Category: Spine

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The Oblique Corridor at L4-L5

SPINE Volume 45, Number 10, pp E552–E559

Study Design. Cross-sectional radioanatomical study.

Objective. The aim of this study was to analyze the prevalence, size, and location of the oblique corridor (OC), and the morphology of the psoas muscle at the L4-L5 disc level.

Summary of Background Data. Lateral lumbar interbody fusion via the OC has the advantage of avoiding injury to the psoas muscle and lumbar plexus. However, the varying anatomy of major vascular structures and the iliopsoas may preclude a safe oblique access to the L4-L5 level.

Methods. Five hundred axial magnetic resonance images of the L4-L5 disc level were shortlisted. OCs were categorized into four grades: Grade 0 ¼ no corridor, Grade 1 ¼ small corridor (1 cm), Grade 2 ¼ moderate corridor (1–2 cm) and Grade 3 ¼ large corridor (>2 cm). OC location was labeled as anterooblique, oblique, or oblique-lateral. Psoas morphology was categorized based on a modified Moro’s classification, where the anterior section was further subdivided into types AI-AIV. Oblique approach was considered nonviable either when there was no corridor due to vascular obstruction (Grade 0) or when the psoas was high-rising (Types AII-AIV).

Results. 10.5% of the selected 449 patients had no measurable OC (grade 0) at the L4-L5 level. There were 35% and 37.2% patients with a grade 1and 2 OC, respectively. The location of the OC was anterior oblique, oblique, and oblique lateral in 3.7%, 89.6%, and 6.7%, respectively. According to the modified Moro’s classification, 19.4% had a high-rising psoas. Predominantly, psoas was either in line with the disc (Type I; 30.7%) or low-rising (Type AI; 47.4%).

Conclusion. Twenty-five percent of the patients did not have an accessible OC either due to obstruction by vascular structures or due to a high-rising psoas. Hence, proper evaluation of the relevant anatomy preoperatively is recommended for early adopters of this technique, as varying anatomy precludes universal suitability of oblique lateral interbody fusion for the L4-L5 level.

Level of Evidence: 3

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In Memoriam: Wolfhard Caspar (1938–2019) A Pioneer of Spinal Microsurgery

SPINE Volume 45, Number 9, pp 563–564, 2020

Dr. Wolfhard Caspar was born on December 29, 1938 in Ventspils, Latvia, and passed away on December 31, 2019 in Bamberg, Germany, just 2 days after his 81st birthday. Dr. Caspar grew up in Germany, having lived here since 1939.

Dr. Wolfhard Caspar presented his scientific and surgical work with eloquent passion. He usually attracted his listeners by his ‘‘unique” way of reporting his experiences. Additionally, he never reached out for presidential honors from different societies. He preferred to pursue achievable perfection in his fields of surgical interest. His goal: Spinal microsurgery tailored to the patient‘s need. His pioneering work in spine surgery is honored by the spine community.

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Spine surgery is kyphosing to spine surgeon

Acta Neurochirurgica (2020) 162:967–971

Spine surgery is a demanding surgical specialty which requires surgeons to operate for hours on end, often compromising good posture. Sustained poor posture in the operating room (OR) can be the source of many adverse health effects on spine surgeons. This study will analyze posture of a spine surgeon in different types of spine surgery cases.

Methods Posture of a surgeon was measured using the UPRIGHT Posture Training Device. The device was worn by the surgeon in the OR through a wide variety of spine surgery cases.

Results The percent time spent slouched while performing cervical, adult deformity, and lumbar spine surgeries is 39.9, 58.9, and 38.6, respectively. For all surgeries recorded, the percent time slouched is 41.6. The average procedure time was 145.3 min, with adult deformity cases on average being the longest (245.6 min) followed by cervical (152.9 min) and then lumbar (122.5 min).

Conclusion Poor posture while operating is very likely to occur for many spine surgeons regardless of case type. This poor posture is maintained for long periods of time given the average spine surgery procedure recorded in the study was roughly 2.5 h long. Spine surgeons should be aware of the tendency for poor posture while operating, and they should try using postureimproving techniques to maintain good spine health.

 

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Uncertainty in the Relationship Between Sagittal Alignment and Patient-Reported Outcomes

Neurosurgery 86:485–491, 2020

Previous studies have reported correlations and precise quantitative relationships between sagittal alignment and health-related quality-of-life (HRQOL) scores. These studies have not reported the extent of uncertainty in these relationships.

OBJECTIVE: To explore the uncertainty in the overall relationships between sagittal alignment and HRQOL and in the predictions of individual patient pain and disability.

