Category: Spine

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Clinical and Surgical Predictors of Complications Following Surgery for the Treatment of Cervical Spondylotic Myelopathy

Clinical_and_Surgical_Predictors_of_Complications

Neurosurgery 79:33–44, 2016

Surgery for cervical spondylotic myelopathy (CSM) is generally safe and effective. Nonetheless, complications occur in 11% to 38% of patients. Knowledge of important predictors of complications will help clinicians identify high-risk patients and institute prevention and management strategies.

OBJECTIVE: To identify clinical and surgical predictors of perioperative complications in CSM patients.

METHODS: Four hundred seventy-nine surgical CSM patients were enrolled in the prospective CSM-International study at 16 sites. A panel of physicians reviewed all adverse events and classified each as related or unrelated to surgery. Univariate analyses were performed to determine differences between patients who experienced a perioperative complication and those who did not. A complication prediction rule was developed using multiple logistic regression.

RESULTS: Seventy-eight patients experienced 89 perioperative complications (16.25%). On univariate analysis, the major clinical risk factors were ossification of the posterior longitudinal ligament (OPLL) (P = .055), number of comorbidities (P = .002), comorbidity score (P = .006), diabetes mellitus (P = .001), and coexisting gastrointestinal (P = .039) and cardiovascular (P = .046) disorders. Patients undergoing a 2-stage surgery (P = .002) and those with a longer operative duration (P = .001) were at greater risk of perioperative complications. A final prediction model consisted of diabetes mellitus (odds ratio [OR] = 1.96, P = .060), number of comorbidities (OR = 1.20, P = .069), operative duration (OR = 1.07, P = .002), and OPLL (OR = 1.75, P = .040).

CONCLUSION: Surgical CSM patients have a higher risk of perioperative complications if they have a greater number of comorbidities, coexisting diabetes mellitus, OPLL, and a longer operative duration. Surgeons can use this information to discuss the risks and benefits of surgery with patients, to plan case-specific preventive strategies, and to ensure appropriate management in the perioperative period.

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Outcomes of Operative and Nonoperative Treatment for Adult Spinal Deformity

adult lumbar scoliosis

Neurosurgery 78:851–861, 2016

High-quality studies that compare operative and nonoperative treatment for adult spinal deformity (ASD) are needed.

OBJECTIVE: To compare outcomes of operative and nonoperative treatment for ASD.

METHODS: This is a multicenter, prospective analysis of consecutive ASD patients opting for operative or nonoperative care. Inclusion criteria were age .18 years and ASD. Operative and nonoperative patients were propensity matched with the baseline Oswestry Disability Index, Scoliosis Research Society-22r, thoracolumbar/lumbar Cobb angle, pelvic incidence–to–lumbar lordosis mismatch (PI-LL), and leg pain score. Analyses were confined to patients with a minimum of 2 years of follow-up.

RESULTS: Two hundred eighty-six operative and 403 nonoperative patients met the criteria, with mean ages of 53 and 55 years, 2-year follow-up rates of 86% and 55%, and mean follow-up of 24.7 and 24.8 months, respectively. At baseline, operative patients had significantly worse health-related quality of life (HRQOL) based on all measures assessed (P < .001) and had worse deformity based on pelvic tilt, pelvic incidence–to– lumbar lordosis mismatch, and sagittal vertical axis (P ≤ .002). At the minimum 2-year follow-up, all HRQOL measures assessed significantly improved for operative patients (P < .001), but none improved significantly for nonoperative patients except for modest improvements in the Scoliosis Research Society-22r pain (P = .04) and satisfaction (P < .001) domains. On the basis of matched operative-nonoperative cohorts (97 in each group), operative patients had significantly better HRQOL at follow-up for all measures assessed (P < .001), except Short Form-36 mental component score (P = .06). At the minimum 2-year follow-up, 71.5% of operative patients had ≥1 complications.

CONCLUSION: Operative treatment for ASD can provide significant improvement of HRQOL at a minimum 2-year follow-up. In contrast, nonoperative treatment on average maintains presenting levels of pain and disability.

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Minimally invasive transforaminal lumbar interbody fusion with the ROSA Spine robot and intraoperative flat-panel CT guidance

Minimally invasive transforaminal lumbar interbody fusion with the ROSATM Spine robot and intraoperative flat-panel CT guidance

Acta Neurochir (2016) 158:1125–1128

Circumferential arthrodesis is commonly used to treat degenerative lumbar diseases. Minimally invasive techniques may enable faster recovery and reduce the incidence of postoperative infections.

