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Timing of surgical stabilization after cervical and thoracic trauma

Invited submission from the Joint Section Meeting on Disorders of the Spine and Peripheral Nerves, March 2004

Todd J. Albert and David H. Kim

✓ Appropriate timing for surgical intervention following destabilizing cervical or thoracic spine trauma remains controversial. Clinical investigators have failed to provide convincing evidence that the timing of surgery significantly affects neurological outcome in most situations. Nevertheless, early surgical stabilization of the injured spine has been shown to provide significant nonneurological benefits such as more rapid patient mobilization, facilitation of treating associated injuries, reduction in rates of pulmonary and pressure sore complications, reduction in duration of intensive care unit and hospital stays, and a decrease in overall medical costs.

The findings of basic science studies have improved our understanding of the molecular and cellular events surrounding initial and secondary spinal cord injury (SCI), and analysis of these findings suggests that the early postinjury period may present a unique opportunity for meaningful intervention. This possibility has been supported by results obtained in animal studies that demonstrate the potential for improving functional outcome when surgical intervention is performed within a few hours following experimental SCI. Despite the absence of significant neurological recovery in most clinical studies, the results of most recent clinical studies strongly support the overall clinical benefits of early surgical intervention, particularly in the setting of unstable thoracic spinal column injury with associated SCI. Based on the best available scientific and clinical evidence, the authors report that it is therefore recommended that surgical stabilization be performed in as timely a fashion as possible, particularly for unstable thoracic spine trauma, within the constraints of the patient's overall medical condition and availability of appropriate resources.

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Kim J. Burchiel, Shirley McCartney, Albert Lee and Ahmed M. Raslan

Object

In this prospective study the authors' objective was to evaluate the accuracy of deep brain stimulation (DBS) electrode placement using image guidance for direct anatomical targeting with intraoperative CT.

Methods

Preoperative 3-T MR images were merged with intraoperative CT images for planning. Electrode targets were anatomical, based on the MR images. A skull-mounted NexFrame system was used for electrode placement, and all procedures were performed under general anesthesia. After electrode placement, intraoperative CT images were merged with trajectory planning images to calculate accuracy. Accuracy was assessed by both vector error and deviation off the planned trajectory.

Results

Sixty patients (33 with Parkinson disease, 26 with essential tremor, and 1 with dystonia) underwent the procedure. Patient's mean age was 64 ± 9.5 years. Over an 18-month period, 119 electrodes were placed (all bilateral, except one). Electrode implant locations were the ventral intermediate nucleus (VIM), globus pallidus internus (GPI), and subthalamic nucleus (STN) in 25, 23, and 12 patients, respectively. Target accuracy measurements were as follows: mean vector error 1.59 ± 1.11 mm and mean deviation off trajectory 1.24 ± 0.87 mm. There was no statistically significant difference between the accuracy of left and right brain electrodes. There was a statistically significant (negative) correlation between the distance of the closest approach of the electrode trajectory to the ventricular wall of the lateral ventricle and vector error (r2 = −0.339, p < 0.05, n = 76), and the deviation from the planned trajectory (r2 = −0.325, p < 0.05, n = 77). Furthermore, when the distance from the electrode trajectory and the ventricular wall was < 4 mm, the correlation of the ventricular distance to the deviation from the planned trajectory was stronger (r2 = −0.419, p = 0.05, n = 19). Electrodes placed in the GPI were significantly more accurate than those placed in the VIM (p < 0.05). Only 1 of 119 electrodes required intraoperative replacement due to a vector error > 3 mm. In this series there was one infection and no intraparenchymal hemorrhages.

Conclusions

Placement of DBS electrodes using an intraoperative CT scanner and the NexFrame achieves an accuracy that is at least comparable to other methods.

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Andrew L. Ko, Albert Lee, Ahmed M. Raslan, Alp Ozpinar, Shirley McCartney and Kim J. Burchiel

OBJECT

Trigeminal neuralgia (TN) occurs and recurs in the absence of neurovascular compression (NVC). To characterize what may be distinct patient populations, the authors examined age at onset in patients with TN with and without NVC.

