Neurosurgery Blog


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

Skip Laminectomy Compared with Laminoplasty for Cervical Compressive Myelopathy:

World Neurosurg. (2018) 120:296-301

This meta-analysis evaluated the clinical outcomes of skip laminectomy relative to laminoplasty for the treatment of cervical compressive myelopathy.

METHODS: The Cochrane library, PubMed MEDLINE, EMBASE, and Web of Science databases were comprehensively searched to identify relevant articles published up to March 18, 2018. All values of weighted mean difference (WMD) or odds ratio are expressed as skip laminectomy relative to laminoplasty.

RESULTS: Four studies comprising 241 patients were included. Skip laminectomy and laminoplasty were comparable in terms of cervical lordotic curvature (weighted mean difference [WMD] L2.37; 95% confidence interval [CI] L6.18 to 1.43; P [ 0.22) and range of motion (WMD e2.65; 95% CI L6.02 to 0.72; P [ 0.12). The pooled data revealed that the mean visual analogue scale score for pain of the skip laminectomy group was significantly lower than that of the laminoplasty group (WMD e0.97; 95% CI L1.90 to L0.05; P [ 0.04), and the rate of axial pain was also significantly lower (WMD 0.26; 95% CI 0.07e0.93; P [ 0.04). The atrophy rates of the deep extensor muscles in the skip laminectomy group (14%) were significantly lower than that of the laminoplasty group (60%).

CONCLUSIONS: This meta-analysis determined that skip laminectomy was superior to laminoplasty in terms of visual analogue scale score and rates of axial pain and muscle atrophy. These results warrant further confirmation in future research.

Lateral lumbar interbody fusion in the elderly

J Neurosurg Spine 29:525–529, 2018

Elderly patients, often presenting with multiple medical comorbidities, are touted to be at an increased risk of peri- and postoperative complications following spine surgery. Various minimally invasive surgical techniques have been developed and employed to treat an array of spinal conditions while minimizing complications. Lateral lumbar interbody fusion (LLIF) is one such approach. The authors describe clinical outcomes in patients over the age of 70 years following stand-alone LLIF.

METHODS A retrospective query of a prospectively maintained database was performed for patients over the age of 70 years who underwent stand-alone LLIF. Patients with posterior segmental fixation and/or fusion were excluded. The preoperative and postoperative values for the Oswestry Disability Index (ODI) were analyzed to compare outcomes after intervention. Femoral neck t-scores were acquired from bone density scans and correlated with the incidence of graft subsidence.

RESULTS Among the study cohort of 55 patients, the median age at the time of surgery was 74 years (range 70–87 years). Seventeen patients had at least 3 medical comorbidities at surgery. Twenty-three patients underwent a 1-level, 14 a 2-level, and 18 patients a 3-level or greater stand-alone lateral fusion. The median estimated blood loss was 25 ml (range 5–280 ml). No statistically significant relationship was detected between volume of blood loss and the number of operative levels. The median length of hospital stay was 2 days (range 1–4 days). No statistically significant relationship was observed between the length of hospital stay and age at the time of surgery. There was one intraoperative death secondary to cardiac arrest, with a mortality rate of 1.8%. One patient developed a transient femoral nerve injury. Five patients with symptomatic graft subsidence subsequently underwent posterior instrumentation. A lower femoral neck t-score < -1.0 correlated with a higher incidence of graft subsidence (p = 0.006). The mean ODI score 1 year postoperatively of 31.1 was significantly (p = 0.003) less than the mean preoperative ODI score of 46.2.

CONCLUSIONS Stand-alone LLIF can be safely and effectively performed in the elderly population. Careful evaluation of preoperative bone density parameters should be employed to minimize risk of subsidence and need for additional surgery. Despite an association with increased comorbidities, age alone should not be a deterrent when considering stand-alone LLIF in the elderly population.


Outcomes of Operative Treatment for Adult Cervical Deformity

Neurosurgery 83:1031–1039, 2018

Despite the potential for profound impact of adult cervical deformity (ACD) on function and health-related quality of life (HRQOL), there are few high-quality studies that assess outcomes of surgical treatment for these patients.

OBJECTIVE: To determine the impact of surgical treatment for ACD on HRQOL.

METHODS: We conducted a prospective cohort study of surgically treated ACD patients eligible for 1-yr follow-up. Baseline deformity characteristics, surgical parameters, and 1-yr HRQOL outcomes were assessed.