Methods: We report on the surgical technique of a transforaminal lumbar interbody fusion (TLIF) procedure performed with the assistance of a new robotic device (ROSATM Spine) and intraoperative flat-panel CT guidance.

Conclusions: The combined use of this new robotic device and intraoperative CT enables accurate and safe arthrodesis in the treatment of degenerative lumbar disc diseases.

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Microsurgical unilateral laminotomy for decompression of lumbar spinal stenosis

Microsurgical unilateral laminotomy for decompression of lumbar spinal stenosis

Acta Neurochir (2016) 158:1103–1113

The microsurgical unilateral laminotomy (MUL) technique for bilateral decompression of lumbar spinal stenosis (LSS) is a less destabilizing alternative to laminectomy and leads to good short-term outcomes. However, little is known about the long-term results including predictive factors.

Methods: Medical records of patients who underwent MUL for LSS decompression between 2005 and 2010 were reviewed, and a questionnaire was distributed to complement the long-term outcome data. The study population consisted of 176 patients including 17 patients with stable grade I spondylolisthesis. Complications and reoperations were meticulously analyzed. Clinical outcome was measured using a modified Prolo scale and was further dichotomized in good vs. poor outcome. Predictive factors were obtained from uni- and multivariate analyses.

Results: The median age of the cohort was 70.0 years and the follow-up 71.7 months. Complications occurred in 5.1%of the patients. The overall reoperation rate was 17.0 %, including surgery, which was exclusively performed at other levels in 4.0 %. The reoperation rate for fusion was 4.5 %. Good neurogenic claudication outcome faded from 98.3 % at hospital discharge to 47.2 % at 6 years. Multivariate analysis identified previous lumbar operation as a potential independent predictor of a reoperation; potential independent predictors of poor longterm claudication outcome were older age, female gender, higher body mass index (BMI) and tobacco smoking.

Conclusions: In our experience, the long-term reoperation rate after MUL for LSS is not negligible and higher in previously operated patients. It seems like the good initial clinical results after MUL may fade over time, and several patient-related predictive factors including potentially modifiable obesity and tobacco smoking seem to play an important role.

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Assessment of Impact of Long-Cassette Standing X-Rays on Surgical Planning for Cervical Pathology

ssessment of Impact of Long-Cassette Standing X-Rays on Surgical Planning for Cervical Pathology

Neurosurgery 78:717–724, 2016

Understanding the role of regional segments of the spine in maintaining global balance has garnered significant attention recently. Long-cassette radiographs (LCR) are necessary to evaluate global spinopelvic alignment. However, it is unclear how LCRs impact operative decision-making for cervical spine pathology.

OBJECTIVE: To evaluate whether the addition of LCRs results in changes to respondents’ operative plans compared to standard imaging of the involved cervical spine in an international survey of spine surgeons.

METHODS: Fifteen cases (5 control cases with normal and 10 test cases with abnormal global alignment) of cervical pathology were presented online with a vignette and cervical imaging. Surgeons were asked to select a surgical plan from 6 options, ranging from the least (1 point) to most (6 points) extensive. Cases were then reordered and presented again with LCRs and the same surgical plan question.

RESULTS: One hundred fifty-seven surgeons completed the survey, of which 79% were spine fellowship trained. The mean response scores for surgical plan increased from 3.28 to 4.0 (P = .003) for test cases with the addition of LCRs. However, no significant changes (P = .10) were identified for the control cases. In 4 of the test cases with significant mid thoracic kyphosis, 29% of participants opted for the more extensive surgical options of extension to the mid and lower thoracic spine when they were provided with cervical imaging only, which significantly increased to 58.3% upon addition of LCRs.

CONCLUSION: In planning for cervical spine surgery, surgeons should maintain a low threshold for obtaining LCRs to assess global spinopelvic alignment.

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New Posterior Atlantoaxial Restricted Non-Fusion Fixation for Atlantoaxial Instability

New Posterior Atlantoaxial Restricted Non-Fusion Fixation for Atlantoaxial Instability

Neurosurgery 78:735–741, 2016

Loss of axial rotation and lateral bending after atlantoaxial fusion reduces a patient’s quality of life. Therefore, effective, nonfusion fixation alternatives are needed for atlantoaxial instability.

OBJECTIVE: To evaluate the initial stability and function of posterior atlantoaxial restricted nonfusion fixation (PAARNF), a new protocol, using cadaveric cervical spines compared with the intact state, destabilization, and posterior C1-C2 rod fixation.

