Tag: fusion

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Outcome of unilateral versus standard open midline approach for bilateral decompression in lumbar spinal stenosis: is “over the top” really better?

J Neurosurg Spine 31:236–245, 2019

In this retrospective analysis of a prospective multicenter cohort study, the authors assessed which surgical approach, 1) the unilateral laminotomy with bilateral spinal canal decompression (ULBD; also called “over the top”) or 2) the standard open bilateral decompression (SOBD), achieves better clinical outcomes in the long-term follow-up. The optimal surgical approach (ULBD vs SOBD) to treat lumbar spinal stenosis remains controversial.

METHODS The main outcomes of this study were changes in a spinal stenosis measure (SSM) symptoms score, SSM function score, and quality of life (sum score of the 3-level version of the EQ-5D tool [EQ-5D-3L]) over time. These outcome parameters were measured at baseline and at 12-, 24-, and 36-month follow-ups. To obtain an unbiased result on the effect of ULBD compared to SOBD the authors used matching techniques relying on propensity scores. The latter were calculated based on a logistic regression model including relevant confounders. Additional outcomes of interest were raw changes in main outcomes and in the Roland and Morris Disability Questionnaire from baseline to 12, 24, and 36 months.

RESULTS For this study, 277 patients met the inclusion criteria. One hundred forty-nine patients were treated by ULBD, and 128 were treated by SOBD. After propensity score matching, 128 patients were left in each group. In the matched cohort, the mean (95% CI) estimated differences between ULBD and SOBD for change in SSM symptoms score from baseline to 12 months were -0.04 (-0.25 to 0.17), to 24 months -0.07 (-0.29 to 0.15), and to 36 months -0.04 (-0.28 to 0.21). For change in SSM function score, the estimated differences from baseline to 12 months were 0.06 (-0.08 to 0.21), to 24 months 0.08 (-0.07 to 0.22), and to 36 months 0.01 (-0.16 to 0.17). Differences in changes between groups in EQ-5D-3L sum scores were estimated to be -0.32 (-4.04 to 3.40), -0.89 (-4.76 to 2.98), and -2.71 (-7.16 to 1.74) from baseline to 12, 24, and 36 months, respectively. None of the group differences between ULBD and SOBD were statistically significant.

CONCLUSIONS Both surgical techniques, ULBD and SOBD, may provide effective treatment options for DLSS patients. The authors further determined that the patient outcome results for the technically more challenging ULBD seem not to be superior to those for the SOBD even after 3 years of follow-up.

 

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Need for arthrodesis following facetectomy for spinal peripheral nerve sheath tumors

J Neurosurg Spine 31:112–122, 2019

Spinal peripheral nerve sheath tumors (PNSTs) are a group of rare tumors originating from the nerve and its supporting structures. Standard surgical management typically entails laminectomy with or without facetectomy to gain adequate tumor exposure. Arthrodesis is occasionally performed to maintain spinal stability and mitigate the risk of postoperative deformity, pain, or neurological deficit. However, the factors associated with the need for instrumentation in addition to PNST resection in the same setting remain unclear.

METHODS An institutional tumor registry at a tertiary care center was queried for patients treated surgically for a primary diagnosis of spinal PNST between 2002 and 2016. An analysis focused on patients in whom a facetectomy was performed during the resection. The addition of arthrodesis at the index procedure comprised the primary outcome. The authors also recorded baseline demographics, tumor characteristics, and surgery-related variables. Logistic regression was used to identify factors associated with increased risk of fusion surgery.

RESULTS A total of 163 patients were identified, of which 56 (32 had facetectomy with fusion, 24 had facetectomy alone) were analyzed. The median age was 48 years, and 50% of the cohort was female. Age, sex, and race, as well as tumor histology and size, were evenly distributed between patients who received facetectomy alone and those who had facetectomy and fusion. On univariate analysis, total versus subtotal facetectomy (OR 9.0, 95% CI 2.01–64.2; p = 0.009) and cervicothoracic versus other spinal region (OR 9.0, 95% CI 1.51–172.9; p = 0.048) were significantly associated with increased odds of performing immediate fusion. On multivariable analysis, only the effect of total facetectomy remained statistically significant (OR 6.75, 95% CI 1.47–48.8; p = 0.025).

CONCLUSIONS The authors found that total facetectomy and cervicothoracic involvement may be highly associated with the need for concomitant arthrodesis at the time of index surgery. These findings may help surgeons to determine the best surgical planning for patients with PNST.

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Incidence and clinical relevance of cage subsidence in anterior cervical discectomy and fusion

Acta Neurochirurgica (2018) 160:873–880

The placement of intervertebral cages in anterior cervical discectomy (ACDF) supposedly maintains foraminal height. The most commonly reported cage-related complication is subsidence, although it is unknown whether a correlation between subsidence and clinical outcome exists. Aim To assess the incidence and relevance of subsidence.

