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Adam S. Kanter and Praveen V. Mummaneni

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Adam S. Kanter, Michael Y. Wang and Praveen V. Mummaneni

Object

Patients with ankylosing spondylitis (AS) who present with cervical spine fractures represent a unique challenge to spine surgeons. These injuries often result in neurological deficits that necessitate early and aggressive surgical management with posterior and/or anterior fixation. The authors introduce a clinical problem-solving algorithm to assist in the surgical management of instability and deformity in this exigent patient population.

Methods

Thirteen patients with AS and fractures of the cervical spine were radiographically evaluated to determine if spinal realignment was obtainable with cervical manipulation or traction. Seven patients had flexible deformities that were stabilized with either anterior or posterior fixation only, and 6 patients had fixed deformities and required circumferential anterior–posterior instrumentation. All patients were observed for neurological outcome, radiographic evidence of bone fusion, and complications.

Results

With the use of the authors' treatment algorithm, all patients were able to achieve satisfactory spinal realignment and bone fusion; 92% of patients achieved postoperative stability or improvement in Nurick and modified Japanese Orthopaedic Association scale scores. One patient experienced neurological deterioration following surgery, and 1 patient died at an acute rehabilitative facility following discharge.

Conclusions

Patients with AS are highly susceptible to extensive neurological injury and spinal deformity after sustaining cervical fractures from even minor traumatic forces. These injuries are uniquely complex in nature and require considerable scrutiny and aggressive surgical management to optimize spinal stability and functional outcomes. The authors' clinical problem-solving algorithm will assist spine surgeons in providing optimal care in this difficult population.

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Vincent Y. Wang, Adam S. Kanter and Praveen V. Mummaneni

✓Ossified ligamentum flavum (OLF) in the thoracic spine is a rare cause of myelopathy, often presenting with progressive symptomatology over an extended period of time. Surgical decompression via wide laminectomy has been the mainstay of treatment for this symptomatic disease phenomenon, but complications such as kyphotic deformity have developed due to extensive bone removal and release of the posterior tension band. The authors present a case of OLF excised via a minimally invasive microsurgical approach in which an expandable tubular retractor system was used. This approach enables complete decompression of the spinal canal while minimizing nerve, vascular, and musculoskeletal disruption, thus maintaining the native biomechanical disposition of the intact vertebral column.

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H. Michael Keyoung, Adam S. Kanter and Praveen V. Mummaneni

✓There are many potential risks associated with spinal deformity correction procedures including transient and/or permanent neurological deficits. Typically, neurological deficits caused by the surgical correction of spinal kyphosis occur acutely during surgery or immediately after surgery. Delayed postoperative neurological deficits are extremely rare.

The authors report a case of delayed neurological deficit that occurred 48 hours after surgical correction of thoracic hyperkyphosis. An 18-year-old man with myotonic dystrophy presented with a 110° T7–L1 kyphosis. The patient underwent an uneventful two-stage correction procedure of the hyperkyphotic deformity. First, anterior discectomies and fusion were performed from T-7 to L-1 using rib autograft, and all segmental vessels were preserved. Subsequently, on the same day, the patient underwent posterior Smith–Petersen osteotomies and T7–L2 pedicle screw fixation. Intact somatosensory and motor evoked potentials were maintained throughout both operations. Postoperatively, he remained neurologically intact without sequelae for nearly 48 hours. On postoperative Day 2, the patient developed delayed monoplegia of the left leg and sensory level loss below T-10.

Medical management enabled complete reversal of the patient's monoplegia and sensory loss. At 2-year follow-up, the patient had no adverse neurological sequelae.

In this case, a delayed postoperative neurological deficit occurred following spinal hyperkyphosis correction. The authors discuss the possible etiological mechanisms behind this complication and suggest strategies for its management.

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Stephen M. Pirris, Sanjay Dhall, Praveen V. Mummaneni and Adam S. Kanter

Surgical access to extraforaminal lumbar disc herniations is complicated due to the unique anatomical constraints of the region. Minimizing complications during microdiscectomies at the level of L5–S1 in particular remains a challenge. The authors report on a small series of patients and provide a video presentation of a minimally invasive approach to L5–S1 extraforaminal lumbar disc herniations utilizing a tubular retractor with microscopic visualization.

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John H. Chi, Sanjay S. Dhall, Adam S. Kanter and Praveen V. Mummaneni

Object

Thoracic disc herniations can be surgically treated with a number of different techniques and approaches. However, surgical outcomes comparing the various techniques are rarely reported in the literature. The authors describe a minimally invasive technique to approach thoracic disc herniations via a transpedicular route with the use of tubular retractors and microscope visualization. This technique provides a safe method to identify the thoracic disc space and perform a decompression with minimal paraspinal soft tissue disruption. The authors compare the results of this approach with clinical results after open transpedicular discectomy.

Methods

The authors performed a retrospective cohort study comparing results in 11 patients with symptomatic thoracic disc herniations treated with either open posterolateral (4 patients) or mini-open transpedicular discectomy (7 patients). Hospital stay, blood loss, modified Prolo score, and Frankel score were used as outcome variables.

Results

Patients who underwent mini-open transpedicular discectomy had less blood loss and showed greater improvement in modified Prolo scores (p = 0.024 and p = 0.05, respectively) than those who underwent open transpedicular discectomy at the time of early follow-up within 1 year of surgery. However, at an average of 18 months of follow-up, the Prolo score difference between the 2 surgical groups was not statistically significant. There were no major or minor surgical complications in the patients who received the minimally invasive technique.

