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The evolution of surgical management for vertebral column tumors

JNSPG 75th Anniversary Invited Review Article

Jared Fridley and Ziya L. Gokaslan

Surgery for the resection of vertebral column tumors has undergone a remarkable evolution over the past several decades. Multiple advancements in surgical techniques, spinal instrumentation, technology, radiation therapy, and medical therapy have led to improved patient survival, function, and decreased morbidity. In this review, the authors discuss major changes in each of these areas in further detail.

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Camilo A. Molina, Nicholas Theodore, A. Karim Ahmed, Erick M. Westbroek, Yigal Mirovsky, Ran Harel, Emanuele Orru’, Majid Khan, Timothy Witham and Daniel M. Sciubba

OBJECTIVE

Augmented reality (AR) is a novel technology that has the potential to increase the technical feasibility, accuracy, and safety of conventional manual and robotic computer-navigated pedicle insertion methods. Visual data are directly projected to the operator’s retina and overlaid onto the surgical field, thereby removing the requirement to shift attention to a remote display. The objective of this study was to assess the comparative accuracy of AR-assisted pedicle screw insertion in comparison to conventional pedicle screw insertion methods.

METHODS

Five cadaveric male torsos were instrumented bilaterally from T6 to L5 for a total of 120 inserted pedicle screws. Postprocedural CT scans were obtained, and screw insertion accuracy was graded by 2 independent neuroradiologists using both the Gertzbein scale (GS) and a combination of that scale and the Heary classification, referred to in this paper as the Heary-Gertzbein scale (HGS). Non-inferiority analysis was performed, comparing the accuracy to freehand, manual computer-navigated, and robotics-assisted computer-navigated insertion accuracy rates reported in the literature. User experience analysis was conducted via a user experience questionnaire filled out by operators after the procedures.

RESULTS

The overall screw placement accuracy achieved with the AR system was 96.7% based on the HGS and 94.6% based on the GS. Insertion accuracy was non-inferior to accuracy reported for manual computer-navigated pedicle insertion based on both the GS and the HGS scores. When compared to accuracy reported for robotics-assisted computer-navigated insertion, accuracy achieved with the AR system was found to be non-inferior when assessed with the GS, but superior when assessed with the HGS. Last, accuracy results achieved with the AR system were found to be superior to results obtained with freehand insertion based on both the HGS and the GS scores. Accuracy results were not found to be inferior in any comparison. User experience analysis yielded “excellent” usability classification.

CONCLUSIONS

AR-assisted pedicle screw insertion is a technically feasible and accurate insertion method.

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Vishwajeet Singh, Tarush Rustagi and Robert Hart

The sacrum forms the distal end of the spine and communicates with the pelvis. Fractures involving the sacrum are complex and may disrupt this vital communication. Neglecting these fractures may result in malunion, which often causes significant alteration in the pelvic parameters and sagittal balance. Management of ensuing deformities is complex and poorly described. The authors present a case of sacral malunion with sagittal imbalance treated with a low lumbar osteotomy.

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Jetan H. Badhiwala, Farshad Nassiri, Christopher D. Witiw, Alireza Mansouri, Saleh A. Almenawer, Leodante da Costa, Michael G. Fehlings and Jefferson R. Wilson

OBJECTIVE

Intraoperative neurophysiological monitoring (IONM) is a useful adjunct in spine surgery, with proven benefit in scoliosis-correction surgery. However, its utility for anterior cervical discectomy and fusion (ACDF) is unclear, as there are few head-to-head comparisons of ACDF outcomes with and without the use of IONM. The authors sought to evaluate the impact of IONM on the safety and cost of ACDF.

METHODS

This was a retrospective analysis of data from the National (Nationwide) Inpatient Sample of the Healthcare Cost and Utilization Project from 2009 to 2013. Patients with a primary procedure code for ACDF were identified, and diagnosis codes were searched to identify cases with postoperative neurological complications. The authors performed univariate and multivariate logistic regression for postoperative neurological complications with use of IONM as the independent variable; additional covariates included age, sex, surgical indication, multilevel fusion, Charlson Comorbidity Index (CCI) score, and admission type. They also conducted propensity score matching in a 1:1 ratio (nearest neighbor) with the use of IONM as the treatment indicator and the aforementioned variables as covariates. In the propensity score–matched cohort, they compared neurological complications, length of stay (LOS), and hospital charges (in US dollars).

RESULTS

A total of 141,007 ACDF operations were identified. IONM was used in 9540 cases (6.8%). No significant association was found between neurological complications and use of IONM on univariate analysis (OR 0.80, p = 0.39) or multivariate regression (OR 0.82, p = 0.45). By contrast, age ≥ 65 years, multilevel fusion, CCI score > 0, and a nonelective admission were associated with greater incidence of neurological complication. The propensity score–matched cohort consisted of 18,760 patients who underwent ACDF with (n = 9380) or without (n = 9380) IONM. Rates of neurological complication were comparable between IONM and non-IONM (0.17% vs 0.22%, p = 0.41) groups. IONM and non-IONM groups had a comparable proportion of patients with LOS ≥ 2 days (19% vs 18%, p = 0.15). The use of IONM was associated with an additional $6843 (p < 0.01) in hospital charges.

