Occipital nerve stimulation (ONS) has been studied in a few clinical trials for the treatment of chronic migraine (CM) with failure to prove sufficient efficacy. To date, peripheral nerve stimulation for the treatment of primary headache is limited to off-label use only. The authors report their institutional experience in CM therapy with combined ONS and supraorbital nerve stimulation (SONS). Fourteen patients treated with dual ONS and SONS for CM were studied with follow-up ranging from 3 to 60 months. Seventy-one percent achieved successful stimulation as defined by a 50% or greater decrease in pain severity. The mean reduction in headache-related visual analog scale (VAS) score was 3.92 ± 2.4. Half of the patients also had resolution of migraine-associated neurological symptoms and returned to normal functional capacity. The main adverse events included lead migration (42.8%), supraorbital lead allodynia (21.4%), and infection (14.2%) with a resulting high reoperation rate (35.7%). The authors' stimulation efficacy was superior to the combined 33% positive response rates (≥ 50% pain reduction) in the published studies of ONS for CM. This is likely due to the fact that topographical paresthesia induced by combined ONS and SONS covers the area of migraine pain better than ONS alone. The authors also discuss effective surgical techniques to prevent patient morbidity.
Gregory J. Przybylski and Ashwini D. Sharan
Object. Patients with deep wound infections complicating previously placed internal instrumentation have been successfully treated by debridement and prolonged postoperative antibiotic therapy, which avoided removal of the hardware. Comparatively fewer patients with pyogenic discitis and vertebral osteomyelitis (PDVO) have undergone single-stage debridement, arthrodesis, and internal fixation. The purpose of this study was to determine the efficacy of combining debridement, arthrodesis in which iliac autograft is used, and segmental internal fixation in a single-stage procedure for patients in whom nonoperative management of PDVO has failed.
Methods. A retrospective analysis of 17 consecutive patients with PDVO treated between July 1996 and September 1999 was performed. Follow-up data (mean 30 months) included office examinations and telephone interviews, and patients were grouped according to the duration of preoperative antibiotic therapy. All patients experienced significant postoperative reduction in pain, and those with neurological deficits improved. Eleven patients were independently ambulatory, and three required a walker; only five had been ambulating independently preoperatively. Two patients died during the 1st postoperative week of medical complications; another developed a wound dehiscence that was managed with debridement, prolonged antibiotic administration, and removal of the hardware 1 year later. In no case was pseudarthrosis demonstrated on dynamic radiography. Most patients received only a 6-week course of intravenous antibiotics postoperatively.
Conclusions. The authors conclude that single-stage debridement, arthrodesis, and internal fixation can be effective in the treatment of PDVO. A 6-week course of postoperative intravenous antibiotics may be sufficient in patients with few risk factors. The harvesting of iliac autograft through the same operative exposure may not increase the risk of secondary infection.
James S. Harrop, Ashwini D. Sharan and Gregory J. Przybylski
Cervical spinal cord injury (SCI) after odontoid fracture is unusual. To identify predisposing factors, the authors evaluated a consecutive series of patients who sustained SCI from odontoid fractures.
A consecutive series of 5096 admissions to the Delaware Valley Regional Spinal Cord Injury Center were reviewed, and 126 patients with neurological impairment at the C1–3 levels were identified. Seventeen patients had acute closed odontoid fractures with neurological deficit. Various parameters including demographics, mechanisms of injury, associated injuries, fracture types/displacements, and radiographic cervical canal dimensions were compared between “complete” and “incomplete” spinal cord injured–patients as well as with neurologically intact patients who had suffered odontoid fractures. There were similar demographics, mechanisms of injury, associated injuries, fracture type/displacement, and canal dimensions in patients with complete and incomplete SCIs. However, only patients with complete injury were ventilator dependent. In comparison with patients with intact spinal cords, spinal cord–injured patients were more commonly males (p = 0.011) who had sustained higher velocity injuries (p = 0.027). The computerized tomography scans of 11 of 17 neurologically impaired patients were compared with those of a random sample of 11 patients with intact spinal cords. Although the anteroposterior diameter (p = 0.028) and cross-sectional area (p = 0.0004) of the cervical spinal canal at the C–2 level were smaller in impaired patients, the displacement of the fragment was not different.
