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Camilo A. Molina, Rachel Sarabia-Estrada, Ziya L. Gokaslan, Timothy F. Witham, Ali Bydon, Jean-Paul Wolinsky, and Daniel M. Sciubba

Object

Recombinant human bone morphogenetic proteins (rhBMPs) are FDA-approved for specific spinal fusion procedures, but their use is contraindicated in spine tumor resection beds because of an unclear interaction between tumor tissue and such growth factors. Interestingly, a number of studies have suggested that BMPs may slow the growth of adenocarcinomas in vitro, and these lesions represent the majority of bony spine tumors. In this study, the authors hypothesized that rhBMP-2 placed in an intraosseous spine tumor in the rat could suppress tumor and delay the onset of paresis in such animals.

Methods

Twenty-six female nude athymic rats were randomized into an experimental group (Group 1) or a positive control group (Group 2). Group 1 (tumor + 15 μg rhBMP-2 sponge, 13 rats) underwent transperitoneal exposure and implantation of breast adenocarcinoma (CRL-1666) into the L-6 spine segment, followed by the implantation of a bovine collagen sponge impregnated with 15 μg of rhBMP-2. Group 2 (tumor + 0.9% NaCl sponge, 13 rats) underwent transperitoneal exposure and tumor implantation in the lumbar spine but no local treatment with rhBMP-2. An additional 8 animals were randomized into 2 negative control groups (Groups 3 and 4). Group 3 (15 μg rhBMP-2 sponge, 4 rats) and Group 4 (0.9% NaCl sponge, 4 rats) underwent transperitoneal exposure of the lumbar spine along with the implantation of rhBMP-2– and saline-impregnated bovine collagen sponges, respectively. Neither of the negative control groups was implanted with tumor. The Basso-Beattie-Bresnahan (BBB) scale was used to monitor daily motor function regression and the time to paresis (BBB score ≤ 7).

Results

In comparison with the positive control animals (Group 2), the experimental animals (Group 1) had statistically significant longer mean (25.8 ± 12.2 vs 13 ± 1.4 days, p ≤ 0.001) and median (20 vs 13 days) times to paresis. In addition, the median survival time was significantly longer in the experimental animals (20 vs 13.5 days, p ≤ 0.0001). Histopathological analysis demonstrated bone growth and tumor inhibition in the experimental animals, whereas bone destruction and cord compression were observed in the positive control animals. Neither of the negative control groups (Groups 3 and 4) demonstrated any evidence of neurological deterioration, morbidity, or cord compromise on either gross or histological analysis.

Conclusions

This study shows that the local administration of rhBMP-2 (15 μg, 10 μl of 1.5-mg/ml solution) in a rat spine tumor model of breast cancer not only fails to stimulate local tumor growth, but also decreases local tumor growth and delays the onset of paresis in rats. This preclinical experiment is the first to show that the local placement of rhBMP-2 in a spine tumor bed may slow tumor progression and delay associated neurological decline.

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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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Taylor E. Purvis, C. Rory Goodwin, Camilo A. Molina, Steven M. Frank, and Daniel M. Sciubba

OBJECTIVE

The aim of this study was to characterize the association between percentage change in hemoglobin (ΔHb)—i.e., the difference between preoperative Hb and in-hospital nadir Hb concentration—and perioperative adverse events among spine surgery patients.

METHODS

Patients who underwent spine surgery at the authors’ institution between December 4, 2008, and June 26, 2015, were eligible for this retrospective study. Patients who underwent the following procedures were included: atlantoaxial fusion, subaxial anterior cervical fusion, subaxial posterior cervical fusion, anterior lumbar fusion, posterior lumbar fusion, lateral lumbar fusion, excision of intervertebral disc, and excision of spinal cord lesion. Data on intraoperative transfusion were obtained from an automated, prospectively collected, anesthesia data management system. Data on postoperative hospital transfusions were obtained through an Internet-based intelligence portal. Percentage ΔHb was defined as: ([preoperative Hb − nadir Hb]/preoperative Hb) × 100. Clinical outcomes included in-hospital morbidity and length of stay associated with percentage ΔHb.