RESULTS: Of 77 ACD patients, 55 (71%) had 1-yr follow-up (64% women, mean age of 62 yr, mean Charlson Comorbidity Index of 0.6, previous cervical surgery in 47%). Diagnoses included cervical sagittal imbalance (56%), cervical kyphosis (55%), proximal junctional kyphosis (7%) and coronal deformity (9%). Posterior fusion was performed in 85% (mean levels = 10), and anterior fusion was performed in 53% (mean levels = 5). Three-column osteotomy was performed in 24%of patients.One year following surgery, ACD patients had significant improvement in Neck Disability Index (50.5 to 38.0, P<.001), neck pain numeric rating scale score (6.9 to 4.3, P<.001), EuroQol 5 dimension (EQ-5D) index (0.51 to 0.66, P< .001), and EQ-5D subscores: mobility (1.9 to 1.7, P=.019), usual activities (2.2 to 1.9, P=.007), pain/discomfort (2.4 to 2.1, P < .001), anxiety/depression (1.8 to 1.5, P = .014).

CONCLUSION: Based on a prospective multicenter series of ACD patients, surgical treatment provided significant improvement in multiple measures of pain and function, including Neck Disability Index, neck pain numeric rating scale score, and EQ-5D. Further follow-up will be necessary to assess the long-term durability of these improved outcomes.


Simple presurgical method of predicting C5 palsy after cervical laminoplasty using C5 nerve root ultrasonography

J Neurosurg Spine 29:365–370, 2018

The incidence of C5 palsy after cervical laminoplasty is approximately 5%. Because C5 palsy is related to cervical foraminal stenosis at the C4–5 level, the authors hypothesized that cervical foraminal stenosis can be diagnosed by examining the C5 nerve root (NR) using ultrasonography. The purpose of this study was to investigate whether postoperative C5 palsy could be predicted using ultrasonography.
METHODS This study used a prospective diagnosis design. In total, 140 patients undergoing cervical laminoplasty were examined with ultrasound. The cross-sectional area (CSA) of the C5 NR was measured on both sides before surgery, and the incidence of postoperative C5 palsy was examined. The difference between the CSA of the patients with and without C5 palsy and the lateral differences in the C5 palsy group were determined.
RESULTS The incidence of C5 palsy was 5% (7 cases). Symptoms manifested at a median of 5 days after surgery (range 1–29 days). The CSA of the C5 NR on the affected side was significantly enlarged in the C5 palsy group compared with that in the no–C5 palsy group (p = 0.001). In addition, in the patients who had C5 palsy, the CSA of the C5 NR was significantly enlarged on the affected side compared with that on the unaffected side (p = 0.02). Receiver operating characteristic analysis indicated that the best threshold value for the CSA of the C5 NR was 10.4 mm2 , which provided 91% sensitivity and 71% specificity.
CONCLUSIONS C5 palsy may be predicted preoperatively using ultrasound. The authors recommend the ultrasonographic measurement of the CSA of the C5 NR prior to cervical laminoplasty.

Use of the Airo mobile intraoperative CT system versus the O-arm for transpedicular screw fixation in the thoracic and lumbar spine

J Neurosurg Spine 29:397–406, 2018

Navigation-enabling technology such as 3D-platform (O-arm) or intraoperative mobile CT (iCT-Airo) systems for use in spinal surgery has considerably improved accuracy over that of traditional fluoroscopy-guided techniques during pedicular screw positioning. In this study, the authors compared 2 intraoperative imaging systems with navigation, available in their neurosurgical unit, in terms of the accuracy they provided for transpedicular screw fixation in the thoracic and lumbar spine.

METHODS The authors performed a retrospective analysis of clinical and surgical data of 263 consecutive patients who underwent thoracic and lumbar spine screw placement in the same center. Data on 97 patients who underwent surgery with iCT-Airo navigation (iCT-Airo group) and 166 with O-arm navigation (O-arm group) were analyzed. Most patients underwent surgery for a degenerative or traumatic condition that involved thoracic and lumbar pedicle screw fixation using an open or percutaneous technique. The primary endpoint was the proportion of patients with at least 1 screw not correctly positioned according to the last intraoperative image. Secondary endpoints were the proportion of screws that were repositioned during surgery, the proportion of patients with a postoperative complication related to screw malposition, surgical time, and radiation exposure. A blinded radiologist graded screw positions in the last intraoperative image according to the Heary classification (grade 1–3 screws were considered correctly placed).

