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  • Journal of Neurosurgery: Spine x
  • By Author: Witham, Timothy F. x
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Hannah M. Carl, A. Karim Ahmed, Nancy Abu-Bonsrah, Rafael De la Garza Ramos, Eric W. Sankey, Zachary Pennington, Ali Bydon, Timothy F. Witham, Jean-Paul Wolinsky, Ziya L. Gokaslan, Justin M. Sacks, C. Rory Goodwin and Daniel M. Sciubba

OBJECTIVE

Resection of metastatic spine tumors can improve patients’ quality of life by addressing pain or neurological compromise. However, resections are often complicated by wound dehiscence, infection, instrumentation failures, and the need for reoperation. Moreover, when reoperations are needed, the most common indication is surgical site infection and wound breakdown. In turn, wound reoperations increase morbidity as well as the length and cost of hospitalization. The aim of this study was to examine perioperative risk factors associated with increased rate of wound reoperations after metastatic spine tumor resection.

METHODS

A retrospective study of patients at a single institution who underwent metastatic spine tumor resection between 2003 and 2013 was conducted. Factors with a p value < 0.200 in a univariate analysis were included in the multivariate model.

RESULTS

A total of 159 patients were included in this study. Karnofsky Performance Scale score > 70, smoking status, hypertension, thromboembolic events, hyperlipidemia, increasing number of vertebral levels, and posterior approach were included in the multivariate analysis. Thromboembolic events (95% CI 1.19–48.5, p = 0.032) and number of levels involved were independently associated with increased wound reoperation rates in the multivariate model. For each additional spinal level involved, the risk for wound reoperations increased by 21% (95% CI 1.03–1.43, p = 0.018).

CONCLUSIONS

Although wound complications and subsequent reoperations are potential risks for all patients with metastatic spine tumor, due to adjuvant radiotherapy and other medical comorbidities, this study identified patients with thromboembolic events or those requiring a larger incision as being at the highest risk. Measures intended to decrease the occurrence of perioperative venous thromboembolism and to improve wound care, especially for long incisions, may decrease wound-related revision surgeries in this vulnerable group of patients.

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Rafael De la Garza Ramos, C. Rory Goodwin, Nancy Abu-Bonsrah, Ali Bydon, Timothy F. Witham, Jean-Paul Wolinsky and Daniel M. Sciubba

OBJECTIVE

The aim of this study was to investigate the incidence of spinal tuberculosis (TB) in the US between 2002 and 2011.

METHODS

The Nationwide Inpatient Sample database from 2002 to 2011 was used to identify patients with a discharge diagnosis of TB and spinal TB. Demographic and hospital data were obtained for all admissions, and included age, sex, race, comorbid conditions, insurance status, hospital location, hospital teaching status, and hospital region. The incidence rate of spinal TB adjusted for population growth was calculated after application of discharge weights.

RESULTS

A total of 75,858 patients with a diagnosis of TB were identified, of whom 2789 had a diagnosis of spinal TB (3.7%); this represents an average of 278.9 cases per year between 2002 and 2011. The incidence of spinal TB decreased significantly—from 0.07 cases per 100,000 persons in 2002 to 0.05 cases per 100,000 in 2011 (p < 0.001), corresponding to 1 case per 2 million persons in the latter year. The median age for patients with spinal TB was 51 years, and 61% were male; 11.6% were patients with diabetes, 11.4% reported recent weight loss, and 8.1% presented with paralysis. There were 619 patients who underwent spinal surgery for TB, with the most common location being the thoracolumbar spine (61.9% of cases); 50% of patients had instrumentation of 3 or more spinal segments.

CONCLUSIONS

During the examined 10-year period, the incidence of spinal TB was found to significantly decrease over time in the US, reaching a rate of 1 case per 2 million persons in 2011. However, the absolute reduction was relatively small, suggesting that although it is uncommon, spinal TB remains a public health concern and most commonly affects male patients approximately 50 years of age. Approximately 20% of patients with spinal TB underwent surgery, most commonly in the thoracolumbar spine.

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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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Ann Liu, Eric W. Sankey, C. Rory Goodwin, Thomas A. Kosztowski, Benjamin D. Elder, Ali Bydon, Timothy F. Witham, Jean-Paul Wolinsky, Ziya L. Gokaslan and Daniel M. Sciubba

OBJECT

Spinal metastases from gynecological cancers are rare, with few cases reported in the literature. In this study, the authors examine a series of patients with spinal metastases from gynecological cancer and review the literature.

METHODS

The cases of 6 consecutive patients who underwent spine surgery for metastatic gynecological cancer between 2007 and 2012 at a single institution were retrospectively reviewed. The recorded demographic, operative, and postoperative factors were reviewed, and the functional outcomes were determined by change in Karnofsky Performance Scale and the American Spine Injury Association (ASIA) score during follow-up. A systematic review of the literature was also performed to evaluate outcomes for patients with similar gynecological metastases to the spine.

