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Iliac screw versus S2 alar-iliac screw fixation in adults: a meta-analysis

Rafael De la Garza Ramos, Jonathan Nakhla, Daniel M. Sciubba, and Reza Yassari

OBJECTIVE

In a meta-analysis, the authors sought to compare outcomes after iliac screw (IS) versus S2 alar-iliac (S2AI) screw fixation in adult patients.

METHODS

A PubMed/MEDLINE database search was performed for studies comparing IS and S2AI screw fixation techniques in adults. Levels of evidence were assigned based on the North American Spine Society guidelines. Three outcomes were examined: 1) revision surgery rate secondary to mechanical failure or wound complications, 2) surgical site infection rate, and 3) screw prominence/pain. Data were pooled and outcomes compared between techniques. Absolute risk reductions (ARRs) were also calculated for outcome measures.

RESULTS

Five retrospective cohort studies (all level III evidence) were included in our analysis. A total of 323 adult patients were included—147 in the IS group (45.5%) and 176 in the S2AI group (54.5%). Overall, revision surgery due to mechanical failure or wound complications was needed in 66 of 323 patients (revision surgery rate 20.4%)—27.9% in the IS group and 14.2% in the S2AI group (13.7% ARR; p < 0.001). Four studies reported wound infections among 278 total patients, with an infection rate of 12.6% (35/278)—25.4% in the IS group and 2.6% in the S2AI group (22.8% ARR; p < 0.001). Three studies examined development of screw prominence/pain; combined, these studies reported screw prominence/pain in 21 of 215 cases (9.8%)—18.1% in the IS group and 1.8% in the S2AI group (16.3% ARR; p < 0.001).

CONCLUSIONS

S2AI screw fixation in adults has a significantly lower mechanical failure and complication rate than IS fixation based on the current best available evidence.

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Resection of spinal column tumors utilizing image-guided navigation: a multicenter analysis

Rani Nasser, Doniel Drazin, Jonathan Nakhla, Lutfi Al-Khouja, Earl Brien, Eli M. Baron, Terrence T. Kim, J. Patrick Johnson, and Reza Yassari

OBJECTIVE

The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions.

METHODS

This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance.

RESULTS

The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14–87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62–865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5–7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1–36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden.

CONCLUSIONS

O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.

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Effect of body mass index on surgical outcomes after posterior spinal fusion for adolescent idiopathic scoliosis

Rafael De la Garza Ramos, Jonathan Nakhla, Rani Nasser, Jacob F. Schulz, Taylor E. Purvis, Daniel M. Sciubba, Merritt D. Kinon, and Reza Yassari

OBJECTIVE

Obesity is an increasing public health concern in the pediatric population. The purpose of this investigation was to examine the impact of body mass index (BMI) on 30-day outcomes after posterior spinal fusion for adolescent idiopathic scoliosis (AIS).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Pediatric database (2013 and 2014) was reviewed. Patients 10–18 years of age who had undergone fusion of 7 or more spinal levels for AIS were included. Thirty-day outcomes (complications, readmissions, and reoperations) were compared based on patient BMI per age- and sex-adjusted growth charts as follows: normal weight (NW; BMI < 85th percentile), overweight (OW; BMI 85th–95th percentile), and obese (OB; BMI > 95th percentile).

RESULTS

Patients eligible for study numbered 2712 (80.1% female and 19.9% male) and had a mean age of 14.4 ± 1.8 years. Average BMI for the entire cohort was 21.9 ± 5.0 kg/m2; 2010 patients (74.1%) were classified as NW, 345 (12.7%) as OW, and 357 (13.2%) as OB. The overall complication rate was 1.3% (36/2712). For NW and OW patients, the complication rate was 0.9% in each group; for OB patients, the rate was 4.2% (p < 0.001). The 30-day readmission rate was 2.0% (55/2712) for all patients, 1.6% for NW patients, 1.2% for OW patients, and 5.0% for OB patients (p < 0.001). The 30-day reoperation rate was 1.4% (39/2712). Based on BMI, this reoperation rate corresponded to 0.9%, 1.2%, and 4.8% for NW, OW, and OB patients, respectively (p < 0.001). After controlling for patient age, number of spinal levels fused, and operative/anesthesia time on multiple logistic regression analysis, obesity remained a significant risk factor for complications (OR 4.61), readmissions (OR 3.16), and reoperations (OR 5.33; all p < 0.001).

