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  • Author or Editor: Charles A. Sansur x
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Andrei F. Joaquim, Catherine C. Shaffrey, Charles A. Sansur and Christopher I. Shaffrey

The authors report a case of man-in-the-barrel (MIB) syndrome occurring after an extensive revision involving thoracoilium instrumentation and fusion for iatrogenic and degenerative scoliosis, progressive kyphosis, and sagittal imbalance. Isolated brachial diplegia is a rare neurological finding often attributed to cerebral ischemia. It has not been previously reported in patients undergoing complex spine surgery. This 70-year-old woman, who had previously undergone T11–S1 fusion for lumbar stenosis and scoliosis, presented with increased difficulty walking and with back pain. She had junctional kyphosis and L5–S1 pseudarthrosis and required revision fusion extending from T-3 to the ilium. In the early postoperative period, she experienced a 30-minute episode of substantial hypotension. She developed delirium and isolated brachial diplegia, consistent with MIB syndrome. Multiple studies were performed to assess the origin of this brachial diplegia. There was no definitive radiological evidence of any causative lesion. After a few days, her cognitive function returned to normal and she regained the ability to move her arms. After several weeks of rehabilitation, she recovered completely. Man-in-the-barrel syndrome is a rare neurological entity. It can result from various mechanisms but most commonly seems to be related to ischemia and is potentially reversible.

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D. Kojo Hamilton, Justin S. Smith, Charles A. Sansur, Aaron S. Dumont and Christopher I. Shaffrey

Object

The originally described technique of atlantoaxial stabilization using C-1 lateral mass and C-2 pars screws includes a C-2 neurectomy to provide adequate hemostasis and visualization for screw placement, enable adequate joint decortication and arthrodesis, and prevent new-onset postoperative C-2 neuralgia. However, inclusion of a C-2 neurectomy for this procedure remains controversial, likely due in part to a lack of studies that have specifically addressed whether it affects patient outcome. The authors' objective was to assess the surgical and clinical impact of routine C-2 neurectomy performed with C1–2 segmental instrumented arthrodesis in a consecutive series of elderly patients with C1–2 instability.

Methods

Forty-four consecutive patients (mean age 71 years) underwent C1–2 instrumented fusion, including C-1 lateral mass screw insertion. Bilateral C-2 neurectomies were performed. Standardized clinical assessments were performed both pre- and postoperatively. Numbness or discomfort in a C-2 distribution was documented at follow-up. Fusion was assessed using the Lenke fusion grade.

Results

Among all 44 patients, mean blood loss was 200 ml (range 100–350 ml) and mean operative time was 129 minutes (range 87–240 minutes). There were no intraoperative complications, and no patients reported new postoperative onset or worsening of C-2 neuralgia postoperatively. Outcomes for the 30 patients with a minimum 13-month follow-up (range 13–72 months) were assessed. At a mean follow-up of 36 months, Nurick grade and pain numeric rating scale scores improved from 3.7 to 1.0 (p < 0.001) and 9.4 to 0.6 (p < 0.001), respectively. The mean postoperative Neck Disability Index score was 7.3%. The fusion rate was 97%, and the patient satisfaction rate was 93%. All 24 patients with preoperative occipital neuralgia reported relief. Seventeen patients noticed C-2 distribution numbness only during examination in the clinic, and 2 patients reported C-2 numbness, but it did not affect their daily function.

Conclusions

In this series of C1–2 instrumented arthrodesis in elderly patients, excellent fusion rates were achieved, and patient satisfaction was not negatively affected by C-2 neurectomy. In the authors' experience, C-2 neurectomy enhanced surgical exposure of the C1–2 joint, thereby facilitating hemostasis, placement of instrumentation, and decortication of the joint space for arthrodesis. Importantly, with C-2 neurectomy in the present series, no cases of new onset postoperative C-2 neuralgia occurred, in contrast to a growing number of reports in the literature documenting new-onset C-2 neuralgia without C-2 neurectomy. On the contrary, 80% of patients in the present series had preoperative occipital neuralgia and in all of these patients this neuralgia was relieved following C1–2 instrumented arthrodesis with C-2 neurectomy.

