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Zachary J. Tempel, Gurpreet S. Gandhoke, Christopher M. Bonfield, David O. Okonkwo and Adam S. Kanter

Object

A hybrid approach of minimally invasive lateral lumbar interbody fusion (LLIF) followed by supplementary open posterior segmental instrumented fusion (PSIF) has shown promising early results in the treatment of adult degenerative scoliosis. Studies assessing the impact of this combined approach on correction of segmental and regional coronal angulation, sagittal realignment, maximum Cobb angle, restoration of lumbar lordosis, and clinical outcomes are needed. The authors report their results of this approach for correction of adult degenerative scoliosis.

Methods

Twenty-six patients underwent combined LLIF and PSIF in a staged fashion. The patient population consisted of 21 women and 5 men. Ages ranged from 40 to 77 years old. Radiographic measurements including coronal angulation, pelvic incidence, lumbar lordosis, and sagittal vertical axis were taken preoperatively and 1 year postoperatively in all patients. Concurrently, the visual analog score (VAS) for back and leg pain, the Oswestry Disability Index (ODI), and Short Form-36 (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores were used to assess clinical outcomes in 19 patients.

Results

At 1-year follow-up, all patients who underwent combined LLIF and PSIF achieved statistically significant mean improvement in regional coronal angles (from 14.9° to 5.8°, p < 0.01) and segmental coronal angulation at all operative levels (p < 0.01). The maximum Cobb angle was significantly reduced postoperatively (from 41.1° to 15.1°, p < 0.05) and was maintained at follow-up (12.0°, p < 0.05). The mean lumbar lordosis–pelvic incidence mismatch was significantly improved postoperatively (from 15.0° to 6.92°, p < 0.05). Although regional lumbar lordosis improved (from 43.0° to 48.8°), it failed to reach statistical significance (p = 0.06). The mean sagittal vertical axis was significantly improved postoperatively (from 59.5 mm to 34.2 mm, p < 0.01). The following scores improved significantly after surgery: VAS for back pain (from 7.5 to 4.3, p < 0.01) and leg pain (from 5.8 to 3.1, p < 0.01), ODI (from 48 to 38, p < 0.01), and PCS (from 27.5 to 35.0, p = 0.01); the MCS score did not improve significantly (from 43.2 to 45.5, p = 0.37). There were 3 major and 10 minor complications.

Conclusions

A hybrid approach of minimally invasive LLIF and open PSIF is an effective means of achieving correction of both coronal and sagittal deformity, resulting in improvement of quality of life in patients with adult degenerative scoliosis.

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Lateral lumbar interbody fusion in the elderly: a 10-year experience

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

Nitin Agarwal, Andrew Faramand, Nima Alan, Zachary J. Tempel, D. Kojo Hamilton, David O. Okonkwo and Adam S. Kanter

OBJECTIVE

Elderly patients, often presenting with multiple medical comorbidities, are touted to be at an increased risk of peri- and postoperative complications following spine surgery. Various minimally invasive surgical techniques have been developed and employed to treat an array of spinal conditions while minimizing complications. Lateral lumbar interbody fusion (LLIF) is one such approach. The authors describe clinical outcomes in patients over the age of 70 years following stand-alone LLIF.

METHODS

A retrospective query of a prospectively maintained database was performed for patients over the age of 70 years who underwent stand-alone LLIF. Patients with posterior segmental fixation and/or fusion were excluded. The preoperative and postoperative values for the Oswestry Disability Index (ODI) were analyzed to compare outcomes after intervention. Femoral neck t-scores were acquired from bone density scans and correlated with the incidence of graft subsidence.

RESULTS

Among the study cohort of 55 patients, the median age at the time of surgery was 74 years (range 70–87 years). Seventeen patients had at least 3 medical comorbidities at surgery. Twenty-three patients underwent a 1-level, 14 a 2-level, and 18 patients a 3-level or greater stand-alone lateral fusion. The median estimated blood loss was 25 ml (range 5–280 ml). No statistically significant relationship was detected between volume of blood loss and the number of operative levels. The median length of hospital stay was 2 days (range 1–4 days). No statistically significant relationship was observed between the length of hospital stay and age at the time of surgery. There was one intraoperative death secondary to cardiac arrest, with a mortality rate of 1.8%. One patient developed a transient femoral nerve injury. Five patients with symptomatic graft subsidence subsequently underwent posterior instrumentation. A lower femoral neck t-score < −1.0 correlated with a higher incidence of graft subsidence (p = 0.006). The mean ODI score 1 year postoperatively of 31.1 was significantly (p = 0.003) less than the mean preoperative ODI score of 46.2.

CONCLUSIONS

Stand-alone LLIF can be safely and effectively performed in the elderly population. Careful evaluation of preoperative bone density parameters should be employed to minimize risk of subsidence and need for additional surgery. Despite an association with increased comorbidities, age alone should not be a deterrent when considering stand-alone LLIF in the elderly population.

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Zachary J. Tempel, Michael M. McDowell, David M. Panczykowski, Gurpreet S. Gandhoke, D. Kojo Hamilton, David O. Okonkwo and Adam S. Kanter

OBJECTIVE

Lateral lumbar interbody fusion (LLIF) is a less invasive surgical option commonly used for a variety of spinal conditions, including in high-risk patient populations. LLIF is often performed as a stand-alone procedure, and may be complicated by graft subsidence, the clinical ramifications of which remain unclear. The aim of this study was to characterize further the sequelae of graft subsidence following stand-alone LLIF.