METHODS: A retrospective analysis of all new adult patients with long-cassette radiographs and complete outcomes questionnaires presenting to the senior author from 2012 to 2014 was performed. Univariable maximum a posteriori linear regression analyses using Bayesian methods were performed. High-density probability intervals for mean regression relationships and for individual values were calculated using minimally informative prior distributions.

RESULTS: A total of 134 patients satisfied inclusion criteria and were included. For Oswestry Disability Index (ODI) vs pelvic incidence-lumbar lordosis (LL), the 90% high-density probability interval ranged from –0.04 to 0.23, indicating that both the magnitude and direction of the relationship were uncertain. For both ODI vs sagittal vertical axis and ODI vs LL, there was uncertainty in the magnitude of the slope.Wide regions of uncertainty were also seen for predicting individual patient scores.

CONCLUSION: We report the previously unpublished degree of uncertainty in the mean quantitative relationships between radiographic sagittal alignment and patient-reported outcomes and in individual patient outcomes scores. Based on these results, establishing treatment thresholds or predicting an individual’s outcome is unreliable. Further research efforts should be focused on developing multilevel hierarchical models incorporating parameter uncertainty and heterogeneous effects.

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Predicting Outcomes After Surgical Decompression for Mild Degenerative Cervical Myelopathy

Neurosurgery, Volume 86, Issue 4, April 2020 :565–573

Patients with mild degenerative cervical myelopathy (DCM) represent a heterogeneous population, and indications for surgical decompression remain controversial.

OBJECTIVE: To dissociate patient phenotypes within the broader population of mild DCM associated with degree of impairment in baseline quality of life (QOL) and surgical outcomes.

METHODS: This was a post hoc analysis of patients with mild DCM (modified Japanese Orthopedic Association [mJOA] 15-17) enrolled in the AOSpine CSM-NA/CSM-I studies. A kmeans clustering algorithm was applied to baseline QOL (Short Form-36 [SF-36]) scores to separate patients into 2 clusters. Baseline variables and surgical outcomes (change in SF- 36 scores at 1 yr) were compared between clusters. A k-nearest neighbors (kNN) algorithm was used to evaluate the ability to classify patients into the 2 clusters by significant baseline clinical variables.

RESULTS: One hundred eighty-five patients were eligible. Two groups were generated by k-means clustering. Cluster 1 had a greater proportion of females (44% vs 28%, P = .029) and symptoms of neck pain (32% vs 11%, P = .001), gait difficulty (57% vs 40%, P = .025), or weakness (75% vs 59%, P=.041). Although baseline mJOA correlated with neither baseline QOL nor outcomes, cluster 1 was associated with significantly greater improvement in disability (P = .003) and QOL (P < .001) scores following surgery. A kNN algorithm could predict cluster classification with 71% accuracy by neck pain, motor symptoms, and gender alone.

CONCLUSION: We have dissociated a distinct patient phenotype of mild DCM, characterized by neck pain, motor symptoms, and female gender associated with greater impairment in QOL and greater response to surgery.

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Percutaneous Transforaminal Endoscopic Discectomy Versus Microendoscopic Discectomy for Lumbar Disc Herniation

SPINE Volume 45, Number 8, pp 493–503

Study Design. A prospective randomized controlled study.

Objective. To clarify whether percutaneous transforaminal endoscopic discectomy (PTED) has better clinical outcomes and less surgical trauma compared with microendoscopic discectomy (MED).

Summary of Background Data. Two kinds of minimally invasive spine surgeries, PTED and MED, are now widely used for the treatment of lumbar disc herniation (LDH). It is still a controversial issue to choose the proper surgical approach.

Methods. In this single-center, open-label, randomized controlled trial, patients were included if they had persistent signs and symptoms of radiculopathy with corresponding imagingconfirmed LDH, and were randomly allocated to PTED or MED group. The primary outcome was the score of Oswestry Disability Index (ODI) and the secondary outcomes included the score of Medical Outcomes Study 36-Item Short-Form Health Survey bodily pain and physical function scales, European Quality of Life-5 Dimensions, and Visual Analogue Scales for back pain and leg pain.

Results. A total of 250 participants were randomly assigned to two treatment groups, 241 of that received the specific surgical procedure. Two hundred twenty-two patients (92.1%) have completed the 2-year follow-up. Both the primary and secondary outcomes did not differ significantly between the two treatment groups at each prespecified follow-up time (P>0.05). For PTED, the postoperative improvement of ODI score in the median herniation subgroup was less compared with paramedian subgroup. For MED, less improvement of ODI score was found in far-lateral herniation subgroup compared with paramedian subgroup. Total complication rate over the course of 2 year was 13.44% in PTED group and 15.57% in MED group (P¼0.639). Ten cases (8.40%) in PTED group and five cases (4.10%) in MED group suffered from residue/recurrence of herniation, for which reoperation was required.