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Charles A. Sansur, Kai-Ming G. Fu, Rod J. Oskouian Jr., Jay Jagannathan, Charles Kuntz iv and Christopher I. Shaffrey

✓ Ankylosing spondylitis (AS) is an inflammatory rheumatic disease whose primary effect is on the axial skeleton, causing sagittal-plane deformity at both the thoracolumbar and cervicothoracic junctions. In the present review article the authors discuss current concepts in the preoperative planning of patients with AS. The authors also review current techniques used to treat sagittal-plane deformity, focusing on pedicle subtraction osteotomy at the thoracolumbar junction, as well as cervical extension osteotomy at the cervicothoracic junction.

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Jay Jagannathan, Christopher I. Shaffrey, Rod J. Oskouian, Aaron S. Dumont, Christian Herrold, Charles A. Sansur and John A. Jane Sr.

Object

Although the clinical outcomes following anterior cervical discectomy and fusion (ACDF) surgery are generally good, 2 major complications are graft migration and nonunion. These complications have led some to advocate rigid internal fixation and/or cervical immobilization postoperatively. This paper examines a single-surgeon experience with single-level ACDF without use of plates or hard collars in patients with degenerative spondylosis in whom allograft was used as the fusion material.

Methods

The authors conducted a retrospective review of a prospective database of (Cloward-type) ACDF operations performed by the senior author (J.A.J.) between July 1996 and June 2005. Radiographic follow-up included static and flexion/extension radiographs obtained to assess fusion, focal and segmental kyphosis, and change in disc space height. At most recent follow-up, the patients' condition was evaluated by an independent physician examiner. The Odom criteria and Neck Disability Index (NDI) were used to assess outcome.

Results

One hundred seventy patients underwent single-level ACDF for degenerative pathology during the study period. Their most common presenting symptoms were pain, weakness, and radiculopathy; 88% of patients noted ≥ 2 neurological complaints. The mean hospital stay was 1.76 days (range 0–36 days), and 3 patients (2%) had major immediate postoperative complications requiring reoperation. The mean duration of follow-up was 22 months (range 12–124 months). Radiographic evidence of fusion was present in 160 patients (94%). Seven patients (4%) showed radiographic evidence of pseudarthrosis, and graft migration was seen in 3 patients (2%). All patients had increases in focal kyphosis at the operated level on postoperative radiographs (mean −7.4°), although segmental alignment was preserved in 133 patients (78%). Mean change in disc space height was 36.5% (range 28–53%). At most recent clinical follow-up, 122 patients (72%) had no complaints referable to cervical disease and were able to carry out their activities of daily living without impairment. The mean postoperative NDI score was 3.2 (median 3, range 0–31).

Conclusions

Single-level ACDF without intraoperative plate placement or the use of a postoperative collar is an effective treatment for cervical spondylosis. Although there is evidence of focal kyphosis and loss of disc space height, radiographic evidence of fusion is comparable to that attained with plate fixation, and the rate of clinical improvement is high.

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Editorial

Surgical complications in adult spondylolisthesis

Michael G. Fehlings and Doron Rabin

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Jay Jagannathan, Ekawut Chankaew, Peter Urban, Aaron S. Dumont, Charles A. Sansur, John Kern, Benjamin Peeler, W. Jeffrey Elias, Francis Shen, Mark E. Shaffrey, Richard Whitehill, Vincent Arlet and Christopher I. Shaffrey

Object

In this paper, the authors review the functional and cosmetic outcomes and complications in 300 patients who underwent treatment for lumbar spine disease via either an anterior paramedian or conventional anterolateral retroperitoneal approach.

