Neurosurgery Blog


Daily bibliographic review of the Neurosurgery Department. La Fe University Hospital. Valencia, Spain

Design and Testing of 2 Novel Scores That Predict Global Sagittal Alignment Utilizing Cervical or Lumbar Plain Radiographs

Neurosurgery 82:163–171, 2018

Global sagittal deformity is an established cause of disability. However, measurements of sagittal alignment are often ignored when patients present with symptoms localizing to the cervical or lumbar spine.

OBJECTIVE: To develop scoring scales to predict the risk of sagittal malalignment in patients with only cervical or lumbar spine radiographs.

METHODS: A retrospective review of a prospectively maintained multicenter adult spinal deformity database was performed. Primary outcome (sagittal malalignment) was defined as a C7 plumbline ≥ 50 mm. Two multivariate logistic regressions were performed using patient characteristics and measurements derived from cervical or lumbar radiographs as covariates. Point scores were assigned to age, body mass index (BMI), and lumbar lordosis or T1 slope by rounding their ß coefficients to the nearest integer.

RESULTS: Nine hundred seventy-nine patients were included, with 652 randomly assigned to the derivation cohort (used to build the score) and 327 comprising the validation set. Final cervical score for the primary outcome included BMI ≥ 25 (1 point), age ≥ 55 yr (2 points), and T1 slope ≥ 27º (2 points). Final lumbar score for the primary outcome included BMI≥25 (1 point), age≥55 yr (1 point), and lumbar lordosis ≥45º (–1 points). High scores for both the cervical and lumbar spine presented with high specificity and positive likelihood ratios of sagittal malalignment.

CONCLUSION: We developed scoring scales to predict global sagittal malalignment utilizing clinical covariates and cervical or lumbar radiographs. Patients with high scores may prompt imaging with long-cassette plain films to evaluate for global sagittal imbalance.

Endoscopic Transseptal Approach with Posterior Nasal Spine Removal: A Wide Surgical Corridor to the Craniovertebral Junction and Odontoid

World Neurosurg. (2018) 110:373-385

The transnasal approach to lesions involving the craniovertebral junction represents a technical challenge because of limited inferior exposure. The endoscopic transseptal approach (EtsA) with posterior nasal spine (PNS) removal is described. This technique can create a wide exposure of the craniovertebral junction, thereby increasing the caudal exposure.

METHODS: On patients undergoing anterior craniovertebral junction decompression, we calculated the degree of exposure on the sagittal plan through a paraseptal route, an EtsA without and with PNS removal. The horizontal exposure and working area with the latter approach were also evaluated.

RESULTS: Five patients underwent the transnasal procedure. The age of patients ranged from 34-71 years. All patients harbored basilar impression. The mean postoperative Nurick grade was improved versus the average preoperative grade. The average follow-up duration was 16 months. All patients underwent occipitocervical fixation. The mean vertical distances, from the clinoid recess to the inferior most limit with the paraseptal approach, EtsA without and with PNS removal were 38.52, 44.12, and 51.16 mm, respectively. The difference between our approach and a standard paraseptal route was statistically significant (P [ 0.041; P< 0.05). The mean horizontal distances were 31.68 mm (mononostril entry) and 35.37 mm (binostril entry). The mean working area was 1795.53 mm2.

CONCLUSIONS: Endoscopic endonasal approaches to the craniovertebral junction are increasing, but the downward extension on the anterior cervical spine represents a limit. Therefore, many surgeons prefer transoral or transcervical approaches. The EtsA with PNS removal allows for a more caudal exposure than the standard paraseptal approach, with reduced nasal trauma.


Reduced Field-of-View Diffusion Tensor Imaging of the Spinal Cord Shows Motor Dysfunction of the Lower Extremities in Patients With Cervical Compression Myelopathy

Spine 2018;43:89–96

Study Design. A cross-sectional study.

Objective. The aim of this study was to quantify spinal cord dysfunction at the tract level in patients with cervical compressive myelopathy (CCM) using reduced field-of-view (rFOV) diffusion tensor imaging (DTI).

Summary of Background Data. Although magnetic resonance imaging (MRI) is the standard used for radiological evaluation of CCM, information acquired by MRI does not necessarily reflect the severity of spinal cord disorder. There is a growing interest in developing imaging methods to quantify spinal cord dysfunction. To acquire high-resolution DTI, a new scheme using rFOV has been proposed.