Conclusion. Over the 2-year follow-up period, PTED did not show superior clinical outcomes and did not appear to be safer procedure for patients with LDH compared with MED. PTED had inferior results for median disc herniation, whereas MED did not appear to be the best option for far-lateral disc herniation.

Level of Evidence: 2

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Double-blind randomized clinical trial of vancomycin in spinal arthrodesis: no effects on surgical site infection

J Neurosurg Spine 32:473–480, 2020

Surgical site infection (SSI) results in high morbidity and mortality in patients undergoing spinal fusion. Using intravenous antibiotics in anesthesia induction reduces the rate of postoperative infection, but it is not common practice to use them topically, despite recent reports that this procedure helps reduce infection. The objective of this study was to determine whether the topical use of vancomycin reduces the rate of postoperative SSI in patients undergoing thoracolumbar fusion.

METHODS A randomized, double-blind clinical trial in a single hospital was performed comparing vancomycin and placebo in thoracolumbar fusion patients.

RESULTS A total of 96 patients were randomized to placebo or vancomycin treatment. The mean patient age was 43 ± 14.88 years, 74% were male, and the most common etiology was fall from height (46.9%). The overall rate of postoperative SSI was 8.3%, and no difference was found between the groups: postoperative infection rates in the vancomycin and placebo groups were 8.2% and 8.5% (relative risk [RR] of SSI not using vancomycin 1.04, 95% confidence interval [CI] 0.28–3.93, p = 0.951), respectively. Patients with diabetes mellitus had higher SSI rates (RR 8.98, 95% CI 1.81–44.61, p = 0.007).

CONCLUSIONS This is the first double-blind randomized clinical trial to evaluate the effects of topical vancomycin on postoperative infection rates in thoracolumbar fusion patients, and the results did not differ significantly from placebo. Clinical trial registration no.: RBR-57wppt (ReBEC; http://www.ensaiosclinicos.gov.br/)

 

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Topping-off technique for stabilization of lumbar degenerative instabilities in 322 patients

J Neurosurg Spine 32:366–372, 2020

Semi-rigid instrumentation (SRI) was introduced to take advantage of the concept of load sharing in surgery for spinal stabilization. The authors investigated a topping-off technique in which interbody fusion is not performed in the uppermost motion segment, thus creating a smooth transition from stabilized to free motion segments. SRI using the topping-off technique also reduces the motion of the adjacent segments, which may reduce the risk of adjacent segment disease (ASD), a frequently observed sequela of instrumentation and fusion, but this technique may also increase the possibility of screw loosening (SL). In the present study the authors aimed to systematically evaluate reoperation rates, clinical outcomes, and potential risk factors and incidences of ASD and SL for this novel approach.

METHODS The authors collected data for the first 322 patients enrolled at their institution from 2009 to 2015 who underwent surgery performed using the topping-off technique. Reoperation rates, patient satisfaction, and other outcome measures were evaluated. All patients underwent pedicle screw–based semi-rigid stabilization of the lumbar spine with a polyetheretherketone (PEEK) rod system.

RESULTS Implantation of PEEK rods during revision surgery was performed in 59.9% of patients. A median of 3 motion segments (range 1–5 segments) were included and a median of 2 motion segments (range 0–4 segments) were fused. A total of 89.4% of patients underwent fusion, 73.3% by transforaminal lumbar interbody fusion (TLIF), 18.4% by anterior lumbar interbody fusion (ALIF), 3.1% by extreme lateral interbody fusion (XLIF), 0.3% by oblique lumbar interbody fusion (OLIF), and 4.9% by combined approaches in the same surgery. Combined radicular and lumbar pain according to a visual analog scale was reduced from 7.9 ± 1.0 to 4.0 ± 3.1, with 56.2% of patients indicating benefit from surgery. After maximum follow-up (4.3 ± 1.8 years), the reoperation rate was 16.4%.

CONCLUSIONS The PEEK rod concept including the topping-off principle seems safe, with at least average patient satisfaction in this patient group. Considering the low rate of first-tier surgeries, the presented results seem at least comparable to those of most other series. Follow-up studies are needed to determine long-term outcomes, particularly with respect to ASD, which might be reduced by the presented approach.

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Usefulness of Timed Up and Go (TUG) Test for Prediction of Adverse Outcomes in Patients Undergoing Thoracolumbar Spine Surgery

Neurosurgery 2019 DOI:10.1093/neuros/nyz480

Spine surgery rates have increased and the high postoperativemorbidity in these patients result in increased costs. Consequently, it is essential to identify patients at risk of adverse outcomes.