RESULTS A total of 1361 screws placed in 97 patients in the iCT-Airo group (503 screws) and in 166 in the O-arm group (858 screws) were graded. Of those screws, 3 (0.6%) in the iCT-Airo group and 4 (0.5%) in the O-arm group were misplaced. No statistically significant difference in final accuracy between these 2 groups or in the subpopulation of patients who underwent percutaneous surgery was found. Three patients in the iCT-Airo group (3.1%, 95% CI 0%–6.9%) and 3 in the O-arm group (1.8%, 95% CI 0%–4.0%) had a misplaced screw (Heary grade 4 or 5). Seven (1.4%) screws in the iCT-Airo group and 37 (4.3%) in the O-arm group were repositioned intraoperatively (p = 0.003). One patient in the iCT-Airo group and 2 in the O-arm group experienced postoperative neurological deficits related to hardware malposition. The mean surgical times in both groups were similar (276 [iCT-Airo] and 279 [O-arm] minutes). The mean exposure to radiation in the iCT-Airo group was significantly lower than that in the O-arm group (15.82 vs 19.12 mSv, respectively; p = 0.02).

CONCLUSIONS Introduction of a mobile CT scanner reduced the rate of screw repositioning, which enhanced patient safety and diminished radiation exposure for patients, but it did not improve overall accuracy compared to that of a mobile 3D platform.


The value of sitting radiographs: analysis of spine flexibility and its utility in preoperative planning for adult spinal deformity surgery

J Neurosurg Spine 29:414–421, 2018

Preoperative planning of thoracolumbar deformity (TLD) surgery has been shown to improve radiographic and clinical outcomes. One of the confounders in attaining optimal postoperative alignment is the reciprocal hyperkyphosis of unfused thoracic segments. Traditional planning utilizes standing radiographs, but the value of sitting radiographs to predict thoracic flexibility has not been investigated. Authors of the present study propose that alignment changes from a sitting to a standing position will predict changes in unfused thoracic segments after TLD correction.

METHODS Patients with degenerative spine pathology underwent preoperative sitting and standing full-spine stereotactic radiography. A subset of TLD patients who had undergone corrections with minimum T10-pelvis fusions was analyzed in terms of pre- to postoperative alignment. Radiographic parameters were analyzed, including the T1 pelvic angle (TPA), T1–L1 pelvic angle (TLPA), lumbar pelvic angle (LPA), pelvic tilt (PT), mismatch between pelvic incidence and lumbar lordosis (PI-LL mismatch), and T2–12 kyphosis (TK). Thoracic compensation was calculated as the expected TK minus actual TK (i.e., [2/3 × PI] – actual TK). Statistical analysis consisted of paired and unpaired t-tests and linear regression analysis.

RESULTS The authors retrospectively identified 137 patients with full-body standing and sitting radiographs. The mean age of the patients was 60.9 years old, 60.0% were female, and the mean BMI was 27.8 kg/m2. The patients demonstrated significantly different radiographic alignments in baseline spinopelvic and global parameters from the preoperative sitting versus the standing positions: LL (-34.20° vs -47.87°, p < 0.001), PT (28.31° vs 17.50°, p < 0.001), TPA (27.85° vs 16.89°, p < 0.001), TLPA (10.63° vs 5.17°, p < 0.001), and LPA (15.86° vs 9.67°, p < 0.001). Twenty patients (65.0% female) with a mean age of 65.3 years and mean BMI of 30.2 kg/m2 had TLD and underwent surgical correction (pre- to postoperative standing change in TPA: 33.90° to 24.50°, p = 0.001). Preoperative sitting radiographs demonstrated significant differences in alignment compared to postoperative standing radiographs: larger TPA (39.10° vs 24.50°, p < 0.001), PT (35.40° vs 28.10°, p < 0.001), LL (-11.20° vs -44.80°, p < 0.001), LPA (22.80° vs 14.20°, p < 0.001), and unfused Cobb (T2 to upper instrumented vertebra [UIV] Cobb angle: 19.95° vs 27.50°, p = 0.039). Also in the TLD group, mean thoracic compensation was 6.75°. In the linear regression analysis, the change from sitting to standing predicted pre- to postoperative changes for TK and the unfused thoracic component of TPA (5° change in preoperative sitting to preoperative standing corresponded to a pre- to postoperative change in standing TK of 6.35° and in standing TPA of 7.23°, R2 = 0.30 and 0.38, respectively).

CONCLUSIONS Sitting radiographs were useful in demonstrating spine flexibility. Among the TLD surgery group, relaxation of the unfused thoracic spine in the sitting position predicted the postoperative increase in kyphosis of the unfused thoracic segments. Sitting radiographs are a useful tool to anticipate reciprocal changes in thoracic alignment that diminish global corrections.