Methods. We enrolled 10 healthy volunteers and 20 patients with CCM in this study. The participants were studied using a 3.0-T MRI system. For DTI acquisitions, diffusion-weighted spinecho rFOV single-shot echo-planar imaging was used. Regions of interest (ROI) for the lateral column (LC) and posterior column (PC) tracts were determined on the basis of a map of fractional anisotropy (FA) of the spinal cord and FA values were measured. The FA of patients with CCM was compared with that of healthy controls and correlated with Japanese Orthopaedic Association (JOA) score.

Results. In LC and PC tracts, FA values in patients with CCM were significantly lower than in healthy volunteers. Total JOA scores correlated moderately with FA in LC and PC tracts. JOA subscores for motor dysfunction of the lower extremities correlated strongly with FA in LC and PC tracts.

Conclusion. It is feasible to evaluate the cervical spinal cord at the tract level using rFOV DTI. Although FA values at the maximum compression level were not well correlated with total JOA scores, they were strongly correlated with JOA subscores for motor dysfunction of the lower extremities. Our findings suggest that FA reflects white matter dysfunction below the maximum compression level and FA can be used as an imaging biomarker of spinal cord dysfunction.

Key words: . Level of Evidence: 4

Clinical and Radiological Mid-Term Outcomes of Lumbar Single-Level Total Disc Replacement

Spine 2018;43:105–113

Study Design. Prospective single-center case cohort study. Objective. Evaluation of clinical and radiographic outcomes of a consecutive 122-patient cohort with discogenic back pain, at 2- to 10-year follow-up periods, treated by a single surgeon, with CHARITE Artificial Disc (DePuy Spine, Raynham, MA).

Summary of Background Data. Minimum 2-year clinical and radiographic level 1 data for the first lumbar artificial disc, the CHARITE Artificial Disc (DePuy Spine), have recently been published, demonstrating sustained clinical benefit of the device for the treatment of degenerative disc disease.

Methods. Patients were assessed preoperatively using clinical outcome measures, including visual analog scale (VAS) score back and leg, Oswestry Disability Index (ODI), 36-Item Short Form Health Survey (SF-36), and Roland-Morris Questionnaires (RMDQ), and further assessed postoperatively, 3-, 6-, 12-months, and yearly thereafter.

Results. Average follow-up was 44.9±3.3 months (n=122). The median age at surgery was 43.0±9.0 years. Preoperative diagnosis included degenerative disc disease in 118 (96.7%) and internal disc disruption in 4 (3.3%). Surgery was performed at L5–S1 in 96 (77.9%) patients and at L4–L5 in 27 (22.1%). Statistically significant clinical improvements from baseline were observed on VAS (back and leg), ODI, SF-36 PCS, SF-36 MCS, and RMDQ 3 months onward. Back VAS scores decreased from 78.221.3 preoperatively to 21.927.8 by final follow-up. ODI scores decreased from 51.117.3 to 16.217.9 at last follow-up. The RMDQ scores also decreased from 16.7±4.7 to 4.2±5.8. SF-36 PCS and MCS increased from 25.7±11.0 to 46.4±10.3 for PCS and from 35.5±17.4 to 51.6±10.8 for MCS. Patient satisfaction surveys indicated that 90.56% patients rated their satisfaction with the surgery as ‘‘excellent’’ or ‘‘good’’ at 2 years. Range of motion averaged 8.6±3.5 (median=8.08) at the last follow-up time point.

Conclusion. Outcomes verify the clinical efficacy of total disc replacement for treatment of discogenic back pain with or without radiculopathy. The outcomes instruments demonstrated statistically significant improvements 3 months onward.

A New Volumetric Radiologic Method to Assess Indirect Decompression After Extreme Lateral Interbody Fusion Using High-Resolution Intraoperative Computed Tomography

World Neurosurg. (2018)109:59-67

Two-dimensional radiographic methods have been proposed to evaluate the radiographic outcome after indirect decompression through extreme lateral interbody fusion (XLIF). However, the assessment of neural decompression in a single plane may underestimate the effect of indirect decompression on central canal and foraminal volumes. The present study aimed to assess the reliability and consistency of a novel 3-dimensional radiographic method that assesses neural decompression by volumetric analysis using a new generation of intraoperative fan-beam computed tomography scanner in patients undergoing XLIF.

METHODS: Prospectively collected data from 7 patients (9 levels) undergoing XLIF was retrospectively analyzed. Three independent, blind raters using imaging analysis software performed volumetric measurements pre- and postoperatively to determine central canal and foraminal volumes. Intrarater and Interrater reliability tests were performed to assess the reliability of this novel volumetric method.

