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Scott L. Parker, Risheng Xu, Matthew J. McGirt, Timothy F. Witham, Donlin M. Long and Ali Bydon

Object

The most common spinal procedure performed in the US is lumbar discectomy for disc herniation. Longterm disc degeneration and height loss occur in many patients after lumbar discectomy. The incidence of mechanical back pain following discectomy varies widely in the literature, and its associated health care costs are unknown. The authors set out to determine the incidence of and the health care costs associated with mechanical back pain attributed to segmental degeneration or instability at the level of a prior discectomy performed at their institution.

Methods

The authors retrospectively reviewed the data for 111 patients who underwent primary, single-level lumbar hemilaminotomy and discectomy for radiculopathy. All diagnostic modalities, conservative therapies, and operative treatments used for the management of postdiscectomy back pain were recorded. Institutional billing and accounting records were reviewed to determine the billed costs of all diagnostic and therapeutic measures.

Results

At a mean follow-up of 37.3 months after primary discectomy, 75 patients (68%) experienced minimal to no back pain, 26 (23%) had moderate back pain requiring conservative treatment only, and 10 (9%) suffered severe back pain that required a subsequent fusion surgery at the site of the primary discectomy. The mean cost per patient for conservative treatment alone was $4696. The mean cost per patient for operative treatment was $42,554. The estimated cost of treatment for mechanical back pain associated with postoperative same-level degeneration or instability was $493,383 per 100 cases of first-time, single-level lumbar discectomy ($4934 per primary discectomy).

Conclusions

Postoperative mechanical back pain associated with same-level degeneration is not uncommon in patients undergoing single-level lumbar discectomy and is associated with substantial health care costs.

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Geoffrey P. Colby, Alexander L. Coon, Daniel M. Sciubba, Ali Bydon, Philippe Gailloud and Rafael J. Tamargo

Spinal dural arteriovenous fistulas (DAVFs) are the most common type of spinal arteriovenous malformation and are an important, underdiagnosed cause of progressive myelopathy and morbidity in patients with spine disorders. Successful microsurgical management of these lesions is dependent on the surgeon's ability to identify vessels of the fistula and to confirm its successful obliteration postintervention. Indocyanine green (ICG) fluorescent angiography is an emerging tool for delineating intraoperative vascular anatomy, and it has significant potential utility in the treatment of vascular disease in the spine.

The authors present the case of a 76-year-old man with progressive and debilitating bilateral lower-extremity weakness and numbness on exertion, in whom a left T-8 spinal DAVF was diagnosed based on results of conventional spinal angiography. Unfavorable anatomy based on angiographic findings precluded endovascular embolization of the fistula, and the patient subsequently underwent T7–9 bilateral laminectomies for microsurgical clip occlusion. Intraoperative ICG fluorescent angiography was used before clip placement to identify the arterialized veins of the fistula, and after clip placement to confirm obliteration of the fistulous connection and restoration of normal blood flow.

Intraoperative ICG angiography serves an important role in the microsurgical treatment of DAVF. It can be used to map the anatomy of the fistula in real time during surgery and to verify fistula obliteration rapidly after clip placement. This report adds to the growing body of literature demonstrating the importance of ICG angiography in vascular neurosurgery of the spine.

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Giannina L. Garcés-Ambrossi, Matthew J. McGirt, Vivek A. Mehta, Daniel M. Sciubba, Timothy F. Witham, Ali Bydon, Jean-Paul Wolinksy, George I. Jallo and Ziya L. Gokaslan

Object

With the introduction of electrophysiological spinal cord monitoring, surgeons have been able to perform radical resection of intramedullary spinal cord tumors (IMSCTs). However, factors associated with tumor resectability, tumor recurrence, and long-term neurological outcome are poorly understood.

Methods

The authors retrospectively reviewed 101 consecutive cases of IMSCT resection in adults and children at a single institution. Neurological function and MR images were evaluated preoperatively, at discharge, 1 month after surgery, and every 6 months thereafter. Factors associated with gross-total resection (GTR), progression-free survival (PFS), and long-term neurological improvement were assessed using multivariate regression analysis.