RESULTS

In this series, details regarding metastatic gynecological cancers to the spine are as follows: 2 patients with cervical cancer (both presented at age 46 years, mean postoperative survival of 32 months), 2 patients with endometrial cancer (mean age of 40 years, mean postoperative survival of 26 months), and 2 patients with leiomyosarcoma (mean age of 44 years, mean postoperative survival of 20 months). All patients presented with pain, and no complications were noted following surgery. All patients with known follow-up had stable or improved neurological outcomes, performance status, and improved pain, without local recurrence of tumor. Overall median survival after diagnosis of metastatic spine lesions for all cases in the literature as well as those treated by the authors was 15 months. When categorized by type, median survival of patients with cervical cancer (n = 2), endometrial cancer (n = 26), and leiomyosarcoma (n = 16) was 32, 10, and 22.5 months, respectively.

CONCLUSIONS

Gynecological cancers metastasizing to the spine are rare. In this series, overall survival following diagnosis of spinal metastasis and surgery was 27 months, with cervical cancer, endometrial cancer, and leiomyosarcoma survival being 32, 26, and 20 months, respectively. Combined with literature cases, survival differs depending on primary histology, with decreasing survival from cervical cancer (32 months) to leiomyosarcoma (22.5 months) to endometrial cancer (10 months). Integrating such information with other patient factors may more accurately guide decision making regarding management of such spinal lesions.

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Varun Puvanesarajah, Sheng-fu Larry Lo, Nafi Aygun, Jason A. Liauw, Ignacio Jusué-Torres, Ioan A. Lina, Uri Hadelsberg, Benjamin D. Elder, Ali Bydon, Chetan Bettegowda, Daniel M. Sciubba, Jean-Paul Wolinsky, Daniele Rigamonti, Lawrence R. Kleinberg, Ziya L. Gokaslan, Timothy F. Witham, Kristin J. Redmond and Michael Lim

OBJECT

The number of patients with spinal tumors is rapidly increasing; spinal metastases develop in more than 30% of cancer patients during the course of their illness. Such lesions can significantly decrease quality of life, often necessitating treatment. Stereotactic radiosurgery has effectively achieved local control and symptomatic relief for these patients. The authors determined prognostic factors that predicted pain palliation and report overall institutional outcomes after spine stereotactic body radiation therapy (SBRT).

METHODS

Records of patients who had undergone treatment with SBRT for either primary spinal tumors or spinal metastases from June 2008 through June 2013 were retrospectively reviewed. Data were collected at the initial visit just before treatment and at 1-, 3-, 6-, and 12-month follow-up visits. Collected clinical data included Karnofsky Performance Scale scores, pain status, presence of neurological deficits, and prior radiation exposure at the level of interest. Radiation treatment plan parameters (dose, fractionation, and target coverage) were recorded. To determine the initial extent of epidural spinal cord compression (ESCC), the authors retrospectively reviewed MR images, assessed spinal instability according to the Bilsky scale, and evaluated lesion progression after treatment.

RESULTS

The study included 99 patients (mean age 60.4 years). The median survival time was 9.1 months (95% CI 6.9–17.2 months). Significant decreases in the proportion of patients reporting pain were observed at 3 months (p < 0.0001), 6 months (p = 0.0002), and 12 months (p = 0.0019) after treatment. Significant decreases in the number of patients reporting pain were also observed at the last follow-up visit (p = 0.00020) (median follow-up time 6.1 months, range 1.0–56.6 months). Univariate analyses revealed that significant predictors of persistent pain after intervention were initial ESCC grade, stratified by a Bilsky grade of 1c (p = 0.0058); initial American Spinal Injury Association grade of D (p = 0.011); initial Karnofsky Performance Scale score, stratified by a score of 80 (p = 0.002); the presence of multiple treated lesions (p = 0.044); and prior radiation at the site of interest (p < 0.0001). However, when multivariate analyses were performed on all variables with p values less than 0.05, the only predictor of pain at last follow-up visit was a prior history of radiation at the site of interest (p = 0.0038), although initial ESCC grade trended toward significance (p = 0.073). Using pain outcomes at 3 months, at this follow-up time point, pain could be predicted by receipt of radiation above a threshold biologically effective dose of 66.7 Gy.

CONCLUSIONS

Pain palliation occurs as early as 3 months after treatment; significant differences in pain reporting are also observed at 6 and 12 months. Pain palliation is limited for patients with spinal tumors with epidural extension that deforms the cord and for patients who have previously received radiation to the same site. Further investigation into the optimal dose and fractionation schedule are needed, but improved outcomes were observed in patients who received radiation at a biologically effective dose (with an a/b of 3.0) of 66.7 Gy or higher.