RESULTS: The interrater reliability between the three raters ranged from 0.800 to 0.952, P < 0.0001. The test-retest analysis on a randomly selected subset of three patients showed good to excellent internal reliability (range of 0.78e1.00) for all 3 raters. There was a significant increase in mean ±20% for right foramen, left foramen, and central canal volumes postoperatively (P = 0.0472; P = 0.0066; P = 0.0003, respectively).

CONCLUSIONS: Here we demonstrate a new volumetric analysis technique that is feasible, reliable, and reproducible amongst independent raters for central canal and foraminal volumes in the lumbar spine using an intraoperative computed tomography scanner


Clinical Presentation, Diagnosis, and Surgical Treatment of Spontaneous Cervical Intradural Disc Herniations

World Neurosurg. (2018) 109:275-284

Spontaneous cervical intradural disc herniation (IDH) is a rare occurrence with limited and disparate information available regarding its presentation, diagnosis, and treatment. However, its accurate detection is vital for planning surgical treatment. In this review of the literature, we collected data from all cervical IDHs described to date. Particular attention was paid to diagnostic findings, surgical approach, and causation for cervical IDH, especially at the cervicothoracic junction.

METHODS: A review for cases of cervical IDH was performed via the following search criteria: (“neck”[MeSH Terms] OR “neck”[All Fields] OR “cervical”[All Fields]) AND intradural[All Fields] AND disc[All Fields]. Thirtyseven cases of cervical disc herniation were identified. Demographic variables identified included age, sex, cervical level of herniation, history of associated cervical trauma, presence of Brown-Séquard syndrome, Horner syndrome, and other neurologic findings, radiographic findings, direction of surgical approach, and postoperative outcomes.

RESULTS: A total of 37 cases of cervical IDH were identified. Most of the cases occurred at the lower levels of the cervical spine, with 35.1% at the C5e C6 level, followed by 24.3% at C6eC7, and lower still at other levels. Of the patients reviewed, 44.4% had a previous history of trauma before manifestation of symptom, with the majority being spontaneous IDH with no previous history of trauma or spine surgery. Brown-Séquard syndrome was present in 43.2% of the patients, whereas 10.8% of patients experienced Horner syndrome. The most common presentations of IDH included quadriplegia, finger/gait ataxia, radiculopathy, and nuchal pain. The degree of neurologic recovery was not associated with patient age. Most of the cervical IDHs in the literature were treated surgically via an anterior approach, but a larger portion of patients who underwent a posterior approach had improved recovery.

CONCLUSIONS: Cervical IDH is a rare event, with this review of the literature outlining the clinical and radiographic parameters of its presentation as well as comparing common surgical strategies for treatment. We outline theories underlying the development of cervical IDH and argue for a posterior surgical approach in which the disc herniation is sequestrated with migration



Transdural Spinal Cord Herniation

World Neurosurg. (2018) 109:242-246.

Recognition of transdural spinal cord herniation has increased over the past decade. This condition remains little known, particularly outside the specialized fields of spinal surgery and neuroradiology, leading to a significant delay in clinical diagnosis and treatment. It should be considered among the differential diagnoses in patients with gradual-onset lower-limb weakness of presumed spinal origin. Reaching a diagnosis using magnetic resonance imaging is essential to refer patients for surgery before their myelopathy worsens.

We describe our surgical experience to untether the spinal cord by wrapping a dura graft around the spinal cord. Three case reports and a review of the literature are discussed.

Early Postoperative Complications for Elderly Patients Undergoing Single-Level Decompression for Lumbar Disc Herniation, Ligamentous Hypertrophy, or Neuroforaminal Stenosis

Neurosurgery 81:1005–1010, 2017

Lumbar decompression for disc herniation is frequently performed on elderly patients, and this trend will continue as the population ages. Clinical reports on the complications of lumbar discectomy show good results and cost effectiveness in young or middle-aged patients.

OBJECTIVE: To assess and compare the morbidity of single-level lumbar disc surgery for radicular pain in a cohort of patients greater than 80 yr of age to that of a middle-aged cohort.