CONCLUSIONS

Body mass index may be significantly associated with short-term outcomes after long-segment fusion procedures for AIS. Although NW and OW patients may have similar 30-day outcomes, OB patients had significantly higher wound complication, readmission, and reoperation rates and longer hospital stays than the NW patients. The findings of this study may help spine surgeons and patients in terms of preoperative risk stratification and perioperative expectations.

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Evaluation of lymphopenia as a predictor of postoperative mortality and major complications in patients undergoing surgery for metastatic spine tumors

Jessica Ryvlin, Mousa K. Hamad, Justin Langro, Benjamin Wang, Pavan Patel, Rafael De la Garza Ramos, Saikiran G. Murthy, Yaroslav Gelfand, and Reza Yassari

OBJECTIVE

Lymphopenia is often seen in advanced metastatic disease and has been associated with poor postoperative outcomes. Limited research has been done to validate this metric in patients with spinal metastases. The objective of this study was to evaluate the capability of preoperative lymphopenia to predict 30-day mortality, overall survival (OS), and major complications in patients undergoing surgery for metastatic spine tumors.

METHODS

A total of 153 patients who underwent surgery for metastatic spine tumor between 2012 and 2022 and met the inclusion criteria were examined. Electronic medical record chart review was conducted to obtain patient demographics, comorbidities, preoperative laboratory values, survival time, and postoperative complications. Preoperative lymphopenia was defined as < 1.0 K/μL based on the institution’s laboratory cutoff value and within 30 days prior to surgery. The primary outcome was 30-day mortality. Secondary outcomes were OS up to 2 years and 30-day postoperative major complications. Outcomes were assessed with logistic regression. Survival analyses were done using the Kaplan-Meier method with log-rank test and Cox regression. Receiver operating characteristic curves were plotted to classify the predictive ability of lymphocyte count as a continuous variable on outcome measures.

RESULTS

Lymphopenia was identified in 47% of patients (72 of 153). The overall 30-day mortality rate was 9% (13 of 153). In logistic regression analysis, lymphopenia was not associated with 30-day mortality (OR 1.35, 95% CI 0.43–4.21; p = 0.609). The mean OS in this sample was 15.6 months (95% CI 13.9–17.3 months), with no significant difference between patients with lymphopenia and those with no lymphopenia (p = 0.157). Cox regression analysis did not show an association between lymphopenia and survival (HR 1.44, 95% CI 0.87–2.39; p = 0.161). The major complication rate was 26% (39 of 153). In univariable logistic regression analysis, lymphopenia was not associated with the development of a major complication (OR 1.44, 95% CI 0.70–3.00; p = 0.326). Finally, receiver operating characteristic curves generated poor discrimination between lymphocyte count and all outcomes, including 30-day mortality (area under the curve 0.600, p = 0.232).

CONCLUSIONS

This study does not support prior research that had shown an independent association between low preoperative lymphocyte level and poor postoperative outcomes following surgery for metastatic spine tumors. Although lymphopenia may be used to predict outcomes in other tumor-related surgeries, this metric may not hold a similar predictive capability in the population undergoing surgery for metastatic spine tumors. Further research into reliable prognostic tools is needed.

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Readmission after spinal epidural abscess management in urban populations: a bi-institutional study

Presented at the 2019 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Michael Longo, Zach Pennington, Yaroslav Gelfand, Rafael De la Garza Ramos, Murray Echt, A. Karim Ahmed, Vijay Yanamadala, Daniel M. Sciubba, and Reza Yassari

OBJECTIVE

The incidence of spinal epidural abscess (SEA) is rising, yet there are few reports discussing readmission rates or predisposing factors for readmission after treatment. The aims of the present study were to determine the rate of 90-day readmission following medical or surgical treatment of SEA in an urban population, identify patients at increased risk for readmission, and delineate the principal causes of readmission.

METHODS

Neurosurgery records from two large urban institutions were reviewed to identify patients who were treated for SEA. Patients who died during admission or were discharged to hospice were excluded. Univariate analysis was performed using chi-square and Student t-tests to identify potential predictors of readmission. A multivariate logistic regression model, controlled for age, body mass index, sex, and institution, was used to determine significant predictors of readmission.

RESULTS

Of 103 patients with identified SEA, 97 met the inclusion criteria. Their mean age was 57.1 years, and 56 patients (57.7%) were male. The all-cause 90-day readmission rate was 37.1%. Infection (sepsis, osteomyelitis, persistent abscess, bacteremia) was the most common cause of readmission, accounting for 36.1% of all readmissions. Neither pretreatment neurological deficit (p = 0.16) nor use of surgical versus medical management (p = 0.33) was significantly associated with readmission. Multivariate analysis identified immunocompromised status (p = 0.036; OR 3.5, 95% CI 1.1–11.5) and hepatic disease (chronic hepatitis or alcohol abuse) (p = 0.033; OR 2.9, 95% CI 1.1–7.7) as positive predictors of 90-day readmission.

