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Praveen V. Mummaneni, Mohamad Bydon, Mohammed Ali Alvi, Andrew K. Chan, Steven D. Glassman, Kevin T. Foley, Eric A. Potts, Christopher I. Shaffrey, Mark E. Shaffrey, Domagoj Coric, John J. Knightly, Paul Park, Michael Y. Wang, Kai-Ming Fu, Jonathan R. Slotkin, Anthony L. Asher, Michael S. Virk, Panagiotis Kerezoudis, Jian Guan, Regis W. Haid and Erica F. Bisson

OBJECTIVE

Since the enactment of the Affordable Care Act in 2010, providers and hospitals have increasingly prioritized patient-centered outcomes such as patient satisfaction in an effort to adapt the “value”-based healthcare model. In the current study, the authors queried a prospectively maintained multiinstitutional spine registry to construct a predictive model for long-term patient satisfaction among patients undergoing surgery for Meyerding grade I lumbar spondylolisthesis.

METHODS

The authors queried the Quality Outcomes Database for patients undergoing surgery for grade I lumbar spondylolisthesis between July 1, 2014, and June 30, 2016. The primary outcome of interest for the current study was patient satisfaction as measured by the North American Spine Surgery patient satisfaction index, which is measured on a scale of 1–4, with 1 indicating most satisfied and 4 indicating least satisfied. In order to identify predictors of higher satisfaction, the authors fitted a multivariable proportional odds logistic regression model for ≥ 2 years of patient satisfaction after adjusting for an array of clinical and patient-specific factors. The absolute importance of each covariate in the model was computed using an importance metric defined as Wald chi-square penalized by the predictor degrees of freedom.

RESULTS

A total of 502 patients, out of a cohort of 608 patients (82.5%) with grade I lumbar spondylolisthesis, undergoing either 1- or 2-level decompression (22.5%, n = 113) or 1-level decompression and fusion (77.5%, n = 389), met the inclusion criteria; of these, 82.1% (n = 412) were satisfied after 2 years. On univariate analysis, satisfied patients were more likely to be employed and working (41.7%, n = 172, vs 24.4%, n = 22; overall p = 0.001), more likely to present with predominant leg pain (23.1%, n = 95, vs 11.1%, n = 10; overall p = 0.02) but more likely to present with lower Numeric Rating Scale score for leg pain (median and IQR score: 7 [5–9] vs 8 [6–9]; p = 0.05). Multivariable proportional odds logistic regression revealed that older age (OR 1.57, 95% CI 1.09–2.76; p = 0.009), preoperative active employment (OR 2.06, 95% CI 1.27–3.67; p = 0.015), and fusion surgery (OR 2.3, 95% CI 1.30–4.06; p = 0.002) were the most important predictors of achieving satisfaction with surgical outcome.

CONCLUSIONS

Current findings from a large multiinstitutional study indicate that most patients undergoing surgery for grade I lumbar spondylolisthesis achieved long-term satisfaction. Moreover, the authors found that older age, preoperative active employment, and fusion surgery are associated with higher odds of achieving satisfaction.

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Siri Sahib Khalsa, Hyeun Sung Kim, Ravindra Singh and Osama Nezar Kashlan

OBJECTIVE

Lumbar central stenosis can theoretically be decompressed with minimal bone removal via an endoscopic approach. Although multiple studies have demonstrated an adequate radiographic decompression, none has quantified the volume of bone removal after endoscopic decompression. The objective of this study was to quantify the 3D volume of bone removed from the lamina and facet joints during endoscopic decompression for lumbar central and lateral recess stenosis.

METHODS

This retrospective study included adults with lumbar spinal stenosis who underwent endoscopic decompression of a single level or 2 noncontiguous lumbar levels. Central stenosis on MRI was graded preoperatively and postoperatively using the Schizas scale. A computer program was developed in MATLAB to semiautomatically perform a 3D volumetric analysis of preoperative and postoperative lumbar CT scans. The volumetric percentage of bone removed from the lamina and facet joints ipsilateral and contralateral to the side of approach was quantified.

