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Ryan M. Kretzer, Daniel M. Sciubba, Carlos A. Bagley, Jean-Paul Wolinsky, Ziya L. Gokaslan and Ira M. Garonzik

Object

The use of pedicle screws (PSs) for instrument-assisted fusion in the cervical and thoracic spine has increased in recent years, allowing smaller constructs with improved biomechanical stability and repositioning possibilities. In the smaller pedicles of the upper thoracic spine, the placement of PSs can be challenging and may increase the risk of damage to neural structures. As an alternative to PSs, translaminar screws can provide spinal stability, and they may be used when pedicular anatomy precludes successful placement of PSs. The authors describe the technique of translaminar screw placement in the T-1 and T-2 vertebrae.

Methods

Seven patients underwent cervicothoracic fusion to treat trauma, neoplasm, or degenerative disease. Nineteen translaminar screws were placed, 13 at T-1 and six at T-2. A single asymptomatic T-2 screw violated the ventral laminar cortex and was removed.

The mean clinical and radiographic follow up exceeded 14 months, at which time there were no cases of screw pull-out, screw fracture, or progressive kyphotic deformity.

Conclusions

Rigid fixation with translaminar screws offers an attractive alternative to PS fixation, allowing the creation of sound spinal constructs and minimizing potential neurological morbidity. Their use requires intact posterior elements, and care should be taken to avoid violation of the ventral laminar wall.

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Joel R. Martin, Owoicho Adogwa, Christopher R. Brown, Maragatha Kuchibhatla, Carlos A. Bagley, Shivanand P. Lad and Oren N. Gottfried

OBJECT

Recent studies have reported that the local delivery of vancomycin powder is associated with a decrease in spinal surgical site infection. This retrospective cohort study compares posterior cervical fusion cases before and after the routine application of spinal vancomycin powder to evaluate the ability of local vancomycin powder to prevent deep wound infection after posterior cervical spinal fusion.

METHODS

Posterior cervical fusion spinal surgeries performed at a single institution were reviewed from January 2011 to July 2013. Each cohort's baseline characteristics, operative data, and rates of wound infection were compared. Associations between infection and vancomycin powder, with and without propensity score adjustment for risk factors, were determined using logistic regression.

RESULTS

A total of 289 patients (174 untreated and 115 treated with vancomycin powder) were included in the study. The cohorts were similar in terms of baseline and operative variables. No significant change in deep wound infection rate was seen between the control group (6.9%) and intervention group (5.2%, p = 0.563). Logistic regression, with and without propensity score adjustment, demonstrated that the use of vancomycin powder did not impact the development of surgical site infection (OR 0.743 [95% CI 0.270–2.04], p = 0.564) and (OR 0.583 [95% CI 0.198–1.718], p = 0.328), respectively.

CONCLUSIONS

Within the context of an ongoing debate on the effectiveness of locally administered vancomycin powder, the authors found no significant difference in the incidence of deep wound infection rates after posterior cervical fusion surgery with routine use of locally applied vancomycin powder. Future prospective randomized series are needed to corroborate these results.

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Isaac O. Karikari, Ankit I. Mehta, Can Solakoglu, Carlos A. Bagley, Michael C. Ain and Oren N. Gottfried

Object

Spinopelvic parameters in children with achondroplasia have not been described. Because they observed a unique sagittal spinopelvic phenotype in some achondroplastic children with very horizontal sacrums, the authors sought to quantify the spinopelvic parameters in a pediatric patient population.

Methods

A retrospective review was performed to identify all children (age range 1 month–10 years) with a diagnosis of achondroplasia between 2004 and 2009. Clinical and radiographic data were analyzed for age, sex, lumbar lordosis (LL), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Differences among these variables were analyzed using a 2-tailed, unpaired Student t-test.