Results

The mean age of the patients was 41 ± 18 years and 17 (17%) of the patients were pediatric. Pathological type included ependymoma in 51 cases, hemangioblastoma in 15, pilocytic astrocytoma in 16, WHO Grade II astrocytoma in 10, and malignant astrocytoma in 9. A GTR was achieved in 60 cases (59%). Independent of histological tumor type, an intraoperatively identifiable tumor plane (OR 25.3, p < 0.0001) and decreasing tumor size (OR 1.2, p = 0.05) were associated with GTR. Thirty-four patients (34%) experienced acute neurological decline after surgery (associated with increasing age [OR 1.04, p = 0.02] and with intraoperative change in motor evoked potentials [OR 7.4, p = 0.003]); in 14 (41%) of these patients the change returned to preoperative baseline within 1 month. In 31 patients (31%) tumor progression developed by last follow-up (mean 19 months). Tumor histology (p < 0.0001) and the presence of an intraoperatively identified tumor plane (hazard ratio [HR] 0.44, p = 0.027) correlated with improved PFS. A GTR resulted in improved PFS for hemangioblastoma (HR 0.004, p = 0.04) and ependymoma (HR 0.2, p = 0.02), but not astrocytoma. Fifty-five patients (55%) maintained overall neurological improvement by last follow-up. The presence of an identifiable tumor plane (HR 3.1, p = 0.0004) and improvement in neurological symptoms before discharge (HR 2.3, p = 0.004) were associated with overall neurological improvement by last follow-up (mean 19 months).

Conclusions

Gross-total resection can be safely achieved in the vast majority of IMSCTs when an intraoperative plane is identified, independent of pathological type. The incidence of acute perioperative neurological decline increases with patient age but will improve to baseline in nearly half of patients within 1 month. Long-term improvement in motor, sensory, and bladder dysfunction may be achieved in a slight majority of patients and occurs more frequently in patients in whom a surgical plane can be identified. A GTR should be attempted for ependymoma and hemangioblastoma, but it may not affect PFS for astrocytoma. For all tumors, the intraoperative finding of a clear tumor plane of resection carries positive prognostic significance across all pathological types.

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Risheng Xu, Mohamad Bydon, Ziya L. Gokaslan, Jean-Paul Wolinsky, Timothy F. Witham and Ali Bydon

Epidural steroid injections are relatively safe procedures, although the risk of hemorrhagic complications in patients undergoing long-term anticoagulation therapy is higher. The American Society for Regional Anesthesia and Pain Medicine has specific guidelines for treatment of these patients when they undergo neuraxial anesthetic procedures. In this paper, the authors present a case in which the current American Society for Regional Anesthesia and Pain Medicine guidelines were strictly followed with respect to withholding and reintroducing warfarin and enoxaparin after an epidural steroid injection, but the patient nevertheless developed a spinal epidural hematoma requiring emergency surgical evacuation. The authors compare the case with the 8 other published cases of postinjection epidural hematomas in patients with coagulopathy, and the specific risk factors that may have contributed to the hemorrhagic complication in this patient is analyzed.

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Giannina L. Garcés-Ambrossi, Matthew J. McGirt, Roger Samuels, Daniel M. Sciubba, Ali Bydon, Ziya L. Gokaslan and George I. Jallo

Object

Although postsurgical neurological outcomes in patients with tethered cord syndrome (TCS) are well known, the rate and development of neurological improvement after first-time tethered cord release is incompletely understood. The authors reviewed their institutional experience with the surgical management of adult TCS to assess the time course of symptomatic improvement, and to identify the patient subgroups most likely to experience improvement of motor symptoms.

Methods

The authors retrospectively reviewed 29 consecutive cases of first-time adult tethered cord release. Clinical symptoms of pain and motor and urinary dysfunction were evaluated at 1 and 3 months after surgery, and then every 6 months thereafter. Rates of improvement in pain and motor or urinary dysfunction over time were identified, and presenting factors associated with improvement of motor symptoms were assessed using a multivariate survival analysis (Cox model).

