from the operator's perspective. Videos were reviewed to assess whether key anatomic landmarks and materials were reliably visualized. Dosimetry and procedural times were recorded. The operator completed a questionnaire following each procedure, detailing benefits, limitations, and visualization mode preferences. Percutaneous vertebroplasty, kyphoplasty, and discectomy procedures were successfully performed using OST-HMD image guidance on a lumbar spine phantom. Dosimetry and procedural time compared favorably with typical procedural times. Conventional and MixR visualization modes were equally effective in providing image guidance, with key anatomic landmarks and materials reliably visualized. This preliminary study demonstrates the feasibility of utilizing OST-HMDs for image guidance in interventional spine procedures. This novel visualization approach may serve as a valuable adjunct tool during minimally invasive percutaneous spine treatment. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

[Current status of thoracoscopic surgery for thoracic and lumbar spine. Part 2: treatment of the thoracic disc hernia, spinal deformities, spinal tumors, infections and miscellaneous].

PubMed

Verdú-López, Francisco; Beisse, Rudolf

2014-01-01

Thoracoscopic surgery or video-assisted thoracic surgery (VATS) of the thoracic and lumbar spine has evolved greatly since it appeared less than 20 years ago. It is currently used in a large number of processes and injuries. The aim of this article, in its two parts, is to review the current status of VATS of the thoracic and lumbar spine in its entire spectrum. After reviewing the current literature, we developed each of the large groups of indications where VATS takes place, one by one. This second part reviews and discusses the management, treatment and specific thoracoscopic technique in thoracic disc herniation, spinal deformities, tumour pathology, infections of the spine and other possible indications for VATS. Thoracoscopic surgery is in many cases an alternative to conventional open surgery. The transdiaphragmatic approach has made endoscopic treatment of many thoracolumbar junction processes possible, thus widening the spectrum of therapeutic indications. These include the treatment of spinal deformities, spinal tumours, infections and other pathological processes, as well as the reconstruction of injured spinal segments and decompression of the spinal canal if lesion placement is favourable to antero-lateral approach. Good clinical results of thoracoscopic surgery are supported by growing experience reflected in a large number of articles. The degree of complications in thoracoscopic surgery is comparable to open surgery, with benefits in regard to morbidity of the approach and subsequent patient recovery. Copyright © 2012 Sociedad Española de Neurocirugía. Published by Elsevier España. All rights reserved.

Late-presenting dural tear: incidence, risk factors, and associated complications.

PubMed

Durand, Wesley M; DePasse, J Mason; Kuris, Eren O; Yang, JaeWon; Daniels, Alan H

2018-04-18

Unrecognized and inadequately repaired intraoperative durotomies may lead to cerebrospinal fluid leak, pseudomeningocele, and other complications. Few studies have investigated durotomy that is unrecognized intraoperatively and requires additional postoperative management (hereafter, late-presenting dural tear [LPDT]), although estimates of LPDT range from 0.6 to 8.3 per 1,000 spinal surgeries. These single-center studies are based on relatively small sample sizes for an event of this rarity, all with <10 patients experiencing LPDT. This investigation is the largest yet conducted on LPDT, and sought to identify incidence, risk factors for, and complications associated with LPDT. This observational cohort study employed the American College of Surgeons National Surgical Quality Improvement Program dataset (years 2012-2015). Patients who underwent spine surgery were identified based on presence of primary listed Current Procedural Terminology (CPT) codes corresponding to spinal fusion or isolated posterior decompression without fusion. The primary variable in this study was occurrence of LPDT, identified as reoperation or readmission with durotomy-specific CPT or International Classification of Diseases, Ninth Revision, Clinical Modification codes but without durotomy codes present for the index procedure. Descriptive statistics were generated. Bivariate and multivariate analyses were conducted using chi-square tests and multiple logistic regression, respectively, generating both risk factors for LPDT and independent association of LPDT with postoperative complications. Statistical significance was defined as p<.05. In total, 86,212 patients were analyzed. The overall rate of reoperation or readmission without reoperation for LPDT was 2.0 per 1,000 patients (n=174). Of LPDT patients, 97.7% required one or more unplanned reoperations (n=170), and 5.7% of patients (n=10) required two reoperations. On multivariate analysis, lumbar procedures (odds ratio [OR] 2.79, p<.0001, vs. cervical), procedures involving both cervical and lumbar levels (OR 3.78, p=.0338, vs. cervical only), procedures with decompression only (OR 1.72, p=.0017, vs. fusion and decompression), and operative duration ≥250 minutes (OR 1.70, p=.0058, vs. <250 minutes) were associated with increased likelihood of LPDT. Late-presenting dural tear was significantly associated with surgical site infection (SSI) (OR 2.54, p<.0001), wound disruption (OR 2.24, p<.0001), sepsis (OR 2.19, p<.0001), thromboembolism (OR 1.71, p<.0001), acute kidney injury (OR 1.59, p=.0281), pneumonia (OR 1.14, p=.0269), and urinary tract infection (UTI) (OR 1.08, p=.0057). Late-presenting dural tears occurred in 2.0 per 1,000 patients who underwent spine surgery. Patients who underwent lumbar procedures, decompression procedures, and procedures with operative duration ≥250 minutes were at increased risk for LPDT. Further, LPDT was independently associated with increased likelihood of SSI, sepsis, pneumonia, UTI, wound dehiscence, thromboembolism, and acute kidney injury. As LPDT is associated with markedly increased morbidity and potential liability risk, spine surgeons should be aware of best-practice management for LPDT and consider it a rare, but possible etiology for developing postoperative complications. Copyright © 2018 Elsevier Inc. All rights reserved.

Risk analysis based on the timing of tracheostomy procedures in patients with spinal cord injury requiring cervical spine surgery.

PubMed

Galeiras, Rita; Mourelo, Mónica; Bouza, María Teresa; Seoane, María Teresa; Ferreiro, María Elena; Montoto, Antonio; Salvador, Sebastián; Seoane, Leticia; Freire, David

2018-05-19

To determine the optimal moment to carry out a tracheostomy in a patient requiring anterior cervical fixation. A retrospective observational study was carried out over an 18-year period on 56 patients who had been admitted to the ICU with acute spinal cord injury (SCI), and who underwent a tracheostomy and surgical fixation. The sample was divided into two groups: An at-risk group (31 patients, who had undergone a tracheostomy prior to the cervical surgery or <4 days after the procedure), and a not at-risk group (25 patients, who had undergone a tracheostomy >4 day following the fixation surgery). Both a descriptive and a comparative study were carried out. The overall trend of the collected data was analysed using cubic splines (graphic methods). The only infectious complications diagnosed as related to the surgical procedure were infection of the surgical wound in two patients of the not at-risk group (12%) and deep-tissue infection in one patient of the at-risk group (3.2%). During the study period, we identified a tendency towards the conduct of early tracheostomies. Our results suggest that the presence of a tracheostomy stoma prior to, or immediately after surgery, is associated with a low risk of infection of the cervical surgical wound in instrumented spinal fusion. Copyright © 2018 Elsevier Inc. All rights reserved.

Spine device clinical trials: design and sponsorship.

PubMed

Cher, Daniel J; Capobianco, Robyn A

2015-05-01

Multicenter prospective randomized clinical trials represent the best evidence to support the safety and effectiveness of medical devices. Industry sponsorship of multicenter clinical trials is purported to lead to bias. To determine what proportion of spine device-related trials are industry-sponsored and the effect of industry sponsorship on trial design. Analysis of data from a publicly available clinical trials database. Clinical trials of spine devices registered on ClinicalTrials.gov, a publicly accessible trial database, were evaluated in terms of design, number and location of study centers, and sample size. The relationship between trial design characteristics and study sponsorship was evaluated using logistic regression and general linear models. One thousand six hundred thrity-eight studies were retrieved from ClinicalTrials.gov using the search term "spine." Of the 367 trials that focused on spine surgery, 200 (54.5%) specifically studied devices for spine surgery and 167 (45.5%) focused on other issues related to spine surgery. Compared with nondevice trials, device trials were far more likely to be sponsored by the industry (74% vs. 22.2%, odds ratio (OR) 9.9 [95% confidence interval 6.1-16.3]). Industry-sponsored device trials were more likely multicenter (80% vs. 29%, OR 9.8 [4.8-21.1]) and had approximately four times as many participating study centers (p<.0001) and larger sample sizes. There were very few US-based multicenter randomized trials of spine devices not sponsored by the industry. Most device-related spine research is industry-sponsored. Multicenter trials are more likely to be industry-sponsored. These findings suggest that previously published studies showing larger effect sizes in industry-sponsored vs. nonindustry-sponsored studies may be biased as a result of failure to take into account the marked differences in design and purpose. Copyright © 2015 Elsevier Inc. All rights reserved.

Operative treatment of new onset radiculopathy secondary to combat injury.

PubMed

Wagner, Scott C; Van Blarcum, Gregory S; Kang, Daniel G; Lehman, Ronald A

2015-02-01

We set out to describe combat-related spine trauma over a 10-year period, and thereby determine the frequency of new onset radiculopathy secondary to injuries sustained in support of combat operations. We performed a retrospective analysis of a surgical database at three military institutions. Patients undergoing spine surgery following a combat-related injury in Afghanistan or Iraq between July 2003 and July 2013 were evaluated. We identified 105 patients with combat-related (Operations Enduring and Iraqi Freedom) spine trauma requiring operative intervention. Of these, 15 (14.3%) patients had radiculopathy as their primary complaint after injury. All patients were diagnosed with herniated nucleus pulposus. The average age was 39 years, with 80% injured in Iraq and 20% in Afghanistan. The most common mechanism of injury was mounted improvised explosive device (33%). The cervical spine was most commonly involved (53%), followed by lumbar spine (40%). Average time from injury to surgery was 23.4 months; 53% of patients had continued symptoms following surgery, and two patients had at least one revision surgery. Two patients were medically retired because of their symptoms. This study is the only of its kind evaluating the operative treatment of traumatic radiculopathy following combat-related trauma. We identified a relatively high rate of radiculopathy in these patients. Reprint & Copyright © 2015 Association of Military Surgeons of the U.S.

Bone morphogenetic protein use in spine surgery-complications and outcomes: a systematic review.

PubMed

Faundez, Antonio; Tournier, Clément; Garcia, Matthieu; Aunoble, Stéphane; Le Huec, Jean-Charles

2016-06-01

Because of significant complications related to the use of autologous bone grafts in spinal fusion surgery, bone substitutes and growth factors such as bone morphogenetic protein (BMP) have been developed. One of them, recombinant human (rh) BMP-2, has been approved by the Food and Drug Administration (FDA) for use under precise conditions. However, rhBMP-2-related side effects have been reported, used in FDA-approved procedures, but also in off-label use.A systematic review of clinical data was conducted to analyse the rhBMP-2-related adverse events (AEs), in order to assess their prevalence and the associated surgery practices. Medline search with keywords "bone morphogenetic protein 2", "lumbar spine", "anterolateral interbody fusion" (ALIF) and the filter "clinical trial". FDA published reports were also included. Study assessment was made by authors (experienced spine surgeons), based on quality of study designs and level of evidence. Extensive review of randomised controlled trials (RCTs) and controlled series published up to the present point, reveal no evidence of a significant increase of AEs related to rhBMP-2 use during ALIF surgeries, provided that it is used following FDA guidelines. Two additional RCTs performed with rhBMP-2 in combination with allogenic bone dowels reported increased bone remodelling in BMP-treated patients. This AE was transient and had no consequence on the clinical outcome of the patients. No other BMP-related AEs were reported in these studies. This literature review confirms that the use of rhBMP-2 following FDA-approved recommendations (i.e. one-level ALIF surgery with an LT-cage) is safe. The rate of complications is low and the AEs had been identified by the FDA during the pre-marketing clinical trials. The clinical efficiency of rhBMP-2 is equal or superior to that of allogenic or autologous bone graft in respect to fusion rate, low back pain disability, patient satisfaction and rate of re-operations. For all other off-label use, the safety and effectiveness of rhBMP-2 have not been established, and further RCTs with high level of evidence are required.

Minimally Invasive Treatment for a Sacral Tarlov Cyst Through Tubular Retractors.

PubMed

Del Castillo-Calcáneo, Juan D; Navarro-Ramírez, Rodrigo; Nakhla, Jonathan; Kim, Eliana; Härtl, Roger

2017-12-01

Tarlov cysts (TC) are focal dilations of arachnoid and dura mater of the spinal posterior nerve root sheath that appear as cystic lesions of the nerve roots typically in the lower spine, especially in the sacrum, which can cause radicular symptoms when they increase in size and compress the nerve roots. Different open procedures have been described to treat TCs, but no minimally invasive procedures have been described to effectively address this pathology. A 29-year-old woman presented with right lower extremity pain and weakness. A magnetic resonance imaging scan demonstrated a lumbosacral TC that protruded through the right L5-S1 foramina. Through a small laminotomy, cyst drainage followed by neck ligation using a Scanlan modified technique through tubular retractors was performed. The patient recovered full motor function within the first days postoperatively and showed no signs of relapse at 6-month follow-up. Minimally invasive spine surgery through tubular retractors can be safely performed for successful excision and ligation of TC using a Scanlan modified technique. Copyright © 2017 Elsevier Inc. All rights reserved.

Oblique Intrathecal Injection in Lumbar Spine Surgery: A Technical Note.

PubMed

Jewett, Gordon A E; Yavin, Daniel; Dhaliwal, Perry; Whittaker, Tara; Krupa, JoyAnne; Du Plessis, Stephan

2017-09-01

Intrathecal morphine (ITM) is an efficacious method of providing postoperative analgesia and reducing pain associated complications. Despite adoption in many surgical fields, ITM has yet to become a standard of care in lumbar spine surgery. Spine surgeons' reticence to make use of the technique may in part be attributed to concerns of precipitating a cerebrospinal fluid (CSF) leak. Herein we describe a method for oblique intrathecal injection during lumbar spine surgery to minimize risk of CSF leak. The dural sac is penetrated obliquely at a 30° angle to offset dural and arachnoid puncture sites. Oblique injection in instances of limited dural exposure is made possible by introducing a 60° bend to a standard 30-gauge needle. The technique was applied for injection of ITM or placebo in 104 cases of lumbar surgery in the setting of a randomized controlled trial. Injection was not performed in two cases (2/104, 1.9%) following preinjection dural tear. In the remaining 102 cases no instances of postoperative CSF leakage attributable to oblique intrathecal injection occurred. Three cases (3/102, 2.9%) of transient CSF leakage were observed immediately following intrathecal injection with no associated sequelae or requirement for postsurgical intervention. In two cases, the observed leak was repaired by sealing with fibrin glue, whereas in a single case the leak was self-limited requiring no intervention. Oblique dural puncture was not associated with increased incidence of postoperative CSF leakage. This safe and reliable method of delivery of ITM should therefore be routinely considered in lumbar spine surgery.

Evaluation of the ROSA™ Spine robot for minimally invasive surgical procedures.

PubMed

Lefranc, M; Peltier, J

2016-10-01

The ROSA® robot (Medtech, Montpellier, France) is a new medical device designed to assist the surgeon during minimally invasive spine procedures. The device comprises a patient-side cart (bearing the robotic arm and a workstation) and an optical navigation camera. The ROSA® Spine robot enables accurate pedicle screw placement. Thanks to its robotic arm and navigation abilities, the robot monitors movements of the spine throughout the entire surgical procedure and thus enables accurate, safe arthrodesis for the treatment of degenerative lumbar disc diseases, exactly as planned by the surgeon. Development perspectives include (i) assistance at all levels of the spine, (ii) improved planning abilities (virtualization of the entire surgical procedure) and (iii) use for almost any percutaneous spinal procedures not limited in screw positioning such as percutaneous endoscopic lumbar discectomy, intracorporeal implant positioning, over te top laminectomy or radiofrequency ablation.

Transient paraplegia due to accidental intrathecal bupivacaine infiltration following pre-emptive analgesia in a patient with missed sacral dural ectasia.

PubMed

Kanna, P Rishimugesh; Sekar, Chelliah; Shetty, Ajoy Prasad; Rajasekaran, Shanmughanathan

2010-11-15

A case report with review of the literature. To highlight the need for careful magnetic resonance imaging evaluation for the presence of incidental lumbosacral dural anomalies before attempting caudal epidural interventions. Pre-emptive analgesia through the caudal epidural route provides good postoperative pain relief in spine surgeries. Several precautions have been advised in the literature. Presence of sacral-dural ectasia should be considered a relative contraindication for this procedure. A 50-year old woman underwent posterior instrumented spinal fusion for L4-L5 spondylolisthesis under general anesthesia. She received single shot caudal epidural analgesia at the start of the procedure. After complete emergence from anesthesia, she had complete motor and sensory loss below the T12 spinal level, which reversed to normal neurology in 6 hours. Retrospective evaluation of the patient's magnetic resonance imaging showed an ectatic, low lying lumbosacral dural sac which had been overlooked in the initial evaluation. The drugs given by the caudal route have been accidentally administered into the thecal sac causing a brief period of neurologic deficit. This unexpected complication has been reported only in the pediatric literature before. It is important to look for the presence of lumbosacral dural anomalies before planning caudal epidural injections in adults also. Sacral dural ectasia and other lumbosacral anomalies must be recognized as contraindications for caudal epidural pre-emptive analgesia for spine surgery. Other modes of postoperative pain relief should be tried in these patients.

Bioactive titan cage Implaspin in treatment of degenerative disease of the cervcal spine--the results from 2007 till 2008.

PubMed

Filip, Michal; Linzer, Petr; Sámal, Filip; Jurek, Patrik; Strnad, Zdenek; Strnad, Jakub

2010-01-01

The authors present results of surgical treatment of cervical spine degenerative disease via Implaspin biotitanium replacement. Surgery was indicated for a group of 24 patients with symptoms of cervical spondylogenic myelopathy or the irritation decay root syndrome non-reacting to conservative treatment. Pre-surgery X-ray and MRI examinations showed spinal canal stenosis caused by the intervertebral disk osteochondrosis combined with prolapse or dorsal osteophytes. Clinical problems of the group of patients were evaluated through the JOA classification before surgery and during the 2nd, the 6th and month 12th after surgery. The surgery rate of success was evaluated in percentages during post-surgery examinations that took place in the 12th month. Based on the JOA classification, that rate of success falls into the good surgery results zone. The post-surgery X-ray examinations showed two sank replacements by 1/3 of its height into the surrounding vertebral bodies. In these cases we performed the control MRI. No signs of the new spinal compression were found and the spinal canal was free in the operated site. Based on our short-term experiences, the Implaspin bioactive replacement seems to be a suitable alternative to the other types of replacements designed for intervertebral fusion in the lower cervical spine area.

Transforaminal endoscopic treatment of lumbar radiculopathy after instrumented lumbar spine fusion.

PubMed

Telfeian, Albert E; Jasper, Gabriele P; Francisco, Gina M

2015-01-01

Transforaminal endoscopic discectomy and foraminotomy is a well-described minimally invasive technique for surgically treating lumbar radiculopathy caused by a herniated disc and foraminal narrowing. To describe the technique and feasibility of transforaminal foraminoplasty for the treatment of lumbar radiculopathy in patients who have already undergone instrumented spinal fusion. Retrospective study. Hospital and ambulatory surgery center After Institutional Review Board approval, charts from 18 consecutive patients with lumbar radiculopathy and instrumented spinal fusions who underwent endoscopic procedures between 2008 and 2013 were reviewed. The average pain relief one year postoperatively was reported to be 67.0%, good results as defined by MacNab. The average preoperative VAS score was 9.14, indicated in our questionnaire as severe and constant pain. The average one year postoperative VAS score was 3.00, indicated in our questionnaire as mild and intermittent pain. This is a retrospective study and only offers one year follow-up data for patients with instrumented fusions who have undergone endoscopic spine surgery. Transforaminal endoscopic discectomy and foraminotomy could be used as a safe, yet, minimally invasive and innovative technique for the treatment of lumbar radiculopathy in the setting of previous instrumented lumbar fusion. IRB approval: Meridian Health: IRB Study # 201206071J

Use of recombinant activated factor VII for reduction of perioperative blood loss during elective surgical correction of spine deformity in a Jehovah's Witness. Case report.

PubMed

Kącka, Katarzyna; Kącki, Wojciech; Merak, Joanna; Błęka, Adam

2010-01-01

Planned surgical procedures at patients who refuse allogenic blood transfusion because of religious convictions are important problem, not only medical but also ethical and juristical. At the study authors report the successful use of activated recombinant factor VII (rFVIIa) for the reduction of perioperative blood loss in four years old child - Jehovah's Witness, who had planned Torode kyphectomy. Applied perioperative management together with preparing to surgery with erythropoietin allowed for reduction of blood loss and avoiding of blood transfusion. Authors state, that appropriate perioperative proceeding makes a possibility of safe surgical procedures also at patients who refuse the transfusion.

Effect of problem and scripting-based learning on spine surgical trainees' learning outcomes.

PubMed

Cong, Lin; Yan, Qi; Sun, Chenjing; Zhu, Yue; Tu, Guanjun

2017-12-01

To assess the impact of problem and scripting-based learning (PSBL) on spine surgical trainees' learning outcomes. 30 spine surgery postgraduate-year-1 residents (PGY-1s) from the First Hospital of China Medical University were randomly divided into two groups. The first group studied spine surgical skills and developed individual judgment under a conventional didactic model, whereas the PSBL group used PBL and Scripted model. A feedback questionnaire and the satisfaction of residents were evaluated by the first assistant surgeon immediately following each procedure. At the end of the study, residents filled out questionnaires focused on identifying the strengths of each teaching method and took a multiple-choice theoretical examination. The results were analyzed by t tests. Significant difference was found between the two groups in total mean score of preparedness and performance feedback statement (P = 0.01) and the questionnaire by PGY-1's opinion on the effectiveness of the two teaching methods (P = 0.004). Compared with the non-PSBL group, the PSBL group had significantly higher mean score of pre-operative preparedness (P = 0.01), but there was no significant difference between the two groups in theoretical examination, intra-operative performance, and overall satisfaction with the PGY-1s. The residents found that PSBL could develop their judgment (P = 0.03) and provide greater satisfaction (P = 0.02), and would like to repeat the experience (P = 0.03). The PSBL method can activate spine residents' prior knowledge and building on existing cognitive frameworks, which is an important tool for improving pre-operative preparedness. We believe that PSBL is an important first step in training spine residents to become confident and safe spine surgeons.

Gunshot wounds to the spine in post-Katrina New Orleans.

PubMed

Trahan, Jayme; Serban, Daniel; Tender, Gabriel C

2013-11-01

Gunshot wounds (GSW) to the spine represent a major health concern within today's society. Our study assessed the epidemiologic characteristics of patients with GSW to the spine treated in New Orleans. A retrospective chart review was performed from January 2007 through November 2011 on all the patients who were seen in the emergency room and diagnosed with a gunshot wound to the spine. Epidemiologic factors, as well as the results of admission toxicology screening, were noted. Outcome analysis was performed on patients undergoing conservative versus operative management for their injuries. Clinical outcomes were assessed using the ASIA classification system. Complications related to initial injury, neurosurgical procedures, and hospital stay were noted. A total of 147 patients were enrolled. Of those diagnosed with a GSW to the spine, 88 (59.8%) received an admission toxicology screen. Seventy-three (83%) patients out of those tested had a positive screen, with the most common substances detected being cannabis, cocaine, and alcohol. In regards to management, 127 (87%) patients were treated conservatively and only one (0.7%) patient improved clinically from ASIA D to E. Of the 20 patients who underwent surgery, one (5%) patient had clinical improvement post-operatively from ASIA C to D. This study evaluates the largest number of patients with GSW to the spine per year treated in a single centre, illustrating the violent nature of New Orleans. In this urban population, there was a clear correlation between drug use and suffering a GSW to the spine. Surgical intervention was seldom indicated in these patients and was predominately used for fixation of unstable fractures and decompression of compressive injuries, particularly below T11. Minimally invasive techniques were used successfully at our institution to minimize the risk of post-operative CSF leak. Copyright © 2013 Elsevier Ltd. All rights reserved.

Variations in 30-day readmissions and length of stay among spine surgeons: a national study of elective spine surgery among US Medicare beneficiaries.

PubMed

Singh, Siddhartha; Sparapani, Rodney; Wang, Marjorie C

2018-06-01

OBJECTIVE Pay-for-performance programs are targeting hospital readmissions. These programs have an underlying assumption that readmissions are due to provider practice patterns that can be modified by a reduction in reimbursement. However, there are limited data to support the role of providers in influencing readmissions. To study this, the authors examined variations in readmission rates by spine surgeon within 30 days among Medicare beneficiaries undergoing elective lumbar spine surgery for degenerative conditions. METHODS The authors applied validated ICD-9-CM algorithms to 2003-2007 Medicare data to select beneficiaries undergoing elective inpatient lumbar spine surgery for degenerative conditions. Mixed models, adjusting for patient demographics, comorbidities, and surgery type, were used to estimate risk of 30-day readmission by the surgeon. Length of stay (LOS) was also studied using these same models. RESULTS A total of 39,884 beneficiaries were operated on by 3987 spine surgeons. The mean readmission rate was 7.2%. The mean LOS was 3.1 days. After adjusting for patient characteristics and surgery type, 1 surgeon had readmission rates significantly below the mean, and only 5 surgeons had readmission rates significantly above the mean. In contrast, for LOS, the patients of 288 surgeons (7.2%) had LOS significantly lower than the mean, and the patients of 397 surgeons (10.0%) had LOS significantly above the mean. These findings were robust to adjustments for surgeon characteristics and clustering by hospital. Similarly, hospital characteristics were not significantly associated with readmission rates, but LOS was associated with hospital for-profit status and size. CONCLUSIONS The authors found almost no variations in readmission rates by surgeon. These findings suggest that surgeon practice patterns do not affect the risk of readmission. Likewise, no significant variation in readmission rates by hospital characteristics were found. Strategies to reduce readmissions would be better targeted at factors other than providers.

Effect of liberal blood transfusion on clinical outcomes and cost in spine surgery patients.

PubMed

Purvis, Taylor E; Goodwin, C Rory; De la Garza-Ramos, Rafael; Ahmed, A Karim; Lafage, Virginie; Neuman, Brian J; Passias, Peter G; Kebaish, Khaled M; Frank, Steven M; Sciubba, Daniel M

2017-09-01

Blood transfusions in spine surgery are shown to be associated with increased patient morbidity. The association between transfusion performed using a liberal hemoglobin (Hb) trigger-defined as an intraoperative Hb level of ≥10 g/dL, a postoperative level of ≥8 g/dL, or a whole hospital nadir between 8 and 10 g/dL-and perioperative morbidity and cost in spine surgery patients is unknown and thus was investigated in this study. This study aimed to describe the perioperative outcomes and economic cost associated with liberal Hb trigger transfusion among spine surgery patients. This is a retrospective study. The surgical billing database at our institution was queried for inpatients discharged between 2008 and 2015 after the following procedures: atlantoaxial fusion, anterior cervical fusion, posterior cervical fusion, anterior lumbar fusion, posterior lumbar fusion, lateral lumbar fusion, other procedures, and tumor-related surgeries. In total, 6,931 patients were included for analysis. The primary outcome was composite morbidity, which was composed of (1) infection (sepsis, surgical-site infection, Clostridium difficile infection, or drug-resistant infection); (2) thrombotic event (pulmonary embolus, deep venous thrombosis, or disseminated intravascular coagulation); (3) kidney injury; (4) respiratory event; and (5) ischemic event (transient ischemic attack, myocardial infarction, or cerebrovascular accident). Data on intraoperative transfusion were obtained from an automated, prospectively collected anesthesia data management system. Data on postoperative hospital transfusion were obtained through a Web-based intelligence portal. Based on previous research, we analyzed the data using three definitions of a liberal transfusion trigger in patients who underwent red blood cell transfusion: a liberal intraoperative Hb trigger as a nadir Hb level of 10 g/dL or greater, a liberal postoperative Hb trigger as a nadir Hb level of 8 g/dL or greater, or a whole hospital nadir Hb level of 8-10 g/dL. Variables analyzed included in-hospital morbidity, mortality, length of stay, and total costs associated with a liberal transfusion strategy. Among patients with a whole hospital stay nadir Hb between 8 and 10 g/dL, transfused patients demonstrated a longer in-hospital stay (median [interquartile range], 6 [5-9] vs. 4 [3-6] days; p<.0001) and a higher perioperative morbidity (n=145 [11.5%] vs. n=74 [6.1%], p<.0001) than those not transfused. Even after adjusting for age, gender, race, American Society of Anesthesiologists class, Charlson Comorbidity Index score, estimated blood loss, baseline Hb value, and surgery type, logistic regression analysis revealed that patients with a nadir Hb of 8-10 g/dL who were transfused had an independently higher risk of perioperative morbidity (odds ratio=2.11, 95% confidence interval, 1.44-3.09; p<.0001). Estimated additional costs associated with liberal trigger use, defined as a transfusion occurring in patients with a whole hospital stay nadir Hb of 8-10 g/dL, ranged from $202,675 to $700,151 annually. Transfusion using a liberal trigger is associated with increased morbidity, even after controlling for possible confounders. Our results suggest that modification of transfusion practice may be a potential area for improving patient outcomes and reducing costs. Copyright © 2017 Elsevier Inc. All rights reserved.

Spinal fusion

MedlinePlus

... of another Abnormal curvatures, such as those from scoliosis or kyphosis Arthritis in the spine, such as ... Spine surgery - discharge Surgical wound care - open Images Scoliosis Spinal fusion - series References Bennett EE, Hwang L, ...

Multimodal intraoperative monitoring: an overview and proposal of methodology based on 1,017 cases

PubMed Central

Eggspuehler, Andreas; Muller, Alfred; Dvorak, Jiri

2007-01-01

To describe different currently available tests of multimodal intraoperative monitoring (MIOM) used in spine and spinal cord surgery indicating the technical parameters, application and interpretation as an easy understanding systematic overview to help implementation of MIOM and improve communication between neurophysiologists and spine surgeons. This article aims to give an overview and proposal of the different MIOM-techniques as used daily in spine and spinal cord surgery at our institution. Intensive research in neurophysiology over the past decades has lead to a profound understanding of the spinal cord, nerve functions and their intraoperative functional evaluation in anaesthetised patients. At present, spine surgeons and neurophysiologist are faced with 1,883 publications in PubMed on spinal cord monitoring. The value and the limitations of single monitoring methods are well documented. The diagnostic power of the multimodal approach in a larger study population in spine surgery, as measured with sensitivity and specificity, is dealt with elsewhere in this supplement (Sutter et al. in Eur Spine J Suppl, 2007). This paper aims to give a detailed description of the different modalities used in this study. Description of monitoring techniques of the descending and ascending spinal cord and nerve root pathways by motor evoked potentials of the spinal cord and muscles elicited after transcranial electrical motor cortex, spinal cord, cauda equina and nerve root stimulation, continuous EMG, sensory cortical and spinal evoked potentials, as well as direct spinal cord evoked potentials applied on 1,017 patients. The method of MIOM, continuously adapted according to the site, stage of surgery and potential danger to nerve tissues, proved to be applicable with online results, reliable and furthermore teachable. PMID:17653777

Preoperative Fiducial Marker Placement in the Thoracic Spine: A Technical Report.

PubMed

Madaelil, Thomas P; Long, Jeremiah R; Wallace, Adam N; Baker, Jonathan C; Ray, Wilson Z; Santiago, Paul; Buchowski, Jacob; Zebala, Lukas P; Jennings, Jack W

2017-05-15

A retrospective review. The aim of this study was to demonstrate proof-of-concept of preoperative percutaneous intraosseous fiducial marker placement before thoracic spine surgery. Wrong-level spine surgery is defined as a never event by Center for Medicare Services, yet the strength of data supporting the implementation of Universal Protocol to limit wrong level surgery is weak. The thoracic spine is especially prone to intraoperative mislocalization, particularly in cases of morbid obesity and anatomic variations. We retrospectively reviewed all cases of preoperative percutaneous image-guided intraosseous placement of a metallic marker in the thoracic spine. Indications for surgery included degenerative disc disease (16/19), osteochondroma resection, spinal metastasis, and ligation of dural arteriovenous malformation. All metallic markers were placed from a percutaneous transpedicular approach under imaging guidance [fluoroscopy and computed tomography (CT) or CT alone]. Patient body mass index (BMI) was recorded. Overweight and obese BMI was defined greater than 25 and 30 kg/m, respectively. All 19 patients underwent fiducial marker placement and intraoperative localization successfully without complication. Twenty-two thoracic spine levels were localized. The T7, T9, T10, and T11 levels were the most often localized at rate of 18.1% for each level (4/22). The most cranial and caudal levels localized were T4 and T11. About 84.2% (16/19) of the cohort was overweight (57.9%; 11/19) or obese (26.3%; 5/19). The median BMI was 30.2 kg/m (range, 23.9-54.3 kg/m). Preoperative percutaneous thoracic fiducial marker placement under imaging guidance is a safe method for facilitating intraoperative localization of the target spinal level, especially in obese patients. Further studies are needed to quantify changes in operative time and radiation exposure. 4.

Maxillofacial trauma - Underestimation of cervical spine injury.

PubMed

Reich, Waldemar; Surov, Alexey; Eckert, Alexander Walter

2016-09-01

Undiagnosed cervical spine injury can have devastating results. The aim of this study was to analyse patients with primary maxillofacial trauma and a concomitant cervical spine injury. It is hypothetised that cervical spine injury is predictable in maxillofacial surgery. A monocentric clinical study was conducted over a 10-year period to analyse patients with primary maxillofacial and associated cervical spine injuries. Demographic data, mechanism of injury, specific trauma and treatments provided were reviewed. Additionally a search of relevant international literature was conducted in PubMed by terms "maxillofacial" AND "cervical spine" AND "injury". Of 3956 patients, n = 3732 (94.3%) suffered from craniomaxillofacial injuries only, n = 174 (4.4%) from cervical spine injuries only, and n = 50 (1.3%) from both craniomaxillofacial and cervical spine injuries. In this study cohort the most prevalent craniofacial injuries were: n = 41 (44%) midfacial and n = 21 (22.6%) skull base fractures. Cervical spine injuries primarily affected the upper cervical spine column: n = 39 (58.2%) vs. n = 28 (41.8%). Only in 3 of 50 cases (6%), the cervical spine injury was diagnosed coincidentally, and the cervical spine column was under immobilised. The operative treatment rate for maxillofacial injuries was 36% (n = 18), and for cervical spine injuries 20% (n = 10). The overall mortality rate was 8% (n = 4). The literature search yielded only 12 papers (11 retrospective and monocentric cohort studies) and is discussed before our own results. In cases of apparently isolated maxillofacial trauma, maxillofacial surgeons should be aware of a low but serious risk of underestimating an unstable cervical spine injury. Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Anterior cervical distraction and screw elevating–pulling reduction for traumatic cervical spine fractures and dislocations

PubMed Central

Li, Haoxi; Yong, Zhiyao; Chen, Zhaoxiong; Huang, Yufeng; Lin, Zhoudan; Wu, Desheng

2017-01-01

Abstract Treatment of cervical fracture and dislocation by improving the anterior cervical technique. Anterior cervical approach has been extensively used in treating cervical spine fractures and dislocations. However, when this approach is used in the treatment of locked facet joints, an unsatisfactory intraoperative reduction and prying reduction increases the risk of secondary spinal cord injury. Thus, herein, the cervical anterior approach was improved. With distractor and screw elevation therapy during surgery, the restoration rate is increased, and secondary injury to the spinal cord is avoided. To discuss the feasibility of the surgical method of treating traumatic cervical spine fractures and dislocations and the clinical application. This retrospective study included the duration of patients’ hospitalization from January 2005 to June 2015. The potential risks of surgery (including death and other surgical complications) were explained clearly, and written consents were obtained from all patients before surgery. The study was conducted on 86 patients (54 males and 32 females, average age of 40.1 ± 5.6 years) with traumatic cervical spine fractures and dislocations, who underwent one-stage anterior approach treatment. The effective methods were evaluated by postoperative follow-up. The healing of the surgical incision was monitored in 86 patients. The follow-up duration was 18 to 36 (average 26.4 ± 7.1) months. The patients achieved bones grafted fusion and restored spine stability in 3 to 9 (average 6) months after the surgery. Statistically, significant improvement was observed by Frankel score, visual analog scale score, Japanese Orthopedic Association score, and correction rate of the cervical spine dislocation pre- and postoperative (P < .01). The modified anterior cervical approach is simple with a low risk but a good effect in reduction. In addition, it can reduce the risk of iatrogenic secondary spinal cord injury and maintain optimal cervical spine stability as observed during follow-ups. Therefore, it is suitable for clinical promotion and application. PMID:28658125

Efficacy of Intraoperative Neurophysiologic Monitoring for Pediatric Cervical Spine Surgery.

PubMed

Tobert, Daniel G; Glotzbecker, Michael P; Hresko, Michael Timothy; Karlin, Lawrence I; Proctor, Mark R; Emans, John B; Miller, Patricia E; Hedequist, Daniel J

2017-07-01

Clinical case series. To investigate the efficacy of intraoperative neuromonitoring in pediatric cervical spine surgery. Intraoperative neuromonitoring (IONM) consisting of somatosensory-evoked potentials (SSEP) and transcranial motor-evoked potentials (tcMEP) has been shown to effectively prevent permaneny neurologic injury in deformity surgery. The role of IONM during pediatric cervical spine surgery is not well documented. Advances in cervical spine instrumentation have expanded the surgical options in pediatric populations. The goal of this study is to report the ability of IONM to detect neurologic injury during pediatric cervical spine instrumentation. A single institution database was queried for pediatric-aged patients who underwent cervical spine instrumentation and fusion between 2011 and 2014. Age, diagnosis, surgical indication, number of instrumented levels, and a complete IONM were extracted. Sensitivity and specificity for the detection of neurologic deficits were calculated with exact 95% confidence intervals. Positive and negative predictive values were calculated with estimated 95% confidence intervals. Sixty-seven patients who underwent cervical spine instrumentation were identified with a mean age of 11.6 years (range 1-18). Diagnoses included instability (27), congenital (11), kyphosis (8), fracture (7), tumor (7), arthritis (4), and basilar invagination (3). Mean number of vertebral levels fused was 4 (range 2-7). All patients underwent cervical instrumentation with SSEP and tcMEP monitoring. A significant change in tcMEP monitoring was observed in 7 subjects (10%). There were no corresponding SSEP changes in these patients. The sensitivity of combined IONM was 75% [95% CI = 24.9, 98.7] and the specificity was 98.5% [92.7, 99.9]. tcMEP is a more sensitive indicator to spinal cord injury than SSEP, which is consistent with previous studies. IONM changes in 10% of a patient population are significant enough to warrant intraoperative determination if true SCI has occurred or is underway and intervene accordingly. 4.

Association Between Baseline Affective Disorders and 30-Day Readmission Rates in Patients Undergoing Elective Spine Surgery.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Mehta, Ankit I; Vasquez, Raul A; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2016-10-01

There is a growing understanding of the prevalence and impact of affective disorders on perception of health status in patients undergoing elective spine surgery. However, the role of these disorders in early readmission is unclear. The aim of this study is to investigate the influence of psychiatric comorbidities on 30-day all-cause readmissions after elective spine surgery. The medical records of 400 patients undergoing elective spine surgery at a major academic medical center were reviewed, of which 107 patients had comprehensive 1- and 2-year patient-reported outcomes data. We identified all unplanned readmissions within 30 days of discharge. The prevalence of affective disorders, such as depression and anxiety, were also assessed. All-cause readmissions within 30 days of discharge was the primary outcome variable. Baseline characteristics were similar between groups. Approximately 6% of patients in this study were readmitted within 30 days of discharge. The rate of readmission was 3-fold more for individuals with a psychiatric comorbidity compared with those without a psychiatric comorbidity (10.34% vs. 3.84%, P = 0.03). In a univariate analysis, race, body mass index, gender, patient age, smoking, diabetes, and fusion levels were associated with increased 30-day readmission rates. However, in a multivariate logistic regression model, depression was an independent predictor of readmission within 30 days of discharge. In addition, there was no significant difference in baseline, 1- and 2-year patient-reported outcomes measures between groups. Our study suggests that psychologic disorders, like depression and anxiety, are independently associated with higher all-cause 30-day readmission rates after elective spine surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Visuo-proprioceptive interactions in degenerative cervical spine diseases requiring surgery.

PubMed

Freppel, S; Bisdorff, A; Colnat-Coulbois, S; Ceyte, H; Cian, C; Gauchard, G; Auque, J; Perrin, P

2013-01-01

Cervical proprioception plays a key role in postural control, but its specific contribution is controversial. Postural impairment was shown in whiplash injuries without demonstrating the sole involvement of the cervical spine. The consequences of degenerative cervical spine diseases are underreported in posture-related scientific literature in spite of their high prevalence. No report has focused on the two different mechanisms underlying cervicobrachial pain: herniated discs and spondylosis. This study aimed to evaluate postural control of two groups of patients with degenerative cervical spine diseases with or without optokinetic stimulation before and after surgical treatment. Seventeen patients with radiculopathy were recruited and divided into two groups according to the spondylotic or discal origin of the nerve compression. All patients and a control population of 31 healthy individuals underwent a static posturographic test with 12 recordings; the first four recordings with the head in 0° position: eyes closed, eyes open without optokinetic stimulation, with clockwise and counter clockwise optokinetic stimulations. These four sensorial situations were repeated with the head rotated 30° to the left and to the right. Patients repeated these 12 recordings 6weeks postoperatively. None of the patients reported vertigo or balance disorders before or after surgery. Prior to surgery, in the eyes closed condition, the herniated disc group was more stable than the spondylosis group. After surgery, the contribution of visual input to postural control in a dynamic visual environment was reduced in both cervical spine diseases whereas in a stable visual environment visual contribution was reduced only in the spondylosis group. The relative importance of visual and proprioceptive inputs to postural control varies according to the type of pathology and surgery tends to reduce visual contribution mostly in the spondylosis group. Copyright © 2013 IBRO. Published by Elsevier Ltd. All rights reserved.

Performance Indicators in Spine Surgery.

PubMed

St-Pierre, Godefroy Hardy; Yang, Michael H; Bourget-Murray, Jonathan; Thomas, Ken C; Hurlbert, Robin John; Matthes, Nikolas

2018-02-15

Systematic review. To elucidate how performance indicators are currently used in spine surgery. The Patient Protection and Affordable Care Act has given significant traction to the idea that healthcare must provide value to the patient through the introduction of hospital value-based purchasing. The key to implementing this new paradigm is to measure this value notably through performance indicators. MEDLINE, CINAHL Plus, EMBASE, and Google Scholar were searched for studies reporting the use of performance indicators specific to spine surgery. We followed the Prisma-P methodology for a systematic review for entries from January 1980 to July 2016. All full text articles were then reviewed to identify any measure of performance published within the article. This measure was then examined as per the three criteria of established standard, exclusion/risk adjustment, and benchmarking to determine if it constituted a performance indicator. The initial search yielded 85 results among which two relevant studies were identified. The extended search gave a total of 865 citations across databases among which 15 new articles were identified. The grey literature search provided five additional reports which in turn led to six additional articles. A total of 27 full text articles and reports were retrieved and reviewed. We were unable to identify performance indicators. The articles presenting a measure of performance were organized based on how many criteria they lacked. We further examined the next steps to be taken to craft the first performance indicator in spine surgery. The science of performance measurement applied to spine surgery is still in its infancy. Current outcome metrics used in clinical settings require refinement to become performance indicators. Current registry work is providing the necessary foundation, but requires benchmarking to truly measure performance. 1.

The 2-year cost-effectiveness of 3 options to treat lumbar spinal stenosis patients.

PubMed

Udeh, Belinda L; Costandi, Shrif; Dalton, Jarrod E; Ghosh, Raktim; Yousef, Hani; Mekhail, Nagy

2015-02-01

Lumbar spinal stenosis (LSS) may result from degenerative changes of the spine, which lead to neural ischemia, neurogenic claudication, and a significant decrease in quality of life. Treatments for LSS range from conservative management including epidural steroid injections (ESI) to laminectomy surgery. Treatments vary greatly in cost and success. ESI is the least costly treatment may be successful for early stages of LSS but often must be repeated frequently. Laminectomy surgery is more costly and has higher complication rates. Minimally invasive lumbar decompression (mild(®) ) is an alternative. Using a decision-analytic model from the Medicare perspective, a cost-effectiveness analysis was performed comparing mild(®) to ESI or laminectomy surgery. The analysis population included patients with LSS who have moderate to severe symptoms and have failed conservative therapy. Costs included initial procedure, complications, and repeat/revision or alternate procedure after failure. Effects measured as change in quality-adjusted life years (QALY) from preprocedure to 2 years postprocedure. Incremental cost-effectiveness ratios were determined, and sensitivity analysis conducted. The mild(®) strategy appears to be the most cost-effective ($43,760/QALY), with ESI the next best alternative at an additional $37,758/QALY. Laminectomy surgery was the least cost-effective ($125,985/QALY). © 2014 World Institute of Pain.

Effect of Smoking Status on Successful Arthrodesis, Clinical Outcome, and Complications After Anterior Lumbar Interbody Fusion (ALIF).

PubMed

Phan, Kevin; Fadhil, Matthew; Chang, Nicholas; Giang, Gloria; Gragnaniello, Cristian; Mobbs, Ralph J

2018-02-01

Anterior lumbar interbody fusion (ALIF) is a surgical technique indicated for the treatment of several lumbar pathologies. Smoking has been suggested as a possible cause of reduced fusion rates after ALIF, although the literature regarding the impact of smoking status on lumbar spine surgery is not well established. This study aims to assess the impact of perioperative smoking status on the rates of perioperative complications, fusion, and adverse clinical outcomes in patients undergoing ALIF surgery. A retrospective analysis was performed on a prospectively maintained database of 137 patients, all of whom underwent ALIF surgery by the same primary spine surgeon. Smoking status was defined by the presence of active smoking in the 2 weeks before the procedure. Outcome measures included fusion rates, surgical complications, Short-Form 12, and Oswestry Disability Index. Patients were separated into nonsmokers (n = 114) and smokers (n = 23). Univariate analysis demonstrated that the percentage of patients with successful fusion differed significantly between the groups (69.6% vs. 85.1%, P = 0.006). Pseudarthrosis rates were shown to be significantly associated with perioperative smoking. Results for other postoperative complications and clinical outcomes were similar for both groups. On multivariate analysis, the rate of failed fusion was significantly greater for smokers than nonsmokers (odds ratio 37.10, P = 0.002). The rate of successful fusion after ALIF surgery was found to be significantly lower for smokers compared with nonsmokers. No significant association was found between smoking status and other perioperative complications or adverse clinical outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

[Application of CWT to extract characteristic monitoring parameters during spine surgery].

PubMed

Chen, Penghui; Wu, Baoming; Hu, Yong

2005-10-01

It is necessary to monitor intraoperative spinal function in order to prevent spinal neurological deficit during spine surgery. This study aims to extract characteristic electrophysiological monitoring parameters during surgical treatment of scoliosis. The problem, "the monitoring parameters in time domain are of great variability and are sensitive to noise", may also be solved in this study. By use of continuous wavelet transform to analyze the intraoperative cortical somatosensory evoked potential (CSEP), three new characteristic monitoring parameters in time-frequency domain (TFD) are extracted. The results indicate that the variability of CSEP characteristic parameters in TFD is lower than the variability of those in time domain. Therefore, the TFD characteristic monitoring parameters are more stable and reliable parameters of latency and amplitude in time domain. The application of TFD monitoring parameters during spine surgery may avoid spinal injury effectively.

The importance of preoperative tissue sampling for mobile spine chordomas: literature review and report of two cases.

PubMed

Zuccato, Jeffrey A; Witiw, Christopher D; Keith, Julia; Dyer, Erin; Saghal, Arjun; da Costa, Leodante

2018-01-01

Pre-operative biopsy and diagnosis of chordomas of the mobile spine is indicated as en bloc resections improve outcomes. This review of the management of mobile spine chordomas includes two cases of unexpected mobile spine chordomas where a preoperative tissue diagnosis was decided against and may have altered surgical decision-making. Two lumbar spine chordomas thought to be metastatic and primary bony lesions preoperatively were not biopsied before surgery and eventual pathology revealed chordoma. Preoperative diagnoses were questioned during surgery after an intraoperative tissue diagnosis of chordoma in one case and unclear pathology with non-characteristic tumor morphology in the other. The surgical plan was altered in these cases to maximize resection as en bloc resection reduces the risk of local recurrence in chordoma. Mobile spine chordomas are rare and en bloc resection is recommended, contrary to the usual approach to more common spine tumors. Since en bloc resection of spine chordomas improves disease free survival, it has been recommended that tissue diagnosis be obtained preoperatively when chordoma is considered in the differential diagnosis, in order to guide surgical planning. We present two cases where a preoperative biopsy was considered but not obtained after neuroradiology consultation and imaging review, which may have been managed differently if the diagnosis of spine chordomas were known pre-operatively.

Long-term follow-up of the surgical management of neuropathic arthropathy of the spine.

PubMed

Haus, Brian M; Hsu, Andrew R; Yim, Eugene S; Meter, Jeffrey J; Rinsky, Lawrence A

2010-06-01

No studies have discussed the long-term surgical management and outcomes of Charcot arthropathy of the spine. This case series presents nine patients treated over 30 years. The study hypothesis was that surgery would reduce instability, pain, recurrence, and the need for revision surgery in the long-term, given previous study findings of successful fusion of Charcot spine in the short-term. To evaluate the long-term outcomes of surgery for Charcot spine. Retrospective case series. Cases took place at Stanford University Medical Center and Santa Clara Valley Medical Center. All patients had either complete paraplegia or dense paraparesis with both major motor and sensory deficits. Seven patients developed Charcot spine after spinal instrumentation for trauma, one after scoliosis repair for meningomyelocele, and one after spinal instrumentation for neuromuscular scoliosis caused by birth injury resulting in C6-C7 quadraplegia. Average time between initial instrumentation and development of Charcot spine was 7.6 years. Two patients underwent posterior fusion alone, six had anterior-posterior fusion, and one was managed with thoracolumbar orthosis. Average follow-up was 14.3 years. Revisions were necessary in 75% (6 of 8) of patients for complications including nonunion, new Charcot joints, recurrent hardware failure, and osteomyelitis. Achieving fusion often required multiple operations, and there were no deaths or neurologic complications. Long-term follow-up showed a high rate of revision surgery. Solid fusions often resulted in late breakdown or new junctional Charcot arthropathies. Patients initially fused to the lumbar spine instead of the sacrum or pelvis had a higher rate of developing another Charcot joint. Fusion was often difficult with persistent nonunions and functional deficits because of decreased mobility. We recommend that Charcot spine well tolerated without skin, seating problems, or dysreflexia should be cautiously observed with conservative management. For surgical care, we recommend three-column stabilization with either combined anterior-posterior or all posterior approaches with anterior support to obtain and secure greater long-term stability. Copyright 2010 Elsevier Inc. All rights reserved.

Minimally invasive "separation surgery" plus adjuvant stereotactic radiotherapy in the management of spinal epidural metastases.

PubMed

Turel, Mazda K; Kerolus, Mena G; O'Toole, John E

2017-01-01

This study aimed to describe the application of minimally invasive surgery (MIS) in separation surgery combined with postoperative stereotactic body radiation therapy (SBRT) in patients with symptomatic metastatic epidural spinal disease. Three techniques are described: (1) MIS posterior separation surgery alone, (2) MIS posterolateral separation surgery with percutaneous pedicle screw placement, and (3) MIS lateral corpectomy with percutaneous pedicle screw placement. Seven representative cases are presented in which the above techniques were applied and after which postoperative SBRT was performed. The seven representative patients (3 male, 4 female) had a mean age of 54 years (range, 46-62 years). Two patients had a primary diagnosis of cholangiocarcinoma and in one patient each a diagnosis of breast, renal, lung adenocarcinoma, melanoma, and urothelial squamous cell carcinoma as their primary tumor. All patients had additional multiorgan disease apart from the metastatic spine involvement. Three patients underwent operations in the lumbar spine, two in the thoracic spine, and one in each of the thoraco-lumbar and lumbo-sacral spine. The average operating time was 149 ± 60.3 min (range, 90-240 min). The mean estimated blood loss was 188.8 cc. The mean length of stay in the hospital was 4 days (range, 3-7 days). There were no surgical complications. All patients received postoperative SBRT (typically 24 Gy in 3 fractions) at a mean of 43.2 days after surgery (range, 30-83). Early reports such as this suggest that MIS techniques can be successfully and safely applied in accomplishing "separation surgery" with adjuvant SBRT in the management of metastatic spinal disease. The potential advantages conferred by MIS techniques such as shortened hospital stay, decreased blood loss, reduced perioperative complications, and earlier initiation of adjuvant radiation are highly desirable in the treatment of this challenging patient population.