OBJECTIVE: To assess whether preoperative Timed Up and Go (TUG) test performance can predict high-grade postoperative complications.

METHODS: A prospective cohort study of patients undergoing elective thoracolumbar spine surgery in a tertiary care hospital between 2017 and 2018. Patients were assessed preoperatively and assigned to the slow-TUG group if unable to perform or test performance time was ≥18.4 s. Primary outcome: high-grade postoperative complications. Secondary outcomes: overall complications, length of stay (LOS), discharge to healthcare facility, readmission and emergency department (ED) presentation. Patients were followed-up until 6 wk after surgery.

RESULTS: One hundred three patients (mean age 62.95 ± 10.97 yr) were enrolled. Slow- TUG group were more likely to be classified as American Society of Anaesthesiology (ASA) class 3 (74.1% vs 47.4%, P=.02), non-independent (25.9% vs 5.3%, P<.01), and frail (92.3% vs 42.1%, P < .01). TUG was an independent predictor of high-grade complications (adjusted odds ratio (OR): 4.97, 95% CI: 1.18-22.47), overall complications (OR: 3.77, 95% CI: 1.33-11.81), discharge to a skilled-nursing facility (OR: 3.2, 95% CI: 1.00-10.70), readmission within 6 wk of surgery (OR: 9.14, 95% CI: 2.39-41.26) and LOS (adjusted incident rate ratio (IRR): 1.45, 95% CI: 1.16-1.80).

CONCLUSION: Compared to traditional risk factors, TUG is an important predictor of adverse postoperative outcomes and may be used preoperatively to identify high-risk thoracolumbar surgery patients.

 

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Anterior Cervical Discectomy and Fusion in the Outpatient Ambulatory Surgery Setting: Analysis of 2000 Consecutive Cases

Neurosurgery 2019 DOI:10.1093/neuros/nyz514

In an effort to improve efficiency of care, ambulatory surgery centers (ASCs) have emerged as lower-cost options. Anterior cervical discectomy and fusion (ACDF) is one of the most prevalent spine surgeries performed and rarely requires overnight stays in the hospital, supporting its migration to the ASC. Recent analyses have called into question the safety of outpatient ACDF, potentially slowing its adoption. ASC-ACDF studies have largely been limited to small series, precluding an accurate assessment of safety.

OBJECTIVE: To analyze 2000 ASC-ACDF cases, describe patient selection and perioperative protocol, and report associated safety profile.

METHODS: A total of 2000 patients who underwent 1 to 3 level ACDF in a single ASC from 2006 to 2018 were included in this retrospective analysis. Patients were observed in a 4-h postanesthesia care unit (PACU) with a multimodal pain management regiment. Data were collected on patient demographics, comorbidities, operative details, and 30- and 90-d morbidity.

RESULTS: Of the 2000 patients, 10 (0.5%) required transfer to an inpatient setting within the 4-h observation. Reasons for transfer included hematoma (2), pain control (2), cerebrospinal fluid leak (1), and medical complications (5). Six patients (0.3%) underwent reoperation within 30 d. All-cause 30-d readmission was 1.9%.

CONCLUSION: An analysis of 2000 ACDF patients in an ASC setting with a standardized perioperative protocol demonstrates that surgical complications occur at a low rate (<1%) and can be appropriately diagnosed and managed in a 4-h PACU. In an effort to decrease healthcare costs, surgeons can safely perform ACDFs in an ASC utilizing patient selection criteria and perioperative management protocols similar to those reported here.

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Kambin’s triangle: definition and new classification schema

J Neurosurg Spine 32:390–398, 2020

Kambin’s triangle is an anatomical corridor used to access critical structures in a variety of spinal procedures. It is considered a safe space because it is devoid of vascular and neural structures of importance. Nonetheless, there is currently significant variation in the literature regarding the exact dimensions and anatomical borders of Kambin’s triangle. This confusion was originally caused by leaving the superior articular process (SAP) unassigned in the description of the working triangle, despite Kambin identifying that structure in his original report. The SAP is the most relevant structure to consider when accessing the transforaminal corridor. Leaving the SAP unassigned has led to an open-handed application of the term “Kambin’s triangle.” That single eponym currently has two potential meanings, one meaning for endoscopic surgeons working through a corridor in the intact spine and a second meaning for surgeons accessing the disc space after a complete or partial facetectomy. Nevertheless, an anatomical corridor should have one consistent definition to clearly communicate techniques and use of instrumentation performed through that space. As such, the authors propose a new surgically relevant classification of this corridor. Assigning the SAP a border requires adding another dimension to the triangle, thereby transforming it into a prism. The term “Kambin’s prism” indicates the assignment of a border to all relevant anatomical structures, allowing for a uniform definition of the 3D space. From there, the classification scheme considers the expansion of the corridor and the extent of bone removal, with a particular focus on the SAP.