Cost-Effectiveness in Adult Spinal Deformity Surgery

Neurosurgery 83:597–601, 2018

The complexity and heterogeneity of adult spinal deformity (ASD) creates significant difficulties in performing high-quality, complete economic analyses. For the same reasons, however, such studies are immensely valuable to clinicians and health policy experts. There has been a paradigm shift towards value-based healthcare provision and as such, there is an increasing focus on demonstrating not just the value ASD surgery, but the provision of care at large. Health-related quality of life measures are an important tool for assessing value of an intervention and its effect on a quality-adjusted life year (QALY). Currently, there are no definitive criteria in regard to assigning the appropriate value to a QALY. A general accepted threshold discussed in literature is $100 000 per QALY gained. However, this figure may be variable across populations, and may not necessarily be applicable in today’s economy, or in all healthcare economies. Fundamentally, an effective treatment method may be associated with a high upfront cost, however, if durable, will be costeffective over time. The emphasis on carotid endarterectomy and CUA in the field of adult spine deformity is relatively recent; therefore, there is a limited amount of data on cost-effectiveness analyses. Continued efforts with emphasis on value-based outcomes are needed with long-term follow-up studies.

The influence of spinopelvic parameters on adjacent-segment degeneration after short spinal fusion for degenerative spondylolisthesis

J Neurosurg Spine 29:407–413, 2018

Spinopelvic parameters, such as the pelvic incidence (PI) angle, sacral slope angle, and pelvic tilt angle, are important anatomical indices for determining the sagittal curvature of the spine and the individual variability of the lumbar lordosis (LL) curve. The aim of this study was to investigate the influence of spinopelvic parameters and LL on adjacent-segment degeneration (ASD) after short lumbar and lumbosacral fusion for single-level degenerative spondylolisthesis.

METHODS The authors retrospectively reviewed the records of all short lumbar and lumbosacral fusion surgeries performed between August 2003 and July 2010 for single-level degenerative spondylolisthesis in their orthopedic department.

RESULTS A total of 30 patients (21 women and 9 men, mean age 64 years) with ASD after lower lumbar or lumbosacral fusion surgery comprised the study group. Thirty matched patients (21 women and 9 men, mean age 63 years) without ASD comprised the control group, according to the following matching criteria: same diagnosis on admission, similar pathologic level (≤ 1 level difference), similar sex, and age. The average follow-up was 6.8 years (range 5–8 years). The spinopelvic parameters had no significant influence on ASD after short spinal fusion.

CONCLUSIONS Neither the spinopelvic parameters nor a mismatch of PI and LL were significant factors responsible for ASD after short spinal fusion due to single-level degenerative spondylolisthesis.

Reduced Acute Care Costs With the ERAS ® Minimally Invasive Transforaminal Lumbar Interbody Fusion Compared With Conventional Minimally Invasive Transforaminal Lumbar Interbody Fusion

Neurosurgery 83:827–834, 2018

Enhancing Recovery After Surgery (ERAS (R)  ) programs have been widely adopted throughout the world, but not in spinal surgery. In this report, we review the implementation of a “fast track”surgery for lumbar fusion and its effect on acute care hospitalization costs.

OBJECTIVE: To determine if a “fast track” surgery methodology results in acute care cost savings.

METHODS: Thirty-eight consecutive ERAS patients were compared with patients undergoing conventional minimally invasive transforaminal lumbar interbody fusion. Differences between these groups included the use of endoscopic decompression, injections of liposomal bupivacaine, and performing the surgery under sedation in the ERAS R  group.

RESULTS: Patients had similar medical comorbidities (2.02 vs 2 for ERAS R  and comparator groups, respectively; P = .458). Body mass index was similar (26.5 vs 27.0; P = .329). ERAS R  patients were older (65 vs 59 yr, P= .031). Both groups had excellent clinical results with an improvement of 23% and 24%, respectively. Intraoperative blood loss was less (68±31 cc vs 231±73, P<0.001). Length of staywas also less with ERAS R  surgery, at ameanof 1.23±0.8 d vs 3.9 ± 1.1 d (P = 0.009). When comparing ERAS R  surgery to standard minimally invasive transforaminal lumbar interbody fusion, the total cost for the acute care hospitalization was $19212vs $22656, respectively(P<0.001). This reflected an average of $3444 in savings, which was a 15.2% reduction.

CONCLUSION: ERAS (R)  programs for spinal fusion surgery have the potential to reduce the costs of acute care. This is made possible by leveraging less invasive interventions to minimize soft tissue damage.

Open-versus French-Door Laminoplasty for the Treatment of Cervical Multilevel Compressive Myelopathy: A Meta-Analysis

World Neurosurg. (2018) 117:129-136

OBJECTIVE: To compare the clinical outcomes and postoperative complications between open-door laminoplasty (ODL) versus French-door laminoplasty (FDL) for the treatment of cervical multilevel compressive myelopathy.