Patient Body Mass Index is an Independent Predictor of 30-Day Hospital Readmission After Elective Spine Surgery.

PubMed

Elsamadicy, Aladine A; Adogwa, Owoicho; Vuong, Victoria D; Mehta, Ankit I; Vasquez, Raul A; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2016-12-01

Hospital readmission within 30 days of index surgery is receiving increased scrutiny as an indicator of poor quality of care. Reducing readmissions achieves the dual benefit of improving quality and reducing costs. With the growing prevalence of obesity, understanding its impact on 30-day unplanned readmissions and patients' perception of health status is important for appropriate risk stratification of patients. The aim of this study was to determine if obesity is an independent risk factor for unplanned 30-day readmissions after elective spine surgery. The medical records of 500 patients (nonobese, n = 281; obese, n = 219) undergoing elective spine surgery at a major academic medical center were reviewed. Preoperative body mass index (BMI) was measured on all patients. BMI that was ≥30 kg/m 2 was classified as obese. Patient demographics, comorbidities, and postoperative complication rates were collected. The primary outcome investigated was unplanned all-cause 30-day hospital readmission. The association between preoperative obesity and 30-day readmission rate was assessed via multivariate logistic regression analysis. Baseline characteristics and operative variables and complication profiles were similar between both cohorts. Overall, 8.6% of patients were readmitted within 30 days of discharge; obese patients experienced a 2-fold increase in 30-day readmission rates (obese 12.33% vs. nonobese 5.69%, P = 0.01). In a multivariate logistic regression analysis, preoperative obesity (BMI ≥30 kg/m 2 ) was found to be an independent predictor of 30-day readmission after elective spine surgery (P = 0.001). Preoperative obesity is an independent risk factor for readmission within 30 days of discharge after elective spine surgery. In a cost-conscious health care climate, preoperative BMI can identify patients at risk for early unplanned hospital readmission. Copyright © 2016 Elsevier Inc. All rights reserved.

Intraoperative ketorolac dose of 15mg versus the standard 30mg on early postoperative pain after spine surgery: A randomized, blinded, non-inferiority trial.

PubMed

Duttchen, Kaylene M; Lo, Andy; Walker, Andrew; McLuckie, Duncan; De Guzman, Cecilia; Roman-Smith, Helen; Davis, Melinda

2017-09-01

The primary aim of this study is to show the non-inferiority of 15mg intraoperative dose of ketorolac as compared to the standard 30mg ketorolac by looking at the visual analog scale pain (VAS) scores 4h after an adult spine surgery. The study design is a prospective randomized non-inferiority clinical trial looking at non-inferiority of intraoperative 15mg ketorolac from the standard 30mg dose. Quaternary care center. 50 adult (18-65years of age) undergoing lumbar decompression spine surgery. Group A received a single intraoperative dose of 15mg ketorolac at the end of surgery and group B received single intraoperative dose of 30mg ketorolac. The primary outcome was the visual analog scale (VAS) pain scores 4h after an adult spine surgery. Secondary measures were morphine usage in the first 8 and 24h postoperatively, numeric rating scores (NRS) up to 24h, sedation, nausea, vomiting, respiratory depression, pruritus and bleeding complications. Intention to treat analysis showed a mean increase in 4h VAS pain score of 7.9mm (95% CI: -4.5mm to 20.4mm) in patients administered 15mg ketorolac. This difference was neither statistically (P=0.207) nor clinically significant (<18mm on VAS scale). A similar increase in the 15mg group was noted through a per protocol analysis, 6.9mm (95% CI: -6.6mm to 20.5mm, P=0.307) greater in the 15mg group. Non-inferiority of 15mg was not confirmed. No significant difference was found in secondary endpoints. Ketorolac 30mg intravenous was not superior to 15mg intravenous for post-operative pain management after spine surgery. However, 15mg failed to meet the pre-specified criteria for non-inferiority to the 30mg dose. Copyright © 2017 Elsevier Inc. All rights reserved.

Blood Type 0 is not associated with increased blood loss in extensive spine surgery✩

PubMed Central

Komatsu, Ryu; Dalton, Jarrod E.; Ghobrial, Michael; Fu, Alexander Y.; Lee, Jae H.; Egan, Cameron; Sessler, Daniel I.; Kasuya, Yusuke; Turan, Alparslan

2016-01-01

Study Objective To investigate whether Type O blood group status is associated with increased intraoperative blood loss and requirement of blood transfusion in extensive spine surgery. Design Retrospective comparative study. Setting University-affiliated, non-profit teaching hospital. Measurements Data from 1,050 ASA physical status 1, 2, 3, 4, and 5 patients who underwent spine surgeries involving 4 or more vertebral levels were analyzed. Patients with Type O blood were matched to similar patients with other blood types using propensity scores, which were estimated via demographic and morphometric data, medical history variables, and extent of surgery. Intraoperative estimated blood loss (EBL) was compared among matched patients using a linear regression model; intraoperative transfusion requirement in volume of red blood cells, fresh frozen plasma, platelet, cryoprecipitate, cell salvaged blood, volume of intraoperative infusion of hetastarch, 5% albumin, crystalloids, and hospital length of hospital (LOS) were compared using Wilcoxon rank-sum tests. Main Results Intraoperative EBL and requirement of blood product transfusion were similar in patients with Type O blood group and those with other blood groups. Conclusion There was no association between Type O blood and increased intraoperative blood loss or blood transfusion requirement during extensive spine surgery, with similar hospital LOS in Type O and non-O patients. PMID:25172503

Obesity in Neurosurgery: A Narrative Review of the Literature.

PubMed

Castle-Kirszbaum, Mendel D; Tee, Jin W; Chan, Patrick; Hunn, Martin K

2017-10-01

Obesity is an important consideration in neurosurgical practice. Of Australian adults, 28.3% are obese and it is estimated that more than two thirds of Australia's population will be overweight or obese by 2025. This review of the effects of obesity on neurosurgical procedures shows that, in patients undergoing spinal surgery, an increased body mass index is a significant risk factor for surgical site infection, venous thromboembolism, major medical complications, prolonged length of surgery, and increased financial cost. Although outcome scores and levels of patient satisfaction are generally lower after spinal surgery in obese patients, obesity is not a barrier to deriving benefit from surgery and, when the natural history of conservative management is taken into account, the long-term benefits of surgery may be equivalent or even greater in obese patients than in nonobese patients. In cranial surgery, the impact of obesity on outcome and complication rates is generally lower. Specific exceptions are higher rates of distal catheter migration after shunt surgery and cerebrospinal fluid leak after posterior fossa surgery. Minimally invasive approaches show promise in mitigating some of the adverse effects of obesity in patients undergoing spine surgery but further studies are needed to develop strategies to reduce obesity-related surgical complications. Copyright © 2017 Elsevier Inc. All rights reserved.

Mid- to long-term outcomes of posterior decompression with instrumented fusion for thoracic ossification of the posterior longitudinal ligament.

PubMed

Koda, Masao; Furuya, Takeo; Okawa, Akihiko; Inada, Taigo; Kamiya, Koshiro; Ota, Mitsutoshi; Maki, Satoshi; Takahashi, Kazuhisa; Yamazaki, Masashi; Aramomi, Masaaki; Ikeda, Osamu; Mannoji, Chikato

2016-05-01

Posterior decompression with instrumented fusion (PDF) surgery has been previously reported as a relatively safe surgical procedure for any type of thoracic ossification of the longitudinal ligament (OPLL). However, mid- to long-term outcomes are still unclear. The aim of the present study was to elucidate the mid- to long-term clinical outcome of PDF surgery for thoracic OPLL patients. The present study included 20 patients who had undergone PDF for thoracic OPLL and were followed for at least 5years. Increment change and recovery rate of the Japanese Orthopaedic Association (JOA) score were assessed. Revision surgery during the follow-up period was also recorded. Average JOA scores were 3.5 preoperatively and 7.1 at final follow-up. The average improvement in JOA score was 3.8 points and the average recovery rate was 47.0%. The JOA score showed gradual increase after surgery, and took 9months to reach peak recovery. As for neurological complications, two patients suffered postoperative paralysis, but both recovered without intervention. Six revision surgeries in four patients were related to OPLL. Additional anterior thoracic decompression for remaining ossification at the same level of PDF surgery was performed in one patient. Decompression surgery for deterioration of symptoms of pre-existing cervical OPLL was performed in three patients. One patient had undergone lumbar and cervical PDF surgery for de novo ossification foci of the lumbar and cervical spine. PDF surgery for thoracic OPLL is thus considered a relatively safe and stable surgical procedure considering the mid- to long-term outcomes. Copyright © 2015 Elsevier Ltd. All rights reserved.

Reliability of the xipho-pubic angle in patients with sagittal imbalance of the spine.

PubMed

Langella, Francesco; Villafañe, Jorge H; Ismael, Maryem; Buric, Josip; Piazzola, Andrea; Lamartina, Claudio; Berjano, Pedro

2018-04-01

Proximal junctional kyphosis (PJK) is a frequent complication that compromises the outcomes of spinal surgery, especially for adult deformity. To the date no single risk factor or cause has been identified that explains its occurrence. The purpose of this study was to investigate the test-retest reliability of the radiologic measurements using xipho-pubic angle (XPA) for subjects undergoing surgery for sagittal misalignment of the spine. Retrospective observational cross-sectional study of prospectively collected data. Full-spine standing lateral radiographs of 50 patients who underwent surgery for fixed sagittal imbalance (preoperative and postoperative) were evaluated. Internal consistency, reproducibility, concurrent validity, and discriminative ability of the XPA. Two physicians measured XPA on the 100 randomly sorted and anonymized radiographs on two occasions, one week apart (test and retest conditions), were calculated for inter and intraobserver agreement. Test-retest reliability of XPA measurement was excellent for pre- (ICC=0.98; P=0.001) and post-surgical (ICC=0.86; P=0.001) radiographs of subjects with sagittal imbalance of the spine. XPA was able to discriminate between preoperative and postoperative radiographs F=17.924, P<0.001) in patients undergoing surgery for fixed sagittal imbalance for both raters. There were significant differences between pre- vs. postoperative XPA, pelvic tilt, lumbar lordosis and sagittal vertical axis values (all P<0.001). Xipho-pubic angle had fair to excellent test-retest reliability, and it did possess validity to discriminate between preoperative and postoperative radiographs in patients undergoing surgery for fixed sagittal imbalance.

Effects of viewing an evidence-based video decision aid on patients' treatment preferences for spine surgery.

PubMed

Lurie, Jon D; Spratt, Kevin F; Blood, Emily A; Tosteson, Tor D; Tosteson, Anna N A; Weinstein, James N

2011-08-15

Secondary analysis within a large clinical trial. To evaluate the changes in treatment preference before and after watching a video decision aid as part of an informed consent process. A randomized trial with a similar decision aid in herniated disc patients had shown decreased rate of surgery in the video group, but the effect of the video on expressed preferences is not known. Subjects enrolling in the Spine Patient Outcomes Research Trial (SPORT) with intervertebral disc herniation, spinal stenosis, or degenerative spondylolisthesis at 13 multidisciplinary spine centers across the United States were given an evidence-based videotape decision aid viewed prior to enrollment as part of informed consent. Of the 2505 patients, 86% (n = 2151) watched the video and 14% (n = 354) did not. Watchers shifted their preference more often than nonwatchers (37.9% vs. 20.8%, P < 0.0001) and more often demonstrated a strengthened preference (26.2% vs. 11.1%, P < 0.0001). Among the 806 patients whose preference shifted after watching the video, 55% shifted toward surgery (P = 0.003). Among the 617 who started with no preference, after the video 27% preferred nonoperative care, 22% preferred surgery, and 51% remained uncertain. After watching the evidence-based patient decision aid (video) used in SPORT, patients with specific lumbar spine disorders formed and/or strengthened their treatment preferences in a balanced way that did not appear biased toward or away from surgery.

Establishment and characterization of an open mini-thoracotomy surgical approach to an ovine thoracic spine fusion model.

PubMed

Yong, Mostyn R N O; Saifzadeh, Siamak; Askin, Geoffrey N; Labrom, Robert D; Hutmacher, Dietmar W; Adam, Clayton J

2014-01-01

A large animal model is required for the assessment of minimally invasive, tissue-engineering-based approaches to thoracic spine fusion, with relevance to deformity correction surgery for human adolescent idiopathic scoliosis. Here, we develop a novel open mini-thoracotomy approach in an ovine model of thoracic interbody fusion that allows the assessment of various fusion constructs, with a focus on novel, tissue-engineering-based interventions. The open mini-thoracotomy surgical approach was developed through a series of mock surgeries, and then applied in a live sheep study. Customized scaffolds were manufactured to conform with intervertebral disc space clearances that were required of the study. Six male Merino sheep aged 4-6 years and weighing 35-45 kg underwent the procedure mentioned earlier and were alloted a survival timeline of 6 months. Each sheep underwent a three-level discectomy (T6/7, T8/9, and T10/11) with a randomly allocated implantation of a different graft substitute at each of the following three levels: (1) polycaprolactone (PCL)-based scaffold plus 0.54 μg recombinant human bone morphogenetic protein-2 (rhBMP-2); (2) PCL-based scaffold alone; or (3) autograft. The sheep were closely monitored postoperatively for signs of pain (i.e., gait abnormalities/teeth gnawing/social isolation). Fusion assessments were conducted postsacrifice using computed tomography and hard-tissue histology. All scientific work was undertaken in accordance with the study protocol that was approved by the Institute's committee on animal research. All six sheep were successfully operated on and reached the allotted survival timeline, thereby demonstrating the feasibility of the surgical procedure and postoperative care. There were no significant complications and during the postoperative period, the animals did not exhibit marked signs of distress according to the previously described assessment criteria. Computed tomographic scanning demonstrated higher fusion grades in the rhBMP-2 plus PCL-based scaffold group in comparison to either PCL-based scaffold alone or autograft. These results were supported by a histological evaluation of the respective groups. This novel open mini-thoracotomy surgical approach to the ovine thoracic spine represents a safe surgical method that can reproducibly form the platform for research into various spine-tissue-engineered constructs and their fusion-promoting properties.

Constipation after thoraco-lumbar fusion surgery.

PubMed

Stienen, Martin N; Smoll, Nicolas R; Hildebrandt, Gerhard; Schaller, Karl; Tessitore, Enrico; Gautschi, Oliver P

2014-11-01

Thoraco-lumbar posterior fusion surgery is a frequent procedure used for patients with spinal instability due to tumor, trauma or degenerative disease. In the perioperative phase, many patients may experience vomiting, bowel irritation, constipation, or may even show symptoms of adynamic ileus possibly due to immobilization and high doses of opioid analgesics and narcotics administered during and after surgery. Retrospective single-center study on patients undergoing thoraco-lumbar fusion surgery for degenerative lumbar spine disease with instability in 2012. Study groups were built according to presence/absence of postoperative constipation, with postoperative constipation being defined as no bowel movement on postoperative days 0-2. Ninety-nine patients (39 males, 60 females) with a mean age of 57.1 ± 17.3 years were analyzed, of which 44 patients with similar age, gender, BMI and ASA-grades showed constipation (44.4%). Occurrence of constipation was associated with longer mean operation times (247 ± 62 vs. 214 ± 71 min; p=0.012), higher estimated blood loss (545 ± 316 vs. 375 ± 332 ml; p<0.001), and higher mean morphine dosages in the postoperative days 0-7 (the difference being significant on postoperative days 1 (48 mg vs. 30.9 mg, p=0.041) and 2 (43.2mg vs. 29.1mg, p=0.028). The equivalence dose of morphine administered during surgery was similar (339 ± 196 vs. 285 ± 144 mg; p=0.286). The use of laxatives in the postoperative days 0-7 was generally high in both study groups, while it was more frequent in patients experiencing constipation. One patient with constipation developed a sonographically confirmed paralytic ileus. Patients with constipation showed a tendency toward longer postoperative hospitalization (7.6 vs. 6.7 days, p=0.136). The rate of constipation was high after thoraco-lumbar fusion surgery. Moreover, it was associated with longer surgery time, higher blood loss, and higher postoperative morphine doses. Further trials are needed to prove if the introduction of faster and less invasive surgery techniques may have a positive side effect on bowel movement after spine surgery as they may reduce operation times, blood loss and postoperative morphine use. Copyright © 2014 Elsevier B.V. All rights reserved.

The evolution of image-guided lumbosacral spine surgery.

PubMed

Bourgeois, Austin C; Faulkner, Austin R; Pasciak, Alexander S; Bradley, Yong C

2015-04-01

Techniques and approaches of spinal fusion have considerably evolved since their first description in the early 1900s. The incorporation of pedicle screw constructs into lumbosacral spine surgery is among the most significant advances in the field, offering immediate stability and decreased rates of pseudarthrosis compared to previously described methods. However, early studies describing pedicle screw fixation and numerous studies thereafter have demonstrated clinically significant sequelae of inaccurate surgical fusion hardware placement. A number of image guidance systems have been developed to reduce morbidity from hardware malposition in increasingly complex spine surgeries. Advanced image guidance systems such as intraoperative stereotaxis improve the accuracy of pedicle screw placement using a variety of surgical approaches, however their clinical indications and clinical impact remain debated. Beginning with intraoperative fluoroscopy, this article describes the evolution of image guided lumbosacral spinal fusion, emphasizing two-dimensional (2D) and three-dimensional (3D) navigational methods.

A Review of Current Clinical Applications of Three-Dimensional Printing in Spine Surgery

PubMed Central

Job, Alan Varkey; Chen, Jing; Baek, Jung Hwan

2018-01-01

Three-dimensional (3D) printing is a transformative technology with a potentially wide range of applications in the field of orthopaedic spine surgery. This article aims to review the current applications, limitations, and future developments of 3D printing technology in orthopaedic spine surgery. Current preoperative applications of 3D printing include construction of complex 3D anatomic models for improved visual understanding, preoperative surgical planning, and surgical simulations for resident education. Intraoperatively, 3D printers have been successfully used in surgical guidance systems and in the creation of patient specific implantable devices. Furthermore, 3D printing is revolutionizing the field of regenerative medicine and tissue engineering, allowing construction of biocompatible scaffolds suitable for cell growth and vasculature. Advances in printing technology and evidence of positive clinical outcomes are needed before there is an expansion of 3D printing applied to the clinical setting. PMID:29503698

A Review of Current Clinical Applications of Three-Dimensional Printing in Spine Surgery.

PubMed

Cho, Woojin; Job, Alan Varkey; Chen, Jing; Baek, Jung Hwan

2018-02-01

Three-dimensional (3D) printing is a transformative technology with a potentially wide range of applications in the field of orthopaedic spine surgery. This article aims to review the current applications, limitations, and future developments of 3D printing technology in orthopaedic spine surgery. Current preoperative applications of 3D printing include construction of complex 3D anatomic models for improved visual understanding, preoperative surgical planning, and surgical simulations for resident education. Intraoperatively, 3D printers have been successfully used in surgical guidance systems and in the creation of patient specific implantable devices. Furthermore, 3D printing is revolutionizing the field of regenerative medicine and tissue engineering, allowing construction of biocompatible scaffolds suitable for cell growth and vasculature. Advances in printing technology and evidence of positive clinical outcomes are needed before there is an expansion of 3D printing applied to the clinical setting.

Cervical Spine Clearance in Pediatric Trauma Centers: The Need for Standardization and an Evidence-based Protocol.

PubMed

Pannu, Gurpal S; Shah, Mitesh P; Herman, Marty J

Cervical spine clearance in the pediatric trauma patient represents a particularly challenging task. Unfortunately, standardized clearance protocols for pediatric cervical clearance are poorly reported in the literature and imaging recommendations demonstrate considerable variability. With the use of a web-based survey, this study aims to define the methods utilized by pediatric trauma centers throughout North America. Specific attention was given to the identification of personnel responsible for cervical spine care, diagnostic imaging modalities used, and the presence or absence of a written pediatric cervical spine clearance protocol. A 10-question electronic survey was given to members of the newly formed Pediatric Cervical Spine Study Group, all of whom are active POSNA members. The survey was submitted via the online service SurveyMonkey (https://www.surveymonkey.com/r/7NVVQZR). The survey assessed the respondent's institution demographics, such as trauma level and services primarily responsible for consultation and operative management of cervical spine injuries. In addition, respondents were asked to identify the protocols and primary imaging modality used for cervical spine clearance. Finally, respondents were asked if their institution had a documented cervical spine clearance protocol. Of the 25 separate institutions evaluated, 21 were designated as level 1 trauma centers. Considerable variation was reported with regards to the primary service responsible for cervical spine clearance. General Surgery/Trauma (44%) is most commonly the primary service, followed by a rotating schedule (33%), Neurosugery (11%), and Orthopaedic Surgery (8%). Spine consults tend to be seen most commonly by a rotating schedule of Orthopaedic Surgery and Neurosurgery. The majority of responding institutions utilize computed tomographic imaging (46%) as the primary imaging modality, whereas 42% of hospitals used x-ray primarily. The remaining institutions reported using a combination of x-ray and computed tomographic imaging. Only 46% of institutions utilize a written, standardized pediatric cervical spine clearance protocol. This study demonstrates a striking variability in the use of personnel, imaging modalities and, most importantly, standardized protocol in the evaluation of the pediatric trauma patient with a potential cervical spine injury. Cervical spine clearance protocols have been shown to decrease the incidence of missed injuries, minimize excessive radiation exposure, decrease the time to collar removal, and lower overall associated costs. It is our opinion that development of a task force or multicenter research protocol that incorporates existing evidence-based literature is the next best step in improving the care of children with cervical spine injuries. Level 4-economic and decision analyses.

An analysis from the Quality Outcomes Database, Part 2. Predictive model for return to work after elective surgery for lumbar degenerative disease.

PubMed

Asher, Anthony L; Devin, Clinton J; Archer, Kristin R; Chotai, Silky; Parker, Scott L; Bydon, Mohamad; Nian, Hui; Harrell, Frank E; Speroff, Theodore; Dittus, Robert S; Philips, Sharon E; Shaffrey, Christopher I; Foley, Kevin T; McGirt, Matthew J

2017-10-01

OBJECTIVE Current costs associated with spine care are unsustainable. Productivity loss and time away from work for patients who were once gainfully employed contributes greatly to the financial burden experienced by individuals and, more broadly, society. Therefore, it is vital to identify the factors associated with return to work (RTW) after lumbar spine surgery. In this analysis, the authors used data from a national prospective outcomes registry to create a predictive model of patients' ability to RTW after undergoing lumbar spine surgery for degenerative spine disease. METHODS Data from 4694 patients who underwent elective spine surgery for degenerative lumbar disease, who had been employed preoperatively, and who had completed a 3-month follow-up evaluation, were entered into a prospective, multicenter registry. Patient-reported outcomes-Oswestry Disability Index (ODI), numeric rating scale (NRS) for back pain (BP) and leg pain (LP), and EQ-5D scores-were recorded at baseline and at 3 months postoperatively. The time to RTW was defined as the period between operation and date of returning to work. A multivariable Cox proportional hazards regression model, including an array of preoperative factors, was fitted for RTW. The model performance was measured using the concordance index (c-index). RESULTS Eighty-two percent of patients (n = 3855) returned to work within 3 months postoperatively. The risk-adjusted predictors of a lower likelihood of RTW were being preoperatively employed but not working at the time of presentation, manual labor as an occupation, worker's compensation, liability insurance for disability, higher preoperative ODI score, higher preoperative NRS-BP score, and demographic factors such as female sex, African American race, history of diabetes, and higher American Society of Anesthesiologists score. The likelihood of a RTW within 3 months was higher in patients with higher education level than in those with less than high school-level education. The c-index of the model's performance was 0.71. CONCLUSIONS This study presents a novel predictive model for the probability of returning to work after lumbar spine surgery. Spine care providers can use this model to educate patients and encourage them in shared decision-making regarding the RTW outcome. This evidence-based decision support will result in better communication between patients and clinicians and improve postoperative recovery expectations, which will ultimately increase the likelihood of a positive RTW trajectory.

Indications for spine surgery: validation of an administrative coding algorithm to classify degenerative diagnoses

PubMed Central

Lurie, Jon D.; Tosteson, Anna N.A.; Deyo, Richard A.; Tosteson, Tor; Weinstein, James; Mirza, Sohail K.

2014-01-01

Study Design Retrospective analysis of Medicare claims linked to a multi-center clinical trial. Objective The Spine Patient Outcomes Research Trial (SPORT) provided a unique opportunity to examine the validity of a claims-based algorithm for grouping patients by surgical indication. SPORT enrolled patients for lumbar disc herniation, spinal stenosis, and degenerative spondylolisthesis. We compared the surgical indication derived from Medicare claims to that provided by SPORT surgeons, the “gold standard”. Summary of Background Data Administrative data are frequently used to report procedure rates, surgical safety outcomes, and costs in the management of spinal surgery. However, the accuracy of using diagnosis codes to classify patients by surgical indication has not been examined. Methods Medicare claims were link to beneficiaries enrolled in SPORT. The sensitivity and specificity of three claims-based approaches to group patients based on surgical indications were examined: 1) using the first listed diagnosis; 2) using all diagnoses independently; and 3) using a diagnosis hierarchy based on the support for fusion surgery. Results Medicare claims were obtained from 376 SPORT participants, including 21 with disc herniation, 183 with spinal stenosis, and 172 with degenerative spondylolisthesis. The hierarchical coding algorithm was the most accurate approach for classifying patients by surgical indication, with sensitivities of 76.2%, 88.1%, and 84.3% for disc herniation, spinal stenosis, and degenerative spondylolisthesis cohorts, respectively. The specificity was 98.3% for disc herniation, 83.2% for spinal stenosis, and 90.7% for degenerative spondylolisthesis. Misclassifications were primarily due to codes attributing more complex pathology to the case. Conclusion Standardized approaches for using claims data to accurately group patients by surgical indications has widespread interest. We found that a hierarchical coding approach correctly classified over 90% of spine patients into their respective SPORT cohorts. Therefore, claims data appears to be a reasonably valid approach to classifying patients by surgical indication. PMID:24525995

Spinal surgery: variations in health care costs and implications for episode-based bundled payments.

PubMed

Ugiliweneza, Beatrice; Kong, Maiying; Nosova, Kristin; Huang, Kevin T; Babu, Ranjith; Lad, Shivanand P; Boakye, Maxwell

2014-07-01

Retrospective, observational. To simulate what episodes of care in spinal surgery might look like in a bundled payment system and to evaluate the associated costs and characteristics. Episode-based payment bundling has received considerable attention as a potential method to help curb the rise in health care spending and is being investigated as a new payment model as part of the Affordable Care Act. Although earlier studies investigated bundled payments in a number of surgical settings, very few focused on spine surgery, specifically. We analyzed data from MarketScan. Patients were included in the study if they underwent cervical or lumbar spinal surgery during 2000-2009, had at least 2-year preoperative and 90-day postoperative follow-up data. Patients were grouped on the basis of their diagnosis-related group (DRG) and then tracked in simulated episodes-of-care/payment bundles that lasted for the duration of 30, 60, and 90 days after the discharge from the index-surgical hospitalization. The total cost associated with each episode-of-care duration was measured and characterized. A total of 196,918 patients met our inclusion criteria. Significant variation existed between DRGs, ranging from $11,180 (30-day bundle, DRG 491) to $107,642 (30-day bundle, DRG 456). There were significant cost variations within each individual DRG. Postdischarge care accounted for a relatively small portion of overall bundle costs (range, 4%-8% in 90-day bundles). Total bundle costs remained relatively flat as bundle-length increased (total average cost of 30-day bundle: $33,522 vs. $35,165 for 90-day bundle). Payments to hospitals accounted for the largest portion of bundle costs (76%). There exists significant variation in total health care costs for patients who undergo spinal surgery, even within a given DRG. Better characterization of impacts of a bundled payment system in spine surgery is important for understanding the costs of index procedure hospital, physician services, and postoperative care on potential future health care policy decision making. N/A.

Evaluation of degenerative disease of the lumbar spine: MR/MR myelography versus conventional myelography/post-myelography CT.

PubMed

Shiban, Ehab; von Lehe, Marec; Simon, Matthias; Clusmann, Hans; Heinrich, Petra; Ringel, Florian; Wilhelm, Kai; Urbach, Horst; Meyer, Bernhard; Stoffel, Michael

2016-08-01

To compare the use of magnetic resonance (MR)/MR myelography (MRM) with conventional myelography/post-myelography CT (convM) for detailed surgery planning in degenerative lumbar disease. Twenty-six patients with suspected complex lumbar degenerative disease underwent MRM in addition to convM as preoperative workup. Surgery was planned based on convM-as usual at our department. Post hoc, surgical planning was repeated planned again-now based on MRM. Furthermore, the MRM-based planning was performed by six independent neurosurgeons (three groups) of different degrees of specialisation. In only 31 % of the patients, post hoc MRM-based planning resulted in the same surgical decision as originally performed, whereas in 69 % (n = 18) a different procedure was indicated. In patients with non-concurring convM- and MRM-based surgical plans, a less extended procedure was the result of MRM in six patients (23 %), a more extended one in five (19 %), and a related to side/level of decompression or nucleotomy different plan in six patients (23 %). In one patient (4 %), the MRM-based planning would have led to a completely different surgery compared to convM. Overall interobserver agreement on the MRM-based planning was substantial. Detailed planning of operative procedures for complex lumbar degenerative disease is highly dependent on the image modality used.

Human mesenchymal stem cells and biomaterials interaction: a promising synergy to improve spine fusion.

PubMed

Barbanti Brodano, G; Mazzoni, E; Tognon, M; Griffoni, C; Manfrini, M

2012-05-01

Spine fusion is the gold standard treatment in degenerative and traumatic spine diseases. The bone regenerative medicine needs (i) in vitro functionally active osteoblasts, and/or (ii) the in vivo induction of the tissue. The bone tissue engineering seems to be a very promising approach for the effectiveness of orthopedic surgical procedures, clinical applications are often hampered by the limited availability of bone allograft or substitutes. New biomaterials have been recently developed for the orthopedic applications. The main characteristics of these scaffolds are the ability to induce the bone tissue formation by generating an appropriate environment for (i) the cell growth and (ii) recruiting precursor bone cells for the proliferation and differentiation. A new prototype of biomaterials known as "bioceramics" may own these features. Bioceramics are bone substitutes mainly composed of calcium and phosphate complex salt derivatives. In this study, the characteristics bioceramics bone substitutes have been tested with human mesenchymal stem cells obtained from the bone marrow of adult orthopedic patients. These cellular models can be employed to characterize in vitro the behavior of different biomaterials, which are used as bone void fillers or three-dimensional scaffolds. Human mesenchymal stem cells in combination with biomaterials seem to be good alternative to the autologous or allogenic bone fusion in spine surgery. The cellular model used in our study is a useful tool for investigating cytocompatibility and biological features of HA-derived scaffolds.

Red blood cell transfusion probability and associated costs in neurosurgical procedures.

PubMed

Barth, Martin; Weiss, Christel; Schmieder, Kirsten

2018-03-20

The extent of red blood cell units (RBC) needed for different neurosurgical procedures and the time point of their administration are widely unknown, which results in generously cross-matching prior to surgery. However, RBC are increasingly requested in the aging western populations, and blood donations are significantly reduced. Therefore, the knowledge of the extent and time point of administration of RBC is of major importance. This is a retrospective single center analysis. The incidence of RBC transfusion during surgery or within 48 h after surgery was analyzed for all neurosurgical patients within 3 years. Costs for cross-matched and transfused RBC were calculated and risk factors for RBC transfusion analyzed. The risk of intraoperative RBC administration was low for spinal and intracranial tumor resections (1.87%) and exceeded 10% only in spinal fusion procedures. This was dependent on the number of fused segments with an intraoperative transfusion risk of > 12.5% with fusion of more than three levels. Multiple logistic regression analysis showed a significantly increased risk for RBC transfusion for female gender (p = 0.006; OR 1.655), higher age (N = 4812; p < 0.0001; OR 1.028), and number of fused segments (N = 737; p < 0.0001; OR 1.433). Annual costs for cross-matching were 783,820.88 USD and for intraoperative RBC administration 121,322.13 USD. Neurosurgical procedures are associated with a low number of RBC needed intraoperatively. Only elective spine fusion procedures with ≥ 3 levels involved and AVM resections seem to require cross-matching of RBC. The present data may allow changing the preoperative algorithm of RBC cross-matching in neurosurgical procedures and help to save resources and costs.

Movement Along the Spine Induced by Transcranial Electrical Stimulation Related Electrode Positioning.

PubMed

Hoebink, Eric A; Journée, Henricus L; de Kleuver, Marinus; Berends, Hanneke; Racz, Ilona; van Hal, Chantal

2016-07-15

A prospective, nonrandomized cohort study. To describe a technique quantifying movement induced by transcranial electrical stimulation (TES) induced movement in relation to the positioning of electrodes during spinal deformity surgery. TES induced movement may cause injuries and delay surgical procedures. When TES movements are evoked, muscles other than those being monitored any adjustments in stimulation protocols and electrode positioning may be expected to minimize movement whereas preserving quality of monitoring. In this study, seismic evoked responses (SER) induced through TES were studied at different electrode positions. Intraoperative TES-motor evoked potentials were carried out in 12 patients undergoing corrective spine surgery. Accelerometer transducers recorded SER in two directions at four different locations of the spine for TES-electrode montage groups Cz-Fz and C3-C4. A paired t test was used to compare the means of SER and the relationship between movement and TES electrode positioning. SERs were strongest in the upper body. All mean SERs values for the Cz-Fz group were up to five times larger when compared with the C3-C4 group. However, there were no differences between the C3-C4 and Cz-Fz groups in the lower body locations. Both electrode montage groups showed a gradual stepwise reduction in all mean SER values along the spine from the cranial to caudal region. For the upper body locations, there were no significant associations between SER and both montages; in contrast, a significant association SER was demonstrated in the lumbar region. At supramaximum levels, movements resulting from multipulse TES are likely caused by relatively strong contractions from muscles in the neck resulting from direct extracranial stimulation. When interchanging electrode montages in individual cases, the movement in the neck may become reduced. At lumbar levels transcranial evoked muscle contractions dominate movement in the surgically exposed areas. 4.

Total Navigation in Spine Surgery; A Concise Guide to Eliminate Fluoroscopy Using a Portable Intraoperative Computed Tomography 3-Dimensional Navigation System.

PubMed

Navarro-Ramirez, Rodrigo; Lang, Gernot; Lian, Xiaofeng; Berlin, Connor; Janssen, Insa; Jada, Ajit; Alimi, Marjan; Härtl, Roger

2017-04-01

Portable intraoperative computed tomography (iCT) with integrated 3-dimensional navigation (NAV) offers new opportunities for more precise navigation in spinal surgery, eliminates radiation exposure for the surgical team, and accelerates surgical workflows. We present the concept of "total navigation" using iCT NAV in spinal surgery. Therefore, we propose a step-by-step guideline demonstrating how total navigation can eliminate fluoroscopy with time-efficient workflows integrating iCT NAV into daily practice. A prospective study was conducted on collected data from patients undergoing iCT NAV-guided spine surgery. Number of scans, radiation exposure, and workflow of iCT NAV (e.g., instrumentation, cage placement, localization) were documented. Finally, the accuracy of pedicle screws and time for instrumentation were determined. iCT NAV was successfully performed in 117 cases for various indications and in all regions of the spine. More than half (61%) of cases were performed in a minimally invasive manner. Navigation was used for skin incision, localization of index level, and verification of implant position. iCT NAV was used to evaluate neural decompression achieved in spinal fusion surgeries. Total navigation eliminates fluoroscopy in 75%, thus reducing staff radiation exposure entirely. The average times for iCT NAV setup and pedicle screw insertion were 12.1 and 3.1 minutes, respectively, achieving a pedicle screw accuracy of 99%. Total navigation makes spine surgery safer and more accurate, and it enhances efficient and reproducible workflows. Fluoroscopy and radiation exposure for the surgical staff can be eliminated in the majority of cases. Copyright © 2017 Elsevier Inc. All rights reserved.

Laparoscopic Spine Surgery

MedlinePlus

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Rational decision making in a wide scenario of different minimally invasive lumbar interbody fusion approaches and devices.

PubMed

Pimenta, Luiz; Tohmeh, Antoine; Jones, David; Amaral, Rodrigo; Marchi, Luis; Oliveira, Leonardo; Pittman, Bruce C; Bae, Hyun

2018-03-01

With the proliferation of a variety of modern MIS spine surgery procedures, it is mandatory that the surgeon dominate all aspects involved in surgical indication. The information related to the decision making in patient selection for specific procedures is mandatory for surgical success. The objective of this study is to present decision-making criteria in minimally invasive surgery (MIS) selection for a variety of patients and pathologies. In this article, practicing surgeons who specialize in various MIS approaches for spinal fusion were engaged to provide expert opinion and literature review on decision making criteria for several MIS procedures. Pros, cons, relative limitations, and case examples are provided for patient selection in treatment with MIS posterolateral fusion (MIS-PLF), mini anterior lumbar interbody fusion (mini-ALIF), lateral interbody fusion (LLIF), MIS posterior lumbar interbody fusion (MIS-PLIF) and MIS transforaminal lumbar interbody fusion (MIS-TLIF). There is a variety of aspects to consider when deciding which modern MIS surgical approach is most appropriate to use based on patient and pathologic characteristics. The surgeon must adapt them to the characteristic of each type of patients, helping them to choose the most effective and efficient therapeutic option for each case.

Assessing Online Patient Education Readability for Spine Surgery Procedures.

PubMed

Long, William W; Modi, Krishna D; Haws, Brittany E; Khechen, Benjamin; Massel, Dustin H; Mayo, Benjamin C; Singh, Kern

2018-03-01

Increased patient reliance on Internet-based health information has amplified the need for comprehensible online patient education articles. As suggested by the American Medical Association and National Institute of Health, spine fusion articles should be written for a 4th-6th-grade reading level to increase patient comprehension, which may improve postoperative outcomes. The purpose of this study is to determine the readability of online health care education information relating to anterior cervical discectomy and fusion (ACDF) and lumbar fusion procedures. Online health-education resource qualitative analysis. Three search engines were utilized to access patient education articles for common cervical and lumbar spine procedures. Relevant articles were analyzed for readability using Readability Studio Professional Edition software (Oleander Software Ltd). Articles were stratified by organization type as follows: General Medical Websites (GMW), Healthcare Network/Academic Institutions (HNAI), and Private Practices (PP). Thirteen common readability tests were performed with the mean readability of each compared between subgroups using analysis of variance. ACDF and lumbar fusion articles were determined to have a mean readability of 10.7±1.5 and 11.3±1.6, respectively. GMW, HNAI, and PP subgroups had a mean readability of 10.9±2.9, 10.7±2.8, and 10.7±2.5 for ACDF and 10.9±3.0, 10.8±2.9, and 11.6±2.7 for lumbar fusion articles. Of 310 total articles, only 6 (3 ACDF and 3 lumbar fusion) were written for comprehension below a 7th-grade reading level. Current online literature from medical websites containing information regarding ACDF and lumbar fusion procedures are written at a grade level higher than the suggested guidelines. Therefore, current patient education articles should be revised to accommodate the average reading level in the United States and may result in improved patient comprehension and postoperative outcomes.

Work intensity in sacroiliac joint fusion and lumbar microdiscectomy

PubMed Central

Frank, Clay; Kondrashov, Dimitriy; Meyer, S Craig; Dix, Gary; Lorio, Morgan; Kovalsky, Don; Cher, Daniel

2016-01-01

Background The evidence base supporting minimally invasive sacroiliac (SI) joint fusion (SIJF) surgery is increasing. The work relative value units (RVUs) associated with minimally invasive SIJF are seemingly low. To date, only one published study describes the relative work intensity associated with minimally invasive SIJF. No study has compared work intensity vs other commonly performed spine surgery procedures. Methods Charts of 192 patients at five sites who underwent either minimally invasive SIJF (American Medical Association [AMA] CPT® code 27279) or lumbar microdiscectomy (AMA CPT® code 63030) were reviewed. Abstracted were preoperative times associated with diagnosis and patient care, intraoperative parameters including operating room (OR) in/out times and procedure start/stop times, and postoperative care requirements. Additionally, using a visual analog scale, surgeons estimated the intensity of intraoperative care, including mental, temporal, and physical demands and effort and frustration. Work was defined as operative time multiplied by task intensity. Results Patients who underwent minimally invasive SIJF were more likely female. Mean procedure times were lower in SIJF by about 27.8 minutes (P<0.0001) and mean total OR times were lower by 27.9 minutes (P<0.0001), but there was substantial overlap across procedures. Mean preservice and post-service total labor times were longer in minimally invasive SIJF (preservice times longer by 63.5 minutes [P<0.0001] and post-service labor times longer by 20.2 minutes [P<0.0001]). The number of postoperative visits was higher in minimally invasive SIJF. Mean total service time (preoperative + OR time + postoperative) was higher in the minimally invasive SIJF group (261.5 vs 211.9 minutes, P<0.0001). Intraoperative intensity levels were higher for mental, physical, effort, and frustration domains (P<0.0001 each). After taking into account intensity, intraoperative workloads showed substantial overlap. Conclusion Compared to a commonly performed lumbar spine surgical procedure, lumbar microdiscectomy, that currently has a higher work RVU, preoperative, intraoperative, and postoperative workload for minimally invasive SIJF is higher. The work RVU for minimally invasive SIJF should be adjusted upward as the relative amount of work is comparable. PMID:27555790

Autofusion in the immature spine treated with growing rods.

PubMed

Cahill, Patrick J; Marvil, Sean; Cuddihy, Laury; Schutt, Corey; Idema, Jocelyn; Clements, David H; Antonacci, M Darryl; Asghar, Jahangir; Samdani, Amer F; Betz, Randal R

2010-10-15

Retrospective case review of skeletally immature patients treated with growing rods. Patients received an average of 9.6 years follow-up care. (1) to identify the rate of autofusion in the growing spine with the use of growing rods; (2) to quantify how much correction can be attained with definitive instrumented fusion after long-term treatment with growing rods; and (3) to describe the extent of Smith-Petersen osteotomies required to gain correction of an autofused spine following growing rod treatment. The safety and use of growing rods for curve correction and maintenance in the growing spine population has been established in published reports. While autofusion has been reported, the prevalence and sequelae are not known. Nine skeletally immature children with scoliosis were identified who had been treated using growing rods. A retrospective review of the medical records and radiographs was conducted and the following data collected: complications, pre- and postoperative Cobb angles at time of initial surgery (growing rod placement), pre- and postoperative Cobb angles at time of final surgery (growing rod removal and definitive fusion), total spine length as measured from T1-S1, % correction since initiation of treatment and at definitive fusion, total number of surgeries, and number of patients found to have autofusion at the time of device removal. The rate of autofusion in children treated with growing rods was 89%. The average percent of the Cobb angle correction obtained at definitive fusion was 44%. On average, 7 osteotomies per patient were required at the time of definitive fusion due to autofusion. Although growing rods have efficacy in the control of deformity within the growing spine, they also have adverse effects on the spine. Immature spines treated with a growing rod have high rates of unintended autofusion which can possibly lead to difficult and only moderate correction at the time of definitive fusion.

Spine Trauma as a Component of Essential Neurosurgery: An Outcomes Analysis from Cambodia.

PubMed

Chua, Michelle H; Hong, Raksmey; Rydeth, Tytim; Vycheth, Iv; Nang, Sam; Vuthy, Din; Park, Kee B

2018-06-01

In recent years, delivery of cost-effective "essential neurosurgery" in resource-limited communities has been recognized as an indispensable part of health care and a global health priority. The aim of this study was to review outcomes from operative management of spine trauma at a resource-limited government hospital in Phnom Penh, Cambodia, and to provide an epidemiologic report to guide prevention programs. A retrospective review of a prospective neurosurgical database was performed to identify risk factors for spine trauma and severe spinal cord injury (American Spinal Injury Association A or American Spinal Injury Association B) and to evaluate the cost-effectiveness of surgery for patients treated at Preah Kossamak Hospital for subaxial and thoracolumbar spine trauma from 2013 to 2016. Surgical treatment was provided to 277 patients with cervical or thoracolumbar spine trauma, including 36 facet dislocations and 135 thoracolumbar burst fractures at a cost of $100-$280 per surgery. Six patients (2.2%) required treatment for postoperative wound infection. Reoperation was performed in 8 patients (2.9%) for wrong-level surgery. Failure of short-segment pedicle screw fixation was discovered in 4 patients (7.0%). Neurologic improvement was reported by 64 patients (65.3%) with incomplete spinal cord injury and available long-term follow-up. Affordable neurosurgical care can be provided in a safe and sustainable manner to patients with traumatic spine and spinal cord injuries in resource-limited communities. This supports the call for essential neurosurgery to be made available around the world to individuals from all socioeconomic strata. Copyright © 2018 Elsevier Inc. All rights reserved.

Gorham disease of the lumbar spine with an abdominal aortic aneurysm: a case report.

PubMed

Kakuta, Yohei; Iizuka, Haku; Kobayashi, Ryoichi; Iizuka, Yoichi; Takahashi, Toru; Mohara, Jun; Takagishi, Kenji

2014-01-01

Reports of Gorham disease of the lumbar spine complicated by abdominal aortic aneurysms are rare. We herein report the case of a patient with Gorham disease of the lumber spine involving an abdominal aortic aneurysm (AAA). Case report. A 49-year-old man had a 1-month history of right leg pain and severe low back pain. Plain lumbar radiography revealed an osteolytic lesion in the L4 vertebral body. Computed tomography images demonstrated the presence of an extensive osteolytic lesion in the L4 vertebral body and an AAA in front of the L4 vertebral body. The patient underwent mass resection, spinal reconstruction, and blood vessel prosthesis implantation. During surgery, it was found that the wall of the aorta had completely disappeared and was shielded by the tumor mass; therefore, we speculated that the mass in the lumbar spine had directly invaded the aorta. The patient was able to walk without right leg or low back pain 1 year after undergoing surgery. No recurrence was demonstrated in the magnetic resonance images taken 1 year and 10 months after surgery. Copyright © 2014 Elsevier Inc. All rights reserved.

The effects of massage therapy after decompression and fusion surgery of the lumbar spine: a case study.

PubMed

Keller, Glenda

2012-01-01

Spinal fusion and decompression surgery of the lumbar spine are common procedures for problems such as disc herniations. Various studies for postoperative interventions have been conducted; however, no massage therapy studies have been completed. The objective of this study is to determine if massage therapy can beneficially treat pain and dysfunction associated with lumbar spinal decompression and fusion surgery. Client is a 47-year-old female who underwent spinal decompression and fusion surgery of L4/L5 due to chronic disc herniation symptoms. The research design was a case study in a private clinic involving the applications of seven, 30-minute treatments conducted over eight weeks. Common Swedish massage and myofascial techniques were applied to the back, shoulders, posterior hips, and posterior legs. Outcomes were assessed using the following measures: VAS pain scale, Hamstring Length Test, Oswestry Disability Index, and the Roland-Morris Disability Questionnaire. Hamstring length improved (in degrees of extension) from pretreatment measurements in the right leg of 40° and left leg 65° to post-treatment measurement at the final visit, when the results were right 50° and left 70°. The Oswestry Disability Index improved 14%, from 50% to 36% disability. Roland-Morris Disability decreased 1 point, from 3/24 to 2/24. The VAS pain score decreased by 2 points after most treatments, and for three of the seven treatments, client had a post-treatment score of 0/10. Massage for pain had short-term effects. Massage therapy seemed to lengthen the hamstrings bilaterally. Massage therapy does appear to have positive effects in the reduction of disability. This study is beneficial for understanding the relationship between massage therapy and clients who have undergone spinal decompression and fusion. Further research is warranted.

Safety and effectiveness of a polyvinyl alcohol barrier in reducing risks of vascular tissue damage during anterior spinal revision surgery.

PubMed

Jeffords, Paul; Li, Jinsheng; Panchal, Deepal; Denoziere, Guilhem; Fetterolf, Donald

2012-05-01

This study was conducted as a controlled, prospective investigation to show the safety and efficacy of a polyvinyl alcohol (PVA) device in a sheep model. To evaluate the ability of a permanent PVA hydrogel barrier to reduce the risk of potential vessel damage during anterior vertebral revision surgery, to provide a nonadhesive barrier at the surgical site, and to create a surgical revision plane of dissection. The development of scar tissue and adhesions presents a significant postoperative problem in spine surgery, where adhesion involvement of overlying structures can cause pain, neurovascular complications, and present a difficult surgical environment during revisions. The devices were implanted onto the ventral surface of exposed lumbar intervertebral discs using an anterolateral approach. One disc separated from the study site was also exposed to serve as a control. Three sheep each were then evaluated with an explant procedure at 30 and 90 days. Extensive sampling was undertaken to evaluate gross anatomic, micropathologic, and biochemical environments and properties of the device. The structural properties and appearance of the device remained intact at both 30 and 90 days. The material remained flexible, hydrophilic, and soft, without visible resorption or decomposition. The material was well tolerated by the animal, with minimal histologic signs of inflammation or rejection. Tissue planes were easily able to be localized by the surgeon attempting to locate the prior surgical site at the time of resection. The PVA vessel shield effectively protected the structures overlying the sheep spine during revision, providing a clear dissection plane for resection at repeat surgery. The overlying structures separated from the previous surgical site with no adhesion, and allowed safe separation of adjacent tissues without the use of sharp dissection.

Aggressive spinal haemangiomas: imaging correlates to clinical presentation with analysis of treatment algorithm and clinical outcomes

PubMed Central

Cloran, Francis J; Pukenas, Bryan A; Loevner, Laurie A; Aquino, Christopher; Schuster, James

2015-01-01

Objective: Aggressive spinal haemangiomas (those with significant osseous expansion/extraosseous extension) represent approximately 1% of spinal haemangiomas and are usually symptomatic. In this study, we correlate imaging findings with presenting symptomatology, review treatment strategies and their outcomes and propose a treatment algorithm. Methods: 16 patients with aggressive haemangiomas were retrospectively identified from 1995 to 2013. Imaging was assessed for size, location, CT/MR characteristics, osseous expansion and extraosseous extension. Presenting symptoms, management and outcomes were reviewed. Results: Median patient age was 52 years. Median size was 4.5 cm. Lumbar spine was the commonest location (n = 8), followed by thoracic spine (n = 7) and sacrum (n = 2); one case involved the lumbosacral junction. 12 haemangiomas had osseous expansion; 13 had extraosseous extension [epidural (n = 11), pre-vertebral/paravertebral (n = 10) and foraminal (n = 6)]. On CT, 11 had accentuated trabeculae and 5 showed lysis. On MRI, eight were T1 hyperintense, six were T1 hypointense and all were T2 hyperintense. 11 symptomatic patients underwent treatment: chemical ablation (n = 6), angioembolization (n = 3, 2 had subsequent surgery), radiotherapy (n = 2, 1 primary and 1 adjuvant) and surgery (n = 4). Median follow-up was 20 months. Four of six patients managed only by percutaneous methods had symptom resolution. Three of four patients requiring surgery had symptom resolution. Conclusion: Aggressive haemangiomas cause significant morbidity. Treatment is multidisciplinary, with surgery reserved for large lesions and those with focal neurological signs. Minimally invasive procedures may be successful in smaller lesions. Advances in knowledge: Aggressive haemangiomas are rare, but knowledge of their imaging features and treatment strategies enhances the radiologist's role in their management. PMID:26313498

Defining the association between operative time and outcomes in children's surgery.