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A New Piece of the Puzzle to Understand Cervical Sagittal Alignment: Utilizing a Novel Angle δ to Describe the Relationship among T1 Vertebral Body Slope, Cervical Lordosis, and Cervical Sagittal Alignment

Neurosurgery 2019 DOI:10.1093/neuros/nyz088

Cervical alignment has become increasingly important in the planning of spine surgery. A relationship between the slope of T1 (T1S), the cervical lordosis (CL), and the overall cervical sagittal vertical axis (cSVA) has previously been demonstrated, but the exact nature of this relationship is poorly understood. In this study, we derive theoretical and empirical equations to better understand how T1S and CL affect cSVA. The first equation was developed on a theoretical basis using inherent trigonometric relationships of the cervical spine. By treating the cervical spine as the arc of a circumference, and by taking into account the cervical height (CH), the geometric relationship between theT1S, CL, and cSVA was described via a trigonometric identity utilizing a novel angle δ subtended by the CH and cSVA (δ = T1S-CL/2). The second equation was developed on an empiric basis by performing a multiple linear regression on data obtained from a retrospective review of a large multicenter deformity database. The theoretical equation determined that the value of cSVA could be expressed as: cSVA = CH ∗ tan(π/180 ∗ (T 1S −CL/2)) . The empirical equation determined that value of cSVA could be expressed as: cSVA = (1.1 ∗ T 1) −(0.43 ∗ CL) + 6.69. In both, the sagittal alignment of the head over the shoulders is directly proportional to the T1S and inversely proportional to CL/2. These 2 equations may allow surgeons to better understand how the CL compensates for the T1S, to accurately predict the postoperative cSVA, and to customize cervical interbody grafts by taking into consideration each individual patient’s specific cervical spine parameters.

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Posterior foraminotomy versus anterior decompression and fusion in patients with cervical degenerative disc disease with radiculopathy

J Neurosurg Spine 32:344–352, 2020

The long-term efficacy of posterior foraminotomy compared with anterior cervical decompression and fusion (ACDF) for the treatment of degenerative disc disease with radiculopathy has not been previously investigated in a population-based cohort.

METHODS All patients in the national Swedish Spine Register (Swespine) from January 1, 2006, until November 15, 2017, with cervical degenerative disc disease and radiculopathy were assessed. Using propensity score matching, patients treated with posterior foraminotomy were compared with those undergoing ACDF. The primary outcome measure was the Neck Disability Index (NDI), a patient-reported outcome score ranging from 0% to 100%, with higher scores indicating greater disability. A minimal clinically important difference was defined as > 15%. Secondary outcomes were assessed with additional patient-reported outcome measures (PROMs).

RESULTS A total of 4368 patients (2136/2232 women/men) met the inclusion criteria. Posterior foraminotomy was performed in 647 patients, and 3721 patients underwent ACDF. After meticulous propensity score matching, 570 patients with a mean age of 54 years remained in each group. Both groups had substantial decreases in their NDI scores; however, after 5 years, the difference was not significant (2.3%, 95% CI −4.1% to 8.4%; p = 0.48) between the groups. There were no significant differences between the groups in EQ-5D or visual analog scale (VAS) for neck and arm scores. The secondary surgeries on the index level due to restenosis were more frequent in the foraminotomy group (6/100 patients vs 1/100), but on the adjacent segments there was no difference between groups (2/100).

CONCLUSIONS In patients with cervical degenerative disc disease and radiculopathy, both groups demonstrated clinical improvements at the 5-year follow-up that were comparable and did not achieve a clinically important difference from one another, even though the reoperation rate favored the ACDF group. This study design obtains population-based results, which are generalizable.

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Cost of Readmissions Following Anterior Cervical Discectomy and Fusion

Neurosurgery DOI:10.1093/neuros/nyz443

Postoperative readmissions are a significant driver of variation in bundled care costs associated with cervical spine surgery.

OBJECTIVE: To determine the factors predicting the cost of readmission episodes following elective anterior cervical discectomy and fusion (ACDF).

METHODS: We queried the Healthcare Cost and Utilization Project Nationwide Readmissions Database for patients undergoing elective ACDF during 2012 to 2015. Multivariable linear regression was performed to establish the factors associated with the cost of each 30-/90-d readmission episode.