METHODS: Cervical areas C0 through C3 were used from 6 cadaveric spines to test flexion-extension, lateral bending, and axial rotation range of motion (ROM). With the use of a machine, 1.5-Nm torque at a rate of 0.1 Nm/s was used and held for 10 seconds. The specimens were loaded 3 times, and data were collected in the third cycle and tested in the following sequence: (1) intact, (2) destabilization (using a type II odontoid fracture model), (3) destabilization with PAARNF (PAARNF group), and (4) rod implantation (rod group). The order of tests for the PAARNF and rod groups was randomly assigned.

RESULTS: The average flexion-extension ROM in the PAARNF group was 7.44 6 2.05, which was significantly less than in the intact (P = .00) and destabilization (P = .00) groups but not significantly different from that of the rod group (P = .07). The average lateral bending ROM (10.59 6 2.33; P = .00) and axial rotation ROM (38.79 6 13.41; P = .00) of the PAARNF group were significantly greater than in the rod group. However, the values of the PAARNF group showed no significant differences compared with those of the intact group.

CONCLUSION: PAARNF restricted atlantoaxial flexion-extension but preserved axial rotation and lateral bending at the atlantoaxial joint in a type II odontoid fracture model. However, it should not be used clinically until further studies have been performed to test the long-term effects of this procedure.

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Posterior Cervical Fusion Using Cervical Interfacet Spacers in Patients With Symptomatic Cervical Pseudarthrosis

Posterior Cervical Fusion Using Cervical Interfacet Spacers in Patients With Symptomatic Cervical Pseudarthrosis

Neurosurgery 78:661–668, 2016

Posterior cervical fusion with cervical interfacet spacer (CIS) is a novel allograft technology offering the potential to provide indirect neuroforaminal decompression while simultaneously enhancing fusion by placing the allograft in compression.

OBJECTIVE: To analyze the clinical and radiological outcomes after posterior cervical fusion with CIS in patients with symptomatic anterior cervical pseudarthroses.

METHODS: Medical records of patients who underwent posterior cervical fusion with CIS for symptomatic pseudarthrosis after anterior cervical diskectomy and fusion were reviewed. Standardized outcome measures such as visual analog scale (VAS) score for neck and arm pain, Neck Disability Index (NDI), and upright lateral cervical radiographs were reviewed.

RESULTS: There were 19 patients with symptomatic cervical pseudarthrosis. Preoperative symptoms included refractory neck or arm pain. The average follow-up was 20 months (range, 12-56 months). There was improvement in VAS score for neck pain (P < .004), radicular arm pain (P < .007), and NDI score (P < .06) after surgery, with 83%, 72%, and 67% of patients showing improvement in their VAS neck pain, VAS arm pain, and NDI scores, respectively. Fusion rate was high, with fusion occurring at all levels treated for pseudarthrosis. There was a small improvement in cervical lordosis (mean difference, 2 6 5.17; P = .09) and slight worsening of C2-7 sagittal vertical axis after surgery (mean difference, 1.89 6 7.87 mm; P = .43).

CONCLUSION: CIS provides an important fusion technique, allowing placement of an allograft in compression for posterior cervical fusion in patients with anterior cervical pseudarthroses. Although there was improvement in clinical outcome measures after surgery, placement of CIS had no clinically significant impact on cervical lordosis and C2-7 sagittal vertical axis.

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Microendoscopic discectomy versus open discectomy for lumbar disc herniation: a meta-analysis

Complications of endoscopic microdiscectomy using the EASYGO! system

Eur Spine J (2016) 25:1373–1381

Purpose: To compare the outcomes of microendoscopic discectomy and open discectomy for patients with lumbar disc herniation.

Methods: An extensive search of studies was performed in PubMed, Medline, Embase, Cochrane library and Google Scholar. The following outcome measures were extracted: visual analogue scale (VAS), Oswestry disability index (ODI), complication, operation time, blood loss and length of hospital stay. Data analysis was conducted with RevMan 5.0.

Results: Five randomized controlled trials involving 501 patients were included in this meta-analysis. The pooled analysis showed that there was no significant difference in the VAS, ODI or complication between the two groups. However, compared with the open discectomy, the microendoscopic discectomy was associated with less blood loss [WMD = -151.01 (-288.22, -13.80), P = 0.03], shorter length of hospital stay [WMD = -69.33 (-110.39, -28.28), P = 0.0009], and longer operation time [WMD = 18.80 (7.83, 29.76), P = 0.0008].