PubMed

Short, Heather L; Fevrier, Helene B; Meisel, Jonathan A; Santore, Matthew T; Heiss, Kurt F; Wulkan, Mark L; Raval, Mehul V

2017-10-01

Prolonged operative time (OT) is considered a reflection of procedural complexity and may be associated with poor outcomes. Our purpose was to explore the association between prolonged OT and complications in children's surgery. 182,857 cases from the 2012-2014 NSQIP-Pediatric were organized into 33 groups. OT for each group was analyzed by quartile, and regression models were used to determine the relationship between prolonged OT and complications. Variations in OT existed for both short and long procedures. Cases in the longest quartile had twice the odds of postoperative complications after adjusting for age, sex and BMI (OR 1.85; 95% CI 1.78-1.91). Procedure-specific prolonged OT was associated with postoperative complications for the majority (85%) of procedural groupings. Prolonged OT was associated with minor complications in gynecologic (OR 4.17; 95% CI 2.19-7.96), urologic (OR 2.88; 95% CI 2.40-3.44), and appendix procedures (OR 2.88; 95% CI 2.49-3.34). There were increased odds of major complications in foregut (OR 6.56; 95% CI 4.99-8.64), gynecologic (OR 3.07; 95% CI 1.84-5.13), and spine procedures (OR 2.99; 95% CI 2.57-3.28). Prolonged OT is associated with increased odds of postoperative complications across a spectrum of children's surgical procedures. Factors contributing to prolonged OT merit further investigation and may serve as a target for future quality improvement. Level III. Copyright © 2017 Elsevier Inc. All rights reserved.

Anterior Cervical Discectomy and Fusion Alters Whole-Spine Sagittal Alignment

PubMed Central

Kim, Jang Hoon; Yi, Seong; Kim, Kyung Hyun; Kuh, Sung Uk; Chin, Dong Kyu; Kim, Keun Su; Cho, Yong Eun

2015-01-01

Purpose Anterior cervical discectomy and fusion (ACDF) has become a common spine procedure, however, there have been no previous studies on whole spine alignment changes after cervical fusion. Our purpose in this study was to determine whole spine sagittal alignment and pelvic alignment changes after ACDF. Materials and Methods Forty-eight patients who had undergone ACDF from January 2011 to December 2012 were enrolled in this study. Cervical lordosis, thoracic kyphosis, lumbar lordosis, sagittal vertical axis (SVA), and pelvic parameters were measured preoperatively and at 1, 3, 6, and 12 months postoperatively. Clinical outcomes were assessed using Visual Analog Scale (VAS) scores and Neck Disability Index (NDI) values. Results Forty-eight patients were grouped according to operative method (cage only, cage & plate), operative level (upper level: C3/4 & C4/5; lower level: C5/6 & C6/7), and cervical lordosis (high lordosis, low lordosis). All patients experienced significant improvements in VAS scores and NDI values after surgery. Among the radiologic parameters, pelvic tilt increased and sacral slope decreased at 12 months postoperatively. Only the high cervical lordosis group showed significantly-decreased cervical lordosis and a shortened SVA postoperatively. Correlation tests revealed that cervical lordosis was significantly correlated with SVA and that SVA was significantly correlated with pelvic tilt and sacral slope. Conclusion ACDF affects whole spine sagittal alignment, especially in patients with high cervical lordosis. In these patients, alteration of cervical lordosis to a normal angle shortened the SVA and resulted in reciprocal changes in pelvic tilt and sacral slope. PMID:26069131

How does sagittal imbalance affect the appropriateness of surgical indications and selection of procedure in the treatment of degenerative scoliosis? Findings from the RAND/UCLA Appropriate Use Criteria study.

PubMed

Daubs, Michael D; Brara, Harsimran S; Raaen, Laura B; Chen, Peggy Guey-Chi; Anderson, Ashaunta T; Asch, Steven M; Nuckols, Teryl K

2018-05-01

Degenerative lumbar scoliosis (DLS) is often associated with sagittal imbalance, which may affect patients' health outcomes before and after surgery. The appropriateness of surgery and preferred operative approaches has not been examined in detail for patients with DLS and sagittal imbalance. The goals of this article were to describe what is currently known about the relationship between sagittal imbalance and health outcomes among patients with DLS and to determine how indications for surgery in patients with DLS differ when sagittal imbalance is present. This study included a literature review and an expert panel using the RAND/University of California at Los Angeles (UCLA) Appropriateness Method. To develop appropriate use criteria for DLS, researchers at the RAND Corporation recently employed the RAND/UCLA Appropriateness Method, which involves a systematic review of the literature and multidisciplinary expert panel process. Experts reviewed a synopsis of published literature and rated the appropriateness of five common operative approaches for 260 different clinical scenarios. In the present work, we updated the literature review and compared panelists' ratings in scenarios where imbalance was present versus absent. This work was funded by the Collaborative Spine Research Foundation, a group of surgical specialty societies and device manufacturers. On the basis of 13 eligible studies that examined sagittal imbalance and outcomes in patients with DLS, imbalance was associated with worse functional status in the absence of surgery and worse symptoms and complications postoperatively. Panelists' ratings demonstrated a consistent pattern across the diverse clinical scenarios. In general, when imbalance was present, surgery was more likely to be appropriate or necessary, including in some situations where surgery would otherwise be inappropriate. For patients with moderate to severe symptoms and imbalance, a deformity correction procedure was usually appropriate and frequently necessary, except in some patients with severe risk factors for complications. Conversely, procedures that did not correct imbalance, when present, were usually inappropriate. Clinical experts agreed that sagittal imbalance is a major factor affecting both when surgery is appropriate and which type of procedure is preferred among patients with DLS. Copyright © 2018 Elsevier Inc. All rights reserved.

Reliable Intraoperative Repair Nuances of Cerebrospinal Fluid Leak in Anterior Cervical Spine Surgery and Review of the Literature.

PubMed

Mitchell, Bartley D; Verla, Terence; Reddy, Duemani; Winnegan, Lona; Omeis, Ibrahim

2016-04-01

Cerebrospinal fluid (CSF) leak during anterior cervical spine surgery can lead to complications, including wound breakdown, meningitis, headaches, need for lumbar drain, or additional surgery. These leaks can be difficult to manage given the limited field of view and lack of deep access. Herein, we describe 8 consecutive patients who underwent intraoperative repair of CSF leak, with no postoperative evidence of wound dehiscence or drainage. A retrospective review was performed on 8 cases where CSF leak was encountered during an anterior cervical spine surgery. Patients had ossification of the posterior longitudinal ligament, intradural disk herniation, or dural ectasia. Intraoperative repair was as follows. First, CSF was drained to low pressure, and durotomy was covered by dural substitute and sealant agent. Then the interbody graft used was manually undersized in the anteroposterior dimension to allow for expansion of the agents used. Anterior instrumentation was then performed. Finally, a wound drain was anchored to a biologic bag for shoulder level passive drainage. In all 8 cases, there were no cases of wound dehiscence or CSF leak using this strategy. Likewise, there was no evidence of cord compression or neurologic deficits. No meningitis or persistent headaches were reported, and there was no need for lumbar drain placement at any time postoperatively. Once durotomy is encountered during anterior spine surgery, draining the CSF to a low pressure followed by dural substitute with a sealing agent, followed by a smaller anteroposterior size graft is an effective strategy of preventing complications in an inescapable problem. Copyright © 2016 Elsevier Inc. All rights reserved.

Effects of Viewing an Evidence-Based Video Decision Aid on Patients’ Treatment Preferences for Spine Surgery

PubMed Central

Lurie, Jon D.; Spratt, Kevin F.; Blood, Emily A.; Tosteson, Tor D.; Tosteson, Anna N. A.; Weinstein, James N.

2011-01-01

Study Design Secondary analysis within a large clinical trial Objective To evaluate the changes in treatment preference before and after watching a video decision aid as part of an informed consent process. Summary of Background Data A randomized trial with a similar decision aid in herniated disc patients had shown decreased rate of surgery in the video group, but the effect of the video on expressed preferences is not known. Methods Subjects enrolling in the Spine Patient Outcomes Research Trial (SPORT) with intervertebral disc herniation (IDH), spinal stenosis (SPS), or degenerative spondylolisthesis (DS) at thirteen multidisciplinary spine centers across the US were given an evidence-based videotape decision aid viewed prior to enrollment as part of informed consent. Results Of the 2505 patients, 86% (n=2151) watched the video and 14% (n=354) did not. Watchers shifted their preference more often than non-watchers(37.9% vs. 20.8%, p < 0.0001) and more often demonstrated a strengthened preference (26.2% vs. 11.1%, p < 0.0001). Among the 806 patients whose preference shifted after watching the video, 55% shifted toward surgery (p=0.003). Among the 617 who started with no preference, after the video 27% preferred non-operative care, 22% preferred surgery, and 51% remained uncertain. Conclusion After watching the evidence-based patient decision aid (video) used in SPORT, patients with specific lumbar spine disorders formed and/or strengthened their treatment preferences in a balanced way that did not appear biased toward or away from surgery. PMID:21358485

Risk-adjusted hospital outcomes for children's surgery.

PubMed

Saito, Jacqueline M; Chen, Li Ern; Hall, Bruce L; Kraemer, Kari; Barnhart, Douglas C; Byrd, Claudia; Cohen, Mark E; Fei, Chunyuan; Heiss, Kurt F; Huffman, Kristopher; Ko, Clifford Y; Latus, Melissa; Meara, John G; Oldham, Keith T; Raval, Mehul V; Richards, Karen E; Shah, Rahul K; Sutton, Laura C; Vinocur, Charles D; Moss, R Lawrence

2013-09-01

BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program-Pediatric was initiated in 2008 to drive quality improvement in children's surgery. Low mortality and morbidity in previous analyses limited differentiation of hospital performance. Participating institutions included children's units within general hospitals and free-standing children's hospitals. Cases selected by Current Procedural Terminology codes encompassed procedures within pediatric general, otolaryngologic, orthopedic, urologic, plastic, neurologic, thoracic, and gynecologic surgery. Trained personnel abstracted demographic, surgical profile, preoperative, intraoperative, and postoperative variables. Incorporating procedure-specific risk, hierarchical models for 30-day mortality and morbidities were developed with significant predictors identified by stepwise logistic regression. Reliability was estimated to assess the balance of information versus error within models. In 2011, 46 281 patients from 43 hospitals were accrued; 1467 codes were aggregated into 226 groupings. Overall mortality was 0.3%, composite morbidity 5.8%, and surgical site infection (SSI) 1.8%. Hierarchical models revealed outlier hospitals with above or below expected performance for composite morbidity in the entire cohort, pediatric abdominal subgroup, and spine subgroup; SSI in the entire cohort and pediatric abdominal subgroup; and urinary tract infection in the entire cohort. Based on reliability estimates, mortality discriminates performance poorly due to very low event rate; however, reliable model construction for composite morbidity and SSI that differentiate institutions is feasible. The National Surgical Quality Improvement Program-Pediatric expansion has yielded risk-adjusted models to differentiate hospital performance in composite and specific morbidities. However, mortality has low utility as a children's surgery performance indicator. Programmatic improvements have resulted in actionable data.

Current Use of Evidence-Based Medicine in Pediatric Spine Surgery.

PubMed

Oetgen, Matthew E

2018-04-01

Evidence-based medicine (EBM) is a process of decision-making aimed at making the best clinical decisions as they relate to patients' health. The current use of EBM in pediatric spine surgery is varied, based mainly on the availability of high-quality data. The use of EBM is limited in idiopathic scoliosis, whereas EBM has been used to investigate the treatment of pediatric spondylolysis. Studies on early onset scoliosis are of low quality, making EBM difficult in this condition. Future focus and commitment to study quality in pediatric spinal surgery will likely increase the role of EBM in these conditions. Copyright © 2017 Elsevier Inc. All rights reserved.

Virtual endoscopic imaging of the spine.

PubMed

Kotani, Toshiaki; Nagaya, Shigeyuki; Sonoda, Masaru; Akazawa, Tsutomu; Lumawig, Jose Miguel T; Nemoto, Tetsuharu; Koshi, Takana; Kamiya, Koshiro; Hirosawa, Naoya; Minami, Shohei

2012-05-20

Prospective trial of virtual endoscopy in spinal surgery. To investigate the utility of virtual endoscopy of the spine in conjunction with spinal surgery. Several studies have described clinical applications of virtual endoscopy to visualize the inside of the bronchi, paranasal sinus, stomach, small intestine, pancreatic duct, and bile duct, but, to date, no study has described the use of virtual endoscopy in the spine. Virtual endoscopy is a realistic 3-dimensional intraluminal simulation of tubular structures that is generated by postprocessing of computed tomographic data sets. Five patients with spinal disease were selected: 2 patients with degenerative disease, 2 patients with spinal deformity, and 1 patient with spinal injury. Virtual endoscopy software allows an observer to explore the spinal canal with a mouse, using multislice computed tomographic data. Our study found that virtual endoscopy of the spine has advantages compared with standard imaging methods because surgeons can noninvasively explore the spinal canal in all directions. Virtual endoscopy of the spine may be useful to surgeons for diagnosis, preoperative planning, and postoperative assessment by obviating the need to mentally construct a 3-dimensional picture of the spinal canal from 2-dimensional computed tomographic scans.

Spine Stereotactic Body Radiotherapy: Indications, Outcomes, and Points of Caution

PubMed Central

Eppinga, Wietse; Charest-Morin, Raphaele; Soliman, Hany; Myrehaug, Sten; Maralani, Pejman Jabehdar; Campbell, Mikki; Lee, Young K.; Fisher, Charles; Fehlings, Michael G.; Chang, Eric L.; Lo, Simon S.; Sahgal, Arjun

2017-01-01

Study Design: A broad narrative review. Objectives: The objective of this article is to provide a technical review of spine stereotactic body radiotherapy (SBRT) planning and delivery, indications for treatment, outcomes, complications, and the challenges of response assessment. The surgical approach to spinal metastases is discussed with an overview of emerging minimally invasive techniques. Methods: A comprehensive review of the literature was conducted on the techniques, outcomes, and developments in SBRT and surgery for spinal metastases. Results: The optimal management of patients with spinal metastases is complex and requires multidisciplinary assessment from an oncologic team that is familiar with the shifting paradigm as a consequence of evolving techniques in surgery and stereotactic radiation, as well as new developments in systemic agents. The Spinal Instability Neoplastic Score and the epidural spinal cord compression (Bilsky) grading system are useful tools that facilitate communication among oncologic team members and can direct management by providing a baseline assessment of risks prior to therapy. The combined multimodality approach with “separation surgery” followed by postoperative spine SBRT achieves thecal sac decompression, improves tumor control, and avoids complications that may be associated with more extensive surgery. Conclusion: Spine SBRT is a highly effective treatment that is capable of delivering ablative doses to the target while sparing the critical organs-at-risk, chiefly the critical neural tissues, within a short and manageable schedule. At the same time, surgery occupies an important role in select patients, particularly with the expanding availability and expertise in minimally invasive techniques. With rapid adoption of spine SBRT in centers outside of the academic setting, it is imperative for the practicing oncologist to understand the relevance and application of these evolving concepts. PMID:28507888

Impact of Intraoperative Steroids on Postoperative Infection Rates and Length of Hospital Stay: A Study of 1200 Spine Surgery Patients.

PubMed

Elsamadicy, Aladine A; Wang, Timothy Y; Back, Adam G; Sergesketter, Amanda; Warwick, Hunter; Karikari, Isaac O; Gottfried, Oren N

2016-12-01

The use of intraoperative steroids and their effects are relatively unknown and remain controversial. The aim of this study was to determine the effects of intraoperative steroid use on postoperative complications and length of hospital stay after spine surgery. Medical records of 1200 adult patients undergoing spine surgery at Duke University Medical Center during the period 2008-2010 were retrospectively reviewed; 495 (41.25%) patients were administered intraoperative steroids, and 705 (58.75%) patients were not administered intraoperative steroids. Patient demographics, comorbidities, and postoperative complication rates were collected. The primary outcomes investigated were postoperative complications, specifically length of hospital stay and infection rates. Patient demographics were similar between both cohorts. Comorbidities were also similar, with the intraoperative steroid use cohort having a higher number of patients with long-term steroid use than the no intraoperative steroid use cohort (6.95% [no steroids] vs. 13.74% [steroid use], P < 0.001). Operative variables, including length of operation and median number of fusion levels operated, were also similar between the 2 groups. Lumbar spine was the most common surgical location. Patients who were administered intraoperative steroids had a shorter length of hospital stay by an average of 1 day (6.06 days ± 6.76 [no steroids] vs. 5.04 days ± 4.86 [steroid use], P = 0.0025), lower rates of urinary tract infections (10.37% [no steroids] vs. 6.88% [steroid use], P = 0.040), and lower rates of other infections that were not deep or superficial surgical site infections (9.22% [no steroids] vs. 6.06% [steroid use], P = 0.0460). Patients who receive intraoperative steroids have shorter hospital stays and lower infection rates after spine surgery. Copyright © 2016 Elsevier Inc. All rights reserved.

Cost analysis of spinal and general anesthesia for the surgical treatment of lumbar spondylosis.

PubMed

Walcott, Brian P; Khanna, Arjun; Yanamadala, Vijay; Coumans, Jean-Valery; Peterfreund, Robert A

2015-03-01

Lumbar spine surgery is typically performed under general anesthesia, although spinal anesthesia can also be used. Given the prevalence of lumbar spine surgery, small differences in cost between the two anesthetic techniques have the potential to make a large impact on overall healthcare costs. We sought to perform a cost comparison analysis of spinal versus general anesthesia for lumbar spine operations. Following Institutional Review Board approval, a retrospective cohort study was performed from 2009-2012 on consecutive patients undergoing non-instrumented, elective lumbar spine surgery for spondylosis by a single surgeon. Each patient was evaluated for both types of anesthesia, with the decision for anesthetic method being made based on a combination of physical status, anatomical considerations, and ultimately a consensus agreement between patient, surgeon, and anesthesiologist. Patient demographics and clinical characteristics were compared between the two groups. Operating room costs were calculated whilst blinded to clinical outcomes and reported in percentage difference. General anesthesia (n=319) and spinal anesthesia (n=81) patients had significantly different median operative times of 175 ± 39.08 and 158 ± 32.75 minutes, respectively (p<0.001, Mann-Whitney U test). Operating room costs were 10.33% higher for general anesthesia compared to spinal anesthesia (p=0.003, Mann-Whitney U test). Complications of spinal anesthesia included excessive movement (n=1), failed spinal attempt (n=3), intraoperative conversion to general anesthesia (n=2), and a high spinal level (n=1). In conclusion, spinal anesthesia can be performed safely in patients undergoing lumbar spine surgery. It has the potential to reduce operative times, costs, and possibly, complications. Further prospective evaluation will help to validate these findings. Copyright © 2014 Elsevier Ltd. All rights reserved.

Spinal cord herniation following cervical meningioma excision: a rare clinical entity and review of literature.

PubMed

Aiyer, Siddharth N; Shetty, Ajoy Prasad; Kanna, Rishi; Maheswaran, Anupama; Rajasekaran, S

2016-05-01

Spinal cord herniation following surgery is an extremely uncommon clinical condition with very few reports in published literature. This condition usually occurs as a spontaneous idiopathic phenomenon often in the thoracic spine or following a scenario of post traumatic spinal cord/nerve root injury. Rarely has it been reported following spinal cord tumor surgery. To document a case of cervical spinal cord herniation as a late onset complication following spinal cord tumor surgery with an atypical presentation of monoparesis. Case report. We describe the clinical presentation, operative procedure, post operative outcome and review of literature of this rare clinical condition. A 57-year-old man presented with right upper limb monoparesis due to a spinal cord herniation 6 years after a cervical intradural meningioma excision. The patients underwent surgery to reduce the herniation and duroplasty with subsequent complete resolution of symptoms. Spinal cord herniation must be considered as differential diagnosis in scenarios of spinal cord tumor excision presenting with late onset neurological deficit. These cases may present as paraparesis, Brown-sequard syndrome and rarely as in our case as monoparesis.

Percutaneous full endoscopic lumbar foraminoplasty for adjacent level foraminal stenosis following vertebral intersegmental fusion in an awake and aware patient under local anesthesia: A case report.

PubMed

Yamashita, Kazuta; Higashino, Kosaku; Sakai, Toshinori; Takata, Yoichiro; Hayashi, Fumio; Tezuka, Fumitake; Morimoto, Masatoshi; Chikawa, Takashi; Nagamachi, Akihiro; Sairyo, Koichi

2017-01-01

Percutaneous endoscopic surgery for the lumbar spine has become established in the last decade. It requires only an 8 mm skin incision, causes minimal damage to the paravertebral muscles, and can be performed under local anesthesia. With the advent of improved equipment, in particular the high-speed surgical drill, the indications for percutaneous endoscopic surgery have expanded to include lumbar spinal canal stenosis. Transforaminal percutaneous endoscopic discectomy has been used to treat intervertebral stenosis. However, it has been reported that adjacent level disc degeneration and foraminal stenosis can occur following intervertebral segmental fusion. When this adjacent level pathology becomes symptomatic, additional fusion surgery is often needed. We performed minimally invasive percutaneous full endoscopic lumbar foraminoplasty in an awake and aware 50-year-old woman under local anesthesia. The procedure was successful with no complications. Her radiculopathy, including muscle weakness and leg pain due to impingement of the exiting nerve, improved after the surgery. J. Med. Invest. 64: 291-295, August, 2017.

Plasma-mediated radiofrequency ablation followed by percutaneous cementoplasty under fluoro-CT guidance: a case report

PubMed Central

Laganà, Domenico; Ianniello, Andrea; Fontana, Federico; Mangini, Monica; Mocciardini, Lucia; Spanò, Emanuela; Piacentino, Filippo; Cuffari, Salvatore; Fugazzola, Carlo

2009-01-01

We report a case of a 81-year-old Caucasian man with colorectal carcinoma, treated by surgery in 1998, referred for palliative treatment of a refractory painful caused by osteolytic metastases of 2.5 cm in back-upper ilium spine. Plasma-mediated radiofrequency ablation was performed under conscious sedation, using Fluoroscopic Computer Tomography guidance. After completing the ablation phase of the procedure, a mixture of bone cement and Biotrace sterile barium sulfate was injected into the ablated cavity. Patient was evaluated by using the Brief Pain Inventory and considering pain interference with daily living at day 1 and 3 and week 1, 2, 3, 4 by means of a telephone interview. A post-procedure Computer Tomography scan was performed to examine the distribution of cement deposition few minutes after the procedure. The plasma mediated RFA and cementoplasty were well tolerated by the patient who did not develop any complication. PMID:19918385

Plasma-mediated radiofrequency ablation followed by percutaneous cementoplasty under fluoro-CT guidance: a case report.

PubMed

Carrafiello, Gianpaolo; Laganà, Domenico; Ianniello, Andrea; Fontana, Federico; Mangini, Monica; Mocciardini, Lucia; Spanò, Emanuela; Piacentino, Filippo; Cuffari, Salvatore; Fugazzola, Carlo

2009-08-17

We report a case of a 81-year-old Caucasian man with colorectal carcinoma, treated by surgery in 1998, referred for palliative treatment of a refractory painful caused by osteolytic metastases of 2.5 cm in back-upper ilium spine. Plasma-mediated radiofrequency ablation was performed under conscious sedation, using Fluoroscopic Computer Tomography guidance. After completing the ablation phase of the procedure, a mixture of bone cement and Biotrace sterile barium sulfate was injected into the ablated cavity.Patient was evaluated by using the Brief Pain Inventory and considering pain interference with daily living at day 1 and 3 and week 1, 2, 3, 4 by means of a telephone interview. A post-procedure Computer Tomography scan was performed to examine the distribution of cement deposition few minutes after the procedure. The plasma mediated RFA and cementoplasty were well tolerated by the patient who did not develop any complication.

Severe macroglossia after posterior fossa and craniofacial surgery in children.

PubMed

Bouaoud, J; Joly, A; Picard, A; Thierry, B; Arnaud, E; James, S; Hennessy, I; McGarvey, B; Cairet, P; Vecchione, A; Vergnaud, E; Duracher, C; Khonsari, R H

2018-04-01

Massive swelling of the tongue can occur after posterior fossa and craniofacial surgery. Several hypotheses have been proposed to explain the occurrence of such severe postoperative macroglossia, but this phenomenon is still poorly understood. Severe postoperative macroglossia can be a life-threatening condition due to upper airway obstruction. Three cases of severe postoperative macroglossia that occurred after cervical spine, craniofacial, and posterior fossa surgical procedures are reported here. These cases required specialized maxillofacial management and a prolonged stay in the intensive care unit. Causal factors involved in this condition are reported, in order to highlight appropriate prevention and treatment options adapted to the management of paediatric patients. An overview of the current literature on severe postoperative macroglossia in paediatric populations is also provided. Copyright © 2017 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

The effects of doxorubicin (adriamycin) on spinal fusion: an experimental model of posterolateral lumbar spinal arthrodesis.

PubMed

Tortolani, P Justin; Park, Andrew E; Louis-Ugbo, John; Attallah-Wasef, Emad S; Kraiwattanapong, Chaiwat; Heller, John G; Boden, Scott D; Yoon, S Tim

2004-01-01

Malignant spinal lesions may require surgical excision and segmental stabilization. The decision to perform a concomitant fusion procedure is influenced in part by the need for adjunctive chemotherapy as well as the patient's anticipated survival. Although some evidence exists that suggests that chemotherapy may inhibit bony healing, no information exists regarding the effect of chemotherapy on spinal fusion healing. To determine the effect of a frequently used chemotherapeutic agent, doxorubicin, on posterolateral spinal fusion rates. Prospective animal model of posterolateral lumbar fusion. Determination of spinal fusion by manual palpation of excised spines. Plain radiographic evaluation of denuded spines to evaluate intertransverse bone formation. Thirty-two New Zealand White rabbits underwent posterior intertransverse process fusion at L5-L6 with the use of iliac autograft bone. Rabbits randomly received either intravenous doxorubicin (2.5 mg/kg) by means of the central vein of the ear at the time of surgery (16 animals) or no treatment (16 animals; the control group). The animals were euthanized at 5 weeks, and the lumbar spines were excised. Spine fusion was assessed by manually palpating (by observers blinded to the treatment group) at the level of arthrodesis, and at the adjacent levels proximal and distal. This provided similar information to surgical fusion assessment by palpation in humans. Fusion was defined as the absence of palpable motion. Posteroanterior radiographs of the excised spines were graded in a blinded fashion using a five-point scoring system (0 to 4) devised to describe the amount of bone observed between the L5-L6 transverse processes. Power analysis conducted before initiation of the study indicated that an allocation of 16 animals to each group would permit detection of at least a 20% difference in fusion rates with statistical significance at p=.05. Eleven of the 16 spines (69%) in the control group and 6 of the 16 spines (38%) in the doxorubicin group fused. This difference was statistically significant (=.038). There was no significant correlation (p>.05) between the radiographic grade of bone formation (0 to 4) and fusion as determined by palpation. There were four wound infections in the control group and four in the doxorubicin group. However, solid fusions were palpated in three of these four spines in both the control and treatment groups. No significant differences in wound complications were noted with doxorubicin administration. A single dose of doxorubicin administered intravenously at the time of surgery appears to play a significant inhibitory role in the process of spinal fusion. If similar effects occur in humans, these data suggest that doxorubicin may be harmful to bone healing in a spine fusion if given during the perioperative period. Further investigation will be necessary to determine the effect of time to aid at determining whether doxorubicin administered several weeks pre- or postoperatively results in improved fusion rate, and whether bone morphogenetic proteins can overcome these inhibitory effects.

The incidence and healthcare costs of persistent postoperative pain following lumbar spine surgery in the UK: a cohort study using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES)

PubMed Central

Samnaliev, Mihail; Kuo, Tzu-Chun; Ni Choitir, Caitriona; Tierney, Travis S; Cumming, David; Manca, Andrea; Taylor, Rod S; Eldabe, Sam

2017-01-01

Objective To characterise incidence and healthcare costs associated with persistent postoperative pain (PPP) following lumbar surgery. Design Retrospective, population-based cohort study. Setting Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) databases. Participants Population-based cohort of 10 216 adults who underwent lumbar surgery in England from 1997/1998 through 2011/2012 and had at least 1 year of presurgery data and 2 years of postoperative follow-up data in the linked CPRD–HES. Primary and secondary outcomes measures Incidence and total healthcare costs over 2, 5 and 10 years attributable to persistent PPP following initial lumbar surgery. Results The rate of individuals undergoing lumbar surgery in the CPRD–HES linked data doubled over the 15-year study period, fiscal years 1997/1998 to 2011/2012, from 2.5 to 4.9 per 10 000 adults. Over the most recent 5-year period (2007/2008 to 2011/2012), on average 20.8% (95% CI 19.7% to 21.9%) of lumbar surgery patients met criteria for PPP. Rates of healthcare usage were significantly higher for patients with PPP across all types of care. Over 2 years following initial spine surgery, the mean cost difference between patients with and without PPP was £5383 (95% CI £4872 to £5916). Over 5 and 10 years following initial spine surgery, the mean cost difference between patients with and without PPP increased to £10 195 (95% CI £8726 to £11 669) and £14 318 (95% CI £8386 to £19 771), respectively. Extrapolated to the UK population, we estimate that nearly 5000 adults experience PPP after spine surgery annually, with each new cohort costing the UK National Health Service in excess of £70 million over the first 10 years alone. Conclusions Persistent pain affects more than one-in-five lumbar surgery patients and accounts for substantial long-term healthcare costs. There is a need for formal, evidence-based guidelines for a coherent, coordinated management strategy for patients with continuing pain after lumbar surgery. PMID:28893756

The incidence and healthcare costs of persistent postoperative pain following lumbar spine surgery in the UK: a cohort study using the Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES).

PubMed

Weir, Sharada; Samnaliev, Mihail; Kuo, Tzu-Chun; Ni Choitir, Caitriona; Tierney, Travis S; Cumming, David; Bruce, Julie; Manca, Andrea; Taylor, Rod S; Eldabe, Sam

2017-09-11

To characterise incidence and healthcare costs associated with persistent postoperative pain (PPP) following lumbar surgery. Retrospective, population-based cohort study. Clinical Practice Research Datalink (CPRD) and Hospital Episode Statistics (HES) databases. Population-based cohort of 10 216 adults who underwent lumbar surgery in England from 1997/1998 through 2011/2012 and had at least 1 year of presurgery data and 2 years of postoperative follow-up data in the linked CPRD-HES. Incidence and total healthcare costs over 2, 5 and 10 years attributable to persistent PPP following initial lumbar surgery. The rate of individuals undergoing lumbar surgery in the CPRD-HES linked data doubled over the 15-year study period, fiscal years 1997/1998 to 2011/2012, from 2.5 to 4.9 per 10 000 adults. Over the most recent 5-year period (2007/2008 to 2011/2012), on average 20.8% (95% CI 19.7% to 21.9%) of lumbar surgery patients met criteria for PPP. Rates of healthcare usage were significantly higher for patients with PPP across all types of care. Over 2 years following initial spine surgery, the mean cost difference between patients with and without PPP was £5383 (95% CI £4872 to £5916). Over 5 and 10 years following initial spine surgery, the mean cost difference between patients with and without PPP increased to £10 195 (95% CI £8726 to £11 669) and £14 318 (95% CI £8386 to £19 771), respectively. Extrapolated to the UK population, we estimate that nearly 5000 adults experience PPP after spine surgery annually, with each new cohort costing the UK National Health Service in excess of £70 million over the first 10 years alone. Persistent pain affects more than one-in-five lumbar surgery patients and accounts for substantial long-term healthcare costs. There is a need for formal, evidence-based guidelines for a coherent, coordinated management strategy for patients with continuing pain after lumbar surgery. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Joint kinematics of surgeons during lumbar pedicle screw placement.

PubMed

Park, Jeong-Yoon; Kim, Kyung-Hyun; Kuh, Sung-Uk; Chin, Dong-Kyu; Kim, Keun-Su; Cho, Yong-Eun

2016-12-01

A surgical robot for spine surgery has recently been developed. The objective is to assess the joint kinematics of the surgeon during spine surgery. We enrolled 18 spine surgeons, who each performed pedicle screw placement, and used an optoelectronic motion analysis system. Using three-dimensional (3D) motion images, distance changes in five joints and angle changes in six joints were calculated during surgery. Distance fluctuations increased gradually from the proximal to the distal joint. Angle fluctuations were largest at the distal point but did not gradually increase, and the elbow showed the second largest fluctuation. Changes along the X axis were larger than those of the Y and Z axes. The distances gradually increased from proximal portions of the body to the hand. In angle changes, the elbow was most dynamic during pedicle screw placement. The surgeons' whole joints carry out a harmonic role during lumbar pedicle screw placement. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.

Ten Important Tips in Treating a Patient with Lumbar Disc Herniation

PubMed Central

Hejrati, Hamid; Ariamanesh, Shahrara

2016-01-01

Lumbar disc herniation is a common spinal disorder that usually responds favorably to conservative treatment. In a small percentage of the patients, surgical decompression is necessary. Even though lumbar discectomy constitutes the most common and easiest spine surgery globally, adverse or even catastrophic events can occur. Appropriate patient selection and effective neural decompression constitute the most important points for better surgical outcomes and avoidance of unpleasant complications. Other important tips include timely performance of magnetic resonance imaging, correct interpretation of scan data, preoperative detection of underlying instability, exclusion of non-discogenic sciatica, determination of the main cause of clinical pathology, avoidance of the wrong side or level, and being sure that the more detailed procedure does not necessarily mean the more effective procedure. PMID:27790328

II Italian intersociety consensus statement on antithrombotic prophylaxis in orthopaedics and traumatology: arthroscopy, traumatology, leg immobilization, minor orthopaedic procedures and spine surgery.

PubMed

Randelli, F; Romanini, E; Biggi, F; Danelli, G; Della Rocca, G; Laurora, N R; Imberti, D; Palareti, G; Prisco, D

2013-03-01

Pharmacological prophylaxis for preventing venous thromboembolism (VTE) is a worldwide established procedure in hip and knee replacement surgery, as well as in the treatment of femoral neck fractures, but few data exist in other fields of orthopaedics and traumatology. Thus, no guidelines or recommendations are available in the literature except for a limited number of weak statements about knee arthroscopy and lower limb fractures. In any case, none of them are a multidisciplinary effort as the one here presented. The Italian Society for Studies on Haemostasis and Thrombosis (SISET), the Italian Society of Orthopaedics and Traumatology (SIOT), the Association of Orthopaedic Traumatology of Italian Hospitals (OTODI), together with the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) and the Italian Society of General Medicine (SIMG) have set down easy and quick suggestions for VTE prophylaxis in a number of surgical conditions for which only scarce evidence is available. This inter-society consensus statement aims at simplifying the approach to VTE prophylaxis in the single patient with the goal to improve its clinical application.

Outcomes after arthroscopic excision of the bony prominence in the treatment of tibial spine avulsion fractures.

PubMed

Shelbourne, K Donald; Urch, Scott E; Freeman, Heather

2011-06-01

The purpose of this study was to determine the outcomes after arthroscopic excision of the bony prominence after a tibial spine avulsion fracture. This study included 7 subjects (5 female and 2 male subjects; mean age, 21.4 years). All subjects underwent preoperative rehabilitation focused on range of motion (ROM) and swelling control. Postoperative rehabilitation focused on regaining symmetric knee hyperextension and flexion. Objective examinations and subjective surveys were obtained at least 1 year after surgery. All subjects achieved normal knee extension; 6 patients achieved normal knee flexion, whereas 1 patient had nearly normal flexion. Physical examination showed a negative Lachman test with a firm end point in all patients, and the mean side-to-side difference for the KT-1000 manual maximum test (MEDmetric, San Diego, CA) was 1.3 mm. No subjects required subsequent anterior cruciate ligament reconstruction. All subjects returned to their previous level of activity without instability symptoms. At a mean of 5.7 years after surgery, the mean International Knee Documentation Committee subjective survey score was 90.6 points overall, with 4.7 out of 5 possible points for the instability question. At latest follow-up, the mean ROM was from 6° of hyperextension to 147° of flexion in the involved knee, compared with 6° of hyperextension to 148° of flexion for the noninvolved knee. The results of arthroscopic excision of the bony fragment after type II, III, or III+ tibial spine avulsion fracture are positive, with good stability, symmetric ROM, and high subjective scores. Most importantly, this procedure allows patients to regain full, symmetric hyperextension of the knee, avoiding the complications associated with extension loss. Level IV, therapeutic case series. Copyright © 2011 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.

Application of full-scale three-dimensional models in patients with rheumatoid cervical spine.

PubMed

Mizutani, Jun; Matsubara, Takeshi; Fukuoka, Muneyoshi; Tanaka, Nobuhiko; Iguchi, Hirotaka; Furuya, Aiharu; Okamoto, Hideki; Wada, Ikuo; Otsuka, Takanobu

2008-05-01

Full-scale three-dimensional (3D) models offer a useful tool in preoperative planning, allowing full-scale stereoscopic recognition from any direction and distance with tactile feedback. Although skills and implants have progressed with various innovations, rheumatoid cervical spine surgery remains challenging. No previous studies have documented the usefulness of full-scale 3D models in this complicated situation. The present study assessed the utility of full-scale 3D models in rheumatoid cervical spine surgery. Polyurethane or plaster 3D models of 15 full-sized occipitocervical or upper cervical spines were fabricated using rapid prototyping (stereolithography) techniques from 1-mm slices of individual CT data. A comfortable alignment for patients was reproduced from CT data obtained with the patient in a comfortable occipitocervical position. Usefulness of these models was analyzed. Using models as a template, appropriate shape of the plate-rod construct could be created in advance. No troublesome Halo-vests were needed for preoperative adjustment of occipitocervical angle. No patients complained of dysphasia following surgery. Screw entry points and trajectories were simultaneously determined with full-scale dimensions and perspective, proving particularly valuable in cases involving high-riding vertebral artery. Full-scale stereoscopic recognition has never been achieved with any existing imaging modalities. Full-scale 3D models thus appear useful and applicable to all complicated spinal surgeries. The combination of computer-assisted navigation systems and full-scale 3D models appears likely to provide much better surgical results.

A technical case report on use of tubular retractors for anterior cervical spine surgery.

PubMed

Kulkarni, Arvind G; Patel, Ankit; Ankith, N V

2017-12-19

The authors put-forth this technical report to establish the feasibility of performing an anterior cervical corpectomy and fusion (ACCF) and a two-level anterior cervical discectomy and fusion (ACDF) using a minimally invasive approach with tubular retractors. First case: cervical spondylotic myelopathy secondary to a large postero-inferiorly migrated disc treated with corpectomy and reconstruction with a mesh cage and locking plate. Second case: cervical disc herniation with radiculopathy treated with a two-level ACDF. Both cases were operated with minimally invasive approach with tubular retractor using a single incision. Technical aspects and clinical outcomes have been reported. No intra or post-operative complications were encountered. Intra-operative blood loss was negligible. The patients had a cosmetic scar on healing. Standard procedure of placement of tubular retractors is sufficient for adequate surgical exposure with minimal invasiveness. Minimally invasive approach to anterior cervical spine with tubular retractors is feasible. This is the first report on use of minimally invasive approach for ACCF and two-level ACDF.

Efficacy of intraoperative monitoring of transcranial electrical stimulation-induced motor evoked potentials and spontaneous electromyography activity to identify acute-versus delayed-onset C-5 nerve root palsy during cervical spine surgery: clinical article.

PubMed

Bhalodia, Vidya M; Schwartz, Daniel M; Sestokas, Anthony K; Bloomgarden, Gary; Arkins, Thomas; Tomak, Patrick; Gorelick, Judith; Wijesekera, Shirvinda; Beiner, John; Goodrich, Isaac

2013-10-01

Deltoid muscle weakness due to C-5 nerve root injury following cervical spine surgery is an uncommon but potentially debilitating complication. Symptoms can manifest upon emergence from anesthesia or days to weeks following surgery. There is conflicting evidence regarding the efficacy of spontaneous electromyography (spEMG) monitoring in detecting evolving C-5 nerve root compromise. By contrast, transcranial electrical stimulation-induced motor evoked potential (tceMEP) monitoring has been shown to be highly sensitive and specific in identifying impending C-5 injury. In this study the authors sought to 1) determine the frequency of immediate versus delayed-onset C-5 nerve root injury following cervical spine surgery, 2) identify risk factors associated with the development of C-5 palsies, and 3) determine whether tceMEP and spEMG neuromonitoring can help to identify acutely evolving C-5 injury as well as predict delayed-onset deltoid muscle paresis. The authors retrospectively reviewed the neuromonitoring and surgical records of all patients who had undergone cervical spine surgery involving the C-4 and/or C-5 level in the period from 2006 to 2008. Real-time tceMEP and spEMG monitoring from the deltoid muscle was performed as part of a multimodal neuromonitoring protocol during all surgeries. Charts were reviewed to identify patients who had experienced significant changes in tceMEPs and/or episodes of neurotonic spEMG activity during surgery, as well as those who had shown new-onset deltoid weakness either immediately upon emergence from the anesthesia or in a delayed fashion. Two hundred twenty-nine patients undergoing 235 cervical spine surgeries involving the C4-5 level served as the study cohort. The overall incidence of perioperative C-5 nerve root injury was 5.1%. The incidence was greatest (50%) in cases with dual corpectomies at the C-4 and C-5 spinal levels. All patients who emerged from anesthesia with deltoid weakness had significant and unresolved changes in tceMEPs during surgery, whereas only 1 had remarkable spEMG activity. Sensitivity and specificity of tceMEP monitoring for identifying acute-onset deltoid weakness were 100% and 99%, respectively. By contrast, sensitivity and specificity for spEMG were only 20% and 92%, respectively. Neither modality was effective in identifying patients who demonstrated delayed-onset deltoid weakness. The risk of new-onset deltoid muscle weakness following cervical spine surgery is greatest for patients undergoing 2-level corpectomies involving C-4 and C-5. Transcranial electrical stimulation-induced MEP monitoring is a highly sensitive and specific technique for detecting C-5 radiculopathy that manifests immediately upon waking from anesthesia. While the absence of sustained spEMG activity does not rule out nerve root irritation, the presence of excessive neurotonic discharges serves both to alert the surgeon of such potentially injurious events and to prompt neuromonitoring personnel about the need for additional tceMEP testing. Delayed-onset C-5 nerve root injury cannot be predicted by intraoperative neuromonitoring via either modality.

Evaluation of an advanced-practice physiotherapist in triaging patients with lumbar spine pain: surgeon-physiotherapist level of agreement and patient satisfaction.

PubMed

Robarts, Susan; Stratford, Paul; Kennedy, Deborah; Malcolm, Barry; Finkelstein, Joel

2017-08-01

Surgery for lumbar spine pain is indicated for specific etiologies. Given the majority of individuals referred to spine surgeons are not surgical candidates, care delivery is inefficient, with consultations being of limited value for most. Using specially trained physiotherapists in triage is a human resource strategy that may optimize surgeons' time and the patient experience. An advanced-practice physiotherapist (APP) and a surgeon assessed consecutive patients with lumbar spine pain presenting at an academic health centre's spine surgery clinic. The second assessor was blinded to the outcome of the first. We used the κ statistic to evaluate surgeon-APP level of chance-corrected agreement concerning patients' need for a surgical consultation. To assess satisfaction with the APP, patients completed a modified version of the validated Visit-specific Questionnaire. The sample included 102 participants (54 women) with a mean age of 54.3 ± 14.3 years and a mean Oswestry Disability Index score of 35.4 ± 16.6. The assessors' overall agreement was 86%. The κ coefficient for the need for a surgical consultation was 0.69 (95% confidence interval 0.54-0.84). The APP identified that 77% of patients did not require a surgical consultation. Twenty-one patients underwent surgery. Satisfaction scores for the APP were very high (mean score 92 out of 100). In triaging patients with lumbar spine pain, the APP and surgeon had a high level of agreement. An APP performing triage at a surgical centre can effectively reduce wait lists by 70%, reserving surgical consultations for those patients in whom they are indicated.

Percutaneous tracheostomy in patients with cervical spine fractures--feasible and safe.

PubMed

Ben Nun, Alon; Orlovsky, Michael; Best, Lael Anson

2006-08-01

The aim of this study is to evaluate the short and long-term results of percutaneous tracheostomy in patients with documented cervical spine fracture. Between June 2000 and September 2005, 38 consecutive percutaneous tracheostomy procedures were performed on multi-trauma patients with cervical spine fracture. Modified Griggs technique was employed at the bedside in the general intensive care department. Staff thoracic surgeons and anesthesiologists performed all procedures. Demographics, anatomical conditions, presence of co-morbidities and complication rates were recorded. The average operative time was 10 min (6-15). Two patients had minor complications. One patients had minor bleeding (50 cc) and one had mild cellulitis. Nine patients had severe paraparesis or paraplegia prior to the PCT procedure and 29 were without neurological damage. There was no PCT related neurological deterioration. Twenty-eight patients were discharged from the hospital, 21 were decannulated. The average follow-up period was 18 months (1-48). There was no delayed, procedure related, complication. These results demonstrate that percutaneous tracheostomy is feasible and safe in patients with cervical spine fracture with minimal short and long-term morbidity. We believe that percutaneous tracheostomy is the procedure of choice for patients with cervical spine fracture who need prolonged ventilatory support.

Quantifying risk of transfusion in children undergoing spine surgery.

PubMed

Vitale, Michael G; Levy, Douglas E; Park, Maxwell C; Choi, Hyunok; Choe, Julie C; Roye, David P

2002-01-01

The risks and costs of transfusion are a great concern in the area of pediatric spine surgery, because it is a blood-intensive procedure with a high risk for transfusion. Therefore, determining the predictors of transfusion in this patient population is an important first step and has the potential to improve upon the current approaches to reducing transfusion rates. In this study, we reveal several predictors of transfusion in a pediatric patient population undergoing spine surgery. In turn, we present a general rule of thumb ("rule of two's") for gauging transfusion risk, thus enhancing the surgeon's approach to avoiding transfusion in certain clinical scenarios. This study was conducted to determine the main factors of transfusion in a population of pediatric patients undergoing scoliosis surgery. The goal was to present an algorithm for quantifying the true risk of transfusion for various patient groups that would highlight patients "at high risk" for transfusion. This is especially important in light of the various risks associated with undergoing a transfusion, as well as the costs involved in maintaining and disposing of exogenous blood materials. This is a retrospective review of a group of children who underwent scoliosis surgery between 1988 and 1995 at an academic institution. A total of 290 patients were analyzed in this study, of which 63 were transfused and 227 were not. No outcomes measures were used in this study. A retrospective review of 290 patients presenting to our institution for scoliosis surgery was conducted, with a focus on socioclinical data related to transfusion risk. Univariate analysis and logistic regression were used to quantify the determinants of transfusion risk. Univariate analysis identified many factors that were associated with the risk of transfusion. However, it is clear that several of these factors are dependent on each other, obscuring the true issues driving transfusion need. We used multivariate analysis to control for the various univariate predictors of transfusion. Our logistic regression model suggested that the type of scoliosis (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.07 to 3.82), degree of curvature (OR, 1.012/degree curve; 95% CI, 1.01 to 1.03), and use of erythropoietin (OR, 0.29; 95% CI, 0.14 to 0.62) were the main determinants of transfusion risk for our population. The main risk factors of transfusion were used to formulate a simple algorithm, which can be used to quantify transfusion risk and to guide efforts to avoid transfusion in children undergoing spinal surgery. Given a 10% baseline risk for transfusion, our "rule of two's" indicates that each risk factor approximately doubles the chance of transfusion, whereas the administration of recombinant human erythropoietin roughly halves the risk of transfusion.

Educational Material for 3D Visualization of Spine Procedures: Methods for Creation and Dissemination.

PubMed

Cramer, Justin; Quigley, Edward; Hutchins, Troy; Shah, Lubdha

2017-06-01

Spine anatomy can be difficult to master and is essential for performing spine procedures. We sought to utilize the rapidly expanding field of 3D technology to create freely available, interactive educational materials for spine procedures. Our secondary goal was to convey lessons learned about 3D modeling and printing. This project involved two parallel processes: the creation of 3D-printed physical models and interactive digital models. We segmented illustrative CT studies of the lumbar and cervical spine to create 3D models and then printed them using a consumer 3D printer and a professional 3D printing service. We also included downloadable versions of the models in an interactive eBook and platform-independent web viewer. We then provided these educational materials to residents with a pretest and posttest to assess efficacy. The "Spine Procedures in 3D" eBook has been downloaded 71 times as of October 5, 2016. All models used in the book are available for download and printing. Regarding test results, the mean exam score improved from 70 to 86%, with the most dramatic improvement seen in the least experienced trainees. Participants reported increased confidence in performing lumbar punctures after exposure to the material. We demonstrate the value of 3D models, both digital and printed, in learning spine procedures. Moreover, 3D printing and modeling is a rapidly expanding field with a large potential role for radiologists. We have detailed our process for creating and sharing 3D educational materials in the hopes of motivating and enabling similar projects.

Effect of employment status on length of hospital stay, 30-day readmission and patient reported outcomes after spine surgery.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Fialkoff, Jared; Mehta, Ankit I; Vasquez, Raul A; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2017-03-01

Growing scrutiny has placed hospitals at the center of readmission prevention. The relationship between pre-operative employment status, length of hospital stays (LOS) and 30-day readmission rates after elective spine surgery remains unclear. The medical records of 360 patients (employed: n=174, unemployed: n=70, retired: n=40, disabled: n=76) undergoing elective spine surgery at a major academic medical center were reviewed. Patient demographics, comorbidities, and post-operative complication rates were recorded. All patients had comprehensive 1-year patient reported outcomes (PROs) measures. We hypothesized that employment status is associated with decreased LOS and decreased risk of 30-day readmission after elective spine surgery. All-cause readmissions within 30 days of discharge was the primary outcome variable. Baseline characteristics were similar in all cohorts. There was no difference in operative time, estimated blood loss (EBL), or number of fusion levels between all patient cohorts. There were no significant differences in peri-operative complication rates between patient cohorts. On average, the LOS was shorter for the employed compared to non-employed patients (4.89 vs. 5.26 days). The rate of 30-day readmission was 2-fold greater unemployed compared to employed patients (5.17% vs. 10%). At 1-year after surgery, employed patients were more likely to express functional improvement (change in ODI score) compared to unemployed patients (ODI: employed: 33.80 vs. unemployed: 41.93). Our study suggests that employment status may be associated with shorter duration of hospital stay, lower 30-day readmission rates and greater functional improvement. Future interventions to reduce unplanned hospital readmissions should consider pre-operative employment status.

Reasons of Dysphagia After Operation of Anterior Cervical Decompression and Fusion.

PubMed

Wu, Bing; Song, Fei; Zhu, Shourong

2017-06-01

Retrospective study. To analyze the reasons, clinical manifestation, risk factors, prevention, and treatment of dysphagia after operation of anterior cervical decompression and fusion (ACDF). Dysphagia is one of severe complications after ACDF. There were a few studies about reasons and prevention of dysphagia. We retrospectively reviewed medical charts of patients who underwent ACDF in our hospital from January 2012 to December 2012. Clinical symptom of dysphagia was recorded at the perioperative period and at the third and sixth month of the follow-up after surgery and assigned according to the Bazaz dysphagia score. We analyzed the reasons and risk factors leading to dysphagia and tried to find effective programs of prevention and treatment. There were 358 patients who underwent ACDF. Of 358 patients, 39 patients including 14 men and 25 women complained of dysphagia. The mean age was 46.8 years, with an age range of 38-67 years. Clinical manifestation of dysphagia included difficulty to swallow, pain during swallowing, sticky throat feeling, and choking. All the patients were followed up over 6 months. The incidences of dysphagia were 10.9%, 6.4%, and 2.7%, respectively, at 1-5 days, 3 months, and 6 months after surgery. There was no severe dysphagia at 3 months after surgery. Mild or moderate dysphagia slightly affected the quality of life. Logistic regression showed multilevel cervical spine, and high-level cervical spine surgeries are high-risk factors for postoperative dysphagia. Dysphagia is a common complication of ACDF. Causes of dysphagia include multilevel cervical spine and upper cervical spine surgeries. Use of methylprednisolone and careful operation can reduce the incidence and result in good prognosis.

Cognitive-Behavioral-Based Physical Therapy for Patients With Chronic Pain Undergoing Lumbar Spine Surgery: A Randomized Controlled Trial.