METHODS: A total of 9451 patients who received a single-level lumbar decompression procedure for disc displacement without myelopathy were retrospectively selected from a multicenter validated surgical database from the American College of Surgeons National Surgical Quality Improvement Program. A cohort with 485 patients greater than 80 yr of age (80+) was compared with a middle-aged cohort with 8966 patients between 45 and 65 yr. Preoperative comorbidity and postoperative outcome variables observed included mortality, myocardial infarction, return to the operating room, sepsis, deep vein thrombosis, transfusions, cardiac arrest necessitating cardiopulmonary resuscitation, coma greater than 24 h, urinary tract infection, acute renal failure, use of ventilator greater than 24 h, pulmonary embolism, pneumonia, wound dehiscence, and postoperative infection.

RESULTS: The preoperative comorbidities and characteristics were significantly different between the middle-aged and the 80+ cohorts, with the older cohort having many more preoperative comorbidities. There was statistically significantly greater postoperative morbidity among the 80+ cohort regarding pulmonary embolism (0.8% vs 0.2%, P = .037), intra/postoperative transfusion requirement (1.9% vs 0.7%, P = .01), urinary tract infection (1.2% vs 0.3%, P = .011), and 30-d mortality (0.4% vs 0.1%, P = .046).

CONCLUSION: In this large sample of patients who received a single-level lumbar decompression procedure for disc displacement without myelopathy, elderly patients, particularly with American Society of Anesthesiologists class 3 and 4, had a statistically significant increase in morbidity and mortality, but the overall risk of complications remains low.


Clinical and radiological results of posterior cervical foraminotomy at two or three levels: a 3-year follow-up

Acta Neurochir (2017) 159:2369–2377

Single-level unilateral posterior cervical foraminotomy is regarded as a safe method. However, the outcomes of posterior cervical foraminotomy performed on two or three levels are uncertain and debated. We aimed to analyze the long-term clinical and radiological outcomes of posterior cervical foraminotomy at two or three levels.

Methods From September 2008 to December 2011, a total of 42 patients who underwent a posterior cervical foraminotomy at two or three levels and were followed for at least 3 years were analyzed with retrospective cohort study. Clinical assessments were performed using the visual analog scale (VAS), neck disability index (NDI) and modified MacNab criteria. Radiological evaluation included the assessment of static and dynamic lateral radiographs to identify instability, postlaminectomy kyphotic deformity, adjacent segmental degeneration (ASD), and focal degeneration.

Results The mean VAS improved from preoperative score 8.5 ± 0.3 to postoperative score 1.8 ± 0.5 significantly. The mean presenting NDI score was 32.9 ± 2.0 and the mean postoperative NDI score was 14.2 ± 1.3. Improvement of radiculopathy was displayed in 39 patients (92.9%). During radiological evaluation, no significant change in disc height related to ASD and focal degeneration was noted. However, we confirmed one patient with radiological instability and one patient with radiological postlaminectomy kyphotic deformity.

Conclusions Posterior cervical foraminotomy at two or three levels is fairly effective for treating patients with cervical radiculopathy, and results in long-lasting pain relief and improved quality of life in nearly all patients. However, further studies of three levels that include more patients are needed.

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

Spine 2018;43:65–71

Study Design. Secondary analysis of data from a prospective multicenter observational study.

Objective. 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.

Summary of Background Data. 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 welldesigned multicenter study.

Methods. 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.

Results. 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.

Conclusion. 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.