RESULTS: A total of 139 877 and 113 418 patients met inclusion criteria for the evaluation of 30- and 90-d readmissions, respectively. Among these, the national rates of 30- and 90-d readmission after an elective ACDF were 3% and 6%, respectively. The median cost of a 30- and 90-d readmission episode was $6727 (IQR: $3844-$13 529) and $8507 (IQR: $4567- $17 460), respectively. Relative predictor importance analysis revealed that the number of procedures at index admission (IA), length of stay at IA, and time elapsed between index surgical admission and readmission were the top predictors of both 30- and 90-d readmission costs (all P < .001). Although cervical myelopathy accounted for only 3.6% of all 30-d readmissions, it accounted for the largest share (8%) of 30-d readmission costs.

CONCLUSION: In this analysis from a national all-payer database, we determined the factors associated with the cost of readmissions following elective ACDF. These results are important in assisting policymakers and payers with a better risk adjustment in bundled care payment systems and for surgeons in implementing readmission cost-reduction efforts.

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Outcomes of Minimally Invasive Transforaminal Lumbar Interbody Fusion With Expandable Lordotic Devices

Neurosurgery, Volume 86, Issue 2, February 2020, Pages E147–E155

Minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) is a well-accepted procedure for the treatment of degenerative lumbar disease. However, its ability to restore lumbar lordosis has been limited. Development of expandable lordotic interbody devices has challenged this limitation, furthering the scope ofminimally invasive surgery.

OBJECTIVE: To evaluate the radiographic and clinical effects of expandable lordotic interbody devices placed through an MIS-TLIF approach.

METHODS: We conducted a retrospective review of 32 1-level and 18 2-level MIS-TLIFs performed using lordotic expandable interbody devices. Lumbar radiographic measurements, Oswestry Disability Index scores (ODI), and Visual Analogue Scale scores (VAS)were obtained at preoperative, 6 wk follow up, and last follow up time points. Last follow up occurred at a mean of 11.5 ± 7.6 mo (mean ± SD).

RESULTS: At 6-wk follow-up, segmental lordosis, disc height, and foraminal height increased by an average of 3.4◦, 6.4 mm, and 4.4 mm, respectively. Only the 2-level group showed a significant increase in lumbar lordosis of 5.8◦. No significant changes occurred in sacral slope, pelvic tilt, or pelvic incidence. Average ODI and VAS decreased by −12.0 and −4.5, respectively. Postoperative lumbar lordosis inversely correlated with preoperative lordosis in patients with an initial Pelvic Incidence to Lumbar Lordosis mismatch (PI-LL) of >10◦, (r=−0.5, P = .009).

CONCLUSION: When applied across 2-levels, MIS-TLIF using expandable lordotic interbody devices produced a significant increase in lumbar lordosis. Preoperative lumbar lordosis was found to be a predictor of postoperative lumbar lordotic change in patients with sagittal imbalance.

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Long-term outcomes of high-dose single-fraction radiosurgery for chordomas of the spine and sacrum

J Neurosurg Spine 32:79–88, 2020

The current treatment of chordomas is associated with significant morbidity, high rates of local recurrence, and the potential for metastases. Stereotactic radiosurgery (SRS) as a primary treatment could reduce the need for en bloc resection to achieve wide or marginal margins. Spinal SRS outcomes support the exploration of SRS’s role in the durable control of these conventionally radioresistant tumors. The goal of the study was to evaluate outcomes of patients with primary chordomas treated with spinal SRS alone or in combination with surgery.

METHODS Clinical records were reviewed for outcomes of patients with primary chordomas of the mobile spine and sacrum who underwent single-fraction SRS between 2006 and 2017. Radiographic local recurrence-free survival (LRFS), overall survival (OS), symptom response, and toxicity were assessed in relation to the extent of surgery.

RESULTS In total, 35 patients with de novo chordomas of the mobile spine (n = 17) and sacrum (n = 18) received SRS and had a median post-SRS follow-up duration of 38.8 months (range 2.0–122.9 months). The median planning target volume dose was a 24-Gy single fraction (range 18–24 Gy). Overall, 12 patients (34%) underwent definitive SRS and 23 patients (66%) underwent surgery and either neoadjuvant or postoperative adjuvant SRS. Definitive SRS was selectively used to treat both sacral (n = 7) and mobile spine (n = 5) chordomas. Surgical strategies for the mobile spine were either intralesional, gross-total resection (n = 5) or separation surgery (n = 7) and for the sacrum en bloc sacrectomy (n = 11). The 3- and 5-year LRFS rates were 86.2% and 80.5%, respectively. Among 32 patients (91%) receiving 24-Gy radiation doses, the 3- and 5-year LRFS rates were 96.3% and 89.9%, respectively. The 3- and 5-year OS rates were 90.0% and 84.3%, respectively. The symptom response rate to treatment was 88% for pain and radiculopathy. The extent or type of surgery was not associated with LRFS, OS, or symptom response rates (p > 0.05), but en bloc resection was associated with higher surgical toxicity, as measured using the Common Terminology Criteria for Adverse Events (version 5.0) classification tool, than epidural decompression and curettage/intralesional resection (p = 0.03). The long-term rate of toxicity ≥ grade 2 was 31%, including 20% grade 3 tissue necrosis, recurrent laryngeal nerve palsy, myelopathy, fracture, and secondary malignancy.