PubMed

Archer, Kristin R; Devin, Clinton J; Vanston, Susan W; Koyama, Tatsuki; Phillips, Sharon E; George, Steven Z; McGirt, Matthew J; Spengler, Dan M; Aaronson, Oran S; Cheng, Joseph S; Wegener, Stephen T

2016-01-01

The purpose of this study was to determine the efficacy of a cognitive-behavioral-based physical therapy (CBPT) program for improving outcomes in patients after lumbar spine surgery. A randomized controlled trial was conducted on 86 adults undergoing a laminectomy with or without arthrodesis for a lumbar degenerative condition. Patients were screened preoperatively for high fear of movement using the Tampa Scale for Kinesiophobia. Randomization to either CBPT or an education program occurred at 6 weeks after surgery. Assessments were completed pretreatment, posttreatment and at 3-month follow-up. The primary outcomes were pain and disability measured by the Brief Pain Inventory and Oswestry Disability Index. Secondary outcomes included general health (SF-12) and performance-based tests (5-Chair Stand, Timed Up and Go, 10-Meter Walk). Multivariable linear regression analyses found that CBPT participants had significantly greater decreases in pain and disability and increases in general health and physical performance compared with the education group at the 3-month follow-up. Results suggest a targeted CBPT program may result in significant and clinically meaningful improvement in postoperative outcomes. CBPT has the potential to be an evidence-based program that clinicians can recommend for patients at risk for poor recovery after spine surgery. This study investigated a targeted cognitive-behavioral-based physical therapy program for patients after lumbar spine surgery. Findings lend support to the hypothesis that incorporating cognitive-behavioral strategies into postoperative physical therapy may address psychosocial risk factors and improve pain, disability, general health, and physical performance outcomes. Copyright © 2016 American Pain Society. Published by Elsevier Inc. All rights reserved.

Association Between Allogeneic Blood Transfusion and Postoperative Infection in Major Spine Surgery.

PubMed

Fisahn, Christian; Jeyamohan, Shiveindra; Norvell, Daniel C; Tubbs, Richard S; Moisi, Marc; Chapman, Jens R; Page, Jeni; Oskouian, Rod J

2017-08-01

Retrospective cohort study. The objective of this study is to compare the incidence of infection in patients who do and do not receive blood transfusions in major deformity surgery (>8 levels). Postoperative infections increase morbidity and mortality rates in spine surgery and generate additional costs for the health care system. It has been proposed that blood transfusions increase the risk of wound infection, urinary tract infection, pneumonia, and sepsis. A total of 56 patients met the study criteria, receiving spine surgery involving the fusion of 8 levels or more. Patient-specific characteristics, starting and ending hematocrits, number of units transfused and infections including urinary tract infection, wound infection, pneumonia, and sepsis were documented. Differences in infection risk between those who did and did not undergo a transfusion and their 95% confidence intervals were calculated. Groups were similar with respect to baseline and surgical characteristics except for smoking status, operative time, estimated blood loss, and ending hematocrit. The overall infection rate was greater in patients who underwent transfusion than those who did not (36% vs. 10%; P=0.03). Wound infections (n=5) were only observed in those who underwent a transfusion. Smokers were more likely to receive a transfusion and more likely to experience infection. A stratified analysis demonstrated an increased risk of infection associated with transfusion; however, the risk was greater in smokers, suggesting the effect of transfusion on infection could be modified by smoking. Patients undergoing transfusion experienced a significantly longer hospital stay (P=0.01). Allogeneic red blood cell transfusion in major spine surgery could be a risk factor for postoperative infection. This increased risk seems to be magnified in those who smoke. Further studies are warranted, and risks of blood loss and transfusion-related complications in smokers also potentially merit exploration. Level 3.

A medium invasiveness multi-level patient's specific template for pedicle screw placement in the scoliosis surgery.

PubMed

Azimifar, Farhad; Hassani, Kamran; Saveh, Amir Hossein; Ghomsheh, Farhad Tabatabai

2017-11-14

Several methods including free-hand technique, fluoroscopic guidance, image-guided navigation, computer-assisted surgery system, robotic platform and patient's specific templates are being used for pedicle screw placement. These methods have screw misplacements and are not always easy to be applied. Furthermore, it is necessary to expose completely a large portions of the spine in order to access fit entirely around the vertebrae. In this study, a multi-level patient's specific template with medium invasiveness was proposed for pedicle screw placement in the scoliosis surgery. It helps to solve the problems related to the soft tissues removal. After a computer tomography (CT) scan of the spine, the templates were designed based on surgical considerations. Each template was manufactured using three-dimensional printing technology under a semi-flexible post processing. The templates were placed on vertebras at four points-at the base of the superior-inferior articular processes on both left-right sides. This helps to obtain less invasive and more accurate procedure as well as true-stable and easy placement in a unique position. The accuracy of screw positions was confirmed by CT scan after screw placement. The result showed the correct alignment in pedicle screw placement. In addition, the template has been initially tested on a metal wire series Moulage (height 70 cm and material is PVC). The results demonstrated that it could be possible to implement it on a real patient. The proposed template significantly reduced screw misplacements, increased stability, and decreased the sliding & the intervention invasiveness.

Estimating the effective radiation dose imparted to patients by intraoperative cone-beam computed tomography in thoracolumbar spinal surgery.

PubMed

Lange, Jeffrey; Karellas, Andrew; Street, John; Eck, Jason C; Lapinsky, Anthony; Connolly, Patrick J; Dipaola, Christian P

2013-03-01

Observational. To estimate the radiation dose imparted to patients during typical thoracolumbar spinal surgical scenarios. Minimally invasive techniques continue to become more common in spine surgery. Computer-assisted navigation systems coupled with intraoperative cone-beam computed tomography (CT) represent one such method used to aid in instrumented spinal procedures. Some studies indicate that cone-beam CT technology delivers a relatively low dose of radiation to patients compared with other x-ray-based imaging modalities. The goal of this study was to estimate the radiation exposure to the patient imparted during typical posterior thoracolumbar instrumented spinal procedures, using intraoperative cone-beam CT and to place these values in the context of standard CT doses. Cone-beam CT scans were obtained using Medtronic O-arm (Medtronic, Minneapolis, MN). Thermoluminescence dosimeters were placed in a linear array on a foam-plastic thoracolumbar spine model centered above the radiation source for O-arm presets of lumbar scans for small or large patients. In-air dosimeter measurements were converted to skin surface measurements, using published conversion factors. Dose-length product was calculated from these values. Effective dose was estimated using published effective dose to dose-length product conversion factors. Calculated dosages for many full-length procedures using the small-patient setting fell within the range of published effective doses of abdominal CT scans (1-31 mSv). Calculated dosages for many full-length procedures using the large-patient setting fell within the range of published effective doses of abdominal CT scans when the number of scans did not exceed 3. We have demonstrated that single cone-beam CT scans and most full-length posterior instrumented spinal procedures using O-arm in standard mode would likely impart a radiation dose within the range of those imparted by a single standard CT scan of the abdomen. Radiation dose increases with patient size, and the radiation dose received by larger patients as a result of more than 3 O-arm scans in standard mode may exceed the dose received during standard CT of the abdomen. Understanding radiation imparted to patients by cone-beam CT is important for assessing risks and benefits of this technology, especially when spinal surgical procedures require multiple intraoperative scans.

Assessment of sensorimotor control in adults with surgical correction for idiopathic scoliosis.

PubMed

Pialasse, Jean-Philippe; Mercier, Pierre; Descarreaux, Martin; Simoneau, Martin

2016-10-01

This study aims at verifying if impaired sensorimotor control observed in adolescents and young adults with scoliosis is also present in adult patients who underwent surgery to reduce their spine deformation. The study included ten healthy adults and ten adults with idiopathic scoliosis who underwent surgery to reduce their spine deformation. Galvanic vestibular stimulation was delivered to assess sensorimotor control. Vertical forces under each foot and horizontal displacement of the upper body were measured before, during and after stimulation. Balance control was assessed by calculating the root mean square values of kinematic and kinetic variables. The amplitude of the vestibular-evoked postural response was 3.4 % (0.8-6.0 %) and 4.5 % (-0.4 to 9.5 %) of the maximal range of motion. Therefore, spine surgery did not limit the postural response. Patients with idiopathic scoliosis exhibited larger body sway than the healthy controls during and immediately after vestibular stimulation. The maximal normalized lateral displacement of the body was 0.85 and 0.40 cm/m and maximal normalized vertical force was 0.78 vs. 0.39 N/kg, for idiopathic scoliosis and healthy groups, respectively. This result suggests that dysfunctional sensorimotor integration is still present even in adult idiopathic scoliosis that underwent spine deformation correction.

Solid Variant of an Aneurysmal Bone Cyst of the Thoracic Spine.

PubMed

Mehta, Varshil; Padalkar, Pravin; Kale, Maya; Kathare, Ambadas

2017-05-01

The solid variant of an aneurysmal bone cyst (ABC) has been observed very rarely, especially those involving the spine. In this case report, we present a very unusual tumour of the thoracic spine which was managed by 360˚ decompression via posterior-only approach and stabilization. A 16-year-old boy presented to us with a sudden onset of weakness in both lower limbs leading to paraplegia. He also had a history of back and chest pain over the past one year. A collapse of the T5 vertebrae on plain radiograph was observed. The patient was immediately shifted to the operation theatre with an initial plan of a total en bloc spondylectomy of the T5. However, intraoperatively, histology favored a solid-ABC variant rather than a spindle cell tumour or giant cell tumour. Thus, the initial plan was revised to a 360˚ decompression without resecting the body en bloc via a posterolateral approach. After surgery, complete resolution of his sensory and motor dysfunction was achieved. His chest and back pain also resolved. The diseased vertebral body gradually healed and new bone formation was seen at 18 months postoperatively. This case report concludes that a solid variant of an ABC should be considered as a differential diagnosis for tumours involving the spine. An intraoperative frozen section procedure should be undertaken, especially during emergency situations. Early diagnosis and appropriate surgical management play an important role in the successful management of a solid variant of ABC.

Virtual reality-based simulators for spine surgery: a systematic review.

PubMed

Pfandler, Michael; Lazarovici, Marc; Stefan, Philipp; Wucherer, Patrick; Weigl, Matthias

2017-09-01

Virtual reality (VR)-based simulators offer numerous benefits and are very useful in assessing and training surgical skills. Virtual reality-based simulators are standard in some surgical subspecialties, but their actual use in spinal surgery remains unclear. Currently, only technical reviews of VR-based simulators are available for spinal surgery. Thus, we performed a systematic review that examined the existing research on VR-based simulators in spinal procedures. We also assessed the quality of current studies evaluating VR-based training in spinal surgery. Moreover, we wanted to provide a guide for future studies evaluating VR-based simulators in this field. This is a systematic review of the current scientific literature regarding VR-based simulation in spinal surgery. Five data sources were systematically searched to identify relevant peer-reviewed articles regarding virtual, mixed, or augmented reality-based simulators in spinal surgery. A qualitative data synthesis was performed with particular attention to evaluation approaches and outcomes. Additionally, all included studies were appraised for their quality using the Medical Education Research Study Quality Instrument (MERSQI) tool. The initial review identified 476 abstracts and 63 full texts were then assessed by two reviewers. Finally, 19 studies that examined simulators for the following procedures were selected: pedicle screw placement, vertebroplasty, posterior cervical laminectomy and foraminotomy, lumbar puncture, facet joint injection, and spinal needle insertion and placement. These studies had a low-to-medium methodological quality with a MERSQI mean score of 11.47 out of 18 (standard deviation=1.81). This review described the current state and applications of VR-based simulator training and assessment approaches in spinal procedures. Limitations, strengths, and future advancements of VR-based simulators for training and assessment in spinal surgery were explored. Higher-quality studies with patient-related outcome measures are needed. To establish further adaptation of VR-based simulators in spinal surgery, future evaluations need to improve the study quality, apply long-term study designs, and examine non-technical skills, as well as multidisciplinary team training. Copyright © 2017 Elsevier Inc. All rights reserved.

A practical laboratory study simulating the percutaneous lumbar transforaminal epidural injection: training model in fresh cadaveric sheep spine.

PubMed

Suslu, Husnu

2012-01-01

Laboratory training models are essential for developing and refining treatment skills before the clinical application of surgical and invasive procedures. A simple simulation model is needed for young trainees to learn how to handle instruments, and to perform safe lumbar transforaminal epidural injections. Our aim is to present a model of a fresh cadaveric sheep lumbar spine that simulates the lumbar transforaminal epidural injection. The material consists of a 2-year-old fresh cadaveric sheep spine. A 4-step approach was designed for lumbar transforaminal epidural injection under C-arm scopy. For the lumbar transforaminal epidural injection, the fluoroscope was adjusted to get a proper oblique view while the material was stabilized in a prone position. The procedure then begin, using the C-arm guidance scopy. The model simulates well the steps of standard lumbar transforaminal epidural injections in the human spine. The cadaveric sheep spine represents a good method for training and it simulates fluoroscopic lumbar transforaminal epidural steroid injection procedures performed in the human spine.

Topical Application of Tranexamic Acid to Reduce Blood Loss During Complex Combat Related Spine Trauma Surgery

DTIC Science & Technology

2015-10-01

AWARD NUMBER: W81XWH-14-2-0177 TITLE: Topical Application of Tranexamic Acid to Reduce Blood Loss During Complex Combat-Related Spine Trauma...COVERED (From - To) 30 Sep 2014 - 29 Sep 2015 4. TITLE AND SUBTITLE Topical Application of Tranexamic Acid to Reduce Blood Loss During Complex...application will be submitted shortly and successfully. 15. SUBJECT TERMS Spine; Tranexamic Acid ; Perioperative blood loss; Trauma; Antifibrinolytic

The Controversy Surrounding Bone Morphogenetic Proteins in the Spine: A Review of Current Research

PubMed Central

Hustedt, Joshua W.; Blizzard, Daniel J.

2014-01-01

Bone morphogenetic proteins have been in use in spinal surgery since 2002. These proteins are members of the TGF-beta superfamily and guide mesenchymal stem cells to differentiate into osteoblasts to form bone in targeted tissues. Since the first commercial BMP became available in 2002, a host of research has supported BMPs and they have been rapidly incorporated in spinal surgeries in the United States. However, recent controversy has arisen surrounding the ethical conduct of the research supporting the use of BMPs. Yale University Open Data Access (YODA) recently teamed up with Medtronic to offer a meta-analysis of the effectiveness of BMPs in spinal surgery. This review focuses on the history of BMPs and examines the YODA research to guide spine surgeons in their use of BMP in spinal surgery. PMID:25506287

Implementation and impact of ICD-10 (Part II).

PubMed

Rahmathulla, Gazanfar; Deen, H Gordon; Dokken, Judith A; Pirris, Stephen M; Pichelmann, Mark A; Nottmeier, Eric W; Reimer, Ronald; Wharen, Robert E

2014-01-01

The transition from the International Classification of Disease-9(th) clinical modification to the new ICD-10 was all set to occur on 1 October 2015. The American Medical Association has previously been successful in delaying the transition by over 10 years and has been able to further postpone its introduction to 2015. The new system will overcome many of the limitations present in the older version, thus paving the way to more accurate capture of clinical information. The benefits of the new ICD-10 system include improved quality of care, potential cost savings, reduction of unpaid claims, and improved tracking of healthcare data. The areas where challenges will be evident include planning and implementation, the cost to transition, a shortage of qualified coders, training and education of the healthcare workforce, and a loss of productivity when this occurs. The impacts include substantial costs to the healthcare system, but the projected long-term savings and benefits will be significant. Improved fraud detection, accurate data entry, ability to analyze cost benefits with procedures, and enhanced quality outcome measures are the most significant beneficial factors with this change. The present Current Procedural Terminology and Healthcare Common Procedure Coding System code sets will be used for reporting ambulatory procedures in the same manner as they have been. ICD-10-PCS will replace ICD-9 procedure codes for inpatient hospital services. The ICD-10-CM will replace the clinical code sets. Our article will focus on the challenges to execution of an ICD change and strategies to minimize risk while transitioning to the new system. With the implementation deadline gradually approaching, spine surgery practices that include multidisciplinary health specialists have to anticipate and prepare for the ICD change in order to mitigate risk. Education and communication is the key to this process in spine practices.

Clinical Incidence of Sacroiliac Joint Arthritis and Pain after Sacropelvic Fixation for Spinal Deformity

PubMed Central

Sainoh, Takeshi; Takaso, Masashi; Inoue, Gen; Orita, Sumihisa; Eguchi, Yawara; Nakamura, Junichi; Aoki, Yasuchika; Ishikawa, Tetsuhiro; Miyagi, Masayuki; Arai, Gen; Kamoda, Hiroto; Suzuki, Miyako; Kubota, Gou; Sakuma, Yoshihiro; Oikawa, Yasuhiro; Yamazaki, Masashi; Toyone, Tomoaki; Takahashi, Kazuhisa

2012-01-01

Purpose Sacroiliac fixation using iliac screws for highly unstable lumbar spine has been reported with an improved fusion rate and clinical results. On the other hand, there is a potential for clinical problems related to iliac fixation, including late sacroiliac joint arthritis and pain. Materials and Methods Twenty patients were evaluated. Degenerative scoliosis was diagnosed in 7 patients, failed back syndrome in 6 patients, destructive spondyloarthropathy in 4 patients, and Charcot spine in 3 patients. All patients underwent posterolateral fusion surgery incorporating lumbar, S1 and iliac screws. We evaluated the pain scores, bone union, and degeneration of sacroiliac joints by X-ray imaging and computed tomography before and 3 years after surgery. For evaluation of low back and buttock pain from sacroiliac joints 3 years after surgery, lidocaine was administered in order to examine pain relief thereafter. Results Pain scores significantly improved after surgery. All patients showed bone union at final follow-up. Degeneration of sacroiliac joints was not seen in the 20 patients 3 years after surgery. Patients showed slight low back and buttock pain 3 years after surgery. However, not all patients showed relief of the low back and buttock pain after injection of lidocaine into the sacroiliac joint, indicating that their pain did not originate from sacroiliac joints. Conclusion The fusion rate and clinical results were excellent. Also, degeneration and pain from sacroiliac joints were not seen within 3 years after surgery. We recommend sacroiliac fixation using iliac screws for highly unstable lumbar spine. PMID:22318832

The use of polyurethane materials in the surgery of the spine: a review.

PubMed

St John, Kenneth R

2014-12-01

The spine contains intervertebral discs and the interspinous and longitudinal ligaments. These structures are elastomeric or viscoelastic in their mechanical properties and serve to allow and control the movement of the bony elements of the spine. The use of metallic or hard polymeric devices to replace the intervertebral discs and the creation of fusion masses to replace discs and/or vertebral bodies changes the load transfer characteristics of the spine and the range of motion of segments of the spine. The purpose of the study was to survey the literature, regulatory information available on the Web, and industry-reported device development found on the Web to ascertain the usage and outcomes of the use of polyurethane polymers in the design and clinical use of devices for spine surgery. A systematic review of the available information from all sources concerning the subject materials' usage in spinal devices was conducted. A search of the peer-reviewed literature combining spinal surgery with polyurethane or specific types and trade names of medical polyurethanes was performed. Additionally, information available on the Food and Drug Administration Web site and for corporate Web sites was reviewed in an attempt to identify pertinent information. The review captured devices that are in testing or have entered clinical practice that use elastomeric polyurethane polymers as disc replacements, dynamic stabilization of spinal movement, or motion limitation to relieve nerve root compression and pain and as complete a listing as possible of such devices that have been designed or tested but appear to no longer be pursued. This review summarizes the available information about the uses to which polyurethanes have been tested or are being used in spinal surgery. The use of polyurethanes in medicine has expanded as modifications to the stability of the polymers in the physiological environment have been improved. The potential for the use of elastomeric materials to more closely match the mechanical properties of the structures being replaced and to maintain motion between spinal segments appears to hold promise. The published results from the use of the devices that are discussed show early success with these applications of elastomeric materials. Copyright © 2014 Elsevier Inc. All rights reserved.

Epithelioid hemangioma of the spine: a case series of six patients and review of the literature.

PubMed

Boyaci, Bilal; Hornicek, Francis J; Nielsen, G Petur; DeLaney, Thomas F; Pedlow, Frank X; Mansfield, Frederick L; Carrier, Charles S; Harms, Jurgen; Schwab, Joseph H

2013-12-01

Epithelioid hemangioma (EH) of bone is a benign vascular tumor that can be locally aggressive. It rarely arises in the spine, and the optimum management of EH of the vertebrae is not well delineated. The report describes our experience treating six patients with EH of the spine in an effort to document the treatment of the rare spinal presentation. This study is designed as a retrospective cohort study. A continuous series of patients with the diagnosis of EH of the spine who presented at our institution. The clinical and radiographic follow-up of the patient population is documented. The Bone Sarcoma Registry at our institution was used to obtain a list of all patients diagnosed with EH of the spine. Medical records, radiographs, and pathology reports were retrospectively reviewed in all cases. Only biopsy-proven cases were included. The six patients included five men and one woman who ranged in age from 20 to 58 years (with an average age of 40 years). The follow-up available for all six patients ranged from 6 to 115 (average 46.8) months. All patients presented with lytic vertebral body lesions. Five patients presented with pain secondary to their tumor, and the tumor in the sixth patient was found incidentally during the workup for a herniated disc. Three patients required surgical management for instability secondary to the destructive nature of their tumors, and two other patients required emergent decompression secondary to spinal cord compression by the tumor. The sixth patient was treated expectantly after biopsy confirmation. Three patients received postoperative radiation therapy as gross tumor remained after surgery. Three patients had gross total resections and did not receive postoperative radiation. Preoperative embolization was used in four patients. One patient continued to have back pain after surgery and radiation and another continued to have ataxia after surgery and radiation. No tumor locally recurred or progressed. Our data suggest that EH of the spine can be locally aggressive and lead to instability and cord compression. Surgery is required in such instances; however, observation should be considered in patients without instability or cord compression. Copyright © 2013 Elsevier Inc. All rights reserved.

Osteoid osteoma of the mobile spine: surgical outcomes in 81 patients.

PubMed

Gasbarrini, Alessandro; Cappuccio, Michele; Bandiera, Stefano; Amendola, Luca; van Urk, Paul; Boriani, Stefano

2011-11-15

A restrospective review of 81 cases of osteoid osteoma of the mobile spine submitted to surgical treatment. Analyze pro and contras of different techniques (conventional and minimally invasive) for the treatment of osteoid osteoma. Intralesional excision has been considered the standard treatment for spinal osteoid osteoma. The high success rate of minimally invasive surgery in the treatment of a variety of spinal disorders lead us to believe this technique can also be applicable for the treatment of osteoid osteoma of the spine. Eighty-one patients affected by osteoid osteoma were consecutively treated by the same team with intralesional excision using conventional or minimally invasive approach by video-assisted endoscopy, microscope, or percutaneous radiofrequency coagulation. The clinical features, the radiologic findings, and the outcome were reviewed. Pain and neurologic symptoms, were scored before surgery, after surgery and at the follow-up. Complications and local recurrences were also recorded. Immediate relief of pain was observed after surgery in all patients. One patient showed mild neurologic impairment before treatment but became free of neurologic symptoms postoperative. Five local recurrences were found in four patients, always associated with pain. Three of these patients underwent surgery for a second time and one patient for a third time. There were two complications because surgery in two patients. One patient developed a pneumothorax, the other a hematoma. No related cases of kyphosis or scoliosis surgery were observed. Conventional excision therapy is a effective and reliable treatment for osteoid osteoma associated to low morbidity and low local recurrence rate. Minimally invasive surgery is emerging as an alternative method, reducing soft tissue trauma and the collateral damage caused by traditional surgical approach, allow patients a more rapid and complete return to normal function.

Immediate Adverse Events in Interventional Pain Procedures: A Multi-Institutional Study.

PubMed

Carr, Carrie M; Plastaras, Christopher T; Pingree, Matthew J; Smuck, Matthew; Maus, Timothy P; Geske, Jennifer R; El-Yahchouchi, Christine A; McCormick, Zachary L; Kennedy, David J

2016-12-01

Interventional procedures directed toward sources of pain in the axial and appendicular musculoskeletal system are performed with increasing frequency. Despite the presence of evidence-based guidelines for such procedures, there are wide variations in practice. Case reports of serious complications such as spinal cord infarction or infection from spine injections lack appropriate context and create a misleading view of the risks of appropriately performed interventional pain procedures. To evaluate adverse event rate for interventional spine procedures performed at three academic interventional spine practices. Quality assurance databases at three academic interventional pain management practices that utilize evidence-based guidelines [1] were interrogated for immediate complications from interventional pain procedures. Review of the electronic medical record verified or refuted the occurrence of a complication. Same-day emergency department transfers or visits were also identified by a records search. Immediate complication data were available for 26,061 consecutive procedures. A radiology practice performed 19,170 epidural steroid (primarily transforaminal), facet, sacroiliac, and trigger point injections (2006-2013). A physiatry practice performed 6,190 spine interventions (2004-2009). A second physiatry practice performed 701 spine procedures (2009-2010). There were no major complications (permanent neurologic deficit or clinically significant bleeding [e.g., epidural hematoma]) with any procedure. Overall complication rate was 1.9% (493/26,061). Vasovagal reactions were the most frequent event (1.1%). Nineteen patients (<0.1%) were transferred to emergency departments for: allergic reactions, chest pain, symptomatic hypertension, and a vasovagal reaction. This study demonstrates that interventional pain procedures are safely performed with extremely low immediate adverse event rates when evidence-based guidelines are observed. © 2016 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Patients' experience of adolescent idiopathic scoliosis surgery: a phenomenological analysis.

PubMed

Honeyman, Cheryl; Davison, Jean

2016-09-12

Background Adolescent idiopathic scoliosis is a three-dimensional curvature of the spine of unknown cause that occurs in often otherwise fit young people. A complex surgical procedure is required for the most severe curves. Quantitative literature suggests scoliosis surgery improves patients' lives, while qualitative literature focuses on patients' concerns rather than their experience. Aims To explore how adolescents interpret their perioperative experience. Method Six participants, aged 15-18, were interviewed and transcripts were analysed. Findings Four themes were identified: shock, fears and worries; parental interaction; coping; and motivation and positivity. Conclusion Participants were reluctant to share concerns, however those they shared related more to fear of the unknown and lack of control than specific issues such as pain. Participants depended on their parents, especially their mothers, during the perioperative period, and they recognised their parents' stress. Participants coped well, were motivated and had a positive outlook.

The efficacy of routine use of recombinant human bone morphogenetic protein-2 in occipitocervical and atlantoaxial fusions of the pediatric spine: a minimum of 12 months' follow-up with computed tomography.

PubMed

Sayama, Christina; Hadley, Caroline; Monaco, Gina N; Sen, Anish; Brayton, Alison; Briceño, Valentina; Tran, Brandon H; Ryan, Sheila L; Luerssen, Thomas G; Fulkerson, Daniel; Jea, Andrew

2015-07-01

OBJECT The purpose of this study focusing on fusion rate was to determine the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2) use in posterior instrumented fusions of the craniocervical junction in the pediatric population. The authors previously reported the short-term (mean follow-up 11 months) safety and efficacy of rhBMP-2 use in the pediatric age group. The present study reports on their long-term results (minimum of 12 months' follow-up) and focuses on efficacy. METHODS The authors performed a retrospective review of 83 consecutive pediatric patients who had undergone posterior occipitocervical or atlantoaxial spine fusion at Texas Children's Hospital or Riley Children's Hospital during the period from October 2007 to October 2012. Forty-nine patients were excluded from further analysis because of death, loss to follow-up, or lack of CT evaluation of fusion at 12 or more months after surgery. Fusion was determined by postoperative CT scan at a minimum of 12 months after surgery. The fusion was graded and classified by a board-certified fellowship-trained pediatric neuroradiologist. Other factors, such as patient age, diagnosis, number of vertebral levels fused, use of allograft or autograft, dosage of bone morphogenetic protein (BMP), and use of postoperative orthosis, were recorded. RESULTS Thirty-four patients had a CT scan at least 12 months after surgery. The average age of the patients at surgery was 8 years, 1 month (range 10 months-17 years). The mean follow-up was 27.7 months (range 12-81 months). There were 37 fusion procedures in 34 patients. Solid fusion (CT Grade 4 or 4-) was achieved in 89.2% of attempts (33 of 37), while incomplete fusion or failure of fusion was seen in 10.8%. Based on logistic regression analysis, there was no significant association between solid fusion and age, sex, BMP dose, type of graft material, use of postoperative orthosis, or number of levels fused. Three of 34 patients (8.8%) required revision surgery. CONCLUSIONS Despite the large number of adult studies reporting positive effects of BMP on bone fusion, our long-term outcomes using rhBMP-2 in the pediatric population suggest that rates of fusion failure are higher than observed in contemporary adult and pediatric reports of occipitocervical and atlantoaxial spine fusions.

The value of intraoperative Gram stain in revision spine surgery.

PubMed

Shifflett, Grant D; Nwachukwu, Benedict U; Bjerke-Kroll, Benjamin T; Kueper, Janina; Koltsov, Jayme B; Sama, Andrew A; Girardi, Federico P; Cammisa, Frank P; Hughes, Alexander P

2015-10-01

Intraoperative cultures and Gram stains are often obtained in cases of revision spine surgery even when clinical signs of infection are not present. The clinical utility and cost-effectiveness of this behavior remain unproven. The aim was to evaluate the clinical utility and cost-effectiveness of routine intraoperative Gram stains in revision spine surgery. This was a retrospective clinical review performed at an academic center in an urban setting. One hundred twenty-nine consecutive adult revision spine surgeries were performed. The outcome measures included intraoperative Gram stains. We retrospectively reviewed the records of 594 consecutive revision spine surgeries performed by four senior surgeons between 2008 and 2013 to identify patients who had operative cultures and Gram stains performed. All revision cases including cervical, thoracic, and lumbar fusion and non-fusion, with and without instrumentation were reviewed. One hundred twenty-nine (21.7%) patients had operative cultures obtained and were included in the study. The most common primary diagnosis code at the time of revision surgery was pseudarthrosis, which was present in 41.9% of cases (54 of 129). Infection was the primary diagnosis in 10.1% (13 of 129) of cases. Operative cultures were obtained in 129 of 595 (21.7%) cases, and 47.3% (61 of 129) were positive. Gram stains were performed in 98 of 129 (76.0%) cases and were positive in 5 of 98 (5.1%) cases. Overall, there was no correlation between revision diagnosis and whether or not a Gram stain was obtained (p=.697). Patients with a history of prior instrumentation were more likely to have a positive Gram stain (p<.0444). Intraoperative Gram staining was found to have a sensitivity of 10.9% (confidence interval [CI] 3.9%-23.6%) and specificity of 100% (CI 93.1%-100%). The positive and negative predictive values were 100% (CI 48.0%-100%) and 57.3% (CI 45.2%-66.2%), respectively. Kappa coefficient was calculated to be 0.1172 (CI 0.0194-0.2151). The cost per discrepant diagnosis (total cost/number discrepant) was $172.10. This study demonstrates that while very specific for infection, the sensitivity of intraoperative Gram staining is low, and agreement between positive cultures and Gram stains is very poor. Gram staining demonstrated limited cost-effectiveness because of the low prevalence of findings that altered patient management. Copyright © 2015 Elsevier Inc. All rights reserved.

Patient misconceptions concerning lumbar spondylosis diagnosis and treatment.

PubMed

Franz, Eric W; Bentley, J Nicole; Yee, Patricia P S; Chang, Kate W C; Kendall-Thomas, Jennifer; Park, Paul; Yang, Lynda J S

2015-05-01

OBJECT Patient outcome measures are becoming increasingly important in the evaluation of health care quality and physician performance. Of the many novel measures currently being explored, patient satisfaction and other subjective measures of patient experience are among the most heavily weighted. However, these subjective measures are strongly influenced by a number of factors, including patient demographics, level of understanding of the disorder and its treatment, and patient expectations. In the present study, patients referred to a neurosurgery clinic for degenerative spinal disorders were surveyed to determine their understanding of lumbar spondylosis diagnosis and treatment. METHODS A multiple-choice, 6-question survey was distributed to all patients referred to a general neurosurgical spine clinic at a tertiary care center over a period of 11 months as a quality improvement initiative to assist the provider with individualized patient counseling. The survey consisted of questions designed to assess patient understanding of the role of radiological imaging in the diagnosis and treatment of low-back and leg pain, and patient perception of the indications for surgical compared with conservative management. Demographic data were also collected. RESULTS A total of 121 surveys were included in the analysis. More than 50% of the patients indicated that they would undergo spine surgery based on abnormalities found on MRI, even without symptoms; more than 40% of patients indicated the same for plain radiographs. Similarly, a large proportion of patients (33%) believed that back surgery was more effective than physical therapy in the treatment of back pain without leg pain. Nearly one-fifth of the survey group (17%) also believed that back injections were riskier than back surgery. There were no significant differences in survey responses among patients with a previous history of spine surgery compared with those without previous spine surgery. CONCLUSIONS These results show that a surprisingly high percentage of patients have misconceptions regarding the diagnosis and treatment of lumbar spondylosis, and that these misconceptions persist in patients with a history of spine surgery. Specifically, patients overemphasize the value of radiological studies and have mixed perceptions of the relative risk and effectiveness of surgical intervention compared with more conservative management. These misconceptions have the potential to alter patient expectations and decrease satisfaction, which could negatively impact patient outcomes and subjective valuations of physician performance. While these results are preliminary, they highlight a need for improved communication and patient education during surgical consultation for lumbar spondylosis.

Does minimal access tubular assisted spine surgery increase or decrease complications in spinal decompression or fusion?

PubMed

Fourney, Daryl R; Dettori, Joseph R; Norvell, Daniel C; Dekutoski, Mark B

2010-04-20

Systematic review. The purpose of this review was to attempt to answer the following 2 clinical questions: (1) Does minimal access tubular assisted spine surgery (MAS) decrease the rate of complications in posterior thoracolumbar decompression and/or fusion surgery compared with traditional open techniques? (2) What strategies to reduce the risk of complications in MAS have been shown to be effective? The objective of minimal access spine surgery is to reduce damage to surrounding tissues while accomplishing the same goals as conventional surgery. Patient demand and marketing for MAS is driven by the perception of better outcomes, although the purported advantages remain unproven. Whether the risk of complications is affected by minimal access techniques is unknown. A systematic review of the English language literature was undertaken for articles published between 1990 and July 2009. Electronic databases and reference lists of key articles were searched to identify published studies that compared the rate of complications after MAS to a control group that underwent open surgery. Single-arm studies were excluded. Two independent reviewers assessed the strength of literature using GRADE criteria assessing quality, quantity, and consistency of results. Disagreements were resolved by consensus. From the 361 articles identified, 13 met a priori criteria and were included for review. All of the studies evaluated only lumbar spine surgery. The single large randomized study showed less favorable results for MAS discectomy, but no significant difference in complication rates. The quality of the other studies, particularly for fusion surgery, was low. Overall, the rates of reoperation, dural tear, cerebrospinal fluid leak, nerve injury, and infection occurred in similar proportions between MAS and open surgery. Blood loss was reduced in MAS fusion; however, the quality of those studies was very low. Operation time and hospital length of stay was variable across studies. There was no evidence to assess the effectiveness of strategies to reduce the risk of complications in MAS. Some data suggests that the rate of complications may decrease with experience. (1) Compared to open techniques, MAS does not decrease the rate of complications for posterior lumbar spinal decompression or fusion. (2) There is no evidence to assess the effectiveness of strategies to reduce the risk of MAS-related complications.

Spinal stenosis

MedlinePlus

... stenosis; LBP - stenosis Patient Instructions Spine surgery - discharge Images Sciatic nerve Spinal stenosis Spinal stenosis References Försth P, Ólafsson G, Carlsson T, et al. A randomized, controlled trial of fusion surgery for lumbar spinal stenosis. N Engl J ...

Improving the clinical evidence of bone graft substitute technology in lumbar spine surgery.

PubMed

Hsu, Wellington K; Nickoli, M S; Wang, J C; Lieberman, J R; An, H S; Yoon, S T; Youssef, J A; Brodke, D S; McCullough, C M

2012-12-01

Bone graft substitutes have been used routinely for spine fusion for decades, yet clinical evidence establishing comparative data remains sparse. With recent scrutiny paid to the outcomes, complications, and costs associated with osteobiologics, a need to improve available data guiding efficacious use exists. We review the currently available clinical literature, studying the outcomes of various biologics in posterolateral lumbar spine fusion, and establish the need for a multicenter, independent osteobiologics registry.

Improving the Clinical Evidence of Bone Graft Substitute Technology in Lumbar Spine Surgery

PubMed Central

Hsu, Wellington K.; Nickoli, M. S.; Wang, J. C.; Lieberman, J. R.; An, H. S.; Yoon, S. T.; Youssef, J. A.; Brodke, D. S.; McCullough, C. M.

2012-01-01

Bone graft substitutes have been used routinely for spine fusion for decades, yet clinical evidence establishing comparative data remains sparse. With recent scrutiny paid to the outcomes, complications, and costs associated with osteobiologics, a need to improve available data guiding efficacious use exists. We review the currently available clinical literature, studying the outcomes of various biologics in posterolateral lumbar spine fusion, and establish the need for a multicenter, independent osteobiologics registry. PMID:24353975

Effects of Conflicts of Interest on Practice Patterns and Complication Rates in Spine Surgery.

PubMed

Cook, Ralph W; Weiner, Joseph A; Schallmo, Michael S; Chun, Danielle S; Barth, Kathryn A; Singh, Sameer K; Hsu, Wellington K

2017-09-01

Retrospective cohort study. We sought to determine whether financial relationships with industry had any impact on operative and/or complication rates of spine surgeons performing fusion surgeries. Recent actions from Congress and the Institute of Medicine have highlighted the importance of conflicts of interest among physicians. Orthopedic surgeons and neurosurgeons have been identified as receiving the highest amount of industry payments among all specialties. No study has yet investigated the potential effects of disclosed industry payments with quality and choices of patient care. A comprehensive database of spine surgeons in the United States with compiled data of industry payments, operative fusion rates, and complication rates was created. Practice pattern data were derived from a publicly available Medicare-based database generated from selected CPT codes from 2011 to 2012. Complication rate data from 2009 to 2013 were extracted from the ProPublica-Surgeon-Scorecard database, which utilizes postoperative inhospital mortality and 30-day-readmission for designated conditions as complications of surgery. Data regarding industry payments from 2013 to 2014 were derived from the Open Payments website. Surgeons performing <10 fusions, those without complication data, and those whose identity could not be verified through public records were excluded. Pearson correlation coefficients and multivariate regression analyses were used to determine the relationship between industry payments, operative fusion rate, and/or complication rate. A total of 2110 surgeons met the inclusion criteria for our database. The average operative fusion rate was 8.8% (SD 4.8%), whereas the average complication rate for lumbar and cervical fusion was 4.1% and 1.9%, respectively. Pearson correlation analysis revealed a statistically significant but negligible relationship between disclosed payments/transactions and both operative fusion and complication rates. Our findings do not support a strong correlation between the payments a surgeon receives from industry and their decisions to perform spine fusion or associated complication rates. Large variability in the rate of fusions performed suggests a poor consensus for indications for spine fusion surgery. 3.

Repeated sugammadex reversal of muscle relaxation during lumbar spine surgery with intraoperative neurophysiological multimodal monitoring.

PubMed

Errando, C L; Blanco, T; Díaz-Cambronero, Ó

2016-11-01

Intraoperative neurophysiological monitoring during spine surgery is usually acomplished avoiding muscle relaxants. A case of intraoperative sugammadex partial reversal of the neuromuscular blockade allowing adequate monitoring during spine surgery is presented. A 38 year-old man was scheduled for discectomy and vertebral arthrodesis throughout anterior and posterior approaches. Anesthesia consisted of total intravenous anesthesia plus rocuronium. Intraoperatively monitoring was needed, and the muscle relaxant reverted twice with low dose sugammadex in order to obtain adequate responses. The doses of sugammadex used were conservatively selected (0.1mg/kg boluses increases, total dose needed 0.4mg/kg). Both motor evoqued potentials, and electromyographic responses were deemed adequate by the neurophysiologist. If muscle relaxation was needed in the context described, this approach could be useful to prevent neurological sequelae. This is the first study using very low dose sugammadex to reverse rocuronium intraoperatively and to re-establish the neuromuscular blockade. Copyright © 2016 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Publicado por Elsevier España, S.L.U. All rights reserved.

Giant Cell Tumor of Cervical Spine Presenting as Acute Asphyxia: Successful Surgical Resection After Down-Staging With Denosumab.

PubMed

Kumar, Rajendra; Meis, Jeanne M; Amini, Behrang; McEnery, Kevin W; Madewell, John E; Rhines, Laurence D; Benjamin, Robert S

2017-05-15

Case report and literature review. To describe treatment of a unique case of acute airway obstruction by a large C7 giant cell tumor (GCT) with preoperative denosumab followed by surgical resection, and review the literature on this rare entity. Standard treatment for GCTs includes surgical resection or curettage and packing. Large lesions in the spine may require preoperative therapy with denosumab, a human monoclonal antibody to RANKL, to facilitate surgery. It is highly unusual for GCT arising in cervical spine to present with acute asphyxia (requiring tracheostomy). We report a patient with large C7 GCT that caused tracheal compression with almost complete airway obstruction requiring emergency intubation. The tumor responded to subcutaneously administered denosumab with marked decrease in size and relief of symptoms. Increased tumor mineralization in response to therapy facilitated subsequent successful surgical tumor resection. The patient remains symptom-free 2 years after surgery without tumor recurrence. Denosumab can shrink the size of large GCTs, providing symptom relief before surgery and facilitate tumor resection. 5.

The impact of a cervical spine diagnosis on the careers of National Football League athletes.

PubMed

Schroeder, Gregory D; Lynch, T Sean; Gibbs, Daniel B; Chow, Ian; LaBelle, Mark W; Patel, Alpesh A; Savage, Jason W; Nuber, Gordon W; Hsu, Wellington K

2014-05-20

Cohort study. To determine the effect of cervical spine pathology on athletes entering the National Football League. The association of symptomatic cervical spine pathology with American football athletes has been described; however, it is unknown how preexisting cervical spine pathology affects career performance of a National Football League player. The medical evaluations and imaging reports of American football athletes from 2003 to 2011 during the combine were evaluated. Athletes with a cervical spine diagnosis were matched to controls and career statistics were compiled. Of a total of 2965 evaluated athletes, 143 players met the inclusion criteria. Athletes who attended the National Football League combine without a cervical spine diagnosis were more likely to be drafted than those with a diagnosis (P = 0.001). Players with a cervical spine diagnosis had a decreased total games played (P = 0.01). There was no difference in the number of games started (P = 0.08) or performance score (P = 0.38). In 10 athletes with a sagittal canal diameter of less than 10 mm, there was no difference in years, games played, games started, or performance score (P > 0.24). No neurological injury occurred during their careers. In 7 players who were drafted with a history of cervical spine surgery (4 anterior cervical discectomy and fusion, 2 foraminotomy, and 1 suboccipital craniectomy with a C1 laminectomy), there was no difference in career longevity or performance when compared with matched controls. This study suggests that athletes with preexisting cervical spine pathology were less likely to be drafted than controls. Players with preexisting cervical spine pathology demonstrated a shorter career than those without; however, statistically based performance and numbers of games started were not different. Players with cervical spinal stenosis and those with a history of previous surgery demonstrated no difference in performance-based outcomes and no reports of neurological injury during their careers.

Symptomatic adjacent segment disease after cervical total disc replacement: re-examining the clinical and radiological evidence with established criteria.

PubMed

Nunley, Pierce D; Jawahar, Ajay; Cavanaugh, David A; Gordon, Charles R; Kerr, Eubulus J; Utter, Phillip Andrew

2013-01-01

Although several publications in the last decade have proved equality in safety and efficacy of the total disc replacement (TDR) to the anterior fusion procedure in cervical spine, the claim that TDR may reduce the incidence of adjacent segment disease (ASD) has not been corroborated by clinical evidence. We attempt to predict the true incidence of symptomatic ASD after TDR surgery in the cervical spine at one or two levels at a median follow-up period of 4 years. A total of 763 patients were screened to participate in four different Food and Drug Administration device exemption trials for artificial cervical disc replacement at three collaborating institutions. Two hundred seventy-one patients qualified and enrolled in the trials. One hundred seventy-three randomized to receive artificial disc replacement surgery, and 167 have completed a 4-year or longer follow-up. Patients experiencing cervical radiculopathy symptoms in the follow-up period were worked-up with clinical examinations, magnetic resonance imaging of the cervical spine, and other diagnostic studies. Once a clinical correlation was established with the imaging evidence of adjacent segment degeneration, a careful record was maintained to document the subsequent medical and/or surgical treatment received by these patients. Statistical analysis was performed to determine the true incidence of and factors affecting the ASD after cervical disc replacement in these patients. Twenty-six patients (15.2%) were identified to satisfy our criteria for ASD at the median follow-up of 51 months, with the annual incidence of 3.1% as calculated by life tables. The actuarial 5-year freedom from ASD rate was 71.6%±0.6%, and the mean period for freedom from ASD was 70.4±2.1 months. The incidence of symptomatic ASD after cervical TDR is 3.1% annually regardless of the patient's age, sex, smoking habits, and design of the TDR device. The presence of osteopenia and lumbar degenerative disease significantly increase the risk of developing ASD after anterior cervical surgery. Copyright © 2013 Elsevier Inc. All rights reserved.

Lumbar spinal stenosis: comparison of surgical practice variation and clinical outcome in three national spine registries.

PubMed

Lønne, Greger; Fritzell, Peter; Hägg, Olle; Nordvall, Dennis; Gerdhem, Paul; Lagerbäck, Tobias; Andersen, Mikkel; Eiskjaer, Søren; Gehrchen, Martin; Jacobs, Wilco; van Hooff, Miranda L; Solberg, Tore K

2018-05-21

Decompression surgery for lumbar spinal stenosis (LSS) is the most common spinal procedure in the elderly. To avoid persisting low back pain, adding arthrodesis has been recommended, especially if there is a coexisting degenerative spondylolisthesis. However, this strategy remains controversial, resulting in practice-based variation. The present study aimed to evaluate in a pragmatic study if surgical selection criteria and variation in use of arthrodesis in three Scandinavian countries can be linked to variation in treatment effectiveness. This is an observational study based on a combined cohort from the national spine registries of Norway, Sweden, and Denmark. Patients aged 50 and older operated during 2011-2013 for LSS were included. Patient-Reported Outcome Measures (PROMs): Oswestry Disability Index (ODI) (primary outcome), Numeric Rating Scale (NRS) for leg pain and back pain, and health-related quality of life (Euro-Qol-5D) were reported. Analysis included case-mix adjustment. In addition, we report differences in hospital stay. Analyses of baseline data were done by analysis of variance (ANOVA), chi-square, or logistic regression tests. The comparisons of the mean changes of PROMs at 1-year follow-up between the countries were done by ANOVA (crude) and analysis of covariance (case-mix adjustment). Out of 14,223 included patients, 10,890 (77%) responded at 1-year follow-up. Apart from fewer smokers in Sweden and higher comorbidity rate in Norway, baseline characteristics were similar. The rate of additional fusion surgery (patients without or with spondylolisthesis) was 11% (4%, 47%) in Norway, 21% (9%, 56%) in Sweden, and 28% (15%, 88%) in Denmark. At 1-year follow-up, the mean improvement for ODI (95% confidence interval) was 18 (17-18) in Norway, 17 (17-18) in Sweden, and 18 (17-19) in Denmark. Patients operated with arthrodesis had prolonged hospital stay. Real-life data from three national spine registers showed similar indications for decompression surgery but significant differences in the use of concomitant arthrodesis in Scandinavia. Additional arthrodesis was not associated with better treatment effectiveness. Copyright © 2018 Elsevier Inc. All rights reserved.

Very late complications of cervical arthroplasty: results of 2 controlled randomized prospective studies from a single investigator site.

PubMed

Hacker, Francis M; Babcock, Rebecca M; Hacker, Robert J

2013-12-15

Prospective, single-site, randomized, Food and Drug Administration-approved investigational device exemption clinical trials of 2 cervical arthroplasty (CA) devices. To evaluate complications with CA occurring more than 4 years after the surgical procedure in Food and Drug Administration clinical trials of the Bryan and Prestige LP arthroplasty devices. Reports of several randomized clinical studies have shown CA to be a safe and effective alternative to anterior cervical fusion in the treatment of degenerative cervical disc disorders. A majority include follow-up intervals of 4 years or less. Between 2002 and 2006, 94 patients were enrolled in Food and Drug Administration studies of the Bryan and Prestige LP cervical disc devices. Charts, imaging studies, and hospital records were reviewed for those who underwent arthroplasty and returned more than 4 years after their surgical procedure with neck-related pain or dysfunction. Excluding adjacent segment disease that occurred with a similar rate for patients who underwent fusion and arthroplasty, 5 patients, all treated with arthroplasty, returned for evaluation of neck and arm symptoms between 48 and 72 months after surgery. Four patients had peridevice vertebral body bone loss. One patient had posterior device migration and presented with myelopathy. Three required revision surgery and 2 were observed. Four patients maintained follow-up and reported stabilization or improvement in symptoms. Despite their similarities, CA and fusion are not equivalent procedures in this study in regard to very late complications. Similar to large joint arthroplasty, delayed device-related complications may occur with CA. These complications commenced well beyond the time frame for complications associated with more traditional cervical spine procedures. Both patients and surgeons should be aware of the potential for very late device-related complications occurring with CA and the need for revision surgery. 1.

Cognitive-behavioral based physical therapy for patients with chronic pain undergoing lumbar spine surgery: a randomized controlled trial

PubMed Central

Archer, Kristin R.; Devin, Clinton J.; Vanston, Susan W.; Koyama, Tatsuki; Phillips, Sharon; George, Steven Z.; McGirt, Matthew J.; Spengler, Dan M.; Aaronson, Oran S.; Cheng, Joseph S.; Wegener, Stephen T.

2015-01-01

The purpose of this study was to determine the efficacy of a cognitive-behavioral based physical therapy (CBPT) program for improving outcomes in patients following lumbar spine surgery. A randomized controlled trial was conducted in 86 adults undergoing a laminectomy with or without arthrodesis for a lumbar degenerative condition. Patients were screened preoperatively for high fear of movement using the Tampa Scale for Kinesiophobia. Randomization to either CBPT or an Education program occurred at 6 weeks after surgery. Assessments were completed pre-treatment, post-treatment and at 3 month follow-up. The primary outcomes were pain and disability measured by the Brief Pain Inventory and Oswestry Disability Index. Secondary outcomes included general health (SF-12) and performance-based tests (5-Chair Stand, Timed Up and Go, 10 Meter Walk). Multivariable linear regression analyses found that CBPT participants had significantly greater decreases in pain and disability and increases in general health and physical performance compared to the Education group at 3 month follow-up. Results suggest a targeted CBPT program may result in significant and clinically meaningful improvement in postoperative outcomes. CBPT has the potential to be an evidence-based program that clinicians can recommend for patients at-risk for poor recovery following spine surgery. PMID:26476267

Laryngeal dislocation after ventral fusion of the cervical spine

PubMed Central

Krauel, Jenny; Winkler, Dietrich; Münscher, Adrian; Tank, Sascha

2013-01-01

We report on a 70-year-old patient who underwent ventral fusion of the cervical spine (C3/4 and C4/5) for spinal canal stenosis performed by the neurosurgery department. The patient suffered an exceedingly rare complication of the surgery – laryngeal dislocation. Had the deformed laryngeal structures been overlooked and the patient extubated as usual after surgery, reintubation would have been impossible due to the associated swelling, which might have had disastrous consequences. Leftward dislocation of the larynx became apparent post-operatively, but prior to extubation. Extubation was therefore postponed and a subsequent computed tomography (CT) scan revealed entrapment of laryngeal structures within the osteosynthesis. A trial of repositioning using microlaryngoscopy performed by otolaryngology (ears, nose and throat) specialists failed, making open surgical revision necessary. At surgery, the entrapped laryngeal tissue was successfully mobilised. Laryngeal oedema developed despite prompt repositioning; thus, necessitating tracheotomy and long-term ventilation. Laryngeal dislocation may be an unusual cause of post-operative neck swelling after anterior cervical spine surgery and should be considered in the differential diagnosis if surgical site haematoma and other causes have been ruled out. Imaging studies including CT of the neck may be needed before extubation to confirm the suspicion and should be promptly obtained to facilitate specific treatment. PMID:23983289

Accuracy of pedicle screw placement comparing robot-assisted technology and the free-hand with fluoroscopy-guided method in spine surgery: An updated meta-analysis.