Methods

Seven surgeons performed anterior lumbar surgeries in 300 patients between August 2004 and December 2006. One hundred and eighty patients were treated with an anterior paramedian approach, and 120 patients with an anterolateral retroperitoneal approach. An access surgeon was used in 220 cases (74%). Postoperative evaluation in all patients consisted of clinic visits, assessment with the modified Scoliosis Research Society–30 instrument, as well as a specific questionnaire relating to wound appearance and patient satisfaction with the wound.

Results

At a mean follow-up of 31 months (range 12–47 months), the mean Scoliosis Research Society–30 score (out of 25) was 21.2 in the patients who had undergone the anterior paramedian approach and 19.4 in those who had undergone the anterolateral retroperitoneal approach (p = 0.005). The largest differences in quality of life measures were observed in the areas of pain control (p = 0.001), self-image (p = 0.004), and functional activity (p = 0.003), with the anterior paramedian group having higher scores in all 3 categories. Abdominal bulging in the vicinity of the surgical site was the most common wound complication observed and was reported by 22 patients in the anterolateral retroperitoneal group (18%), and 2 patients (1.1%) in the anterior paramedian group. Exposures of ≥ 3 levels with the anterolateral approach were associated with abdominal bulging (p = 0.04), while 1- or 2-level exposures were not (p > 0.05). Overall satisfaction with incisional appearance was higher in patients with an anterior paramedian incision (p = 0.001) and with approaches performed by an access surgeon (p = 0.004).

Conclusions

Patients who undergo an anterior paramedian approach to the lumbar spine have a higher quality of life and better cosmetic outcomes than patients undergoing an anterolateral retroperitoneal approach.

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Rod J. Oskouian Jr., Christopher I. Shaffrey, Richard Whitehill, Charles A. Sansur, Nader Pouratian, Adam S. Kanter, Ashok R. Asthagiri, Aaron S. Dumont, Jason P. Sheehan, W. Jeffrey Elias and Mark E. Shaffrey

Object

The purpose of this study was to evaluate the results obtained in patients who underwent anterior stabilization for three-column thoracolumbar fractures.

Methods

The authors retrospectively reviewed available clinical and radiographic data (1997–2006) to classify three-column thoracolumbar fractures according to the Association for the Study of Internal Fixation (AO) system, neurological status, spinal canal compromise, pre- and postoperative segmental angulation, and arthrodesis rate.

The mean computed tomography–measured preoperative spinal canal compromise was 48.3% (range 8–92%), and the mean vertebral body height loss was 39.4%. The mean preoperative kyphotic deformity of 14.9° improved to 4.6° at the final follow-up examination. Although this angulation had increased a mean of 1.8° during the follow-up period, the extent of correction was still significant compared with the preoperative angulation (p < 0.01). There were no cases of vascular complication or neurological deterioration.

Conclusions

Contemporary anterior spinal reconstruction techniques can allow certain types of unstable three-column thoracolumbar fractures to be treated via an anterior approach alone. Compared with traditional posterior approaches, the anterior route spares lumbar motion segments and obviates the need for harvesting of the iliac crest.

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Charles A. Sansur, Davis L. Reames, Justin S. Smith, D. Kojo Hamilton, Sigurd H. Berven, Paul A. Broadstone, Theodore J. Choma, Michael James Goytan, Hilali H. Noordeen, Dennis Raymond Knapp Jr., Robert A. Hart, Reinhard D. Zeller, William F. Donaldson III, David W. Polly Jr., Joseph H. Perra, Oheneba Boachie-Adjei and Christopher I. Shaffrey

Object

This is a retrospective review of 10,242 adults with degenerative spondylolisthesis (DS) and isthmic spondylolisthesis (IS) from the morbidity and mortality (M&M) index of the Scoliosis Research Society (SRS). This database was reviewed to assess complication incidence, and to identify factors that were associated with increased complication rates.