RESULTS

Nineteen patients with 21 treated lumbar levels were included in the study. Preoperatively, the number of levels with Schizas stenosis grades B, C, and D were 5, 12, and 4, respectively. Stenosis grades improved postoperatively to grades A, B, C, and D for 17, 3, 1, and 0 levels, respectively. All levels improved by at least 1 stenosis grade. The volumetric percentage of laminar bone removed was 15.5% (95% CI 11.2%–19.8%, p < 0.001) from the ipsilateral lamina and 8.8% (95% CI 5.7%–11.8%, p < 0.001) from the contralateral lamina. The percentage of facet joint resection was 5.3% (95% CI 4.2%–6.4%, p < 0.001) and 4.3% (95% CI 2.2%–6.4%, p < 0.001) for the ipsilateral and contralateral facet joints, respectively. Average pain scores, as measured by the visual analog scale, improved from 7.9 preoperatively to 2.2 by 3–10 months postoperatively (p < 0.001).

CONCLUSIONS

Endoscopic lumbar decompression achieves improvement in the radiographic grade of lumbar central stenosis with minimal bone removal from the lamina and facet joints. Future prospective studies are needed to validate the findings of this study with more comprehensive clinical outcomes.

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Bumsoo Park, Sung-Hyun Noh and Jeong-Yoon Park

OBJECTIVE

With the development of minimally invasive procedures, percutaneous pedicle screw systems have been used to attempt to correct spondylolisthesis. No previous studies have reported on reduction measures using long tab percutaneous pedicle screws for spondylolisthesis. Additional intraoperative correction has been proposed with the “swing” technique. This study was conducted to compare the efficacy of standard minimally invasive transforaminal interbody fusion (MIS-TLIF) with the efficacy of MIS-TLIF with the “swing” technique (MIS-TLIF and swing) in lumbar spondylolisthesis.

METHODS

This was a matched-control study and included 30 consecutive patients who were followed up for 6 months after surgery. Of those patients, 15 were treated with operative reduction via MIS-TLIF with the “swing” technique, whereas the other 15 were treated with the standard MIS-TLIF procedure. The swing technique is a new reduction procedure for use with long tab percutaneous screws. In the swing technique, the entire system is swung back and forth several times after all constructs are placed. Only patients with Meyerding grade I or II lumbar spondylolisthesis were included in the study (18 with grade I and 12 with grade II). Perioperative and clinical outcomes, radiological parameters (Meyerding grade, percentage of slip, slip correction rate, segmental lordosis, and lumbar lordosis) were compared between groups at 6 months after surgery.

RESULTS

Demographic data did not differ significantly between the 2 groups. Postoperative clinical outcomes showed significant improvement in both groups. Postoperative radiological parameters showed that the degree of spondylolisthesis (swing: 4.7% vs standard: 8.9%) and reduction rate (swing: 77.3% vs standard: 57.1%) favored the swing group. The swing technique effectively decreased the degree of spondylolisthesis (swing: 24.1% to 4.7% vs standard: 21.8% to 8.9%). No complications related to the procedure were reported.

CONCLUSIONS

MIS-TLIF with the “swing” technique with long tab percutaneous pedicle screws is a safe and effective reduction method for monosegmental spondylolisthesis. This technique cannot only alleviate symptoms but also achieve nearly completely reduction of slippage.

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Dachling Pang

This review summarizes the classification, anatomy, and embryogenesis of complex spinal cord lipomas, and it describes in some detail the new technique of total lipoma resection and radical reconstruction of the affected neural placode. Its specific mission is to tackle two main issues surrounding the management of complex dysraphic lipomas: whether total resection confers better long-term benefits than partial resection and whether total resection fares better than conservative treatment—i.e., no surgery—for asymptomatic lipomas. Accordingly, the 24-year progression-free survival data of the author and colleagues’ series of over 300 cases of total resection are compared with historical data from multiple series (including the author and colleagues’ own) of partial resection, and total resection data specifically for asymptomatic lesions are compared with the two known series of nonsurgical treatment of equivalent numbers of patients. These comparisons amply support the author’s recommendation of total resection for most complex lipomas, with or without symptoms. The notable exception is the asymptomatic chaotic lipoma, whose peculiar anatomical relationship with the neural tissue defies even this aggressive surgical approach and consequently projects worse results (admittedly of a small number of cases) than for the other two lipoma subtypes of dorsal and transitional lesions. Prophylactic resection of asymptomatic chaotic lipomas is therefore not currently endorsed.