Results

Forty children, 23 males and 17 females, with achondroplasia were identified during the study period. The mean age was 2.6 years. Two groups of patients were identified based on PT (that is, negative or positive tilt and horizontal or not horizontal sacrum). A negative PT was identified in all children with an extremely horizontal sacrum. Seventeen children had a negative PT (mean −16.6°), and the mean parameters in this group were 65.4° for LL, 31.7° for TLK, 18.5° for TK, 43.3° for SS, and 26.4° for PI. Twenty-three children had a positive PT (mean 17.9°), and the mean parameters in this group were 53.4° for LL, 41.5° for TLK, 9.6° for TK, 30.8° for SS, and 43.8° for PI. A statistically significant difference was observed for LL (p = 0.01), TLK (p = 0.05), SS (p = 0.006), PT (p = 0.006), and PI (0.0002).

Conclusions

Spinopelvic parameters in achondroplasia are potentially dichotomous. The future implications of this observation are not known and will need to be explored in future long-term studies that follow pediatric patients with achondroplasia through adulthood.

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Ajay Mantha, Federico G. Legnani, Carlos A. Bagley, Gary L. Gallia, Ira Garonzik, Gustavo Pradilla, Eric Amundson, Betty M. Tyler, Henry Brem and Ziya L. Gokaslan

Object. Although metastatic spinal disease constitutes a significant percentage of all spinal column tumors, an accessible and reproducible animal model has not been reported. In this study the authors describe the technique for creating an intraosseous spinal tumor model in rats and present a functional and histological analysis.

Methods. Eighteen female Fischer 344 rats were randomized into two groups. Group 1 animals underwent a transabdominal exposure and implantation of CRL-1666 breast adenocarcinoma into the L-6 vertebral body (VB). Animals in Group 2 underwent a sham operation. Hindlimb function was tested daily by using the Basso-Beattie-Bresnahan scale. Sixteen days after tumor implantation, animals were killed and their spines were removed for histological assessment. Statistical analysis was performed using the Wilcoxon signed-rank test.

By Day 15 functional analysis showed a significant decrease in motor function in Group 1 animals (median functional score 2 of 21) compared with Group 2 rats (median functional score 21 of 21) (p = 0.0217). The onset of paraparesis in Group 1 occurred within 14 to 16 days of surgery. Histopathological analysis showed tumor proliferation through the VB and into the spinal canal, with marked osteolytic activity and spinal cord compression.

Conclusions. Analysis of these findings demonstrates the consistency of tumor growth in this model and validates the utility of functional testing for onset of paresis. This new rat model allows for the preclinical evaluation of novel therapeutic treatments for patients harboring metastatic spine disease.

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Aladine A. Elsamadicy, Owoicho Adogwa, Emily Lydon, Amanda Sergesketter, Rayan Kaakati, Ankit I. Mehta, Raul A. Vasquez, Joseph Cheng, Carlos A. Bagley and Isaac O. Karikari

OBJECTIVE

Depression is the most prevalent affective disorder in the US, and patients with spinal deformity are at increased risk. Postoperative delirium has been associated with inferior surgical outcomes, including morbidity and mortality. The relationship between depression and postoperative delirium in patients undergoing spine surgery is relatively unknown. The aim of this study was to determine if depression is an independent risk factor for the development of postoperative delirium in patients undergoing decompression and fusion for deformity.

METHODS

The medical records of 923 adult patients (age ≥ 18 years) undergoing elective spine surgery at a single major academic institution from 2005 through 2015 were reviewed. Of these patients, 255 (27.6%) patients had been diagnosed with depression by a board-certified psychiatrist and constituted the Depression group; the remaining 668 patients constituted the No-Depression group. Patient demographics, comorbidities, and intra- and postoperative complication rates were collected for each patient and compared between groups. The primary outcome investigated in this study was rate of postoperative delirium, according to DSM-V criteria, during initial hospital stay after surgery. The association between depression and postoperative delirium rate was assessed via multivariate logistic regression analysis.