Methods Literature searches were performed in PubMed, MEDLINE, Embase,Web of Science, COCHRANE, and CENTRAL. The inclusion criteria were as follows: ≥ 20 patients, ADCF with cage, subsidence assessed, and primary data. Risk of bias was assessed using adjusted Cochrane checklists.

Results Seventy-one studies, comprising 4784 patients, were included. Subsidence was generally defined as ≥ 3-mm loss of height comparing postoperative intervertebral heights with heights at last follow-up. Mean incidence of subsidence was 21% (range 0–83%). Of all patients, 46% of patients received polyether-ether-ketone (PEEK) cages, 31% received titanium cages, 18% received cage-screw-combinations, and 5% received polymethyl-methacrylate (PMMA) cages. Patients treated with cagescrew- combinations had significantly less subsidence than patients treated with PEEK, titanium, or PMMA cages (15.1% vs. 23.5% vs. 24.9% vs. 30.2%; p < 0.001). Thirteen studies assessed clinical outcome in relation to subsidence; the majority did not find a significant correlation. Only four studies correlated subsidence to cage size and/or height; no correlation was established.

Conclusions Subsidence in ACDF with cages occurs in 21% of patients. The risk for subsidence seems lower using PEEK or titanium cages or adding screws.Whether subsidence affects clinical outcome is not satisfactorily evaluated in the available literature. Future studies on this correlation are warranted in order to establish the additional value of the interposition of a cage in ACDF.

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Lumbar Fusion for Degenerative Disease: A Systematic Review and Meta-Analysis

Neurosurgery 80:701–715, 2017

Due to uncertain evidence, lumbar fusion for degenerative indications is associated with the greatest measured practice variation of any surgical procedure.

OBJECTIVE: To summarize the current evidence on the comparative safety and efficacy of lumbar fusion, decompression-alone, or nonoperative care for degenerative indications.

METHODS: A systematic review was conducted using PubMed, MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (up to June 30, 2016). Comparative studies reporting validated measures of safety or efficacy were included. Treatment effects were calculated through DerSimonian and Laird random effects models.

RESULTS: The literature search yielded 65 studies (19 randomized controlled trials, 16 prospective cohort studies, 15 retrospective cohort studies, and 15 registries) enrolling a total of 302 620 patients. Disability, pain, and patient satisfaction following fusion, decompression-alone, or nonoperative care were dependent on surgical indications and study methodology. Relative to decompression-alone, the risk of reoperation following fusion was increased for spinal stenosis (relative risk [RR] 1.17, 95% confidence interval [CI] 1.06-1.28) and decreased for spondylolisthesis (RR 0.75, 95% CI 0.68-0.83). Among patients with spinal stenosis, complications were more frequent following fusion (RR 1.87, 95% CI 1.18-2.96). Mortality was not significantly associated with any treatment modality.

CONCLUSION: Positive clinical change was greatest in patients undergoing fusion for spondylolisthesis while complications and the risk of reoperation limited the benefit of fusion for spinal stenosis. The relative safety and efficacy of fusion for chronic low back pain suggests careful patient selection is required (PROSPERO International Prospective Register of Systematic Reviews number, CRD42015020153).

 

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Contribution of Lordotic Correction on C5 Palsy Following Cervical Laminectomy and Fusion

Neurosurgery 79:816–822, 2016

C5 palsy is a well-reported complication of cervical spine surgery. The implication of sagittal cervical alignment parameters and their changes after surgery on the incidence of C5 palsy remains unclear.

OBJECTIVE: We review cervical alignment changes in our cases of C5 palsy after cervical laminectomy and fusion.

METHODS: Cases of C5 palsy were retrospectively compared with a control group. Preoperative and postoperative upright plain film radiographs were analyzed in blinded fashion.

RESULTS: Spine registry analysis identified 148 patients who underwent cervical laminectomy and fusion by the senior author over 5 years. There were 18 (12%) cases complicated by postoperative C5 palsy. Nine of these 18 patients had prerequisite upright films and were compared with a randomly constructed case control group of 20 patients. There were no statistically significant differences between the 2 groups in age, proportion of males, and preoperative Nurick score. Measures of sagittal alignment did not differ significantly between the 2 groups on preoperative and postoperative imaging. When comparing the amount of alignment change between preoperative and postoperative upright imaging, however, patients with C5 palsy had a statistically higher amount of average C4-C5 Cobb angle change (22.53 vs 0.78; P = .01). Logistic regression analysis demonstrated that lordotic change in both C4-C5 and C2-C7 Cobb angles were associated with development of palsy.

CONCLUSION: Lordotic cervical correction, as measured on upright imaging, was statistically larger in patients who had C5 palsy. The role of deformity correction in C5 palsy deserves further study and may inform intraoperative decision making.

