Category: Spine

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Curve Laterality for Lateral Lumbar Interbody Fusion in Adult Scoliosis Surgery: The Concave Versus Convex Controversy

Neurosurgery 83:1219–1225, 2018

Minimally invasive lateral lumbar interbody fusion (LLIF) is an effective adjunct in adult degenerative scoliosis (ADS) surgery. LLIF approaches performed fromthe concavity or convexity have inherent approach-related risks and benefits.

OBJECTIVE: To analyze LLIF approach-related complications and radiographic and clinical outcomes in patients with ADS.

METHODS: A multicenter retrospective review of a minimally invasive adult spinal deformity database was queried with a minimum of 2-yr follow-up. Patients were divided into 2 groups as determined by the side of the curve from which the LLIF was performed: concave or convex.

RESULTS: No differences between groups were noted in demographic, and preoperative or postoperative radiographic parameters (all P > .05). There were 8 total complications in the convex group (34.8%) and 21 complications in the concave group (52.5%; P = .17). A subgroup analysis was performed in 49 patients in whom L4-5 was in the primary curve and not in the fractional curve. In this subset of patients, there were 6 complications in the convex group (31.6%) compared to 19 in the concave group (63.3%; P < .05) and both groups experienced significant improvements in coronal Cobb angle, Oswestry Disability Index, and Visual Analog Scale score with no difference between groups.

CONCLUSION: Patients undergoing LLIF for ADS had no statistically significant clinical or operative complication rates regardless of a concave or convex approach to the curve. Clinical outcomes and coronal plane deformity improved regardless of approach side. However, in cases wherein L4-5 is in the primary curve, approaching the fractional curve at L4-5 from the concavity may be associated with a higher complication rate compared to a convex approach.

 

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CT for thoracic and lumbar spine fractures: Can CT findings accurately predict posterior ligament complex injury?

European Spine Journal (2018) 27:3007–3015

This study aims to determine whether secondary CT findings can predict posterior ligament complex (PLC) injury in patients with acute thoracic (T) or lumbar (L) spine fractures.

Methods This is a retrospective study of 105 patients with acute thoracic and lumbar spine fractures on CT, with MRI as the reference standard for PLC injury. Three readers graded CT for facet joint alignment (FJA), widening (FJW), pedicle or lamina fracture (PLF), spinous fracture (SPF), interspinous widening (ISW), vertebral translation (VBT), and posterior endplate fracture (PEF). Univariate and multivariate logistic regression analyses were performed separately for each reader to test for associations between CT and PLC injury, and diagnostic performance of CT was calculated.

Results Fifty-three of 105 patients had PLC injury by MRI. Statistically significant predictors of PLC injury were VBT, PLF, ISW, and SPF. Using these four CT findings, odds of PLC injury ranged from 3.8 to 5.6 for one positive finding, but increased to 13.6–25.1 for two or more. At least one positive CT finding was found to yield average sensitivity of 82% and specificity 59%, while two or more yielded sensitivity 46% and specificity 88%.

Conclusion While no individual CT finding is sufficiently accurate to diagnose or exclude PLC injury, greater the number of positive CT findings (VBT, PLF, ISW, and SPF), the higher the odds of PLC injury. The presence of a single abnormal CT finding may warrant confirmatory MRI for PLC injury, while two or more CT findings may have adequate specificity to avoid need for MRI prior to surgical intervention.

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Total En Bloc Spondylectomy for Lumbar Spinal Tumors by Paraspinal Approach

World Neurosurg. (2018)120:28-35

OBJECTIVE: To report and describe a modified posterioronly
approach (paraspinal approach) for total en bloc
spondylectomy (TES) of lumbar spinal tumors.

METHODS: From February 2013 to June 2014, 5 patients
with lumbar spinal tumors who underwent TES through a
posterior-only paraspinal approach were studied retrospectively;
operative time, blood loss, complications,
neurologic outcomes, and degree of resection were
recorded to evaluate the efficacy of this surgical method.

RESULTS: Patients included 3 men and 2 women with a
mean age of 48.4 years (range, 46e52 years). Two lesions
were located in L2, 2 lesions were located in L3, and 1
lesion was located in L4. Three patients had solitary
metastatic tumors (lung cancer in 2 cases, breast cancer
in 1 case), and 2 patients had primary tumors (osteosarcoma
and plasma cell tumor). According to the surgical
classification of spinal tumors by Tomita et al., 4 cases
were type 4 and 1 case was type 1. Mean operative time
was 464 minutes (range, 420-510 minutes), and mean
blood loss was 1280 mL (range, 1000-1500 mL). One
patient had cerebrospinal fluid leakage, and 1 had transient
motor weakness because of nerve root traction.
Mean follow-up time was 20.6 months (range, 12e30
months), and all patients had improved or stable neurologic
function. No local recurrence was observed at last
follow-up.