Results

The mean patient age was 38 ± 13 years. The causes of TCS included lipomyelomeningocele in 3 patients (10%), tight filum in 3 (10%), lumbosacral lipoma in 4 (14%), intradural tumor in 3 (10%), previous lumbosacral surgery in 2 (7%), and previous repair of myelomeningocele in 14 (48%). The mean ± SD duration of symptoms before presentation was 5 ± 7 months. Clinical presentation included diffuse pain/parasthesias in both lower extremities in 13 patients (45%), or perineal distribution in 18 (62%), lower extremity weakness in 17 (59%), gait difficulties in 17 (59%), and bladder dysfunction in 14 (48%). Laminectomy was performed in a mean of 2.5 ± 0.7 levels per patient, and 9 patients (30%) received duraplasty. At 18 months postoperatively, 47% of patients had improved urinary symptoms, 69% had improved lower extremity weakness and gait, and 79% had decreased painful dysesthesias. Median time to symptomatic improvement was least for pain (1 month), then motor (2.3 months), and then urinary symptoms (4.3 months; p = 0.04). In patients demonstrating improvement, 96% improved within 6 months of surgery. Only 4% improved beyond 1-year postoperatively. In a multivariate analysis, the authors found that patients who presented with asymmetrical lower extremity weakness (p = 0.0021, hazard ratio 5.7) or lower extremity hyperreflexia (p = 0.037, hazard ratio = 4.1) were most likely to experience improvement in motor symptoms.

Conclusions

In the authors' experience, pain and motor and urinary dysfunction improve postoperatively in the majority of patients. The rate of symptomatic improvement was greatest for pain resolution, followed by motor, and then urinary improvement. Patients who experienced improvement in any symptom had done so by 6 months after tethered cord release. Patients with asymmetrical motor symptoms or lower extremity hyperreflexia at presentation were most likely to experience improvements in motor symptoms. These findings may help guide patient education and surgical decision-making.

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Risheng Xu, Giannina L. Garcés-Ambrossi, Matthew J. McGirt, Timothy F. Witham, Jean-Paul Wolinsky, Ali Bydon, Ziya L. Gokaslan and Daniel M. Sciubba

Object

Adequate decompression of the thoracic spinal cord often requires a complete vertebrectomy. Such procedures can be performed from an anterior/transthoracic, posterior, or combined approach. In this study, the authors sought to compare the clinical outcomes of patients with spinal metastatic tumors undergoing anterior, posterior, and combined thoracic vertebrectomies to determine the efficacy and operative morbidity of such approaches.

Methods

A retrospective review was conducted of all patients undergoing thoracic vertebrectomies at a single institution over the past 7 years. Characteristics of patients and operative procedures were documented. Neurological status, perioperative variables, and complications were assessed and associations with each approach were analyzed.

Results

Ninety-one patients (mean age 55.5 ± 13.7 years) underwent vertebrectomies via an anterior (22 patients, 24.2%), posterior (45 patients, 49.4%), or combined anterior-posterior approach (24 patients, 26.4%) for metastatic spinal tumors. The patients did not differ significantly preoperatively in terms of neurological assessments on the Nurick and American Spinal Injury Association Impairment scales, ambulatory ability, or other comorbidities. Anterior approaches were associated with less blood loss than posterior approaches (1172 ± 1984 vs 2486 ± 1645 ml, respectively; p = 0.03) or combined approaches (1172 ± 1984 vs 2826 ± 2703 ml, respectively; p = 0.05) but were associated with a similar length of stay compared with the other treatment cohorts (11.5 ± 9.3 [anterior] vs 11.3 ± 8.6 [posterior] vs 14.3 ± 6.7 [combined] days; p = 0.35). The posterior approach was associated with a higher incidence of wound infection compared with the anterior approach cohort (26.7 vs 4.5%, respectively; p = 0.03), and patients in the posterior approach group experienced the highest rates of deep vein thrombosis (15.6% [posterior] vs 0% [other 2 groups]; p = 0.02). However, the posterior approach demonstrated the lowest incidence of pneumothorax (4.4%; p < 0.0001) compared with the other 2 cohorts. Duration of chest tube use was greater in the combined patient group compared with the anterior approach cohort (8.8 ± 6.2 vs 4.7 ± 2.3 days, respectively; p = 0.01), and the combined group also experienced the highest rates of radiographic pleural effusion (83.3%; p = 0.01). Postoperatively, all groups improved neurologically, although functional outcome in patients undergoing the combined approach improved the most compared with the other 2 groups on both the Nurick (p = 0.04) and American Spinal Injury Association Impairment scales (p = 0.03).