CONCLUSIONS

The use of IONM was not associated with a reduced rate of neurological complications following ACDF. Limitations of the data source precluded a specific assessment of the effectiveness of IONM in preventing neurological complications in patients with more complex pathology (i.e., ossification of the posterior longitudinal ligament or cervical deformity).

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Syed I. Khalid, Ryan Kelly, Adam Carlton, Owoicho Adogwa, Patrick Kim, Arjun Ranade, Jessica Moreno, Samantha Maasarani, Rita Wu, Patrick Melville and Jonathan Citow

OBJECTIVE

With the costs related to the United States medical system constantly rising, efforts are being made to turn traditional inpatient procedures into outpatient same-day surgeries. In this study the authors looked at the various comorbidities and perioperative complications and their impact on readmission rates of patients undergoing outpatient versus inpatient 3- and 4-level anterior cervical discectomy and fusion (ACDF).

METHODS

This was a retrospective study of 337 3- and 4- level ACDF procedures in 332 patients (5 patients had both primary and revision surgeries that were included in this total of 337 procedures) between May 2012 and June 2017. In total, 331 procedures were analyzed, as 6 patients were lost to follow-up. Outpatient surgery was performed for 299 procedures (102 4-level procedures and 197 3-level procedures), and inpatient surgery was performed for 32 procedures (11 4-level procedures and 21 3-level procedures). Age, sex, comorbidities, number of fusion levels, pain level, and perioperative complications were compared between both cohorts.

RESULTS

Analysis was performed for 331 3- and 4-level ACDF procedures done at 6 different hospitals. The overall 30-day readmission rate was 1.2% (outpatient 3 [1.0%] vs inpatient 1 [3.1%], p = 0.847). Outpatients had increased readmission risk, with comorbidities of coronary artery disease (OR 1.058, p = 0.039), autoimmune disease (OR 1.142, p = 0.006), diabetes (OR 1.056, p = 0.001), and chronic kidney disease (OR 0.933, p = 0.035). Perioperative complications of delirium (OR 2.709, p < 0.001) and surgical site infection (OR 2.709, p < 0.001) were associated with increased risk of 30-day hospital readmission in outpatients compared to inpatients.

CONCLUSIONS

This study demonstrates the safety and effectiveness of 3- and 4-level ACDF surgery, although various comorbidities and perioperative complications may lead to higher readmission rates. Patient selection for outpatient 3- and 4-level ACDF cases might play a role in the safety of performing these procedures in the ambulatory setting, but further studies are needed to accurately identify which factors are most pertinent for appropriate selection.

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Brandon Sherrod, Michael Karsy, Jian Guan, Andrea A. Brock, Ilyas M. Eli, Erica F. Bisson and Andrew T. Dailey

OBJECTIVE

The objective of this study was to investigate the effect of hospital type and patient transfer during the treatment of patients with vertebral fracture and/or spinal cord injury (SCI).

METHODS

The National Inpatient Sample (NIS) database was queried to identify patients treated in Utah from 2001 to 2011 for vertebral column fracture and/or SCI (ICD-9-CM codes 805, 806, and 952). Variables related to patient transfer into and out of the index hospital were evaluated in relation to patient disposition, hospital length of stay, mortality, and cost.

RESULTS

A total of 53,644 patients were seen (mean [± SEM] age 55.3 ± 0.1 years, 46.0% females, 90.2% white), of which 10,620 patients were transferred from another institution rather than directly admitted. Directly admitted (vs transferred) patients showed a greater likelihood of routine disposition (54.4% vs 26.0%) and a lower likelihood of skilled nursing facility disposition (28.2% vs 49.2%) (p < 0.0001). Directly admitted patients also had a significantly shorter length of stay (5.6 ± 6.7 vs 7.8 ± 9.5 days, p < 0.0001) and lower total charges ($26,882 ± $37,348 vs $42,965 ± $52,118, p < 0.0001). A multivariable analysis showed that major operative procedures (hazard ratio [HR] 1.7, 95% confidence interval [CI] 1.4–2.0, p < 0.0001) and SCI (HR 2.1, 95% CI 1.6–2.8, p < 0.0001) were associated with reduced survival whereas patient transfer was associated with better survival rates (HR 0.4, 95% CI 0.3–0.5, p < 0.0001). A multivariable analysis of cost showed that disposition (β = 0.1), length of stay (β = 0.6), and major operative procedure (β = 0.3) (p < 0.0001) affected cost the most.