Odontoid fractures are an infrequent cause of SCI. Patients with these injuries typically are males who have smaller spinal canals and have sustained high velocity injuries.
Karol Osipowicz, Michael R. Sperling, Ashwini D. Sharan and Joseph I. Tracy
Predicting cognitive function following resective surgery remains an important clinical goal. Each MRI neuroimaging technique can potentially provide unique and distinct insight into changes that occur in the structural or functional organization of “at-risk” cognitive functions. The authors tested for the singular and combined power of 3 imaging techniques (functional MRI [fMRI], resting state fMRI, diffusion tensor imaging) to predict cognitive outcome following left (dominant) anterior temporal lobectomy for intractable epilepsy.
The authors calculated the degree of deviation from normal, determined the rate of change in this measure across the pre- and postsurgical imaging sessions, and then compared these measures for their ability to predict verbal fluency changes following surgery.
The data show that the 3 neuroimaging techniques, in a combined model, can reliably predict cognitive outcome following anterior temporal lobectomy for medically intractable temporal lobe epilepsy.
These findings suggest that these 3 imaging modalities can be used effectively, in an additive fashion, to predict functional reorganization and cognitive outcome following anterior temporal lobectomy.
James S. Harrop, Ashwini D. Sharan, Edward H. Scheid Jr., Alexander R. Vaccaro and Gregory J. Przybylski
Object. The authors sought to identify variables that predispose patients with acute American Spinal Injury Association (ASIA) Grade A cervical spinal cord injury (SCI) to require tracheostomies for ventilator support or airway protection.
Methods. A retrospective analysis was performed of 178 consecutive patients with a cervical ASIA Grade A SCI who were admitted through the Delaware Valley SCI Center at Thomas Jefferson Hospital during a 6-year period. Exclusion criteria included injury occurring more than 48 hours prior to admission, death within 14 days of admission or nontraumatic SCI. Twenty-two patients were excluded based on these criteria. Parameters evaluated in the remaining population (156 patients) included demographics, cervical vertebral ASIA level, tracheostomy placement, pneumonia, premorbid pulmonary disease, smoking history, evidence of direct thoracic/lung trauma, operative intervention, associated appendicular trauma, and preexisting medical comorbidities.
The ASIA classification of the 156 patients included in this analysis were C-2 (eight), C-3 (11), C-4 (64), C-5 (36), C-6 (20), C-7 (13), and C-8 (four). Tracheostomies were performed in 107 of these 156 patients. Statistical analysis revealed a significant relationship between tracheostomy and patient age (p = 0.0048), preexisting medical conditions (p = 0.0417), premorbid lung disease (p = 0.0177), higher cervical ASIA level (p < 0.0001), and the presence of pneumonia (p < 0.0001). No patient with a C-8 ASIA A injury required tracheostomy, whereas all C-2 and C-3 ASIA A—injured patients underwent tracheostomies. Patients older than 45 years of age with ASIA A levels between C-4 and C-7 more commonly required tracheostomy (p < 0.005) than patients younger than 45 years of age.
Conclusions. Several risk factors were identified that corresponded to the frequent tracheostomy placement in the acute injury phase after complete cervical SCI. Early tracheostomy may be considered in patients with multiple risk factors to reduce duration of stay in the intensive care unit and facilitate ventilatory weaning.
James S. Harrop, Marco T. Silva, Ashwini D. Sharan, Steven J. Dante and Frederick A. Simeone
Object. The authors conducted a study to identify the effectiveness and morbidity rate associated with treating cervicothoracic disc disease (radiculopathy) via a posterior approach.
Methods. Nineteen patients underwent posterior cervicothoracic laminoforaminotomy during a 5.6-year period. Medical records, imaging studies, office charts, hospital records, and phone interview data were reviewed. Specific information analyzed included patient demographics, side of lesion, and conservative treatment, symptoms, and pre- and postoperative pain levels. Pain was rated using a visual analog scale and classified into a radicular and neck component.
