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  • By Author: Lubelski, Daniel x
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Zach Pennington, Daniel Lubelski, Erick M. Westbroek, A. Karim Ahmed, Jeff Ehresman, Matthew L. Goodwin, Sheng-Fu Lo, Timothy F. Witham, Ali Bydon, Nicholas Theodore and Daniel M. Sciubba

OBJECTIVE

Postoperative C5 palsy affects 7%–12% of patients who undergo posterior cervical decompression for degenerative cervical spine pathologies. Minimal evidence exists regarding the natural history of expected recovery and variables that affect palsy recovery. The authors investigated pre- and postoperative variables that predict recovery and recovery time among patients with postoperative C5 palsy.

METHODS

The authors included patients who underwent posterior cervical decompression at a tertiary referral center between 2004 and 2018 and who experienced postoperative C5 palsy. All patients had preoperative MR images and full records, including operative note, postoperative course, and clinical presentation. Kaplan-Meier survival analysis was used to evaluate both times to complete recovery and to new neurological baseline—defined by deltoid strength on manual motor testing of the affected side—as a function of clinical symptoms, surgical maneuvers, and the severity of postoperative deficits.

RESULTS

Seventy-seven patients were included, with an average age of 64 years. The mean follow-up period was 17.7 months. The mean postoperative C5 strength was grade 2.7/5, and the mean time to first motor examination with documented C5 palsy was 3.5 days. Sixteen patients (21%) had bilateral deficits, and 9 (12%) had new-onset biceps weakness; 36% of patients had undergone C4–5 foraminotomy of the affected root, and 17% had presented with radicular pain in the dermatome of the affected root. On univariable analysis, patients’ reporting of numbness or tingling (p = 0.02) and a baseline deficit (p < 0.001) were the only predictors of time to recovery. Patients with grade 4+/5 weakness had significantly shorter times to recovery than patients with grade 4/5 weakness (p = 0.001) or ≤ grade 3/5 weakness (p < 0.001). There was no difference between those with grade 4/5 weakness and those with ≤ grade 3/5 weakness. Patients with postoperative strength < grade 3/5 had a < 50% chance of achieving complete recovery.

CONCLUSIONS

The timing and odds of recovery following C5 palsy were best predicted by the magnitude of the postoperative deficit. The use of C4–5 foraminotomy did not predict the time to or likelihood of recovery.

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Ethan Cottrill, Zach Pennington, A. Karim Ahmed, Daniel Lubelski, Matthew L. Goodwin, Alexander Perdomo-Pantoja, Erick M. Westbroek, Nicholas Theodore, Timothy Witham and Daniel Sciubba

OBJECTIVE

Nonunion is a common complication of spinal fusion surgeries. Electrical stimulation technologies (ESTs)—namely, direct current stimulation (DCS), capacitive coupling stimulation (CCS), and inductive coupling stimulation (ICS)—have been suggested to improve fusion rates. However, the evidence to support their use is based solely on small trials. Here, the authors report the results of meta-analyses of the preclinical and clinical data from the literature to provide estimates of the overall effect of these therapies at large and in subgroups.

METHODS

A systematic review of the English-language literature was performed using PubMed, Embase, and Web of Science databases. The query of these databases was designed to include all preclinical and clinical studies examining ESTs for spinal fusion. The primary endpoint was the fusion rate at the last follow-up. Meta-analyses were performed using a Freeman-Tukey double arcsine transformation followed by random-effects modeling.

RESULTS

A total of 33 articles (17 preclinical, 16 clinical) were identified, of which 11 preclinical studies (257 animals) and 13 clinical studies (2144 patients) were included in the meta-analysis. Among preclinical studies, the mean fusion rates were higher among EST-treated animals (OR 4.79, p < 0.001). Clinical studies similarly showed ESTs to increase fusion rates (OR 2.26, p < 0.001). Of EST modalities, only DCS improved fusion rates in both preclinical (OR 5.64, p < 0.001) and clinical (OR 2.13, p = 0.03) populations; ICS improved fusion in clinical studies only (OR 2.45, p = 0.014). CCS was not effective at increasing fusion, although only one clinical study was identified. A subanalysis of the clinical studies found that ESTs increased fusion rates in the following populations: patients with difficult-to-fuse spines, those who smoke, and those who underwent multilevel fusions.

CONCLUSIONS

The authors found that electrical stimulation devices may produce clinically significant increases in arthrodesis rates among patients undergoing spinal fusion. They also found that the pro-arthrodesis effects seen in preclinical studies are also found in clinical populations, suggesting that findings in animal studies are translatable. Additional research is needed to analyze the cost-effectiveness of these devices.