Level of Evidence: 2

Relative lumbar lordosis and lordosis distribution index

Neurosurg Focus 43 (6):E5, 2017

The subtraction of lumbar lordosis (LL) from the pelvic incidence (PI) offers an estimate of the LL required for a given PI value. Relative LL (RLL) and the lordosis distribution index (LDI) are PI-based individualized measures. RLL quantifies the magnitude of lordosis relative to the ideal lordosis as defined by the magnitude of PI. LDI defines the magnitude of lower arc lordosis in proportion to total lordosis. The aim of this study was to compare RLL and PI – LL for their ability to predict postoperative complications and their correlations with health-related quality of life (HRQOL) scores.
METHODS Inclusion criteria were ≥ 4 levels of fusion and ≥ 2 years of follow-up. Mechanical complications were proximal junctional kyphosis/proximal junctional failure, distal junctional kyphosis/distal junctional failure, rod breakage, and implant-related complications. Correlations between PI – LL, RLL, PI, and HRQOL were analyzed using the Pearson correlation coefficient. Mechanical complication rates in PI – LL, RLL, LDI, RLL, and LDI interpreted together, and RLL subgroups for each PI – LL category were compared using chi-square tests and the exact test. Predictive models for mechanical complications with RLL and PI – LL were analyzed using binomial logistic regressions.
RESULTS Two hundred twenty-two patients (168 women, 54 men) were included. The mean age was 52.2 ± 19.3 years (range 18–84 years). The mean follow-up was 28.8 ± 8.2 months (range 24–62 months). There was a significant correlation between PI – LL and PI (r = 0.441, p < 0.001), threatening the use of PI – LL to quantify spinopelvic mismatch for different PI values. RLL was not correlated with PI (r = -0.093, p > 0.05); therefore, it was able to quantify divergence from ideal lordosis for all PI values. Compared with PI – LL, RLL had stronger correlations with HRQOL scores (p < 0.05). Discrimination performance was better for the model with RLL than for PI – LL. The agreement between RLL and PI – LL was high (k = 0.943, p < 0.001), moderate (k = 0.455, p < 0.001), and poor (k = -0.154, p = 0.343), respectively, for large, average, and small PI sizes. When analyzed by RLL, each PI – LL category was further divided into distinct groups of patients who had different mechanical complication rates (p < 0.001).
CONCLUSIONS Using the formula of PI – LL may be insufficient to quantify normolordosis for the whole spectrum of PI values when applied as an absolute numeric value in conjunction with previously reported population-based average thresholds of 10° and 20°. Schwab PI – LL groups were found to constitute an inhomogeneous group of patients. RLL offers an individualized quantification of LL for all PI sizes. Compared with PI – LL, RLL showed a greater association with both mechanical complications and HRQOL. The use of RLL and LDI together, instead of PI – LL, for surgical planning may result in lower mechanical complication rates and better long-term HRQOL.

What Is the Fate of Pseudarthrosis Detected 1 Year After Anterior Cervical Discectomy and Fusion?

Spine 2018;43:E23–E28

Objective. To investigate the consequences and appropriate management of pseudarthrosis after anterior cervical discectomy and fusion (ACDF).

Summary of Background Data. Pseudarthrosis is a frequent complication of ACDF and causes unsatisfactory results. Little is known about long-term prognosis of detecting pseudarthrosis 1 year after ACDF.

Methods. Eighty-nine patients with a minimum 2-year followup were included. ACDF surgery using allograft and plating was performed: single-level in 51 patients, two-level in 26 patients, and three-level in 12 patients. Presence of pseudarthrosis was evaluated 1 year postoperatively and then the nonunion segments were re-evaluated 2 years postoperatively. Demographic data were assessed to identify the risk factors associated with pseudarthrosis. A visual analogue scale for neck/arm pain and the Neck Disability Index were analyzed preoperatively and at 1 and 2 years postoperatively.

Results. Pseudarthrosis was detected in 29 patients (32.6%) 1 year postoperatively: 15of 51 patients after single-level surgery, 9 of 26 patients after two-level surgery, and 5 of 12 patients after three-level surgery. Only eight patients showed persistent nonunion at 2 years: 3 of 15 patients after single-level surgery, 3 of 9 after two-level surgery, and 2 of 5 after three-level surgery. The remaining 21 patients (72.4%) achieved bony fusion 2 years postoperatively without any intervention. Patients who underwent two-level or three-level ACDF had a significantly higher pseudarthrosis rate than those who underwent single-level ACDF, with odds ratios of 1.844 and 3.147, respectively. The improvements in visual analogue scale for neck pain and Neck Disability Index scores in the persistent nonunion group were significantly lower than those in the final union group at 2 years.

Conclusion. Patients with pseudarthrosis detected 1 year postoperatively may be observed without any intervention because approximately 70% of them will eventually fuse by the 2-year point. Early revision could, however, be considered if the pseudarthrosis is associated with considerable neck pain after multilevel ACDF.

Level of Evidence: 3

Cervical Spine Deformity—Part 3: Posterior Techniques, Clinical Outcome, and Complications

Neurosurgery 81:893–898, 2017

The goals of cervical deformity surgery include deformity correction, restoration of horizontal gaze, decompression of neural elements, spinal stabilization with a biomechanically sound construct, and meticulous arthrodesis technique to prevent pseudoarthrosis and minimizing surgical complications.

Many different surgical options exist, but selecting the correct approach that ensures the optimal clinical outcome can be challenging and often controversial. In this last part of the cervical deformity review series, various posterior deformity correction techniques are discussed in detail, along with an overview of surgical outcome and postoperative complications.

The Role of Hypoxia in Angiogenesis and Extracellular Matrix Regulation of Intervertebral Disc Cells During Inflammatory Reactions

Neurosurgery 81:867–875, 2017

The intervertebral disc (IVD) is an avascular structure, and is therefore stable under hypoxic conditions. Previous studies have demonstrated that hypoxia might be related to symptomatic degenerative disc diseases (DDDs); however, the pathomechanism is still poorly understood.