Methods

The SRS M&M database was queried to identify cases of DS and IS treated between 2004 and 2007. Complications were identified and analyzed based on age, surgical approach, spondylolisthesis type/grade, and history of previous surgery. Age was stratified into 2 categories: > 65 years and ≤ 65 years. Surgical approach was stratified into the following categories: decompression without fusion, anterior, anterior/posterior, posterior without instrumentation, posterior with instrumentation, and interbody fusion. Spondylolisthesis grades were divided into low-grade (Meyerding I and II) versus high-grade (Meyerding III, IV, and V) groups. Both univariate and multivariate analyses were performed.

Results

In the 10,242 cases of DS and IS reported, there were 945 complications (9.2%) in 813 patients (7.9%). The most common complications were dural tears, wound infections, implant complications, and neurological complications (range 0.7%–2.1%). The mortality rate was 0.1%. Diagnosis of DS had a significantly higher complication rate (8.5%) when compared with IS (6.6%; p = 0.002). High-grade spondylolisthesis correlated strongly with a higher complication rate (22.9% vs 8.3%, p < 0.0001). Age > 65 years was associated with a significantly higher complication rate (p = 0.02). History of previous surgery and surgical approach were not significantly associated with higher complication rates. On multivariate analysis, only the grade of spondylolisthesis (low vs high) was in the final best-fit model of factors associated with the occurrence of complications (p < 0.0001).

Conclusions

The rate of total complications for treatment of DS and IS in this series was 9.2%. The total percentage of patients with complications was 7.9%. On univariate analysis, the complication rate was significantly higher in patients with high-grade spondylolisthesis, a diagnosis of DS, and in older patients. Surgical approach and history of previous surgery were not significantly correlated with increased complication rates. On multivariate analysis, only the grade of spondylolisthesis was significantly associated with the occurrence of complications.

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Kai-Ming G. Fu, Justin S. Smith, David W. Polly Jr., Joseph H. Perra, Charles A. Sansur, Sigurd H. Berven, Paul A. Broadstone, Theodore J. Choma, Michael J. Goytan, Hilali H. Noordeen, D. Raymond Knapp Jr., Robert A. Hart, Reinhard D. Zeller, William F. Donaldson III, Oheneba Boachie-Adjei and Christopher I. Shaffrey

Object

The purpose of this study was to evaluate the prospectively collected Scoliosis Research Society (SRS) database to assess the incidences of morbidity and mortality (M&M) in the operative treatment of degenerative lumbar stenosis, one of the most common procedures performed by spine surgeons.

Methods

All patients who underwent surgical treatment for degenerative lumbar stenosis between 2004 and 2007 were identified from the SRS M&M database. Inclusion criteria for analysis included an age ≥ 21 years and no history of lumbar surgery. Patients were treated with either decompression alone or decompression with concomitant fusion. Statistical comparisons were performed using a 2-sided Fisher exact test.

Results

Of the 10,329 patients who met the inclusion criteria, 6609 (64%) were treated with decompression alone, and 3720 (36%) were treated with decompression and fusion. Among those who underwent fusion, instrumentation was placed in 3377 (91%). The overall mean patient age was 63 ± 13 years (range 21–96 years). Seven hundred nineteen complications (7.0%), including 13 deaths (0.1%), were identified. New neurological deficits were reported in 0.6% of patients. Deaths were related to cardiac (4 cases), respiratory (5 cases), pulmonary embolus (2 cases), and sepsis (1 case) etiologies, and a perforated gastric ulcer (1 case). Complication rates did not differ based on patient age or whether fusion was performed. Minimally invasive procedures were associated with fewer complications and fewer new neurological deficits (p = 0.01 and 0.03, respectively).

Conclusions

The results from this analysis of the SRS M&M database provide surgeons with useful information for preoperative counseling of patients contemplating surgical intervention for symptomatic degenerative lumbar stenosis.