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Patricia L. Zadnik, C. Rory Goodwin, Kristophe J. Karami, Ankit I. Mehta, Anubhav G. Amin, Mari L. Groves, Jean-Paul Wolinsky, Timothy F. Witham, Ali Bydon, Ziya L. Gokaslan and Daniel M. Sciubba

OBJECT

Multiple myeloma is the most common primary tumor of the spine and is the most common primary malignant tumor of bone. Although spinal myeloma is classically a radiosensitive lesion, clinical or radiographic signs of instability merit surgical intervention. The authors present the epidemiology, surgical indications, and outcome data of a series of consecutive cases involving 31 surgically treated patients with diagnoses of multiple myeloma and plasmacytoma of the spine (the largest such series reported to date).

METHODS

Surgical instability was the criterion for operative intervention in this patient cohort. The Spinal Instability Neoplastic Score (SINS) was used to make this assessment of instability. The cases were analyzed using location of the lesion, spinal levels involved, Frankel score, adjuvant therapy, functional outcome, and patient survival.

RESULTS

All patients undergoing surgical intervention were determined to have indeterminate or gross spinal column instability according to SINS criteria. The median survival was 78.9 months. No significant difference in survival was seen for patients with higher SINS scores or for older patients (> 55 years). There was a statistically significant difference in survival benefit observed for patients receiving chemotherapy and radiation versus radiation alone as an adjuvant to surgery (p = 0.02).

CONCLUSIONS

In this 10-year analysis, the authors report outcomes of surgical intervention for patients with indeterminate or gross spinal instability due to multiple myeloma and plasmacytoma of the spine with improved neurological function following surgery and low rates of instrumentation failure.

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Mohamad Bydon, Mohamed Macki, Rafael De la Garza-Ramos, Daniel M. Sciubba, Jean-Paul Wolinsky, Ziya L. Gokaslan, Timothy F. Witham and Ali Bydon

OBJECT

This study aimed to identify the factors predicting an increased risk for reoperation in patients who had undergone a lumbar laminectomy.

METHODS

The authors retrospectively reviewed the electronic medical records of all patients who had undergone firsttime, bilateral laminectomy at 1, 2, or 3 levels for lumbar spondylosis at the authors' institution. Patients who underwent fusion, laminotomy, discectomy, or complete facetectomy were excluded. The patients' preoperative symptoms and comorbidities were also obtained from their medical records.

RESULTS

Over an average follow-up period of 46.8 months, of 500 patients who had undergone laminectomy at 1, 2, or 3 levels, 81 patients (16.2%) developed subsequent spinal disorders that required a reoperation. A multiple logistic regression analysis identified smoking as an independent predictor of reoperation (OR 2.15, p = 0.01). Smoking was also an independent predictor of reoperation after a single-level laminectomy (OR 11.3, p = 0.02) and after a multilevel (that is, involving 2 or 3 levels) laminectomy (OR 1.98, p = 0.05). For 72 patients undergoing reoperation only for spinal degeneration, smoking remained an independent, statistically significant predictor of reoperation (OR 2.06, p = 0.04). Nine patients underwent reoperation for nondegenerative conditions (hematoma, wound infection, or wound dehiscence), and in these patients, chronic obstructive pulmonary disease was the only statistically significant predictor of reoperation (OR 8.92, p = 0.03).

CONCLUSIONS

Smoking was the strongest predictor of reoperation in patients who had undergone single-level laminectomy, multilevel laminectomy, or reoperation for progression of spinal degeneration. These findings suggest that smokers have worse outcomes of lumbar decompression than nonsmokers.

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Michelle J. Clarke, Patricia L. Zadnik, Mari L. Groves, Daniel M. Sciubba, Timothy F. Witham, Ali Bydon, Ziya L. Gokaslan and Jean-Paul Wolinsky

OBJECT

Recently, aggressive surgical techniques and a push toward en bloc resections of certain tumors have resulted in a need for creative spinal column reconstruction. Iatrogenic instability following these resections requires a thoughtful approach to adequately transfer load-bearing forces from the skull and upper cervical spine to the subaxial spine.

METHODS

The authors present a series of 7 cases in which lateral mass reconstruction with a cage or fibular strut graft was used to provide load-bearing support, including 1 case of bilateral cage placement.

RESULTS

The authors discuss the surgical nuances of en bloc resection of high cervical tumors and explain their technique for lateral mass cage placement. Additionally, they provide their rationale for the use of these constructs throughout the craniocervical junction and subaxial spine.

CONCLUSIONS

Lateral mass reconstruction provides a potential alternative or adjuvant method of restoring the load-bearing capabilities of the cervical spine.