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Justin S. Smith, Christopher I. Shaffrey, Christopher P. Ames and Lawrence G. Lenke

Care of the patient with adult spinal deformity (ASD) has evolved from being primarily supportive to now having the ability to directly treat and correct the spinal pathology. The focus of this narrative literature review is to briefly summarize the history of ASD treatment, discuss the current state of the art of ASD care with focus on surgical treatment and current challenges, and conclude with a discussion of potential developments related to ASD surgery.

In the past, care for ASD was primarily based on supportive measures, including braces and assistive devices, with few options for surgical treatments that were often deemed high risk and reserved for rare situations. Advances in anesthetic and critical care, surgical techniques, and instrumentation now enable almost routine surgery for many patients with ASD. Despite the advances, there are many remaining challenges currently impacting the care of ASD patients, including increasing numbers of elderly patients with greater comorbidities, high complication and reoperation rates, and high procedure cost without clearly demonstrated cost-effectiveness based on standard criteria. In addition, there remains considerable variability across multiple aspects of ASD surgery. For example, there is currently very limited ability to provide preoperative individualized counseling regarding optimal treatment approaches (e.g., operative vs nonoperative), complication risks with surgery, durability of surgery, and likelihood of achieving individualized patient goals and satisfaction. Despite the challenges associated with the current state-of-the-art ASD treatment, surgery continues to be a primary option, as multiple reports have demonstrated the potential for surgery to significantly improve pain and disability. The future of ASD care will likely include techniques and technologies to markedly reduce complication rates, including greater use of navigation and robotics, and a shift toward individualized medicine that enables improved counseling, preoperative planning, procedure safety, and patient satisfaction.

Advances in the care of ASD patients have been remarkable over the past few decades. The current state of the art enables almost routine surgical treatment for many types of ASD that have the potential to significantly improve pain and disability. However, significant challenges remain, including high complication rates, lack of demonstrated cost-effectiveness, and limited ability to meaningfully counsel patients preoperatively on an individual basis. The future of ASD surgery will require continued improvement of predictability, safety, and sustainability.

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Michael Kern, Matthias Setzer, Lutz Weise, Ali Mroe, Holger Frey, Katharina Frey, Volker Seifert and Stephan Duetzmann

OBJECTIVE

The treatment of patients with spinal stenosis and concurrent degenerative spondylolisthesis is controversial. Two large randomized controlled clinical trials reported contradictory results. The authors hypothesized that a substantial number of patients will show evidence of micro-instability after a sole decompression procedure.

METHODS

This study was a retrospective analysis of all cases of lumbar spinal stenosis treated at the Frankfurt University Clinic (Universitätsklinik Frankfurt) from 2010 through 2013. Patients who had associated spondylolisthesis underwent upright MRI studies in flexion and extension for identification of subtle signs of micro-instability. Clinical outcome was assessed by means of SF-36 bodily pain (BP) and physical functioning (PF) scales.

RESULTS

A total of 21 patients were recruited to undergo upright MRI studies. The mean duration of follow-up was 65 months (SD 16 months). Of these 21 patients, 10 (47%) showed signs of micro-instability as defined by movement of > 4 mm on flexion/extension MRI. Comparison of mean SF-36 BP and PF scores in the group of patients who showed micro-instability versus those who did not showed no statistically significant difference on either scale.

CONCLUSIONS

There seems to be a substantial subset of patients who develop morphological micro-instability after sole decompression procedures but do not experience any clinically significant effect of the instability.