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Occipitocervical Fixation: A Single Surgeon’s Experience With 120 Patients

occipitocervical-fixation-a-single-surgeons-experience-with-120-patients

Neurosurgery 79:549–560, 2016

Occipitocervical junction instability can lead to serious neurological injury or death. Open surgical fixation is often necessary to provide definitive stabilization. However, long-term results are limited to small case series.

OBJECTIVE: To review the causes of occipitocervical instability, discuss the indications for surgical intervention, and evaluate long-term surgical outcomes after occipitocervical fixation.

METHODS: The charts of all patients undergoing posterior surgical fixation of the occipitocervical junction by the senior author were retrospectively reviewed. A total of 120 consecutive patients were identified for analysis. Patient demographic characteristics, occipitocervical junction pathology, surgical indications, and clinical and radiographic outcomes are reported.

RESULTS: The study population consisted of 64 male and 56 female patients with a mean age of 39.9 years (range, 7 months to 88 years). Trauma was the most common cause of instability, occurring in 56 patients (47%). Ninety patients (75%) were treated with screw/rod constructs; wiring was used in 30 patients (25%). The median number of fixated segments was 5 (O-C4). Structural bone grafts were implanted in all patients (100%). Preoperative neurological deficits were present in 83 patients (69%); 91% of those patients improved with surgery. Mean follow-up was 35.1 6 27.4 months (range, 0-123 months). Two patients died, and 10 were lost to follow-up before the end of the 6-month follow-up period. Fusion was confirmed in 107 patients (89.1%). The overall complication rate was 10%, including 3 patients with vertebral artery injuries and 2 patients who required revision surgery.

CONCLUSION: Occipitocervical fixation is a durable treatment option with acceptable morbidity for patients with occipitocervical instability.

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Esophageal perforation after anterior cervical spine surgery

esophageal-perforation-after-anterior-cervical-spine-surgery

J Neurosurg Spine 25:285–291, 2016

Esophageal perforation is a rare but well-known complication of anterior cervical spine surgery. The authors performed a systematic review of the literature to evaluate symptomatology, direct causes, repair methods, and associated complications of esophageal injury.

Methods A PubMed search that adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines included relevant clinical studies and case reports (articles written in the English language that included humans as subjects) that reported patients who underwent anterior spinal surgery and sustained some form of esophageal perforation. Available data on clinical presentation, the surgical procedure performed, outcome measures, and other individual variables were abstracted from 1980 through 2015.

Results The PubMed search yielded 65 articles with 153 patients (mean age 44.7 years; range 14–85 years) who underwent anterior spinal surgery and sustained esophageal perforation, either during surgery or in a delayed fashion. The most common indications for initial anterior cervical spine surgery in these cases were vertebral fracture/dislocation (n = 77), spondylotic myelopathy (n = 15), and nucleus pulposus herniation (n = 10). The most commonly involved spinal levels were C5–6 (n = 51) and C6–7 (n = 39). The most common presenting symptoms included dysphagia (n = 63), fever (n = 24), neck swelling (n = 23), and wound leakage (n = 18). The etiology of esophageal perforation included hardware failure (n = 31), hardware erosion (n = 23), and intraoperative injury (n = 14). The imaging modalities used to identify the esophageal perforations included modified contrast dye swallow studies, CT, endoscopy, plain radiography, and MRI. Esophageal repair was most commonly achieved using a modified muscle flap, as well as with primary closure. Outcomes measured in the literature were often defined by the time to oral intake following esophageal repair. Complications included pneumonia (n = 6), mediastinitis (n = 4), osteomyelitis (n = 3), sepsis (n = 3), acute respiratory distress syndrome (n = 2), and recurrent laryngeal nerve damage (n = 1). The mortality rate of esophageal perforation in the analysis was 3.92% (6 of 153 reported patients).

Conclusions Esophageal perforation after anterior cervical spine surgery is a rare complication. This systematic review demonstrates that these perforations can be stratified into 3 categories based on the timing of symptomatic onset: intraoperative, early postoperative (within 30 days of anterior spinal surgery), and delayed. The most common source of esophageal injury is hardware erosion or migration, each of which may vary in their time to symptomatic manifestation.

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Complication Rates Associated With Adult Cervical Deformity Surgery

prospective-multicenter-assessment-of-early-complication-rates-associated-with-adult-cervical-deformity-surgery-in-78-patients

Neurosurgery 79:378–388, 2016

Few reports have focused on treatment of adult cervical deformity (ACD).

OBJECTIVE: To present early complication rates associated with ACD surgery.