RESULTS

Patient demographics and comorbidities other than depression were similar in the 2 groups. In the Depression group, 85.1% of the patients were taking an antidepressant prior to surgery. There were no significant between-group differences in intraoperative variables and rates of complications other than delirium. Postoperative complication rates were also similar between the cohorts, including rates of urinary tract infection, fever, deep and superficial surgical site infection, pulmonary embolism, deep vein thrombosis, urinary retention, and proportion of patients transferred to the intensive care unit. In total, 66 patients (7.15%) had an episode of postoperative delirium, with depressed patients experiencing approximately a 2-fold higher rate of delirium (10.59% vs 5.84%). In a multivariate logistic regression analysis, depression was an independent predictor of postoperative delirium after spine surgery in spinal deformity patients (p = 0.01).

CONCLUSIONS

The results of this study suggest that depression is an independent risk factor for postoperative delirium after elective spine surgery. Further studies are necessary to understand the effects of affective disorders on postoperative delirium, in hopes to better identify patients at risk.

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Owoicho Adogwa, Aladine A. Elsamadicy, Amanda Sergesketter, Victoria D. Vuong, Ankit I. Mehta, Raul A. Vasquez, Joseph Cheng, Carlos A. Bagley and Isaac O. Karikari

OBJECTIVE

Wound infections following spinal surgery for deformity place a high toll on patients, providers, and the health care system. The prophylactic application of intraoperative vancomycin powder has been shown to lower the infection risk after thoracolumbar decompression and fusion for deformity correction. The purpose of this study was to assess the microbiological patterns of postoperative surgical site infections (SSIs) after prophylactic use of vancomycin powder in adult patients undergoing spinal deformity surgery.

METHODS

All cases involving adult patients who underwent spinal deformity reconstruction at Duke University Medical Center between 2011 and 2013 with a minimum of 3 months of clinical follow-up were retrospectively reviewed. In all cases included in the study, crystalline vancomycin powder was applied to the surgical bed for infection prophylaxis. Baseline characteristics, operative details, rates of wound infection, and microbiological data for each case were gathered by direct medical record review.

RESULTS

A total of 1200 consecutive spine operations were performed for deformity between 2011 and 2013. Review of the associated records demonstrated 34 cases of SSI, yielding an SSI rate of 2.83%. The patients’ mean age (± SD) was 62.08 ± 14.76 years. The patients’ mean body mass index was 30.86 ± 7.15 kg/m2, and 29.41% had a history of diabetes. The average dose of vancomycin powder was 1.41 ± 2.77 g (range 1–7 g). Subfascial drains were placed in 88% of patients. All SSIs occurred within 30 days of surgery, with deep wound infections accounting for 50%. In 74% of the SSIs cultures were positive, with about half the organisms being gram negative, such as Citrobacter freundii, Proteus mirabilis, Morganella morgani, and Pseudomonas aeruginosa. There were no adverse clinical outcomes related to the local application of vancomycin.

CONCLUSIONS

Our study suggests that in the setting of prophylactic vancomycin powder use, the preponderance of SSIs are caused by gram-negative organisms or are polymicrobial. Further randomized control trials of prophylactic adjunctive measures are warranted to help guide the choice of empirical antibiotic therapy while awaiting culture data.

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Owoicho Adogwa, Ryan Owens, Isaac Karikari, Vijay Agarwal, Oren N. Gottfried, Carlos A. Bagley, Robert E. Isaacs and Joseph S. Cheng

Object

Despite advances in technology and understanding in spinal physiology, reoperation for symptomatic adjacent-segment disease (ASD), same-level recurrent stenosis, and pseudarthrosis in elderly patients continues to occur. While revision lumbar surgery is effective, attention has turned to questions on the utility and value of the revision decompression and fusion procedure. To date, an analysis of the cost and health state gain associated with revision lumbar surgery in elderly patients with symptomatic pseudarthrosis, ASD, or same-level recurrent lumbar stenosis has yet to be performed. The aim of this study was to assess the long-term outcomes and cost-effectiveness of revision surgery in elderly patients with recurrent or persistent back and leg pain.

