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Max C. Lee, Michael Y. Wang, Richard G. Fessler, Jason Liauw and Daniel H. Kim

Object

Placement of instrumentation in the setting of a spinal infection has always been controversial. Although the use of allograft and autograft bone has been accepted as safe, demonstrations of the effectiveness of titanium have been speculative, based on several retrospective reviews. The authors' goal in this study was to demonstrate the effectiveness of instrumentation in the setting of a spinal infection by retrospectively reviewing their cases over the last 4 years and searching the literature regarding instrumentation in patients with pyogenic spinal infections.

Methods

The authors conducted a retrospective review of their cumulative data on spinal infections. Diagnosis was based on subjective and objective clinical findings, along with radiographic and laboratory evaluation of infection and mechanical stability. Patients with medically managed disease and those who did not receive instrumentation were eliminated from this review.

Of 105 patients with spinal infections who were admitted to the neurosurgical service between January 2000 and June 2004, 30 underwent surgical debridement necessitating spinal instrumentation. There were 17 women and 13 men in this group ranging from 28 to 86 years of age. Follow-up duration ranged from 3 to 54 months. There was one death, which occurred 3 months postsurgery. In three patients a deep wound infection developed, necessitating intervention, and two patients experienced a graft expulsion. Twenty-nine patients went on to demonstrate adequate fusion based on follow-up neuroimaging studies.

Conclusions

The goal of neurosurgical intervention in the setting of spinal infection is to obtain an organism culture and the debridement of infection while maintaining neurological and mechanical stability. The authors demonstrate the effectiveness of radical debridement of infected bone and placement of instrumentation in patients with spinal infections.

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Michael Y. Wang

complication. Despite these statistics, the outcomes from ASD surgery can be highly rewarding for the patient. 4 , 17 Recently, many surgeons have attempted to leverage the purported benefits of MIS to treat deformity problems. 2 , 15 , 20 Indeed, claims of reduced blood loss, lower infection rates, and quicker mobilization would appear to address many of the major drawbacks of ASD surgery. 16 Thus, a variety of techniques have evolved in an attempt to apply MIS methodologies to correct coronal and sagittal deformities. To date, most methods have focused on using a

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Karthik Madhavan, Lee Onn Chieng, Valerie L. Armstrong and Michael Y. Wang

access, indwelling venous catheters for hemodialysis, and urinary tract infections (UTIs). ESRD patients typically receive 3 to 5 years of dialysis before they receive a renal transplant. 68 Chronic kidney disease by itself, prolonged hemodialysis, and iatrogenic immunosuppression are additional risk factors for infection in transplant patients. 7 , 30 , 41 , 61 , 81 This eventually leads to the risk of development of osteomyelitis or discitis with progression to epidural abscess and neurological deficits. The first line of treatment for ESRD patients with no

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The evolution of minimally invasive spine surgery

JNSPG 75th Anniversary Invited Review Article

Jang W. Yoon and Michael Y. Wang

METRx tubular system, a paramedian tubular approach gained popularity with minimally invasive spine surgeons, and a flurry of reports emerged for lumbar discectomy, ipsi-contralateral central canal decompression, thoracic discectomy, tumor removal, infection treatment, etc. 20 , 21 , 42 , 43 , 67 Advantages of the paramedian tubular approach in comparison to the transforaminal approach included wider exposure, ability to perform wider bony decompression, and bimanual access. Endoscopic Techniques Coincident with the proliferation of tubular techniques, other surgeons

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Michael Y. Wang and Praveen V. Mummaneni

D ue to advances in medical care, the life expectancy of Americans has increased significantly over the past half century. However, with this lengthening of the human lifespan has come an increase in the prevalence of disorders associated with aging, including adult spinal deformity. Adult thoracolumbar scoliosis and kyphosis can be the consequence of numerous etiologies, including progression of a preexisting deformity, delayed posttraumatic sequelae, infection, progressive disc and facet joint degeneration, iatrogenic spinal destabilization, and

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Michael Y. Wang and Gerd Bordon

were not rescanned. CT scans were obtained at 1 year after surgery. There were no cases of symptomatic proximal junction kyphosis. Complications Complications in this series are shown in Table 3 . Intraoperative complications included one unintentional durotomy. Postoperative complications included one wound infection and one watershed stroke that developed due to preexisting but undiagnosed bilateral carotid artery stenosis (degree of stenosis 99%). Implant and hardware complications included one iliac screw-rod dislodgment and one interbody graft extrusion

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Joanna E. Gernsback and Michael Y. Wang

erratic blood glucose levels led us to choose the MIS TLIF approach to limit the risk of postoperative infection. After an extensive preoperative discussion and evaluation and given the severity of her symptoms, the patient chose surgery. The procedure was performed with the patient in the prone position on a Jackson table. A midline incision was used, followed by placement of a Taylor retractor to allow access for a right-sided laminotomy and medial facetectomy. The nerve roots at L-4 and L-5 were decompressed dorsally, and the disc space was cleared of cartilage. An

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Michael Y. Wang and Michael Thambuswamy

wound infection or breakdown in 2 patients (100% from posterior surgery). F ig . 4. Images obtained in a 63-year-old Caucasian man who presented confined to a wheelchair with severe tetraparesis. Sagittal MR imaging (A) and axial CT (B) demonstrated severe stenosis to less than 4 mm at the widest (sagittal diameter) point. The patient underwent a combined anterior-posterior surgery for decompression and stabilization (C) . An intraoperative dural tear resulted in an anterior neck pseudomeningocele noted on CT (D) , which required subsequent surgery

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Matthew J. McGirt, Scott L. Parker, Jason Lerner, Luella Engelhart, Tyler Knight and Michael Y. Wang

S urgical site infection in the setting of lumbar fusion can result in perioperative morbidity and associated medical resource utilization. 3 , 22 Rates of spinal SSI reported in the literature vary widely from 0.7% to 16%. 2 , 3 , 11 , 25 Surgical site infections in the spine can be difficult to manage and often necessitate prolonged hospitalizations, extended courses of antibiotic therapy, and repeated surgery for wound debridement or instrumentation removal. Delayed complications associated with the presence of deep infection may also occur, and these

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Michael Y. Wang, Peng-Yuan Chang and Jay Grossman

anesthesia. However, 3 patients required a return to the operating room. The first was the case of cage displacement described above. The other two were patients early in the series who developed an infection of the interbody graft. The presentation was with sepsis, which was treated effectively with an incision and drainage followed by intravenous antibiotic therapy. Other complications included 1 case of atrial fibrillation, treated medically, and 1 case of an upper-extremity deep venous thrombosis, treated without anticoagulation. Two patients developed transient