Conclusions: Microendoscopic discectomy, which requires a demanding learning curve, may be a safe and effective alternative to conventional open discectomy for patients with lumbar disc herniation.

 

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ALIF and total disc replacement versus 2-level circumferential fusion with TLIF: a prospective, randomized, clinical and radiological trial

ALIF-TDR vs TLIF

Eur Spine J (2016) 25:1558–1566

Study design: Prospective, randomized trial.

Purpose: The treatment of degenerative disc disease (DDD) with two-level fusion has been associated with a reasonable rate of complications. The aim of the present study was to compare (Hybrid) stand-alone anterior lumbar interbody fusion (ALIF) at L5/S1 with total disc replacement at L4/5 (TDR) as an alternative surgical strategy to (Fusion) 2-level circumferential fusion employing trans- foraminal lumbar interbody fusion (TLIF) with transpedicular stabilization at L4–S1.

Methods: A total of 62 patients with symptomatic DDD of segments L5/S1 (Modic ≥2°) and L4/5 (Modic ≤2°; positive discography) were enrolled; 31 were treated with Hybrid and 31 with Fusion. Preoperatively, at 0, 12, and a mean follow-up of 37 months, clinical (ODI, VAS) and radiological evaluations (plain/extension-flexion radiographs evaluated for implant failure, fusion, global and segmental lordosis, and ROM) were performed.

Results: In 26 of 31 Hybrid and 24 of 31 Fusion patients available at the final follow-up, we found a significant clinical improvement compared to preoperatively. Hybrid patients had significantly lower VAS scores immediately postoperatively and at follow-up compared to Fusion patients. The complication rates were low and similar between the groups. Lumbar lordosis increased in both groups. The increase was mainly located at L4–S1 in the Hybrid group and at L1–L4 in the Fusion group. Hybrid patients presented with increased ROM at L4/5 and L3/4, and Fusion patients presented with increased ROM at L3/4, with significantly greater ROM at L3/4 compared to Hybrid patients at follow-up.

Conclusions Hybrid surgery is a viable surgical alternative for the presented indication. Approach-related inferior trauma and the balanced restoration of lumbar lordosis resulted in superior clinical outcomes compared to two-level circumferential fusion with TLIF.

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A Randomized, Controlled Trial of Fusion Surgery for Lumbar Spinal Stenosis

lumbar stenosis

N Engl J Med 2016;374:1413-23

The efficacy of fusion surgery in addition to decompression surgery in patients who have lumbar spinal stenosis, with or without degenerative spondylolisthesis, has not been substantiated in controlled trials.

METHODS: We randomly assigned 247 patients between 50 and 80 years of age who had lumbar spinal stenosis at one or two adjacent vertebral levels to undergo either decompression surgery plus fusion surgery (fusiongroup) or decompression surgery alone(decompression-alonegroup). Randomization was stratified according to the presence of preoperative degenerative spondylolisthesis (in 135 patients) or its absence. Outcomes were assessed with the use of patient-reported outcome measures, a 6-minute walk test, and a health economic evaluation. The primary outcome was the score on the Oswestry Disability Index (ODI; which ranges from 0 to 100, with higher scores indicating more severe disability) 2 years after surgery. The primary analysis, which was a per-protocol analysis, did not include the 14 patients who did not receive the assigned treatment and the 5 who were lost to follow-up.

RESULTS: There was no significant difference between the groups in the mean score on the ODI at 2 years (27 in the fusion group and 24 in the decompression-alone group, P=0.24) or in the results of the 6-minute walk test (397 m in the fusion group and 405 m in the decompres- sion-alone group, P=0.72). Results were similar between patients with and those without spondylolisthesis. Among the patients who had 5 years of follow-up and were eligible for inclusion in the 5-year analysis, there were no significant differences between the groups in clinical outcomes at 5 years. The mean length of hospitalization was 7.4 days in the fusion group and 4.1 days in the decompression-alone group (P<0.001). Operating time was longer, the amount of bleeding was greater, and surgical costs were higher in the fusion group than in the decompression-alone group. During a mean follow-up of 6.5 years, additional lumbar spine surgery was performed in 22% of the patients in the fusion group and in 21% of those in the decompression-alone group.

CONCLUSIONS: Among patients with lumbar spinal stenosis, with or without degenerative spondylolisthesis, decompression surgery plus fusion surgery did not result in better clinical outcomes at 2 years and 5 years than did decompression surgery alone.