OBJECTIVE: To identify the effect of hypoxia on the production of inflammatory mediators, angiogenic factors, and extracellularmatrix-regulating enzymes of IVD cells during inflammatory reactions.

METHODS: Human nucleus pulposus (NP) and annulus fibrosus (AF) cells harvested during surgery for DDDs were cultured in macrophage conditioned media or interleukin (IL)-1β-stimulated media under hypoxic (2%) and normoxic (21%) conditions. Hypoxiainducible factor-1α transcription factor activation was analyzed by western blotting. IL-6, IL-8, vascular endothelial growth factor (VEGF), vascular cell adhesion molecule (VCAM), matrix metalloproteinase (MMP)-1,MMP-3, tissue inhibitor ofmetalloprotease (TIMP)-1, and TIMP-2 in conditioned media weremeasured by an enzyme-linked immunosorbent assay.

RESULTS: NP cells expressed higher hypoxia-inducible factor-1α in the IL-1β-stimulated group under hypoxic condition. MMP-1 was significantly increased in the AF cells under hypoxic condition; TIMP-1 and TIMP-2 were significantly decreased in both naïve NP and AF cells during hypoxia. Both cells in macrophage conditioned media significantly diminished the production of IL-6 and VCAM, while VEGF significantly increased during hypoxia. After 1 ng/mL IL-1β stimulation, IL-8, VEGF, MMP-1, and MMP-3 were significantly increased in both cell types during hypoxia, while VCAM, TIMP-1, and TIMP-2 were decreased.

CONCLUSION: We found that hypoxia can enhance the angiogenic ability of IVD during inflammatory reactions, and cause progress in development of DDD via extracellular matrix regulation in this in vitro study.

A Staged Protocol for Circumferential Minimally Invasive Surgical Correction of Adult Spinal Deformity

Neurosurgery 81:733–739, 2017

Minimally invasive surgery (MIS) techniques used for management of adult spinal deformity (ASD) aim to decrease the physiological demand on patients and minimize postoperative complications. A circumferential MIS (cMIS) protocol offers the potential to maximize this advantage over standard open approaches, through the concurrent use of multiple MIS techniques.

OBJECTIVE: To demonstrate through a case example the execution of a cMIS protocol for management of an ASD patient with severe deformity.

METHODS: Thorough preoperative assessment, surgical planning, and medical optimization were completed. Deformity correction was performed over 2 stages. During the first stage, interbody fusion was performed via an oblique lateral approach at all levels of the lumbar spine intended to be included in the final construct. The patient was kept as an inpatient and mobilized postoperatively. They were then re-imaged with standing films. The second stage occurred after 3 d and involved percutaneous instrumentation of all levels. Posterior fusion of the thoracic levels was achieved through decortication of pars and facets. These areas were accessed through the intermuscular plane established by the percutaneous screws. The patient was mobilizing on their first postoperative day.

RESULTS: In a 66-yr-old female with severe sagittal imbalance and debilitating back pain, effective use of this cMIS protocol allowed for correction of the Cobb angle from 52◦ to 4◦ correction of spinopelvic parameters and 13 cm of sagittal vertical axis improvement. No complications were identified by 2 yr postoperative.

CONCLUSION: As a systematization of multiple MIS techniques combined, in a specific and staged manner, this cMIS protocol could provide a safe and effective approach to the management of ASD.


Patterns of C-2 fracture in the elderly: comparison of etiology, treatment, and mortality among speci c fracture types

J Neurosurg Spine 27:494–500, 2017

Previous studies have focused on Type II odontoid fractures and have failed to report on the effect of other C-2 fracture types on treatment and outcome. The purpose of this study was to compare patient characteristics, cause of injury, predisposing factors to fracture, treatments, and mortality rates among C-2 fracture types in a cohort of elderly patients 70 years of age and older.

METHODS A retrospective cohort study design was used. Patients who sustained a C-2 fracture between 2002 and 2011 and who were admitted to the authors’ Level 1 trauma center were identified using the Discharge Abstract Database and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) code S12.1. Fractures were classified as odontoid Type I, II, or III; hangman’s; C-2 complex (hangman’s appearance on sagittal images, Type III odontoid on coronal cuts); and other (miscellaneous). Age, sex, predisposing factors to falls, cause of injury, treatment, presence of autofusion in the subaxial cervical spine, and mortality rates were compared between fracture patterns.