CONCLUSIONS High-dose spinal SRS offers the chance for durable radiological control and effective symptom relief with acceptable toxicity in patients with primary chordomas as either a definitive or adjuvant therapy.

 

 

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Perioperative complications with multilevel anterior and posterior cervical decompression and fusion

J Neurosurg Spine 32:9–14, 2020

Cervical spondylotic myelopathy (CSM) is a progressive degenerative pathology that frequently affects older individuals and causes spinal cord compression with symptoms of neck pain, radiculopathy, and weakness. Anterior decompression and fusion is the primary intervention to prevent neurological deterioration; however, in severe cases, circumferential decompression and fusion is necessary. Published data regarding perioperative morbidity associated with these complex operations are scarce. In this study, the authors sought to add to this important body of literature by documenting a large single-surgeon experience of single-session circumferential cervical decompression and fusion.

METHODS A retrospective analysis was performed to identify intended single-stage anterior-posterior or posterioranterior- posterior cervical spine decompression and fusion surgeries performed by the primary surgeon (V.C.T.) at Rush University Medical Center between 2009 and 2016. Cases in which true anterior-posterior cervical decompression and fusion was not performed (i.e., those involving anterior-only, posterior-only, or delayed circumferential fusion) were excluded from analysis. Data including standard patient demographic information, comorbidities, previous surgeries, and intraoperative course, along with postoperative outcomes and complications, were collected and analyzed. Perioperative morbidity was recorded during the 90 days following surgery.

RESULTS Seventy-two patients (29 male and 43 female, mean age 57.6 years) were included in the study. Fourteen patients (19.4%) were active smokers, and 56.9% had hypertension, the most common comorbidity. The most common clinical presentation was neck pain in 57 patients (79.2%). Twenty-three patients (31.9%) had myelopathy, and 32 patients (44.4%) had undergone prior cervical spine surgery. Average blood loss was 613 ml. Injury to the vertebral artery was encountered in 1 patient (1.4%). Recurrent laryngeal nerve palsy was observed in 2 patients (2.8%). Two patients (2.8%) had transient unilateral hand grip weakness. There were no permanent neurological deficits. Dysphagia was encountered in 45 patients (62.5%) postoperatively, with 23 (32%) requiring nasogastric parenteral nutrition and 9 (12.5%) patients ultimately undergoing percutaneous endoscopic gastrostomy (PEG) placement. Nine of the 72 patients required a tracheostomy. The incidence of pneumonia was 6.9% (5 patients) overall, and 2 of these patients were in the tracheostomy group. Superficial wound infections occurred in 4 patients (5.6%). Perioperative death occurred in 1 patient. Reoperation was necessary in 10 patients (13.9%). Major perioperative complications (permanent neurological deficit, vascular injury, tracheostomy, PEG tube, stroke, or death) occurred in 30.6% of patients. The risk of minor perioperative complications (temporary deficit, dysphagia, deep vein thrombosis, pulmonary embolism, urinary tract infection, pneumonia, or wound infection) was 80.6%.

CONCLUSIONS Single-session anterior-posterior cervical decompression and fusion is an inherently morbid operation required in select patients with cervical spondylotic myelopathy. In this large single-surgeon series, there was a major perioperative complication risk of 30.6% and minor perioperative complication risk of 80.6%. This overall elevated risk for postoperative complications must be carefully considered and discussed with the patient preoperatively. In some situations, shared decision making may lead to the conclusion that a procedure of lesser magnitude may be more appropriate.

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Lumbar disc extrusions reduce faster than bulging discs due to an active role of macrophages in sciatica

Acta Neurochirurgica (2020) 162:79–85

This retrospective observational histological study aims to associate the size and type of disc herniation with the degree of macrophage infiltration in disc material retrieved during disc surgery in patients with sciatica.

