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Mohamed Macki, Rafael De la Garza-Ramos, Ashley A. Murgatroyd, Kenneth P. Mullinix, Xiaolei Sun, Bryan W. Cunningham, Brandon A. McCutcheon, Mohamad Bydon and Ziya L. Gokaslan

OBJECTIVE

Aggressive sacral tumors often require en bloc resection and lumbopelvic reconstruction. Instrumentation failure and pseudarthrosis remain a clinical concern to be addressed. The objective in this study was to compare the biomechanical stability of 3 distinct techniques for sacral reconstruction in vitro.

METHODS

In a human cadaveric model study, 8 intact human lumbopelvic specimens (L2–pelvis) were tested for flexion-extension range of motion (ROM), lateral bending, and axial rotation with a custom-designed 6-df spine simulator as well as axial compression stiffness with the MTS 858 Bionix Test System. Biomechanical testing followed this sequence: 1) intact spine; 2) sacrectomy (no testing); 3) Model 1 (L3–5 transpedicular instrumentation plus spinal rods anchored to iliac screws); 4) Model 2 (addition of transiliac rod); and 5) Model 3 (removal of transiliac rod; addition of 2 spinal rods and 2 S-2 screws). Range of motion was measured at L4–5, L5–S1/cross-link, L5–right ilium, and L5–left ilium.

RESULTS

Flexion-extension ROM of the intact specimen at L4–5 (6.34° ± 2.57°) was significantly greater than in Model 1 (1.54° ± 0.94°), Model 2 (1.51° ± 1.01°), and Model 3 (0.72° ± 0.62°) (p < 0.001). Flexion-extension at both the L5–right ilium (2.95° ± 1.27°) and the L5–left ilium (2.87° ± 1.40°) for Model 3 was significantly less than the other 3 cohorts at the same level (p = 0.005 and p = 0.012, respectively). Compared with the intact condition, all 3 reconstruction groups statistically significantly decreased lateral bending ROM at all measured points. Axial rotation ROM at L4–5 for Model 1 (2.01° ± 1.39°), Model 2 (2.00° ± 1.52°), and Model 3 (1.15° ± 0.80°) was significantly lower than the intact condition (5.02° ± 2.90°) (p < 0.001). Moreover, axial rotation for the intact condition and Model 3 at L5–right ilium (2.64° ± 1.36° and 2.93° ± 1.68°, respectively) and L5–left ilium (2.58° ± 1.43° and 2.93° ± 1.71°, respectively) was significantly lower than for Model 1 and Model 2 at L5–right ilium (5.14° ± 2.48° and 4.95° ± 2.45°, respectively) (p = 0.036) and L5–left ilium (5.19° ± 2.34° and 4.99° ± 2.31°) (p = 0.022). Last, results of the axial compression testing at all measured points were not statistically different among reconstructions.

CONCLUSIONS

The addition of a transverse bar in Model 2 offered no biomechanical advantage. Although the implementation of 4 iliac screws and 4 rods conferred a definitive kinematic advantage in Model 3, that model was associated with significantly restricted lumbopelvic ROM.

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Nancy Abu-Bonsrah, C. Rory Goodwin, Gezzer Ortega, Fizan Abdullah, Edward Cornwell, Rafael De la Garza-Ramos, Mari L. Groves, Michael Ain, Paul D. Sponseller and Daniel M. Sciubba

OBJECTIVE

Spinal arthrodesis is routinely performed in the pediatric population. However, there is limited information on the short-term outcomes of pediatric patients who have undergone spine fusion. Thus, the authors conducted a retrospective review of the Pediatric National Surgical Quality Improvement Program (NSQIP) database to determine the short-term mortality, complication, reoperation, and readmission rates of pediatric patients who underwent spinal arthrodesis for all indications.

METHODS

The Pediatric NSQIP database was queried for all patients who underwent spinal arthrodesis between 2012 and 2014. Patient demographics, comorbidities, body mass index, American Society of Anesthesiologists classification, and operative time were abstracted. Short-term mortality, reoperation, and readmission rates and complications were also noted. Univariate and multivariate analyses were performed to delineate patient risk factors that influence short-term mortality, complications, reoperation, and readmission rates.