PubMed

Fan, Yong; Du, Jin Peng; Liu, Ji Jun; Zhang, Jia Nan; Qiao, Huan Huan; Liu, Shi Chang; Hao, Ding Jun

2018-06-01

A miniature spine-mounted robot has recently been introduced to further improve the accuracy of pedicle screw placement in spine surgery. However, the differences in accuracy between the robotic-assisted (RA) technique and the free-hand with fluoroscopy-guided (FH) method for pedicle screw placement are controversial. A meta-analysis was conducted to focus on this problem. Several randomized controlled trials (RCTs) and cohort studies involving RA and FH and published before January 2017 were searched for using the Cochrane Library, Ovid, Web of Science, PubMed, and EMBASE databases. A total of 55 papers were selected. After the full-text assessment, 45 clinical trials were excluded. The final meta-analysis included 10 articles. The accuracy of pedicle screw placement within the RA group was significantly greater than the accuracy within the FH group (odds ratio 95%, "perfect accuracy" confidence interval: 1.38-2.07, P < .01; odds ratio 95% "clinically acceptable" Confidence Interval: 1.17-2.08, P < .01). There are significant differences in accuracy between RA surgery and FH surgery. It was demonstrated that the RA technique is superior to the conventional method in terms of the accuracy of pedicle screw placement.

Complications associated with prone positioning in elective spinal surgery.

PubMed

DePasse, J Mason; Palumbo, Mark A; Haque, Maahir; Eberson, Craig P; Daniels, Alan H

2015-04-18

Complications associated with prone surgical positioning during elective spine surgery have the potential to cause serious patient morbidity. Although many of these complications remain uncommon, the range of possible morbidities is wide and includes multiple organ systems. Perioperative visual loss (POVL) is a well described, but uncommon complication that may occur due to ischemia to the optic nerve, retina, or cerebral cortex. Closed-angle glaucoma and amaurosis have been reported as additional etiologies for vision loss following spinal surgery. Peripheral nerve injuries, such as those caused by prolonged traction to the brachial plexus, are more commonly encountered postoperative events. Myocutaneous complications including pressure ulcers and compartment syndrome may also occur after prone positioning, albeit rarely. Other uncommon positioning complications such as tongue swelling resulting in airway compromise, femoral artery ischemia, and avascular necrosis of the femoral head have also been reported. Many of these are well-understood and largely avoidable through thoughtful attention to detail. Other complications, such as POVL, remain incompletely understood and thus more difficult to predict or prevent. Here, the current literature on the complications of prone positioning for spine surgery is reviewed to increase awareness of the spectrum of potential complications and to inform spine surgeons of strategies to minimize the risk of prone patient morbidity.

Complications associated with prone positioning in elective spinal surgery

PubMed Central

DePasse, J Mason; Palumbo, Mark A; Haque, Maahir; Eberson, Craig P; Daniels, Alan H

2015-01-01

Complications associated with prone surgical positioning during elective spine surgery have the potential to cause serious patient morbidity. Although many of these complications remain uncommon, the range of possible morbidities is wide and includes multiple organ systems. Perioperative visual loss (POVL) is a well described, but uncommon complication that may occur due to ischemia to the optic nerve, retina, or cerebral cortex. Closed-angle glaucoma and amaurosis have been reported as additional etiologies for vision loss following spinal surgery. Peripheral nerve injuries, such as those caused by prolonged traction to the brachial plexus, are more commonly encountered postoperative events. Myocutaneous complications including pressure ulcers and compartment syndrome may also occur after prone positioning, albeit rarely. Other uncommon positioning complications such as tongue swelling resulting in airway compromise, femoral artery ischemia, and avascular necrosis of the femoral head have also been reported. Many of these are well-understood and largely avoidable through thoughtful attention to detail. Other complications, such as POVL, remain incompletely understood and thus more difficult to predict or prevent. Here, the current literature on the complications of prone positioning for spine surgery is reviewed to increase awareness of the spectrum of potential complications and to inform spine surgeons of strategies to minimize the risk of prone patient morbidity. PMID:25893178

A simple scoring system for predicting early major complications in spine surgery: the cumulative effect of age and size of surgery.

PubMed

Brasil, Albert Vincent Berthier; Teles, Alisson R; Roxo, Marcelo Ricardo; Schuster, Marcelo Neutzling; Zauk, Eduardo Ballverdu; Barcellos, Gabriel da Costa; Costa, Pablo Ramon Fruett da; Ferreira, Nelson Pires; Kraemer, Jorge Luiz; Ferreira, Marcelo Paglioli; Gobbato, Pedro Luis; Worm, Paulo Valdeci

2016-10-01

To analyze the cumulative effect of risk factors associated with early major complications in postoperative spine surgery. Retrospective analysis of 583 surgically-treated patients. Early "major" complications were defined as those that may lead to permanent detrimental effects or require further significant intervention. A balanced risk score was built using multiple logistic regression. Ninety-two early major complications occurred in 76 patients (13%). Age > 60 years and surgery of three or more levels proved to be significant independent risk factors in the multivariate analysis. The balanced scoring system was defined as: 0 points (no risk factor), 2 points (1 factor) or 4 points (2 factors). The incidence of early major complications in each category was 7% (0 points), 15% (2 points) and 29% (4 points) respectively. This balanced scoring system, based on two risk factors, represents an important tool for both surgical indication and for patient counseling before surgery.

What are the Rates, Reasons, and Risk Factors of 90-day Hospital Readmission After Lumbar Discectomy?: An Institutional Experience.

PubMed

Kohls, Morgan R; Jain, Nikhil; Khan, Safdar N

2018-06-07

This is a retrospective cohort study. To report the rate, reasons, and risk factors for 90-day readmissions after lumbar discectomy at an academic medical center. Several studies have reported complications and readmissions after spine surgery; however, only one previous study has focused specifically on lumbar discectomy. As the patient profile and morbidity of various spine procedures is different, focus on procedure-specific complications and readmissions will be beneficial. Patients who underwent lumbar discectomy for unrelieved symptoms of prolapsed intervertebral disk and had at least 90 days of follow-up at an academic institution (2013-2014) were included. Retrospective review of electronic medical record was performed to record demographic and clinical profile of patients. Details of lumbar discectomy, index hospital stay, discharge disposition, hospital readmission within 90 days, reason for readmission and treatment given have been reported. Risk factors for hospital readmission were analyzed by multivariate logistic regression analysis. A total of 356 patients with a mean age of 45.0±13.8 years were included. The 90-day readmission rate was 5.3% (19/360) of which two-third patients were admitted within 30 days giving a 30-day readmission rate of 3.7% (13/356). The top 2 primary reasons for readmission included back and/or leg pain, numbness, or tingling (42.9%), and persistent cerebrospinal fluid leak or seroma (25.0%). On adjusted analysis, risk factors associated with higher risk of readmission included incidental durotomy [odds ratio (OR), 26.2; 95% confidence interval (CI), 5.3-129.9] and discharge to skilled nursing facility/inpatient rehabilitation (OR, 25.2; 95% CI, 2.7-235.2). Increasing age was a negative predictor of readmission (OR, 0.95; 95% CI, 0.91-0.99). Incidental durotomy, younger age, and discharge to nursing facility were associated with higher risk of 90-day hospital readmission after lumbar discectomy. As compared with extensive spine procedures, patient comorbidity burden may not be as significant in predicting readmission after this relatively less invasive procedure.

Tomographie par coherence optique pour le guidage de chirurgies minimalement invasives du rachis

NASA Astrophysics Data System (ADS)

Beaudette, Kathy

Adolescent idiopathic scoliosis is a complex 3D deformity of the spine which requires surgical intervention in severe cases of the condition. The existing corrective procedure of scoliosis is very invasive; it involves a long incision and a large instrumentation, in addition to the fusion of a section of the spine. To improve postoperative conditions and to preserve patients' spinal flexibility, novel fusionless surgical approaches involving growth modulation are under investigation. With this objective in mind, a multidisciplinary team from École Polytechnique of Montreal and Sainte-Justine University Hospital Research Center is developing a surgical technique based on the insertion of micro-staples between vertebral growth plates and corresponding intervertebral disks. Each micro-staple passively modulates the vertebral growth on the convex side of the scoliotic curvature. This modulation modifies vertebral geometry which, for scoliotic patients, presents a wedging deformity. The modulation induced by these devices could lead to the correction of the curvature of the spine. This innovative procedure would preserve the flexibility of the spine as well as the health of intervertebral disks, in addition to being compatible with minimally invasive approaches. However, to be efficient, the micro-staples must be placed at the junction between the growth plate and the disk with a sub-millimeter precision. An intraoperative guiding system is therefore required to ensure the success of the intervention. Optical coherence tomography (OCT) is a promising candidate for this application. OCT is based on low-coherence interferometry and provides cross-sectional images with a resolution about 10 μm for a depth of 2 to 3 mm. This technique allows for the real-time acquisition of images and is compatible with endoscopy, thereby showing a potential for the intraoperative guidance of minimally invasive surgeries (MIS) of the spine. The main objective of this master's project is therefore to evaluate the possibility of using OCT to localize as well as identify spinal structures (such as growth plates, osseous tissue, intervertebral disks and connective tissue) and to guide the insertion of micro-staples. To attain this objective, an OCT handheld probe was designed and developed according to the surgical constraints of MIS performed by thoracoscopy (through the thorax). This probe has an external diameter of 17 mm and is 30 cm long. Coupled with a fibered interferometer, the axial and lateral resolutions of the probe are of 16 and 27 μm respectively. The OCT probe was used in vivo during an open surgery on a porcine model. Different tissues within the operative window (lung, muscles, osseous tissues and intervertebral disk) were imaged during the procedure. These preliminary in vivo tests demonstrated that the probe is capable of identifying different types of tissue with a good sensitivity and an adequate penetration depth. These results also showed that a visual inspection of the in vivo OCT images alone is not sufficient to localize the growth plates on the vertebrae. An ex vivo study using porcine vertebrae was therefore performed to identify quantitative markers in order to facilitate the interpretation of in vivo OCT images. OCT images were initially compared to corresponding histological sections. The ensuing results showed that the connective tissue layer presents a band pattern due to the birefringence properties of the collagen-rich tissue. The intervertebral disk was also shown to have a characteristic lamellar structure on OCT images. Lastly, within growth plate and osseous tissue locations, the OCT signal decay is monotonic, but with different attenuation coefficients (different slopes). Relative attenuation coefficients were therefore measured for each tissue (growth plate, osseous tissue, connective tissue and intervertebral disk) on several specimens and were compared. These results showed that growth plates present an average relative attenuation coefficient statistically different from the other tissues. An automatic growth plate segmentation algorithm was then developed and tested. The algorithm was applied to images from an ex vivo specimen of a porcine vertebra and successfully identified most of the growth plate (> 75%) amidst the osseous tissue of the vertebral body and the intervertebral disk. This master's project shows that OCT presents contrast, resolution and penetration depth that are sufficient for the identification of musculoskeletal structures of the spine. It is thus reasonable to believe that, ultimately, OCT could be used for the intraoperative guiding of the insertion of micro-staples during corrective surgeries of scoliosis.

Outcomes of Spinal Fusion for Cervical Kyphosis in Children with Neurofibromatosis.

PubMed

Helenius, Ilkka J; Sponseller, Paul D; Mackenzie, William; Odent, Thierry; Dormans, John P; Asghar, Jahangir; Rathjen, Karl; Pahys, Joshua M; Miyanji, Firoz; Hedequist, Daniel; Phillips, Jonathan H

2016-11-02

Cervical kyphosis may occur with neurofibromatosis type I (NF1) and is often associated with vertebral dysplasia. Outcomes of cervical spinal fusion in patients with NF1 are not well described because of the rarity of the condition. We aimed to (1) characterize the clinical presentation of cervical kyphosis and (2) report the outcomes of posterior and anteroposterior cervical fusion for the condition in these children. The medical records and imaging studies of 22 children with NF1 who had undergone spinal fusion for cervical kyphosis (mean, 67°) at a mean age of 11 years and who had been followed for a minimum of 2 years were reviewed. Thirteen children presented with neck pain; 10, with head tilt; 9, with a previous cervical laminectomy or fusion; and 5, with a neurologic deficit. Two patients had spontaneous dislocation of the mid-cervical spine without a neurologic deficit. Eleven had scoliosis, with the major curve measuring a mean of 61°. Nine patients underwent posterior and 13 underwent anteroposterior surgery. Twenty-one received spinal instrumentation, and 1 was not treated with instrumentation. Preoperative halo traction was used for 9 patients, and it reduced the mean preoperative kyphosis by 34% (p = 0.0059). At the time of final follow-up, all spinal fusion sites had healed and the cervical kyphosis averaged 21° (mean correction, 69%; p < 0.001). The cervical kyphosis correction was significantly better after the anteroposterior procedures (83%) than after the posterior-only procedures (58%) (p = 0.031). Vertebral dysplasia and erosion continued in all 17 patients who had presented with dysplasia preoperatively. Thirteen patients had complications, including 5 new neurologic deficits and 8 cases of junctional kyphosis. Nine patients required revision surgery. Junctional kyphosis was more common in children in whom ≤5 levels had been fused (p = 0.054). Anteroposterior surgery provided better correction of cervical kyphosis than posterior spinal fusion in children with NF1. Erosion of vertebral bodies continued during the postoperative follow-up period in all patients who had presented with dysplastic changes preoperatively. The cervical spine should be screened in all children with NF1. Fusion should include at least 6 levels to prevent junctional kyphosis. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence. Copyright © 2016 by The Journal of Bone and Joint Surgery, Incorporated.

Minimally Invasive Spinal Surgery with Intraoperative Image-Guided Navigation

PubMed Central

Kim, Terrence T.; Johnson, J. Patrick; Pashman, Robert; Drazin, Doniel

2016-01-01

We present our perioperative minimally invasive spine surgery technique using intraoperative computed tomography image-guided navigation for the treatment of various lumbar spine pathologies. We present an illustrative case of a patient undergoing minimally invasive percutaneous posterior spinal fusion assisted by the O-arm system with navigation. We discuss the literature and the advantages of the technique over fluoroscopic imaging methods: lower occupational radiation exposure for operative room personnel, reduced need for postoperative imaging, and decreased revision rates. Most importantly, we demonstrate that use of intraoperative cone beam CT image-guided navigation has been reported to increase accuracy. PMID:27213152

Principles of management of thoracolumbar fractures.

PubMed

Dai, Li-yang

2012-05-01

There is little consensus on treatment of thoracolumbar fractures, which are one of the most controversial areas in spine surgery. The great variations in clinical decision making may come from differences in evaluation of spine stability with these fractures. Few high-quality studies concerning optimal treatment of thoracolumbar fractures have been conducted. This article reviews the conflicting results and recommendations for management of thoracolumbar fractures of currently published reports. Specifically, it addresses issues regarding evaluation of stability, indications for operative treatment, timing of surgery, surgical approach, and fusion length. © 2012 Tianjin Hospital and Blackwell Publishing Asia Pty Ltd.

Retrospective review of percutaneous synovial cyst ruptures: increased thickness of the T2 hypointense rim on post-rupture MRI may be associated with need for subsequent surgery.

PubMed

Kwan, Benjamin Y M; Salehi, Fateme; Jia, Sang; McGregor, Stuart; Duggal, Neil; Pelz, David; Sharma, Manas

2017-08-01

To analyze MRI characteristics of lumbar facet synovial cysts and distinguish those requiring subsequent surgical management for recurrence, after percutaneous synovial cyst rupture. Retrospective chart review conducted in patients undergoing percutaneous synovial cyst rupture between February 2012 and April 2015. Pre- and post-percutaneous rupture procedure MRI spine studies were serially reviewed. Synovial cyst sizes, T1 and T2 signal characteristics and changes therein, T2 hypointense (or 'dark rim') thickness and change, and changes in the complexity of cyst signals were compared. Operative notes for patients who underwent subsequent surgical removal of recurrent synovial cysts were reviewed. 24 patients received 41 percutaneous synovial cyst rupture procedures, with a technical success rate of 82.9%. There was a significant difference in the mean increased thickness of the T2 hypointense rim on the first post-rupture MRI scan (p=0.0411) between patients requiring subsequent surgery and those who did not. There was a significant difference in the average sizes of synovial cysts before the procedure (p=0.0483) in those requiring subsequent surgery and those who did not. Five complications were noted (12.2%), mostly involving leg pain or weakness. Of the nine patients who underwent subsequent surgery post-synovial cyst rupture, six of the surgeries had recorded difficulty pertaining to scarring and/or adherence of the cyst to dura. A larger increase in thickness of the T2 hypointense rim on the first post-rupture MRI scan and a larger synovial cyst size were associated with the need for subsequent surgical resection. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Results of Database Studies in Spine Surgery Can Be Influenced by Missing Data.

PubMed

Basques, Bryce A; McLynn, Ryan P; Fice, Michael P; Samuel, Andre M; Lukasiewicz, Adam M; Bohl, Daniel D; Ahn, Junyoung; Singh, Kern; Grauer, Jonathan N

2017-12-01

National databases are increasingly being used for research in spine surgery; however, one limitation of such databases that has received sparse mention is the frequency of missing data. Studies using these databases often do not emphasize the percentage of missing data for each variable used and do not specify how patients with missing data are incorporated into analyses. This study uses the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to examine whether different treatments of missing data can influence the results of spine studies. (1) What is the frequency of missing data fields for demographics, medical comorbidities, preoperative laboratory values, operating room times, and length of stay recorded in ACS-NSQIP? (2) Using three common approaches to handling missing data, how frequently do those approaches agree in terms of finding particular variables to be associated with adverse events? (3) Do different approaches to handling missing data influence the outcomes and effect sizes of an analysis testing for an association with these variables with occurrence of adverse events? Patients who underwent spine surgery between 2005 and 2013 were identified from the ACS-NSQIP database. A total of 88,471 patients undergoing spine surgery were identified. The most common procedures were anterior cervical discectomy and fusion, lumbar decompression, and lumbar fusion. Demographics, comorbidities, and perioperative laboratory values were tabulated for each patient, and the percent of missing data was noted for each variable. These variables were tested for an association with "any adverse event" using three separate multivariate regressions that used the most common treatments for missing data. In the first regression, patients with any missing data were excluded. In the second regression, missing data were treated as a negative or "reference" value; for continuous variables, the mean of each variable's reference range was computed and imputed. In the third regression, any variables with > 10% rate of missing data were removed from the regression; among variables with ≤ 10% missing data, individual cases with missing values were excluded. The results of these regressions were compared to determine how the different treatments of missing data could affect the results of spine studies using the ACS-NSQIP database. Of the 88,471 patients, as many as 4441 (5%) had missing elements among demographic data, 69,184 (72%) among comorbidities, 70,892 (80%) among preoperative laboratory values, and 56,551 (64%) among operating room times. Considering the three different treatments of missing data, we found different risk factors for adverse events. Of 44 risk factors found to be associated with adverse events in any analysis, only 15 (34%) of these risk factors were common among the three regressions. The second treatment of missing data (assuming "normal" value) found the most risk factors (40) to be associated with any adverse event, whereas the first treatment (deleting patients with missing data) found the fewest associations at 20. Among the risk factors associated with any adverse event, the 10 with the greatest effect size (odds ratio) by each regression were ranked. Of the 15 variables in the top 10 for any regression, six of these were common among all three lists. Differing treatments of missing data can influence the results of spine studies using the ACS-NSQIP. The current study highlights the importance of considering how such missing data are handled. Until there are better guidelines on the best approaches to handle missing data, investigators should report how missing data were handled to increase the quality and transparency of orthopaedic database research. Readers of large database studies should note whether handling of missing data was addressed and consider potential bias with high rates or unspecified or weak methods for handling missing data.

Rehabilitation of patients with thoracic spine injury treated by spring alloplasty.

PubMed

Kiwerski, J

1983-12-01

Stabilization of the traumatic injured spine by means of springs, called spring alloplasty, was introduced into clinical practice by Professor M. Weiss in 1965 and has been applied in the Warsaw Medical Academy Rehabilitation Clinic ( Konstancin ) ever since. The springs here replace the damaged system of posterior ligaments of the spine, restoring its stability and alleviating the front (often damaged) part of the body. This method has been used in surgery on about 350 patients mainly with spinal injury in the thoracic and thoracolumbar levels. Spine stabilization by the method in question usually makes it possible to start an early verticalization and an active rehabilitation. The verticalization of the patient in a specially designed bed is introduced as early as a few days after the accident, and attempts at active verticalization are made in 2-3 weeks time after surgery, thus the rehabilitation process is substantially precipitated and the period of hospital treatment is significantly reduced. The methodology of rehabilitation of the patients in question has been presented and functional effects of the treatment have been discussed in the paper.

Open versus percutaneous instrumentation in thoracolumbar fractures: magnetic resonance imaging comparison of paravertebral muscles after implant removal.

PubMed

Ntilikina, Yves; Bahlau, David; Garnon, Julien; Schuller, Sébastien; Walter, Axel; Schaeffer, Mickaël; Steib, Jean-Paul; Charles, Yann Philippe

2017-08-01

OBJECTIVE Percutaneous instrumentation in thoracolumbar fractures is intended to decrease paravertebral muscle damage by avoiding dissection. The aim of this study was to compare muscles at instrumented levels in patients who were treated by open or percutaneous surgery. METHODS Twenty-seven patients underwent open instrumentation, and 65 were treated percutaneously. A standardized MRI protocol using axial T1-weighted sequences was performed at a minimum 1-year follow-up after implant removal. Two independent observers measured cross-sectional areas (CSAs, in cm 2 ) and region of interest (ROI) signal intensity (in pixels) of paravertebral muscles by using OsiriX at the fracture level, and at cranial and caudal instrumented pedicle levels. An interobserver comparison was made using the Bland-Altman method. Reference ROI muscle was assessed in the psoas and ROI fat subcutaneously. The ratio ROI-CSA/ROI-fat was compared for patients treated with open versus percutaneous procedures by using a linear mixed model. A linear regression analyzed additional factors: age, sex, body mass index (BMI), Pfirrmann grade of adjacent discs, and duration of instrumentation in situ. RESULTS The interobserver agreement was good for all CSAs. The average CSA for the entire spine was 15.7 cm 2 in the open surgery group and 18.5 cm 2 in the percutaneous group (p = 0.0234). The average ROI-fat and ROI-muscle signal intensities were comparable: 497.1 versus 483.9 pixels for ROI-fat and 120.4 versus 111.7 pixels for ROI-muscle in open versus percutaneous groups. The ROI-CSA varied between 154 and 226 for open, and between 154 and 195 for percutaneous procedures, depending on instrumented levels. A significant difference of the ROI-CSA/ROI-fat ratio (0.4 vs 0.3) was present at fracture levels T12-L1 (p = 0.0329) and at adjacent cranial (p = 0.0139) and caudal (p = 0.0100) instrumented levels. Differences were not significant at thoracic levels. When adjusting based on age, BMI, and Pfirrmann grade, a significant difference between open and percutaneous procedures regarding the ROI-CSA/ROI-fat ratio was present in the lumbar spine (p < 0.01). Sex and duration of instrumentation had no significant influence. CONCLUSIONS Percutaneous instrumentation decreased muscle atrophy compared with open surgery. The MRI signal differences for T-12 and L-1 fractures indicated less fat infiltration within CSAs in patients who received percutaneous treatment. Differences were not evidenced at thoracic levels, where CSAs were smaller. Fat infiltration was not significantly different at lumbar levels with either procedure in elderly patients with associated discopathy and higher BMI. In younger patients, there was less fat infiltration of lumbar paravertebral muscles with percutaneous procedures.

Effect of Social Support and Marital Status on Perceived Surgical Effectiveness and 30-Day Hospital Readmission.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Vuong, Victoria D; Mehta, Ankit I; Vasquez, Raul A; Cheng, Joseph; Bagley, Carlos A; Karikari, Isaac O

2017-12-01

Retrospective cohort review. To determine whether higher levels of social support are associated with improved surgical outcomes after elective spine surgery. The medical records of 430 patients (married, n = 313; divorced/separated/widowed, n = 71; single, n = 46) undergoing elective spine surgery at a major academic medical center were reviewed. Patients were categorized by their marital status at the time of surgery. Patient demographics, comorbidities, and postoperative complication rates were collected. All patients had prospectively collected outcomes measures and a minimum of 1-year follow-up. Patient reported outcomes instruments (Oswestry Disability Index, Short Form-36, and visual analog scale-back pain/leg pain) were completed before surgery, then at 1 year after surgery. Baseline characteristics were similar in all cohorts. There was no statistically significant difference in the length of hospital stay across all 3 cohorts, although "single patients" had longer duration of in-hospital stays that trended toward significance (single 6.24 days vs married 4.53 days vs divorced/separated/widowed 4.55 days, P = .05). Thirty-day readmission rates were similar across all cohorts (married 7.03% vs divorced/separated/widowed 7.04% vs single 6.52%, P = .99). Additionally, there were no significant differences in baseline and 1-year patient reported outcomes measures between all groups. Increased social support did not appear to be associated with superior short and long-term clinical outcomes after spine surgery; however, it was associated with a shorter duration of in-hospital stay with no increase in 30-day readmission rates.

49 CFR 572.115 - Lumbar spine and pelvis.

Code of Federal Regulations, 2010 CFR

2010-10-01

... 49 Transportation 7 2010-10-01 2010-10-01 false Lumbar spine and pelvis. 572.115 Section 572.115... 50th Percentile Male § 572.115 Lumbar spine and pelvis. The specifications and test procedure for the lumbar spine and pelvis are identical to those for the SID dummy as set forth in § 572.42 except that the...

49 CFR 572.115 - Lumbar spine and pelvis.

Code of Federal Regulations, 2014 CFR

2014-10-01

... 49 Transportation 7 2014-10-01 2014-10-01 false Lumbar spine and pelvis. 572.115 Section 572.115... 50th Percentile Male § 572.115 Lumbar spine and pelvis. The specifications and test procedure for the lumbar spine and pelvis are identical to those for the SID dummy as set forth in § 572.42 except that the...

49 CFR 572.115 - Lumbar spine and pelvis.

Code of Federal Regulations, 2011 CFR

2011-10-01

... 49 Transportation 7 2011-10-01 2011-10-01 false Lumbar spine and pelvis. 572.115 Section 572.115... 50th Percentile Male § 572.115 Lumbar spine and pelvis. The specifications and test procedure for the lumbar spine and pelvis are identical to those for the SID dummy as set forth in § 572.42 except that the...

49 CFR 572.115 - Lumbar spine and pelvis.

Code of Federal Regulations, 2012 CFR

2012-10-01

... 49 Transportation 7 2012-10-01 2012-10-01 false Lumbar spine and pelvis. 572.115 Section 572.115... 50th Percentile Male § 572.115 Lumbar spine and pelvis. The specifications and test procedure for the lumbar spine and pelvis are identical to those for the SID dummy as set forth in § 572.42 except that the...

49 CFR 572.115 - Lumbar spine and pelvis.

Code of Federal Regulations, 2013 CFR

2013-10-01

... 49 Transportation 7 2013-10-01 2013-10-01 false Lumbar spine and pelvis. 572.115 Section 572.115... 50th Percentile Male § 572.115 Lumbar spine and pelvis. The specifications and test procedure for the lumbar spine and pelvis are identical to those for the SID dummy as set forth in § 572.42 except that the...

Developments in ambulatory surgery in orthopedics in France in 2016.

PubMed

Hulet, C; Rochcongar, G; Court, C

2017-02-01

Under the new categorization introduced by the Health Authorities, ambulatory surgery (AS) in France now accounts for 50% of procedures, taking all surgical specialties together. The replacement of full hospital admission by AS is now well established and recognized. Health-care centers have learned, in coordination with the medico-surgical and paramedical teams, how to set up AS units and the corresponding clinical pathways. There is no single model handed down from above. The authorities have encouraged these developments, partly by regulations but also by means of financial incentives. Patient eligibility and psychosocial criteria are crucial determining factors for the success of the AS strategy. The surgeons involved are strongly committed. Feedback from many orthopedic subspecialties (shoulder, foot, knee, spine, hand, large joints, emergency and pediatric surgery) testify to the rise of AS, which now accounts for 41% of all orthopedic procedures. Questions remain, however, concerning the role of the GP in the continuity of care, the role of innovation and teaching, the creation of new jobs, and the attractiveness of AS for surgeons. More than ever, it is the patient who is "ambulatory", within an organized structure in which surgical technique and pain management are well controlled. Not all patients can be eligible, but the AS concept is becoming standard, and overnight stay will become a matter for medical and surgical prescription. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

A Systematic Review of the Semi-Sitting Position in Neurosurgical Patients with Patent Foramen Ovale - How Frequent is Paradoxical Embolism?

PubMed

Klein, Johann; Juratli, Tareq A; Weise, Matthias; Schackert, Gabriele

2018-04-25

The semi-sitting position is preferred in some surgeries of the posterior fossa and the cervical spine. At the same time, it is associated with the risk of air embolism. In the presence of a patent foramen ovale (PFO) with intracardial right-to-left shunt, an air embolism can result in a paradoxical embolism to the heart or brain. It is unclear whether the risk-benefit ratio favors the semi-sitting position in this scenario. Therefore, we conducted a systematic review of the relevant studies published after 2007 by searching the databases PubMed, Science Direct and the Cochrane Database of Systematic Reviews for relevant articles. Studies were included in the analysis if the presence of PFO was stated and if the occurrence of paradoxical embolism was evaluated in patients who underwent neurosurgical procedures in the semi-sitting position. We identified four observational studies with a total of 977 patients who underwent surgery of the posterior fossa or cervical spine in the semi-sitting position; among them, 82 had a PFO. In 33 of these patients (40.2%) air embolism occurred. No paradoxical embolism was detected. In experienced medical centers, neurosurgery in the semi-sitting position is feasible with acceptable risk even in patients with PFO. If the PFO is large or a permanent right-to-left shunt is present in a patient with a history of paradoxical embolism, it may be reasonable to repair the PFO before surgery if the semi-sitting position is strongly preferred. The risk analysis must be made on a case-by-case basis. Copyright © 2018 Elsevier Inc. All rights reserved.

A survey on patients' knowledge and expectations during informed consent for spinal surgery: can we improve the shared decision-making process?

PubMed

Weckbach, Sebastian; Kocak, Tugrul; Reichel, Heiko; Lattig, Friederike

2016-01-01

The informed medical consent in surgery requires to some point basic medical knowledge. The treating physicians while explaining the details and risks of the recommended procedure often imply this. We hypothesized, that patients do not have adequate medical understanding to decide about the ongoing therapy and its potential complications based on knowledge jeopardizing the patients' safety. We conducted a retrospective analysis of a prospective database using a multiple choice questionnaire with 10 basic questions about anatomy, clinical symptoms and therapies of spinal diseases in our spine clinic at a German university hospital. Included were all patients at the spine clinic who agreed to the study and to fill in the questionnaire. Furthermore the patients age, mother tongue, the past spinal surgical history, the length of duration of symptoms and the patients education were inquired. The data were analyzed descriptive. Included were 248 patients with an average age of 59 years (16-88 a). 70 % of all patients used German as their mother tongue. 30 % of the included patients already had spinal surgery and suffered on average for 13.4 years because of their spinal disorder. Overall 32.6 % of all questions were answered correctly (range 0.8-68 %). A correlation of correctly answered questions and the patients' age, duration of symptoms, mother tongue, education and past surgical history could not be described. The percentage of correctly answered questions is almost as low as the likelihood of nearness in guessing. Having this in mind the patients do not choose any treatment option based on knowledge. The physicians need to provide more basic knowledge to the patients. This would increase the amount of successful therapies, content patients and the patients safety.

Individualized 3D printing navigation template for pedicle screw fixation in upper cervical spine

PubMed Central

Guo, Fei; Dai, Jianhao; Zhang, Junxiang; Ma, Yichuan; Zhu, Guanghui; Shen, Junjie; Niu, Guoqi

2017-01-01

Purpose Pedicle screw fixation in the upper cervical spine is a difficult and high-risk procedure. The screw is difficult to place rapidly and accurately, and can lead to serious injury of spinal cord or vertebral artery. The aim of this study was to design an individualized 3D printing navigation template for pedicle screw fixation in the upper cervical spine. Methods Using CT thin slices data, we employed computer software to design the navigation template for pedicle screw fixation in the upper cervical spine (atlas and axis). The upper cervical spine models and navigation templates were produced by 3D printer with equal proportion, two sets for each case. In one set (Test group), pedicle screws fixation were guided by the navigation template; in the second set (Control group), the screws were fixed under fluoroscopy. According to the degree of pedicle cortex perforation and whether the screw needed to be refitted, the fixation effects were divided into 3 types: Type I, screw is fully located within the vertebral pedicle; Type II, degree of pedicle cortex perforation is <1 mm, but with good internal fixation stability and no need to renovate; Type III, degree of pedicle cortex perforation is >1 mm or with the poor internal fixation stability and in need of renovation. Type I and Type II were acceptable placements; Type III placements were unacceptable. Results A total of 19 upper cervical spine and 19 navigation templates were printed, and 37 pedicle screws were fixed in each group. Type I screw-placements in the test group totaled 32; Type II totaled 3; and Type III totaled 2; with an acceptable rate of 94.60%. Type I screw placements in the control group totaled 23; Type II totaled 3; and Type III totaled 11, with an acceptable rate of 70.27%. The acceptability rate in test group was higher than the rate in control group. The operation time and fluoroscopic frequency for each screw were decreased, compared with control group. Conclusion The individualized 3D printing navigation template for pedicle screw fixation is easy and safe, with a high success rate in the upper cervical spine surgery. PMID:28152039

Individualized 3D printing navigation template for pedicle screw fixation in upper cervical spine.

PubMed

Guo, Fei; Dai, Jianhao; Zhang, Junxiang; Ma, Yichuan; Zhu, Guanghui; Shen, Junjie; Niu, Guoqi

2017-01-01

Pedicle screw fixation in the upper cervical spine is a difficult and high-risk procedure. The screw is difficult to place rapidly and accurately, and can lead to serious injury of spinal cord or vertebral artery. The aim of this study was to design an individualized 3D printing navigation template for pedicle screw fixation in the upper cervical spine. Using CT thin slices data, we employed computer software to design the navigation template for pedicle screw fixation in the upper cervical spine (atlas and axis). The upper cervical spine models and navigation templates were produced by 3D printer with equal proportion, two sets for each case. In one set (Test group), pedicle screws fixation were guided by the navigation template; in the second set (Control group), the screws were fixed under fluoroscopy. According to the degree of pedicle cortex perforation and whether the screw needed to be refitted, the fixation effects were divided into 3 types: Type I, screw is fully located within the vertebral pedicle; Type II, degree of pedicle cortex perforation is <1 mm, but with good internal fixation stability and no need to renovate; Type III, degree of pedicle cortex perforation is >1 mm or with the poor internal fixation stability and in need of renovation. Type I and Type II were acceptable placements; Type III placements were unacceptable. A total of 19 upper cervical spine and 19 navigation templates were printed, and 37 pedicle screws were fixed in each group. Type I screw-placements in the test group totaled 32; Type II totaled 3; and Type III totaled 2; with an acceptable rate of 94.60%. Type I screw placements in the control group totaled 23; Type II totaled 3; and Type III totaled 11, with an acceptable rate of 70.27%. The acceptability rate in test group was higher than the rate in control group. The operation time and fluoroscopic frequency for each screw were decreased, compared with control group. The individualized 3D printing navigation template for pedicle screw fixation is easy and safe, with a high success rate in the upper cervical spine surgery.

Open MR imaging in spine surgery: experimental investigations and first clinical experiences.

PubMed

Verheyden, P; Katscher, S; Schulz, T; Schmidt, F; Josten, C

1999-01-01

The latest open MRI technology allows to perform open and closed surgical procedures under real-time imaging. Before performing spinal trauma surgery preclinical examinations had to be done to evaluate the artifacts caused by the implants. The MRT presented is a prototype developed by GE. Two vertically positioned magnetic coils are installed in an operation theater. By that means two surgeons are able to access the patient between the two coils. Numerous tests regarding the material of instruments and implants were necessary in advance. The specific size of the artifact depending on the pulse sequence and the positioning within the magnetic field had to be examined. The magnifying factors of the artifact in the spin echo sequence regarding titanium are between 1.7 and 3.2, depending on the direction of the magnetic vector. Regarding stainless steel they are between 8.4 and 8.5. In the gradient echo sequence the factors are between 7.5 and 7.7 for titanium and between 16.9 and 18.0 for stainless steel. The tip of an implant is imaged with an accuracy of 0 to 2 mm. Since September 1997 16 patients with unstable fractures of the thoracic and lumbar spine have been treated by dorsal instrumentation in the open MRI. Percutaneous insertion of the internal fixator has proven a successful minimally invasive procedure. The positioning of the screws in the pedicle is secure, the degree of indirect reduction of the posterior wall of the vertebral body can be imaged immediately. The diameter of the spinal canal can be determined in any plane. The open MRI has proven useful in orthopedic and trauma surgery. The size and configuration of the artifacts caused by instruments and implants is predictable. Therefore exact positioning of the implants is achieved more easily. Dorsal instrumentation of unstable thoracolumbar fractures with a percutaneous technique has turned out safe and less traumatic under MR-imaging. Real-time imaging of soft tissue and bone in any plane improves security for the patient and allows the surgeon to work less invasively and more precisely.

Multilevel 3D Printing Implant for Reconstructing Cervical Spine With Metastatic Papillary Thyroid Carcinoma.

PubMed

Li, Xiucan; Wang, Yiguo; Zhao, Yongfei; Liu, Jianheng; Xiao, Songhua; Mao, Keya

2017-11-15

MINI: A 3D printing technology is proposed for reconstructing multilevel cervical spine (C2-C4) after resection of metastatic papillary thyroid carcinoma. The personalized porous implant printed in Ti6AL4V provided excellent physicochemical properties and biological performance, including biocompatibility, osteogenic activity, and bone ingrowth effect. A unique case report. A three-dimensional (3D) printing technology is proposed for reconstructing multilevel cervical spine (C2-C4) after resection of metastatic papillary thyroid carcinoma in a middle-age female patient. Papillary thyroid carcinoma is a malignant neoplasm with a relatively favorable prognosis. A metastatic lesion in multilevel cervical spine (C2-C4) destroys neurological functions and causes local instability. Radical excision of the metastasis and reconstruction of the cervical vertebrae sequence conforms with therapeutic principles, whereas the special-shaped multilevel upper-cervical spine requires personalized implants. 3D printing is an additive manufacturing technology that produces personalized products by accurately layering material under digital model control via a computer. Reporting of this recent technology for reconstructing multilevel cervical spine (C2-C4) is rare in the literature. Anterior-posterior surgery was performed in one stage. Radical resection of the metastatic lesion (C2-C4) and thyroid gland, along with insertion of a personalized implant manufactured by 3D printing technology, were performed to rebuild the cervical spine sequences. The porous implant was printed in Ti6AL4V with perfect physicochemical properties and biological performance, such as biocompatibility and osteogenic activity. Finally, lateral mass screw fixation was performed via a posterior approach. Patient neurological function gradually improved after the surgery. The patient received 11/17 on the Japanese Orthopedic Association scale and ambulated with a personalized skull-neck-thorax orthosis on postoperative day 11. She received radioiodine I therapy. The plane x-rays and computed tomography revealed no implant displacement or subsidence at the 12-month follow-up mark. The presented case substantiates the use of 3D printing technology, which enables the personalization of products to solve unconventional problems in spinal surgery. 5.

Cerebrospinal fluid leaks following spinal surgery: use of fat grafts for prevention and repair. Technical note.

PubMed

Black, Perry

2002-03-01

Cerebrospinal fluid (CSF) leaks are relatively common following spinal surgery. A midline dural tear in the spine is readily repaired by direct application of sutures; however, far-lateral or ventral dural tears are problematic. Fat is an ideal sealant because it is impermeable to water. In this paper the author reports his experience with using fat grafts for the prevention or repair of CSF leaks and proposes a technique in which a large sheet of fat, harvested from the patient's subcutaneous layer, is used to cover not only the dural tear(s) but all of the exposed dura and is tucked into the lateral recess. This procedure prevents CSF from seeping around the fat, which may be tacked to the dura with a few sutures. Fibrin glue is spread on the surface of the fat and is further covered with Surgicel or Gelfoam. For ventral dural tears (associated with procedures in which disc material is excised), fat is packed into the disc space to seal off the ventral dural leak. Dural suture lines following spinal intradural exploration are prophylatically protected from CSF leakage in the same manner. With one exception, 27 dural tears noted during 1650 spinal procedures were successfully repaired using this technique. There was one case of postoperative CSF leakage in 140 cases in which intradural exploration for tumor or other lesions was undertaken. Both postoperative CSF leaks were controlled by applying additional skin sutures. The use of a fat graft is recommended as a rapid, effective means of prevention and repair of CSF leaks following spinal surgery.

Transoral robotic surgery of craniocervical junction and atlantoaxial spine: a cadaveric study.

PubMed

Lee, John Y K; O'Malley, Bert W; Newman, Jason G; Weinstein, Gregory S; Lega, Bradley; Diaz, Jason; Grady, M Sean

2010-01-01

The goal of this study was to determine the potential role and current limitations of the da Vinci surgical robot in transoral decompression of craniocervical junction (CCJ). The da Vinci Surgical System was used in 2 cadaver heads with neck and clavicles intact. Both neurosurgeons and otolaryngologists familiar with the open microscopic procedure, as well as the transoral robotic surgical procedure, undertook dissection and decompression of the CCJ. The robotic system provided superb illumination and 3D depth perception even several centimeters deep to the posterior oropharyngeal mucosa. The 30 degrees endoscope improved cephalad visualization, eliminating the need to split the soft palate for exposure of the lower clivus. The "intuitive" nature of the da Vinci surgical robot arms provided an advantage in allowing the ability to suture the dura mater in a deep, dark corridor. Because visualization was excellent, tremor-free closure was possible. The authors' findings suggest that transoral robotic surgery, with the da Vinci robot system, holds great potential for decompression of the CCJ as well as resection of both extra- and intradural tumors of this region. Further instrument development is necessary and continued investigation is warranted.

Predicting Likelihood of Surgery Prior to First Visit in Patients with Back and Lower Extremity Symptoms: A simple mathematical model based on over 8000 patients.

PubMed

Boden, Lauren M; Boden, Stephanie A; Premkumar, Ajay; Gottschalk, Michael B; Boden, Scott D

2018-02-09

Retrospective analysis of prospectively collected data. To create a data-driven triage system stratifying patients by likelihood of undergoing spinal surgery within one year of presentation. Low back pain (LBP) and radicular lower extremity (LE) symptoms are common musculoskeletal problems. There is currently no standard data-derived triage process based on information that can be obtained prior to the initial physician-patient encounter to direct patients to the optimal physician type. We analyzed patient-reported data from 8006 patients with a chief complaint of LBP and/or LE radicular symptoms who presented to surgeons at a large multidisciplinary spine center between September 1, 2005 and June 30, 2016. Univariate and multivariate analysis identified independent risk factors for undergoing spinal surgery within one year of initial visit. A model incorporating these risk factors was created using a random sample of 80% of the total patients in our cohort, and validated on the remaining 20%. The baseline one-year surgery rate within our cohort was 39% for all patients and 42% for patients with LE symptoms. Those identified as high likelihood by the center's existing triage process had a surgery rate of 45%. The new triage scoring system proposed in this study was able to identify a high likelihood group in which 58% underwent surgery, which is a 46% higher surgery rate than in non-triaged patients and a 29% improvement from our institution's existing triage system. The data-driven triage model and scoring system derived and validated in this study (Spine Surgery Likelihood model [SSL-11]), significantly improved existing processes in predicting the likelihood of undergoing spinal surgery within one year of initial presentation. This triage system will allow centers to more selectively screen for surgical candidates and more effectively direct patients to surgeons or non-operative spine specialists. 4.

Quality of life in preoperative patients with sacroiliac joint dysfunction is at least as depressed as in other lumbar spinal conditions.

PubMed

Cher, Daniel Joseph; Reckling, W Carlton

2015-01-01

Pain from the sacroiliac joint (SIJ) is an under-recognized cause of low back pain. The degree to which SIJ pain decreases quality of life has not been directly compared to other more familiar conditions of the lumbar spine. Multivariate regression analysis of individual patient data from two prospective multicenter clinical trials of SIJ fusion and three prospective multicenter clinical trials of surgical treatments for degenerative lumbar spine conditions. Controlling for baseline demographic parameters as well as a validated disability score, quality of life scores (EuroQOL 5-D and SF-36) were, in most cases, lower in the SIJ cohorts compared to the three other spine surgery cohorts. Patients with SIJ dysfunction considering surgery have decrements in quality of life as or more severe compared to patients with degenerative spondylolisthesis, spinal stenosis, and intervertebral disc herniation.

Spine surgeon's kinematics during discectomy, part II: operating table height and visualization methods, including microscope.

PubMed

Park, Jeong Yoon; Kim, Kyung Hyun; Kuh, Sung Uk; Chin, Dong Kyu; Kim, Keun Su; Cho, Yong Eun

2014-05-01

Surgeon spine angle during surgery was studied ergonomically and the kinematics of the surgeon's spine was related with musculoskeletal fatigue and pain. Spine angles varied depending on operation table height and visualization method, and in a previous paper we showed that the use of a loupe and a table height at the midpoint between the umbilicus and the sternum are optimal for reducing musculoskeletal loading. However, no studies have previously included a microscope as a possible visualization method. The objective of this study is to assess differences in surgeon spine angles depending on operating table height and visualization method, including microscope. We enrolled 18 experienced spine surgeons for this study, who each performed a discectomy using a spine surgery simulator. Three different methods were used to visualize the surgical field (naked eye, loupe, microscope) and three different operating table heights (anterior superior iliac spine, umbilicus, the midpoint between the umbilicus and the sternum) were studied. Whole spine angles were compared for three different views during the discectomy simulation: midline, ipsilateral, and contralateral. A 16-camera optoelectronic motion analysis system was used, and 16 markers were placed from the head to the pelvis. Lumbar lordosis, thoracic kyphosis, cervical lordosis, and occipital angle were compared between the different operating table heights and visualization methods as well as a natural standing position. Whole spine angles differed significantly depending on visualization method. All parameters were closer to natural standing values when discectomy was performed with a microscope, and there were no differences between the naked eye and the loupe. Whole spine angles were also found to differ from the natural standing position depending on operating table height, and became closer to natural standing position values as the operating table height increased, independent of the visualization method. When using a microscope, lumbar lordosis, thoracic kyphosis, and cervical lordosis showed no differences according to table heights above the umbilicus. This study suggests that the use of a microscope and a table height above the umbilicus are optimal for reducing surgeon musculoskeletal fatigue.

Comparative Cohort Study of Percutaneous Pedicle Screw Implantation without Versus with Navigation in Patients Undergoing Surgery for Degenerative Lumbar Disc Disease.

PubMed

Fomekong, Edward; Pierrard, Julien; Raftopoulos, Christian

2018-03-01

The major limitation of computer-based three-dimensional fluoroscopy is increased radiation exposure of patients and operating room staff. Combining spine navigation with intraoperative three-dimensional fluoroscopy (io3DF) can likely overcome this shortcoming, while increasing pedicle screw accuracy rate. We compared data from a cohort of patients undergoing lumbar percutaneous pedicle screw placement using io3DF alone or in combination with spine navigation. This study consisted of 168 patients who underwent percutaneous pedicle screw implantation between 2009 and 2016. The primary endpoint was to compare pedicle screw accuracy between the 2 groups. Secondary endpoints were to compare radiation exposure of patients and operating room staff, duration of surgery, and postoperative complications. In group 1, 438 screws were placed without navigation guidance; in group 2, 276 screws were placed with spine navigation. Mean patient age in both groups was 58.6 ± 14.1 years. The final pedicle accuracy rate was 97.9% in group 1 and 99.6% in group 2. Average radiation dose per patient was significantly larger in group 1 (571.9 mGym 2 ) than in group 2 (365.6 mGym 2 ) (P = 0.000088). Surgery duration and complication rate were not significantly different between the 2 groups (P > 0.05). io3DF with spine navigation minimized radiation exposure of patients and operating room staff and provided an excellent percutaneous pedicle screw accuracy rate with no permanent complications compared with io3DF alone. This setup is recommended, especially for patients with a complex degenerative spine condition. Copyright © 2017 Elsevier Inc. All rights reserved.

[Financing of inpatient orthopaedics and trauma surgery in the 2011 G-DRG System].

PubMed

Franz, D; Schemmann, F; Roeder, N; Siebert, H; Mahlke, L

2011-09-01

The German DRG system forms the basis for billing inpatient hospital services. It includes not only the case groups (G-DRGs), but also copayments. This paper analyses and evaluates the relevant developments of the 2011 G-DRG system for orthopaedics and traumatology from the medical and classificatory perspective. An analysis was performed of relevant diagnoses, medical procedures and G-DRGs in the 2010 and 2011 versions based on the publications of the German DRG Institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). A number of codes for surgical measures have been newly established or modified - above all in foot surgery, arthroscopic surgery and wound surgery. Here, the identification and the correct and performance-based mapping of complex and elaborate scenarios was again the focus of the restructuring of the G-DRG system. The G-DRG structure in orthopaedics and traumatology is changed, especially for polytraumata. The allocation of common cases with a standardized treatment pattern appears to be appropriate and the reimbursement adequate. For the less common and more complex cases the 2011 G-DRG system still shows need for further modification (e.g. polytraumata, joint replacement, spine surgery). The proper integration of the modified OPS classification for foot surgery to the appropriate G-DRGs will be essential to maintain the high quality of the reimbursement structure for the future.

Minimally invasive “separation surgery” plus adjuvant stereotactic radiotherapy in the management of spinal epidural metastases

PubMed Central

Turel, Mazda K; Kerolus, Mena G; O'Toole, John E

2017-01-01

Aim: This study aimed to describe the application of minimally invasive surgery (MIS) in separation surgery combined with postoperative stereotactic body radiation therapy (SBRT) in patients with symptomatic metastatic epidural spinal disease. Methods: Three techniques are described: (1) MIS posterior separation surgery alone, (2) MIS posterolateral separation surgery with percutaneous pedicle screw placement, and (3) MIS lateral corpectomy with percutaneous pedicle screw placement. Seven representative cases are presented in which the above techniques were applied and after which postoperative SBRT was performed. Results: The seven representative patients (3 male, 4 female) had a mean age of 54 years (range, 46–62 years). Two patients had a primary diagnosis of cholangiocarcinoma and in one patient each a diagnosis of breast, renal, lung adenocarcinoma, melanoma, and urothelial squamous cell carcinoma as their primary tumor. All patients had additional multiorgan disease apart from the metastatic spine involvement. Three patients underwent operations in the lumbar spine, two in the thoracic spine, and one in each of the thoraco-lumbar and lumbo-sacral spine. The average operating time was 149 ± 60.3 min (range, 90–240 min). The mean estimated blood loss was 188.8 cc. The mean length of stay in the hospital was 4 days (range, 3–7 days). There were no surgical complications. All patients received postoperative SBRT (typically 24 Gy in 3 fractions) at a mean of 43.2 days after surgery (range, 30–83). Conclusions: Early reports such as this suggest that MIS techniques can be successfully and safely applied in accomplishing “separation surgery” with adjuvant SBRT in the management of metastatic spinal disease. The potential advantages conferred by MIS techniques such as shortened hospital stay, decreased blood loss, reduced perioperative complications, and earlier initiation of adjuvant radiation are highly desirable in the treatment of this challenging patient population. PMID:28694595

Vertebral coplanar alignment: a standardized technique for three dimensional correction in scoliosis surgery: technical description and preliminary results in Lenke type 1 curves.