CONCLUSIONS: The posterior-only paraspinal approach
is a valid alternative for TES of lumbar spinal tumors,
especially for overweight or muscular patients.

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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.

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Predictors of Poor Outcome in Patients Submitted to Minimally Invasive Transforaminal Lumbar Interbody Fusion

World Neurosurg. (2018) 119:488-493

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) has become an increasingly popular method for lumbar arthrodesis. While having similar long-term outcomes when compared with open TLIF, it decreases the amount of intraoperative blood loss and iatrogenic muscle damage, the intensity of postoperative pain, and the duration of hospital stay. However, uncertainty remains about which factors contribute to outcomes in these patients. The purpose of this study was to retrospectively analyze a cohort of patients submitted to MI-TLIF and to identify factors that can be associated with a worse postoperative outcome.

METHODS: Clinical records from 283 patients were assessed and, according to Odom’s criteria, postoperative clinical outcome at 12 months was classified as excellent, good, fair, and poor. Demographic variables, clinical data, and surgery-related data were analyzed, looking for associations between them and clinical outcome. A binomial logistic regression analysis was then performed to include those associations.

RESULTS: The main variables associated with worse prognosis (“poor” class according to Odom’s criteria) were a period of sick leave longer than 3 months before the surgery, age younger than 50 years, lytic spondylolisthesis, L5-S1 level, and occurrence of complications. These 5 conditions were included in a logistic regression analysis, and 3 of them were independently associated with poor outcome: operative complications, age younger than 50 years, and sick leave longer than 3 months before surgery. –

CONCLUSIONS: Younger patients, those on a sick leave for more than 3 months before surgery, or those who suffered surgical complications tended to have less satisfactory results after MI-TLIF.

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Drivers of Variability in 90-Day Cost for Elective Anterior Cervical Discectomy and Fusion for Cervical Degenerative Disease

Neurosurgery 83:898–904, 2018

Value-based episode of care reimbursement models is being investigated to curb unsustainable health care costs. Any variation in the cost of index spine surgery can affect the payment bundling during the 90-d global period.

OBJECTIVE: To determine the drivers of variability in cost for patients undergoing elective anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease.

METHODS: Four hundred forty-five patients undergoing elective ACDF for cervical spine degenerative diagnoses were included in the study. The direct 90-d cost was derived as sum of cost of surgery, cost associated with postdischarge utilization. Multiple variable linear regression models were built for total 90-d cost.

RESULTS: The mean 90-d direct cost was $17685 ± $5731. In a multiple variable linear regression model, the length of surgery, number of levels involved, length of hospital stay, preoperative history of anticoagulation medication, health-care resource utilization including number of imaging, any complications and readmission encounter were the significant contributor to the 90-d cost. The model performance as measured by R2 was 0.616.

CONCLUSION: There was considerable variation in total 90-d cost for elective ACDF surgery. Our model can explain about 62% of these variations in 90-d cost. The episode of care reimbursement models needs to take into account these variations and be inclusive of the factors that drive the variation in cost to develop a sustainable payment model. The generalized applicability should take in to account the differences in patient population, surgeons’ and institution-specific differences.

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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.

 

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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.

 

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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.

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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.

 

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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.

 

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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.

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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.

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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.

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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.

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A pedicle-lengthening osteotomy for the treatment of lumbar spinal stenosis