Methods

After reviewing their institutional database, the authors found 69 patients 65 years of age and older who had undergone revision decompression and instrumented fusion for back and leg pain associated with pseudarthrosis (17 patients), same-level recurrent stenosis (24 patients), or ASD (28 patients) and included them in this study. Total 2-year back-related medical resource utilization and health state values (quality-adjusted life years [QALYs], calculated from the EQ-5D, the EuroQol-5D health survey, with US valuation) were assessed. Two-year resource use was multiplied by unit costs based on Medicare national allowable payment amounts. The mean total 2-year cost per QALY gained after revision surgery was assessed.

Results

The mean (± standard deviation) time between the index surgery and revision surgery was 3.51 ± 3.63 years. A mean cumulative 2-year gain of 0.35 QALY was observed after revision surgery. The mean total 2-year cost of revision surgery was $28,256 ± $3000 (ASD: $28,829 ± $3812, pseudarthrosis: $28,069 ± $2508, same-level recurrent stenosis: $27,871 ± $2375). Revision decompression and extension of fusion was associated with a mean 2-year cost of $80,594 per QALY gained.

Conclusions

Revision decompression and fusion provided a significant gain in health state utility for elderly patients with symptomatic pseudarthrosis, same-level recurrent stenosis, or ASD, with a mean 2-year cost of $80,594 per QALY gained. When indicated, revision surgery for symptomatic ASD, same-level recurrent stenosis, and pseudarthrosis is a valuable treatment option for elderly patients experiencing persistent back and leg pain. Findings in this study provided a value measure of surgery that can be compared with future cost-per-QALY-gained studies of medical management or alternative surgical approaches.

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Owoicho Adogwa, Isaac O. Karikari, Kevin R. Carr, Max Krucoff, Divya Ajay, Parastou Fatemi, Edgar L. Perez, Joseph S. Cheng, Carlos A. Bagley and Robert E. Isaacs

Object

A spinal epidural abscess (SEA) is a rare but severe infection requiring prompt recognition and management. The incidence of SEA has doubled in the past decade, owing to an aging population and to increased use of spinal instrumentation and vascular access. The optimal management of SEAs in patients 50 years of age and older remains a matter of considerable debate. In an older patient population with multiple comorbidities, whether intravenous antibiotics alone or in combination with surgery lead to superior outcomes remains unknown. The present study retrospectively analyzes cases of SEAs, in patients 50 years of age and older, treated at Duke University Medical Center over the past 15 years.

Methods

Eighty-two patients underwent treatment for a spinal epidural abscess between 1999 and 2013. There were 46 men and 36 women, whose overall mean age (± SD) was 65 ± 8.58 years (range 50–82 years). The mean duration of clinical follow-up was 41.38 ± 86.48 weeks. Thirty patients (37%) underwent surgery for removal of the abscess, whereas 52 (63%) were treated more conservatively, undergoing CT-guided aspiration or receiving antibiotics alone based on the results of blood cultures. The correlation between pretreatment variables and outcomes was evaluated in a multivariate regression analysis.

Results

Back pain and severe motor deficits were the most common presenting symptoms. Compared with baseline neurological status, the majority of patients (68%) reported being neurologically “better” or “unchanged.” Twelve patients (15%) had a good outcome (7 [23%] treated operatively vs 5 [10%] treated nonoperatively, p = 0.03), while clinical status in 41 patients (50%) remained unchanged (10 [33%] treated operatively vs 31 [60%] treated nonoperatively, p = 0.01). Overall, 20 patients (25%) died (9 [30%] treated operatively vs 11 [21%] treated nonoperatively, p = 0.43). In a multivariate logistic regression model, an increasing baseline level of pain, the presence of paraplegia or quadriplegia on initial presentation, and a dorsally located SEA were independently associated with poor outcomes.

Conclusions

The results of the study suggest that in patients 50 years of age and older, early surgical decompression combined with intravenous antimicrobial therapy was not associated with superior clinical outcomes when compared with intravenous antimicrobial therapy alone.