RESULTS

A total of 3949 patients who underwent spine surgery were identified. Of these, 1204 patients (30.5%) received at least 1 unit of packed red blood cells. The median nadir Hb level was 10.6 g/dl (interquartile range 8.7–12.4 g/dl), yielding a mean percentage ΔHb of 23.6% (SD 15.4%). Perioperative complications occurred in 234 patients (5.9%) and were more common in patients with a larger percentage ΔHb (p = 0.017). Hospital-related infection, which occurred in 60 patients (1.5%), was also more common in patients with greater percentage ΔHb (p = 0.001).

CONCLUSIONS

Percentage ΔHb is independently associated with a higher risk of developing any perioperative complication and hospital-related infection. The authors’ results suggest that percentage ΔHb may be a useful measure for identifying patients at risk for adverse perioperative events.

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Seba Ramhmdani, Marc Comair, Camilo A. Molina, Daniel M. Sciubba, and Ali Bydon

Interspinous process devices (IPDs) have been developed as less-invasive alternatives to spinal fusion with the goal of decompressing the spinal canal and preserving segmental motion. IPD implantation is proposed to treat symptoms of lumbar spinal stenosis that improve during flexion. Recent indications of IPD include lumbar facet joint syndrome, which is seen in patients with mainly low-back pain. Long-term outcomes in this subset of patients are largely unknown. The authors present a previously unreported complication of coflex (IPD) placement: the development of a large compressive lumbar synovial cyst. A 64-year-old woman underwent IPD implantation (coflex) at L4–5 at an outside hospital for low-back pain that occasionally radiates to the right leg. Postoperatively, her back and right leg pain persisted and worsened. MRI was repeated and showed a new, large synovial cyst at the previously treated level, severely compressing the patient’s cauda equina. Four months later, she underwent removal of the interspinous process implant, bilateral laminectomy, facetectomy, synovial cyst resection, interbody fusion, and stabilization. At the 3-month follow-up, she reported significant back pain improvement with some residual leg pain. This case suggests that facet arthrosis may not be an appropriate indication for placement of coflex.

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A. Karim Ahmed, Zachary Pennington, Camilo A. Molina, Yuanxuan Xia, C. Rory Goodwin, and Daniel M. Sciubba

Effective en bloc resection of primary spinal tumors necessitates careful consideration of adjacent anatomical structures in order to achieve negative margins and reduce surgical morbidity. This can be particularly challenging in the cervical spine, where vital neurovascular and connective tissues are present in the region. Early multidisciplinary surgical planning that includes clinicians and engineers can both optimize surgical planning and enable a more feasible resection with oncological margins. The aim of the current work was to demonstrate two cases that involved multidisciplinary surgical planning for en bloc resection of primary cervical spine tumors, successfully utilizing 3D-printed patient models and neoadjuvant therapies.

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Camilo A. Molina, Nicholas Theodore, A. Karim Ahmed, Erick M. Westbroek, Yigal Mirovsky, Ran Harel, Emanuele Orru’, Majid Khan, Timothy Witham, and Daniel M. Sciubba

OBJECTIVE

Augmented reality (AR) is a novel technology that has the potential to increase the technical feasibility, accuracy, and safety of conventional manual and robotic computer-navigated pedicle insertion methods. Visual data are directly projected to the operator’s retina and overlaid onto the surgical field, thereby removing the requirement to shift attention to a remote display. The objective of this study was to assess the comparative accuracy of AR-assisted pedicle screw insertion in comparison to conventional pedicle screw insertion methods.

METHODS

Five cadaveric male torsos were instrumented bilaterally from T6 to L5 for a total of 120 inserted pedicle screws. Postprocedural CT scans were obtained, and screw insertion accuracy was graded by 2 independent neuroradiologists using both the Gertzbein scale (GS) and a combination of that scale and the Heary classification, referred to in this paper as the Heary-Gertzbein scale (HGS). Non-inferiority analysis was performed, comparing the accuracy to freehand, manual computer-navigated, and robotics-assisted computer-navigated insertion accuracy rates reported in the literature. User experience analysis was conducted via a user experience questionnaire filled out by operators after the procedures.