METHODS: We comprehensively searched PubMed, EMBASE, Cochrane library, and China National Knowledge Infrastructure to identify relevant articles. The search results were last updated on January 1, 2018. All values of weighted mean difference (WMD) and odds ratio are expressed as ODL relative to FDL.

RESULTS: Six studies containing 430 patients were included in our metaanalysis. In randomized controlled trials, there was no significant difference in Japanese Orthopaedic Association (JOA) scores between ODL and FDL groups (WMD, 0.06; 95% confidence limits [CL], e0.52 to 0.64; P [ 0.84). However, in the retrospective trials, JOA scores were significantly higher in the ODL group than in the FDL group (WMD, 0.95; 95% CL, 0.55e1.34; P < 0.05). The pooled data showed that the magnitude of spinal canal expansion in the ODL group was higher than in the FDL group (WMD, 24.39%; 95% confidence interval, 12.33e36.45; P < 0.05).

CONCLUSIONS: The present meta-analysis showed that the magnitude of canal expansion was higher with ODL than with FDL. There is a lack of compelling evidence to prove the superiority of one procedure over the other.

Comparison of Multilevel Cervical Disc Replacement and Multilevel Anterior Discectomy and Fusion: A Systematic Review of Biomechanical and Clinical Evidence

World Neurosurg. (2018) 116:94-104

OBJECTIVE: The aim of this study was to comprehensively compare the clinical and biomechanical efficiency of anterior cervical discectomy and fusion (ACDF) with anterior cervical disc replacement (ACDR) for treatment of multilevel cervical disc disease using a meta-analysis and systematical review.

METHODS: A literature search was performed using PubMed, MEDLINE, EMBASE, and the Cochrane Library for articles published between January 1960 and December 2017. Both clinical and biomechanical parameters were analyzed. Statistical tests were conducted by Revman 5.3. Nineteen studies including 10 clinical studies and 9 biomechanical studies were filtered out.

RESULTS: The pooled results for clinical efficiency showed that no significant difference was observed in blood loss (P [ 0.09; mean difference [MD], 7.38; confidence interval [CI], e1.16 to 15.91), hospital stay (P[ 0.33; MD, L0.25; CI, L0.76 to 0.26), Japanese Orthopaedic Association scores (P [ 0.63; MD, L0.11; CI, L0.57 to 0.34), visual analog scale (P [ 0.08; MD, L0.50; CI, L1.06 to 0.05), and Neck Disability Index (P [ 0.33; MD, L0.55; CI, L1.65 to 0.56) between the 2 groups. Compared with ACDF, ACDR did show increased surgical time (P [ 0.03; MD, 31.42; CI, 2.71e60.14). On the other hand, ACDR showed increased index range of motion (ROM) (P < 0.00001; MD, 13.83; CI, 9.28e 18.39), lower rates of adjacent segment disease (ASD) (P [ 0.001; odds ratio [OR], 0.27; CI, 0.13e0.59), complications (P [ 0.006; OR, 0.62; CI, 0.45e0.87), and rate of subsequent surgery (P < 0.00001; OR, 0.25; CI, 0.14e0.44). As for biomechanical performance, ACDR maintained index ROM and avoided compensation in adjacent ROM and tissue pressure.

CONCLUSIONS: Multilevel ACDR may be an effective and safe alternative to ACDF in terms of clinical and biomechanical performance. However, further multicenter and prospective studies should be conducted to obtain a stronger and more reliable conclusion.

NuNec™ Cervical Disc Arthroplasty Improves Quality of Life in Cervical Radiculopathy and Myelopathy: A 2-Year Follow-up

Neurosurgery 83:422–428, 2018

Anterior cervical disc replacement is an alternative to fusion for the treatment of selected cases of radiculopathy andmyelopathy. We report clinical and radiological outcomes after disc replacement with the NuNec™ artificial cervical disc (Pioneer (R)  Surgical Technology, Marquette, Michigan) with subgroup analysis.

OBJECTIVE: To review clinical and radiological outcomes after anterior cervical disc replacement with the NuNec™ artificial cervical disc.

METHODS: A consecutive case series of patients undergoing cervical disc replacement with the NuNec™ artificial disc was conducted. Clinical outcomes were assessed by questionnaires preoperatively and up to 2 yr postoperatively including neck and arm pain, Neck Disability Index, Euroqol 5-dimensions, and Short Form-36; x-rays from the same period were analyzed for range of movement and presence of heterotopic ossification.