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A Cost-Effectiveness Comparison Between Open Transforaminal and Minimally Invasive Lateral Lumbar Interbody Fusions

lateral lumbar interbody fusion

Neurosurgery 78:585–595, 2016

Direct cost comparisons between minimally invasive spine surgeries and the open options are rare.

OBJECTIVE: To compare healthcare costs associated with open transforaminal lumbar interbody fusion (TLIF) and minimally invasive lateral lumbar interbody fusion (LLIF) by calculating the incremental cost-effectiveness ratio (ICER) and to calculate the thresholds for minimum clinically important difference and minimum cost-effective difference for patient-reported outcome measures at the 2-year follow-up.

METHODS: Forty-five patients who underwent single-level TLIF and 29 patients who underwent single-level stand-alone LLIF were included in the comparison. All costs from diagnosis through the 2-year follow-up were available from a comprehensive single-center data bank within a unified hospital system. Payment provided for all spine-related medical resource use from the time of diagnosis through 2 years was recorded. A 0% discount rate was applied. Quality-adjusted life-years (QALYs) were calculated from the EuroQol-5D collected in an unbiased manner. Difference in total cost per QALY gained for LLIF minus that for TLIF was assessed as the estimate of the ICER from a US perspective.

RESULTS: Significant improvements were observed at the 2-year follow-up for both TLIF and LLIF with the Short Form-36 physical component summary, Oswestry Disability Index, visual analog scale back pain and leg pain scores, and EuroQol-5D. ICER calculations revealed similar mean cumulative QALYs gained at the 2-year interval (0.67 for TLIF and 0.60 for LLIF; P = .33). Median total costs of care after TLIF and LLIF were $44 068 and $45 574, respectively (P = .96). Minimum cost-effective difference thresholds with an anchor of ,$50 000 per QALY were higher than minimum clinically important difference thresholds for all patient-reported outcome measures. Total mean cost and EuroQol-5D were statistically equivalent between the 2 treatment groups.

CONCLUSION: TLIF and LLIF produced equivalent 2-year patient outcomes at an equivalent cost-effectiveness profile.

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Outcome of conservative and surgical treatment of pyogenic spondylodiscitis

pyogenic spondylodiscitis

Eur Spine J (2016) 25:983–999

Spondylodiscitis is a spinal infection affecting primarily the intervertebral disk and the adjacent vertebral bodies. Currently many aspects of the treatment of pyogenic spondylodiscitis are still a matter of debate.

Purpose The aim of this study was to review the currently available literature systematically to determine the outcome of patients with pyogenic spondylodiscitis for conservative and surgical treatment strategies.

Methods A systematic electronic search of MEDLINE, EMBASE, Cochrane Collaboration, and Web of Science regarding the treatment of pyogenic spondylodiscitis was performed. Included articles were assessed on risk of bias according the Cochrane Handbook for Systematic Reviews of Interventions, and the quality of evidence and strength of recommendation was evaluated according the GRADE approach.

Results: 25 studies were included. Five studies had a high or moderate quality of evidence. One RCT suggest that 6 weeks of antibiotic treatment of pyogenic spondylodiscitis results in a similar outcome when compared to longer treatment duration. However, microorganism-specific studies suggest that at least 8 weeks of treatment is required for S. aureus and 8 weeks of Daptomycin for MRSA. The articles that described the outcome of surgical treatment strategies show that a large variety of surgical techniques can successfully treat spondylodiscitis. No additional long-term beneficial effect of surgical treatment could be shown in the studies comparing surgical versus antibiotic only treatment.

Conclusion There is a strong level of recommendation for 6 weeks of antibiotic treatment in pyogenic spondylodiscitis although this has only been shown by one recent RCT. If surgical treatment is indicated, it has been suggested by two prospective studies with strong level of recommendation that an isolated anterior approach could result in a better clinical outcome.

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Posterior Reduction of Fixed Atlantoaxial Dislocation and Basilar Invagination by Atlantoaxial Facet Joint Release and Fixation

Posterior Reduction of Fixed Atlantoaxial Dislocation and Basilar Invagination by Atlantoaxial Facet Joint Release and Fixation- A Modified Technique With 174 Cases

Neurosurgery 78:391–400, 2016

Treatment of fixed atlantoaxial dislocation (AAD) with basilar invagination (BI) is challenging.

OBJECTIVE: To introduce a modified technique to reduce fixed AAD and BI through a posterior approach.

METHODS: From 2007 to 2013, 174 patients with fixed AAD and BI underwent surgical reduction by posterior atlantoaxial facet joint release and fixation technique.