METHODS: A prospective multicenter database of consecutive operative ACD patients was reviewed for early (#30 days from surgery) complications. Enrollment required at least 1 of the following: cervical kyphosis .10 degrees, cervical scoliosis .10 degrees, C2-7 sagittal vertical axis .4 cm, or chin-brow vertical angle .25 degrees.

RESULTS: Seventy-eight patients underwent surgical treatment for ACD (mean age, 60.8 years). Surgical approaches included anterior-only (14%), posterior-only (49%), anterior-posterior (35%), and posterior-anterior-posterior (3%). Mean numbers of fused anterior and posterior vertebral levels were 4.7 and 9.4, respectively. A total of 52 early complications were reported, including 26 minor and 26 major. Twenty-two (28.2%) patients had at least 1 minor complication, and 19 (24.4%) had at least 1 major complication. Overall, 34 (43.6%) patients had at least 1 complication. The most common complications included dysphagia (11.5%), deep wound infection (6.4%), new C5 motor deficit (6.4%), and respiratory failure (5.1%). One (1.3%) mortality occurred. Early complication rates differed significantly by surgical approach: anterior-only (27.3%), posterior-only (68.4%), and anterior-posterior/posterior-anterior- posterior (79.3%) (P = .007).

CONCLUSION: This report provides benchmark rates for overall and specific ACD surgery complications. Although the surgical approach(es) used were likely driven by the type and complexity of deformity, there were significantly higher complication rates associated with combined and posterior-only approaches compared with anterior-only approaches. These findings may prove useful in treatment planning, patient counseling, and ongoing efforts to improve safety of care.

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Surgery for adult spondylolisthesis: a systematic review of the evidence

spondylolistesis

Eur Spine J (2016) 25:2359–2367

Surgery for isthmic and degenerative spondylolisthesis (SL) in adults is carried out very frequently in everyday practice. However, it is still unclear whether the results of surgery are better than those of conservative treatment and whether decompression alone or instrumented fusion with decompression should be recommended. In addition, the role of reduction is unclear.

Four clinically relevant key questions were addressed in this study: (1) Is surgery more successful than conservative treatment in relation to pain and function in adult patients with isthmic SL? (2) Is surgery more successful than conservative treatment in relation to pain and function in adult patients with degenerative SL? (3) Is instrumented fusion with decompression more successful in relation to pain and function than decompression alone in adult patients with degenerative SL and spinal canal stenosis? (4) Is instrumented fusion with reduction more successful in relation to pain and function than instrumented fusion without reduction in adult patients with isthmic or degenerative SL?

A systematic PubMed search was carried out to identify randomized and nonrandomized controlled trials on these topics. Papers were analyzed systematically in a search for the best evidence.A total of 18 studies was identified and analyzed: two for question 1, eight for question 2, four for question 3, and four for question 4.

Surgery appears to be better than conservative treatment in adults with isthmic SL (poor evidence) and also in adults with degenerative SL (good evidence). Instrumented fusion with decompression appears to be more successful than decompression alone in adults with degenerative SL and spinal stenosis (poor evidence). Reduction and instrumented fusion does not appear to be more successful than instrumented fusion without reduction in adults with isthmic or degenerative SL (moderate evidence).

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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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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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Subsidence after lateral interbody fusion

Assessment and classi cation of subsidence after lateral interbody fusion using serial computed tomography

J Neurosurg Spine 23:589–597, 2015

Intervertebral cage settling during bone remodeling after lumbar lateral interbody fusion (LIF) is a common occurrence during the normal healing process. Progression of this settling with endplate collapse is defined as subsidence. The purposes of this study were to 1) assess the rate of subsidence after minimally invasive (MIS) LIF by CT, 2) distinguish between early cage subsidence (ECS) and delayed cage subsidence (DCS), 3) propose a descriptive method for classifying the types of subsidence, and 4) discuss techniques for mitigating the risk of subsidence after MIS LIF.

Methods A total of 128 consecutive patients (with 178 treated levels in total) underwent MIS LIF performed by a single surgeon. The subsidence was deemed to be ECS if it was evident on postoperative Day 2 CT images and was therefore the result of an intraoperative vertebral endplate injury and deemed DCS if it was detected on subsequent CT scans (≥ 6 months postoperatively). Endplate breaches were categorized as caudal (superior endplate) and/or cranial (inferior endplate), and as ipsilateral, contralateral, or bilateral with respect to the side of cage insertion. Subsidence seen in CT images (radiographic subsidence) was measured from the vertebral endplate to the caudal or cranial margin of the cage (in millimeters). Patient-reported outcome measures included visual analog scale, Oswestry Disability Index, and 36-Item Short Form Health Survey physical and mental component summary scores.