CONCLUSIONS

The most common indication for readmission was persistent infection. Readmission was unrelated to baseline neurological status or management strategy. However, both hepatic disease and baseline immunosuppression significantly increased the odds of 90-day readmission after SEA treatment. Patients with these conditions may require closer follow-up upon discharge to reduce overall morbidity and hospital costs associated with SEA.

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Separation surgery for metastatic epidural spinal cord compression: comparison of a minimally invasive versus open approach

Murray Echt, Ariel Stock, Rafael De la Garza Ramos, Evan Der, Mousa Hamad, Ryan Holland, Phillip Cezayirli, Rani Nasser, Vijay Yanamadala, and Reza Yassari

OBJECTIVE

The aim of this study was to compare outcomes of separation surgery for metastatic epidural spinal cord compression (MESCC) in patients undergoing minimally invasive surgery (MIS) versus open surgery.

METHODS

A retrospective study of patients undergoing MIS or standard open separation surgery for MESCC between 2009 and 2019 was performed. Both groups received circumferential decompression via laminectomy and a transpedicular approach for partial corpectomy to debulk ventral epidural disease, as well as instrumented stabilization. Outcomes were compared between the two groups.

RESULTS

There were 17 patients in the MIS group and 24 in the open surgery group. The average age of the MIS group was significantly older than the open surgery group (65.5 vs 56.6 years, p < 0.05). The preoperative Karnofsky Performance Scale score of the open group was significantly lower than that of the MIS group, with averages of 63.0% versus 75.9%, respectively (p = 0.02). This was also evidenced by the higher proportion of emergency procedures performed in the open group (9 of 24 patients vs 0 of 17 patients, p = 0.004). The average Spine Instability Neoplastic Score, number of levels fused, and operative parameters, including length of stay, were similar. The average estimated blood loss difference for the open surgery versus the MIS group (783 mL vs 430 mL, p < 0.05) was significant, although the average amount of packed red blood cells transfused was not significantly different (325 mL vs 216 mL, p = 0.39). Time until start of radiation therapy was slightly less in the MIS than the open surgery group (32.8 ± 15.6 days vs 43.1 ± 20.3 days, p = 0.069). Among patients who underwent open surgery with long-term follow-up, 20% were found to have local recurrence compared with 12.5% of patients treated with the MIS technique. No patients in either group developed hardware failure requiring revision surgery.

CONCLUSIONS

MIS for MESCC is a safe and effective approach for decompression and stabilization compared with standard open separation surgery, and it significantly reduced blood loss during surgery. Although there was a trend toward a faster time to starting radiation treatment in the MIS group, both groups received similar postoperative radiotherapy doses, with similar rates of local recurrence and hardware failure. An increased ability to perform MIS in emergency settings as well as larger, prospective studies are needed to determine the potential benefits of MIS over standard open separation surgery.

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Thirty-day readmission and reoperation rates after single-level anterior cervical discectomy and fusion versus those after cervical disc replacement

Niketh Bhashyam, Rafael De la Garza Ramos, Jonathan Nakhla, Rani Nasser, Ajit Jada, Taylor E. Purvis, Daniel M. Sciubba, Merritt D. Kinon, and Reza Yassari

OBJECTIVE

The goal of this study was to compare 30-day readmission and reoperation rates after single-level anterior cervical discectomy and fusion (ACDF) versus those after cervical disc replacement (CDR).

METHODS

The authors used the 2013–2014 American College of Surgeons National Surgical Quality Improvement Program database. Included were adult patients who underwent first-time single-level ACDF or CDR for cervical spondylosis or disc herniation. Primary outcome measures were readmission and/or reoperation within 30 days of the original surgery. Logistic regression analysis was used to assess the independent effect of the procedure (ACDF or CDR) on outcome, and results are presented as odds ratios with 95% confidence intervals.