RESULTS: There was 1 death in the series, and 3 patients were lost to follow-up. The follow-up period ranged from 12 to 52 months (mean: 35.2 months) for the remaining 170 patients. Neurological improvement was observed in 168 of 170 patients (98.8%), and was stable in 1 (0.06%) and exacerbated in 1 (0.06%), with the Japanese Orthopedic Association scores increasing from 11.4 preoperatively to 15.8 postoperatively (P , .01). Radiologically, complete or .90% reduction was attained in 107 patients (62.9%), 60% to 90% reduction was attained in 51 patients (30%), and ,50% reduction was attained in 12 patients (7.1%), who underwent additional transoral decompression. Complete decompression was demonstrated in all 170 patients. Solid bony fusion was demonstrated in 167 patients at follow-up (98.2%).

CONCLUSION: This series showed the safety and efficacy of the posterior C1-2 facet joint release and reduction technique for the treatment of AAD and BI. Most fixed AAD and BI cases are reducible via this method. In most cases, this method avoids transoral odontoidectomy and cervical traction. Compared with the occiput-C2 screw method, this short-segment C1-2 technique exerts less antireduction shearing force, guarantees longer bone purchase, and provides more immediate stabilization.

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Orientation of the facet joints in degenerative rotatory lumbar scoliosis

Orientation of the facet joints in degenerative rotatory lumbar scoliosis- an MR study on 52 patients

Acta Neurochir (2016) 158:473–479

Because of a degenerative component, degenerative rotatory scoliosis seems different from congenital and idiopathic subtypes of the disease. This study aims to examine the orientation of facet joints, as a known cause of degeneration, in patients with degenerative rotatory scoliosis.

Methods Lumbar magnetic resonance (MR) images and plain radiographs of 52 symptomatic patients (mean age, 50.17 years) with degenerative rotatory lumbar scoliosis (mean curve, 19.22 degrees) and 50 healthy individuals were reviewed. Facet joint angles in rotated segments and the minimum neural foramen width at all lumbar levels were measured by three observers and the average was recorded.

Results The maximum vertebral rotation was most frequent at L4-L5 (75 %), and the majority was of type I (84.6 %) according to the Nash-Moe classification. At all lumbar spinal levels the mean facet joint angles were significantly higher on the side of rotation (L2-L3, 57.92 degrees; L3-L4, 45.00 degrees; L4-L5, 43.88 degrees) compared to those on the contralateral side (L2-L3, 20.42 degrees; L3-L4, 15.48 degrees; L4-L5, 13.12 degrees) and in controls (L2-L3, 30.21 degrees; L3- L4, 40.81 degrees; L4-L5, 45.20 degrees) (p<0.001 for all comparisons). The mean facet joint angle increased significantly from L4-L5 to L2-L3 in cases and reversely in controls. The mean minimum neural foramen width was 1.29 ± 0.85 mm on the side of rotation, 5.50 ± 1.09 mm on the contralateral side, and 6.78± 1.75 mm in controls (p<0.001).

Conclusions Substantial asymmetries and abnormal orientations in facet joints were documented in patients with degenerative rotatory lumbar scoliosis. Such asymmetries may adversely affect neural foramen width.

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Biportal endoscopic spinal surgery (BESS) for treatment of lumbar spinal stenosis

Biportal endoscopic spinal surgery (BESS) for treatment of lumbar spinal stenosis

Acta Neurochir (2016) 158:459–463

Prevalent endoscopic spine surgeries have shown limitations especially in spinal stenosis. Biportal endoscopic surgery is introduced to manage central and foraminal stenosis with its wide range of access angle and clear view.

Methods The authors provide an introduction of this technique followed by a description of the surgical anatomy with discussion on its indications and advantages. In particular, tricks to avoid complications are also presented.

Conclusions Effective circumferential and focal decompression were achieved in most cases without damage to the spinal structural integrity with preservation of muscular and ligamentous attachments. The biportal endoscopic spinal surgery (BESS) may be safely used as an alternative minimally invasive procedure for lumbar spinal stenosis.

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Long-term outcomes after surgical and endovascular treatment of spinal dural arteriovenous fistulae

SDAVF

Eur Spine J (2016) 25:748–754

To examine the validity of our treatment strategy for spinal dural arteriovenous fistulae (SDAVF), based on the treatment results and the long-term outcome.

Methods This study included 50 SDAVF patients (38 men, 12 women, mean age 63.2 years) with progressive myelopathy. The treatment strategy involved embolization as the initial management tool and surgery if embolization was considered unsuitable. Their medical records were evaluated to identify the treatment results and functional outcomes. The mean follow-up period was 81.2 months (range 27–184 months).