Conclusions

The mini-open transpedicular discectomy for thoracic disc herniations results in better modified Prolo scores at early postoperative intervals and less blood loss during surgery than open posterolateral discectomy. The authors' technique is described in detail and an intraoperative video is provided.

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Fred C. Lam, Adam S. Kanter, David O. Okonkwo, James W. Ogilvie and Praveen V. Mummaneni

In the first part of this 2-part historical review, the authors outlined the early diagnostic and therapeutic strategies used in the management of spinal deformity. In this second part, they expand upon those early innovations and further detail the advances from 1990 to the modern era.

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Adam S. Kanter, David S. Bradford, David O. Okonkwo, Setti S. Rengachary and Praveen V. Mummaneni

Seven millennia of anthropological artifacts and historical tales reference human spinal deformity, its diagnosis, and treatment—many of the latter of which turned out to be worse than the deformity itself. From Hippocrates to Harrington to the 21st century, the literature base has expanded in exponential fashion to yield an imperfect but constantly improving body of evidence, experience, and understanding of this challenging disease phenomenon. This review details the pre-1990 innovations, whose failures and successes have equally contributed to the advancement and dissemination of the increasingly evidence-based field of spinal deformity.

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The comprehensive anatomical spinal osteotomy and anterior column realignment classification

Presented at the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Juan S. Uribe, Frank Schwab, Gregory M. Mundis Jr., David S. Xu, Jacob Januszewski, Adam S. Kanter, David O. Okonkwo, Serena S. Hu, Deviren Vedat, Robert Eastlack, Pedro Berjano and Praveen V. Mummaneni

OBJECTIVE

Spinal osteotomies and anterior column realignment (ACR) are procedures that allow preservation or restoration of spine lordosis. Variations of these techniques enable different degrees of segmental, regional, and global sagittal realignment. The authors propose a comprehensive anatomical classification system for ACR and its variants based on the level of technical complexity and invasiveness. This serves as a common language and platform to standardize clinical and radiographic outcomes for the utilization of ACR.

METHODS

The proposed classification is based on 6 anatomical grades of ACR, including anterior longitudinal ligament (ALL) release, with varying degrees of posterior column release or osteotomies. Additionally, a surgical approach (anterior, lateral, or posterior) was added. Reliability of the classification was evaluated by an analysis of 16 clinical cases, rated twice by 14 different spine surgeons, and calculation of Fleiss kappa coefficients.

RESULTS

The 6 grades of ACR are as follows: grade A, ALL release with hyperlordotic cage, intact posterior elements; grade 1 (ACR + Schwab grade 1), additional resection of the inferior facet and joint capsule; grade 2 (ACR + Schwab grade 2), additional resection of both superior and inferior facets, interspinous ligament, ligamentum flavum, lamina, and spinous process; grade 3 (ACR + Schwab grade 3), additional adjacent-level 3-column osteotomy including pedicle subtraction osteotomy; grade 4 (ACR + Schwab grade 4), 2-level distal 3-column osteotomy including pedicle subtraction osteotomy and disc space resection; and grade 5 (ACR + Schwab grade 5), complete or partial removal of a vertebral body and both adjacent discs with or without posterior element resection. Intraobserver and interobserver reliability were 97% and 98%, respectively, across the 14-reviewer cohort.

CONCLUSIONS

The proposed anatomical realignment classification provides a consistent description of the various posterior and anterior column release/osteotomies. This reliability study confirmed that the classification is consistent and reproducible across a diverse group of spine surgeons.

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Khoi D. Than, Praveen V. Mummaneni, Kelly J. Bridges, Stacie Tran, Paul Park, Dean Chou, Frank La Marca, Juan S. Uribe, Todd D. Vogel, Pierce D. Nunley, Robert K. Eastlack, Neel Anand, David O. Okonkwo, Adam S. Kanter and Gregory M. Mundis Jr.

OBJECTIVE

High-quality studies that compare outcomes of open and minimally invasively placed pedicle screws for adult spinal deformity are needed. Therefore, the authors compared differences in complications from a circumferential minimally invasive spine (MIS) surgery and those from a hybrid surgery.

METHODS

A retrospective review of a multicenter database of patients with spinal deformity who were treated with an MIS surgery was performed. Database inclusion criteria included an age of ≥ 18 years and at least 1 of the following: a coronal Cobb angle of > 20°, a sagittal vertical axis of > 5 cm, a pelvic incidence–lumbar lordosis angle of > 10°, and/or a pelvic tilt of > 20°. Patients were propensity matched according to the levels instrumented.

RESULTS

In this database, a complete data set was available for 165 patients, and after those who underwent 3-column osteotomy were excluded, 137 patients were available for analysis; 76 patients remained after propensity matching (MIS surgery group 38 patients, hybrid surgery group 38 patients). The authors found no difference in demographics, number of levels instrumented, or preoperative and postoperative radiographic results. At least 1 complication was suffered by 55.3% of patients in the hybrid surgery group and 44.7% of those in the MIS surgery group (p = 0.359). Patients in the MIS surgery group had significantly fewer neurological, operative, and minor complications than those in the hybrid surgery group. The reoperation rates in both groups were similar. The most common complication category for the MIS surgery group was radiographic and for the hybrid surgery group was neurological. Patients in both groups experienced postoperative improvement in their Oswestry Disability Index and visual analog scale (VAS) back and leg pain scores (all p < 0.05); however, MIS surgery provided a greater reduction in leg pain according to VAS scores.

CONCLUSIONS

Overall complication rates in the MIS and hybrid surgery groups were similar. MIS surgery resulted in significantly fewer neurological, operative, and minor complications. Reoperation rates in the 2 groups were similar, and despite complications, the patients reported significant improvement in their pain and function.