RESULTS

A total of 6077 patients met the inclusion criteria; 5590 (92.0%) patients underwent single-level ACDF, and 487 (8.0%) patients underwent CDR. The readmission rates were 2.6% for ACDF and 0.4% for CDR (p = 0.003). When stratified according to age groups, only patients between the ages of 41 and 60 years who underwent ACDF had a significantly higher readmission rate than those who underwent CDR (2.5% vs 0.7%, respectively; p = 0.028). After controlling for patient age, sex, body mass index, smoking status, history of chronic obstructive pulmonary disease (COPD), diabetes, hypertension, steroid use, and American Society of Anesthesiologists (ASA) class, patients who underwent CDR were significantly less likely to undergo readmission within 30 days than patients who underwent ACDF (OR 0.23 [95% CI 0.06–0.95]; p = 0.041). Patients with a history of COPD (OR 1.97 [95% CI 1.08–3.57]; p = 0.026) or hypertension (OR 1.62 [95% CI 1.10–2.38]; p = 0.013) and those at ASA Class IV (OR 14.6 [95% CI 1.69–125.75]; p = 0.015) were significantly more likely to require readmission within 30 days. The reoperation rates were 1.2% for ACDF and 0.4% for CDR (p = 0.086), and multivariate analysis revealed that CDR was not associated with lower odds of reoperation (OR 0.60 [95% CI 0.14–2.55]; p = 0.492). However, increasing age was associated with a higher risk (OR 1.02 [95% CI 1.00–1.05]; p = 0.031) of reoperation; a 2% increase in risk per year of age was found.

CONCLUSIONS

Patients who underwent single-level ACDF had a higher readmission rate than those who underwent single-level CDR in this study. When stratified according to age, this effect was seen only in the 41- to 60-year age group. No significant difference in the 30-day single-level ACDF and single-level CDR reoperation rates was found. Although patients in the ACDF group were older and sicker, other unmeasured covariates might have accounted for the increased rate of readmission in this group, and further investigation is encouraged.

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Selecting the lowest instrumented vertebra in a multilevel posterior cervical fusion across the cervicothoracic junction: a biomechanical investigation

Yaroslav Gelfand, Daniel Franco, Merritt D. Kinon, Rafael De la Garza Ramos, Reza Yassari, Jonathan A. Harris, Samantha Flamand, Joshua P. McGuckin, Jorge L. Gonzalez, Jonathan M. Mahoney, and Brandon S. Bucklen

OBJECTIVE

Posterior cervical fusion is a common surgical treatment for patients with myeloradiculopathy or regional deformity. Several studies have found increased stresses at the cervicothoracic junction (CTJ) and significantly higher revision surgery rates in multilevel cervical constructs that terminate at C7. The purpose of this study was to investigate the biomechanical effects of selecting C7 versus T1 versus T2 as the lowest instrumented vertebra (LIV) in multisegmental posterior cervicothoracic fusion procedures.

METHODS

Seven fresh-frozen cadaveric cervicothoracic spines (C2–L1) with ribs intact were tested. After analysis of the intact specimens, posterior rods and lateral mass screws were sequentially added to create the following constructs: C3–7 fixation, C3–T1 fixation, and C3–T2 fixation. In vitro flexibility tests were performed to determine the range of motion (ROM) of each group in flexion-extension (FE), lateral bending (LB), and axial rotation (AR), and to measure intradiscal pressure of the distal adjacent level (DAL).

RESULTS

In FE, selecting C7 as the LIV instead of crossing the CTJ resulted in the greatest increase in ROM (2.54°) and pressure (29.57 pound-force per square inch [psi]) at the DAL in the construct relative to the intact specimen. In LB, selecting T1 as the LIV resulted in the greatest increase in motion (0.78°) and the lowest increase in pressure (3.51 psi) at the DAL relative to intact spines. In AR, selecting T2 as the LIV resulted in the greatest increase in motion (0.20°) at the DAL, while selecting T1 as the LIV resulted in the greatest increase in pressure (8.28 psi) in constructs relative to intact specimens. Although these trends did not reach statistical significance, the observed differences were most apparent in FE, where crossing the CTJ resulted in less motion and lower intradiscal pressures at the DAL.

CONCLUSIONS

The present biomechanical cadaveric study demonstrated that a cervical posterior fixation construct with its LIV crossing the CTJ produces less stress in its distal adjacent discs compared with constructs with C7 as the LIV. Future clinical testing is necessary to determine the impact of this finding on patient outcomes.