CONCLUSIONS

Overall, transferred patients had lower mortality but greater likelihood for poor outcomes, longer length of stay, and higher cost compared with directly admitted patients. These results suggest some significant benefits to transferring patients with acute injury to facilities capable of providing appropriate treatment, but also support the need to further improve coordinated care of transferred patients, including surgical treatment and rehabilitation.

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Gustav Burström, Christian Buerger, Jurgen Hoppenbrouwers, Rami Nachabe, Cristian Lorenz, Drazenko Babic, Robert Homan, John M. Racadio, Michael Grass, Oscar Persson, Erik Edström and Adrian Elmi Terander

OBJECTIVE

The goal of this study was to develop and validate a system for automatic segmentation of the spine, pedicle identification, and screw path suggestion for use with an intraoperative 3D surgical navigation system.

METHODS

Cone-beam CT (CBCT) images of the spines of 21 cadavers were obtained. An automated model-based approach was used for segmentation. Using machine learning methodology, the algorithm was trained and validated on the image data sets. For measuring accuracy, surface area errors of the automatic segmentation were compared to the manually outlined reference surface on CBCT. To further test both technical and clinical accuracy, the algorithm was applied to a set of 20 clinical cases. The authors evaluated the system’s accuracy in pedicle identification by measuring the distance between the user-defined midpoint of each pedicle and the automatically segmented midpoint. Finally, 2 independent surgeons performed a qualitative evaluation of the segmentation to judge whether it was adequate to guide surgical navigation and whether it would have resulted in a clinically acceptable pedicle screw placement.

RESULTS

The clinically relevant pedicle identification and automatic pedicle screw planning accuracy was 86.1%. By excluding patients with severe spinal deformities (i.e., Cobb angle > 75° and severe spinal degeneration) and previous surgeries, a success rate of 95.4% was achieved. The mean time (± SD) for automatic segmentation and screw planning in 5 vertebrae was 11 ± 4 seconds.

CONCLUSIONS

The technology investigated has the potential to aid surgeons in navigational planning and improve surgical navigation workflow while maintaining patient safety.

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Kirsten E. Stoner, Kingsley O. Abode-Iyamah, Vincent A. Magnotta, Matthew A. Howard III and Nicole M. Grosland

OBJECTIVE

Cervical myelopathy (CM) is a common and debilitating form of spinal cord injury caused by chronic compression; however, little is known about the in vivo mechanics of the healthy spinal cord during motion and how these mechanics are altered in CM. The authors sought to measure 3D in vivo spinal cord displacement and strain fields from MR images obtained during physiological motion of healthy individuals and cervical myelopathic patients.

METHODS

Nineteen study participants, 9 healthy controls and 10 CM patients, were enrolled in the study. All study participants had 3T MR images acquired of the cervical spine in neutral, flexed, and extended positions. Displacement and strain fields and corresponding principal strain were obtained from the MR images using image registration.

RESULTS

The healthy spinal cord displaces superiorly in flexion and inferiorly in extension. Principal strain is evenly distributed along the spinal cord. The CM spinal cord displaces less than the healthy cord and the magnitude of principal strain is higher, at the midcervical levels.

CONCLUSIONS

Increased spinal cord compression during cervical myelopathy limits motion of the spinal cord and increases spinal cord strain during physiological motion. Future studies are needed to investigate how treatment, such as surgical intervention, affects spinal cord mechanics.

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Anneli Peolsson, Håkan Löfgren, Åsa Dedering, Birgitta Öberg, Peter Zsigmond, Henrik Hedevik and Johanna Wibault

OBJECTIVE

Information about postoperative rehabilitation for cervical radiculopathy (CR) is scarce. The aim of this study was to investigate the additional benefits of structured postoperative rehabilitation (SPT), which was performed in all patients, compared with a pragmatic standard postoperative approach (SA), in which rehabilitation was used as needed and patients sought physiotherapy on their own without a referral, in patients with MRI evidence of disc herniation and concomitant clinical signs who underwent surgery for CR.

METHODS

Patients (n = 202) were randomized to receive SPT or SA. Included key variables in the present study were primary and selected secondary outcomes of a prospective randomized controlled multicenter study. The main outcome was the Neck Disability Index (NDI) score. The NDI score, pain variables, self-efficacy, and health-related quality of life were investigated at baseline and 3, 6, 12, and 24 months postoperatively.

RESULTS

SPT provided no additional benefits over SA (p = 0.08 to p = 0.99) at the postoperative 2-year follow-up. Both groups improved over time (p < 0.0001), with no reported adverse effects.

CONCLUSIONS

One can conclude that SPT offered no additional benefits over SA; however, patients tolerated postoperative neck exercises without any negative side effects. These findings are important for the development of future active and neck-specific postoperative rehabilitation interventions for patients with CR.

Clinical trial registration no.: NCT01547611 (clinicaltrials.gov)