There is evidence that the neurosurgical procedure of cranioplasty is as ancient as its better-known counterpart, trephination. With origins in pre-Incan Peru, cranioplasty remains an important reconstructive procedure for modern craniofacial surgery teams to master. Solutions to the often challenging problem of repairing skull defects continue to evolve to improve patient outcomes. Throughout recorded history, advances in cranioplasty have paralleled major military conflicts due to survivorship after trephination or decompressive craniectomy. Primitive skull coverings used in Peru were later replaced during the Middle Ages by grafts obtained in animals and humans. Improved survivorship secondary to advances in anesthesia and battlefield medicine during the Crimean War and the American Civil War allowed the use of tantalum and acrylic cranioplasty to evolve during World Wars I and II. In the modern era of the Iraq and Afghanistan conflicts, greater survivorship after cranial injury due to improvements in protective armor, medical evacuation, and early “far-forward” neurosurgical treatment have occurred. Consequently, the last decade has seen great advancement in cranial defect reconstruction, including custom-fabricated alloplast implants and the emergence of regenerative cranial treatments such as distraction osteogenesis, protected bone regeneration, and free tissue transfers. Comprehensive rehabilitation after neurotrauma has emerged as the new standard of care.
Christopher M. Bonfield, Anand R. Kumar and Peter C. Gerszten
Matthew B. Maserati, Matthew J. Tormenti, David M. Panczykowski, Christopher M. Bonfield and Peter C. Gerszten
The authors report the use and preliminary results of a novel hybrid dynamic stabilization and fusion construct for the surgical treatment of degenerative lumbar spine pathology.
The authors performed a retrospective chart review of all patients who underwent posterior lumbar instrumentation with the Dynesys-to-Optima (DTO) hybrid dynamic stabilization and fusion system. Preoperative symptoms, visual analog scale (VAS) pain scores, perioperative complications, and the need for subsequent revision surgery were recorded. Each patient was then contacted via telephone to determine current symptoms and VAS score. Follow-up was available for 22 of 24 patients, and the follow-up period ranged from 1 to 22 months. Clinical outcome was gauged by comparing VAS scores prior to surgery and at the time of telephone interview.
A total of 24 consecutive patients underwent lumbar arthrodesis surgery in which the hybrid system was used for adjacent-level dynamic stabilization. The mean preoperative VAS score was 8.8, whereas the mean postoperative VAS score was 5.3. There were five perioperative complications that included 2 durotomies and 2 wound infections. In addition, 1 patient had a symptomatic medially placed pedicle screw that required revision. These complications were not thought to be specific to the DTO system itself. In 3 patients treatment failed, with treatment failure being defined as persistent preoperative symptoms requiring reoperation.
The DTO system represents a novel hybrid dynamic stabilization and fusion construct. The technique holds promise as an alternative to multilevel lumbar arthrodesis while potentially decreasing the risk of adjacent-segment disease following lumbar arthrodesis. The technology is still in its infancy and therefore follow-up, when available, remains short. The authors report their preliminary experience using a hybrid system in 24 patients, along with short-interval clinical and radiographic follow-up.
Matthew J. Tormenti, Matthew B. Maserati, Christopher M. Bonfield, Peter C. Gerszten, John J. Moossy, Adam S. Kanter, Richard M. Spiro and David O. Okonkwo
Since its original description in 1982, transforaminal lumbar interbody fusion (TLIF) has grown in popularity as a means for achieving circumferential fusion. The authors sought to define the perioperative complication rates of the TLIF procedure at a large academic medical center.
For all eligible patients from a consecutive series of 531 TLIF procedures, the institution's complication database and the medical record were reviewed to identify complications. Medical, nonprocedure-related complications such as myocardial infarction and pulmonary embolism were excluded due to inconsistency in the recording of these complications in the database. Rates were calculated for each type of complication, and subgroup analysis was performed to investigate the effect of previous lumbar surgery, and of multilevel versus single-level interbody fusion on complication rates. Odds ratios were calculated and evaluated using chi-square analysis.
Five hundred thirty-one patients underwent a TLIF procedure during the study period. Two hundred forty-four patients (46%) had undergone a previous lumbar operation. Interbody fusion was performed at 1 level in 317 patients, at 2 levels in 188 patients, at 3 levels in 24 patients, and at 4 levels in 2 patients. One hundred thirty-five patients (25.4%) had at least one procedure-related complication. The most common complications were durotomy (14.3% of patients) and infection (3.8% of patients). Symptomatic screw misplacement (2.1% of patients) and interbody cage migration (1.8% of patients) were less common complications. The overall complication rate was greater in those patients who had undergone a previous operation (OR 1.75, 95% CI 1.18–2.59; p < 0.01) and in those who had multilevel surgery (OR 1.54, 95 % CI 1.04–2.28; p = 0.03), and the incidence of durotomy was higher in patients who had a previous operation (OR 1.75, 95% CI 1.07–2.87; p = 0.03). These differences were statistically significant. Durotomy also occurred more frequently in patients who had multilevel interbody fusion (OR 1.49, 95% CI 0.92–2.43; p = 0.13). A trend toward higher infection rates in those patients who underwent multilevel interbody fusion was observed (OR 1.5, 95% CI 0.62–3.68; p = 0.49), but this was not statistically significant. Infection rates did not differ between revision and first-time surgeries.
Transforaminal lumbar interbody fusion has gained widespread popularity as a procedure for achieving arthrodesis in the lumbar spine. Complications occurred more often in patients undergoing revision surgery or multilevel interbody fusion. Durotomy and infection were the most common complications in this series.