Results Four patients had ECS in a total of 4 levels. The radiographic subsidence (DCS) rates were 10% (13 of 128 patients) and 8% (14 of 178 levels), with 3% of patients (4 of 128) exhibiting clinical subsidence. In the DCS levels, 3 types of subsidence were evident on coronal and sagittal CT scans: Type 1, caudal contralateral, in 14% (2 of 14), Type 2, caudal bilateral with anterior cage tilt, in 64% (9 of 14), and Type 3, both endplates bilaterally, in 21% (3 of 14). The mean subsidence in the DCS levels was 3.2 mm. There was no significant difference between the numbers of patients in the subsidence (DCS) and no-subsidence groups who received clinical benefit from the surgical procedure, based on the minimum clinically important difference (p > 0.05). There was a significant difference between the fusion rates at 6 months (p = 0.0195); however, by 12 months, the difference was not significant (p = 0.2049).

Conclusions The authors distinguished between ECS and DCS. Radiographic subsidence (DCS) was categorized using descriptors for the location and severity of the subsidence. Neither interbody fusion rates nor clinical outcomes were affected by radiographic subsidence. To protect patients from subsidence after MIS LIF, the surgeon needs to take care with the caudal endplate during cage insertion. If a caudal bilateral (Type 2) endplate breach is detected, supplemental posterior fixation to arrest progression and facilitate fusion is recommended.

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Two-level corpectomy versus three-level discectomy for cervical spondylotic myelopathy

Two-level corpectomy versus three-level discectomy for cervical spondylotic myelopathy

J Neurosurg Spine 23:280–289, 2015

In the treatment of cervical spondylotic myelopathy (CSM), anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF) are effective decompressive techniques. It remains to be determined whether ACCF and ACDF offer equivalent outcomes for multilevel CSM. In this study, the authors compared perioperative, radiographic, and clinical outcomes between 2-level ACCF and 3-level ACDF.

Methods Between 2006 and 2012, all patients at the authors’ hospital who underwent 2-level ACCF or 3-level ACDF performed by 1 of 2 surgeons were identified. Primary outcomes of interest were sagittal Cobb angle, adjacent-segment disease (ASD) requiring surgery, neck pain measured by visual analog scale (VAS), and Nurick score. Secondary outcomes of interest included estimated blood loss (EBL), length of stay, perioperative complications, and radiographic pseudarthrosis rate. Chi-square tests and 2-tailed Student t-tests were used to compare the 2 groups. A subgroup analysis of patients without posterior spinal fusion (PSF) was also performed.

Results Twenty patients underwent 2-level ACCF, and 35 patients underwent 3-level ACDF during a 6-year period. Preoperative Nurick scores were higher in the ACCF group (2.1 vs 1.1, p = 0.014), and more patients underwent PSF in the 2-level ACCF group compared with patients in the 3-level ACDF group (60.0% vs 17.1%, p = 0.001). Otherwise there were no significant differences in demographics, comorbidities, and baseline clinical parameters between the 2 groups. Two-level ACCF was associated with significantly higher EBL compared with 3-level ACDF for the anterior stage of surgery (382.2 ml vs 117.9 ml, p < 0.001). Two-level ACCF was also associated with a longer hospital stay compared with 3-level ACDF (7.2 days vs 4.9 days, p = 0.048), but a subgroup comparison of patients without PSF showed no significant difference in length of stay (3.1 days vs 4.4 days for 2-level ACCF vs 3-level ACDF, respectively; p = 0.267). Similarly, there was a trend toward more complications in the 2-level ACCF group (20.0%) than the 3-level ACDF group (5.7%; p = 0.102), but a subgroup analysis that excluded those who had second-stage PSF no longer showed the same trend (2-level ACCF, 0.0% vs 3-level ACDF, 3.4%; p = 0.594). There were no significant differences between the ACCF group and the ACDF group in terms of postoperative sagittal Cobb angle (7.2° vs 12.1°, p = 0.173), operative ASD (6.3% vs 3.6%, p = 0.682), and radiographic pseudarthrosis rate (6.3% vs 7.1%, p = 0.909). Both groups had similar improvement in mean VAS neck pain scores (3.4 vs 3.2 for ACCF vs ACDF, respectively; p = 0.860) and Nurick scores (0.8 vs 0.7, p = 0.925).

Conclusions Two-level ACCF was associated with greater EBL and longer hospital stays when patients underwent a second-stage PSF. However, the length of stay was similar when patients underwent anterior-only decompression with either 2-level ACCF or 3-level ACDF. Furthermore, perioperative complication rates were similar in the 2 groups when patients underwent anterior decompression without PSF. Both groups obtained similar postoperative cervical lordosis, operative ASD rates, radiographic pseudarthrosis rates, neurological improvement, and pain relief.

