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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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Editorial

Metastatic spinal cord tumors

Mark N. Hadley

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Kaisorn L. Chaichana, Courtney Pendleton, Daniel M. Sciubba, Jean-Paul Wolinsky and Ziya L. Gokaslan

Object

Metastatic epidural spinal cord compression (MESCC) is a relatively common and debilitating complication of metastatic disease that often results in neurological deficits. Recent studies have supported decompressive surgery over radiation therapy for patients who present with MESCC. These studies, however, have grouped all patients with different histological types of metastatic disease into the same study population. The differential outcomes for patients with different histological types of metastatic disease therefore remain unknown.

Methods

An institutional database of patients undergoing decompressive surgery for MESCC at an academic tertiary-care institution between 1996 and 2006 was retrospectively reviewed. Patients with primary lung, breast, prostate, kidney, or gastrointestinal (GI) cancer or melanoma were identified. Fisher exact and log-rank analyses were used to compare pre-, peri-, and postoperative variables and survival for patients with these different types of primary cancers.

Results

Twenty-seven patients with primary lung cancer, 26 with breast cancer, 20 with prostate cancer, 21 with kidney cancer, 13 with GI cancer, and 7 with melanoma were identified and categorized. All of these patients were followed up for a mean ± SD of 10.8 ± 3.8 months following surgery. Patients with primary lung and prostate cancers were typically older than patients with other types of primary cancers. Patients with prostate cancer had the shortest duration of symptoms and more commonly presented with motor deficits, while patients with breast cancer more commonly had cervical spine involvement and compression fractures. For all histological types, > 90% of patients retained the ability to ambulate following surgery. However, the group with the highest percentage of patients who regained ambulatory function after decompressive surgery was the lung cancer group. Patients with breast or kidney cancer and those with melanoma had the highest median duration of survival following decompressive surgery.

Conclusions

The present study identifies differences in presenting symptoms, operative course, perioperative complications, long-term ambulatory outcomes, and duration of survival for patients with lung, breast, prostate, kidney, and GI cancers and melanoma. This understanding may allow better risk stratification for patients with MESCC.

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Daniel M. Sciubba, Joseph C. Noggle, Ananth K. Vellimana, Hassan Alosh, Matthew J. McGirt, Ziya L. Gokaslan and Jean-Paul Wolinsky

Object

Stabilization of the cervical spine can be challenging when instrumentation involves the axis. Fixation with C1–2 transarticular screws combined with posterior wiring and bone graft placement has yielded excellent fusion rates, but the technique is technically demanding and places the vertebral arteries (VAs) at risk. Placement of screws in the pars interarticularis of C-2 as described by Harms and Melcher has allowed rigid fixation with greater ease and theoretically decreases the risk to the VA. However, fluoroscopy is suggested to avoid penetration laterally, medially, and superiorly to avoid damage to the VA, spinal cord, and C1–2 joint, respectively. The authors describe how, after meticulous dissection of the C-2 pars interarticularis, such screws can be placed accurately and safely without the use of fluoroscopy.

Methods

Prospective follow-up was performed in 55 consecutive patients who underwent instrumented fusion of C-2 by a single surgeon. The causes of spinal instability and type and extent of instrumentation were documented. All patients underwent preoperative CT or MR imaging scans to determine the suitability of C-2 screw placement. Intraoperatively, screws were placed following dissection of the posterior pars interarticularis. Postoperative CT scans were performed to determine the extent of cortical breach. Patients underwent clinical follow-up, and complications were recorded as vascular or neurological. A CT-based grading system was created to characterize such breaches objectively by location and magnitude via percentage of screw diameter beyond the cortical edge (0 = none; I = < 25% of screw diameter; II = 26–50%; III = 51–75%; IV = 76–100%).

Results

One-hundred consecutive screws were placed in the pedicle of the axis by a single surgeon using external landmarks only. In 10 cases, only 1 screw was placed because of a preexisting VA anatomy or bone abnormality noted preoperatively. In no case was screw placement aborted because of complications noted during drilling. Early complications occurred in 2 patients and were limited to 1 wound infection and 1 transient C-2 radiculopathy. There were 15 total breaches (15%), 2 of which occurred in the same patient. Twelve breaches were lateral (80%), and 3 were superior (20%). There were no medial breaches. The magnitude of the breach was classified as I in 10 cases (66.7% of breaches), II in 3 cases (20% of breaches), III in 1 case (6.7%), and IV in 1 case (6.7%).