Methods Disc tissue of 119 sciatica patients was embedded in paraffin and stained with hematoxylin and CD68. Tissue samples were categorized as mild (0–10/cm2), moderate (10–100/cm2), and considerable (> 100/cm2) macrophage infiltration. All 119 patients received an MRI at baseline, and 108 received a follow-up MRI at 1-year. MRIs were reviewed for the size and type of the disc herniations, and for Modic changes in the vertebral endplates.

Results Baseline characteristics and duration of symptoms before surgery were comparable in all macrophage infiltration groups. The degree of macrophage infiltration was not associated with herniation size at baseline, but significantly associated with reduction of size of the herniated disc at 1-year post surgery. Moreover, the degree of macrophage infiltration was higher in extrusion in comparison with bulging (protrusion) of the disc. Results were comparable in patients with and without Modic changes.

Conclusion Macrophage infiltration was positively associated with an extruded type of disc herniation as well as the extent of reduction of the herniated disc during 1-year follow-up in patients with sciatica. This is an indication that the macrophages play an active role in reducing herniated discs. An extruded disc herniation has a larger surface for the macrophages to adhere to, which leads to more size reduction.

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Safety of Outpatient Anterior Cervical Discectomy and Fusion: A Systematic Review and Meta-Analysis

Neurosurgery 86:30–45, 2020

Anterior cervical discectomy and fusion (ACDF) is being increasingly offered on an outpatient basis. However, the safety profile of outpatient ACDF remains poorly defined.

OBJECTIVE: To review the medical literature on the safety of outpatient ACDF.

METHODS: We systematically reviewed the literature for articles published before April 1, 2018, describing outpatient ACDF and associated complications, including incidence of reoperation, stroke, thrombolytic events, dysphagia, hematoma, and mortality. A random-effects analysis was performed comparing complications between the inpatient and outpatient groups.

RESULTS: We identified 21 articles that satisfied the selection criteria, of which 15 were comparative studies. Most of the existing studies were retrospective, with a lack of level I or II studies on this topic. We found no statistically significant difference between inpatient and outpatient ACDF in overall complications, incidence of stroke, thrombolytic events, dysphagia, and hematoma development. However, patients undergoing outpatient ACDF had lower reported reoperation rates (P < .001), mortality (P < .001), and hospitalization duration (P < .001).

CONCLUSION: Our meta-analysis indicates that there is a lack of high level of evidence studies regarding the safety of outpatient ACDF. However, the existing literature suggests that outpatient ACDF can be safe, with low complication rates comparable to inpatient ACDF in well-selected patients. Patients with advanced age and comorbidities such as obesity and significant myelopathy are likely not suitable for outpatient ACDF. Spine surgeons must carefully evaluate each patient to decide whether outpatient ACDF is a safe option. Higher quality, large prospective randomized control trials are needed to accurately demonstrate the safety profile of outpatient ACDF.

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Stem cell injections for axial back pain: a systematic review of associated risks and complications with a case illustration of diffuse hyperplastic gliosis resulting in cauda equina syndrome

J Neurosurg Spine 31:906–913, 2019

Axial low-back pain is a disease of epidemic proportions that exerts a heavy global toll on the active workforce and results in more than half a trillion dollars in annual costs. Stem cell injections are being increasingly advertised as a restorative solution for various degenerative diseases and are becoming more affordable and attainable by the public. There have been multiple reports in the media of these injections being easily available abroad outside of clinical trials, but scientific evidence supporting them remains scarce. The authors present a case of a serious complication after a stem cell injection for back pain and provide a systematic review of the literature of the efficacy of this treatment as well as the associated risks and complications.

METHODS A systematic review of the literature was performed using the PubMed, Google Scholar, and Scopus online electronic databases to identify articles reporting stem cell injections for axial back pain in accordance with the PRISMA guidelines. The primary focus was on outcomes and complications. A case of glial hyperplasia of the roots of the cauda equina directly related to stem cell injections performed abroad is also reported.

RESULTS The authors identified 14 publications (including a total of 147 patients) that met the search criteria. Three of the articles presented data for the same patient population with different durations of follow-up and were thus analyzed as a single study, reducing the total number of studies to 12. In these 12 studies, follow-up periods ranged from 6 months to 6 years, with 50% having a follow-up period of 1 year or less. Most studies reported favorable outcomes, although 36% used subjective measures. There was a tendency for pain relief to wane after 6 months to 2 years, with patients seeking a surgical solution. Only 1 study was a randomized controlled trial (RCT).

CONCLUSIONS There are still insufficient data to support stem cell injections for back pain. Additional RCTs with longterm follow-up are necessary before statements can be made regarding the efficacy and safety.

 

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