Conclusions

Decisions regarding the approach to thoracic vertebrectomy may be complex. This study found that although anterior approaches to the thoracic vertebrae have been historically associated with significant pulmonary complications, in our experience these rates are nevertheless quite comparable to that encountered via a posterior or combined approach. In fact, the posterior approach was found to be associated with a higher risk for some perioperative complications such as wound infection and deep vein thromboses. Finally, the combined anteriorposterior approach may provide greater ambulatory and neurological improvements in properly selected patients.

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Matthew J. McGirt, Beril Gok, Starane Shepherd, Joseph Noggle, Giannina L. Garcés Ambrossi, Ali Bydon and Ziya L. Gokaslan

Object

Hyperglycemia has been shown to potentiate ischemic injury of the spinal cord by quenching vasodilators and potentiating tissue acidosis and free radical production. Steroid-induced hyperglycemia is a common event in the surgical management of metastatic epidural spinal cord compression (MESCC). The goal in this study was to determine whether experimentally induced hyperglycemia accelerates neurological decline in an established animal model of MESCC.

Methods

Sixteen Fischer 344 rats underwent a transabdominal approach for implantation of a CRL-1666 breast adenocarcinoma cell line within the vertebral body of L-6. After 72 hours of recovery from tumor implantation, the animals received intraperitoneal injections every 12 hours of either 2 g/kg dextrose in 5 ml 0.09% saline (hyperglycemia, 8 rats) or 5 ml 0.09% saline alone (normoglycemia, 8 rats). Weights were taken daily, and the hindlimb function was tested daily after tumor implantation by using the Basso-Beattie-Bresnahan (BBB) scale (score range 1–21). Animals were killed at time of paralysis (BBB Score < 7), and the volume of epidural tumor growth within the spinal canal was measured. To determine the degree of hyperglycemia induced by this dextrose regimen, a surrogate group of 10 Fischer 344 rats underwent intraperitoneal injections of 2 g/kg dextrose (5 rats) or 0.09% saline (5 rats) every 12 hours, and serum glucose levels were assessed 1, 3, 6, 8, 10, and 12 hours after injections for 24 hours.

Results

Dextrose versus saline injections resulted in elevated mean serum glucose at 3 (259 vs 103 μg/dl), 6 (219 vs 102 μg/dl), 8 (169 vs 102 μg/dl), and 10 hours (118 vs 99 μg/dl) after injection, returning to normal levels by 12 hours (96 vs 103 μg/dl) just prior to subsequent injection. All rats had normal hindlimb function for the first 8 days after tumor implantation. Hyperglycemic versus normoglycemic rats demonstrated a worsened median BBB score by postimplantation Day 9 (Score 20 vs 21, p = 0.023) through Day 16 (Score 8 vs 12, p = 0.047). Epidural tumor volume demonstrated a near-linear growth rate across both groups; however, hyperglycemic rats developed paralysis earlier (median 15.5 vs 17.5 days, p = 0.0035), with significantly less epidural tumor volume (2.75 ± 0.38 cm3 vs 4 ± 0.41 cm3, p < 0.001) at time of paralysis.

Conclusions

In a rat model of metastatic epidural spinal cord compression, rats maintained in a hyperglycemic state experienced accelerated time to paralysis. Also, less epidural tumor volume was required to cause paralysis in hyperglycemic rats. These results suggest that hyperglycemic states may contribute to decreased spinal cord tolerance to compression resulting from MESCC. Clinical studies evaluating the effect of aggressive glucose control in patients with MESCC may be warranted.

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Daniel M. Sciubba, Clarke Nelson, Beryl Gok, Matthew J. McGirt, Gregory S. McLoughlin, Joseph C. Noggle, Jean Paul Wolinsky, Timothy F. Witham, Ali Bydon and Ziya L. Gokaslan

Object

Resection of sacral tumors has been shown to improve survival, since the oncological prognosis is commonly correlated with the extent of local tumor control. However, extensive soft-tissue resection in close proximity to the rectum may predispose patients to wound complications and infection. To identify potential risk factors, a review of clinical outcomes for sacral tumor resections over the past 5 years at a single institution was completed, paying special attention to procedure-related complications.