Data in 19 patients (seven women and 12 men) who underwent 20 procedures (one patient underwent separate bilateral foraminotomies) were analyzed. The mean patient age was 54.8 years (range 38–73 years), and the follow-up period ranged from 23 to 62 months. Symptom duration ranged from 1 to 14 months (mean 3.4 months) and consisted of weakness, numbness, and painful radiculopathies in 11, 16, and 20 cases, respectively. Motor weakness was identified in 11 of 19 patients (mean grade of 4.35), and postoperatively strength normalized in eight of 11 (mean grade of 4.79). The improvement in motor scores was significant (p = 0.007). Pain was the most common presenting symptom. Preoperative radiculopathies were rated between 0 and 10 (mean 7.45), and postoperatively scores were reduced to 0 to 3 (mean 0.2) which was significant (p < 0.0001). Preoperative neck pain was rated between 0 and 8 (mean 2.55), and on follow up ranged from 0 to 2 (mean 0.5), which was also significant (p = 0.001).
Conclusions. Posterior cervicothoracic foraminotomy was a safe and effective procedure in the treatment of patients with laterally located disc herniations.
Sanjay Yadla, George M. Ghobrial, Peter G. Campbell, Mitchell G. Maltenfort, James S. Harrop, John K. Ratliff and Ashwini D. Sharan
Complications after spine surgery have an impact on overall outcome and health care expenditures. The increased cost of complications is due in part to associated prolonged hospital stays. The authors propose that certain complications have a greater impact on length of stay (LOS) than others and that those complications should be the focus of future targeted prevention efforts. They conducted a retrospective analysis of a prospectively maintained database to identify complications with the greatest impact on LOS as well as the predictive value of these complications with respect to 90-day readmission rates.
Data on 249 patients undergoing spine surgery at Thomas Jefferson University from May to December 2008 were collected by a study auditor. Any complications occurring within 30 days of surgery were recorded as was overall LOS for each patient. Stepwise regression analysis was performed to determine whether specific complications had a statistically significant effect on LOS. For correlation, all readmissions within 90 days were recorded and organized by complication for comparison with those complications affecting LOS.
The mean LOS for patients without postoperative complications was 6.9 days. Patients who developed pulmonary complications had an associated increase in LOS of 11.1 days (p < 0.005). The development of a urinary tract infection (UTI) was associated with an increase in LOS of 3.4 days (p = 0.002). A new neurological deficit was associated with an increase in LOS of 8.2 days (p = 0.004). Complications requiring return to the operating room (OR) showed a trend toward an increase in LOS of 4.7 days (p = 0.09), as did deep wound infections (3.3 days, p = 0.08). The most common reason for readmission was for wound drainage (n = 21; surgical drainage was required in 10 [4.01%] of these 21 cases). The most common diagnoses for readmission, in decreasing order of incidence, were categorized as hardware malpositioning (n = 4), fever (n = 4), pulmonary (n = 2), UTI (n = 2), and neurological deficit (n = 1). Complications affecting LOS were not found to be predictive of readmission (p = 0.029).
Postoperative complications in patients who have undergone spine surgery are not uncommon and are associated with prolonged hospital stays. In the current cohort, the occurrence of pulmonary complications, UTI, and new neurological deficit had the greatest effect on overall LOS. Further study is required to determine the causative factors affecting readmission. These specific complications may be high-yield targets for cost reduction and/or prevention efforts.
Sanjay Yadla, Jennifer Malone, Peter G. Campbell, Mitchell G. Maltenfort, James S. Harrop, Ashwini D. Sharan and John K. Ratliff
The reported incidence of complications in spine surgery varies widely. Variable study methodologies may open differing avenues for potential bias, and unclear definitions of perioperative complication make analysis of the literature challenging. Although numerous studies have examined the morbidity associated with specific procedures or diagnoses, no prospective analysis has evaluated the impact of preoperative diagnosis on overall early morbidity in spine surgery. To accurately assess perioperative morbidity in patients undergoing spine surgery, a prospective analysis of all patients who underwent spine surgery by the neurosurgical service at a large tertiary care center over a 6-month period was conducted. The correlation between preoperative diagnosis and the incidence of postoperative complications was assessed.