RESULTS One hundred forty-one patients were included; their mean age was 82 years. Fractures included Type II odontoid (57%), complex (19%), Type III odontoid (11%), hangman’s (8%), and other (5%). Falls from a standing height accounted for 47% of injuries, and 65% of patients had ≥ 3 risk factors for falls. Subaxial autofusion was more common in odontoid fractures (p = 0.002). Treatment was mainly nonoperative (p < 0.0001). The 1-year mortality rate was 27%. Four patients died of spinal cord injury.

CONCLUSIONS Although not as common as Type II odontoid fractures, other C-2 fractures including hangman’s, complex, and Type III odontoid fractures accounted for close to half of the injuries in the study cohort. There were few differences between the fracture types with respect to cause of injury, predisposing factors, or mortality rate. However, surgical treatment was more common for Type II odontoid fractures.

Transforaminal Lumbar Interbody Fusion Versus Mini-open Anterior Lumbar Interbody Fusion With Oblique Self-anchored Stand-alone Cages for the Treatment of Lumbar Disc Herniation

Spine 2017;42:E1259–E1265

The aim of this study was to evaluate the clinical and radiological outcomes of mini-open ALIF (MO-ALIF) with self-anchored stand-alone cages for the treatment of lumbar disc herniation in comparison with transforaminal lumbar interbody fusion (TLIF). Summary of Background Data. Currently, whether ALIF is superior to TLIF for the treatment of lumbar disc herniation remains controversial.

Summary of Background Data. Currently, whether ALIF is superior to TLIF for the treatment of lumbar disc herniation remains controversial.

Methods. This study retrospectively reviewed 82 patients who underwent MO-ALIF with self-anchored standalone cages (n=42) or TLIF (n=40) for the treatment of lumbar disc herniation between April 2013 and October 2014. Patient demographics, intraoperative parameters, and perioperative complications were collated. Clinical outcomes were evaluated using the visual analog scale (VAS) scoring, the Oswestry Disability Index (ODI) for pain in the leg and back, and radiological outcomes, including fusion, lumbar lordosis (LL), disc height (DH), and cage subsidence were evaluated at each follow-up for up to 2 years.

Results. Patients who underwent TLIF had a significantly higher volume of blood loss (295.2±81.4 vs. 57.0±15.2mL) and longer surgery time (130.7±45.1 vs. 60.4±20.8 min) than those who had MO-ALIF. Compared with baseline, both groups had significant improvements in the VAS and ODI scores and DH and LL postoperatively, though no significant difference was found between the two groups regarding these indexes. All patients reached solid fusion at the final follow-up in both groups. Three patients (3/42) with three levels (3/50) suffered from cage subsidence in the MO-ALIF group; meanwhile, no cage subsidence occurred in the TLIF group. Conclusion. MO-ALIF with self-anchored stand-alone cages is a safe and effective treatment of lumbar disc herniation with less surgical trauma and similar clinical and radiological outcomes compared with TLIF.

Conclusion. MO-ALIF with self-anchored stand-alone cages is a safe and effective treatment of lumbar disc herniation with less surgical trauma and similar clinical and radiological outcomes compared with TLIF.

Level of Evidence: 3

Predictors for Patient Discharge Destination After Elective Anterior Cervical Discectomy and Fusion

Spine 2017;42:1538–1544

Study Design. Retrospective study of prospectively collected data.

Objective. To identify risk factors for nonhome patient discharge after elective anterior cervical discectomy and fusion (ACDF).

Summary of Background Data. ACDF is one of the most performed spinal procedures and this is expected to increase in the coming years. To effectively deal with an increasing patient volume, identifying variables associated with patient discharge destination can expedite placement applications and subsequently reduce hospital length of stay.

Methods. The 2011 to 2014 ACS-NSQIP database was queried using Current Procedural Terminology (CPT) codes 22551 or 22554. Patients were divided into two cohorts based on discharge destination. Bivariate and multivariate logistic regression analyses were employed to identify predictors for patient discharge destination and extended hospital length of stay.