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Minimally invasive spine surgery for adult degenerative lumbar scoliosis

Minimally invasive spine surgery for adult degenerative lumbar scoliosis

Neurosurg Focus 36 (5):E7, 2014

Historically, adult degenerative lumbar scoliosis (DLS) has been treated with multilevel decompression and instrumented fusion to reduce neural compression and stabilize the spinal column. However, due to the profound morbidity associated with complex multilevel surgery, particularly in elderly patients and those with multiple medical comorbidities, minimally invasive surgical approaches have been proposed. The goal of this meta-analysis was to review the differences in patient selection for minimally invasive surgical versus open surgical procedures for adult DLS, and to compare the postoperative outcomes following minimally invasive surgery (MIS) and open surgery.

Methods. In this meta-analysis the authors analyzed the complication rates and the clinical outcomes for patients with adult DLS undergoing complex decompressive procedures with fusion versus minimally invasive surgical approaches. Minimally invasive surgical approaches included decompressive laminectomy, microscopic decompression, lateral and extreme lateral interbody fusion (XLIF), and percutaneous pedicle screw placement for fusion. Mean patient age, complication rates, reoperation rates, Cobb angle, and measures of sagittal balance were investigated and compared between groups.

Results. Twelve studies were identified for comparison in the MIS group, with 8 studies describing the lateral interbody fusion or XLIF and 4 studies describing decompression without fusion. In the decompression MIS group, the mean preoperative Cobb angle was 16.7° and mean postoperative Cobb angle was 18°. In the XLIF group, mean pre- and postoperative Cobb angles were 22.3° and 9.2°, respectively. The difference in postoperative Cobb angle was statistically significant between groups on 1-way ANOVA (p = 0.014). Mean preoperative Cobb angle, mean patient age, and complication rate did not differ between the XLIF and decompression groups. Thirty-five studies were identified for inclusion in the open surgery group, with 18 studies describing patients with open fusion without osteotomy and 17 papers detailing outcomes after open fusion with osteotomy. Mean preoperative curve in the open fusion without osteotomy and with osteotomy groups was 41.3° and 32°, respectively. Mean reoperation rate was significantly higher in the osteotomy group (p = 0.008). On 1-way ANOVA comparing all groups, there was a statistically significant difference in mean age (p = 0.004) and mean preoperative curve (p = 0.002). There was no statistically significant difference in complication rates between groups (p = 0.28).

Conclusions. The results of this study suggest that surgeons are offering patients open surgery or MIS depending on their age and the severity of their deformity. Greater sagittal and coronal correction was noted in the XLIF versus decompression only MIS groups. Larger Cobb angles, greater sagittal imbalance, and higher reoperation rates were found in studies reporting the use of open fusion with osteotomy. Although complication rates did not significantly differ between groups, these data are difficult to interpret given the heterogeneity in reporting complications between studies.

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Adjacent Segment Disease After Anterior Cervical Discectomy and Fusion in a Large Series

ASD1

Neurosurgery 74:139–146, 2014

Adjacent segment disease (ASD) development is known to occur after anterior cervical discectomy and fusion (ACDF).

OBJECTIVE: To study the relationship between index ACDF levels and the location of ASD development (above/below), as well as the effect of fusion length on ASD development.

METHODS: We report 888 patients who underwent ACDF for cervical spondylosis over a twenty-year period at a single institution. Of these patients, 108 had re-do surgery due to symptomatic ASD. Patients were followed for an average of 92.4 6 52.6 months after the index ACDF.

RESULTS: In agreement with previous ACDF case series, we found the highest rates of cervical spinal degenerative disease requiring surgery at C5/C6, followed by C6/C7. Interestingly, neither the inherent location of index ACDF nor the length of instrumented arthrodesis appeared to correlate with the propensity to develop ASD. However, patients were more likely to develop ASD above the index level of fusion. This was true even for patients undergoing a second revision surgery due to recurrent ASD. Importantly, our data are consistent with existing in vitro biomechanical data in cadaveric spines.

CONCLUSION: We describe in detail the location and length of arthrodesis for index ACDFs, as well as first and second revision fusion surgeries in one of the largest Western cohorts in the literature. Our findings support the theory that iatrogenically introduced stress and instability at adjacent spinal segments contribute to the pathogenesis of ASD.

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Arthroplasty Versus Fusion in Single-Level Cervical Degenerative Disc Disease

Fusion

Spine 2013;38:E1096–E1107

Study Design. A systematic review of randomized controlled trials (RCTs).

Objective. To assess the effects of arthroplasty versus fusion in the treatment of radiculopathy or myelopathy, or both, due to singlelevel cervical degenerative disc disease.

Summary of Background Data. There is ongoing debate about whether fusion or arthroplasty is superior in the treatment of single-level cervical degenerative disc disease. Mainly because the intended advantage of arthroplasty compared with fusion, prevention of symptoms due to adjacent segment degeneration in the long term, is not confirmed yet. Until sufficient long-term results become available, it is important to know whether results of 1 of the 2 treatments are superior to the other in the first 1 to 2 years.