METHODS

A retrospective review of patients undergoing posterior fossa surgery for Type I TN at Oregon Health & Science University from 2009 to 2013 was undertaken. Charts were reviewed, and imaging and operative data were collected for patients with and without NVC. Mean, median, and the empirical cumulative distribution of onset age were determined. Statistical analysis was performed using Student t-test, Wilcoxon and Kolmogorov-Smirnoff tests, and Kaplan-Meier analysis. Multivariate analysis was performed using a Cox proportional hazards model.

RESULTS

The charts of 219 patients with TN were reviewed. There were 156 patients who underwent posterior fossa exploration and microvascular decompression or internal neurolysis: 129 patients with NVC and 27 without NVC. Mean age at symptoms onset for patients with and without NVC was 51.1 and 42.6 years, respectively. This difference (8.4 years) was significant (t-test: p = 0.007), with sufficient power to detect an effect size of 8.2 years. Median age between groups with and without NVC was 53.25 and 41.2 years, respectively (p = 0.003). Histogram analysis revealed a bimodal age at onset in patients without NVC, and cumulative distribution of age at onset revealed an earlier presentation of symptoms (p = 0.003) in patients without NVC. Chi-square analysis revealed a trend toward female predominance in patients without NVC, which was not significant (p = 0.08). Multivariate analysis revealed that age at onset was related to NVC but not sex, symptom side or distribution, or patient response to medical treatment.

CONCLUSIONS

NVC is neither sufficient nor necessary for the development of TN. Patients with TN without NVC may represent a distinct population of younger, predominantly female patients. Further research into the pathophysiology underlying this debilitating disease is needed.

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Albert Lee, Shirley McCartney, Cole Burbidge, Ahmed M. Raslan and Kim J. Burchiel

Object

Vascular compression of the trigeminal nerve is the most common factor associated with the etiology of trigeminal neuralgia (TN). Microvascular decompression (MVD) has proven to be the most successful and durable surgical approach for this disorder. However, not all patients with TN manifest unequivocal neurovascular compression (NVC). Furthermore, over time patients with an initially successful MVD manifest a relentless rate of TN recurrence.

Methods

The authors performed a retrospective review of cases of TN Type 1 (TN1) or Type 2 (TN2) involving patients 18 years or older who underwent evaluation (and surgery when indicated) at Oregon Health & Science University between July 2006 and February 2013. Surgical and imaging findings were correlated.

Results

The review identified a total of 257 patients with TN (219 with TN1 and 38 with TN2) who underwent high-resolution MRI and MR angiography with 3D reconstruction of combined images using OsiriX. Imaging data revealed that the occurrence of TN1 and TN2 without NVC was 28.8% and 18.4%, respectively. A subgroup of 184 patients underwent surgical exploration. Imaging findings were highly correlated with surgical findings, with a sensitivity of 96% for TN1 and TN2 and a specificity of 90% for TN1 and 66% for TN2.

Conclusions

Magnetic resonance imaging detects NVC with a high degree of sensitivity. However, despite a diagnosis of TN1 or TN2, a significant number of patients have no NVC. Trigeminal neuralgia clearly occurs and recurs in the absence of NVC.

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Sam Q. Sun, Ammar H. Hawasli, Jiayi Huang, Michael R. Chicoine and Albert H. Kim

The management of WHO Grade II “atypical” meningiomas (AMs) and Grade III “malignant” meningiomas (MMs) remains controversial and under-investigated in prospective studies. The roles of surgery, radiation therapy, radiosurgery, and chemotherapy have been incompletely delineated. This has left physicians to decipher how they should treat patients on a case-by-case basis. In this study, the authors review the English-language literature on the management and clinical outcomes associated with AMs and MMs diagnosed using the WHO 2000/2007 grading criteria. Twenty-two studies for AMs and 7 studies for MMs were examined in detail. The authors examined clinical decision points using the literature and concepts from evidence-based medicine. Acknowledging the retrospective nature of the studies concerning AM and MM, the authors did find evidence for the following clinical strategies: 1) maximal safe resection of AM and MM; 2) active surveillance after gross-total resection of AM; 3) adjuvant radiation therapy after subtotal resection of AM, especially in the absence of putative radioresistant features; and 4) adjuvant radiation therapy after resection of MM.