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Ankit I. Mehta, Owoicho Adogwa, Isaac O. Karikari, Paul Thompson, Terence Verla, Ulysses T. Null, Allan H. Friedman, Joseph S. Cheng, Carlos A. Bagley and Robert E. Isaacs

Object

Intradural extramedullary (IDEM) neoplasms are uncommon lesions that can pose a challenge for resection. Numerous factors affect the resectability and ultimately the outcome of these lesions. The authors report their 10-year institutional experience with the resection of IDEM neoplasms, focusing on the effect of location on surgical outcomes.

Methods

The authors performed a retrospective review of 96 consecutive patients who presented with a cervical and/or thoracic IDEM tumor that was resected between February 2000 and July 2009. All patients underwent MRI, and the axial location of the tumor was categorized as anterior, posterior, or lateral. Postoperative complications were assessed, as was neurological status at the patient's last follow-up clinic visit. Major complications assessed included CSF leakage requiring lumbar drainage, reexploration for epidural hematoma, and major postoperative neurological deficits.

Results

The mean ± SD age at presentation was 51.16 ± 17.87 years. Major surgical approach–related complications occurred in 15% of patients. Major non–approach related surgical complications occurred in 7.1% of patients, while minor complications occurred in 14.2% of patients. Postoperative neurological deficits occurred most commonly in the thoracic spine between T-1 and T-8. Based on axial spinal cord location, the surgery-related complications rates for all anterior tumors (n = 12) was 41.6%, whereas that for all lateral tumors (n = 69) was 4.4% and that for all posteriorly located tumors (n = 17) was 0%.

Conclusions

Spinal IDEM tumors that are anteriorly located in the upper thoracic spine were found to have the highest rate of surgery-related complications and postoperative neurological deficits. This finding may be associated with the unforgiving anatomy of the upper thoracic spine in which there is a higher cord-to-canal ratio and a tenuous vascular supply.

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Daniel M. Sciubba, Joseph C. Noggle, Neena I. Marupudi, Carlos A. Bagley, Markus J. Bookland, Benjamin S. Carson Sr., Michael C. Ain and George I. Jallo

Object

Achondroplasia is a hereditary form of dwarfism caused by a defect in endochondral bone formation, resulting in skeletal abnormalities including short stature, shortened limb bones, macrocephaly, and small vertebral bodies. In the pediatric population, symptomatic spinal stenosis occurs at all spinal levels due to the abnormally narrow bone canal. In this study, clinical outcomes were assessed in children with achondroplasia after spinal canal decompression.

Methods

A retrospective review was conducted involving pediatric patients with heterozygous achondroplasia and symptomatic stenosis after decompressive procedures at the authors' institution within a 9-year period. Measured outcomes included resolution of symptoms, need for repeated surgery, presence of fusion, development of deformity, and complications.

Forty-four pediatric patients underwent a total of 60 decompressive procedures. The average patient age at surgery was 12.7 years (range 5–21 years). Forty-nine operations were performed for initial treatment of stenosis, and 11 were performed as revision surgeries on previously operated levels. A large proportion of patients (> 60%) required additional cervicomedullary decompressions, most often preceding the symptoms of spinal stenosis. Of the initial procedures, decompression locations included 32 thoracolumbar (65%), 10 lumbar (20%), four cervical (8%), two cervicothoracic (4%), and one thoracic (2%). Forty-three of the decompressive procedures (72%) included spinal fusion procedures. Of the 11 revisions, five were fusion procedures for progressive deformity at levels previously decompressed but not fused (all thoracolumbar), five were for decompressions of symptomatic junctional stenosis with extension of fusion, and one was for repeated decompression at the same level due to recurrence of symptomatic stenosis.

Conclusions

Decompression of the spinal canal in pediatric patients with achondroplasia can be accomplished safely with significant clinical benefit. Patients with a history of cervicomedullary compression may be at an increased risk of developing symptomatic stenosis prior to adolescence. Fusion procedures are recommended in patients with a large decompression overlying a thoracolumbar kyphosis to avoid progressive postoperative deformity.