Methods. We searched electronic databases for randomized controlled trials. We included randomized controlled trials that directly compared any type of cervical fusion with any type of cervical arthroplasty, with at least 1 year of follow-up. Study selection was performed independently by 3 review authors, and “risk of bias” assessment and data extraction were independently performed by 2 review authors. In case of missing data, we contacted the study authors or the study sponsor. We assessed the quality of evidence.

Results. Nine studies (2400 participants) were included in this review; 5 of these studies had a low risk of bias. Results for the arthroplasty group were better than the fusion group for all primary comparisons, often statistically significant. For none of the primary outcomes was a clinically relevant difference in effect size shown. Quality of the evidence was low to moderate.

Conclusion. There is low to moderate quality evidence that results are consistently in favor of arthroplasty, often statistically significant. However, differences in effect size were invariably small and not clinically relevant for all primary outcomes.

Level of Evidence: 1

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Complications associated with the surgical treatment of cervical spondylotic myelopathy

J Neurosurg Spine 16:425–432, 2012. (http://thejns.org/doi/abs/10.3171/ 2012.1.SPINE11467) 

Rates of complications associated with the surgical treatment of cervical spondylotic myelopathy (CSM) are not clear. Appreciating these risks is important for patient counseling and quality improvement. The authors sought to assess the rates of and risk factors associated with perioperative and delayed complications associated with the surgical treatment of CSM.

Methods. Data from the AOSpine North America Cervical Spondylotic Myelopathy Study, a prospective, multicenter study, were analyzed. Outcomes data, including adverse events, were collected in a standardized manner and externally monitored. Rates of perioperative complications (within 30 days of surgery) and delayed complications (31 days to 2 years following surgery) were tabulated and stratified based on clinical factors.

Results. The study enrolled 302 patients (mean age 57 years, range 29–86) years. Of 332 reported adverse events, 73 were classified as perioperative complications (25 major and 48 minor) in 47 patients (overall perioperative complication rate of 15.6%). The most common perioperative complications included minor cardiopulmonary events (3.0%), dysphagia (3.0%), and superficial wound infection (2.3%). Perioperative worsening of myelopathy was reported in 4 patients (1.3%). Based on 275 patients who completed 2 years of follow-up, there were 14 delayed complications (8 minor, 6 major) in 12 patients, for an overall delayed complication rate of 4.4%. Of patients treated with anterior-only (n = 176), posterior-only (n = 107), and combined anterior-posterior (n = 19) procedures, 11%, 19%, and 37%, respectively, had 1 or more perioperative complications. Compared with anterior-only approaches, posterior-only approaches had a higher rate of wound infection (0.6% vs 4.7%, p = 0.030). Dysphagia was more common with combined anterior-posterior procedures (21.1%) compared with anterior-only procedures (2.3%) or posterior-only procedures (0.9%) (p < 0.001). The incidence of C-5 radiculopathy was not associated with the surgical approach (p = 0.8). The occurrence of perioperative complications was associated with increased age (p = 0.006), combined anterior-posterior procedures (p = 0.016), increased operative time (p = 0.009), and increased operative blood loss (p = 0.005), but it was not associated with comorbidity score, body mass index, modified Japanese Orthopaedic Association score, smoking status, anterior-only versus posterior-only approach, or specific procedures. Multivariate analysis of factors associated with minor or major complications identified age (OR 1.029, 95% CI 1.002–1.057, p = 0.035) and operative time (OR 1.005, 95% CI 1.002–1.008, p = 0.001). Multivariate analysis of factors associated with major complications identified age (OR 1.054, 95% CI 1.015–1.094, p = 0.006) and combined anterior-posterior procedures (OR 5.297, 95% CI 1.626–17.256, p = 0.006).

Conclusions. For the surgical treatment of CSM, the vast majority of complications were treatable and without long-term impact. Multivariate factors associated with an increased risk of complications include greater age, increased operative time, and use of combined anterior-posterior procedures.

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A Prospective, Randomized Trial Comparing Expansile Cervical Laminoplasty and Cervical Laminectomy and Fusion for Multilevel Cervical Myelopathy

Neurosurgery 70:264–277, 2012 DOI: 10.1227/NEU.0b013e3182305669

Controversy exists as to the best posterior operative procedure to treat multilevel compressive cervical spondylotic myelopathy.

OBJECTIVE: To determine clinical, radiological, and patient satisfaction outcomes between expansile cervical laminoplasty (ECL) and cervical laminectomy and fusion (CLF).

METHODS: We performed a prospective, randomized study of ECL vs CLF in patients suffering from cervical spondylotic myelopathy. End points included the Short Form-36, Neck Disability Index, Visual Analog Scale, modified Japanese Orthopedic Association score, Nurick score, and radiographic measures.

