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Michelle J. Clarke, Patricia L. Zadnik, Mari L. Groves, Hormuzdiyar H. Dasenbrock, Daniel M. Sciubba, Wesley Hsu, Timothy F. Witham, Ali Bydon, Ziya L. Gokaslan, and Jean-Paul Wolinsky

Object

Traditionally, hemisacrectomy and internal hemipelvectomy procedures have required both an anterior and a posterior approach. A posterior-only approach has the potential to complete an en bloc tumor resection and spinopelvic reconstruction while reducing surgical morbidity.

Methods

The authors describe 3 cases in which en bloc resection of the hemisacrum and ilium and subsequent lumbopelvic and pelvic ring reconstruction were performed from a posterior-only approach. Two more traditional anterior and posterior staged procedures are also included for comparison.

Results

In all 3 cases, an oncologically appropriate surgery and spinopelvic reconstruction were performed through a posterior-only approach.

Conclusions

The advantage of a midline posterior approach is the ability to perform a lumbosacral reconstruction, necessary in cases in which the S-1 body is iatrogenically disrupted during tumor resection.

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Camilo A. Molina, Christopher P. Ames, Dean Chou, Laurence D. Rhines, Patrick C. Hsieh, Patricia L. Zadnik, Jean-Paul Wolinsky, Ziya L. Gokaslan, and Daniel M. Sciubba

Object

Chordomas involving the mobile spine are ideally managed via en bloc resection with reconstruction to optimize local control and possibly offer cure. In the cervical spine, local anatomy poses unique challenges, limiting the feasibility of aggressive resection. The authors present a multi-institutional series of 16 cases of cervical chordomas removed en bloc. Particular attention was paid to clinical outcome, complications, and recurrence. In addition, outcomes were assessed according to position of tumor at the C1–2 level versus the subaxial (SA) spine (C3–7).

Methods

The authors reviewed cases involving patients who underwent en bloc resection of cervical chordoma at 4 large spine centers. Patients were included if the lesion epicenter involved the C-1 to C-7 vertebral bodies. Demographic data and details of surgery, follow-up course, exposure to adjuvant therapy, and complications were obtained. Outcome was correlated with presence of tumor in C1–2 versus subaxial spine via a Student t-test.

Results

Sixteen patients were identified (mean age at presentation 55 ± 14 years). Seven cases (44%) cases involved C1–2, and 16 involved the subaxial spine. Median survival did not differ significantly different between the C1–2 (72 months) and SA (60 months) groups (p = 0.65). A combined (staged anteroposterior) approach was used in 81% of the cases. Use of the combined approach was significantly more common in treatment of subaxial than C1–2 tumors (100% vs 57%, p = 0.04). En bloc resection was attempted via an anterior approach in 6% of cases (C1–2: 14.3%; SA: 0%; p = 0.17) and a posterior approach in 13% of cases (C1–2: 29%; SA: 0%; p = 0.09). The most commonly reported margin classification was marginal (56% of cases), followed by violated (25%) and wide (19%). En bloc excision of subaxial tumors was significantly more likely to result in marginal margins than excision of C1–2 tumors (C1–2: 29%; SA: 78%; p = 0.03). C1–2 tumors were associated with significantly higher rates of postoperative complications (C1–2: 71%; SA: 22%; p = 0.03). Both local and distant tumor recurrence was greatest for C1–2 tumors (local C1–2: 29%; local SA: 11%; distant C1–2: 14%; distant SA: 0%). Statistical analysis of tumor recurrence based on tumor location was not possible due to the small number of cases. There was no between-groups difference in exposure to postoperative adjuvant radiotherapy. There was no difference in median survival between groups receiving proton beam radiotherapy or intensity-modulated radiotherapy versus no radiation therapy (p = 0.8).

Conclusions

Compared with en bloc resection of chordomas involving the subaxial cervical spine, en bloc resection of chordomas involving the upper cervical spine (C1–2) is associated with poorer outcomes, such as less favorable margins, higher rates of complications, and increased tumor recurrence. Data from this cohort do not support a statistically significant difference in survival for patients with C1–2 versus subaxial disease, but larger studies are needed to further study survival differences.

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Mohamad Bydon, Risheng Xu, Anubhav G. Amin, Mohamed Macki, Paul Kaloostian, Daniel M. Sciubba, Jean-Paul Wolinsky, Ali Bydon, Ziya L. Gokaslan, and Timothy F. Witham

Object

A number of imaging techniques have been introduced to minimize the risk of pedicle screw placement. Intraoperative CT has been recently introduced to assist in spinal instrumentation. The aim of this study was to study the effectiveness of intraoperative CT in enhancing the safety and accuracy of pedicle screw placement.

Methods

The authors included all cases from December 2009 through July 2012 in which intraoperative CT scanning was used to confirm pedicle screw placement.

Results

A total of 203 patients met the inclusion criteria. Of 1148 screws, 103 screws (8.97%) were revised intraoperatively in 72 patients (35.5%): 14 (18.42%) were revised in the cervical spine (C-2 or C-7), 25 (7.25%) in the thoracic spine, and 64 (8.80%) in the lumbar spine. Compared with screws in the thoracic and lumbar regions, pedicle screws placed in the cervical region were statistically more likely to be revised (p = 0.0061). Two patients (0.99%) required reoperations due to undetected misplacement of pedicle screws.

Conclusions

The authors describe one of the first North American experiences using intraoperative CT scanning to confirm the placement of pedicle screws. Compared with a similar cohort of patients from their institution who had pedicle screws inserted via the free-hand technique with postoperative CT, the authors found that the intraoperative CT lowers the threshold for pedicle screw revision, resulting in a statistically higher rate of screw revision in the thoracic and lumbar spine (p < 0.0001). During their 2.5-year experience with the intraoperative CT, the authors did not find a reduction in rates of reoperation for misplaced pedicle screws.

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

Pheochromocytomas of the spine are uncommon and require careful preoperative planning. The authors retrospectively reviewed the charts of 5 patients with metastatic spinal pheochromocytoma who had undergone surgical treatment over the past 10 years at their medical center. They reviewed patient age, history of pheochromocytoma resection, extent and location of metastases, history of alpha blockage, surgical level, surgical procedure, postoperative complications, tumor recurrence, and survival. Metastases involved the cervical (1 patient), thoracic (3 patients), and lumbar (2 patients) levels. Preoperative treatment included primary pheochromocytoma resection, chemotherapy, alpha blockade, embolization, and radiation. Three patients had tumor recurrence, and 2 underwent 2-stage reoperations for tumor extension. Hemodynamic complications were common: 2 patients developed pulseless electrical activity arrest within 4 months after surgery, 1 patient had profound postoperative tachycardia with fever and an elevated creatine kinase level, and 1 patient experienced transient postoperative hypotension and paraplegia. One patient died of complications related to disseminated cerebral and spinal disease.

With careful preoperative and surgical management, patients with symptomatic metastatic spinal pheochromocytoma can benefit from aggressive surgical treatment. Postoperative cardiovascular complications are common even months after surgery, and patients should be closely monitored long term.

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Sean Dangelmajer, Patricia L. Zadnik, Samuel T. Rodriguez, Ziya L. Gokaslan, and Daniel M. Sciubba

Object

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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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.