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Da Zou, Weishi Li, Fei Xu and Guohong Du

OBJECTIVE

The aim of this study was to evaluate the use of Hounsfield unit (HU) values of the S1 body to diagnose osteoporosis in patients with lumbar degenerative diseases.

METHODS

The records of 316 patients of ages ≥ 50 years and requiring surgery for lumbar degenerative diseases were reviewed. The bone mineral density (BMD) of the S1 body and L1 was measured in HU with preoperative lumbar CT. Circular regions of interest (ROIs) were placed on midaxial and midsagittal images of the S1 body. Dual-energy x-ray absorptiometry (DXA) and the criterion of L1 HU ≤ 110 HU were used to diagnose osteoporosis. The area under the receiver operating characteristic curve (AUC) was calculated to assess the use of HUs of the S1 body to diagnose osteoporosis.

RESULTS

The interobserver and intraobserver reliability of measuring HU of the S1 body was excellent with intraclass correlation coefficients over 0.8 (p < 0.001). The correlation between HUs of the S1 body and average T-score of L1–4 was significant with Pearson correlation coefficients ≥ 0.60 (p < 0.001). The AUCs for using HUs of the S1 body to diagnose osteoporosis were 0.86 and 0.88 for axial HU and sagittal HU, respectively (p < 0.001). The HU thresholds with balanced sensitivity and specificity for diagnosing osteoporosis were 202 HU for axial HU (sensitivity: 76%; specificity: 76%) and 185 HU for sagittal HU (sensitivity: 80%; specificity: 80%).

CONCLUSIONS

Both sagittal and axial HUs of the S1 body are useful tools for assessing BMD and diagnosing osteoporosis. Measuring HUs of the S1 body preoperatively from lumbar CT may help with surgical planning for patients with lumbar degenerative diseases.

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Courtney M. Schusse, Kris Smith and Cornelia Drees

OBJECTIVE

Hemispherectomy is a surgical technique that is established as a standard treatment in appropriately selected patients with drug-resistant epilepsy. It has proven to be successful in pediatric patients with unilateral hemispheric lesions but is underutilized in adults. This study retrospectively evaluated the clinical outcomes after hemispherectomy in adult patients with refractory epilepsy.

METHODS

This study examined 6 cases of hemispherectomy in adult patients at Barrow Neurological Institute. In addition, all case series of hemispherectomy in adult patients were identified through a literature review using MEDLINE and PubMed. Case series of patients older than 18 years were included; reports of patients without clear follow-up duration or method of validated seizure outcome quantification were excluded. Seizure outcome was based on the Engel classification.

RESULTS

A total of 90 cases of adult hemispherectomy were identified, including 6 newly added by Barrow Neurological Institute. Sixty-five patients underwent functional hemispherectomy; 25 patients had anatomical hemispherectomy. Length of follow-up ranged from 9 to 456 months. Seizure freedom was achieved in 80% of patients. The overall morbidity rate was low, with 9 patients (10%) having new or additional postoperative speech or language dysfunction, and 19 patients (21%) reporting some worsening of hemiparesis. No patients lost ambulatory or significant functional ability, and 2 patients had objective ambulatory improvement. Among the 41 patients who underwent additional formal neuropsychological testing postoperatively, overall stability or improvement was seen.

CONCLUSIONS

Hemispherectomy is a valuable surgical tool for properly selected adult patients with pre-existing hemiparesis and intractable epilepsy. In published cases, as well as in this series, the procedure has overall been well tolerated without significant morbidity, and the majority of patients have been rendered free of seizures.

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Liang Li, Jiantao Yang, Bengang Qin, Honggang Wang, Yi Yang, Jintao Fang, Gang Chen, Xiaolin Liu, Zhehui Tu and Liqiang Gu

OBJECTIVE

Human acellular nerve allograft applications have increased in clinical practice, but no studies have quantified their influence on reconstruction outcomes for high-level, greater, and mixed nerves, especially the brachial plexus. The authors investigated the functional outcomes of human acellular nerve allograft reconstruction for nerve gaps in patients with brachial plexus injury (BPI) undergoing contralateral C7 (CC7) nerve root transfer to innervate the upper trunk, and they determined the independent predictors of recovery in shoulder abduction and elbow flexion.

