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Mohamad Bydon, Risheng Xu, David Santiago-Dieppa, Mohamed Macki, Daniel M. Sciubba, Jean-Paul Wolinsky, Ali Bydon, Ziya L. Gokaslan and Timothy F. Witham

Object

The aim of this study was to study the long-term outcomes of patients undergoing instrumented posterior fusion of the lumbar spine.

Methods

The authors present 511 patients who underwent instrumented arthrodesis for lumbar degenerative disease over a 23-year period at a single institution. Patients underwent follow-up for an average of 39.73 ± 46.52 months (± SD) after the index lumbar arthrodesis procedure.

Results

The average patient age was 59.45 ± 13.48 years. Of the 511 patients, 502 (98.24%) presented with back pain, 379 (74.17%) with radiculopathy, 76 (14.87%) with motor weakness, and 32 (6.26%) with preoperative bowel/bladder dysfunction. An average of 2.04 ± 1.03 spinal levels were fused. Postoperatively, patients experienced a significant improvement in back pain (p < 0.0001) and radiculopathy (p < 0.0001). Patients with fusions excluding the sacrum (floating fusions) were statistically more likely to develop adjacent-segment disease (ASD) than those with fusion constructs ending at S-1 distally (p = 0.030) but were less likely to develop postoperative radiculopathy (p = 0.030). In the floating fusion cohort, 31 (12.11%) of 256 patients had cephalad ASD, whereas 39 (15.29%) of 255 patients in the lumbosacral cohort had cephalad ASD development; this was not statistically different (p = 0.295). This suggests that caudad ASD development in the floating fusion cohort is due to the added risk of an unfused L5–S1 vertebral level. Because of the elevated risk of symptomatic radiculopathy but lower risk of ASD, patients in the lumbosacral fusion cohort had a reoperation rate similar to those undergoing floating fusions (p = 0.769).

Conclusions

In this paper, the authors present one of the largest cohorts in the Western literature of patients undergoing instrumented fusion for degenerative lumbar spine disease. Patients who had floating lumbar fusions were statistically more likely to develop ASD over time than those who had lumbosacral fusions incorporating the S-1 spinal segment, but were less likely to experience postoperative radicular symptoms. Additional prospective studies may more clearly delineate the long-term risks of instrumented posterolateral fusions of the lumbar spine.

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Dimitrios Mathios, Paul Edward Kaloostian, Ali Bydon, Daniel M. Sciubba, Jean Paul Wolinsky, Ziya L. Gokaslan and Timothy F. Witham

Reconstruction of the lumbosacral junction is a considerable challenge for spinal surgeons due to the unique anatomical constraints of this region as well as the vectors of force that are applied focally in this area. The standard cages, both expandable and nonexpendable, often fail to reconstitute the appropriate anatomical alignment of the lumbosacral junction. This inadequate reconstruction may predispose the patient to continued back pain and neurological symptoms as well as possible pseudarthrosis and instrumentation failure. The authors describe their preoperative planning and the technical characteristics of their novel reconstruction technique at the lumbosacral junction using a cage with adjustable caps. Based precisely on preoperative measurements that maintain the appropriate Cobb angle, they performed reconstruction of the lumbosacral junction in a series of 3 patients. All 3 patients had excellent installation of the cages used for reconstruction. Postoperative CT scans were used to radiographically confirm the appropriate reconstruction of the lumbosacral junction. All patients had a significant reduction in pain, had neurological improvement, and experienced no instrumentation failure at the time of latest follow-up. Taking into account the inherent morphology of the lumbosacral junction and carefully planning the technical characteristics of the cage installation preoperatively and intraoperatively, the authors achieved favorable clinical and radiographic outcomes in all 3 cases. Based on this small case series, this technique for reconstruction of the lumbosacral junction appears to be a safe and appropriate method of reconstruction of the anterior spinal column in this technically challenging region of the spine.

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Kaisorn L. Chaichana, Mohamad Bydon, David R. Santiago-Dieppa, Lee Hwang, Gregory McLoughlin, Daniel M. Sciubba, Jean-Paul Wolinsky, Ali Bydon, Ziya L. Gokaslan and Timothy Witham

Object

Posterior lumbar spinal fusion for degenerative spine disease is a common procedure, and its use is increasing annually. The rate of infection, as well as the factors associated with an increased risk of infection, remains unclear for this patient population. A better understanding of these features may help guide treatment strategies aimed at minimizing infection for this relatively common procedure. The authors' goals were therefore to ascertain the incidence of postoperative spinal infections and identify factors associated with postoperative spinal infections.