RESULTS

The overall screw placement accuracy achieved with the AR system was 96.7% based on the HGS and 94.6% based on the GS. Insertion accuracy was non-inferior to accuracy reported for manual computer-navigated pedicle insertion based on both the GS and the HGS scores. When compared to accuracy reported for robotics-assisted computer-navigated insertion, accuracy achieved with the AR system was found to be non-inferior when assessed with the GS, but superior when assessed with the HGS. Last, accuracy results achieved with the AR system were found to be superior to results obtained with freehand insertion based on both the HGS and the GS scores. Accuracy results were not found to be inferior in any comparison. User experience analysis yielded “excellent” usability classification.

CONCLUSIONS

AR-assisted pedicle screw insertion is a technically feasible and accurate insertion method.

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Camilo A. Molina, Christopher F. Dibble, Sheng-fu Larry Lo, Timothy Witham, and Daniel M. Sciubba

En bloc spinal tumor resections are technically demanding procedures with high morbidity because of the conventionally large exposure area and aggressive resection goals. Stereotactic surgical navigation presents an opportunity to perform the smallest possible resection plan while still achieving an en bloc resection. Augmented reality (AR)–mediated spine surgery (ARMSS) via a mounted display with an integrated tracking camera is a novel FDA-approved technology for intraoperative “heads up” neuronavigation, with the proposed advantages of increased precision, workflow efficiency, and cost-effectiveness. As surgical experience and capability with this technology grow, the potential for more technically demanding surgical applications arises. Here, the authors describe the use of ARMSS for guidance in a unique osteotomy execution to achieve an en bloc wide marginal resection of an L1 chordoma through a posterior-only approach while avoiding a tumor capsule breach. A technique is described to simultaneously visualize the navigational guidance provided by the contralateral surgeon’s tracked pointer and the progress of the BoneScalpel aligned in parallel with the tracked instrument, providing maximum precision and safety. The procedure was completed by reconstruction performed with a quad-rod and cabled fibular strut allograft construct, and the patient did well postoperatively. Finally, the authors review the technical aspects of the approach, as well as the applications and limitations of this new technology.

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Ann Liu, Yike Jin, Ethan Cottrill, Majid Khan, Erick Westbroek, Jeff Ehresman, Zach Pennington, Sheng-fu L. Lo, Daniel M. Sciubba, Camilo A. Molina, and Timothy F. Witham

OBJECTIVE

Augmented reality (AR) is a novel technology which, when applied to spine surgery, offers the potential for efficient, safe, and accurate placement of spinal instrumentation. The authors report the accuracy of the first 205 pedicle screws consecutively placed at their institution by using AR assistance with a unique head-mounted display (HMD) navigation system.

METHODS

A retrospective review was performed of the first 28 consecutive patients who underwent AR-assisted pedicle screw placement in the thoracic, lumbar, and/or sacral spine at the authors’ institution. Clinical accuracy for each pedicle screw was graded using the Gertzbein-Robbins scale by an independent neuroradiologist working in a blinded fashion.

RESULTS

Twenty-eight consecutive patients underwent thoracic, lumbar, or sacral pedicle screw placement with AR assistance. The median age at the time of surgery was 62.5 (IQR 13.8) years and the median body mass index was 31 (IQR 8.6) kg/m2. Indications for surgery included degenerative disease (n = 12, 43%); deformity correction (n = 12, 43%); tumor (n = 3, 11%); and trauma (n = 1, 4%). The majority of patients (n = 26, 93%) presented with low-back pain, 19 (68%) patients presented with radicular leg pain, and 10 (36%) patients had documented lower extremity weakness. A total of 205 screws were consecutively placed, with 112 (55%) placed in the lumbar spine, 67 (33%) in the thoracic spine, and 26 (13%) at S1. Screw placement accuracy was 98.5% for thoracic screws, 97.8% for lumbar/S1 screws, and 98.0% overall.

CONCLUSIONS

AR depicted through a unique HMD is a novel and clinically accurate technology for the navigated insertion of pedicle screws. The authors describe the first 205 AR-assisted thoracic, lumbar, and sacral pedicle screws consecutively placed at their institution with an accuracy of 98.0% as determined by a Gertzbein-Robbins grade of A or B.