METHODS

A retrospective review of prospectively collected data was conducted on consecutive patients who underwent stand-alone LLIF between July 2008 and June 2015; 297 patients (623 levels) met inclusion criteria. Imaging studies were examined to grade graft subsidence according to Marchi criteria, and compared between those who required revision surgery and those who did not. Additional variables recorded included levels fused, DEXA (dual-energy x-ray absorptiometry) T-score, body mass index, and routine demographic information. The data were analyzed using the Student t-test, chi-square analysis, and logistic regression analysis to identify potential confounding factors.

RESULTS

Of 297 patients, 34 (11.4%) had radiographic evidence of subsidence and 18 (6.1%) required revision surgery. The median subsidence grade for patients requiring revision surgery was 2.5, compared with 1 for those who did not. Chi-square analysis revealed a significantly higher incidence of revision surgery in patients with high-grade subsidence compared with those with low-grade subsidence. Seven of 18 patients (38.9%) requiring revision surgery suffered a vertebral body fracture. High-grade subsidence was a significant predictor of the need for revision surgery (p < 0.05; OR 12, 95% CI 1.29–13.6), whereas age, body mass index, T-score, and number of levels fused were not. This relationship remained significant despite adjustment for the other variables (OR 14.4; 95% CI 1.30–15.9).

CONCLUSIONS

In this series, more than half of the patients who developed graft subsidence following stand-alone LLIF required revision surgery. When evaluating patients for LLIF, supplemental instrumentation should be considered during the index surgery in patients with a significant risk of graft subsidence.

Restricted access

David J. Salvetti, Zachary J. Tempel, Ezequiel Goldschmidt, Nicole A. Colwell, Federico Angriman, David M. Panczykowski, Nitin Agarwal, Adam S. Kanter and David O. Okonkwo

OBJECTIVE

Nutritional deficiency negatively affects outcomes in many health conditions. In spine surgery, evidence linking preoperative nutritional deficiency to postoperative surgical site infection (SSI) has been limited to small retrospective studies. Authors of the current study analyzed a large consecutive cohort of patients who had undergone elective spine surgery to determine the relationship between a serum biomarker of nutritional status (preoperative prealbumin levels) and SSI.

METHODS

The authors conducted a retrospective review of the electronic medical charts of patients who had undergone posterior spinal surgeries and whose preoperative prealbumin level was available. Additional data pertinent to the risk of SSI were also collected. Patients who developed a postoperative SSI were identified, and risk factors for postoperative SSI were analyzed. Nutritional deficiency was defined as a preoperative serum prealbumin level ≤ 20 mg/dl.

RESULTS

Among a consecutive series of 387 patients who met the study criteria for inclusion, the infection rate for those with preoperative prealbumin ≤ 20 mg/dl was 17.8% (13/73), versus 4.8% (15/314) for those with preoperative prealbumin > 20 mg/dl. On univariate and multivariate analysis a low preoperative prealbumin level was a risk factor for postoperative SSI with a crude OR of 4.29 (p < 0.01) and an adjusted OR of 3.28 (p = 0.02). In addition, several previously known risk factors for infection, including diabetes, spinal fusion, and number of operative levels, were significant for the development of an SSI.

CONCLUSIONS

In this consecutive series, preoperative prealbumin levels, a serum biomarker of nutritional status, correlated with the risk of SSI in elective spine surgery. Prehabilitation before spine surgery, including strategies to improve nutritional status in patients with nutritional deficiencies, may increase value and improve spine care.

Free access

Nitin Agarwal, Prateek Agarwal, Ashley Querry, Anna Mazurkiewicz, Zachary J. Tempel, Robert M. Friedlander, Peter C. Gerszten, D. Kojo Hamilton, David O. Okonkwo and Adam S. Kanter

OBJECTIVE

Previous studies have demonstrated the efficacy of infection prevention protocols in reducing infection rates. This study investigated the effects of the development and implementation of an infection prevention protocol that was augmented by increased physician awareness of spinal fusion surgical site infection (SSI) rates and resultant cost savings.

METHODS

A cohort clinical investigation over a 10-year period was performed at a single tertiary spine care academic institution. Preoperative infection control measures (chlorohexidine gluconate bathing, Staphylococcus aureus nasal screening and decolonization) followed by postoperative infection control measures (surgical dressing care) were implemented. After the implementation of these infection control measures, an awareness intervention was instituted in which all attending and resident neurosurgeons were informed of their individual, independently adjudicated spinal fusion surgery infection rates and rankings among their peers. During the course of these interventions, the overall infection rate was tracked as well as the rates for those neurosurgeons who complied with the preoperative and postoperative infection control measures (protocol group) and those who did not (control group).

RESULTS

With the implementation of postoperative surgical dressing infection control measures and physician awareness, the postoperative spine surgery infection rate decreased by 45% from 3.8% to 2.1% (risk ratio 0.55; 95% CI 0.32–0.93; p = 0.03) for those in the protocol cohort, resulting in an estimated annual cost savings of $291,000. This reduction in infection rate was not observed for neurosurgeons in the control group, although the overall infection rate among all neurosurgeons decreased by 54% from 3.3% to 1.5% (risk ratio 0.46; 95% CI 0.28–0.73; p = 0.0013).

CONCLUSIONS

A novel paradigm for spine surgery infection control combined with physician awareness methods resulted in significantly decreased SSI rates and an associated cost reduction. Thus, information sharing and physician engagement as a supplement to formal infection control measures result in improvements in surgical outcomes and costs.