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Mohamad Bydon, Joseph A. Lin, Rafael de la Garza-Ramos, Daniel M. Sciubba, Jean Paul Wolinsky, Timothy F. Witham, Ziya L. Gokaslan and Ali Bydon

Object

This study was undertaken to compare surgical outcomes between patients with atlantoaxial versus subaxial cervical synovial cysts (CSCs) and to compare outcomes between patients who underwent decompression alone versus decompression and fusion for the treatment of CSCs.

Methods

The authors present a series of 17 cases involving patients treated at their institution and report the surgical outcomes. Due to the rarity of CSCs, a meta-analysis was conducted, and results of the literature search were combined with the case series to enhance the power of the study.

Results

Seventeen patients underwent surgical treatment for CSCs at our institution: 3 patients (17.6%) had atlantoaxial cysts and 14 (82.3%) had subaxial cysts. Of the 17 patients, 16 underwent a decompression and fusion; most patients experienced symptom resolution at last follow-up, and there were no cyst recurrences. A total of 54 articles (including the current series) and 101 patients were included in the meta-analysis. The mean age at presentation was 64 ± 13.9 years, and the most common symptoms were motor and sensory deficits. Forty-one patients (40.6%) presented with atlantoaxial cysts, and 60 (59.4%) with subaxial cysts. There were no significant differences between groups in terms of presenting symptoms, Nurick scores, surgical treatment, or surgical outcomes. Fifty-two patients (51.4%) underwent surgical decompression without fusion, while 49 patients (48.6%) underwent fusion. The preoperative Nurick scores were significantly lower in the fused group (p = 0.001), with an average score of 1.32 compared with 2.75 in the nonfused group. After a mean follow-up of 16.5 months, a difference of means analysis between final and preoperative Nurick scores revealed that patients who received a decompression alone improved on average 1.66 points (95% CI 1.03–2.29) compared with 0.8 points (95% CI 0.23–1.39) in the fused group (p = 0.004). However, there was no statistically significant difference in symptom resolution between the groups, and the rate of cyst recurrence was found to be 0%.

Conclusions

In this study, patients with CSCs had similar outcomes regardless of cyst location and regardless of whether they underwent decompression only or fusion. In the authors' institutional experience, 16 of 17 patients underwent fusion due to underlying spinal instability. While there were no reports of cyst recurrence in their series or in the literature in patients who only received decompression, this is likely due to the limited follow-up time available for the study population. Longer follow-up and prospective and biomechanical studies are needed to corroborate these findings.

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Mohamad Bydon, Dimitrios Mathios, Mohamed Macki, Rafael de la Garza-Ramos, Daniel M. Sciubba, Timothy F. Witham, Jean-Paul Wolinsky, Ziya L. Gokaslan and Ali Bydon

Object

The authors conducted a study to investigate the rate and timing of reoperation due to symptom recurrence after unilateral posterior cervical foraminotomy (PCF).

Methods

The authors retrospectively reviewed demographic, surgical, and clinical data from 151 patients who underwent unilateral PCF at their institution with an average follow-up of 4.15 years. The main outcome variables were reoperation rate, time to reoperation, and short- and long-term radiculopathy improvement rates. Kaplan-Meier analyses were conducted to assess risk of reoperation and recurrence of radiculopathy over time.

Results

After index PCF in 151 patients, the overall reoperation rate was 9.9% (15 patients). The average time until reoperation was 2.4 years, and the average last follow-up examination was 4.15 years after the first surgery. Patients who presented with preoperative neck pain in addition to radiculopathy had a higher risk for reoperation and a shorter time to reoperation. The majority of patients who underwent a reoperation had an anterior cervical discectomy and fusion (80%). A smaller number of patients had reoperation that included a repeat PCF (6.7%) or laminectomy with posterior cervical fusion (13.3%). The rate of same-level reoperation (6.6%, 10 patients) was significantly higher (p = 0.05) when compared with adjacent-segment (1.3%, 2 patients) or distant-segment (1.9%, 3 patients) reoperation. At last follow-up, the overall rate of improvement in radiculopathy was 85%, with the majority of patients (91.4%) experiencing resolution as early as 1 month after index surgery. Following the subgroup that experienced initial symptom improvement, 16.1% of these patients experienced radiculopathy recurrence an average of 7.3 years after the initial operation. While the reoperation rate for the overall cohort in this series was 9.9%, patients with follow-up periods longer than 2 years had a reoperation rate of 18.3%. Moreover, patients with more than 10 years of follow-up had a reoperation rate of 24.3%.

Conclusions

PCF is a procedure performed to address nerve root compression in the cervical spine. The authors evaluated 151 patients who underwent unilateral PCF and found a reoperation rate of 9.9% at an average of 2.4 years after the initial surgery (6.6% at same level, 3.3% elsewhere). The reoperation rates reached 18.3% and 24.3% in patients with follow-up periods longer than 2 and 10 years, respectively. The authors' analysis revealed that patients with no preoperative neck pain had the lowest rates of revision surgery after PCF.