RESULTS: A total of 44 NuNec™ discs were implanted in 33 patients. Clinical improvements were seen in all outcomes; significant improvements on the Neck Disability Index, Euroqol 5-dimensions, and physical domain of the Short Form-36 were maintained at 2 yr. There was a mean of 4◦ range of movement at the replacement disc level at 2 yr, a significant reduction from baseline; there was also progression in levels of heterotopic ossification. Complications included temporary dysphagia (10%) and progression of disease requiring foraminotomy (6%); no surgery for adjacent level disease was required. There was no significant difference in the outcomes of the radiculopathy and myelopathy groups.

CONCLUSION: Clinical outcomes using the NuNec™ disc replacement are comparable with other disc replacements. Although the range of movement is reduced, the reoperation rate is very low.

Full-endoscopic uniportal decompression in disc herniations and stenosis of the thoracic spine using the interlaminar, extraforaminal, or transthoracic retropleural approach

J Neurosurg Spine 29:157–168, 2018

Surgery for thoracic disc herniation and spinal canal stenosis is comparatively rare and often challenging. Individual planning and various surgical techniques and approaches are required. The key factors for selecting the technique and approach are anatomical location, consistency of the pathology, general condition of the patient, and the surgeon’s experience. The objective of the study was to evaluate the technical implementation and outcomes of a full endoscopic uniportal technique via the interlaminar, extraforaminal, or transthoracic retropleural approach in patients with symptomatic disc herniation and stenosis of the thoracic spine, taking specific advantages and disadvantages and literature into consideration.

METHODS Between 2009 and 2015, decompression was performed in 55 patients with thoracic disc herniation or stenosis using a full-endoscopic uniportal technique via an interlaminar, extraforaminal, or transthoracic retropleural approach. Imaging and clinical data were collected during follow-up examinations for 18 months.

RESULTS Sufficient decompression was achieved in the full-endoscopic uniportal technique. One patient required revision due to secondary bleeding, and another exhibited persistent deterioration on myelopathy. No other serious complications were observed. All but one patient experienced regression or improvement of their symptoms.

CONCLUSIONS The full-endoscopic uniportal technique with an interlaminar, extraforaminal, or transthoracic retropleural approach was found to be a sufficient and minimally invasive method. To cover the entire range of thoracic disc herniations and stenosis within the criteria named, all full-endoscopic approaches are required


After 9 Years of 3-Column Osteotomies, Are We Doing Better? Performance Curve Analysis of 573 Surgeries With 2-Year Follow-up

Neurosurgery 83:69–75, 2018

In spinal deformity treatment, the increased utilization of 3-column (3CO) osteotomies reflects greater comfort and better training among surgeons. This study aims to evaluate the longitudinal performance and adverse events (complications or revisions) for a multicenter group following a decade of 3CO.

OBJECTIVE: To investigate if performance of 3CO surgeries improves with years of practice. METHODS:Patientswhounderwent 3COfor spinal deformity with intra/postoperative and revision data collected up to 2 yrwere included. Patientswere chronologically divided into 4 even groups. Demographics, baseline deformity/correction, and surgical metrics were compared using Student t-test. Postoperative and revision rates were compared using Chi-square analysis.

RESULTS: Five hundred seventy-three patients were stratified into: G1 (n=143, 2004-2008), G2 (n = 142, 2008-2009), G3 (n = 144, 2009-2010), G4 (n = 144 2010-2013). The most recent patients were more disabled by Oswestry disability index (G4=49.2 vs G1=38.3, P=.001), and received a larger osteotomy resection (G4 = 26◦ vs G1 = 20◦, P = .011) than the earliest group. There was a decrease in revision rate (45%, 35%, 33%, 30%, P = .039), notably in revisions for pseudarthrosis (16.7% G1 vs 6.9% G4, P = .007). Major complication rates also decreased (57%, 50%, 46%, 39%, P = .023) as did excessive blood loss (>4 L, 27.2 vs 16.7%, P =.023) and bladder/bowel deficit (4.2% vs 0.7% P=.002). Successful outcomes (no complications or revision) significantly increased (P = .001).

CONCLUSION:Over 9 yr, 3COs are being performed on an increasingly disabled population while gaining a greater correction at the osteotomy site. Revisions and complication rate decreased while success rate improved during the 2-yr follow-up period.

Impact of local steroid application on dysphagia following an anterior cervical discectomy and fusion: results of a prospective, randomized single-blind trial

J Neurosurg Spine 29:10–17, 2018

Intraoperative local steroid application has been theorized to reduce swelling and improve swallowing in the immediate period following anterior cervical discectomy and fusion (ACDF). Therefore, the purpose of this study was to quantify the impact of intraoperative local steroid application on patient-reported swallow function and swelling after ACDF.