Methods

Between 2002 and 2007, 46 patients with sacral tumors were treated with surgery. Demographic data, details of surgery, type of tumor, and patient characteristics associated with surgical site infections (SSIs) were collected; these data included presence of the following variables: diabetes, obesity, smoking, steroid use, previous surgery, previous radiation, cerebrospinal fluid leak, number of spinal levels exposed, instrumentation, number of surgeons scrubbed in to the procedure, serum albumin level, and combined anterior-posterior approach. Logistic regression analysis was implemented to find an association of such variables with the presence of SSI.

Results

A total of 46 patients were treated for sacral tumor resections; 20 were male (43%) and 26 were female (57%), with an average age of 46 years (range 11–83 years). Histopathological findings included the following: chordoma in 19 (41%), ependymoma in 5 (11%), rectal adenocarcinoma in 5 (11%), giant cell tumor in 4 (9%), and other in 13 (28%). There were 18 cases of wound infection (39%), and 2 cases of repeat surgery for tumor recurrence (1 chordoma and 1 giant cell tumor). Factors associated with increased likelihood of infection included previous lumbosacral surgery (p = 0.0184; odds ratio [OR] 7.955) and number of surgeons scrubbed in to the operation (p = 0.0332; OR 4.018). Increasing age (p = 0.0864; OR 1.031), presence of complex soft-tissue reconstruction (p = 0.118; OR 3.789), and bowel and bladder dysfunction (p = 0.119; OR 2.667) demonstrated a trend toward increased risk of SSI.

Conclusions

Patients undergoing sacral tumor surgery may be at greater risk for developing wound complications due to the extensive soft-tissue resections often required, especially with the increased potential for contamination from the neighboring rectum. In this study, it appears that previous lumbosacral surgery, number of surgeons scrubbed in, patient age, bowel and bladder dysfunction, and complex tissue reconstruction may predict those patients more prone to developing postoperative SSIs.

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Risheng Xu, Daniel M. Sciubba, Ziya L. Gokaslan and Ali Bydon

Abnormal ossification of spinal ligaments is a well-known cause of myelopathy in East Asian populations, with ossification of the ligamentum flavum (OLF) and the posterior longitudinal ligament being the most prevalent. In Caucasian populations, OLF is rare, and there has been only 1 documented case of the disease affecting more than 5 spinal levels. In this report, the authors describe the clinical presentation, imaging characteristics, and management of the second published case of a Caucasian man with OLF affecting almost the entire thoracic spine. The literature is then reviewed with regard to OLF epidemiology, pathogenesis, presentation, and treatment.

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Beril Gok, Daniel M. Sciubba, Gregory S. McLoughlin, Matthew McGirt, Selim Ayhan, Jean-Paul Wolinsky, Ali Bydon, Ziya L. Gokaslan and Timothy F. Witham

Object

In patients with cervical spondylotic myelopathy (CSM), ventral disease and loss of cervical lordosis are considered to be relative indications for anterior surgery. However, anterior decompression and fusion operations may be associated with an increased risk of swallowing difficulty and an increased risk of nonunion when extensive decompression is performed. The authors reviewed cases involving patients with CSM treated via an anterior approach, paying special attention to neurological outcome, fusion rates, and complications.

Methods

Retrospectively, 67 cases involving consecutive patients with CSM requiring an anterior decompression were reviewed: 46 patients underwent anterior surgery only (1-to3-level anterior cervical discectomy and fusion [ACDF] or 1-level corpectomy), and 21 patients who required > 3-level ACDF or ≥ 2-level corpectomy underwent anterior surgery supplemented by a posterior instrumented fusion procedure.

Results

Postoperative improvement in Nurick grade was seen in 43 (93%) of 46 patients undergoing anterior decompression and fusion alone (p < 0.001) and in 17 (81%) of 21 patients undergoing anterior decompression and fusion with supplemental posterior fusion (p = 0.0015). The overall complication rate for this series was 25.4%. Interestingly, the overall complication rate was similar for both the lone anterior surgery and combined anterior-posterior groups, but the incidence of adjacent-segment disease was greater in the lone anterior surgery group.

Conclusions

Significant improvement in Nurick grade can be achieved in patients who undergo anterior surgery for cervical myelopathy for primarily ventral disease or loss of cervical lordosis. In selected high-risk patients who undergo multilevel ventral decompression, supplemental posterior fixation and arthrodesis allows for low rates of construct failure with acceptable added morbidity.