Results. A total of 14,602 patients met the inclusion criteria for the study of which 498 (3.4%) had nonhome discharge. Multivariate logistic regression found that Hispanic versus Black race/ ethnicity (odds ratio, OR¼0.21, 0.05–0.91, P¼0.037), American Indian or Alaska Native, Asian, Native Hawaiian or Pacific Islander versus Black race/ethnicity (OR¼0.52, 0.34–0.80, p-value¼0.003), White versus Black race/ethnicity (OR¼0.55, 0.42–0.71), elderly age 65 years (OR¼3.32, 2.72–4.06), obesity (OR¼0.77, 0.63–0.93, P¼0.008), diabetes (OR¼1.32, 1.06–1.65, P¼0.013), independent versus partially/totally dependent functional status (OR¼0.11, 0.08–0.15), operation time 4hours (OR¼2.46, 1.87–3.25), cardiac comorbidity (OR ¼1.38, 1.10– 1.72, P ¼0.005), and ASA Class 3 (OR¼2.57, 2.05–3.20) were predictive factors in patient discharge to a facility other than home. In addition, multivariate logistic regression analysis also found nonhome discharge to be the most predictive variable in prolonged hospital length of stay.

Conclusion. Several predictive factors were identified in patient discharge to a facility other than home, many being preoperative variables. Identification of these factors can expedite patient discharge applications and potentially can reduce hospital stay, thereby reducing the risk of hospital acquired conditions and minimizing health care costs.

Level of Evidence: 3

Anterior lumbar discectomy and fusion for acute cauda equina syndrome caused by recurrent disc prolapse

J Neurosurg Spine 27:352–356, 2017

There is a lack of information and consensus regarding the optimal treatment for recurrent disc herniation previously treated by posterior discectomy, and no reports have described an anterior approach for recurrent disc herniation causing cauda equina syndrome (CES). Revision posterior decompression, irrespective of the presence of CES, has been reported to be associated with significantly higher rates of dural tears, hematomas, and iatrogenic nerve root damage.

The authors describe treatment and outcomes in 3 consecutive cases of patients who underwent anterior lumbar discectomy and fusion (ALDF) for CES caused by recurrent disc herniations that had been previously treated with posterior discectomy. All 3 patients were operated on within 12 hours of presentation and were treated with an anterior retroperitoneal lumbar approach. Follow-up ranged from 12 to 24 months. Complete retrieval of herniated disc material was achieved without encountering significant epidural scar tissue in all 3 cases. No perioperative infection or neurological injury occurred, and all 3 patients had neurological recovery with restoration of bladder and bowel function and improvement in back and leg pain.

ALDF is one option to treat CES caused by recurrent lumbar disc prolapse previously treated with posterior discectomy. The main advantage is that it avoids dissection around epidural scar tissue, but the procedure is associated with other risks and further evaluation of its safety in larger series is required.

Microendoscopic laminotomy versus conventional laminoplasty for cervical spondylotic myelopathy: 5-year follow-up study

J Neurosurg Spine 27:403–409, 2017

The goal of this study was to characterize the long-term clinical and radiological results of articular segmental decompression surgery using endoscopy (cervical microendoscopic laminotomy [CMEL]) for cervical spondylotic myelopathy (CSM) and to compare outcomes to conventional expansive laminoplasty (ELAP).

METHODS Consecutive patients with CSM who required surgical treatment were enrolled. All enrolled patients (n = 78) underwent CMEL or ELAP. All patients were followed postoperatively for more than 5 years. The preoperative and 5-year follow-up evaluations included neurological assessment (Japanese Orthopaedic Association [JOA] score), JOA recovery rates, axial neck pain (using a visual analog scale), the SF-36, and cervical sagittal alignment (C2–7 subaxial cervical angle).

RESULTS Sixty-one patients were included for analysis, 31 in the CMEL group and 30 in the ELAP group. The mean preoperative JOA score was 10.1 points in the CMEL group and 10.9 points in the ELAP group (p > 0.05). The JOA recovery rates were similar, 57.6% in the CMEL group and 55.4% in the ELAP group (p > 0.05). The axial neck pain in the CMEL group was significantly lower than that in the ELAP group (p < 0.01). At the 5-year follow-up, cervical alignment was more favorable in the CMEL group, with an average 2.6° gain in lordosis (versus 1.2° loss of lordosis in the ELAP group [p < 0.05]) and lower incidence of postoperative kyphosis.

CONCLUSIONS CMEL is a novel, less invasive technique that allows for multilevel posterior cervical decompression for the treatment of CSM. This 5-year follow-up data demonstrates that after undergoing CMEL, patients have similar neurological outcomes to conventional laminoplasty, with significantly less postoperative axial pain and improved subaxial cervical lordosis when compared with their traditional ELAP counterparts.

Neurosurgery Department. “La Fe” University Hospital. Valencia, Spain


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