Methods

Data obtained in adult patients who underwent instrumented posterior lumbar fusion for degenerative spine disease between 1993 and 2010 were retrospectively reviewed. Stepwise multivariate proportional hazards regression analysis was used to identify factors associated with infection. Variables with p < 0.05 were considered statistically significant.

Results

During the study period, 817 consecutive patients underwent lumbar fusion for degenerative spine disease, and 37 patients (4.5%) developed postoperative spine infection at a median of 0.6 months (IQR 0.3–0.9). The factors independently associated with an increased risk of infection were increasing age (RR 1.004 [95% CI 1.001–1.009], p = 0.049), diabetes (RR 5.583 [95% CI 1.322–19.737], p = 0.02), obesity (RR 6.216 [95% CI 1.832–9.338], p = 0.005), previous spine surgery (RR 2.994 [95% CI 1.263–9.346], p = 0.009), and increasing duration of hospital stay (RR 1.155 [95% CI 1.076–1.230], p = 0.003). Of the 37 patients in whom infection developed, 21 (57%) required operative intervention but only 3 (8%) required instrumentation removal as part of their infection management.

Conclusions

This study identifies that several factors—older age, diabetes, obesity, prior spine surgery, and length of hospital stay—were each independently associated with an increased risk of developing infection among patients undergoing instrumented lumbar fusion for degenerative spine disease. The overwhelming majority of these patients were treated effectively without hardware removal.

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Paul E. Kaloostian, Jennifer E. Kim, Ali Bydon, Daniel M. Sciubba, Jean-Paul Wolinsky, Ziya L. Gokaslan and Timothy F. Witham

Object

The authors describe the largest case series of 8 patients with intracranial hemorrhage (ICH) after spinal surgery and identify associated pre-, intra-, and postoperative risk factors in relation to outcome.

Methods

The authors retrospectively reviewed the cases of 8 patients treated over 16 years at a single institution and also reviewed the existing literature and collected demographic, treatment, and outcome information from 33 unique cases of remote ICH after spinal surgery.

Results

The risk factors most correlated with ICH postoperatively were the presence of a CSF leak intraoperatively and the use of drains postoperatively with moderate hourly serosanguineous output in the early postoperative period.

Conclusions

Intracranial hemorrhage is a rare complication of spinal surgery that is associated with CSF leakage and use of drains postoperatively, with moderate serosanguinous output. These associations do not justify a complete avoidance of drains in patients with CSF leakage but may guide the treating physician to keep in mind drain output and timing of drain removal, while noting any changes in neurological examination status in the meantime. Additionally, continued and worsening neurological symptoms after spinal surgery may warrant cranial imaging to rule out intracranial hemorrhage, usually within the first 24 hours after surgery. The presence of cerebellar hemorrhage and hydrocephalus indicated a trend toward worse outcome.

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Mohamad Bydon, Risheng Xu, Kyriakos Papademetriou, Daniel M. Sciubba, Jean-Paul Wolinsky, Timothy F. Witham, Ziya L. Gokaslan, George Jallo and Ali Bydon

Object

Unintended durotomies are a common complication of spine surgery and are often correlated with increased postoperative morbidity. Recently, ultrasonic bone curettes have been introduced in spine surgery as a possible alternative to the conventional high-speed drill, offering the potential for greater bone-cutting precision and less damage to surrounding soft tissues. To date, however, few studies have investigated the safety and efficacy of the ultrasonic bone curette in reducing the rates of incidental durotomy compared with the high-speed drill.

Methods

The authors retrospectively reviewed the records of 337 consecutive patients who underwent posterior cervical or thoracic decompression at a single institution between January 2009 and September 2011. Preoperative pathologies, the location and extent of spinal decompression, and the use of an ultrasonic bone curette versus the high-speed drill were noted. The rates of incidental durotomy, as well as hospital length of stay (LOS) and perioperative outcomes, were compared between patients who were treated using the ultrasonic bone curette and those treated using a high-speed drill.

Results

Among 88 patients who were treated using an ultrasonic bone curette and 249 who were treated using a high-speed drill, 5 (5.7%) and 9 (3.6%) patients had an unintentional durotomy, respectively. This finding was not statistically significant (p = 0.40). No patients in either cohort experienced statistically higher rates of perioperative complications, although patients treated using an ultrasonic bone curette tended to have a longer hospital LOS. This difference may be attributed to the fact that this series contained a statistically higher number of metastatic tumor cases (p < 0.0001) in the ultrasonic bone curette cohort, likely increasing the LOS for that patient population. In 13 patients, the dural defect was repaired intraoperatively. No patients who experienced an incidental durotomy had new-onset or permanent neurological deficits postoperatively.