Conclusions

Free-hand placement of screws in the C-2 pedicle can be done safely and effectively without the use of intraoperative fluoroscopy or navigation when the pars interarticularis/pedicle is assessed preoperatively with CT or MR imaging and found to be suitable for screw placement. When breaches do occur, they are overwhelmingly lateral in location, breach < 50% of the screw diameter, and in the authors' experience, are not clinically significant.

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Brian J. Williams, Benjamin D. Fox, Daniel M. Sciubba, Dima Suki, Shi Ming Tu, Deborah Kuban, Ziya L. Gokaslan, Laurence D. Rhines and Ganesh Rao

Object

Significant improvements in neurological function and pain relief are the benefits of aggressive surgical management of spinal metastatic disease. However, there is limited literature regarding the management of tumors with specific histological features. In this study, a series of patients undergoing spinal surgery for metastatic prostate cancer were reviewed to identify predictors of survival and functional outcome.

Methods

The authors retrospectively reviewed the records of all patients who were treated with surgery for prostate cancer metastases to the spine between 1993 and 2005 at a single institution. Particular attention was given to initial presentation, operative management, clinical and neurological outcomes, and factors associated with complications and overall survival.

Results

Forty-four patients underwent a total of 47 procedures. The median age at spinal metastasis was 66 years (range 50–84 years). Twenty-four patients had received previous external-beam radiation to the site of spinal involvement, with a median dose of 70 Gy (range 30–74 Gy). Frankel scores on discharge were significantly improved when compared with preoperative scores (p = 0.001). Preoperatively, 32 patients (73%) were walking and 33 (75%) were continent. On discharge, 36 (86%) of 42 patients were walking, and 37 (88%) of 42 were continent. Preoperatively, 40 patients (91%) were taking narcotics, with a median morphine equivalent dose of 21.5 mg/day, and 28 patients (64%) were taking steroids, with a median dose of 16 mg/day. At discharge, the median postoperative morphine equivalent dose was 12 mg/day, and the median steroid dose was 0 mg/day (p < 0.001). Complications occurred in 15 (32%) of 47 procedures, with 9 (19%) considered major, and there were 4 deaths within 30 days of surgery. The median overall survival was 5.4 months. Gleason score (p = 0.002), total number of metastases (p = 0.001), and the degree of spinal canal compression (p = 0.001) were independent predictors of survival. Age ≥ 65 years at the time of surgery was an independent predictor of a postoperative complication (p = 0.005).

Conclusions

In selected patients with prostate cancer metastases to the spine, aggressive surgical decompression and spinal reconstruction is a useful treatment option. The results show that on average, neurological outcome is improved and use of analgesics is reduced. Gleason score, metastatic burden, and degree of spinal canal compression may be associated with survival following surgery, and thus should be considered carefully prior to opting for surgical management.

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Daniel M. Sciubba, Rory J. Petteys, Giannina L. Garces-Ambrossi, Joseph C. Noggle, Matthew J. McGirt, Jean-Paul Wolinsky, Timothy F. Witham and Ziya L. Gokaslan

Sacral tumors pose significant challenges to the managing physician from diagnostic and therapeutic perspectives. Although these tumors are often diagnosed at an advanced stage, patients may benefit from good clinical outcomes if an aggressive multidisciplinary approach is used. In this review, the epidemiology, clinical presentation, imaging characteristics, treatment options, and published outcomes are discussed. Special attention is given to the specific anatomical constraints that make tumors in this region of the spine more difficult to effectively manage than those in the mobile portions of the spine.

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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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Gregory S. McLoughlin, Daniel M. Sciubba, S. Kaiser Ali, Justin G. Weinkauf and Daryl R. Fourney

The authors describe a patient who underwent orthotopic cardiac transplantation after an undifferentiated cardiac sarcoma was diagnosed. While receiving immunosuppressive therapy, the patient developed spinal column metastases and cauda equina syndrome requiring surgical decompression and stabilization. This occurred despite an exhaustive search for metastatic disease prior to the transplantation. To the authors' knowledge, this represents the first reported case of an undifferentiated cardiac sarcoma metastasis to the spine.

This previously healthy 18-year-old woman presented with a myocardial infarction. Investigations revealed a left atrial tumor, which was resected. Following local recurrence, the patient underwent extensive studies to rule out systemic disease. Orthotopic heart–lung transplantation was then performed. While receiving postoperative immunosuppressive therapy the patient presented with cauda equina syndrome secondary to metastatic tumor compression at the L-5 level.

Despite a comprehensive screening process to exclude metastatic disease prior to transplantation, spinal metastases occurred while this patient was receiving immunosuppressive therapy. This represents a previously unreported and clinically significant complication for undifferentiated cardiac sarcoma.