PubMed

Vallespir, Gabriel Pizà; Flores, Jesús Burgos; Trigueros, Ignacio Sanpera; Sierra, Eduardo Hevia; Fernández, Pedro Doménech; Olaverri, Juan Carlos Rodríguez; Alonso, Manuel García; Galea, Rafael Ramos; Francisco, Antonio Pérez; Rodríguez de Paz, Beatriz; Carbonell, Pedro Gutiérrez; Thomas, Javier Vicente; López, José Luís González; Paulino, José Ignacio Maruenda; Pitarque, Carlos Barrios; García, Oscar Riquelme

2008-06-15

Prospective multicentric study. To present the preliminary results of an innovative method for standardized correction of scoliosis, vertebral coplanar alignment (VCA), based on a novel concept: the relocation of vertebral axis in a single plane. Normal standing spine has no rotation in coronal or transverse planes, therefore X and Z axis of vertebrae are in the same plane: they are coplanar. VCA intends to relocate these axis in one plane, correcting rotation and translation, while X axis are returned to its normal posterior divergence in sagittal plane in thoracic spine. Twenty-five consecutive adolescent idiopathic scoliosis patients (Lenke type 1) underwent posterior surgery with segmental pedicle screw fixation. Slotted tubes were attached to convex side screws. Two longitudinal rods were inserted through the end of tubes. Then, they were separated along the slots, driving the tubes into one plane, making the axis of the vertebrae coplanar and thus correcting transverse rotation and coronal translation. To obtain kyphosis, distal ends of the tubes were spread in thoracic spine. Correction was maintained by locking a definitive rod in the concave side, then tubes were retrieved and the convex side rod, inserted and tightened. Correction was assessed on preoperative and postoperative full-spine standing radiograph. Vertebral rotation was measured on computed tomography-scan and magnetic resonance imaging. Preoperative average thoracic curves of 61 degrees were corrected to 16 degrees (73%). Preoperative average thoracolumbar curves of 39 degrees were corrected to 12 degrees (70%). Preoperative average thoracic apical rotation of 24 degrees was corrected to 11 degrees (56%). Preoperative average thoracic kyphosis of 18 degrees remained unchanged after surgery; however, no patients had kyphosis <10 degrees after surgery. Rib hump improved from 30 to 11 mm (65%). There were no perioperative complications. VCA provided excellent correction of coronal and transverse planes with normalization of thoracic kyphosis in Lenke type 1 adolescent idiopathic scoliosis surgery.

What you need to know about ossification of the posterior longitudinal ligament to optimize cervical spine surgery: A review

PubMed Central

Epstein, Nancy E.

2014-01-01

What are the risks, benefits, alternatives, and pitfalls for operating on cervical ossification of the posterior longitudinal ligament (OPLL)? To successfully diagnose OPLL, it is important to obtain Magnetic Resonance Images (MR). These studies, particularly the T2 weighted images, provide the best soft-tissue documentation of cord/root compression and intrinsic cord abnormalities (e.g. edema vs. myelomalacia) on sagittal, axial, and coronal views. Obtaining Computed Tomographic (CT) scans is also critical as they best demonstrate early OPLL, or hypertrophied posterior longitudinal ligament (HPLL: hypo-isodense with punctate ossification) or classic (frankly ossified) OPLL (hyperdense). Furthermore, CT scans reveal the “single layer” and “double layer” signs indicative of OPLL penetrating the dura. Documenting the full extent of OPLL with both MR and CT dictates whether anterior, posterior, or circumferential surgery is warranted. An adequate cervical lordosis allows for posterior cervical approaches (e.g. lamionplasty, laminectomy/fusion), which may facilitate addressing multiple levels while avoiding the risks of anterior procedures. However, without lordosis and with significant kyphosis, anterior surgery may be indicated. Rarely, this requires single/multilevel anterior cervical diskectomy/fusion (ACDF), as this approach typically fails to address retrovertebral OPLL; single or multilevel corpectomies are usually warranted. In short, successful OPLL surgery relies on careful patient selection (e.g. assess comorbidities), accurate MR/CT documentation of OPLL, and limiting the pros, cons, and complications of these complex procedures by choosing the optimal surgical approach. Performing OPLL surgery requires stringent anesthetic (awake intubation/positioning) and also the following intraoperative monitoring protocols: Somatosensory evoked potentials (SSEP), motor evoked potentials (MEP), and electromyography (EMG). PMID:24843819

Obstructive hydrocephalus as a result of giant cell tumor of the thoracic spine: A case report

PubMed Central

WEI, CHENG-YU; CHEN, SHUO-TSUNG; TAI, HSU-CHIH; WANG, WEN-BING; CHANG, CHI-CHU; WANG, YAO-CHIN; WEI, LI; KUNG, WOON-MAN

2016-01-01

Giant cell tumors (GCTs) are rare bone tumors that account for ~5% of all primary bone tumors. When GCTs occur in the spine, patients usually present with localized pain and neurological symptoms, such as radiating pain or hyperesthesia. In the current report, an unusual case of a GCT of the thoracic spine associated with hydrocephalus is described. A 48-year-old male presented with urinary retention, loss of sensation in the lower limbs and inability to walk. The patient eventually developed hydrocephalus combined with altered consciousness, indicated by an inability to follow simple commands. Magnetic resonance (MR) imaging demonstrated the presence of a soft tissue mass at the T2 level, and biopsy examination of the tissue confirmed that it was a GCT. The patient experienced a sudden loss of consciousness due to an acute episode of obstructive hydrocephalus. A ventriculoperitoneal shunting procedure was performed to treat the hydrocephalus, and the patient regained normal consciousness, although the paraplegia persisted. An MR examination performed 30 months following surgery demonstrated that the tumor size was stable, consistent with the slow growth that is characteristic of GCTs. Diagnosis of GCTs may be challenging, and relies on radiographic and histopathologic findings. Although rare, acute hydrocephalus as a result of GCTs should not be excluded from a differential diagnosis. PMID:26870164

Geographic variations in the cost of spine surgery.

PubMed

Goz, Vadim; Rane, Ajinkya; Abtahi, Amir M; Lawrence, Brandon D; Brodke, Darrel S; Spiker, William Ryan

2015-09-01

Retrospective review. To define the geographic variation in costs of anterior cervical discectomy and fusion (ACDF) and posterolateral fusion (PLF). ACDF and lumbar PLF are common procedures that are used in the treatment of spinal pathologies. To optimize value, both the benefits and costs of an intervention must be quantified. Data on costs are scarce in comparison with data on total charges. This study aims at defining the costs of ACDF and PLF and describing the geographic variation within the United States. Medicare Provider Utilization and Payment data were used to investigate the costs associated with ACDF, PLF, and total knee arthroplasty (TKA). Average total costs of the procedures were compared by state and geographic region. Combined professional and facility costs for a single-level ACDF had a national mean of $13,899. Total costs for a single-level PLF had a mean of $25,858. Total costs for a primary TKA had a national mean of $13,039. The cost increased to an average of $22,138 for TKA with major comorbidities. Analysis of geographic trends showed statistically significant differences in total costs of PLF, TKA, and TKA, with major complications or comorbidities between geographic regions (P < 0.01 for all). Three of the 4 procedures (PLF, TKA, and TKA with major complications or comorbidities) showed statistically significant variation in cost between geographic regions. The Midwest provided the lowest cost for all procedures. Similar geographic trends in the cost of spinal fusions and TKAs suggest that these trends may not be limited to spine-related procedures. Surgical costs were found to correlate with cost of living but were not associated with the population of the state. These data shed light on the actual cost of common surgical procedures throughout the United States and will allow further progress toward the development of cost-effective, value-driven care. 3.

Lumbar lateral shift in a patient with interspinous device implantation: a case report.

PubMed

Peterson, Seth; Hodges, Cheri

2016-09-01

Lumbar lateral shift (LLS) is a common clinical observation but has rarely been described in a patient with a history of lumbar surgery. The purpose of the current case report was to describe the use of the McKenzie Method of Mechanical Diagnosis and Therapy (MDT) in the multi-modal treatment of a patient with an LLS and a history of multiple surgical procedures in the lumbar spine, including interspinous process device (IPD) implantation. A 72-year-old female with chronic low back pain (LBP) and a surgical history in the lumbar spine was referred to physical therapy for radiating leg pain and presented with a right LLS. Her chief complaints included sitting for long periods, vacuuming and ascending stairs into her home. The patient was treated during eight visits over 30 days. Treatment interventions included manual shift correction, self-correction and management, joint mobilisation below the level of IPD implantation ,neurophysiology education, and development of a home exercise programme. At discharge, her leg pain was resolved and all goals had been met. The patient reported maintenance of gains at 6-month follow-up. Utilisation of the MDT approach, including LLS correction, produced positive outcomes in a complex patient with previous IPD implantation. Future research should investigate treatment and outcomes after invasive spinal procedures in similar patient populations to better inform clinical management. 4.

A novel use of the Spine Tango registry to evaluate selection bias in patient recruitment into clinical studies: an analysis of patients participating in the Lumbar Spinal Stenosis Outcome Study (LSOS).

PubMed

Becker, H-J; Nauer, S; Porchet, F; Kleinstück, F S; Haschtmann, D; Fekete, T F; Steurer, J; Mannion, A F

2017-02-01

Patients enrolled in clinical studies typically represent a sub-set of all who are eligible, and selection bias may compromise the generalizability of the findings. Using Registry data, we evaluated whether surgical patients recruited by one of the referring centres into the Lumbar Spinal Stenosis Outcome Study (LSOS; a large-scale, multicentre prospective observational study to determine the probability of clinical benefit after surgery) differed in any significant way from those who were eligible but not enrolled. Data were extracted for all patients with lumbar spinal stenosis registered in our in-house database (interfaced to Eurospine's Spine Tango Registry) from 2011 to 2013. Patient records and imaging were evaluated in relation to the admission criteria for LSOS to identify those who would have been eligible for participation but were not enrolled (non-LSOS). The Tango surgery data and Core Outcome Measures Index (COMI) data at baseline and 3 and 12 months after surgery were analysed to evaluate the factors associated with LSOS enrolment or not. 514 potentially eligible patients were identified, of which 94 (18%) were enrolled into LSOS (range 2-48% for the 6 spine surgeons involved in recruiting patients) and 420 (82%) were not; the vast majority of the latter were due to non-referral to the study by the surgeon, with only 5% actually refusing participation. There was no significant difference in gender, age, BMI, smoking status, or ASA score between the two groups (p ≥ 0.18). Baseline COMI was significantly (p = 0.002) worse in the non-LSOS group (7.4 ± 1.9) than the LSOS group (6.7 ± 1.9). There were no significant group differences in any Tango surgery parameters (additional spine patholothegies, operation time, blood loss, complications, etc.) although significantly more patients in the non-LSOS group had a fusion procedure (38 vs 18% in LSOS; p = 0.0004). Postoperatively, neither the COMI nor its subdomain scores differed significantly between the groups (p > 0.05). Multiple logistic regression revealed that worse baseline COMI (p = 0.021), surgeon (p = 0.003), and having fusion (p = 0.014) predicted non-enrolment in LSOS. A high proportion of eligible patients were not enrolled in the study. Non-enrolment was explained in part by the specific surgeon, worse baseline COMI status, and having a fusion. The findings may reflect a tendency of the referring surgeon not to overburden more disabled patients and those undergoing more extensive surgery with the commitments of a study. Beyond these factors, non-enrolment appeared to be somewhat arbitrary, and was likely related to surgeon forgetfulness, time constraints, and administrative errors. Researchers should be aware of potential selection bias in their clinical studies, measure it (where possible) and discuss its implications for the interpretation of the study's findings.

AN AUDIT OF THE CURRENT PRACTICES OF AIRWAY MANAGEMENT IN PATIENTS UNDERGOING SURGERY FOR ATLANTO-AXIAL DISLOCATION IN A SINGLE INSTITUTION.

PubMed

Redhu, Shruti; Radhakrishnan, M; Rao, G S Umamaheswara

2015-06-01

Patients with atlanto axial dislocation (AAD) undergo stabilisation procedures under general anesthesia. Airway management in these patients is difficult as cervical spine movements during laryngoscopy can worsen spinal cord damage. Though multiple airway devices are used to intubate the trachea of these patients, there is no evidence of superiority of one technique over another. This retrospective study was designed to audit the practice of airway management during surgery for AAD over a 5 year period, starting from 2006 till 2011. Patients' demographics, airway intervention techniques, types of surgical procedures, postoperative neurological and respiratory deterioration were recorded from the case files. Association between the types of airway interventions and the postoperative neurological and respiratory deterioration were analysed. One hundred and six patients underwent surgery for AAD during the study period. Sixty one percent of the patients were intubated with the help of a fiberoptic bronchoscope (FOB) and among them 15% received general anesthesia to facilitate FOB. Eighteen patients developed neurological deterioration and 15 patients developed respiratory weakness requiring ventilation postoperatively. Congenital AAD patients had higher chances for extubation at the end of surgery when intubated using FOB (p = 0.007). Among the AAD patients, female gender had significantly higher incidence of neurological deterioration compared to males. In the current audit, there was no correlation between the perioperative variables and postoperative respiratory and neurological deterioration. Most of the respiratory problems occurred between 2-5 postoperative days stressing the need for extended intensive postoperative monitoring of these patients.

Interventional spine and pain procedures in patients on antiplatelet and anticoagulant medications: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the European Society of Regional Anaesthesia and Pain Therapy, the American Academy of Pain Medicine, the International Neuromodulation Society, the North American Neuromodulation Society, and the World Institute of Pain.

PubMed

Narouze, Samer; Benzon, Honorio T; Provenzano, David A; Buvanendran, Asokumar; De Andres, José; Deer, Timothy R; Rauck, Richard; Huntoon, Marc A

2015-01-01

Interventional spine and pain procedures cover a far broader spectrum than those for regional anesthesia, reflecting diverse targets and goals. When surveyed, interventional pain and spine physicians attending the American Society of Regional Anesthesia and Pain Medicine (ASRA) 11th Annual Pain Medicine Meeting exhorted that existing ASRA guidelines for regional anesthesia in patients on antiplatelet and anticoagulant medications were insufficient for their needs. Those surveyed agreed that procedure-specific and patient-specific factors necessitated separate guidelines for pain and spine procedures. In response, ASRA formed a guidelines committee. After preliminary review of published complication reports and studies, committee members stratified interventional spine and pain procedures according to potential bleeding risk as low-, intermediate-, and high-risk procedures. The ASRA guidelines were deemed largely appropriate for the low- and intermediate-risk categories, but it was agreed that the high-risk targets required an intensive look at issues specific to patient safety and optimal outcomes in pain medicine. The latest evidence was sought through extensive database search strategies and the recommendations were evidence-based when available and pharmacology-driven otherwise. We could not provide strength and grading of these recommendations as there are not enough well-designed large studies concerning interventional pain procedures to support such grading. Although the guidelines could not always be based on randomized studies or on large numbers of patients from pooled databases, it is hoped that they will provide sound recommendations and the evidentiary basis for such recommendations.

Neurosurgeons in Japan Are Exclusively Brain Surgeons.

PubMed

Asamoto, Shunji

2017-03-01

In Japan, neurosurgeons have traditionally mainly treated brain diseases, with most cases involving the spine and spinal diseases historically being treated by orthopedists. Nowadays, spinal surgery is 1 of the many subspecialties in the neurosurgical field in Japan. Most patients with neurological deficits or suspected neurological diseases see board-certified neurosurgeons directly in Japan, not through referrals from family physicians or specialists in other fields. Problems originating in the spine and spinal cord have been overlooked or misdiagnosed in these situations. Neurosurgeons in Japan must rethink the educational program to include advanced trauma life support and spinal surgery. Copyright © 2016. Published by Elsevier Inc.

Defensive Medicine in U.S. Spine Neurosurgery.

PubMed

Din, Ryan S; Yan, Sandra C; Cote, David J; Acosta, Michael A; Smith, Timothy R

2017-02-01

Observational cross-sectional survey. To compare defensive practices of U.S. spine and nonspine neurosurgeons in the context of state medical liability risk. Defensive medicine is a commonly reported and costly phenomenon in neurosurgery. Although state liability risk is thought to contribute greatly to defensive practice, variation within neurosurgical specialties has not been well explored. A validated, online survey was sent via email to 3344 members of the American Board of Neurological Surgeons. The instrument contained eight question domains: surgeon characteristics, patient characteristics, practice type, insurance type, surgeon liability profile, basic surgeon reimbursement, surgeon perceptions of medical legal environment, and the practice of defensive medicine. The overall response rate was 30.6% (n = 1026), including 499 neurosurgeons performing mainly spine procedures (48.6%). Spine neurosurgeons had a similar average practice duration as nonspine neurosurgeons (16.6 vs 16.9 years, P = 0.64) and comparable lifetime case volume (4767 vs 4,703, P = 0.71). The average annual malpractice premium for spine neurosurgeons was similar to nonspine neurosurgeons ($104,480.52 vs $101,721.76, P = 0.60). On average, spine neurosurgeons had a significantly higher rate of ordering labs, medications, referrals, procedures, and imaging solely for liability concerns compared with nonspine neurosurgeons (89.2% vs 84.6%, P = 0.031). Multivariate analysis revealed that spine neurosurgeons were roughly 3 times more likely to practice defensively compared with nonspine neurosurgeons (odds ratio, OR = 2.9, P = 0.001) when controlling for high-risk procedures (OR = 7.8, P < 0.001), annual malpractice premium (OR = 3.3, P = 0.01), percentage of patients publicly insured (OR = 1.1, P = 0.80), malpractice claims in the last 3 years (OR = 1.13, P = 0.71), and state medical-legal environment (OR = 1.3, P = 0.37). State-based medical legal environment is not a significant driver of increased defensive medicine associated with neurosurgical spine procedures. 3.

Current Practices in Lumbar Surgery Perioperative Rehabilitation: A Scoping Review.

PubMed

Marchand, Andrée-Anne; O'Shaughnessy, Julie; Châtillon, Claude-Édouard; Sorra, Karin; Descarreaux, Martin

The objective of this review was to identify current practices and relevant patient-reported and objective outcome measures with regard to rehabilitation protocols directed at the lumbar spine in perioperative procedure settings in order to inform clinical practice and future research. A literature search was performed in MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), the Cochrane Central Register of Controlled Trials, PEDro (Physiotherapy Evidence Database), and PubMed using terms relevant to surgical interventions, rehabilitation, and the lumbar spine. Twenty-nine studies met the inclusion criteria, and 28 investigated postoperative forms of rehabilitation. Patient-reported outcomes typically used were pain and disability, although a wide range of objective measures based on physical capacities were often reported. Rehabilitation programs, for the most part, included some form of strengthening exercises alone or in combination with stabilization exercises, aerobic conditioning, stretching, or education. Despite most studies reporting statistically significant results between intervention groups, considering clinically significant improvement within intervention groups yielded a different portrait. A wide range of objective and subjective outcomes is used to document changes after active rehabilitation. Program components include both active and assisted interventions combined with various means of education and discussion. Multimodal rehabilitation protocols after lumbar surgery may be used to improve patient-reported and objective outcome measures such as pain, disability, and physical function. Further research should be conducted on the effects of preoperative rehabilitation programs. Copyright © 2016. Published by Elsevier Inc.

The impact of spine stability on cervical spinal cord injury with respect to demographics, management, and outcome: a prospective cohort from a national spinal cord injury registry.

PubMed

Paquet, Jérôme; Rivers, Carly S; Kurban, Dilnur; Finkelstein, Joel; Tee, Jin W; Noonan, Vanessa K; Kwon, Brian K; Hurlbert, R John; Christie, Sean; Tsai, Eve C; Ahn, Henry; Drew, Brian; Bailey, Christopher S; Fourney, Daryl R; Attabib, Najmedden; Johnson, Michael G; Fehlings, Michael G; Parent, Stefan; Dvorak, Marcel F

2018-01-01

Emergent surgery for patients with a traumatic spinal cord injury (SCI) is seen as the gold standard in acute management. However, optimal treatment for those with the clinical diagnosis of central cord syndrome (CCS) is less clear, and classic definitions of CCS do not identify a unique population of patients. The study aimed to test the authors' hypothesis that spine stability can identify a unique group of patients with regard to demographics, management, and outcomes, which classic CCS definitions do not. This is a prospective observational study. The sample included participants with cervical SCI included in a prospective Canadian registry. The outcome measures were initial hospitalization length of stay, change in total motor score from admission to discharge, and in-hospital mortality. Patients with cervical SCI from a prospective Canadian SCI registry were grouped into stable and unstable spine cohorts. Bivariate analyses were used to identify differences in demographic, injury, management, and outcomes. Multivariate analysis was used to better understand the impact of spine stability on motor score improvement. No conflicts of interest were identified. Compared with those with an unstable spine, patients with cervical SCI and a stable spine were older (58.8 vs. 44.1 years, p<.0001), more likely male (86.4% vs. 76.1%, p=.0059), and have more medical comorbidities. Patients with stable spine cervical SCI were more likely to have sustained their injury by a fall (67.4% vs. 34.9%, p<.0001), and have high cervical (C1-C4; 58.5% vs. 43.3%, p=.0009) and less severe neurologic injuries (ASIA Impairment Scale C or D; 81.3% vs. 47.5%, p<.0001). Those with stable spine injuries were less likely to have surgery (67.6% vs. 92.6%, p<.0001), had shorter in-hospital lengths of stay (median 84.0 vs. 100.5 days, p=.0062), and higher total motor score change (20.7 vs. 19.4 points, p=.0014). Multivariate modeling revealed that neurologic severity of injury and spine stability were significantly related to motor score improvement; patients with stable spine injuries had more motor score improvement. We propose that classification of stable cervical SCI is more clinically relevant than classic CCS classification as this group was found to be unique with regard to demographics, neurologic injury, management, and outcome, whereas classic CCS classifications do not . This classification can be used to assess optimal management in patients where it is less clear if and when surgery should be performed. Copyright © 2017 Elsevier Inc. All rights reserved.

Bilateral sagittal split mandibular osteotomies for enhanced exposure of the anterior cervical spine in children: technical note.

PubMed

Karsy, Michael; Moores, Neal; Siddiqi, Faizi; Brockmeyer, Douglas L; Bollo, Robert J

2017-04-01

The bilateral sagittal split mandibular osteotomy (BSSMO), a common maxillofacial technique for expanding the oropharynx during treatment of micrognathia, is a rarely employed but useful adjunct to improve surgical access to the ventral cervical spine in children. Specifically, it provides enhanced exposure of the craniocervical junction in the context of midface hypoplasia, and of the subaxial cervical spine in children with severe kyphosis. The authors describe their technique for BSSMO and evaluate long-term outcomes in patients. The pediatric neurosurgical database at a single center was queried to identify children who underwent BSSMO as an adjunct to cervical spine surgery over a 22-year study period (1993-2015). The authors retrospectively reviewed clinical and radiographic data in all patients. The authors identified 5 children (mean age 5.3 ± 3.1 years, range 2.1-10.0 years) who underwent BSSMO during cervical spine surgery. The mean clinical follow-up was 3.0 ± 1.9 years. In 4 children, BSSMO was used to increase the size of the oropharynx and facilitate transoral resection of the odontoid and anterior decompression of the craniocervical junction. In 1 patient with subaxial kyphosis and chin-on-chest deformity, BSSMO was used to elevate the chin, improve anterior exposure of the subaxial cervical spine, and facilitate cervical corpectomy. Careful attention to neurovascular structures, including the inferior alveolar nerve, lingual nerve, and mental branch of the inferior alveolar artery, as well as minimizing tongue manipulation and compression, are critical to complication avoidance. The BSSMO is a rarely used but extremely versatile technique that significantly enhances anterior exposure of the craniocervical junction and subaxial cervical spine in children in whom adequate visualization of critical structures is not otherwise possible.

Reconstruction of Thoracic Spine Using a Personalized 3D-Printed Vertebral Body in Adolescent with T9 Primary Bone Tumor.

PubMed

Choy, Wen Jie; Mobbs, Ralph J; Wilcox, Ben; Phan, Steven; Phan, Kevin; Sutterlin, Chester E

2017-09-01

Neurosurgery and spine surgery have the potential to benefit from the use of 3-dimensional printing (3DP) technology due to complex anatomic considerations and the delicate nature of surrounding structures. We report a procedure that uses a 3D-printed titanium T9 vertebral body implant post T9 vertebrectomy for a primary bone tumor. A 14-year-old female presented with progressive kyphoscoliosis and a pathologic fracture of the T9 vertebra with sagittal and coronal deformity due to a destructive primary bone tumor. Surgical resection and reconstruction was performed in combination with a 3D-printed, patient-specific implant. Custom design features included porous titanium end plates, corrective angulation of the implant to restore sagittal balance, and pedicle screw holes in the 3D implant to assist with insertion of the device. In addition, attachment of the anterior column construct to the posterior pedicle screw construct was possible due to the customized features of the patient-specific implant. An advantage of 3DP is the ability to manufacture patient-specific implants, as in the current case example. Additionally, the use of 3DP has been able to reduce operative time significantly. Surgical procedures can be preplanned using 3DP patient-specific models. Surgeons can train before performing complex procedures, which enhances their presurgical planning in order to maximize patient outcomes. When considering implants and prostheses, the use of 3DP allows a superior anatomic fit for the patient, with the potential to improve restoration of anatomy. Copyright © 2017 Elsevier Inc. All rights reserved.

Improved method for sectioning pectoral spines of catfish for age determination

USGS Publications Warehouse

Blouin, Marc A.; Hall, Glenda R.

1990-01-01

The advantages of this method are: (1) spine sections are clear, with uniform thickness and little tissue damage; (2) no time-consuming procedures are necessary; (3) the original spine remains intact for future sectioning; and (4) the thick, single blade does not warp.

Does Nasal Carriage of Staphylococcus aureus Increase the Risk of Postoperative Infections After Elective Spine Surgery: Do Most Infections Occur in Carriers?

PubMed

Adogwa, Owoicho; Vuong, Victoria D; Elsamadicy, Aladine A; Lilly, Daniel T; Desai, Shyam A; Khalid, Syed; Cheng, Joseph; Bagley, Carlos A

2018-05-14

Wound infections after adult spinal deformity surgery place a high toll on patients, providers, and the healthcare system. Staphylococcus aureus is a common cause of postoperative wound infections, and nasal colonization by this organism may be an important factor in the development of surgical site infections (SSIs). The aim is to investigate whether post-operative surgical site infections after elective spine surgery occur at a higher rate in patients with methicillin-resistant S. aureus (MRSA) nasal colonization. Consecutive patients undergoing adult spinal deformity surgery between 2011-2013 were enrolled. Enrolled patients were followed up for a minimum of 3 months after surgery and received similar peri-operative infection prophylaxis. Baseline characteristics, operative details, rates of wound infection, and microbiologic data for each case of post-operative infection were gathered by direct medical record review. Local vancomycin powder was used in all patients and sub-fascial drains were used in the majority (88%) of patients. 1200 operative spine cases were performed for deformity between 2011 and 2013. The mean ± standard deviation age and body mass index were 62.08 ± 14.76 years and 30.86 ± 7.15 kg/m 2 , respectively. 29.41% had a history of diabetes. All SSIs occurred within 30 days of surgery, with deep wound infections accounting for 50% of all SSIs. Of the 34 (2.83%) cases of SSIs that were identified, only 1 case occurred in a patient colonized with MRSA. Our study suggests that the preponderance of SSIs occurred in patients without nasal colonization by methicillin-resistant S. aureus. Future prospective multi-institutional studies are needed to corroborate our findings. Copyright © 2018 Elsevier Inc. All rights reserved.

The Influence of Pelvic Incidence and Lumbar Lordosis Mismatch on Development of Symptomatic Adjacent Level Disease Following Single-Level Transforaminal Lumbar Interbody Fusion.

PubMed

Tempel, Zachary J; Gandhoke, Gurpreet S; Bolinger, Bryan D; Khattar, Nicolas K; Parry, Philip V; Chang, Yue-Fang; Okonkwo, David O; Kanter, Adam S

2017-06-01

Annual incidence of symptomatic adjacent level disease (ALD) following lumbar fusion surgery ranges from 0.6% to 3.9% per year. Sagittal malalignment may contribute to the development of ALD. To describe the relationship between pelvic incidence-lumbar lordosis (PI-LL) mismatch and the development of symptomatic ALD requiring revision surgery following single-level transforaminal lumbar interbody fusion for degenerative lumbar spondylosis and/or low-grade spondylolisthesis. All patients who underwent a single-level transforaminal lumbar interbody fusion at either L4/5 or L5/S1 between July 2006 and December 2012 were analyzed for pre- and postoperative spinopelvic parameters. Using univariate and logistic regression analysis, we compared the spinopelvic parameters of those patients who required revision surgery against those patients who did not develop symptomatic ALD. We calculated the predictive value of PI-LL mismatch. One hundred fifty-nine patients met the inclusion criteria. The results noted that, for a 1° increase in PI-LL mismatch (preop and postop), the odds of developing ALD requiring surgery increased by 1.3 and 1.4 fold, respectively, which were statistically significant increases. Based on our analysis, a PI-LL mismatch of >11° had a positive predictive value of 75% for the development of symptomatic ALD requiring revision surgery. A high PI-LL mismatch is strongly associated with the development of symptomatic ALD requiring revision lumbar spine surgery. The development of ALD may represent a global disease process as opposed to a focal condition. Spine surgeons may wish to consider assessment of spinopelvic parameters in the evaluation of degenerative lumbar spine pathology. Copyright © 2017 by the Congress of Neurological Surgeons

Biomechanics of the lower thoracic spine after decompression and fusion: a cadaveric analysis.

PubMed

Lubelski, Daniel; Healy, Andrew T; Mageswaran, Prasath; Benzel, Edward C; Mroz, Thomas E

2014-09-01

Few studies have evaluated the extent of biomechanical destabilization of thoracic decompression on the upper and lower thoracic spine. The present study evaluates lower thoracic spinal stability after laminectomy, unilateral facetectomy, and unilateral costotransversectomy in thoracic spines with intact sternocostovertebral articulations. To assess the biomechanical impact of decompression and fixation procedures on lower thoracic spine stability. Biomechanical cadaveric study. Sequential surgical decompression (laminectomy, unilateral facetectomy, unilateral costotransversectomy) and dorsal fixation were performed on the lower thoracic spine (T8-T9) of human cadaveric spine specimens with intact rib cages (n=10). An industrial robot was used to apply pure moments to simulate flexion-extension (FE), lateral bending (LB), and axial rotation (AR) in the intact specimens and after decompression and fixation. Global range of motion (ROM) between T1-T12 and intrinsic ROM between T7-T11 were measured for each specimen. The decompression procedures caused no statistically significant change in either global or intrinsic ROM compared with the intact state. Instrumentation, however, reduced global motion for AR (45° vs. 30°, p=.0001), FE (24° vs. 19°, p=.02), and LB (47° vs. 36°, p=.0001) and for intrinsic motion for AR (17° vs. 4°, p=.0001), FE (8° vs. 1°, p=.0001), and LB (12° vs. 1°, p=.0001). No significant differences were identified between decompression of the upper versus lower thoracic spine, with trends toward significantly greater ROM for AR and lower ROM for LB in the lower thoracic spine. The lower thoracic spine was not destabilized by sequential unilateral decompression procedures. Addition of dorsal fixation increased segment rigidity at intrinsic levels and also reduced overall ROM of the lower thoracic spine to a greater extent than did fusing the upper thoracic spine (level of the true ribs). Despite the lack of true ribs, the lower thoracic spine was not significantly different compared with the upper thoracic spine in FE and LB after decompression, although there were trends toward significance for greater AR after decompression. In certain patients, instrumentation may not be needed after unilateral decompression of the lower thoracic spine; further validation and additional clinical studies are warranted. Copyright © 2014 Elsevier Inc. All rights reserved.

Cervical Spine Instrumentation in Children.

PubMed

Hedequist, Daniel J; Emans, John B

2016-06-01

Instrumentation of the cervical spine enhances stability and improves arthrodesis rates in children undergoing surgery for deformity or instability. Various morphologic and clinical studies have been conducted in children, confirming the feasibility of anterior or posterior instrumentation of the cervical spine with modern implants. Knowledge of the relevant spine anatomy and preoperative imaging studies can aid the clinician in understanding the pitfalls of instrumentation for each patient. Preoperative planning, intraoperative positioning, and adherence to strict surgical techniques are required given the small size of children. Instrumentation options include anterior plating, occipital plating, and a variety of posterior screw techniques. Complications related to screw malposition include injury to the vertebral artery, neurologic injury, and instrumentation failure.

Perioperative Blood Management in Pediatric Spine Surgery.

PubMed

Oetgen, Matthew E; Litrenta, Jody

2017-07-01

Blood management strategies are integral to successful outcomes in many types of orthopaedic surgery. These strategies minimize blood loss and transfusion requirements, ultimately decreasing complications, improving outcomes, and potentially eliminating risks associated with allogeneic transfusion. Practices to achieve these goals include preoperative evaluation and optimization of hemoglobin, the use of pharmacologic agents or anesthetic methods, intraoperative techniques to improve hemostasis and cell salvage, and the use of predonated autologous blood. Guidelines can also help manage allogeneic transfusions in the perioperative period. Although the literature on blood management has focused primarily on arthroplasty and adult spine surgery, pediatric spinal fusion for scoliosis involves a large group of patients with a specific set of risk factors for transfusion and distinct perioperative considerations. A thorough understanding of blood management techniques will improve surgical planning, limit transfusion-associated risks, maintain hemostasis, and optimize outcomes in this pediatric population.

Patient-reported allergies predict postoperative outcomes and psychosomatic markers following spine surgery.

PubMed

Xiong, David D; Ye, Wenda; Xiao, Roy; Miller, Jacob A; Mroz, Thomas E; Steinmetz, Michael P; Nagel, Sean J; Machado, Andre G

2018-05-22

Prior studies have shown that patient-reported allergies can be prognostic of poorer postoperative outcomes. To investigate the correlation between self-reported allergies and outcomes after cervical or lumbar spine surgery. Retrospective cohort study at a single tertiary-care institution. All patients undergoing cervical or lumbar spine surgery from 2009-2014. The primary outcome measure was change in the EuroQol-5 Dimensions (EQ-5D) following surgery. Secondary outcomes included change in the Pain Disability Questionnaire (PDQ) and Patient Health Questionnaire-9 (PHQ-9), achieving the minimal clinically important difference (MCID) in these measures, as well as cost of admission. Prior to and following surgery, EQ-5D, PDQ, and PHQ-9 were recorded for patients with available data. Paired student's t-tests were used to compare change in these measures following surgery. Multivariable linear and logistic regression were used to assess the relationship between the log transformation of the total number of allergies and outcomes. 592 cervical patients and 4,465 lumbar patients were included. The median number of reported allergies was two. The EQ-5D index increased from 0.539 to 0.703 for cervical patients and from 0.530 to 0.676 for lumbar patients (p<0.01 for both). Patients experienced significant pain improvement by the PDQ (80.1 to 58.2 for cervical patients, 79.4 to 58.1 for lumbar patients; p<0.01). Using multivariable logistic regression, the log transformation of number of allergies predicted significantly higher odds of achieving the PDQ MCID (OR = 2.09, 95% CI 1.05-4.15, p=0.02 for cervical patients; OR = 1.30, 95% CI 1.03-1.68, p=0.03 for lumbar patients). However, this relationship was not durable for patients with follow-up exceeding 1 year. The log transformation of number of allergies for lumbar patients predicted significantly increased cost of admission (β=$3,597, p<0.01) and trended towards significance among cervical patients (β=$1,842, p=0.10). Patient-reported allergies correlate with subjective improvement in pain and disability following spine surgery and may serve as a marker of postoperative outcomes. The relationship between allergies and PDQ improvement may be secondary to the short-term expectation-actuality discrepancy, as this relationship was not durable beyond 1 year. Copyright © 2018 Elsevier Inc. All rights reserved.

Geriatric comanagement reduces perioperative complications and shortens duration of hospital stay after lumbar spine surgery: a prospective single-institution experience.

PubMed

Adogwa, Owoicho; Elsamadicy, Aladine A; Vuong, Victoria D; Moreno, Jessica; Cheng, Joseph; Karikari, Isaac O; Bagley, Carlos A

2017-12-01

OBJECTIVE Geriatric patients undergoing lumbar spine surgery have unique needs due to the physiological changes of aging. They are at risk for adverse outcomes such as delirium, infection, and iatrogenic complications, and these complications, in turn, contribute to the risk of functional decline, nursing home admission, and death. Whether preoperative and perioperative comanagement by a geriatrician reduces the incidence of in-hospital complications and length of in-hospital stay after elective lumbar spine surgery remains unknown. METHODS A unique model of comanagement for elderly patients undergoing lumbar fusion surgery was implemented at a major academic medical center. The Perioperative Optimization of Senior Health (POSH) program was launched with the aim of improving outcomes in elderly patients (> 65 years old) undergoing complex lumbar spine surgery. In this model, a geriatrician evaluates elderly patients preoperatively, in addition to performing routine preoperative anesthesia surgical screening, and comanages them daily throughout the course of their hospital stay to manage medical comorbid conditions and coordinate multidisciplinary rehabilitation along with the neurosurgical team. The first 100 cases were retrospectively reviewed after initiation of the POSH protocol and compared with the immediately preceding 25 cases to assess the incidence of perioperative complications and clinical outcomes. RESULTS One hundred twenty-five patients undergoing lumbar decompression and fusion were enrolled in this pilot program. Baseline characteristics were similar between both cohorts. The mean length of in-hospital stay was 30% shorter in the POSH cohort (6.13 vs 8.72 days; p = 0.06). The mean duration of time between surgery and patient mobilization was significantly shorter in the POSH cohort compared with the non-POSH cohort (1.57 days vs 2.77 days; p = 0.02), and the number of steps ambulated on day of discharge was 2-fold higher in the POSH cohort (p = 0.04). Compared with the non-POSH cohort, the majority of patients in the POSH cohort were discharged to home (24% vs 54%; p = 0.01). CONCLUSIONS Geriatric comanagement reduces the incidence of postoperative complications, shortens the duration of in-hospital stay, and contributes to improved perioperative functional status in elderly patients undergoing elective spinal surgery for the correction of adult degenerative scoliosis.

Adverse Outcomes After Palliative Radiation Therapy for Uncomplicated Spine Metastases: Role of Spinal Instability and Single-Fraction Radiation Therapy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lam, Tai-Chung, E-mail: lamtaichung@gmail.com; Uno, Hajime; Krishnan, Monica

2015-10-01

Purpose: Level I evidence demonstrates equivalent pain response after single-fraction (SF) or multifraction (MF) radiation therapy (RT) for bone metastases. The purpose of this study is to provide additional data to inform the incidence and predictors of adverse outcomes after RT for spine metastases. Methods and Materials: At a single institution, 299 uncomplicated spine metastases (without cord compression, prior RT, or surgery) treated with RT from 2008 to 2013 were retrospectively reviewed. The spinal instability neoplastic score (SINS) was used to assess spinal instability. The primary outcome was time to first spinal adverse event (SAE) at the site, including symptomaticmore » vertebral fracture, hospitalization for site-related pain, salvage surgery, interventional procedure, new neurologic symptoms, or cord compression. Fine and Gray's multivariable model assessed associations of the primary outcome with SINS, SF RT, and other significant baseline factors. Propensity score matched analysis further assessed the relationship of SF RT to first SAEs. Results: The cumulative incidence of first SAE after SF RT (n=66) was 6.8% at 30 days, 16.9% at 90 days, and 23.6% at 180 days. For MF RT (n=233), the incidence was 3.5%, 6.4%, and 9.2%, respectively. In multivariable analysis, SF RT (hazard ratio [HR] = 2.8, 95% confidence interval [CI] 1.5-5.2, P=.001) and SINS ≥11 (HR=2.5 , 95% CI 1.3-4.9, P=.007) were predictors of the incidence of first SAE. In propensity score matched analysis, first SAEs had developed in 22% of patients with SF RT versus 6% of those with MF RT cases (HR=3.9, 95% CI 1.6-9.6, P=.003) at 90 days after RT. Conclusion: In uncomplicated spinal metastases treated with RT alone, spinal instability with SINS ≥11 and SF RT were associated with a higher rate of SAEs.« less

Exploring the role of 3-dimensional simulation in surgical training: feedback from a pilot study.

PubMed

Podolsky, Dale J; Martin, Allan R; Whyne, Cari M; Massicotte, Eric M; Hardisty, Michael R; Ginsberg, Howard J

2010-12-01

Randomized control study assessing the efficacy of a pedicle screw insertion simulator. To evaluate the efficacy of an in-house developed 3-dimensional software simulation tool for teaching pedicle screw insertion, to gather feedback about the utility of the simulator, and to help identify the context and role such simulation has in surgical education. Traditional instruction for pedicle screw insertion technique consists of didactic teaching and limited hands-on training on artificial or cadaveric models before guided supervision within the operating room. Three-dimensional computer simulation can provide a valuable tool for practicing challenging surgical procedures; however, its potential lies in its effective integration into student learning. Surgical residents were recruited from 2 sequential years of a spine surgery course. Patient and control groups both received standard training on pedicle screw insertion. The patient group received an additional 1-hour session of training on the simulator using a CT-based 3-dimensional model of their assigned cadaver's spine. Qualitative feedback about the simulator was gathered from the trainees, fellows, and staff surgeons, and all pedicles screws physically inserted into the cadavers during the courses were evaluated through CT. A total of 185 thoracic and lumbar pedicle screws were inserted by 37 trainees. Eighty-two percent of the 28 trainees who responded to the questionnaire and all fellows and staff surgeons felt the simulator to be a beneficial educational tool. However, the 1-hour training session did not yield improved performance in screw placement. A 3-dimensional computer-based simulation for pedicle screw insertion was integrated into a cadaveric spine surgery instructional course. Overall, the tool was positively regarded by the trainees, fellows, and staff surgeons. However, the limited training with the simulator did not translate into widespread comfort with its operation or into improvement in physical screw placement.

Association between Asymptomatic Urinary Tract Infection and Postoperative Spine Infection in Elderly Women : A Retrospective Analysis Study

PubMed Central

Lee, Seung-Eun; Park, Yong-Sook; Kim, Young-Baeg

2010-01-01

Objective The purpose of this study is to identify the relationship between asymptomatic urinary tract infection (aUTI) and postoperative spine infection. Methods A retrospective review was done in 355 women more than 65 years old who had undergone laminectomy and/or discectomy, and spinal fusion, between January 2004 and December 2008. Previously postulated risk factors (i.e., instrumentation, diabetes, prior corticosteroid therapy, previous spinal surgery, and smoking) were investigated. Furthermore, we added aUTI that was not previously considered. Results Among 355 patients, 42 met the criteria for aUTI (Bacteriuria ≥ 105 CFU/mL and no associated symptoms). A postoperative spine infection was evident in 15 of 355 patients. Of the previously described risk factors, multi-levels (p < 0.05), instrumentation (p < 0.05) and diabetes (p < 0.05) were proven risk factors, whereas aUTI (p > 0.05) was not statistically significant. However, aUTI with Foley catheterization was statistically significant when Foley catheterization was added as a variable to the all existing risk factors. Conclusion aUTI is not rare in elderly women admitted to the hospital for lumbar spine surgery. The results of this study suggest that aUTI with Foley catheterization may be considered a risk factor for postoperative spine infection in elderly women. Therefore, we would consider treating aUTI before operating on elderly women who will need Foley catheterization. PMID:20461166

Complete segmental resection of the spine, including the spinal cord, for telangiectatic osteosarcoma: a report of 2 cases.

PubMed

Murakami, Hideki; Tomita, Katsuro; Kawahara, Norio; Oda, Makoto; Yahata, Tetsutaro; Yamaguchi, Takehiko

2006-02-15

Two case reports of telangiectatic osteosarcoma treated with complete segmental resection of the spine, including the spinal cord. To report the en bloc tumor excision, including the spinal cord, for telangiectatic osteosarcoma, and discuss the indication of cord transection and influence after cutting the spinal cord. To our knowledge, there are no previous reports describing telangiectatic osteosarcoma of the spine and the subsequent en bloc excision of the spine, including the spinal cord. The clinical and radiographic presentations of 2 cases with telangiectatic osteosarcoma are presented. Because these 2 cases already had complete paralysis for at least 1 month, it was suspected that there was no possibility of recovering spinal cord function. Complete segmental spinal resection (total en bloc spondylectomy) was performed. At that level, the spinal cord was also cut and resected. En bloc excision of the tumor with a wide margin was achieved in both cases. In the resected specimen, the nerve cells in the spinal cord had lapsed into degenerative necrosis. The pathologic findings showed that there was no hope for recovery of spinal cord function. En bloc spinal resection, including the spinal cord, is an operation allowed when there is no hope for recovery of spinal cord function. This surgery should be accepted as an option in spine tumor surgeries.

Risk Factors for Low Back Pain and Spine Surgery: A Retrospective Cohort Study in Soldiers.

PubMed

Kardouni, Joseph R; Shing, Tracie L; Rhon, Daniel I

2016-11-01

Musculoskeletal low back pain (LBP) is commonly treated symptomatically, with practice guidelines advocating reserving surgery for cases that fail conservative care. This study examined medical comorbidities and demographic variables as risk factors for chronic/recurrent LBP, spinal surgery, and time to surgery. A 2015 retrospective cohort study was conducted in U.S. Army soldiers (N=1,092,420) from 2002 to 2011. Soldiers with medical encounters for LBP were identified using ICD-9 codes. Surgical treatment for LBP was identified according to Current Procedural Terminology codes. Comorbid medical conditions (psychological disorders, sleep disorders, tobacco use, alcohol use, obesity) and demographic variables were examined as risk factors for chronic/recurrent LBP within 1 year of the incident encounter, surgery for LBP, and time to surgery. Of 383,586 patients with incident LBP, 104,169 (27%) were treated for chronic/recurrent LBP and 7,446 (1.9%) had surgery. Comorbid variables showed increased risk of chronic/recurrent LBP ranging from 26% to 52%. Tobacco use increased risk for surgery by 33% (risk ratio, 1.33; 95% CI=1.24, 1.44). Comorbid variables showed 10%-42% shorter time to surgery (psychological disorders, time ratio [TR]=0.90, 95% CI=0.83, 0.98; sleep disorders, TR=0.68, 95% CI=0.60, 0.78; obesity, TR=0.88, 95% CI=0.79, 0.98; tobacco use, TR=0.58, 95% CI=0.54, 0.63; alcohol use, TR=0.85, 95% CI=0.70, 1.05). Women showed 20% increased risk of chronic/recurrent LBP than men but 42% less risk of surgery. In the presence of comorbidities associated with mental health, sleep, obesity, tobacco use, and alcohol use, LBP shows increased risk of becoming chronic/recurrent and faster time to surgery. Published by Elsevier Inc.

Complications Related to the Recombinant Human Bone Morphogenetic Protein 2 Use in Posterior Cervical Fusion.

PubMed

Takahashi, Shinji; Buser, Zorica; Cohen, Jeremiah R; Roe, Allison; Myhre, Sue L; Meisel, Hans-Joerg; Brodke, Darrel S; Yoon, S Tim; Park, Jong-Beom; Wang, Jeffrey C; Youssef, Jim A

2017-11-01

A retrospective cohort study. To compare the complications between posterior cervical fusions with and without recombinant human bone morphogenetic protein 2 (rhBMP2). Use of rhBMP2 in anterior cervical spinal fusion procedures can lead to potential complications such as neck edema, resulting in airway complications or neurological compression. However, there are no data on the complications associated with the "off-label" use of rhBMP2 in upper and lower posterior cervical fusion approaches. Patients from the PearlDiver database who had a posterior cervical fusion between 2005 and 2011 were identified. We evaluated complications within 90 days after fusion and data was divided in 2 groups: (1) posterior cervical fusion including upper cervical spine O-C2 (upper group) and (2) posterior cervical fusion including lower cervical spine C3-C7 (lower group). Complications were divided into: any complication, neck-related complications, wound-related complications, and other complications. Of the 352 patients in the upper group, 73 patients (20.7%) received rhBMP2, and 279 patients (79.3%) did not. Likewise, in the lower group of 2372 patients, 378 patients (15.9%) had surgery with rhBMP2 and 1994 patients (84.1%) without. In the upper group, complications were observed in 7 patients (9.6%) with and 34 patients (12%) without rhBMP2. In the lower group, complications were observed in 42 patients (11%) with and 276 patients (14%) without rhBMP2. Furthermore, in the lower group the wound-related complications were significantly higher in the rhBMP2 group (23 patients, 6.1%) compared with the non-rhBMP2 group (75 patients, 3.8%). Our data showed that the use of rhBMP2 does not increase the risk of complications in upper cervical spine fusion procedures. However, in the lower cervical spine, rhBMP2 may elevate the risk of wound-related complications. Overall, there were no major complications associated with the use of rhBMP2 for posterior cervical fusion approaches. Level III.

Early developed ASD (adjacent segmental disease) in patients after surgical treatment of the spine due to cancer metastases.

PubMed

Guzik, Grzegorz

2017-05-12

The causes of ASD are still relatively unknown. Correlation between clinical status of patients and radiological MRI findings is of primary importance. The radiological classifications proposed by Pfirmann and Oner are most commonly used to assess intradiscal degenerative changes. The aim of the study was to assess the influence of the extension of spine fixation on the risk of developing ASD in a short time after surgery. A total of 332 patients with spinal tumors were treated in our hospital between 2010 and 2013. Of these patients, 287 underwent surgeries. A follow-up MRI examination was performed 12 months after surgical treatment. The study population comprised of 194 patients. Among metastases, breast cancer was predominant (29%); neurological deficits were detected in 76 patients. Metastases were seen in the thoracic (45%) and lumbar (30%) spine; in 25% of cases, they were of multisegmental character. Pathological fractures concerned 88% of the patients. Statistical calculations were made using the χ2 test. Statistical analysis was done using the Statistica v. 10 software. A p value <0.05 was accepted as statistically significant. The study population was divided on seven groups according to applied treatment. Clinical signs of ASD were noted in only seven patients. Two patients had symptoms of nerve root irritation in the lumbar spine. Twenty-two patients (11%) were diagnosed with ASD according to the MRI classifications by Oner, Rijt, and Ramos, while the more sensitive Pfirmann classification allowed to detect the disease in 46 patients (24%). Healthy or almost healthy discs of Oner type I correlated with the criteria of Pfirmann types II and III. The percentage of the incidence of ASD diagnosed 1 year after the surgery using the Pfirmann classifications was significantly higher than diagnosed according to the clinical examination. The incidence of ASD in patients after spine surgeries due to cancer metastases does not differ between the study groups. ASD detectability based on clinical signs is significantly lower than ASD detectability based on MR images according to the system by Pfirrmann et.al. ASD risk increase among patients with multilevel fixation.

Intraoperative evaluation of device placement in spine surgery using known-component 3D-2D image registration

NASA Astrophysics Data System (ADS)

Uneri, A.; De Silva, T.; Goerres, J.; Jacobson, M. W.; Ketcha, M. D.; Reaungamornrat, S.; Kleinszig, G.; Vogt, S.; Khanna, A. J.; Osgood, G. M.; Wolinsky, J.-P.; Siewerdsen, J. H.

2017-04-01

Intraoperative x-ray radiography/fluoroscopy is commonly used to assess the placement of surgical devices in the operating room (e.g. spine pedicle screws), but qualitative interpretation can fail to reliably detect suboptimal delivery and/or breach of adjacent critical structures. We present a 3D-2D image registration method wherein intraoperative radiographs are leveraged in combination with prior knowledge of the patient and surgical components for quantitative assessment of device placement and more rigorous quality assurance (QA) of the surgical product. The algorithm is based on known-component registration (KC-Reg) in which patient-specific preoperative CT and parametric component models are used. The registration performs optimization of gradient similarity, removes the need for offline geometric calibration of the C-arm, and simultaneously solves for multiple component bodies, thereby allowing QA in a single step (e.g. spinal construct with 4-20 screws). Performance was tested in a spine phantom, and first clinical results are reported for QA of transpedicle screws delivered in a patient undergoing thoracolumbar spine surgery. Simultaneous registration of ten pedicle screws (five contralateral pairs) demonstrated mean target registration error (TRE) of 1.1  ±  0.1 mm at the screw tip and 0.7  ±  0.4° in angulation when a prior geometric calibration was used. The calibration-free formulation, with the aid of component collision constraints, achieved TRE of 1.4  ±  0.6 mm. In all cases, a statistically significant improvement (p  <  0.05) was observed for the simultaneous solutions in comparison to previously reported sequential solution of individual components. Initial application in clinical data in spine surgery demonstrated TRE of 2.7  ±  2.6 mm and 1.5  ±  0.8°. The KC-Reg algorithm offers an independent check and quantitative QA of the surgical product using radiographic/fluoroscopic views acquired within standard OR workflow. Such intraoperative assessment could improve quality and safety, provide the opportunity to revise suboptimal constructs in the OR, and reduce the frequency of revision surgery.