RESULTS

A total of 4420 pediatric patients who underwent spinal fusion were identified. Common indications for surgical intervention included acquired/idiopathic scoliosis or kyphoscoliosis (71.2%) and genetic/syndromic scoliosis (10.7%). The mean patient age was 13.7 ± 2.9 years, and 70% of patients were female. The overall 30-day mortality was 0.14%. Multivariate analysis showed that female sex and pulmonary comorbidities significantly increased the odds of reoperation, with odds ratios of 1.43 and 1.78, respectively.

CONCLUSIONS

In the NSQIP database for pediatric patients undergoing spinal arthrodesis for all causes, there was a 3.6% unplanned reoperation rate, a 3.96% unplanned readmission rate, and a 9.0% complication rate. This analysis provides data for risk stratification of pediatric patients undergoing spinal arthrodesis, allowing for optimized care.

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Debebe Theodros, C. Rory Goodwin, Matthew T. Bender, Xin Zhou, Tomas Garzon-Muvdi, Rafael De la Garza-Ramos, Nancy Abu-Bonsrah, Dimitrios Mathios, Ari M. Blitz, Alessandro Olivi, Benjamin Carson, Chetan Bettegowda and Michael Lim

OBJECTIVE

Trigeminal neuralgia (TN) is characterized by intermittent, paroxysmal, and lancinating pain along the distribution of the trigeminal nerve. Microvascular decompression (MVD) directly addresses compression of the trigeminal nerve. The purpose of this study was to determine whether patients undergoing MVD as their first surgical intervention experience greater pain control than patients who undergo subsequent MVD.

METHODS

A retrospective review of patient records from 1998 to 2015 identified a total of 942 patients with TN and 500 patients who underwent MVD. After excluding several cases, 306 patients underwent MVD as their first surgical intervention and 175 patients underwent subsequent MVD. Demographics and clinicopathological data and outcomes were obtained for analysis.

RESULTS

In patients who underwent subsequent MVD, surgical intervention was performed at an older age (55.22 vs 49.98 years old, p < 0.0001) and the duration of symptoms was greater (7.22 vs 4.45 years, p < 0.0001) than for patients in whom MVD was their first surgical intervention. Patients who underwent initial MVD had improved pain relief and no improvement in pain rates compared with those who had subsequent MVD (95.8% and 4.2% vs 90.3% and 9.7%, respectively, p = 0.0041).

Patients who underwent initial MVD had significantly lower rates of facial numbness in the pre- and postoperative periods compared with patients who underwent subsequent MVD (p < 0.0001). The number of complications in both groups was similar (p = 0.4572).

CONCLUSIONS

The results demonstrate that patients who underwent other procedures prior to MVD had less pain relief and a higher incidence of facial numbness despite rates of complications similar to patients who underwent MVD as their first surgical intervention.

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Rafael De la Garza-Ramos, Amit Jain, Khaled M. Kebaish, Ali Bydon, Peter G. Passias and Daniel M. Sciubba

OBJECTIVE

The goal of this study was to compare inpatient morbidity and mortality after adult spinal deformity (ASD) surgery in teaching versus nonteaching hospitals in the US.

METHODS

The Nationwide Inpatient Sample was used to identify surgical patients with ASD between 2002 and 2011. Only patients > 21 years old and elective cases were included. Patient characteristics, inpatient morbidity, and inpatient mortality were compared between teaching and nonteaching hospitals. A multivariable logistic regression analysis was performed to examine the effect of hospital teaching status on surgical outcomes.

RESULTS

A total of 7603 patients were identified, with 61.2% (n = 4650) in the teaching hospital group and 38.8% (n = 2953) in the nonteaching hospital group. The proportion of patients undergoing revision procedures was significantly different between groups (5.2% in teaching hospitals vs 3.9% in nonteaching hospitals, p = 0.008). Likewise, complex procedures (defined as fusion of 8 or more segments and/or osteotomy) were more common in teaching hospitals (27.3% vs 21.7%, p < 0.001). Crude overall complication rates were similar in teaching hospitals (47.9%) compared with nonteaching hospitals (49.8%, p = 0.114). After controlling for patient characteristics, case complexity, and revision status, patients treated at teaching hospitals were significantly less likely to develop a complication when compared with patients treated at a nonteaching hospital (OR 0.89; 95% CI 0.82–0.98). The mortality rate was 0.4% in teaching hospitals and < 0.4% in nonteaching hospitals (p = 0.210).

CONCLUSIONS

Patients who undergo surgery for ASD at a teaching hospital may have significantly lower odds of complication development compared with patients treated at a nonteaching hospital.