RESULTS: A survey of academic North American spine surgeons (n = 30) demonstrated that CLF is the most commonly used (70%) posterior procedure to treat multilevel spondylotic cervical myelopathy. A total of 16 patients were randomized: 7 to CLF and 9 to ECL. Both groups showed improvements in their Nurick grade and Japanese Orthopedic Association score postoperatively, but only the improvement in the Nurick grade for the ECL group was statistically significant (P < .05). The cervical range of motion between C2 and C7 was reduced by 75% in the CLF group and by only 20% in the ECL group in a comparison of preoperative and postoperative range of motion. The overall increase in canal area was significantly (P < .001) greater in the CLF group, but there was a suggestion that the adjacent level was more narrowed in the CLF group in as little as 1 year postoperatively.

CONCLUSION: In many respects, ECL compares favorably to CLF. Although the patient numbers were small, there were significant improvements in pain measures in the ECL group while still maintaining range of motion. Restoration of spinal canal area was superior in the CLF group.

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Cost-effectiveness of transforaminal lumbar interbody fusion for Grade I degenerative spondylolisthesis

J Neurosurg Spine 15:138–143, 2011. DOI: 10.3171/2011.3.SPINE10562

Transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis-associated back and leg pain is associated with improvement in pain, disability, and quality of life. However, given the rising health care costs associated with spinal fusion procedures and varying results of recent cost-utility studies, the cost-effectiveness of TLIF remains unclear. The authors set out to assess the comprehensive costs of TLIF at their institution and to determine its cost-effectiveness in the treatment of degenerative spondylolisthesis.

Methods. Forty-five patients undergoing TLIF for Grade I degenerative spondylolisthesis–associated back and leg pain after 6–12 months of conservative therapy were included. The authors assessed the 2-year back pain visual analog scale (VAS) score, leg pain VAS score, Oswestry Disability Index, and total back-related medical resource utilization, missed work, and health-state values (quality-adjusted life years [QALYs], calculated from EQ-5D with US valuation). Two-year resource use was multiplied by unit costs based on Medicare national allowable payment amounts (direct cost), and patient and caregiver workday losses were multiplied by the self-reported gross-of-tax wage rate (indirect cost). The mean total 2-year cost per QALY gained after TLIF was assessed.

Results. Compared with preoperative health states reported after at least 6 months of medical management, a significant improvement in back pain VAS score, leg pain VAS score, and Oswestry Disability Index was observed 2 years after TLIF, with a mean 2-year gain of 0.86 QALYs. The mean ± SD total 2-year cost of TLIF was $36,836 ± $11,800 (surgery cost, $21,311 ± $2800; outpatient resource utilization cost, $3940 ± $2720; indirect cost, $11,584 ± $11,363). Transforaminal lumbar interbody fusion was associated with a mean 2-year cost per QALY gained of $42,854.

Conclusions. Transforaminal lumbar interbody fusion improved pain, disability, and quality of life in patients with degenerative spondylolisthesis–associated back and leg pain. The total cost per QALY gained for TLIF was $42,854 when evaluated 2 years after surgery with Medicare fees, suggesting that TLIF is a cost-effective treatment of lumbar spondylolisthesis.

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A Review of Complications Associated With Craniocervical Fusion Surgery

Neurosurgery 67:1396–1403, 2010 DOI: 10.1227/NEU.0b013e3181f1ec73

Fusion at the craniovertebral junction is performed to treat instability of the upper cervical spine and occiput. The literature consists exclusively of case series in which complication rate and avoidance are variably addressed.

OBJECTIVE: To describe the rates of various complications encountered during craniocervical fusions and discuss preoperative and perioperative strategies useful for risk reduction. METHODS: A computerized search of PubMed for literature on craniocervical fusion and other upper cervical fusions was performed. Keywords used in the search included: occipitocervical fusion, odontoid screw, atlantoaxial fusion, with and without complications, anterior fixation, lateral mass screw, transarticular screw, halo, vertebral artery injury, and odontoid fracture. References were limited to studies on human subjects. Other sources were identified from the reference lists of relevant publications.

RESULTS: Twenty-two reports described data derived from 2274 procedures analyzed for complications. The most commonly encountered perioperative complications were related to instrumentation failure after nonunion with rates as high as 7% during occipitocervical fusion and 6.7% during atlantoaxial fusion. Other commonly encountered complications included injury to the vertebral artery (1.3%-4.1% during placement of C1-C2 transarticular screws, most commonly in the case of high-riding vertebral artery), dural tears, and wound infection.

CONCLUSION: Occipitocervical or atlantoaxial fusion procedures can be performed with low morbidity. Safety is enhanced with appropriate preoperative assessment of anatomic variants and preparation for perioperative management of complications.

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