METHODS A prospective, randomized single-blind controlled trial was conducted. A priori power analysis determined that 104 subjects were needed to detect an 8-point difference in the Quality of Life in Swallowing Disorders (SWAL-QOL) questionnaire score. One hundred four patients undergoing 1- to 3-level ACDF procedures for degenerative spinal pathology were randomized to Depo-Medrol (DEPO) or no Depo-Medrol (NODEPO) cohorts. Prior to surgical closure, patients received 1 ml of either Depo-Medrol (DEPO) or saline (NODEPO) applied to a Gelfoam carrier at the surgical site. Patients were blinded to the application of steroid or saline following surgery. The SWAL-QOL questionnaire was administered both pre- and postoperatively. A ratio of the prevertebral swelling distance to the anteroposterior diameter of each vertebral body level was calculated at the involved levels ± 1 level by using pre- and postoperative lateral radiographs. The ratios of all levels were averaged and multiplied by 100 to obtain a swelling index. An air index was calculated in the same manner but using the tracheal air window diameter in place of the prevertebral swelling distance. Statistical analysis was performed using the Student t-test and chi-square analysis. Statistical significance was set at p < 0.05.

RESULTS Of the 104 patients, 55 (52.9%) were randomized to the DEPO cohort and 49 (47.1%) to the NODEPO group. No differences in baseline patient demographics or preoperative characteristics were demonstrated between the two cohorts. Similarly, estimated blood loss and length of hospitalization did not differ between the cohorts. Neither was there a difference in the mean change in the scaled total SWAL-QOL score, swelling index, and air index between the groups at any time point. Furthermore, no complications were observed in either group (retropharyngeal abscess or esophageal perforation).

CONCLUSIONS The results of this prospective, randomized single-blind study did not demonstrate an impact of local intraoperative steroid application on patient-reported swallowing function or swelling following ACDF. Neither did the administration of Depo-Medrol lead to an earlier hospital discharge than that in the NODEPO cohort. These results suggest that intraoperative local steroid administration may not provide an additional benefit to patients undergoing ACDF procedures.


Total en-bloc spondylectomy through a posterior approach: technique and surgical outcome in thoracic metastases

Acta Neurochirurgica (2018) 160:1373–1376

In 1981, Roy-Camille et al. have firstly reported the total en-bloc spondylectomy (TES) through a posterior approach for cases of malignant spine tumors in order to reduce the local recurrence and to increase the patient’s survival. By then, this surgery has been increasingly gaining recognition. However, it requires a high level of technical ability and knowledge of spinal anatomy, physiology, and biomechanics.

Method Herein, we report the patient’s selection and technique to execute the TES for cases of thoracic metastasis.

Conclusion This surgery is technically demanding so the patient’s selection requires a careful pre-operative evaluation. However, it can be suggested for patients affected by intracompartmental lesions with a good prognosis since the tumor’s progression is “limited” by local barriers as demonstrated by histological studies.

Lumbar disk herniation during pregnancy: a review on general management and timing of surgery

Acta Neurochir (2018) 160:1361–1370

Objective Provide an overview of existing management strategies to suggest a guideline for surgical management of lumbar disk herniation in pregnant women based on time of presentation.

Methods We performed a narrative review on the topic using the PubMed database. A total of 63 relevant articles published after 1992 were identified, of which 17 fulfilled selection criteria.

Results A total of 22 published cases of spine surgery for disk herniation during pregnancy were found in 17 studies on the topic. Prone positioning was reported in the majority of cases during the first and early second trimester. C-sections were performed prior to spine surgery in the prone position for the majority of patients operated during the third trimester. The left lateral position with continued pregnancy was preferred during the latter half of the second trimester when delivery of the fetus cannot yet be performed but surgery is indicated.

Conclusion Spine surgery during pregnancy is a rare scenario but can be performed safely when needed if providers adhere to general guidelines. Surgical approaches and overall management are influenced by the stage of pregnancy.

Operative Approaches for Lumbar Disc Herniation: A Systematic Review and Multiple Treatment Meta-Analysis of Conventional and Minimally Invasive Surgeries

World Neurosurg. (2018) 114:391-407

Minimally invasive surgery (MIS) techniques have emerged as viable and safe alternatives for lumbar disc herniation, including percutaneous discectomy, percutaneous endoscopic discectomy, and tubulardiscectomy (TD). We present here a systematic review and a multiple-treatment metaanalysis evaluating the operative outcomes and patient-reported outcomes of open/microdiscectomy (OD/MD) and all MIS approaches for lumbar disc herniation.