Results Complete obliteration was achieved in 22 (71.0 %) of 31 embolized patients and in 18 of 19 (94.7 %) operated patients. The initial success rate was significantly lower in embolized than operated patients. At the last follow-up, 33 of the 50 patients (66 %) manifested im- proved gait and 16 (32 %) improved micturition. The ac- tivity of daily living (ADL) was improved in 33 (66 %). When we compared the rates of functional improvement at the last follow-up, there was no significant difference be- tween patients treated initially by embolization or surgery.

Conclusions The long-term outcomes in SDAVF patients treated by multidisciplinary management with first-line embolization were comparable to those in earlier surgical series. However, our results were unable to demonstrate the superiority of endovascular embolization to surgical treatment for SDAVF. For the purpose of justifying endovascular embolization as a first-line treatment for SDAVF, it will be necessary to show further improvement in both the initial treatment success and the complication rates.

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Incidence of Adjacent Segment Disease Requiring Reoperation After Lumbar Laminectomy Without Fusion

ADJACENT SEGMENT DISEASE AFTER LUMBAR LAMINECTOMY

Neurosurgery 78:192–199, 2016

Adjacent segment disease (ASD) has not been described after laminectomy without fusion.

OBJECTIVE: To determine the incidence of ASD after a 1- or 2-level lumbar laminectomy.

METHODS: We retrospectively reviewed medical records of all patients who underwent 1- or 2-level, bilateral lumbar laminectomy without fusion for degenerative spinal disease (all follow-up $1 year). ASD was defined as clinical and/or radiographic evidence of degenerative spinal disease that required reoperation at the level above or below the index laminectomy.

RESULTS: Of the 398 patients, the incidence of ASD requiring reoperation was 10%. The 39 ASD cases were almost equally distributed at L2-L3 (31%), L3-L4 (26%), and L5-S1 (31%), and to a lesser extent at L4-L5 (15%) (P = .51). The ASD incidences of 10% and 9% were equivalent after a 1- and 2-level laminectomy, respectively (P = .76). Rostral ASD was statistically more common than caudal ASD after both the 1- (P , .001) and 2- (P , .001) level laminectomy. Of the 39 ASD cases, 95% required laminectomy, 26% discectomy, and 49% fusion. Average time to ASD was 4 years. After a Kaplan-Meier analysis, time to reoperation for ASD was equivalent among the 1- and 2-level laminectomy cohorts (log-rank test, P = .13).

CONCLUSION: The cumulative incidence of ASD requiring reoperation was 10% over a mean of 4 years. Both the 1- and 2-level laminectomy cohorts experienced equivalent incidences and rates of ASD. Of the 39 operations for ASD, about half required a fusion.

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Treatment of isolated cervical facet fractures

cervical facet fracture

J Neurosurg Spine 24:347–354, 2016

In this clinically based systematic review of cervical facet fractures, the authors’ aim was to determine the optimal clinical care for patients with isolated fractures of the cervical facets through a systematic review.

Methods A systematic review of nonoperative and operative treatment methods of cervical facet fractures was performed. Reduction and stabilization treatments were compared, and analysis of postoperative outcomes was performed. MEDLINE and Scopus databases were used. This work was supported through support received from the Association for Collaborative Spine Research and AOSpine North America.

Results Eleven studies with 368 patients met the inclusion criteria. Forty-six patients had bilateral isolated cervical facet fractures and 322 had unilateral isolated cervical facet fractures. Closed reduction was successful in 56.4% (39 patients) and 63.8% (94 patients) of patients using a halo vest and Gardner-Wells tongs, respectively. Comparatively, open reduction was successful in 94.9% of patients (successful reduction of open to closed reduction OR 12.8 [95% CI 6.1–26.9], p < 0.0001); 183 patients underwent internal fixation, with an 87.2% success rate in maintaining anatomical alignment. When comparing the success of patients who underwent anterior versus posterior procedures, anterior approaches showed a 90.5% rate of maintenance of reduction, compared with a 75.6% rate for the posterior approach (anterior vs posterior OR 3.1 [95% CI 1.0–9.4], p = 0.05).

Conclusions In comparison with nonoperative treatments, operative treatments provided a more successful outcome in terms of failure of treatment to maintain reduction for patients with cervical facet fractures. Operative treatment appears to provide superior results to the nonoperative treatments assessed.

