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Michael Y. Wang

- and postoperative lateral 36-in radiographs (C and D) . F ig . 5. Representative case showing 1 of the 3 patients with inadequate management of the fractional curve, resulting in suboptimal coronal alignment. Inadequate management may result in the need for future revision surgery. All patients underwent 12-month postoperative CT scanning. Fusion status was verified as complete at all levels in 22 of the 25 patients. All interbody fusion sites demonstrated evidence of bridging bone across the intervertebral disc space ( Fig. 6 ). In all 3 cases in

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Michael Y. Wang and Barth A. Green

Object

Cervical stenotic myelopathy can be treated via anterior or posterior approaches. In anterior cervical decompression and fusion (ACDF), because the risks and likelihood of pseudarthrosis increase with the number of treated segments, attempts are typically made to limit the number of treated levels. Thus, postoperative recurrence of myelopathy following ACDF may occur because stenotic levels were not treated or because adjacent segments have degenerated. Revision decompressive surgery via an anterior approach is one solution; however, if the stenosis involves multiple levels a posterior decompressive laminoplasty can be performed as an alternative.

Methods

Twenty-four cases treated over an 8-year period were identified and data were retrospectively reviewed. In 15 cases posterior decompressive surgery was necessary because of progressive spinal degeneration and stenosis (five cases following initial treatment for radiculopathy, seven after initial treatment for spondylotic myelopathy, and three due to spreading of an ossified posterior longitudinal ligament). In nine cases revision surgery was undertaken because the initial decompression was inadequate.

The mean follow-up period after the second surgery was 16 months. Improvements in myelopathy were seen in 83% of patients (mean improvement of 1.25 points on the Nurick Scale). Preoperative severe gait disorders were associated with poor recovery. Complications included two cases of transient C-5 nerve root palsy and two cases of new persistent axial neck pain.

Conclusions

Laminoplasty is a straightforward and effective treatment for failed ACDF due to inadequate decompression or progressive degeneration of the spinal column, avoiding reentry through scar tissue. In terms of myeolpathic pain, the recovery rate is comparable with that related to revision ACDF.

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Michael Y. Wang and Jay Grossman

nonunion, such as implant loosening or worsening axial pain. There were no cases with a perioperative complication (i.e., no deaths, medical complications, worsening neurological status, or revision surgeries). Discussion While rapid recovery following minimally invasive decompression surgery has been achieved, obtaining these results with fusion surgery has been more elusive. Several investigators have previously reported on their attempts to accelerate recovery after lumbar spinal fusion surgery utilizing a combination of minimally invasive techniques with a

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Michael Y. Wang and Gerd Bordon

, Galbusera F , Brayda-Bruno M : Revision surgery after PSO failure with rod breakage: a comparison of different techniques . Eur Spine J 23 : Suppl 6 610 – 615 , 2014 18 Manwaring JC , Bach K , Ahmadian AA , Deukmedjian AR , Smith DA , Uribe JS : Management of sagittal balance in adult spinal deformity with minimally invasive anterolateral lumbar interbody fusion: a preliminary radiographic study . J Neurosurg Spine 20 : 515 – 522 , 2014 19 Mummaneni PV , Dhall SS , Ondra SL , Mummaneni VP , Berven S : Pedicle subtraction

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Faiz U. Ahmad and Michael Y. Wang

.7 3.6 1 2 2.9% 1 4 2 3 2 3 3 2 3 4 Only 2 patients had symptoms due to screw misplacement, one with pain and numbness and another with only numbness. Both patients underwent reoperation for screw repositioning, one during the same admission and the other months later. These cases involved the L-5 and S-1 levels, respectively, and both had highly angulated and medialized pedicles rendering an indistinct medial wall ( Fig. 3C ). Both patients improved after the revision surgery. There were 46 facet violations in 410 screws (11

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Lynn B. McGrath Jr., Karthik Madhavan, Lee Onn Chieng, Michael Y. Wang and Christoph P. Hofstetter

developed as a minimally invasive approach for effectively decompressing stenotic lumbar foramina, and has been shown to result in good clinical outcomes. 2 , 8 , 12 Cadaveric studies have been undertaken and have further demonstrated the anatomical effectiveness of endoscopic foraminotomies in achieving foraminal decompression. 6 The purpose of this study was to investigate the utility of endoscopic foraminotomy for highly targeted revision surgery in selected patients with persistent radiculopathy following lumbar fusion surgery. Methods Patient Population

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Timur M. Urakov, Ken Hsuan-kan Chang, S. Shelby Burks and Michael Y. Wang

screws inserted 256 50 306 Mean time (min/screw) 3.6 5.7 0.009 * Mean fluoroscopy time (sec/screw) 1.15 1.73 0.13 Revision surgery 8 1 9 Mean speed (min/screw) 0.158  Revision surgery 3.8  Initial surgery 4.5 Mean fluoroscopy time (sec/case) 0.059   Revision surgery 7.4   Initial surgery 12 Screw position on postop CT  No. of screws available for review 77 24 101 0.033 *   Breached 6 6 12   Grade 1 3 4 7   Grade 2 3 1 4   Grade 3 0 1 1 * Statistically significant. Of the 30 patients who underwent screw placement, 21 patients were undergoing their first implantation

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Michael Y. Wang, Ram Vasudevan and Stefan A. Mindea

for revision surgery is to opt for an entirely different access route to the spine. Minimally invasive surgical techniques to fuse and decompress the spinal column have become increasingly popular over the past decade. In particular, the minimally invasive lateral approach innovated by Pimenta has become popular given the advent of electrophysiological navigation and tubular retractor technology. 5 , 7 , 12 These developments have allowed for less invasive access to the spinal column by navigating through the lumbosacral plexus and psoas muscle using real- time

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Gregory W. Basil, John Paul G. Kolcun and Michael Y. Wang

merely had their pathologies “pruned,” only to require further trimming at a later point in time. These critics may conclude that we are proposing a sleight of hand: do less surgery now so you can do more later! Create “repeat customers”! Instead, we argue that a minimalist approach to treating spinal pathology will result in the maximum long-term satisfaction for both the patient and the surgeon. Although it will surely result in some patients requiring revision surgery years down the line, more importantly it will create a healthy practice with vertically integrated

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Michael Y. Wang, Matthew D. Cummock, Yong Yu and Rikin A. Trivedi

-term results between the 2 types of surgical procedures. Delayed revision surgeries or the treatment of adjacent-segment problems may differ between the groups. Furthermore, the perioperative charges do not account for any outpatient treatments, such as therapy, medications, and imaging that may have differed between groups. Conclusions Minimally invasive lumbar interbody fusion is a safe and effective method for decompressing and fusing the spine. While this study is limited by comparing patients with unilateral versus bilateral lower-extremity symptoms, we