METHODS: The PICO approach and PRISMA (i.e., Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed to query existing online databases since their inception to 2016, which yielded 14 studies after we applied the inclusion/exclusion criteria. The Cochrane Collaboration’s tool for assessing risk of bias in randomized trials was used to assess the risk of bias in each study was used to assess the risk of bias in each study. Each outcome was assessed across all studies with the GRADE (i.e., Grading of Recommendations, Assessment, Development and Evaluations) criteria.

RESULTS: There were 1707 patients analyzed, with 782 (45.81%) undergoing OD/MD, 491 (28.76%) undergoing TD, 199 (11.65%) undergoing percutaneous endoscopic discectomy, and 235 (13.76%) patients undergoing percutaneous discectomy. TD was found to be associated with significantly worse Oswestry Disability Index scores (mean difference 1.17, P [ 0.03) whereas OD/MD was associated with worse Oswestry Disability Index scores compared with all other approaches (mean difference 2.61, P [ 0.03), significantly longer duration of stay (mean difference 2.96, P [ 0.04), and more blood loss (mean difference 30.53, P < 0.001). In terms of complications, TD was found to be associated with a greater rate of overall complications (odds ratio [OR] 1.49, P [ 0.002), greater incidence of dural tears (OR 1.72 P [ 0.04), and recurrent herniation (OR 2.09, P [ 0.0007). Finally, OD/MD was associated with significantly lower incidence of revision surgery (OR 0.53, P [ 0.0007).

CONCLUSIONS: Our meta-analysis revealed that tubular-discectomy and percutaneous-endoscopic-discectomy, the most commonly employed MIS techniques for discectomy, can be used as safe alternatives for open discectomy depending on the preference of the operating surgeon.

Adjacent Segment Degeneration After Anterior Cervical Discectomy and Fusion With an Autologous Iliac Crest Graft: A Magnetic Resonance Imaging Study of 59 Patients With a Mean Follow-up of 27 Years

Neurosurgery, 82, 6, 799–807, 2018

Anterior cervical decompression and fusion (ACDF) is a widely accepted surgical technique for the treatment of degenerative disc disease. ACDF is associated with adjacent segment degeneration (ASD).
OBJECTIVE: To assess whether physiological aging of the spine would overcome ASD by comparing adjacent to adjoining segments more than 18 yr after ACDF.
METHODS: Magnetic resonance imaging of 59 (36 male, 23 female) patients who underwent ACDF was performed to assess degeneration. The mean follow-up was 27 yr (18-45 yr). Besides measuring the disc height, a 5-step grading system (segmental degeneration index [SDI]) including disc signal intensity, anterior and posterior disc protrusion, narrowing of the disc space, and foraminal stenosis was used to assess the grade of adjacent and adjoining segments.
RESULTS: The SDI of cranial and caudal adjacent segments was significantly higher compared to adjoining segments (P < .001). The disc height of cranial and caudal adjacent segments was significantly lower compared to adjoining segments (P < .001, P < .01). The SDI of adjacent segments in patients with repeat cervical procedure was significantly higher than in patients without repeat procedure (P = .02, P = .01). The disc height of the cranial adjacent segments in patients with repeat procedure was significantly lower than in patients without repeat procedure (P = .01).
CONCLUSION: The physiological aging of the cervical spine does not overcome ASD. The disc height and the SDI in adjacent segment are significantly worse compared to adjoining segments. Patients who underwent repeat procedure had even worse findings of disc height and SDI.

State of the Art Treatment of Spinal Metastatic Disease

Neurosurgery 82:757–769, 2018

Treatment paradigms for patients with spine metastases have evolved significantly over the past decade. Incorporating stereotactic radiosurgery into these paradigms has been particularly transformative, offering precise delivery of tumoricidal radiation doses with sparing of adjacent tissues. Evidence supports the safety and efficacy of radiosurgery as it currently offers durable local tumor control with low complication rates even for tumors previously considered radioresistant to conventional radiation.

The role for surgical intervention remains consistent, but a trend has been observed toward less aggressive, often minimally invasive, techniques. Using modern technologies and improved instrumentation, surgical outcomes continue to improve with reduced morbidity.

Additionally, targeted agents such as biologics and checkpoint inhibitors have revolutionized cancer care, improving both local control and patient survivals. These advances have brought forth a need for new prognostication tools and a more critical review of long-term outcomes. The complex nature of current treatment schemes necessitates a multidisciplinary approach including surgeons, medical oncologists, radiation oncologists, interventionalists, and pain specialists.

This review recapitulates the current state-of-the-art, evidence-based data on the treatment of spinal metastases, integrating these data into a decision framework, NOMS, which integrates the 4 sentinel decision points in metastatic spine tumors: Neurologic, Oncologic, Mechanical stability, and Systemic disease and medical co-morbidities.

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


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