Lee Onn Chieng, Karthik Madhavan and Steven Vanni
Rheumatoid arthritis (RA) is one of the most debilitating autoimmune diseases affecting the craniovertebral junction (CVJ). Patients predominantly present with myelopathic symptoms and intractable neck pain. The surgical approach traditionally has been either a combined anterior and posterior approach or a posterior-only approach. In this article, the authors review pooled data from the literature and discuss the benefits of the two types of approaches.
A search of the PubMed database was conducted using key words that describe spine deformities in RA and specific spinal interventions. The authors evaluated the neurological outcomes based on the Ranawat scale in both the groups through chi-square analysis. Multiple logistic regression was carried out to further examine for potential confounders. Any adverse sequalae resulting from either approach were also documented. Because all the procedures performed via a transoral approach in the analyzed articles also involved posterior fixation, for convenience of comparison, the combined procedures are referred to as “anterior approach” or “anterior-posterior” in the present study.
The search yielded 233 articles, of which 11 described anterior approaches and 14 evaluated posterior approaches. The statistical analysis showed that patients treated with a posterior approach fared better than those treated with an anterior (combined) approach. It was noted that those patients in whom the cervical subluxations were reducible on traction predominantly underwent posterior approaches.
CVJ instability is a serious complication of RA that requires surgical intervention. Although the anterior-posterior combined approach can provide direct decompression, it is associated with morbidity, and the analysis showed no statistically significant benefit to patients. In contrast, the posterior approach has been shown to provide statistically significant superiority with respect to stabilization and subsequent pannus reduction. Surgical approaches are undertaken based on the reducibility of subluxations with traction and the vector of compressive force. However, the choice of surgical approach should be based on the individual patient's pathology.
Karthik Madhavan, Steven Vanni and Seth K. Williams
The medical management of discitis and osteomyelitis with long-term antibiotic therapy and bracing usually results in eradicated infection. Surgical management is appropriate when medical management fails and in some cases with pyogenic deformity or neurological deficit. The success of surgery depends on adequate debridement of the necrotic infected disc and vertebral body, along with anterior column reconstruction and vertebral stabilization. Debridement is typically performed via an anterior retroperitoneal approach, which can necessitate mobilization of the great vessels for proper exposure. Mobilization can be technically difficult and lead to vascular injury. The purpose of this study was to evaluate an alternative technique for the surgical treatment of lumbar discitis and osteomyelitis using a direct lateral retroperitoneal approach, which allows for thorough debridement and anterior column reconstruction while avoiding the need to mobilize the great vessels.
A retrospective chart analysis was performed for all patients who had presented with lumbar discitis and osteomyelitis and had undergone surgical management via the direct lateral retroperitoneal approach in the period from 2006 to 2013. Collected data included surgical blood loss, perioperative complications (wound infection, vascular injury, approach-related complications, and neurological injury), need for secondary procedures, microbiological and laboratory results, and efficacy of infection eradication. Imaging studies were reviewed as well.
Ten patients, 7 male and 3 female, underwent this procedure at the authors' institution in the defined period. Average blood loss was 272 ml (range 150–800 ml, with 800 ml in the only 2-level case). There were no vascular injuries. Average follow-up was 680 days, although 4 patients did not complete the follow-up beyond 6 months. Eight patients underwent immediate posterior pedicle screw instrumentation. Two patients did not undergo posterior instrumentation, and one of these developed a kyphotic deformity that required a secondary posterior procedure. Infection was eradicated in all patients according to a history, physical examination, imaging studies, and laboratory parameters (complete blood count, erythrocyte sedimentation rate, and C-reactive protein). One patient developed a painful neuroma at the iliac crest harvest site, and one patient had a retroperitoneal hematoma. Otherwise, there were no approach-related neurological injuries or complications. Neither was there any postoperative surgical site infection.
The direct lateral approach for the surgical treatment of lumbar discitis and osteomyelitis allows for thorough debridement and spinal reconstruction without the need to mobilize the great vessels. This technique effectively eradicated infection in all cases, with reasonable blood loss and no vascular injuries. This approach should be considered as an alternative to the open anterior approach. The authors recommend posterior instrumentation to prevent the development of kyphosis.
Michael Y. Wang, Barth A. Green, Sachin Shah, D.O. Steven Vanni and Allan D. O. Levi
An aging population will require that surgeons increasingly consider operative intervention in elderly patients. To perform this surgery safely will require an understanding of the factors that predict successful outcomes as well as complications.
Records of patients older than the age of 75 years who underwent lumbar spinal stenosis surgery were retrospectively reviewed. Preexisting medical illnesses were analyzed using the Charlson Weighted Comorbidity Index. Ambulatory function was rated on a four-point scale. Statistical analysis was performed using a one-tailed t-test with unpaired variance.
Eighty-eight patients treated between 1994 and 2001 were identified. Forty-five percent were women and 52 patients underwent spinal fusion. The follow-up period averaged 21 months. Back pain was present preoperatively in 89%; after surgery 43% experienced complete relief and 33% partial improvement. Leg pain was present preoperatively in 98%; after surgery 43% experienced complete relief and 42% partial improvement. Of the 33 patients with preoperative gait disturbances, 61% improved at least one point on the ambulatory scale. Wound complications and systemic complications were demonstrated in 24 and 16 patients, respectively. There were no deaths. Age (p = 0.322), number of fused levels (p = 0.371), and the number of laminectomy levels (p = 0.254) were not predictive of complications. Length of operative time (p = 0.003) and the CharlsonWeighted Comorbidity Index score (p = 0.088) were associated with both systemic and wound complications.
Surgery in patients older than age 75 years can be conducted safely and with similar outcome rates as in younger patients. The CharlsonWeighted Comorbidity Index score and operative time were predictive of the risk of complications.
Joseph R. O'Brien and William D. Smith