J Neurosurg Spine 29:241–249, 2018

Lumbar spinal stenosis (LSS) is a common condition that leads to significant disability, particularly in the elderly. Current therapeutic options have certain drawbacks. This study evaluates the 5-year clinical and radiographic results of a minimally invasive pedicle-lengthening osteotomy (PLO) for symptomatic LSS.
METHODS A prospective, single-arm, clinical pilot study was conducted involving 20 patients (mean age 61.7 years) with symptomatic LSS treated by a PLO procedure at 1 or 2 lumbar levels. All patients had symptoms of neurogenic claudication or radiculopathy secondary to LSS, and had not improved after a minimum 6-month course of nonoperative treatment. Eleven patients had a Meyerding grade I degenerative spondylolisthesis in addition to LSS. Clinical outcomes were measured using the Oswestry Disability Index, Zürich Claudication Questionnaire, 12-Item Short Form Health Survey, and a visual analog scale for back and leg pain. Procedural variables, neurological outcomes, adverse events, and radiological imaging (plain radiographs and CT scans) were collected at the 1.5-, 3-, 6-, 9-, 12-, 24-, and 60-month time points.
RESULTS The PLOs were performed through percutaneous incisions, with minimal blood loss in all cases. There were no operative complications. Four adverse events occurred during the follow-up period. Statistically significant improvement was observed in each of the outcome instruments and maintained over the 5-year follow-up period. Imaging studies, reviewed by an independent radiologist, showed no evidence of device subsidence, migration, breakage, or heterotopic ossification. Thin-slice CT scans documented healing of the osteotomy site in all patients at the 6-month time point and an increase of 115% in the mean cross-sectional area of the spinal canal.
CONCLUSIONS Treatment of patients with symptomatic LSS with a PLO procedure provided substantial enlargement of the area of the spinal canal and favorable clinical results for both disease-specific and non–disease-specific outcome
measures at all follow-up time points out to 5 years. Future research is needed to compare this technique to alternative
therapies for LSS.
https://thejns.org/doi/abs/10.3171/2017.11.SPINE16664
KEYWORDS lumbar; spine; spinal stenosis; decompression; pedicle osteotomy; minimally invasive; clinical trial;
spondylolisthesis

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Radiological adjacent-segment degeneration in L4–5 spondylolisthesis: comparison between dynamic stabilization and minimally invasive transforaminal lumbar interbody fusion

J Neurosurg Spine 29:250–258, 2018

Pedicle screw–based dynamic stabilization has been an alternative to conventional lumbar fusion for the surgical management of low-grade spondylolisthesis. However, the true effect of dynamic stabilization on adjacent segment degeneration (ASD) remains undetermined. Authors of this study aimed to investigate the incidence of ASD and to compare the clinical outcomes of dynamic stabilization and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF).

METHODS The records of consecutive patients with Meyerding grade I degenerative spondylolisthesis who had undergone surgical management at L4–5 in the period from 2007 to 2014 were retrospectively reviewed. Patients were divided into two groups according to the surgery performed: Dynesys dynamic stabilization (DDS) group and MI-TLIF group. Pre- and postoperative radiological evaluations, including radiography, CT, and MRI studies, were compared. Adjacent discs were evaluated using 4 radiological parameters: instability (antero- or retrolisthesis), disc degeneration (Pfirrmann classification), endplate degeneration (Modic classification), and range of motion (ROM). Clinical outcomes, measured with the visual analog scale (VAS) for back and leg pain, the Oswestry Disability Index (ODI), and the Japanese Orthopaedic Association (JOA) scores, were also compared.

RESULTS A total of 79 patients with L4–5 degenerative spondylolisthesis were included in the analysis. During a mean follow-up of 35.2 months (range 24–89 months), there were 56 patients in the DDS group and 23 in the MI-TLIF group. Prior to surgery, both groups were very similar in demographic, radiological, and clinical data. Postoperation, both groups had similarly significant improvement in clinical outcomes (VAS, ODI, and JOA scores) at each time point of evaluation. There was a lower chance of disc degeneration (Pfirrmann classification) of the adjacent discs in the DDS group than in the MI-TLIF group (17% vs 37%, p = 0.01). However, the DDS and MI-TLIF groups had similar rates of instability (15.2% vs 17.4%, respectively, p = 0.92) and endplate degeneration (1.8% vs 6.5%, p = 0.30) at the cranial (L3–4) and caudal (L5–S1) adjacent levels after surgery. The mean ROM in the cranial and caudal levels was also similar in the two groups. None of the patients required secondary surgery for any ASD (defined by radiological criteria).

CONCLUSIONS The clinical improvements after DDS were similar to those following MI-TLIF for L4–5 Meyerding grade I degenerative spondylolisthesis at 3 years postoperation. According to radiological evaluations, there was a lower chance of disc degeneration in the adjacent levels of the patients who had undergone DDS. However, other radiological signs of ASD, including instability, endplate degeneration, and ROM, were similar between the two groups. Although none of the patients in the present series required secondary surgery, a longer follow-up and a larger number of patients would be necessary to corroborate the protective effect of DDS against ASD.

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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.

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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.

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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

 

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