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Andrew L. Ko, Alp Ozpinar, Albert Lee, Ahmed M. Raslan, Shirley McCartney and Kim J. Burchiel

OBJECT

Trigeminal neuralgia (TN) occurs and recurs in the absence of neurovascular compression (NVC). While microvascular decompression (MVD) is the most effective treatment for TN, it is not possible when NVC is not present. Therefore, the authors sought to evaluate the safety, efficacy, and durability of internal neurolysis (IN), or “nerve combing,” as a treatment for TN without NVC.

METHODS

This was a retrospective review of all cases of Type 1 TN involving all patients 18 years of age or older who underwent evaluation (and surgery when appropriate) at Oregon Health & Science University between July 2006 and February 2013. Chart reviews and telephone interviews were conducted to assess patient outcomes. Pain intensity was evaluated with the Barrow Neurological Institute (BNI) Pain Intensity scale, and the Brief Pain Inventory–Facial (BPI-Facial) was used to assess general and face-specific activity. Pain-free survival and durability of successful pain relief (BNI pain scores of 1 or 2) were statistically evaluated with Kaplan-Meier analysis. Prognostic factors were identified and analyzed using Cox proportional hazards regression.

RESULTS

A total of 177 patients with Type 1 TN were identified. A subgroup of 27 was found to have no NVC on high-resolution MRI/MR angiography or at surgery. These patients were significantly younger than patients with classic Type 1 TN. Long-term follow-up was available for 26 of 27 patients, and 23 responded to the telephone survey. The median follow-up duration was 43.4 months. Immediate postoperative results were comparable to MVD, with 85% of patients pain free and 96% of patients with successful pain relief. At 1 year and 5 years, the rate of pain-free survival was 58% and 47%, respectively. Successful pain relief at those intervals was maintained in 77% and 72% of patients. Almost all patients experienced some degree of numbness or hypesthesia (96%), but in patients with successful pain relief, this numbness did not significantly impact their quality of life. There was 1 patient with a CSF leak and 1 patient with anesthesia dolorosa. Previous treatment for TN was identified as a poor prognostic factor for successful outcome.

CONCLUSIONS

This is the first report of IN with meaningful outcomes data. This study demonstrated that IN is a safe, effective, and durable treatment for TN in the absence of NVC. Pain-free outcomes with IN appeared to be more durable than radiofrequency gangliolysis, and IN appears to be more effective than stereotactic radiosurgery, 2 alternatives to posterior fossa exploration in cases of TN without NVC. Given the younger age distribution of patients in this group, consideration should be given to performing IN as an initial treatment. Accrual of further outcomes data is warranted.

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Francis Lovecchio, Jeffrey G. Stepan, Ajay Premkumar, Michael E. Steinhaus, Maria Sava, Peter Derman, Han Jo Kim and Todd Albert

OBJECTIVE

Patients with lumbar spine pathology are at high risk for opioid misuse. Standardizing prescribing practices through an institutional intervention may reduce the overprescribing of opiates, leading to a decrease in the risk for opioid misuse and the number of pills available for diversion. Without quantitative data on the “minimum necessary quantity” of opioids appropriate for postdischarge prescriptions, the optimal method for changing existing prescribing practices is unknown. The purpose of this study was to determine whether mandatory provider education and prescribing guidelines could modify prescriber behavior and lead to a decreased amount of opioids prescribed at hospital discharge following lumbar spine surgery.

METHODS

Qualified staff were required to attend a mandatory educational conference, and a consensus method among the spine service was used to publish qualitative prescribing guidelines. Prescription data for 2479 patients who had undergone lumbar spine surgery were captured and compared based on the timing of surgery. The preintervention group consisted of 1177 patients who had undergone spine surgery in the period before prescriber education and guidelines (March 1, 2016–November 1, 2016). The postintervention group consisted of 1302 patients who had undergone spine surgery after the dissemination of the guidelines (February 1, 2017–October 1, 2017). Surgeries were classified as decompression or fusion procedures. Patients who had undergone surgeries for infection and patients on long-acting opioids were excluded.