Conclusions

The safety and efficacy of ultrasonic bone curettes in spine surgery has not been well established. This study shows that the ultrasonic bone curette has a similar safety profile compared with the high-speed drill, although both are capable of causing iatrogenic dural tears during spine surgery.

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Patricia Zadnik, Rachel Sarabia-Estrada, Mari L. Groves, Camilo Molina, Christopher Jackson, Edward McCarthy, Ziya L. Gokaslan, Ali Bydon, Jean-Paul Wolinsky, Timothy F. Witham and Daniel M. Sciubba

Object

Metastatic spine disease is prevalent in cancer victims; 10%–30% of the 1.2 million new patients diagnosed with cancer in the US exhibit spinal metastases. Unfortunately, treatments are limited for these patients, as disseminated disease is often refractory to chemotherapy and is difficult to treat with surgical intervention alone. New animal models that accurately recapitulate the human disease process are needed to study the behavior of metastases in real time.

Methods

In this study the authors report on a cell line that reliably generates bony metastases following intracardiac injection and can be tracked in real time using optical bioluminescence imaging. This line, RBC3, was derived from a metastatic breast adenocarcinoma lesion arising in the osseous spine of a rat following intracardiac injection of MDA-231 human breast cancer cells.

Results

Upon culture and reinjection of RBC3, a statistically significantly increased systemic burden of metastatic tumor was noted. The resultant spine lesions were osteolytic, as demonstrated by small animal CT scanning.

Conclusions

This cell line generates spinal metastases that can be tracked in real time and may serve as a useful tool in the study of metastatic disease in the spine.

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Hormuzdiyar H. Dasenbrock, Stephen P. Juraschek, Lonni R. Schultz, Timothy F. Witham, Daniel M. Sciubba, Jean-Paul Wolinsky, Ziya L. Gokaslan and Ali Bydon

Object

Advocates of minimally invasive discectomy (MID) have promoted this operation as an alternative to open discectomy (OD), arguing that there may be less injury to the paraspinal muscles, decreased postoperative pain, and a faster recovery time. However, a recently published large randomized controlled trial (RCT) comparing these approaches reported inferior relief of leg pain in patients undergoing MID. The authors conducted a meta-analysis to evaluate complications and improvement in leg pain in patients with radiculopathy enrolled in RCTs comparing OD to MID.

Methods

The authors performed a literature search using Medline and EMBASE of studies indexed between January 1990 and January 2011. Predetermined RCT eligibility included the usage of tubular retractors during MID, a minimum follow-up duration of 1 year, and quantification of pain with the visual analog scale (VAS). Trials that only evaluated patients with recurrent disc herniation were excluded. Data on operative parameters, complications, and VAS scores of leg pain were extracted by 2 investigators. A meta-analysis was performed assuming random effects to determine the difference in mean change for continuous outcomes and the risk ratio for binary outcomes.

Results

Six trials comprising 837 patients (of whom 388 were randomized to MID and 449 were randomized to OD) were included. The mean operative time was 49 minutes during MID and 44 minutes during OD; this difference was not statistically significant. Incidental durotomies occurred significantly more frequently during MID (5.67% compared with 2.90% for OD; RR 2.05, 95% CI 1.05–3.98). Intraoperative complications (incidental durotomies and nerve root injuries) were also significantly more common in patients undergoing MID (RR 2.01, 95% CI 1.07–3.77). The mean preoperative VAS score for leg pain was 6.9 in patients randomized to MID and 7.2 in those randomized to OD. With long-term follow-up (1–2 years postoperatively), the mean VAS score improved to 1.6 in both the MID and OD cohorts. There was no significant difference in relief of leg pain between the 2 approaches with either short-term follow-up (2–3 months postoperatively, 0.81 points on the VAS, 95% CI −4.71 to 6.32) or long-term follow-up (2.64 on the VAS, 95% CI −2.15 to 7.43). Reoperation for recurrent herniation was more common in patients randomized to the MID group (8.50% compared with 5.35% in patients randomized to the OD group), but this difference was not statistically significant (RR 1.56, 95% CI 0.92–2.66). Total complications did not differ significantly between the operations (RR 1.50, 95% CI 0.97–2.33).

Conclusions

The current evidence suggests that both OD and MID lead to a substantial and equivalent long-term improvement in leg pain. Adequate decompression, regardless of the operative approach used, may be the primary determinant of pain relief—the major complaint of many patients with radiculopathy. Incidental durotomies occurred significantly more frequently during MID, but total complications did not differ between the techniques.