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Rafael De la Garza-Ramos, Risheng Xu, Seba Ramhmdani, Thomas Kosztowski, Mohamad Bydon, Daniel M. Sciubba, Jean-Paul Wolinsky, Timothy F. Witham, Ziya L. Gokaslan and Ali Bydon

OBJECTIVE

The purpose of this study was to report the long-term clinical outcomes following 3- and 4-level anterior cervical discectomy and fusion (ACDF).

METHODS

A retrospective review of all adult neurosurgical patients undergoing elective ACDF for degenerative disease at a single institution between 1996 and 2013 was performed. Patients who underwent first-time 3- or 4-level ACDF were included; patients with previous cervical spine surgery, those undergoing anterior/posterior approaches, and those with corpectomy were excluded. Outcome measures included perioperative complication rates, fusion rates, need for revision surgery, Nurick Scores, Odom's criteria, symptom resolution, neck visual analog scale (VAS) pain score, and persistent narcotics usage.

RESULTS

Seventy-one patients who underwent 3-level ACDF and 26 patients who underwent 4-level ACDF were identified and followed for an average of 7.6 ± 4.2 years. There was 1 case (3.9%) of deep wound infection in the 4-level group and 1 case in the 3-level group (1.4%; p = 0.454). Postoperatively, 31% of patients in the 4-level group complained of dysphagia, compared with 12.7% in the 3-level group (p = 0.038). The fusion rate was 84.6% after 4-level ACDF and 94.4% after 3-level ACDF (p = 0.122). At last follow-up, a significantly higher proportion of patients in the 4-level group continued to have axial neck pain (53.8%) than in the 3-level group (31%; p = 0.039); the daily oral morphine equivalent dose was significantly higher in the 4-level group (143 ± 97 mg/day) than in the 3-level group (25 ± 10 mg/day; p = 0.030). Outcomes based on Odom's criteria were also different between cohorts (p = 0.044), with a significantly lower proportion of patients in the 4-level ACDF group experiencing an excellent/good outcome.

CONCLUSIONS

In this study, patients who underwent 4-level ACDF had significantly higher rates of dysphagia, postoperative neck pain, and postoperative narcotic usage when compared with patients who underwent 3-level ACDF. Pseudarthrosis and deep wound infection rates were also higher in the 4-level group, although this did not reach statistical significance. Additionally, a smaller proportion of patients achieved a good/excellent outcome in the 4-level group than in the 3-level group. These findings suggest a significant increase of perioperative morbidity and worsened outcomes for patients who undergo 4- versus 3-level ACDF.

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Rafael De la Garza-Ramos, Mario Benvenutti-Regato and Enrique Caro-Osorio

OBJECTIVE

The authors' objective was to identify the 100 most-cited research articles in the field of spinal oncology.

METHODS

The Thomson Reuters Web of Science service was queried for the years 1864–2015 without language restrictions. Articles were sorted in descending order of the number of times they were cited by other studies, and all titles and abstracts were screened to identify the research areas of the top 100 articles. Levels of evidence were assigned on the basis of the North American Spine Society criteria.

RESULTS

The authors identified the 100 most-cited articles in spinal oncology, which collectively had been cited 20,771 times at the time of this writing. The oldest article on this top 100 list had been published in 1931, and the most recent in 2008; the most prolific decade was the 1990s, with 34 articles on this list having been published during that period. There were 4 studies with Level I evidence, 3 with Level II evidence, 9 with Level III evidence, 70 with Level IV evidence, and 2 with Level V evidence; levels of evidence were not assigned to 12 studies because they were not on therapeutic, prognostic, or diagnostic topics. Thirty-one unique journals contributed to the 100 articles, with the Journal of Neurosurgery contributing most of the articles (n = 25). The specialties covered included neurosurgery, orthopedic surgery, neurology, radiation oncology, and pathology. Sixty-seven articles reported clinical outcomes. The most common country of article origin was the United States (n = 62), followed by Canada (n = 8) and France (n = 7). The most common topics were spinal metastases (n = 35), intramedullary tumors (n = 18), chordoma (n = 17), intradural tumors (n = 7), vertebroplasty/kyphoplasty (n = 7), primary bone tumors (n = 6), and others (n = 10). One researcher had authored 6 studies on the top 100 list, and 7 authors had 3 studies each on this list.

CONCLUSIONS

This study identified the 100 most-cited research articles in the area of spinal oncology. The studies highlighted the multidisciplinary and multimodal nature of spinal tumor management. Recognition of historical articles may guide future spinal oncology research.