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Effects of methylene blue on postoperative low-back pain and functional outcomes after lumbar open discectomy: a triple-blind, randomized placebo-controlled trial

Surgical technique and effectiveness of microendoscopic discectomy for large uncontained lumbar disc herniations

J Neurosurg Spine 24:7–15, 2016

Despite advances in surgical and anesthesiology techniques, many patients continue to experience postoperative pain after lumbar disc operations. This study aims to investigate the effects of methylene blue (MB) on preventing postoperative low-back pain (LBP) with or without radicular pain and improving the quality of life (QOL) in patients undergoing lumbar open discectomy.

Methods This is a prospective, randomized, triple-blind, placebo-controlled clinical trial, which was conducted at Shiraz University of Medical Sciences between July 2011 to January 2012. Of a total of 130 patients, 115 were eligible for participation; 56 received 1 ml of MB solution at a concentration of 0.5% (MB group) and 59 received an equivalent volume of normal saline (control group). Primary outcomes were the control of LBP with or without radicular pain, which was evaluated preoperatively and at 24 hours and 3 months after surgery with the use of a visual analog scale (VAS), and the improvement of QOL, which was assessed preoperatively and 3 months postoperatively by means of the Persian translation of the Oswestry Disability Index questionnaire.

Results The mean VAS scores for LBP were significantly lower in the MB group compared with the control group at 24 hours (1.25 ± 0.97 vs 2.80 ± 0.69, p < 0.001) and 3 months (1.02 ± 1.29 vs 2.07 ± 1.10, p = 0.019) after treatment. The mean radicular pain scores decreased significantly in the 2 groups at 24 hours after surgery, but the mean radicular pain score was significantly lower in the MB-treated patients than the control group. However, the difference between radicular pain scores in the MB group (1 ± 1.1) and the control group (1.2 ± 1) was not statistically significant (p = 0.64). The reduction in LBP was greater in the MB group than the control group (8.11 ± 1.74 vs 6.07 ± 1.52, p = 0.023, CI 95% –1.37 to –0.10). The functional QOL improved significantly 3 months after the operation in both groups (p < 0.001). Moderate disability occurred more frequently in the control group than in the MB group (14.5% vs 7.7%, p = 0.004). No toxicity, adverse effects, or complications were found in the group of patients treated with MB injection.

Conclusions A single dose of MB (1 ml 0.5%) for coating the dura and surrounding tissues (facet and muscle) shows promising results in terms of safety, reduction of postoperative pain, and functional outcome compared with placebo.

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Repeated 3.0 Tesla Magnetic Resonance Imaging After Clinically Successful Lumbar Disc Surgery

Repeated 3.0 Tesla Magnetic Resonance Imaging After Clinically Successful Lumbar Disc Surgery

Spine 2016;41:239–245

Study Design. Prospective cohort study.

Objective. To describe the naturally occurring magnetic resonance imaging (MRI) findings after successful microsurgical removal of lumbar disc herniation with repeated MRI examinations.

Summary of Background Data. The interpretation of MRI after spinal surgery may be particularly challenging and image findings do not always correlate to clinical findings. Early postoperative MRI has limited value in the evaluation of patients after surgery for lumbar disc herniation.

Methods. Prospective study of 30 successfully operated patients, which underwent 3.0 T MRI within 24 h after surgery for lumbar disc herniation and repeated at 6 weeks and 3 months postoperatively. Postoperative image findings (nerve root enhancement, nerve root thickening, displacement or compression of the nerve root, and residual mass size and signal) were assessed quantitatively. Inter-rater reliability was tested.

Results. Inter-rater reliability between neuroradiologists was moderate for assessed MRI variables. In the immediate postoperative phase, compression or dislocation of the nerve root at the operated level was common. A residual mass at the operated level was seen in 80%, 47%, and 33% after 24 h, 6 weeks, and 3 months, respectively. Postoperative dislocation or compression of the nerve root from residual masses was seen in 67%, 24%, and 14% after 24 h, 6 weeks, and 3 months, respectively. A residual mass with a higher signal than muscle on T2-weighted images was seen in 80%, 30%, and 17% after 24 h, 6 weeks, and 3 months, respectively.

Conclusion. A residual mass with compression or dislocation of the nerve root at the operated level, that disappears over 3 months, is a common MRI finding in patients successfully operated for symptomatic lumbar disc herniation. An expectant approach instead of early reoperations may perhaps be preferred in patients with residual pain and root compression due to residual masses with high T2-signal since these often seem to resolve spontaneously.

Level of Evidence: 3

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