Deformable registration for image-guided spine surgery: preserving rigid body vertebral morphology in free-form transformations

NASA Astrophysics Data System (ADS)

Reaungamornrat, S.; Wang, A. S.; Uneri, A.; Otake, Y.; Zhao, Z.; Khanna, A. J.; Siewerdsen, J. H.

2014-03-01

Purpose: Deformable registration of preoperative and intraoperative images facilitates accurate localization of target and critical anatomy in image-guided spine surgery. However, conventional deformable registration fails to preserve the morphology of rigid bone anatomy and can impart distortions that confound high-precision intervention. We propose a constrained registration method that preserves rigid morphology while allowing deformation of surrounding soft tissues. Method: The registration method aligns preoperative 3D CT to intraoperative cone-beam CT (CBCT) using free-form deformation (FFD) with penalties on rigid body motion imposed according to a simple intensity threshold. The penalties enforced 3 properties of a rigid transformation - namely, constraints on affinity (AC), orthogonality (OC), and properness (PC). The method also incorporated an injectivity constraint (IC) to preserve topology. Physical experiments (involving phantoms, an ovine spine, and a human cadaver) as well as digital simulations were performed to evaluate the sensitivity to registration parameters, preservation of rigid body morphology, and overall registration accuracy of constrained FFD in comparison to conventional unconstrained FFD (denoted uFFD) and Demons registration. Result: FFD with orthogonality and injectivity constraints (denoted FFD+OC+IC) demonstrated improved performance compared to uFFD and Demons. Affinity and properness constraints offered little or no additional improvement. The FFD+OC+IC method preserved rigid body morphology at near-ideal values of zero dilatation (D = 0.05, compared to 0.39 and 0.56 for uFFD and Demons, respectively) and shear (S = 0.08, compared to 0.36 and 0.44 for uFFD and Demons, respectively). Target registration error (TRE) was similarly improved for FFD+OC+IC (0.7 mm), compared to 1.4 and 1.8 mm for uFFD and Demons. Results were validated in human cadaver studies using CT and CBCT images, with FFD+OC+IC providing excellent preservation of rigid morphology and equivalent or improved TRE. Conclusions: A promising method for deformable registration in CBCT-guided spine surgery has been identified incorporating a constrained FFD to preserve bone morphology. The approach overcomes distortions intrinsic to unconstrained FFD and could better facilitate high-precision image-guided spine surgery.

Current strategies for the restoration of adequate lordosis during lumbar fusion

PubMed Central

Barrey, Cédric; Darnis, Alice

2015-01-01

Not restoring the adequate lumbar lordosis during lumbar fusion surgery may result in mechanical low back pain, sagittal unbalance and adjacent segment degeneration. The objective of this work is to describe the current strategies and concepts for restoration of adequate lordosis during fusion surgery. Theoretical lordosis can be evaluated from the measurement of the pelvic incidence and from the analysis of spatial organization of the lumbar spine with 2/3 of the lordosis given by the L4-S1 segment and 85% by the L3-S1 segment. Technical aspects involve patient positioning on the operating table, release maneuvers, type of instrumentation used (rod, screw-rod connection, interbody cages), surgical sequence and the overall surgical strategy. Spinal osteotomies may be required in case of fixed kyphotic spine. AP combined surgery is particularly efficient in restoring lordosis at L5-S1 level and should be recommended. Finally, not one but several strategies may be used to achieve the need for restoration of adequate lordosis during fusion surgery. PMID:25621216

Indications for Direct Laryngoscopic Examination of Vocal Cord Function Prior to Anterior Cervical Surgery

PubMed Central

Nazemi, Alireza; Carmouche, Jonathan; Albert, Todd; Behrend, Caleb

2016-01-01

Recurrent laryngeal nerve palsy (RLNP) is among the most common complications in both thyroid surgeries and anterior approaches to the cervical spine, having both a diverse etiology and presentation. Most bilateral paresis, with subsequent devastating impact on patients, are due to failure to recognize unilateral recurrent laryngeal nerve paralysis and, although rare, are entirely preventable with appropriate history and screening. Recurrent laryngeal nerve palsy has been shown to present asymptomatically in as high as 32% of cases, which yields limitations on exclusively screening with physical examination. Based on the available literature, diagnosis of unilateral RLNP is the critical factor in preventing the occurrence of bilateral RLNP as the surgeon may elect to operate on the injured side to prevent bilateral paresis. Analysis of incidence rates shows postoperative development of unilateral RLNP is 13.1 (95% confidence interval [CI]: 6.1-28.1) and 13.90 (95% CI: 6.6-29.3) times more likely in anterior spine and thyroid surgery, respectively, in comparison with intubation. Currently, there is no consensus on when to order a preoperative laryngoscopic examination prior to anterior cervical spine surgery. The importance of patient history should be emphasized, as it is the basis for indications of preoperative laryngoscopy. Efforts to minimize postoperative complications must be made, especially when considering the rising rate of cervical fusion. This study presents a systematic review of the literature defining key causes of RLNP, with a probability-based protocol to indicate direct laryngoscopy prior to anterior cervical surgery as a screening tool in the prevention of bilateral RLNP. PMID:28255513

What is the learning curve for robotic-assisted pedicle screw placement in spine surgery?

PubMed

Hu, Xiaobang; Lieberman, Isador H

2014-06-01

Some early studies with robotic-assisted pedicle screw implantation have suggested these systems increase accuracy of screw placement. However, the relationship between the success rate of screw placement and the learning curve of this new technique has not been evaluated. We determined whether, as a function of surgeon experience, (1) the success rate of robotic-assisted pedicle screw placement improved, (2) the frequency of conversion from robotic to manual screw placement decreased, and (3) the frequency of malpositioned screws decreased. Between June 2010 and August 2012, the senior surgeon (IHL) performed 174 posterior spinal procedures using pedicle screws, 162 of which were attempted with robotic assistance. The use of the robotic system was aborted in 12 of the 162 procedures due to technical issues (registration failure, software crash, etc). The robotic system was successfully used in the remaining 150 procedures. These were the first procedures performed with the robot by the senior surgeon, and in this study, we divided the early learning curve into five groups: Group 1 (Patients 1-30), Group 2 (Patients 31-60), Group 3 (Patients 61-90), Group 4 (Patients 91-120), and Group 5 (Patients 121-150). One hundred twelve patients (75%) had spinal deformity and 80 patients (53%) had previous spine surgery. The accuracy of screw placement in the groups was assessed based on intraoperative biplanar fluoroscopy and postoperative radiographs. The results from these five groups were compared to determine the effect on the learning curve. The numbers of attempted pedicle screw placements were 359, 312, 349, 359, and 320 in Groups 1 to 5, respectively. The rates of successfully placed screws using robotic guidance were 82%, 93%, 91%, 95%, and 93% in Groups 1 to 5. The rates of screws converted to manual placement were 17%, 7%, 8%, 4%, and 7%. Of the robotically placed screws, the screw malposition rates were 0.8%, 0.3%, 1.4%, 0.8%, and 0%. The rate of successfully placed pedicle screws improved with increasing experience. The rate of the screws that were converted to manual placement decreased with increasing experience. The frequency of screw malposition was similar over the learning curve at 0% to 1.4%. Future studies will need to determine whether this finding is generalizable to others. Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

PREPARE: Pre-surgery physiotherapy for patients with degenerative lumbar spine disorder: a randomized controlled trial protocol.

PubMed

Lindbäck, Yvonne; Tropp, Hans; Enthoven, Paul; Abbott, Allan; Öberg, Birgitta

2016-07-11

Current guidelines for the management of patients with specific low back pain pathology suggest non-surgical intervention as first-line treatment, but there is insufficient evidence to make recommendations of the content in the non-surgical intervention. Opinions regarding the dose of non-surgical intervention that should be trialled prior to decision making about surgery intervention vary. The aim of the present study is to investigate if physiotherapy administrated before surgery improves function, pain and health in patients with degenerative lumbar spine disorder scheduled for surgery. The patients are followed over two years. A secondary aim is to study what factors predict short and long term outcomes. This study is a single blinded, 2-arm, randomized controlled trial with follow-up after the completion of pre-surgery intervention as well as 3, 12 and 24 months post-surgery. The study will recruit men and women, 25 to 80 years of age, scheduled for surgery due to; disc herniation, spinal stenosis, spondylolisthesis or degenerative disc disease. A total of 202 patients will be randomly allocated to a pre-surgery physiotherapy intervention or a waiting list group for 9 weeks. The waiting-list group will receive standardized information about surgery, post-surgical rehabilitation and advice to stay active. The pre-surgery physiotherapy group will receive physiotherapy 2 times per week, consisting of a stratified classification treatment, based on assessment findings. One of the following treatments will be selected; a) Specific exercises and mobilization, b) Motor control exercises or c) Traction. The pre-surgery physiotherapy group will also be prescribed a tailor-made general supervised exercise program. The physiotherapist will use a behavioral approach aimed at reducing patient fear avoidance and increasing activity levels. They will also receive standardized information about surgery, post-surgical rehabilitation and advice to stay active. Primary outcome measure is Oswestry Disability Index. Secondary outcome measures are the visual analogue scale for back and leg pain, pain drawing, health related quality of life, Hospital anxiety and depression scale, Fear avoidance beliefs questionnaire, Self-efficacy scale and Work Ability Index. The study findings will help improve the treatment of patients with degenerative lumbar spine disorder scheduled for surgery. ClinicalTrials.gov reference: NCT02454400 (Trial registration date: August 31st 2015) and has been registered on ClinicalTrials.gov, identifier: NCT02454400 .

[Management of spine injuries in polytraumatized patients].

PubMed

Heyde, C E; Ertel, W; Kayser, R

2005-09-01

The management of spine injuries in polytraumatized patients remains a great challenge for the diagnostic procedures and institution of appropriate treatment by integrating spinal trauma treatment into the whole treatment concept as well as following the treatment steps for the injured spine itself. The established concept of "damage control" and criteria regarding the optimal time and manner for operative treatment of the injured spine in the polytrauma setting is presented and discussed.

Acute hospital costs after minimally invasive versus open lumbar interbody fusion: data from a US national database with 6106 patients.

PubMed

Wang, Michael Y; Lerner, Jason; Lesko, James; McGirt, Matthew J

2012-08-01

Retrospective multi-institutional database review. To determine if minimally invasive interbody fusion is associated with cost savings when compared with open surgery. Minimally invasive spine (MIS) surgeries are increasingly recognized as equivalent to open procedures. Although these techniques have been advocated for reducing pain, disability, and length of hospitalization, to date there has been little data demonstrating these benefits. This study analyzed inpatient hospital records from the Premier Perspective database (2002 to 2009), including patients who underwent a posterior lumbar fusion with interbody cage placement by ICD-9 code, and had implant charge codes that allowed determination if MIS pedicle screws were utilized. Exclusion criteria included a refusion surgery, deformity, >2 levels, and anterior fusion. Total costs were adjusted for covariates (age, sex, race, hospital geography and setting, payor, and comorbidities) using an analysis of covariance model. A total of 6106 patients were identified (1667 MIS and 4439 open). Length of stay (LOS) for 1-level MIS surgery averaged of 3.35 days versus 3.6 days for open surgery (P≤0.006). For 2-level MIS surgery LOS averaged of 3.4 days versus 4.03 days for open surgery (P≤0.001). Total inflation-adjusted acute hospitalization cost averaged $29,187 for 1-level MIS procedures versus $29,947 for open surgery, a nonsignificant difference (P=0.55). Total inflation-adjusted acute hospitalization cost averaged $2106 lower for 2-level MIS surgery (total costs of $33,879 for MIS vs. $35,984 for open surgery, P=0.0023). Cost savings were attributable primarily to lower room and board ($857), operating room ($359), pharmacy ($304), and laboratory ($166) costs in the MIS group. High variances in the 2-level open surgery with prolonged hospital stay also accounted for overall cost differences. This data from a large nationwide sample of hospitalizations demonstrates that MIS lumbar interbody fusion results in a statistically significant reduction in hospital LOS and a reduction in total hospital costs with 2-level surgery after adjusting for significant covariates. The majority of cost savings from MIS surgery were due to more rapid mobilization and discharge, as well as a reduction in outliers with extended hospitalizations.

Malpractice litigation following spine surgery.

PubMed

Daniels, Alan H; Ruttiman, Roy; Eltorai, Adam E M; DePasse, J Mason; Brea, Bielinsky A; Palumbo, Mark A

2017-10-01

OBJECTIVE Adverse events related to spine surgery sometimes lead to litigation. Few studies have evaluated the association between spine surgical complications and medical malpractice proceedings, outcomes, and awards. The aim of this study was to identify the most frequent causes of alleged malpractice in spine surgery and to gain insight into patient demographic and clinical characteristics associated with medical negligence litigation. METHODS A search for "spine surgery" spanning February 1988 to May 2015 was conducted utilizing the medicolegal research service VerdictSearch (ALM Media Properties, LLC). Demographic data for the plaintiff and defendant in addition to clinical data for the procedure and legal outcomes were examined. Spinal cord injury, anoxic/hypoxic brain injury, and death were classified as catastrophic complications; all other complications were classified as noncatastrophic. Both chi-square and t-tests were used to evaluate the effect of these variables on case outcomes and awards granted. RESULTS A total of 569 legal cases were examined; 335 cases were excluded due to irrelevance or insufficient information. Of the 234 cases included in this investigation, 54.2% (127 cases) resulted in a defendant ruling, 26.1% (61) in a plaintiff ruling, and 19.6% (46) in a settlement. The awards granted for plaintiff rulings ranged from $134,000 to $38,323,196 (mean $4,045,205 ± $6,804,647). Awards for settlements ranged from $125,000 to $9,000,000 (mean $1,930,278 ± $2,113,593), which was significantly less than plaintiff rulings (p = 0.022). Compared with cases without a delay in diagnosis of the complication, the cases with a diagnostic delay were more likely to result in a plaintiff verdict or settlement (42.9% vs 72.7%, p = 0.007) than a defense verdict, and were more likely to settle out of court (17.5% vs 40.9%, p = 0.008). Similarly, compared with cases without a delay in treatment of the complication, those with a therapeutic delay were more likely to result in a plaintiff verdict or settlement (43.7% vs 68.4%, p = 0.03) than a defense verdict, and were more likely to settle out of court (18.1% vs 36.8%, p = 0.04). Overall, 28% of cases (66/234) involved catastrophic complications. Physicians were more likely to lose cases (plaintiff verdict or settlement) with catastrophic complications (66.7% vs 37.5%, p < 0.001). In cases with a plaintiff ruling, catastrophic complications resulted in significantly larger mean awards than noncatastrophic complications ($6.1M vs $2.9M, p = 0.04). The medical specialty of the provider and the age or sex of the patient were not associated with the case outcome or award granted (p > 0.05). The average time to a decision for defendant verdicts was 5.1 years; for plaintiff rulings, 5.0 years; and for settlements, 3.4 years. CONCLUSIONS Delays in the diagnosis and the treatment of a surgical complication predict legal case outcomes favoring the plaintiff. Catastrophic complications are linked to large sums awarded to the plaintiff and are predictive of rulings against the physician. For physician defendants, the costs of settlements are significantly less than those of losing in court. Although this study provides potentially valuable data from a large series of postoperative litigation cases, it may not provide a true representation of all jurisdictions, each of which has variable malpractice laws and medicolegal environments.

Therapeutic strategy and outcome of spine tumors in pregnancy: a report of 21 cases and literature review.

PubMed

Meng, Tong; Yin, Huabin; Li, Zhenxi; Li, Bo; Zhou, Wang; Wang, Jing; Zhou, Lei; Song, Dianwen; Xiao, Jianru

2015-02-01

A retrospective study was performed. To illustrate the characteristics of spine tumors during pregnancy and obtain better insight into therapeutic strategies of such tumors by analyzing 21 cases treated in Changzheng Hospital and reviewing previous reports in the literature. The concurrence of spine tumors and pregnancy is relatively rare. There are controversies over the treatment options for this disease, which increase the difficulty of the clinical treatment. Between 2002 and 2013, 21 pregnant patients were identified with spine tumors. Clinical data including symptoms, signs, treatment options, and obstetrical and neonatal outcomes were recorded and preserved. Clinical data and treatment efficacy were analyzed via medical record review. The median age of the 21 patients was 28.87 years (interquartile range, 6.00 yr). Tumor types in this series were giant cell tumor (5 cases), hemangioma (5 cases), schwannoma (4 cases), eosinophilic granuloma (2 cases), neurofibroma (1 case), multiple myeloma (1 case), and with metastatic tumor (3 cases). Two patients underwent spine surgery during pregnancy and 8 patients accepted tumor resection immediately after delivery. Pregnancy termination occurred in 5 patients, whereas the rest of the patients smoothly gave birth to healthy babies including 3 premature infants. Two patients died and 2 patients experienced local recurrence during follow-up. With close observation, it was found that most of pregnant patients with benign spine tumors could postpone surgery after delivery. Surgical treatment should be adopted during pregnancy when patients are with highly malignant tumor or experience a sharp deterioration and the guard of it is safer than radiotherapy and chemotherapy during pregnancy. 4.

Perspective of Value-Based Management of Spinal Disorders in Brazil.

PubMed

Teles, Alisson R; Righesso, Orlando; Gullo, Maria Carolina R; Ghogawala, Zoher; Falavigna, Asdrubal

2016-03-01

The state of value-based management of spinal disorders and ongoing Brazilian strategies toward its implementation are highlighted in this article. The health care system, economic impact of spine surgery, use of patient-reported outcomes, ongoing studies about health economics, and current strategies toward implementation of quality assessment of spine care in Brazil are reviewed. During the past 20 years, there has been an increase of 226% in the number and 540% in the total cost of spine surgeries in the public health system. Examples of economic regulatory mechanisms involve the process of health technology assessment and the auditing processes imposed by health insurance companies. Some barriers to implementing clinical registries were identified from a large Latin American survey. Strategies based on education and technical support have been conducted to improve the quality of comparative-effectiveness research in spine care. Only 1 cost-utility study on spine care has been published until now. The paradigm of value-based management of spinal disorders is still incipient in Brazil. Some issues from our analysis must be emphasized: (1) Brazil presents many regional disparities and scarce resources for health care; it is crucial for the health system to allocate resources based on the value of interventions; (2) because of the high economic and social burden of developing new technologies for diagnosis and treatment, research in health economics of spine care in Brazil should be prioritized; (3) these efforts would help to provide a more accessible and effective health system for patients with spinal problems. Copyright © 2016 Elsevier Inc. All rights reserved.

Perioperative aspirin management after POISE-2: some answers, but questions remain.

PubMed

Gerstein, Neal Stuart; Carey, Michael Christopher; Cigarroa, Joaquin E; Schulman, Peter M

2015-03-01

Aspirin constitutes important uninterrupted lifelong therapy for many patients with cardiovascular (CV) disease or significant (CV) risk factors. However, whether aspirin should be continued or withheld in patients undergoing noncardiac surgery is a common clinical conundrum that balances the potential of aspirin for decreasing thrombotic risk with its possibility for increasing perioperative blood loss. In this focused review, we describe the role of aspirin in treating and preventing cardiovascular disease, summarize the most important literature on the perioperative use of aspirin (including the recently published PeriOperative ISchemic Evaluation [POISE]-2 trial), and offer current recommendations for managing aspirin during the perioperative period. POISE-2 suggests that aspirin administration during the perioperative period does not change the risk of a cardiovascular event and may result in increased bleeding. However, these findings are tempered by a number of methodological issues related to the study. On the basis of currently available literature, including POISE-2, aspirin should not be administered to patients undergoing surgery unless there is a definitive guideline-based primary or secondary prevention indication. Aside from closed-space procedures, intramedullary spine surgery, or possibly prostate surgery, moderate-risk patients taking lifelong aspirin for a guideline-based primary or secondary indication may warrant continuation of their aspirin throughout the perioperative period.

Biomechanical Comparisons of Pull Out Strengths After Pedicle Screw Augmentation with Hydroxyapatite, Calcium Phosphate, or Polymethylmethacrylate in the Cadaveric Spine.

PubMed

Yi, Seong; Rim, Dae-Cheol; Park, Seoung Woo; Murovic, Judith A; Lim, Jesse; Park, Jon

2015-06-01

In vertebrae with low bone mineral densities pull out strength is often poor, thus various substances have been used to fill screw holes before screw placement for corrective spine surgery. We performed biomechanical cadaveric studies to compare nonaugmented pedicle screws versus hydroxyapatite, calcium phosphate, or polymethylmethacrylate augmented pedicle screws for screw tightening torques and pull out strengths in spine procedures requiring bone screw insertion. Seven human cadaveric T10-L1 spines with 28 vertebral bodies were examined by x-ray to exclude bony abnormalities. Dual-energy x-ray absorptiometry scans evaluated bone mineral densities. Twenty of 28 vertebrae underwent ipsilateral fluoroscopic placement of 6-mm holes augmented with hydroxyapatite, calcium phosphate, or polymethylmethacrylate, followed by transpedicular screw placements. Controls were pedicle screw placements in the contralateral hemivertebrae without augmentation. All groups were evaluated for axial pull out strength using a biomechanical loading frame. Mean pedicle screw axial pull out strength compared with controls increased by 12.5% in hydroxyapatite augmented hemivertebrae (P = 0.600) and by 14.9% in calcium phosphate augmented hemivertebrae (P = 0.234), but the increase was not significant for either method. Pull out strength of polymethylmethacrylate versus hydroxyapatite augmented pedicle screws was 60.8% higher (P = 0.028). Hydroxyapatite and calcium phosphate augmentation in osteoporotic vertebrae showed a trend toward increased pedicle screw pull out strength versus controls. Pedicle screw pull out force of polymethylmethacrylate in the insertion stage was higher than that of hydroxyapatite. However, hydroxyapatite is likely a better clinical alternative to polymethylmethacrylate, as hydroxyapatite augmentation, unlike polymethylmethacrylate augmentation, stimulates bone growth and can be revised. Copyright © 2015 Elsevier Inc. All rights reserved.

Complications and Morbidities of Mini-open Anterior Retroperitoneal Lumbar Interbody Fusion: Oblique Lumbar Interbody Fusion in 179 Patients.

PubMed

Silvestre, Clément; Mac-Thiong, Jean-Marc; Hilmi, Radwan; Roussouly, Pierre

2012-06-01

A retrospective study including 179 patients who underwent oblique lumbar interbody fusion (OLIF) at one institution. To report the complications associated with a minimally invasive technique of a retroperitoneal anterolateral approach to the lumbar spine. Different approaches to the lumbar spine have been proposed, but they are associated with an increased risk of complications and a longer operation. A total of 179 patients with previous posterior instrumented fusion undergoing OLIF were included. The technique is described in terms of: the number of levels fused, operative time and blood loss. Persurgical and postsurgical complications were noted. Patients were age 54.1 ± 10.6 with a BMI of 24.8 ± 4.1 kg/m(2). The procedure was performed in the lumbar spine at L1-L2 in 4, L2-L3 in 54, L3-L4 in 120, L4-L5 in 134, and L5-S1 in 6 patients. It was done at 1 level in 56, 2 levels in 107, and 3 levels in 16 patients. Surgery time and blood loss were, respectively, 32.5 ± 13.2 minutes and 57 ± 131 ml per level fused. There were 19 patients with a single complication and one with two complications, including two patients with postoperative radiculopathy after L3-5 OLIF. There was no abdominal weakness or herniation. Minimally invasive OLIF can be performed easily and safely in the lumbar spine from L2 to L5, and at L1-2 for selected cases. Up to 3 levels can be addressed through a 'sliding window'. It is associated with minimal blood loss and short operations, and with decreased risk of abdominal wall weakness or herniation.

Ergonomic assessment of the French and American position for laparoscopic cholecystectomy in the MIS Suite.

PubMed

Kramp, Kelvin H; van Det, Marc J; Totte, Eric R; Hoff, Christiaan; Pierie, Jean-Pierre E N

2014-05-01

Cholecystectomy was one of the first surgical procedures to be performed with laparoscopy in the 1980s. Currently, two operation setups generally are used to perform a laparoscopic cholecystectomy: the French and the American position. In the French position, the patient lies in the lithotomy position, whereas in the American position, the patient lies supine with the left arm in abduction. To find an ergonomic difference between the two operation setups the movements of the surgeon's vertebral column were analyzed in a crossover study. The posture of the surgeon's vertebral column was recorded intraoperatively using an electromagnetic motion-tracking system with three sensors attached to the head and to the trunk at the levels of Th1 and S1. A three-dimensional posture analysis of the cervical and thoracolumbar spine was performed to evaluate four surgeons removing a gallbladder in the French and American position. The body angles assessed were flexion/extension of the cervical and thoracolumbar spine, axial rotation of the cervical and thoracolumbar spine, lateroflexion of the cervical and thoracolumbar spine, and the orientation of the head in the sagittal plane. For each body angle, the mean, the percentage of operation time within an ergonomic acceptable range, and the relative frequencies were calculated and compared. No statistical difference was observed in the mean body angles or in the percentages of operation time within an acceptable range between the French and the American position. The relative frequencies of the body angles might indicate a trend toward slight thoracolumbar flexion in the French position. In a modern dedicated minimally invasive surgery suite, the body posture of the neck and trunk and the orientation of the head did not differ significantly between the French and American position.

Time Demand and Radiation Dose in 3D-Fluoroscopy-based Navigation-assisted 3D-Fluoroscopy-controlled Pedicle Screw Instrumentations.

PubMed

Balling, Horst

2018-05-01

Prospective single-center cohort study to record additional time requirements and radiation dose in navigation-assisted O-arm-controlled pedicle screw (PS) instrumentations. The aim of this study was to evaluate amount of extra-time and radiation dose for navigation-assisted PS instrumentations of the thoracolumbosacral spine using O-arm 3D-real-time-navigation (O3DN) compared to non-navigated spinal procedures (NNSPs) with a single C-arm and postoperative computed tomography (CT) scan for controlling PS positions. 3D-navigation is reported to enhance PS insertion accuracy. But time-consuming navigational steps and considerable additional radiation doses seem to limit this modern technique's attraction. A detailed analysis of additional time demand and extra-radiation dose in 3D-navigated spine surgery is not provided in literature, yet. From February 2011 through July 2015, 306 consecutive posterior instrumentations were performed in vertebral levels T10-S1 using O3DN for PS insertion. The duration of procedure-specific navigational steps of the overall collective (I) and the last cohort of 50 consecutive O3DN-surgeries (II) was compared to the average duration of analogous surgical steps in 100 consecutive NNSP using a single C-arm. 3D-radiation dose (dose-length-product, DLP) of navigational and postinstrumentation O-arm scans in group I and II was compared to the average DLP of 100 diagnostic lumbar CT scans. The average presurgical time from patient positioning on the operating table to skin incision was 46.2 ± 10.1 minutes (O3DN, I) and 40.6 ± 9.8 minutes (O3DN, II) versus 30.6 ± 8.3 minutes (NNSP) (P < 0.001, each). Intraoperative interruptions for scanning and data processing took 3.0 ± 0.6 minutes. DLPs averaged 865.1 ± 360.8 mGycm (O3DN, I) and 562.1 ± 352.6 mGycm (O3DN, II) compared to 575.5 ± 316.5 mGycm in diagnostic lumbar CT scans (P < 0.001 (I), P ≈ 0.81 [II]). After procedural experience, navigated surgeries can be performed with an additional time demand of 13.0 minutes compared to NNSP, and with a total DLP below that of a diagnostic lumbar CT scan (P ≈ 0.81). 4.

Complications of correction for focal kyphosis after posterior osteotomy and the corresponding management.

PubMed

Zeng, Yan; Chen, Zhongqiang; Guo, Zhaoqing; Qi, Qiang; Li, Weishi; Sun, Chuiguo

2013-10-01

A clinical retrospective study. To analyze the complications and relevant management of the correction procedure for focal kyphosis. The treatment of focal kyphosis is a difficult problem in spine surgery. The potential complications of surgery should be considered cautiously and managed positively. Eighty-one patients with focal kyphosis were treated by posterior osteotomy and correction. The etiology was posttraumatic in 31 cases, healed tuberculosis in 31 cases, congenital in 17 cases, and iatrogenic in 2 cases. The surgical procedures were pedicle subtraction osteotomy in 19 cases, posterior osteotomy with anterior opening-posterior closing correction in 23 cases, and posterior vertebral column resection with dual axial rotation correction in 39 cases. The intraoperative and postoperative complications were summarized, and the corresponding management was described in detail. The average follow-up time was 31 months. Among patients who underwent pedicle subtraction osteotomy, the intraoperative and postoperative complications included 3 cases of dural tear and 1 case of wound infection. For posterior osteotomy with anterior opening-posterior closing correction, the complications included 4 cases of dural tear, 1 case of wound infection, and 1 case of instrumentation loosening and recurrence of kyphosis . For posterior vertebral column resection with dual axial rotation correction, the complications included 3 cases of dural tear, 5 cases of nerve root injury, 1 case of titanium mesh loosening, 1 case of osteotomy segment migration, 2 cases of transient neurological compromise, and 1 case of instrumentation loosening and kyphosis recurrence. All the complications were treated positively and pertinently. During the posterior osteotomy and correction of focal kyphosis, the risk of surgery increases along with the more severe deformity and the more complicated surgical procedure. However, most complications do not significantly affect the outcome if treated appropriately.

The international spine registry SPINE TANGO: status quo and first results

PubMed Central

Melloh, Markus; Aghayev, Emin; Zweig, Thomas; Barz, Thomas; Theis, Jean-Claude; Chavanne, Albert; Grob, Dieter; Aebi, Max; Roeder, Christoph

2008-01-01

With an official life time of over 5 years, Spine Tango can meanwhile be considered the first international spine registry. In this paper we present an overview of frequency statistics of Spine Tango for demonstrating the genesis of questionnaire development and the constantly increasing activity in the registry. Results from two exemplar studies serve for showing concepts of data analysis applied to a spine registry. Between 2002 and 2006, about 6,000 datasets were submitted by 25 centres. Descriptive analyses were performed for demographic, surgical and follow-up data of three generations of the Spine Tango surgery and follow-up forms. The two exemplar studies used multiple linear regression models to identify potential predictor variables for the occurrence of dura lesions in posterior spinal fusion, and to evaluate which covariates influenced the length of hospital stay. Over the study period there was a rise in median patient age from 52.3 to 58.6 years in the Spine Tango data pool and an increasing percentage of degenerative diseases as main pathology from 59.9 to 71.4%. Posterior decompression was the most frequent surgical measure. About one-third of all patients had documented follow-ups. The complication rate remained below 10%. The exemplar studies identified “centre of intervention” and “number of segments of fusion” as predictors of the occurrence of dura lesions in posterior spinal fusion surgery. Length of hospital stay among patients with posterior fusion was significantly influenced by “centre of intervention”, “surgeon credentials”, “number of segments of fusion”, “age group” and “sex”. Data analysis from Spine Tango is possible but complicated by the incompatibility of questionnaire generations 1 and 2 with the more recent generation 3. Although descriptive and also analytic studies at evidence level 2++ can be performed, findings cannot yet be generalised to any specific country or patient population. Current limitations of Spine Tango include the low number and short duration of follow-ups and the lack of sufficiently detailed patient data on subgroup levels. Although the number of participants is steadily growing, no country is yet represented with a sufficient number of hospitals. Nevertheless, the benefits of the project for the whole spine community become increasingly visible. PMID:18446386

Self-referrals versus physician referrals: What new patient visit yields an actual surgical case?

PubMed

Herring, Eric Z; Peck, Matthew R; Vonck, Caroline E; Smith, Gabriel A; Mroz, Thomas E; Steinmetz, Michael P

2018-06-15

OBJECTIVE Spine surgeons in the United States continue to be overwhelmed by an aging population, and patients are waiting weeks to months for appointments. With a finite number of clinic visits per surgeon, analysis of referral sources needs to be explored. In this study, the authors evaluated patient referrals and their yield for surgical volume at a tertiary care center. METHODS This is a retrospective study of new patient visits by the spine surgery group at the Cleveland Clinic Center for Spine Health from 2011 to 2016. Data on all new or consultation visits for 5 identified spinal surgeons at the Center for Spine Health were collected. Patients with an identifiable referral source and who were at least 18 years of age at initial visit were included in this study. Univariate analysis was used to identify demographic differences among referral groups, and then multivariate analysis was used to evaluate those referral groups as significant predictors of surgical yield. RESULTS After adjusting for demographic differences across all referrals, multivariate analysis identified physician referrals as more likely (OR 1.48, 95% CI 1.04-2.10, p = 0.0293) to yield a surgical case than self-referrals. General practitioner referrals (OR 0.5616, 95% CI 0.3809-0.8278, p = 0.0036) were identified as less likely to yield surgical cases than referrals from interventionalists (OR 1.5296, p = 0.058) or neurologists (OR 1.7498, 95% CI 1.0057-3.0446, p = 0.0477). Additionally, 2 demographic factors, including distance from home and age, were identified as predictors of surgery. Local patients (OR 1.21, 95% CI 1.13-1.29, p = 0.018) and those 65 years of age or older (OR 0.80, 95% CI 0.72-0.87, p = 0.0023) were both more likely to need surgery after establishing care with a spine surgeon. CONCLUSIONS In conclusion, referrals from general practitioners and self-referrals are important areas where focused triaging may be necessary. Further research into midlevel providers and nonsurgical spine provider's role in these referrals for spine pathology is needed. Patients from outside of the state or younger than 65 years could benefit from pre-visit screening as well to optimize a surgeon's clinic time use and streamline patient care.

Vocal fold immobility: a longitudinal analysis of etiology over 20 years.

PubMed

Rosenthal, Laura H Swibel; Benninger, Michael S; Deeb, Robert H

2007-10-01

To determine the current etiology of vocal fold immobility, identify changing trends over the last 20 years, and compare results to historical reports. The present study is a retrospective analysis of all patients seen within a tertiary care institution between 1996 and 2005 with vocal fold immobility. The results were combined with a previous study of patients within the same institution from 1985 through 1995. Results were compared to the literature. The medical records of all patients assigned a primary or additional diagnostic code for vocal cord paralysis were obtained from the electronic database. Eight hundred twenty-seven patients were available for analysis (435 from the most recent cohort), which is substantially larger than any reported series to date. Vocal fold immobility was most commonly associated with a surgical procedure (37%). Nonthyroid surgeries (66%), such as anterior cervical approaches to the spine and carotid endarterectomies, have surpassed thyroid surgery (33%) as the most common iatrogenic causes. These data represent a change from historical figures in which extralaryngeal malignancies were considered the major cause of unilateral immobility. Thyroidectomy continues to cause the majority (80%) of iatrogenic bilateral vocal fold immobility and 30% of all bilateral immobility. This 20-year longitudinal assessment revealed that the etiology of unilateral vocal fold immobility has changed such that there has been a shift from extralaryngeal malignancies to nonthyroid surgical procedures as the major cause. Thyroid surgery remains the most common cause of bilateral vocal fold immobility.

Ultraclean air for prevention of postoperative infection after posterior spinal fusion with instrumentation: a comparison between surgeries performed with and without a vertical exponential filtered air-flow system.

PubMed

Gruenberg, Marcelo F; Campaner, Gustavo L; Sola, Carlos A; Ortolan, Eligio G

2004-10-15

This study retrospectively compared infection rates between adult patients after posterior spinal instrumentation procedures performed in a conventional versus an ultraclean air operating room. To evaluate if the use of ultraclean air technology could decrease the infection rate after posterior spinal arthrodesis with instrumentation. Postoperative wound infection after posterior arthrodesis remains a feared complication in spinal surgery. Although this frequent complication results in a significant problem, the employment of ultraclean air technology, as it is commonly used for arthroplasty, has not been reported as a possible alternative to reduce the infection rate after complex spine surgery. One hundred seventy-nine patients having posterior spinal fusion with instrumentation were divided into 2 groups: group I included 139 patients operated in a conventional operating room, and group II included 40 patients operated in a vertical laminar flow operating room. Patient selection was performed favoring ultraclean air technology for elective cases in which high infection risk was considered. A statistical analysis of the infection rate and its associated risk factors between both groups was assessed. We observed 18 wound infections in group I and 0 in group II. Comparison of infection rates using the chi-squared test showed a statistically significant difference (P <0.017). The use of ultraclean air technology reduced the infection rate after complex spinal procedures and appears to be an interesting alternative that still needs to be prospectively studied with a randomized protocol.

Implementation and impact of ICD-10 (Part II)

PubMed Central

Rahmathulla, Gazanfar; Deen, H. Gordon; Dokken, Judith A.; Pirris, Stephen M.; Pichelmann, Mark A.; Nottmeier, Eric W.; Reimer, Ronald; Wharen, Robert E.

2014-01-01

Background: The transition from the International Classification of Disease-9th clinical modification to the new ICD-10 was all set to occur on 1 October 2015. The American Medical Association has previously been successful in delaying the transition by over 10 years and has been able to further postpone its introduction to 2015. The new system will overcome many of the limitations present in the older version, thus paving the way to more accurate capture of clinical information. Methods: The benefits of the new ICD-10 system include improved quality of care, potential cost savings, reduction of unpaid claims, and improved tracking of healthcare data. The areas where challenges will be evident include planning and implementation, the cost to transition, a shortage of qualified coders, training and education of the healthcare workforce, and a loss of productivity when this occurs. The impacts include substantial costs to the healthcare system, but the projected long-term savings and benefits will be significant. Improved fraud detection, accurate data entry, ability to analyze cost benefits with procedures, and enhanced quality outcome measures are the most significant beneficial factors with this change. Results: The present Current Procedural Terminology and Healthcare Common Procedure Coding System code sets will be used for reporting ambulatory procedures in the same manner as they have been. ICD-10-PCS will replace ICD-9 procedure codes for inpatient hospital services. The ICD-10-CM will replace the clinical code sets. Our article will focus on the challenges to execution of an ICD change and strategies to minimize risk while transitioning to the new system. Conclusion: With the implementation deadline gradually approaching, spine surgery practices that include multidisciplinary health specialists have to anticipate and prepare for the ICD change in order to mitigate risk. Education and communication is the key to this process in spine practices. PMID:25184098

Blood-loss Management in Spine Surgery.

PubMed

Bible, Jesse E; Mirza, Muhammad; Knaub, Mark A

2018-01-15

Substantial blood loss during spine surgery can result in increased patient morbidity and mortality. Proper preoperative planning and communication with the patient, anesthesia team, and operating room staff can lessen perioperative blood loss. Advances in intraoperative antifibrinolytic agents and modified anesthesia techniques have shown promising results in safely reducing blood loss. The surgeon's attention to intraoperative hemostasis and the concurrent use of local hemostatic agents also can lessen intraoperative bleeding. Conversely, the use of intraoperative blood salvage has come into question, both for its potential inability to reduce the need for allogeneic transfusions as well as its cost-effectiveness. Allogeneic blood transfusion is associated with elevated risks, including surgical site infection. Thus, desirable transfusion thresholds should remain restrictive.

Biomechanical analysis of disc pressure and facet contact force after simulated two-level cervical surgeries (fusion and arthroplasty) and hybrid surgery.

PubMed

Park, Jon; Shin, Jun Jae; Lim, Jesse

2014-12-01

The objective of this study was designed to compare 2-level cervical disc surgery (2-level anterior cervical discectomy and fusion [ACDF] or disc arthroplasty) and hybrid surgery (ACDF/arthroplasty) in terms of postoperative adjacent-level intradiscal pressure (IDP) and facet contact force (FCF). Twenty-four cadaveric cervical spines (C3-T2) were tested in various modes, including extension, flexion, and bilateral axial rotation, to compare adjacent-level IDP and FCF after specified treatments as follows: 1) C5-C6 arthroplasty using ProDisc-C (Synthes Spine, West Chester, Pennsylvania, USA) and C6-C7 ACDF, 2) C5-C6 ACDF and C6-C7 arthroplasty using ProDisc-C, 3) 2-level C5-C6/C6-C7 disc arthroplasties, and 4) 2-level C5-C6/C6-C7 ACDF. IDPs were recorded at anterior, central, and posterior disc portions. After 2-level cervical arthrodesis (ACDF), IDP increased significantly at the anterior annulus of distal adjacent-level disc during flexion and axial rotation and at the center of proximal adjacent-level disc during flexion. In contrast, after cervical specified treatments, including disc arthroplasty (2-level disc arthroplasties and hybrid surgery), IDP decreased significantly at the anterior annulus of distal adjacent-level disc during flexion and extension and was unchanged at the center of proximal adjacent-level disc during flexion. Two-level cervical arthrodesis also tended to adversely impact facet loads, increasing distal rather than proximal adjacent-level FCF. Both hybrid surgery and 2-level arthroplasties seem to offer significant advantages over 2-level arthrodesis by reducing IDP at adjacent levels and approximating FCF of an intact spine. These findings suggest that cervical arthroplasties and hybrid surgery are an alternative to reduce IDP and facet loads at adjacent levels. Copyright © 2014 Elsevier Inc. All rights reserved.

Is spine deformity surgery in patients with spastic cerebral palsy truly beneficial?: a patient/parent evaluation.

PubMed

Watanabe, Kota; Lenke, Lawrence G; Daubs, Michael D; Watanabe, Kei; Bridwell, Keith H; Stobbs, Georgia; Hensley, Marsha

2009-09-15

Retrospective clinical outcome study. To evaluate the clinical outcomes and satisfaction associated with the surgical treatment of neuromuscular spinal deformity secondary to cerebral palsy. Controversy still exists regarding whether spinal deformity surgery is truly a beneficial surgery for patients with cerebral palsy (CP) since there is limited functional benefit and higher perioperative complications rates in this patient population. Neuromuscular patient evaluation questionnaires were answered retrospectively by 84 patients/families of spastic CP patients undergoing spinal fusion. The average follow-up was 6.2 years (range: 2-16). The questionnaires were designed to assess expectation, cosmesis, function, patient care, quality of life, pulmonary function, pain, health status, self-image, and satisfaction. Questionnaire results, complications, and radiographic data were divided into "satisfied group" and "less satisfied group" and we analyzed reasons of satisfaction and dissatisfaction. The overall satisfaction rate was 92%. Ninety-three percent reported improvement with sitting balance, 94% with cosmesis, and 71% in patient's quality of life. Functional improvements seemed limited, but 8% to 40% of the patients still perceived the surgical results as improvement. The postoperative complication rate was 27%. The mean preoperative Cobb angle of the major curve was 88 degrees (range: 53 degrees-141 degrees), which corrected to 39 degrees (range: 5 degrees-88 degrees) after surgery. The less satisfied group had a significantly higher late complication rate, less correction of the major curve, greater residual major curve, and hyperlordosis of the lumbar spine after surgery. Despite the perioperative difficulties seen with CP patients, the majority of the patient/parents were satisfied with the results of the spinal deformity surgery. Functional improvements were limited but 8% to 40% of the patients still perceived the results as improved. The reason for less than optimal satisfaction appears to be due to less correction of the major curve, greater residual major Cobb angle, hyperlordosis of the lumbar spine after surgery, and late postoperative complications.

Airway management in cervical spine injury

PubMed Central

Austin, Naola; Krishnamoorthy, Vijay; Dagal, Arman

2014-01-01

To minimize risk of spinal cord injury, airway management providers must understand the anatomic and functional relationship between the airway, cervical column, and spinal cord. Patients with known or suspected cervical spine injury may require emergent intubation for airway protection and ventilatory support or elective intubation for surgery with or without rigid neck stabilization (i.e., halo). To provide safe and efficient care in these patients, practitioners must identify high-risk patients, be comfortable with available methods of airway adjuncts, and know how airway maneuvers, neck stabilization, and positioning affect the cervical spine. This review discusses the risks and benefits of various airway management strategies as well as specific concerns that affect patients with known or suspected cervical spine injury. PMID:24741498

Resolution of low back symptoms after corrective surgery for dropped-head syndrome: a report of two cases.

PubMed

Koda, Masao; Furuya, Takeo; Inada, Taigo; Kamiya, Koshiro; Ota, Mitsutoshi; Maki, Satoshi; Ikeda, Osamu; Aramomi, Masaaki; Takahashi, Kazuhisa; Yamazaki, Masashi; Mannoji, Chikato

2015-10-07

Cervical deformity can influence global sagittal balance. We report two cases of severe low back pain and lower extremity radicular pain associated with dropped-head syndrome. Symptoms were relieved by cervical corrective surgery. Two Japanese women with dropped head syndrome complained of severe low back pain and lower extremity radicular pain on walking. Radiographs showed marked cervical spine kyphosis and lumbar spine hyperlordosis. After cervicothoracic posterior corrective fusion was performed, cervical kyphosis was corrected and lumbar lordosis decreased, and low back pain and leg pain were relieved in both patients. Cervical deformity can influence global sagittal balance. Marked cervical kyphosis in patients with dropped-head syndrome can induce compensatory thoracolumbar hyperlordosis. Low back symptoms in patients with dropped-head syndrome are attributable to this compensatory lumbar hyperlordosis. Symptoms of lumbar canal stenosis may result from cervical deformity and can be improved with cervical corrective surgery.

Congenital spine deformities: a new screening indication for blunt cerebrovascular injuries after cervical trauma?

PubMed

Capone, Christine; Burjonrappa, Sathyaprasad

2010-12-01

Blunt cerebrovascular injuries (BCVI) carry significant morbidity if not diagnosed and treated early. A high index of clinical suspicion is needed to recognize the injury patterns associated with this condition and to order the requisite imaging studies needed to diagnose it accurately. We report of BCVI associated with a congenital cervical spine malformation after blunt trauma. We recommend inclusion of cervical spine malformations to the current Eastern Association for the Surgery of Trauma screening criteria for BCVI and explain our rationale for the same. Copyright © 2010 Elsevier Inc. All rights reserved.

Do surgeon credentials affect the rate of incidental durotomy during spine surgery.

PubMed

Murray, N J; Demetriades, A K; Rolton, D; Nnadi, C

2014-08-01

Incidental durotomy is a potential complication of spinal surgery which can cause a number of intra-operative and post-operative complications. The purpose of this study was to determine if the primary operator's credentials impacted on the incidence of durotomy intra-operatively. Prospectively collected data of operator credentials in relation to the incidence of durotomy were acquired from the International Eurospine Tango database. The significance of variability and risk factors between operators was measured using the Chi-squared test. Data from a total of 3,764 patients were captured from the Tango registry. Of these 162 (4.3%) had a durotomy. Of the total number of patients, the primary operator was neurosurgical in 1,369 (36.4%) cases; orthopaedic in 180 (4.8%) cases; other (pre-certification) in 236 (6.3%) cases; specialised spine surgeon in 1,741 (46.3%) cases; 6 cases had missing operator data. cerebrospinal fluid (CSF) leak occurred in 57 (4.16%) of neurosurgeon-operated cases; 5 (2.78%) orthopaedic-operated cases; 19 (4.06%) of other surgeon-operated cases; and 81 (4.65%) in specialised spine surgeon-operated cases. Using Chi-squared test, the significance of the variation in incidence of CSF leak between primary operator groups was not statistically significant (P = 0.1405). From the data captured and analysed, the rate of durotomy ranged from 2.78 to 4.65% between operator groups with a mean rate of 4.3%. The primary operator credentials do not appear to significantly impact the rate of durotomy in spine surgery.

Corticosteroid Administration to Prevent Complications of Anterior Cervical Spine Fusion: A Systematic Review

PubMed Central

Zadegan, Shayan Abdollah; Jazayeri, Seyed Behnam; Abedi, Aidin; Bonaki, Hirbod Nasiri; Vaccaro, Alexander R.; Rahimi-Movaghar, Vafa

2017-01-01

Study Design: Systematic review. Objectives: Anterior cervical approach is associated with complications such as dysphagia and airway compromise. In this study, we aimed to systematically review the literature on the efficacy and safety of corticosteroid administration as a preventive measure of such complications in anterior cervical spine surgery with fusion. Methods: Following a systematic literature search of MEDLINE, Embase, and Cochrane databases in July 2016, all comparative human studies that evaluated the effect of steroids for prevention of complications in anterior cervical spine surgery with fusion were included, irrespective of number of levels and language. Risk of bias was assessed using MINORS (Methodological Index for Non-Randomized Studies) checklist and Cochrane Back and Neck group recommendations, for nonrandomized and randomized studies, respectively. Results: Our search yielded 556 articles, of which 9 studies (7 randomized controlled trials and 2 non–randomized controlled trials) were included in the final review. Dysphagia was the most commonly evaluated complication, and in most studies, its severity or incidence was significantly lower in the steroid group. Although prevertebral soft tissue swelling was less commonly assessed, the results were generally in favor of steroid use. The evidence for airway compromise and length of hospitalization was inconclusive. Steroid-related complications were rare, and in both studies that evaluated the fusion rate, it was comparable between steroid and control groups in long-term follow-up. Conclusions: Current literature supports the use of steroids for prevention of complications in anterior cervical spine surgery with fusion. However, evidence is limited by substantial risk of bias and small number of studies reporting key outcomes. PMID:29796378

Percutaneous pedicle screw placement under single dimensional fluoroscopy with a designed pedicle finder-a technical note and case series.

PubMed

Tsuang, Fon-Yih; Chen, Chia-Hsien; Kuo, Yi-Jie; Tseng, Wei-Lung; Chen, Yuan-Shen; Lin, Chin-Jung; Liao, Chun-Jen; Lin, Feng-Huei; Chiang, Chang-Jung

2017-09-01

Minimally invasive spine surgery has become increasingly popular in clinical practice, and it offers patients the potential benefits of reduced blood loss, wound pain, and infection risk, and it also diminishes the loss of working time and length of hospital stay. However, surgeons require more intraoperative fluoroscopy and ionizing radiation exposure during minimally invasive spine surgery for localization, especially for guidance in instrumentation placement. In addition, computer navigation is not accessible in some facility-limited institutions. This study aimed to demonstrate a method for percutaneous screws placement using only the anterior-posterior (AP) trajectory of intraoperative fluoroscopy. A technical report (a retrospective and prospective case series) was carried out. Patients who received posterior fixation with percutaneous pedicle screws for thoracolumbar degenerative disease or trauma comprised the patient sample. We retrospectively reviewed the charts of consecutive 670 patients who received 4,072 pedicle screws between December 2010 and August 2015. Another case series study was conducted prospectively in three additional hospitals, and 88 consecutive patients with 413 pedicle screws were enrolled from February 2014 to July 2016. The fluoroscopy shot number and radiation dose were recorded. In the prospective study, 78 patients with 371 screws received computed tomography at 3 months postoperatively to evaluate the fusion condition and screw positions. In the retrospective series, the placement of a percutaneous screw required 5.1 shots (2-14, standard deviation [SD]=2.366) of AP fluoroscopy. One screw was revised because of a medialwall breach of the pedicle. In the prospective series, 5.8 shots (2-16, SD=2.669) were required forone percutaneous pedicle screw placement. There were two screws with a Grade 1 breach (8.6%), both at the lateral wall of the pedicle, out of 23 screws placed at the thoracic spine at T9-T12. Forthe lumbar and sacral areas, there were 15 Grade 1 breaches (4.3%), 1 Grade 2 breach (0.3%), and 1 Grade 3 breach (0.3%). No revision surgery was necessary. This method avoids lateral shots of fluoroscopy during screw placement and thus decreases the operation time and exposes surgeons to less radiation. At the same time, compared with the computer-navigated procedure, it is less facility-demanding, and provides satisfactory reliability and accuracy. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

An assessment of data and methodology of online surgeon scorecards.