RESULTS

For all lumbar spine surgeries (decompression and fusion), the mean amount of opioids prescribed at discharge was lower after the educational program and distribution of prescribing guidelines (629 ± 294 oral morphine equivalent [OME] preintervention vs 490 ± 245 OME postintervention, p < 0.001). The mean number of prescribed pills also decreased (81 ± 26 vs 66 ± 22, p < 0.001). Prescriptions for 81 or more tablets dropped from 65.5% to 25.5%. Tramadol was prescribed more frequently after prescriber education (9.9% vs 18.6%, p < 0.001). Refill rates within 6 weeks were higher after the institutional intervention (7.6% vs 12.4%, p < 0.07).

CONCLUSIONS

Qualitative guidelines and prescriber education are effective in reducing the amount of opioids prescribed at discharge and encouraging the use of weaker opioids. Coupling provider education with prescribing guidelines is likely synergistic in achieving larger reductions. The sustainability of these changes is yet to be determined.

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Albert H. Kim, Manish K. Kasliwal, Brendan McNeish, V. Michelle Silvera, Mark R. Proctor and Edward R. Smith

Object

Spinal cord tethering due to a thickened filum terminale is a well-described entity that can be treated surgically. Postoperative MR imaging of the lumbar spine is performed for unrelated issues or for the development of new symptoms suggestive of cord retethering. A lack of radiological criteria for successful detethering makes interpretation of postoperative MR images challenging. The delineation of postoperative radiological characteristics of a sectioned filum terminale is therefore valuable to clinicians managing these often complex cases.

Methods

The clinical data for 16 patients who underwent sectioning of a fatty and thickened filum between 2001 and 2010 and in whom pre- and postoperative MR imaging studies were available were analyzed. Medical records were interrogated for preoperative neurological examination, operative details, and postoperative follow-up. The MR images were examined by both a neurosurgeon and a neuroradiologist to assess postoperative radiological characteristics.

Results

The patients' age at time of surgery ranged from 0.3 to 19.8 years (mean 7.5 years). Postoperative MR imaging was performed between 0.03 and 7.36 years after the procedure (mean 2.5 years). Indications for postoperative imaging included new neurological symptoms (11 of 16 patients), routine interval imaging (3 of 16), and possible development of pseudomeningocele (2 of 16). Filum discontinuity was confirmed in 79% of cases postoperatively. Filum remnants appeared thicker after surgery in most cases (80%), a phenomenon most often appreciated in the cephalad end of the sectioned filum. Postoperatively, the conus was elevated in 5 cases (31%) and was found to be more ventrally located in 7 cases (44%).

Conclusions

Discontinuity, along with thickening of the upper and lower remnants of a sectioned filum, may constitute important radiological features of a detethered filum. Radiological signs of conus relaxation, signified by elevation or a more ventral position, although reassuring, were less reliably observed postoperatively. Because it may be difficult to know if the goals of surgery were met on purely clinical grounds in this patient population, knowledge of the postoperative characteristics of a sectioned filum may aid the practicing neurosurgeon in the management of these complex cases.

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David Y. A. Dadey, Ashwin A. Kamath, Matthew D. Smyth, Michael R. Chicoine, Eric C. Leuthardt and Albert H. Kim

OBJECTIVE

The precision of laser probe insertion for interstitial thermal therapy of deep-seated lesions is limited by the method of stereotactic guidance. The objective of this study was to evaluate the feasibility of customized STarFix 3D-printed stereotactic platforms to guide laser probe insertion into mesiotemporal and posterior fossa targets.

METHODS

The authors conducted a retrospective review of 5 patients (12–55 years of age) treated with laser interstitial thermal therapy (LITT) in which STarFix platforms were used for probe insertion. Bone fiducials were implanted in each patient's skull, and subsequent CT scans were used to guide the design of each platform and incorporate desired treatment trajectories. Once generated, the platforms were mounted on the patients' craniums and used to position the laser probe during surgery. Placement of the laser probe and the LITT procedure were monitored with intraoperative MRI. Perioperative and follow-up MRI were performed to identify and monitor changes in target lesions.

RESULTS

Accurate placement of the laser probe was observed in all cases. For all patients, thermal ablation was accomplished without intraoperative complications. Of the 4 patients with symptomatic lesions, 2 experienced complete resolution of symptoms, and 1 reported improved symptoms compared with baseline.

CONCLUSIONS

Customized stereotactic platforms were seamlessly incorporated into the authors' previously established LITT workflow and allowed for accurate treatment delivery.