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Interhospital transfer status for spinal metastasis patients in the United States is associated with more severe clinical presentations and higher rates of inpatient complications

Rafael De la Garza Ramos, Christine Park, Edwin McCray, Meghan Price, Timothy Y. Wang, Tara Dalton, César Baëta, Melissa M. Erickson, Norah Foster, Zach Pennington, John H. Shin, Daniel M. Sciubba, Khoi D. Than, Isaac O. Karikari, Christopher I. Shaffrey, Muhammad M. Abd-El-Barr, Reza Yassari, and C. Rory Goodwin

OBJECTIVE

In patients with metastatic spinal disease (MSD), interhospital transfer can potentially impact clinical outcomes as the possible benefits of transferring a patient to a higher level of care must be weighed against the negative effects associated with potential delays in treatment. While the association of clinical outcomes and transfer status has been examined in other specialties, the relationship between transfer status, complications, and risk of mortality in patients with MSD has yet to be explored. The purpose of this study was to examine the impact of transfer status on in-hospital mortality and clinical outcomes in patients diagnosed with MSD.

METHODS

The National (Nationwide) Inpatient Sample (NIS) database was retrospectively queried for adult patients diagnosed with vertebral pathological fracture and/or spinal cord compression in the setting of metastatic disease between 2012 and 2014. Demographics, baseline characteristics (e.g., metastatic spinal cord compression [MSCC] and paralysis), comorbidities, type of intervention, and relevant patient outcomes were controlled in a multivariable logistic regression model to analyze the association of transfer status with patient outcomes.

RESULTS

Within the 10,360 patients meeting the inclusion and exclusion criteria, higher rates of MSCC (50.2% vs 35.9%, p < 0.001) and paralysis (17.3% vs 8.4%, p < 0.001) were observed in patients transferred between hospitals compared to those directly admitted. In univariable analysis, a higher percentage of transferred patients underwent surgical intervention (p < 0.001) when compared with directly admitted patients. After controlling for significant covariates and surgical intervention, transferred patients were more likely to develop in-hospital complications (OR 1.34, 95% CI 1.18–1.52, p < 0.001), experience prolonged length of stay (OR 1.33, 95% CI 1.16–1.52, p < 0.001), and have a discharge disposition other than home (OR 1.70, 95% CI 1.46–1.98, p < 0.001), with no significant difference in inpatient mortality rates.

CONCLUSIONS

Patients with MSD who were transferred between hospitals demonstrated more severe clinical presentations and higher rates of inpatient complications compared to directly admitted patients, despite demonstrating no difference in in-hospital mortality rates.

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Optimizing the residency application process: insights from neurological surgery during the pandemic virtual application cycle

Robert Romano, Debraj Mukherjee, L. Madison Michael II, Judy Huang, M. Harrison Snyder, Vamsi P. Reddy, Katherine Guzman, Pamela Lane, Jeremiah N. Johnson, Nathan R. Selden, Stacey Q. Wolfe, and on behalf of the Society of Neurological Surgeons

OBJECTIVE

In this article, the authors describe the impact of the COVID-19 virtual match cycle and discuss approaches to optimize future cycles through applicant and neurosurgical education leadership insights.

METHODS

Anonymous surveys of neurosurgery program leaders (program directors and program chairs), program administrators (PAs), and 2020–2021 neurosurgery residency match applicants were distributed by the SNS, in conjunction with the Association of Resident Administrators in Neurological Surgery and AANS Young Neurosurgeons Committee.

RESULTS

Responses were received from 77 (67.0%) of 115 PAs, 119 (51.7%) of 230 program leaders, and 124 (44.3%) of 280 applicants representing geographically diverse regions. During the virtual application cycle relative to the previous year, programs received more Electronic Residency Application Service applications (mean 314.8 vs 285.3, p < 0.0001) and conducted more applicant interviews (mean 45.2 vs 39.9, p = 0.0003). More than 50% of applicants applied to > 80 programs; 60.3% received ≤ 20 interview invitations, and 9% received > 40 invitations. Overall, 65% of applicants completed ≤ 20 interviews, whereas 34.7% completed > 20 interviews. Program leaders described one 4-week home subinternship (93.3%) and two 4-week external subinternships (68.9%) as optimal neurosurgical exposure; 62.8% of program leaders found the standardized letter of recommendation template to be somewhat (47.5%) or significantly (15.3%) helpful. Applicants, PAs, and program leaders all strongly preferred a hybrid model of in-person and virtual interview options for future application cycles over all in-person or all virtual options. Ninety-three percent of applicants reported matching within their top 10–ranked programs, and 52.9% of programs matched residents within the same decile ranking as in previous years.

CONCLUSIONS

Optimizing a national strategy for the neurosurgery application process that prioritizes equity and reduces costs, while ensuring adequate exposure for applicants to gain educational opportunities and evaluate programs, is critical to maintain a successful training system.