PubMed

Xu, Linda W; Li, Amy; Swinney, Christian; Babu, Maya; Veeravagu, Anand; Wolfe, Stacey Quintero; Nahed, Brian V; Ratliff, John K

2017-02-01

OBJECTIVE Recently, 2 surgeon rating websites (Consumers' Checkbook and ProPublica) were published to allow the public to compare surgeons through identifying surgeon volume and complication rates. Among neurosurgeons and orthopedic surgeons, only cervical and lumbar spine, hip, and knee procedures were included in this assessment. METHODS The authors examined the methodology of each website to assess potential sources of inaccuracy. Each online tool was queried for reports on neurosurgeons specializing in spine surgery and orthopedic surgeons specializing in spine, hip, or knee surgery. Surgeons were chosen from top-ranked hospitals in the US, as recorded by a national consumer publication ranking system, within the fields of neurosurgery and orthopedic surgery. The results were compared for accuracy and surgeon representation, and the results of the 2 websites were also compared. RESULTS The methodology of each site was found to have opportunities for bias and limited risk adjustment. The end points assessed by each site were actually not complications, but proxies of complication occurrence. A search of 510 surgeons (401 orthopedic surgeons [79%] and 109 neurosurgeons [21%]) showed that only 28% and 56% of surgeons had data represented on Consumers' Checkbook and ProPublica, respectively. There was a significantly higher chance of finding surgeon data on ProPublica (p < 0.001). Of the surgeons from top-ranked programs with data available, 17% were quoted to have high complication rates, 13% with lower volume than other surgeons, and 79% had a 3-star out of 5-star rating. There was no significant correlation found between the number of stars a surgeon received on Consumers' Checkbook and his or her adjusted complication rate on ProPublica. CONCLUSIONS Both the Consumers' Checkbook and ProPublica websites have significant methodological issues. Neither site assessed complication occurrence, but rather readmissions or prolonged length of stay. Risk adjustment was limited or nonexistent. A substantial number of neurosurgeons and orthopedic surgeons from top-ranked hospitals have no ratings on either site, or have data that suggests they are low-volume surgeons or have higher complication rates. Consumers' Checkbook and ProPublica produced different results with little correlation between the 2 websites in how surgeons were graded. Given the significant methodological issues, incomplete data, and lack of appropriate risk stratification of patients, the featured websites may provide erroneous information to the public.

"The Jackson Table Is a Pain in the…": A Qualitative Study of Providers' Perception Toward a Spinal Surgery Table.

PubMed

Asiedu, Gladys B; Lowndes, Bethany R; Huddleston, Paul M; Hallbeck, Susan

2018-03-01

The aim of this study was to define health care providers' perceptions toward prone patient positioning for spine surgery using the Jackson Table, which has not been hitherto explored. We analyzed open-ended questionnaire data and interviews conducted with the spine surgical team regarding the current process of spinal positioning/repositioning using the Jackson Table. Participants were asked to provide an open-ended explanation as to whether they think the current process of spinal positioning/repositioning is safe for the staff or patients. Follow-up qualitative interviews were conducted with 11 of the participants to gain an in-depth understanding of the challenges and safety issues related to prone patient positioning. Data analysis resulted in 6 main categories: general challenges with patient positioning, role-specific challenges, challenges with the Jackson Table and the "sandwich" mechanism, safety concerns for patients, safety concerns for the medical staff, and recommendations for best practices. This study is relevant to everyday practice for spinal surgical team members and advances our understanding of how surgical teams qualitatively view the current process of patient positioning for spinal surgery. Providers recommended best practices for using the Jackson Table, which can be achieved through standardized practice for transfer of patients, educational tools, and checklists for equipment before patient transfer and positioning. This research has identified several important practice opportunities for improving provider and patient safety in spine surgery.

Outcomes of Posterolateral Fusion with and without Instrumentation and of Interbody Fusion for Isthmic Spondylolisthesis: A Prospective Study.

PubMed

Endler, Peter; Ekman, Per; Möller, Hans; Gerdhem, Paul

2017-05-03

Various methods for the treatment of isthmic spondylolisthesis are available. The aim of this study was to compare outcomes after posterolateral fusion without instrumentation, posterolateral fusion with instrumentation, and interbody fusion. The Swedish Spine Register was used to identify 765 patients who had been operated on for isthmic spondylolisthesis and had at least preoperative and 2-year outcome data; 586 of them had longer follow-up (a mean of 6.9 years). The outcome measures were a global assessment of leg and back pain, the Oswestry Disability Index (ODI), the EuroQol-5 Dimensions (EQ-5D) Questionnaire, the Short Form-36 (SF-36), a visual analog scale (VAS) for back and leg pain, and satisfaction with treatment. Data on additional lumbar spine surgery was searched for in the register, with the mean duration of follow-up for this variable being 10.6 years after the index procedure. Statistical analyses were performed with analysis of covariance or competing-risks proportional hazards regression, adjusted for baseline differences in the studied variables, smoking, employment status, and level of fusion. Posterolateral fusion without instrumentation was performed in 102 patients; posterolateral fusion with instrumentation, in 452; and interbody fusion, in 211. At 1 year, improvement was reported in the global assessment for back pain by 54% of the patients who had posterolateral fusion without instrumentation, 68% of those treated with posterolateral fusion with instrumentation, and 70% of those treated with interbody fusion (p = 0.009). The VAS for back pain and reported satisfaction with treatment showed similar patterns (p = 0.003 and p = 0.017, respectively), whereas other outcomes did not differ among the treatment groups at 1 year. At 2 years, the global assessment for back pain indicated improvement in 57% of the patients who had undergone posterolateral fusion without instrumentation, 70% of those who had posterolateral fusion with instrumentation, and 71% of those treated with interbody fusion (p = 0.022). There were no significant outcome differences at the mean 6.9-year follow-up interval. There was an increased hazard ratio for additional lumbar spine surgery after interbody fusion (4.34; 95% confidence interval [CI] = 1.71 to 11.03) and posterolateral fusion with instrumentation (2.56; 95% CI = 1.02 to 6.42) compared with after posterolateral fusion without instrumentation (1.00; reference). Fusion with instrumentation, with or without interbody fusion, was associated with more improvement in back pain scores and higher satisfaction with treatment compared with fusion without instrumentation at 1 year, but the difference was attenuated with longer follow-up. Fusion with instrumentation was associated with a significantly higher risk of additional spine surgery. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Outcome of traditional growing rods for correction of apical vertebra rotation in early-onset scoliosis].

PubMed

Sun, X; Xu, L; Chen, Z H; Chen, X; Du, C Z; Li, S; Liu, Z; Qian, B P; Wang, B; Zhu, Z Z; Qiu, Y

2018-03-01

Objective: To evaluate the correction result of traditional dual growing rods on apical vertebral rotation. Methods: This study recruited 19 early-onset scoliosis patients (6 boys and 13 girls) who had received traditional dual growing rods treatment at Department of Spine Surgery, Nanjing Drum Tower Hospital from January 2009 to July 2015. The age at initial surgery was (5.7±1.7)years(range, 3 to 9 years). Measurements of primary curve magnitude, height of T(1)-S(1), apical vertebral translation(AVR), apical vertebral body-rib ratio, apical vertebral rotation, thoracic rotation and rib hump were compared between pre-operatively, post-operatively, and at latest follow-up, through a paired- t test. Pearson correlation test was used for correlation analysis between parameters. Results: All patients had a follow-up of (49.5±12.8)months(range, 24 to 71 months). A total of 111 operative procedures were performed, among which there were 92 lengthening procedures, averagely 4.8 lengthening procedures per patient. The average interval for each lengthening procedure was 10 months. The Cobb angle of primary curve was notably decreased from (66.5±13.2)° to (35.2±10.9)°( t =24.013, P <0.01), and no significant correction loss was found at the latest follow-up ((36.7±10.7)°)( t =-1.324, P =0.202). In addition, significant correction of AVR, thoracic rotation, apical vertebral translation, apical vertebra body-rib ratio, and rib hump were noted after initial surgery. Whereas, these parameters significant increased during follow-up(all P <0.05) except for thoracic rotation. Pearson correlation analysis showed that the increase of AVR during follow-up significantly correlated with change of apical vertebra translation, apical vertebral body-rib ratio, and rib hump( r =0.652, 0.814, 0.695; all P <0.05). Conclusions: Significant correction of AVR can be achieved after initial surgery in early-onset scoliosis patients treated with traditional dual growing rods. However, such a technique can hardly prevent the deterioration of AVR during follow-up.

Adjunctive vancomycin powder in pediatric spine surgery is safe.

PubMed

Gans, Itai; Dormans, John P; Spiegel, David A; Flynn, John M; Sankar, Wudbhav N; Campbell, Robert M; Baldwin, Keith D

2013-09-01

Therapeutic level II cohort study. To evaluate the safety of adjunctive local application of vancomycin powder (VP) for infection prophylaxis in posterior instrumented thoracic and lumbar spine wounds in pediatric patients weighing more than 25 kg. Spine surgeons have largely turned to vancomycin prophylaxis in an attempt to decrease the incidence of late surgical site infection and acute surgical site infection from methicillin-resistant Staphylococcus aureus. In adult patients, the adjunctive local application of VP with an intravenous cephalosporin has been shown to decrease postsurgical wound infection rates significantly; however, the safety of VP as an adjunct in pediatric spine surgery has not been reported. We reviewed data collected under a systematic protocol specifically designed to monitor the safety profile of VP. We measured changes in creatinine and systemic vancomycin levels after intrawound application of 500 mg of unreconstituted VP during spine deformity correction surgery in patients weighing more than 25 kg (patients also received routine intravenous cephalosporin prophylaxis). Laboratory values were measured preoperatively and on postoperative days 1 and 4. Any adverse reactions and infections through available follow-up (2-8 mo) were recorded. Eighty-seven consecutive pediatric patients with spinal deformity weighing more than 25 kg who received intraoperative VP during a 9-month period were identified. Sixty-three percent of the patients in this series had adolescent idiopathic scoliosis, 15% congenital scoliosis, 15% neuromuscular scoliosis, and 5% spondylolisthesis. The average change in creatinine levels between the preoperative and postoperative day 1 draw was -0.03 and between the preoperative and postoperative day 4 draw was -0.075. The postoperative systemic vancomycin levels remained undetectable. None of the patients experienced nephrotoxicity or red man syndrome. Three of the 87 patients developed a surgical site infection. In this cohort there were no clinically significant changes in creatinine level or systemic vancomycin level caused by use of intraoperative VP. 2.

Local effect of zoledronic acid on new bone formation in posterolateral spinal fusion with demineralized bone matrix in a murine model.

PubMed

Zwolak, Pawel; Farei-Campagna, Jan; Jentzsch, Thorsten; von Rechenberg, Brigitte; Werner, Clément M

2018-01-01

Posterolateral spinal fusion is a common orthopaedic surgery performed to treat degenerative and traumatic deformities of the spinal column. In posteriolateral spinal fusion, different osteoinductive demineralized bone matrix products have been previously investigated. We evaluated the effect of locally applied zoledronic acid in combination with commercially available demineralized bone matrix putty on new bone formation in posterolateral spinal fusion in a murine in vivo model. A posterolateral sacral spine fusion in murine model was used to evaluate the new bone formation. We used the sacral spine fusion model to model the clinical situation in which a bone graft or demineralized bone matrix is applied after dorsal instrumentation of the spine. In our study, group 1 received decortications only (n = 10), group 2 received decortication, and absorbable collagen sponge carrier, group 3 received decortication and absorbable collagen sponge carrier with zoledronic acid in dose 10 µg, group 4 received demineralized bone matrix putty (DBM putty) plus decortication (n = 10), and group 5 received DBM putty, decortication and locally applied zoledronic acid in dose 10 µg. Imaging was performed using MicroCT for new bone formation assessment. Also, murine spines were harvested for histopathological analysis 10 weeks after surgery. The surgery performed through midline posterior approach was reproducible. In group with decortication alone there was no new bone formation. Application of demineralized bone matrix putty alone produced new bone formation which bridged the S1-S4 laminae. Local application of zoledronic acid to demineralized bone matrix putty resulted in significant increase of new bone formation as compared to demineralized bone matrix putty group alone. A single local application of zoledronic acid with DBM putty during posterolateral fusion in sacral murine spine model increased significantly new bone formation in situ in our model. Therefore, our results justify further investigations to potentially use local application of zoledronic acid in future clinical studies.

A New Classification System to Report Complications in Growing Spine Surgery: A Multicenter Consensus Study.

PubMed

Smith, John T; Johnston, Charles; Skaggs, David; Flynn, John; Vitale, Michael

2015-12-01

The use of growth-sparing instrumentation in pediatric spinal deformity is associated with a significant incidence of adverse events. However, there is no consistent way to report these complications, allowing for meaningful comparison of different growth-sparing techniques and strategies. The purpose of this study is to develop consensus for a new classification system to report these complications. The authors, who represent lead surgeons from 5 major pediatric spine centers, collaborated to develop a classification system to report complications associated with growing spine surgery. Following IRB approval, this system was then tested using a minimum of 10 patients from each center with at least 2-year follow-up after initial implantation of growing instrumentation to assess ease of use and consistency in reporting complications. Inclusion criteria were only patients who had surgical treatment of early onset scoliosis and did not include casting or bracing.Complications are defined as an unplanned medical event in the course of treatment that may or may not affect final outcome. Severity refers to the level of care and urgency required to treat the complication, and can be classified as device related or disease related. Severity grade (SV) I is a complication that does not require unplanned surgery, and can be corrected at the next scheduled surgery. SVII requires an unplanned surgery, with SVIIA requiring a single trip and SVIIB needing multiple trips for resolution. SVIII is a complication that substantially alters the planned course of treatment. Disease-related complications are classified as grade SVI if no hospitalization is required and grade SVII if hospitalization is required. SVIV was defined as death, either disease or device related. A total of 65 patients from 5 institutions met enrollment criteria for the study; 56 patients had at least 1 complication and 9 had no complications. There were 14 growing rods, 47 VEPTRs, ,and 4 hybrid constructs. The average age at implant was 4.7 years. There were an average of 5.4 expansions, 1.6 revisions, and 0.8 exchanges per patient. The minimum follow-up was 2 years. The most common complications were migration (60), infection (31), pneumonia (21), and instrumentation failure (23). When classified, the complications were grade I (57), grade IIA (79), grade IIB (10), and grade III (6). Well-documented uncertainty in clinical decision making in this area highlights the need for more rigorous clinical research. Reporting complications standardized for severity and impact on the course of treatment in growing spine surgery is a necessary prerequisite for meaningful comparative evaluation of different treatment options. This study shows that although complications were common, only 9% (SVIII) were severe enough to change the planned course of treatment. We propose that future studies reporting complications of different methods of growth-sparing spine surgery use this classification moving forward so that meaningful comparisons can be made between different treatment techniques.

Mitigating adverse event reporting bias in spine surgery.

PubMed

Auerbach, Joshua D; McGowan, Kevin B; Halevi, Marci; Gerling, Michael C; Sharan, Alok D; Whang, Peter G; Maislin, Greg

2013-08-21

Recent articles in the lay press and literature have raised concerns about the ability to report honest adverse event data from industry-sponsored spine surgery studies. To address this, clinical trials may utilize an independent Clinical Events Committee (CEC) to review adverse events and readjudicate the severity and relatedness accordingly. We are aware of no prior study that has quantified either the degree to which investigator bias is present in adverse event reporting or the effect that an independent CEC has on mitigating this potential bias. The coflex Investigational Device Exemption study is a prospective randomized controlled trial comparing coflex (Paradigm Spine) stabilization with lumbar spinal fusion to treat spinal stenosis and spondylolisthesis. Investigators classified the severity of adverse events (mild, moderate, or severe) and their relationship to the surgery and device (unrelated, unlikely, possibly, probably, or definitely). An independent CEC, composed of three spine surgeons without affiliation to the study sponsor, reviewed and reclassified all adverse event reports submitted by the investigators. The CEC reclassified the level of severity, relation to the surgery, and/or relation to the device in 394 (37.3%) of 1055 reported adverse events. The proportion of adverse events that underwent reclassification was similar in the coflex and fusion groups (37.9% compared with 36.0%, p = 0.56). The CEC was 5.3 (95% confidence interval [CI], 2.6 to 10.7) times more likely to upgrade than downgrade the adverse event. The CEC was 7.3 (95% CI, 5.1 to 10.6) times more likely to upgrade than downgrade the relationship to the surgery and 11.6 (95% CI, 7.5 to 18.8) times more likely to upgrade than downgrade the relationship to the device. The status of the investigator's financial interest in the company had little effect on the reclassification of adverse events. Thirty-seven percent of adverse events were reclassified by the CEC; the large majority of the reclassifications were an upgrade in the level of severity or a designation of greater relatedness to the surgery or device. An independent CEC can identify and mitigate potential inherent investigator bias and facilitate an accurate assessment of the safety profile of an investigational device, and a CEC should be considered a requisite component of future clinical trials.

Impact of Resident Involvement in Neurosurgery: An American College of Surgeons’ National Surgical Quality Improvement Program Database Analysis of 33,977 Patients

PubMed Central

Kumar, Prateek; Seicean, Sinziana; Neuhauser, Duncan; Selman, Warren R.; Bambakidis, Nicholas C.

2018-01-01

Objective There is conflicting and limited literature on the effect of intraoperative resident involvement on surgical outcomes. Our study assessed effects of resident involvement on outcomes in patients undergoing neurosurgery. Methods We identified 33,977 adult neurosurgical cases from 374 hospitals in the 2006–2012 National Surgical Quality Improvement Program, a prospectively collected national database with established reproducibility and validity. Outcomes were compared according to resident involvement before and after 1:1 matching on procedure and perioperative risk factors. Results Resident involvement was documented in 13,654 cases. We matched 10,170 resident-involved cases with 10,170 attending-alone. In the matched sample, resident involvement was associated with increased surgery duration (average, 34 minutes) and slight increases in odds for prolonged hospital stay (odds ratio, 1.2; 95% confidence interval [CI], 1.2–1.3) and complications (odds ratio, 1.2; 95% CI, 1.1–1.3) including infections (odds ratio, 1.4; 95% CI, 1.2–1.7). Increased risk for infections persisted after controlling for surgery duration (odds ratio, 1.3; 95% CI, 1.1–1.5). The majority of cases were spine surgeries, and resident involvement was not associated with morbidity or mortality for malignant tumor and aneurysm patients. Training level of residents was not associated with differences in outcomes. Conclusion Resident involvement was more common in sicker patients undergoing complex procedures, consistent with academic centers undertaking more complex cases. After controlling for patient and intraoperative characteristics, resident involvement in neurosurgical cases continued to be associated with longer surgical duration and slightly higher infection rates. Longer surgery duration did not account for differences in infection rates. PMID:29656619

Image-guided radiofrequency ablation of spinal tumors: preliminary experience with an expandable array electrode.

PubMed

Grönemeyer, Dietrich H W; Schirp, Sven; Gevargez, Athour

2002-01-01

Metastases to the spine are a challenging problem. Percutaneous, image-guided tumor ablation with a thermal energy source, such as radiofrequency, has received increasing attention as a promising technique for the treatment of focal malignant disease. We used radiofrequency ablation for patients with unresectable, osteolytic spine metastases under computed tomographic and fluoroscopic guidance. The purpose of this study was to determine the feasibility, effectiveness, and safety of radiofrequency ablation as a palliative procedure to reduce pain and back pain-related disability in patients with vertebral and paravertebral spine tumors who were not able to benefit from radiotherapy, chemotherapy, or surgery. Between November 1999 and January 2001, 10 patients with unresectable spine metastases were treated with radiofrequency ablation. For the ablation we used a 50-W radiofrequency generator that is connected to an expandable electrode catheter (RITA Medical System Inc., Mountain View, CA). The mean patient age was 64.4 years. Metastases were ablated in the thoracic spine, the lumbar spine, and/or the sacral bone. Tumor diameter ranged from 1.5 to 9 cm. Combined computed tomographic and fluoroscopic guidance was used to guide the procedure. Operations were carried out without heavy sedation with the patient under local anesthesia only. The thermal lesion was produced by applying temperatures of 50 degrees to 120 degrees C for 8-12 minutes. Vertebroplasty was performed in four patients by use of 3 to 5.5 mL of polymethyl methacrylate. Therapy outcome was documented by magnet resonance imaging. Before the therapy and on follow-up of an average of 5.8 months, pain was assessed with the help of the Visual Analogue Scale. Back pain-related disability was measured with the Hannover Functional Ability Questionnaire. Neurologic and health status were documented on the Frankel score and the Karnofsky index. At follow-up, 9 of 10 patients reported reduced pain (Visual Analogue Scale). In patients who experienced pain relief, there was an average relative pain reduction of 74.4%. Back pain-related disability was reduced by an average of 27%. Neurologic function was preserved in nine patients and improved in one. General health was stabilized in six patients, slightly increased (by 10%-20%) in two patients, significantly enhanced (by 50%) in one patient, and slightly reduced in one patient. No complications were reported. In the treated region, magnetic resonance imaging showed no further tumor growth after the therapy. Radiofrequency ablation was successfully performed in all 10 patients. Needles were placed accurately under image guidance, and a controlled lesion was created. Pain- and back pain-related disability was clearly reduced, and neurologic function was preserved or stabilized. When confirmed by further investigation, this therapy may be a new option for patients with unresectable spine tumors that do not respond to radiotherapy and chemotherapy.

Training Standards in Neuroendovascular Surgery: Program Accreditation and Practitioner Certification.

PubMed

Day, Arthur L; Siddiqui, Adnan H; Meyers, Philip M; Jovin, Tudor G; Derdeyn, Colin P; Hoh, Brian L; Riina, Howard; Linfante, Italo; Zaidat, Osama; Turk, Aquilla; Howington, Jay U; Mocco, J; Ringer, Andrew J; Veznedaroglu, Erol; Khalessi, Alexander A; Levy, Elad I; Woo, Henry; Harbaugh, Robert; Giannotta, Steven

2017-08-01

Neuroendovascular surgery is a medical subspecialty that uses minimally invasive catheter-based technology and radiological imaging to diagnose and treat diseases of the central nervous system, head, neck, spine, and their vasculature. To perform these procedures, the practitioner needs an extensive knowledge of the anatomy of the nervous system, vasculature, and pathological conditions that affect their physiology. A working knowledge of radiation biology and safety is essential. Similarly, a sufficient volume of clinical and interventional experience, first as a trainee and then as a practitioner, is required so that these treatments can be delivered safely and effectively. This document has been prepared under the aegis of the Society of Neurological Surgeons and its Committee for Advanced Subspecialty Training in conjunction with the Joint Section of Cerebrovascular Surgery for the American Association of Neurological Surgeons and Congress of Neurological Surgeons, the Society of NeuroInterventional Surgery, and the Society of Vascular and Interventional Neurology. The material herein outlines the requirements for institutional accreditation of training programs in neuroendovascular surgery, as well as those needed to obtain individual subspecialty certification, as agreed on by Committee for Advanced Subspecialty Training, the Society of Neurological Surgeons, and the aforementioned Societies. This document also clarifies the pathway to certification through an advanced practice track mechanism for those current practitioners of this subspecialty who trained before Committee for Advanced Subspecialty Training standards were formulated. Representing neuroendovascular surgery physicians from neurosurgery, neuroradiology, and neurology, the above mentioned societies seek to standardize neuroendovascular surgery training to ensure the highest quality delivery of this subspecialty within the United States. © 2017 American Heart Association, Inc.

Elevated Patient Body Mass Index Does Not Negatively Affect Self-Reported Outcomes of Thoracolumbar Surgery: Results of a Comparative Observational Study with Minimum 1-Year Follow-Up

PubMed Central

Manson, Neil A.; Green, Alana J.; Abraham, Edward P.

2015-01-01

Study Design Retrospective study. Objective Quantify the effect of obesity on elective thoracolumbar spine surgery patients. Methods Five hundred consecutive adult patients undergoing thoracolumbar spine surgery to treat degenerative pathologies with minimum follow-up of at least 1 year were included. Primary outcome measures included Numerical Rating Scales for back and leg pain, the Short Form 36 Physical Component Summary and Mental Component Summary, the modified Oswestry Disability Index, and patient satisfaction scores collected preoperatively and at 3, 6, 12, and 24 months postoperatively. Secondary outcome measures included perioperative and postoperative adverse events, postoperative emergency department presentation, hospital readmission, and revision surgeries. Patients were grouped according to World Health Organization body mass index (BMI) guidelines to isolate the effect of obesity on primary and secondary outcome measures. Results Mean BMI was 30 kg/m2, reflecting a significantly overweight population. Each BMI group reported statistically significant improvement on all self-reported outcome measures. Contrary to our hypothesis, however, there was no association between BMI group and primary outcome measures. Patients with BMI of 35 to 39.99 visited the emergency department with complaints of pain significantly more often than the other groups. Otherwise, we did not detect any differences in the secondary outcome measures between BMI groups. Conclusions Patients of all levels of obesity experienced significant improvement following elective thoracolumbar spine surgery. These outcomes were achieved without increased risk of postoperative complications such as infection and reoperation. A risk–benefit algorithm to assist with surgical decision making for obese patients would be valuable to surgeons and patients alike. PMID:26933611

Trajectory of health-related quality of life and its determinants in patients who underwent lumbar spine surgery: a 1-year longitudinal study.

PubMed

Lin, En-Yuan; Chen, Pin-Yuan; Tsai, Pei-Shan; Lo, Wen-Cheng; Chiu, Hsiao-Yean

2018-06-02

The purpose of the study was to investigate the trajectory and determinants of changes in health-related quality of life (HRQoL) in the first year after lumbar spine surgery. A total of 154 consecutive patients who underwent lumbar spine surgery were included in this prospective longitudinal observational study. All participants were asked to complete a battery of questionnaires (Taiwanese version of World Health Organization Quality of Life-BREF, Numerical Rating Scale for leg and back pain, Mandarin Chinese version of the Clinically Useful Depression Outcome Scale, and Chinese version of the Pittsburgh Sleep Quality Index). The Japanese Orthopedic Association score was evaluated by neurosurgeons. The measurement time points were 1 week before and on the first, sixth, and twelfth month after lumbar spinal surgery. A linear mix model was used for data analyses. The analyses revealed significant upward trends in HRQoL, particularly in physical health and social relationships during the study period. Patients who aged < 65 years and reported a higher level of functional status experienced a more favorable HRQoL in physical health over time (p = .002 and .02, respectively). Participants who complained of poor sleep quality yielded poorer HRQoL in physical health over time (p = .03). More severe depressive symptom was associated with the poorer HRQoL in social relationships over time (p < .001). To improve the HRQoL, healthcare providers need to pay attention to changes in sleep quality, neurological functions, and depressive symptoms in people receiving lumbar surgery, particularly individuals with increasing age. Concrete interventions and strategies aimed to enhancing HRQoL in these patients are essential.

Surgical management of metastatic tumors of the cervical spine.

PubMed

Davarski, Atanas N; Kitov, Borislav D; Zhelyazkov, Christo B; Raykov, Stefan D; Kehayov, Ivo I; Koev, Ilyan G; Kalnev, Borislav M

2013-01-01

To present the results from the clinical presentation, the imaging diagnostics, surgery and postoperative status of 17 patients with cervical spine metastases, to analyse all data and make the respective conclusions and compare them with the available data in the literature. The study analysed data obtained by patients with metastatic cervical tumours treated in St George University Hospital over a period of seven years. All patients underwent diagnostic imaging tests which included, separately or in combination, cervical x-rays, computed tomography scan and magnetic-resonance imaging. Severity of neurological damage and its pre- and postoperative state was graded according to the Frankel Scale. For staging and operating performance we used the Tomita scale and Harrington classification. Seven patients had only one affected vertebra, 4 patients--two vertebrae, one patient--three vertebrae, 2 patients--four vertebrae, and in the other 3 patients more than one segment was affected. Surgery was performed in 12 patients. One level anterior corpectomy was performed in 6 patients, three patients had two-level surgery, and one patient--three-level corpectomy; in the remaining 2 cases we used posterior approach in surgery. Complete corpectomy was performed in 4 patients, subtotal corpectomy was used in 6 patients and partial--in 2 patients. Anterior stabilization system ADD plus (Ulrich GmbH & Co. KG, Ulm, Germany) was implanted in 2 patients; in 8 patients anterior titanium plate and bone graft were used, and in 1 patient--posterior cervical stabilization system. Because of the pronounced pain syndrome and frequent neurological lesions as a result of the cervical spine metastases use of surgery is justified. The main purpose is to maximize tumor resection, achieve optimal spinal cord and nerve root decompression and stabilize the affected segment.

Poor Nutrition Status and Lumbar Spine Fusion Surgery in the Elderly: Readmissions, Complications, and Mortality.

PubMed

Puvanesarajah, Varun; Jain, Amit; Kebaish, Khaled; Shaffrey, Christopher I; Sciubba, Daniel M; De la Garza-Ramos, Rafael; Khanna, Akhil Jay; Hassanzadeh, Hamid

2017-07-01

Retrospective database review. To quantify the medical and surgical risks associated with elective lumbar spine fusion surgery in patients with poor preoperative nutritional status and to assess how nutritional status alters length of stay and readmission rates. There has been recent interest in quantifying the increased risk of complications caused by frailty, an important consideration in elderly patients that is directly related to comorbidity burden. Preoperative nutritional status is an important contributor to both sarcopenia and frailty and is poorly studied in the elderly spine surgery population. The full 100% sample of Medicare data from 2005 to 2012 were utilized to select all patients 65 to 84 years old who underwent elective 1 to 2 level posterior lumbar fusion for degenerative pathology. Patients with diagnoses of poor nutritional status within the 3 months preceding surgery were selected and compared with a control cohort. Outcomes that were assessed included major medical complications, infection, wound dehiscence, and mortality. In addition, readmission rates and length of stay were evaluated. When adjusting for demographics and comorbidities, malnutrition was determined to result in significantly increased odds of both 90-day major medical complications (adjusted odds ratio, OR: 4.24) and 1-year mortality (adjusted OR: 6.16). Multivariate analysis also demonstrated that malnutrition was a significant predictor of increased infection (adjusted OR: 2.27) and wound dehiscence (adjusted OR: 2.52) risk. Length of stay was higher in malnourished patients, though 30-day readmission rates were similar to controls. Malnutrition significantly increases complication and mortality rates, whereas also significantly increasing length of stay. Nutritional supplementation before surgery should be considered to optimize postoperative outcomes in malnourished individuals. 3.

Surgical management of contiguous multilevel thoracolumbar tuberculous spondylitis.

PubMed

Qureshi, Muhammad Asad; Khalique, Ahmed Bilal; Afzal, Waseem; Pasha, Ibrahim Farooq; Aebi, Max

2013-06-01

Tuberculous spondylitis (TBS) is the most common form of extra-pulmonary tuberculosis. The mainstay of TBS management is anti-tuberculous chemotherapy. Most of the patients with TBS are treated conservatively; however in some patients surgery is indicated. Most common indications for surgery include neurological deficit, deformity, instability, large abscesses and necrotic tissue mass or inadequate response to anti-tuberculous chemotherapy. The most common form of TBS involves a single motion segment of spine (two adjoining vertebrae and their intervening disc). Sometimes TBS involves more than two adjoining vertebrae, when it is called multilevel TBS. Indications for correct surgical management of multilevel TBS is not clear from literature. We have retrospectively reviewed 87 patients operated in 10 years for multilevel TBS involving the thoracolumbar spine at our spine unit. Two types of surgeries were performed on these patients. In 57 patients, modified Hong Kong operation was performed with radical debridement, strut grafting and anterior instrumentation. In 30 patients this operation was combined with pedicle screw fixation with or without correction of kyphosis by osteotomy. Patients were followed up for correction of kyphosis, improvement in neurological deficit, pain and function. Complications were noted. On long-term follow-up (average 64 months), there was 9.34 % improvement in kyphosis angle in the modified Hong Kong group and 47.58 % improvement in the group with pedicle screw fixation and osteotomy in addition to anterior surgery (p < 0.001). Seven patients had implant failures and revision surgeries in the modified Hong Kong group. Neurological improvement, pain relief and functional outcome were the same in both groups. We conclude that pedicle screw fixation with or without a correcting osteotomy should be added in all patients with multilevel thoracolumbar tuberculous spondylitis undergoing radical debridement and anterior column reconstruction.

Failed less invasive lumbar spine surgery as a predictor of subsequent fusion outcomes.

PubMed

Gillard, Douglas M; Corenman, Donald S; Dornan, Grant J

2014-04-01

It is not uncommon for patients to undergo less invasive spine surgery (LISS) prior to succumbing to lumbar fusion; however, the effect of failed LISS on subsequent fusion outcomes is relatively unknown. The aim of this study was to test the hypothesis that patients who suffered failed LISS would afford inferior subsequent fusion outcomes when compared to patients who did not have prior LISS. After IRB approval, registry from a spine surgeon was queried for consecutive patients who underwent fusion for intractable low back pain. The 47 qualifying patients were enrolled and split into two groups based upon a history for prior LISS: a prior surgery group (PSG) and a non-prior surgery group (nPSG). Typical postoperative outcome questionnaires, which were available in 80.9% of the patients (38/47) at an average time point of 40.4 months (range, 13.5-66.1 months), were comparatively analysed and failed to demonstrate significant difference between the groups, e.g. PSG v. nPSG: ODI--14.6 ± 10.9 vs. 17.2 ± 19.4 (P = 0.60); SF12-PCS--10.9 ± 11.0 vs. 8.7 ± 12.4 (p = 0.59); bNRS--3.0 (range -2-7) vs. 2.0 (range -3-8) (p = 0.91). Patient satisfaction, return to work rates, peri-operative complications, success of fusion and rate of revision surgery were also not different. Although limited by size and retrospective design, the results of this rare investigation suggest that patients who experience a failed LISS prior to undergoing fusion will not suffer inferior fusion outcomes when compared to patients who did not undergo prior LISS.

A Randomized Controlled Trial of Low-Dose Tranexamic Acid versus Placebo to Reduce Red Blood Cell Transfusion During Complex Multilevel Spine Fusion Surgery.

PubMed

Carabini, Louanne M; Moreland, Natalie C; Vealey, Ryan J; Bebawy, John F; Koski, Tyler R; Koht, Antoun; Gupta, Dhanesh K; Avram, Michael J

2018-02-01

Multilevel spine fusion surgery for adult deformity correction is associated with significant blood loss and coagulopathy. Tranexamic acid reduces blood loss in high-risk surgery, but the efficacy of a low-dose regimen is unknown. Sixty-one patients undergoing multilevel complex spinal fusion with and without osteotomies were randomly assigned to receive low-dose tranexamic acid (10 mg/kg loading dose, then 1 mg·kg -1 ·hr -1 throughout surgery) or placebo. The primary outcome was the total volume of red blood cells transfused intraoperatively. Thirty-one patients received tranexamic acid, and 30 patients received placebo. Patient demographics, risk of major transfusion, preoperative hemoglobin, and surgical risk of the 2 groups were similar. There was a significant decrease in total volume of red blood cells transfused (placebo group median 1460 mL vs. tranexamic acid group 1140 mL; median difference 463 mL, 95% confidence interval 15 to 914 mL, P = 0.034), with a decrease in cell saver transfusion (placebo group median 490 mL vs. tranexamic acid group 256 mL; median difference 166 mL, 95% confidence interval 0 to 368 mL, P = 0.042). The decrease in packed red blood cell transfusion did not reach statistical significance (placebo group median 1050 mL vs. tranexamic acid group 600 mL; median difference 300 mL, 95% confidence interval 0 to 600 mL, P = 0.097). Our results support the use of low-dose tranexamic acid during complex multilevel spine fusion surgery to decrease total red blood cell transfusion. Copyright © 2017 Elsevier Inc. All rights reserved.

Comparison of lifetime incremental cost:utility ratios of surgery relative to failed medical management for the treatment of hip, knee and spine osteoarthritis modelled using 2-year postsurgical values

PubMed Central

Tso, Peggy; Walker, Kevin; Mahomed, Nizar; Coyte, Peter C.; Rampersaud, Y. Raja

2012-01-01

Background Demand for surgery to treat osteoarthritis (OA) of the hip, knee and spine has risen dramatically. Whereas total hip (THA) and total knee arthroplasty (TKA) have been widely accepted as cost-effective, spine surgeries (decompression, decompression with fusion) to treat degenerative conditions remain underfunded compared with other surgeries. Methods An incremental cost–utility analysis comparing decompression and decompression with fusion to THA and TKA, from the perspective of the provincial health insurance system, was based on an observational matched-cohort study of prospectively collected outcomes and retrospectively collected costs. Patient outcomes were measured using short-form (SF)-36 surveys over a 2-year follow-up period. Utility was modelled over the lifetime, and quality-adjusted life years (QALYs) were determined. We calculated the incremental cost per QALY gained by estimating mean incremental lifetime costs and QALYs of surgery compared with medical management of each diagnosis group after discounting costs and QALYs at 3%. Sensitivity analyses were also conducted. Results The lifetime incremental cost:utility ratios (ICURs) discounted at 3% were $5321 per QALY for THA, $11 275 per QALY for TKA, $2307 per QALY for spinal decompression and $7153 per QALY for spinal decompression with fusion. The sensitivity analyses did not alter the ranking of the lifetime ICURs. Conclusion In appropriately selected patients with leg-dominant symptoms secondary to focal lumbar spinal stenosis who have failed medical management, the lifetime ICUR for surgical treatment of lumbar spinal stenosis is similar to those of THA and TKA for the treatment of OA. PMID:22630061

4- and 5-level anterior fusions of the cervical spine: review of literature and clinical results

PubMed Central

Koller, Heiko; Ferraris, Luis; Maier, Oliver; Hitzl, Wolfgang; Metz-Stavenhagen, Peter

2007-01-01

In the future, there will be an increased number of cervical revision surgeries, including 4- and more-levels. But, there is a paucity of literature concerning the geometrical and clinical outcome in these challenging reconstructions. To contribute to current knowledge, we want to share our experience with 4- and 5-level anterior cervical fusions in 26 cases in sight of a critical review of literature. At index procedure, almost 50% of our patients had previous cervical surgeries performed. Besides failed prior surgeries, indications included degenerative multilevel instability and spondylotic myelopathy with cervical kyphosis. An average of 4.1 levels was instrumented and fused using constrained (26.9%) and non-constrained (73.1%) screw-plate systems. At all, four patients had 3-level corpectomies, and three had additional posterior stabilization and fusion. Mean age of patients at index procedure was 54 years with a mean follow-up intervall of 30.9 months. Preoperative lordosis C2-7 was 6.5° in average, which measured a mean of 15.6° at last follow-up. Postoperative lordosis at fusion block was 14.4° in average, and 13.6° at last follow-up. In 34.6% of patients some kind of postoperative change in construct geometry was observed, but without any catastrophic construct failure. There were two delayed unions, but finally union rate was 100% without any need for the Halo device. Eleven patients (42.3%) showed an excellent outcome, twelve good (46.2%), one fair (3.8%), and two poor (7.7%). The study demonstrated that anterior-only instrumentations following segmental decompressions or use of the hybrid technique with discontinuous corpectomies can avoid the need for posterior supplemental surgery in 4- and 5-level surgeries. However, also the review of literature shows that decreased construct rigidity following more than 2-level corpectomies can demand 360° instrumentation and fusion. Concerning construct rigidity and radiolographic course, constrained plates did better than non-constrained ones. The discussion of our results are accompanied by a detailed review of literature, shedding light on the biomechanical challenges in multilevel cervical procedures and suggests conclusions. PMID:17605052

Etiology of Readmissions Following Orthopaedic Procedures and Medical Admissions. A Comparative Analysis.

PubMed

Maslow, Jed; Hutzler, Lorraine; Slover, James; Bosco, Joseph

2015-12-01

The Federal Government, the largest payer of health care, considers readmission within 30 days of discharge an indicator of quality of care. Many studies have focused on causes for and strategies to reduce readmissions following medical admissions. However, few studies have focused on the differences between them. We believe that the causes for readmission following orthopaedic surgery are markedly different than those following medical admissions, and therefore, the strategies developed to reduce medical readmissions will not be as effective in reducing readmissions after elective orthopaedic surgery. All unplanned 30-day readmissions following an index hospitalization for an elective orthopaedic procedure (primary and revision total joint arthroplasty and spine procedure) or for one of the three publicly reported medical conditions (AMI, HF, and pneumonia, which accounted for 11% of readmissions) were identified at our institution from 2010 through 2012. A total of 268 patients and 390 medical patients were identified as having an unplanned 30-day readmission. We reviewed a prospectively collected data base to determine the reason for readmission in each encounter. A total of 233 (86.9%) orthopaedic patients were readmitted for surgical complications, most commonly for a wound infection (56.0%) or wound complication (11.6%). Following an index admission of HF or AMI, the primary reason for readmission was a disease of the circulatory system (55.9% and 57.4%, respectively). Following an index admission for pneumonia, the primary reason for readmission was a disease of the respiratory system (34.5%). The causes of readmissions following orthopaedic surgery and medical admissions are different. Patients undergoing orthopaedic procedures are readmitted for surgical complications, frequently unrelated to aftercare, and medicine patients are readmitted for reasons related to the index diagnosis. Interventions designed to reduce orthopaedic readmissions must focus on reducing surgical complications, differing from interventions designed to reduce readmissions following medical admissions, which focus on medical diagnoses.

Surgery of violence. V. Missile wounds of the head and spine.

PubMed Central

Gordon, D S

1975-01-01

The patient with a cerebral gunshot wound has a very unstable condition. In Belfast emphasis has been laid on rapid evacuation and on starting resuscitation within a few minutes of injury. Early and adequate transfusion combats shock; controlled ventilation helps limit the rise in intracranial pressure. Intracranial haematomata should be sought by early operation. Operation seldom improves neurological function in missile wounds of the spine. PMID:1125629

Anterior cervical pedicle screw and plate fixation using fluoroscope-assisted pedicle axis view imaging: a preliminary report of a new cervical reconstruction technique

PubMed Central

Kato, Fumihiko; Ito, Keigo; Nakashima, Hiroaki; Machino, Masaaki

2009-01-01

Anterior procedures in the cervical spine are feasible in cases having anterior aetiologies such as anterior neural compression and/or severe kyphosis. Halo vests or anterior plates are used concurrently for cases with long segmental fixation. Halo vests are bothersome and anterior plate fixation is not adequately durable. We developed a new anterior pedicle screw (APS) and plate fixation procedure that can be used with fluoroscope-assisted pedicle axis view imaging. Six patients (3 men and 3 women; mean age, 54 years) with anterior multisegmental aetiology were included in this study. Their original diagnoses comprised cervical myelopathy and/or radiculopathy (n = 4), posterior longitudinal ligament ossification (n = 1) and post-traumatic kyphosis (n = 1). All patients underwent anterior decompression and strut grafting with APS and plate fixation. Mean operative time was 192 min and average blood loss was 73 ml. Patients were permitted to ambulate the next day with a cervical collar. Local sagittal alignment was characterised by 3.5° of kyphosis preoperatively, which improved to 6.8° of lordosis postoperatively and 5.2° of lordosis at final follow-up. Postoperative improvement and early bony union were observed in all cases. There was no serious complication except for two cases of dysphagia. Postoperative imaging demonstrated screw exposure in one screw, but no pedicle perforation. APS and plate fixation is useful in selected cases of multisegmental anterior reconstruction of cervical spine. However, the adequate familiarity and experience with both cervical pedicle screw fixation and the imaging technique used for visualising the pedicle during surgery are crucial for this procedure. PMID:19343377

Three-column osteotomy surgery versus standard surgical management for the correction of adult spinal deformity: a cohort study.

PubMed

Ji, Xinran; Chen, Hua; Zhang, Yiling; Zhang, Lihai; Zhang, Wei; Berven, Sigurd; Tang, Peifu

2015-02-03

The aim of this study was to analyze and compare the surgical data, clinical outcomes, and complications between three-column osteotomy (3-COS) and standard surgical management (SSM) for the treatment of adult spine deformity (ASD). A total of 112 patients who underwent consecutive 3-COS (n = 48) and SSM (n = 64) procedures for ASD correction at a single institution from 2001 to 2011 were reviewed in this study. The outcomes were assessed using the Scoliosis Research Society (SRS)-22 scores. The complications of patients with 3-COS and SSM were also compared. No significant differences were found in patient characteristics between SSM and 3-COS groups. Surgical data and radiographic parameters showed that the patients of the 3-COS group suffered more severe ASD than those of the SSM group. The distribution of surgical complications revealed that SSM group underwent more complications than 3-COS groups with no significant differences. At final follow-up, the total SRS-22 score of SSM was not significant between pre-operation and post-operation. However, the total SRS-22 score of 3-COS at final follow-up was significantly higher than pre-operation. For severe ASD patients with high grade pelvic incidence (PI), pelvic tilt (PT), and PI/lumbar lordosis (LL) mismatch and who have subjected to spine surgeries more than twice before, 3-COS might be more effective than SSM in improving the clinical outcomes. However, due to the higher reoperation rate of 3-COS, SSM may be more appropriate than SSM for correcting the not serious ASD patients.

CT-guided infiltration saves surgical intervention and fastens return to work compared to anatomical landmark-guided infiltration in patients with lumbosciatica.

PubMed

Deml, Moritz C; Buhr, Michael; Wimmer, Matthias D; Pflugmacher, Robert; Riedel, Rainer; Rommelspacher, Yorck; Kabir, Koroush

2015-07-01

Infiltration procedures are a common treatment of lumbar radiculopathy. There is a wide variety of infiltration techniques without an established gold standard. Therefore, we compared the effectiveness of CT-guided transforaminal infiltrations versus anatomical landmark-guided transforaminal infiltrations at the lower lumbar spine in case of acute sciatica at L3-L5. A retrospective chart review was conducted of 107 outpatients treated between 2009 and 2011. All patients were diagnosed with lumbar radiculopathic pain secondary to disc herniation in L3-L5. A total of 52 patients received CT-guided transforaminal infiltrations; 55 patients received non-imaging-guided nerve root infiltrations. The therapeutic success was evaluated regarding number of physician contacts, duration of treatment, type of analgesics used and loss of work days. Defined endpoint was surgery at the lower lumbar spine. In the CT group, patients needed significantly less oral analgesics (p < 0.001). Overall treatment duration and physician contacts were significantly lower in the CT group (p < 0.001 and 0.002) either. In the CT group, patients lost significant fewer work days due to incapacity (p < 0.001). Surgery had to be performed in 18.2 % of the non-imaging group patients (CT group: 1.9 %; p = 0.008). This study shows that CT-guided periradicular infiltration in lumbosciatica caused by intervertebral disc herniation is significantly superior to non-imaging, anatomical landmark-guided infiltration, regarding the parameters investigated. The high number of treatment failures in the non-imaging group underlines the inferiority of this treatment concept.

Robotic digital subtraction angiography systems within the hybrid operating room.

PubMed

Murayama, Yuichi; Irie, Koreaki; Saguchi, Takayuki; Ishibashi, Toshihiro; Ebara, Masaki; Nagashima, Hiroyasu; Isoshima, Akira; Arakawa, Hideki; Takao, Hiroyuki; Ohashi, Hiroki; Joki, Tatsuhiro; Kato, Masataka; Tani, Satoshi; Ikeuchi, Satoshi; Abe, Toshiaki

2011-05-01

Fully equipped high-end digital subtraction angiography (DSA) within the operating room (OR) environment has emerged as a new trend in the fields of neurosurgery and vascular surgery. To describe initial clinical experience with a robotic DSA system in the hybrid OR. A newly designed robotic DSA system (Artis zeego; Siemens AG, Forchheim, Germany) was installed in the hybrid OR. The system consists of a multiaxis robotic C arm and surgical OR table. In addition to conventional neuroendovascular procedures, the system was used as an intraoperative imaging tool for various neurosurgical procedures such as aneurysm clipping and spine instrumentation. Five hundred one neurosurgical procedures were successfully conducted in the hybrid OR with the robotic DSA. During surgical procedures such as aneurysm clipping and arteriovenous fistula treatment, intraoperative 2-/3-dimensional angiography and C-arm-based computed tomographic images (DynaCT) were easily performed without moving the OR table. Newly developed virtual navigation software (syngo iGuide; Siemens AG) can be used in frameless navigation and in access to deep-seated intracranial lesions or needle placement. This newly developed robotic DSA system provides safe and precise treatment in the fields of endovascular treatment and neurosurgery.

Use of minimally invasive spine surgical instruments for the treatment of bone tumors.

PubMed

Reeves, Russell A; DeWolf, Matthew C; Shaughnessy, Peter J; Ames, James B; Henderson, Eric R

2017-11-01

Orthopedic oncologists often encounter patients with minor bony lesions that are difficult to access surgically and therefore require large exposures out of proportion to the severity of disease that confer significant patient morbidity. Minimally invasive surgical techniques offer the advantage of smaller incisions, shorter operative times, decreased tissue damage, and decreased costs. A variety of surgical procedures have emerged using minimally invasive technologies, particularly in the field of spine surgery. Areas covered: In this article, we describe the Minimal Exposure Tubular Retractor (METRx TM ) System which is a minimally invasive surgical device that utilizes a series of dilators to permit access to a surgical site of interest. This system was developed for use in treatment of disc herniation, spinal stenosis, posterior lumbar interbody fusion, transforaminal lumbar interbody fusion and spinal cord stimulation implantation. We also describe novel uses of this system for minimally invasive biopsy and treatment of benign and metastatic bone lesions at our institution. Expert commentary: Minimally invasive surgical techniques will continue to expand into the field of orthopedic oncology. With a greater number of studies proving the safety and effectiveness of this technique, the demand for minimally invasive treatments will grow.

Percutaneous anterolateral balloon kyphoplasty for metastatic lytic lesions of the cervical spine

PubMed Central

Anagnostidis, Kleovoulos S.; AlZeer, Ziad; Kapetanos, George A.

2010-01-01

The purpose of our report is to describe a new application of kyphoplasty, the percutaneous anterolateral balloon kyphoplasty that we performed in two cases of metastatic osteolytic lesions in cervical spine. The first patient, aged 48 years, with primary malignancy in lungs had two metastatic lesions in C2 and C6 vertebrae. Patient’s complaints were about pain and restriction of movements (due to the pain) in the cervical spine. The second patient, aged 70 years, with primary malignancy in stomach, had multiple metastatic lesions in thoracolumbar spine and C3, C4 and C5 vertebrae without neurological symptoms. The main symptoms were from cervical spine with severe pain even in bed rest and systematic use of opiate-base analgesis. The preoperative status was evaluated with X-rays, CT scan, MRI scan and with Karnofsky score and visual analogue pain (VAS) scale. Both patients underwent percutaneous anterolateral balloon kyphoplasty via the anterolateral approach in cervical spine under general anaesthesia. No clinical complications occurred during or after the procedure. Both patients experienced pain relief immediately after balloon kyphoplasty and during the following days. The stiffness also resolved rapidly and cervical collars were removed. VAS score significantly improved from 85 and 95 preoperatively to 30 in both patients. Karnofsky score showed also improvement from 40 and 30 preoperatively to 80 and 70, respectively, at the final follow-up (7 months after the procedure). Fluoroscopy-guided percutaneous anterolateral ballon kyphoplasty proved to be safe and effective minimally invasive procedure for metastatic osteolytic lesions of the cervical spine, reducing pain and avoiding vertebral collapse. Experience and attention are necessary in order to avoid complications. PMID:20499113

The Internet as a communication tool for orthopedic spine fellowships in the United States.

PubMed

Silvestre, Jason; Guzman, Javier Z; Skovrlj, Branko; Overley, Samuel C; Cho, Samuel K; Qureshi, Sheeraz A; Hecht, Andrew C

2015-04-01

Orthopedic residents seeking additional training in spine surgery commonly use the Internet to manage their fellowship applications. Although studies have assessed the accessibility and content of Web sites in other medical specialties, none have looked at orthopedic spine fellowship Web sites (SFWs). The purpose of this study was to evaluate the accessibility of information from commonly used databases and assess the content of SFWs. This was a Web site accessibility and content evaluation study. A comprehensive list of available orthopedic spine fellowship programs was compiled by accessing program lists from the SF Match, North American Spine Society, Fellowship and Residency Electronic Interactive Database (FREIDA), and Orthopaedicsone.com (Ortho1). These databases were assessed for accessibility of information including viable links to SFWs and responsive program contacts. A Google search was used to identify SFWs not readily available on these national databases. SFWs were evaluated based on online education and recruitment content. Evaluators found 45 SFWs of 63 active programs (71%). Available SFWs were often not readily accessible from national program lists, and no program afforded a direct link to their SFW from SF Match. Approximately half of all programs responded via e-mail. Although many programs described surgical experience (91%) and research requirements (87%) during the fellowship, less than half mentioned didactic instruction (46%), journal clubs (41%), and national meetings or courses attended (28%). Evaluators found an average 45% of fellow recruitment content. Comparison of SFWs by program characteristics revealed three significant differences. Programs with greater than one fellowship position had greater online education content than programs with a single fellow (p=.022). Spine fellowships affiliated with an orthopedic residency program maintained greater education (p=.006) and recruitment (p=.046) content on their SFWs. Most orthopedic spine surgery programs underuse the Internet for fellow education and recruitment. The inaccessibility of information and paucity of content on SFWs allow for future opportunity to optimize these resources. Copyright © 2015 Elsevier Inc. All rights reserved.