METHODS

Forty-five patients with partial or total BPI were eligible for this retrospective study after CC7 nerve root transfer to the upper trunk using human acellular nerve allografts. Deltoid and biceps muscle strength, degree of shoulder abduction and elbow flexion, Semmes-Weinstein monofilament test, and static two-point discrimination (S2PD) were examined according to the modified British Medical Research Council (mBMRC) scoring system, and disabilities of the arm, shoulder, and hand (DASH) were scored to establish the function of the affected upper limb. Meaningful recovery was defined as grades of M3–M5 or S3–S4 based on the scoring system. Subgroup analysis and univariate and multivariate logistic regression analyses were conducted to identify predictors of human acellular nerve allograft reconstruction.

RESULTS

The mean follow-up duration and the mean human acellular nerve allograft length were 48.1 ± 10.1 months and 30.9 ± 5.9 mm, respectively. Deltoid and biceps muscle strength was grade M4 or M3 in 71.1% and 60.0% of patients. Patients in the following groups achieved a higher rate of meaningful recovery in deltoid and biceps strength, as well as lower DASH scores (p < 0.01): age < 20 years and age 20–29 years; allograft lengths ≤ 30 mm; and patients in whom the interval between injury and surgery was < 90 days. The meaningful sensory recovery rate was approximately 70% in the Semmes-Weinstein monofilament test and S2PD. According to univariate and multivariate logistic regression analyses, age, interval between injury and surgery, and allograft length significantly influenced functional outcomes.

CONCLUSIONS

Human acellular nerve allografts offered safe reconstruction for 20- to 50-mm nerve gaps in procedures for CC7 nerve root transfer to repair the upper trunk after BPI. The group in which allograft lengths were ≤ 30 mm achieved better functional outcome than others, and the recommended length of allograft in this procedure was less than 30 mm. Age, interval between injury and surgery, and allograft length were independent predictors of functional outcomes after human acellular nerve allograft reconstruction.

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Ryan A. Gellner, Eamon T. Campolettano, Eric P. Smith and Steven Rowson

OBJECTIVE

Youth football attracts approximately 3.5 million participants every year, but concern has recently arisen about the long-term effects of experiencing repetitive head accelerations from a young age due to participation in football. The objective of this study was to quantify total involvement in high-magnitude impacts among individual players in youth football practices. The authors explored the relationship between the total number of high-magnitude accelerations in which players were involved (experienced either by themselves or by other players) during practices and the number of high-magnitude accelerations players experienced.

METHODS

A local cohort of 94 youth football players (mean age 11.9 ± 1.5, mean body mass 50.3 ± 16.4 kg) from 4 different teams were recruited and outfitted with helmet-mounted accelerometer arrays. The teams were followed for one season each for a total of 128 sessions (practices, games, and scrimmages). All players involved in high-magnitude (greater than 40g) head accelerations were subsequently identified through analysis of practice film.

RESULTS

Players who experienced more high-magnitude accelerations were more likely to be involved in impacts associated with high-magnitude accelerations in other players. A small subset of 6 players (6%) were collectively involved in 230 (53%) high-magnitude impacts during practice, were involved in but did not experience a high-magnitude acceleration 78 times (21% of the 370 one-sided high-magnitude impacts), and experienced 152 (30%) of the 502 high-magnitude accelerations measured. Quarterbacks/running backs/linebackers were involved in the greatest number of high-magnitude impacts in practice and experienced the greatest number of high-magnitude accelerations. Which team a player was on was an important factor, as one team showed much greater head impact exposure than all others.

CONCLUSIONS

This study showed that targeting the most impact-prone players for individualized interventions could reduce high-magnitude acceleration exposure for entire teams. These data will help to further quantify elevated head acceleration exposure and enable data-driven interventions that modify exposure for individual players and entire teams.