Data were prospectively collected on 248 consecutive patients undergoing spine surgery performed by the neurosurgical service at the Thomas Jefferson University Hospital from May to December 2008. A standardized definition of minor and major complications was applied to all adverse events occurring within 30 days of surgery. Data on diagnosis, complications, and length of stay were retrospectively assessed using stepwise multivariate analysis. Patients were analyzed by preoperative diagnosis (neoplasm, infection, degenerative disease, trauma) and level of surgery (cervical or thoracolumbar).
Total early complication incidence was 53.2%, with a minor complication incidence of 46.4% and a major complication incidence of 21.3%. Preoperative diagnosis correlated only with the occurrence of minor complications in the overall cohort (p = 0.02). In patients undergoing surgery of the thoracolumbar spine, preoperative diagnosis correlated with presence of a complication and the number of complications (p = 0.003). Within this group, patients with preoperative diagnoses of infection and neoplasm were more often affected by isolated and multiple complications (p = 0.05 and p = 0.02, respectively). Surgeries across the cervicothoracic and thoracolumbar junctions were associated with higher incidences of overall complication than cervical or lumbar surgery alone (p = 0.04 and p = 0.03, respectively). Median length of stay was 5 days for patients without a complication. Length of stay was significantly greater for patients with a minor complication (10 days, p < 0.0001) and even greater for patients with a major complication (14 days, p < 0.0001).
The incidence of complications found in this prospective analysis is higher than that reported in previous studies. This association may be due to a greater accuracy of record-keeping, absence of recall bias via prospective data collection, high complexity of pathology and surgical approaches, or application of a more liberal definition of what constitutes a complication. Further large-scale prospective studies using clear definitions of complication are necessary to ascertain the true incidence of early postoperative complications in spine surgery.
George M. Ghobrial, Sara Beygi, Matthew J. Viereck, Joshua E. Heller, Ashwini Sharan, Jack Jallo, James S. Harrop and Srinivas Prasad
Syringomyelia is a potentially debilitating disease that involves abnormal CSF flow mechanics; its incidence after traumatic spinal cord injury (SCI) is approximately 15%. Treatment consists of restoration of CSF flow, typically via arachnoidolysis and syrinx decompression. The authors present a case of pronounced syringomyelia in a patient with concomitant severe cervical myelomalacia to demonstrate unilateral C-5 palsy as a potential complication of aggressive syrinx decompression at a remote level.
A 56-year-old man with a remote history of SCI at T-11 (ASIA [American Spinal Injury Association] Grade A) presented with complaints of ascending motor and sensory weakness into the bilateral upper extremities that had progressed over 1 year. MRI demonstrated severe distortion of the spinal cord at the prior injury level of T10–11, where an old anterior column injury and prior hook-rod construct was visualized. Of note, the patient had a holocord syrinx with demonstrable myelomalacia. To restore CSF flow and decompress the spinal cord, T-2 and T-3 laminectomies, followed by arachnoidolysis and syringopleural shunt placement, were performed. Postoperatively on Day 1, with the exception of a unilateral deltoid palsy, the patient had immediate improvement in upper-extremity strength and myelopathy. He was discharged from the hospital on postoperative Day 5; however, at his 2-week follow-up visit, a persistent unilateral deltoid palsy was noted. MRI demonstrated a significant reduction in the holocord syrinx, no neural foraminal stenosis, and a significant positional shift of the ventral spinal cord. Further motor recovery was noted at the 8-month follow-up.
Syringomyelia is a debilitating disease arising most often as a result of traumatic SCI. In the setting of myelomalacia with a pronounced syrinx, C-5 palsy is a potential complication of syrinx decompression.
John K. Ratliff, Bryan Lebude, Todd Albert, Tony Anene-Maidoh, Greg Anderson, Phillip Dagostino, Mitchel Maltenfort, Alan Hilibrand, Ashwini Sharan and Alexander R. Vaccaro
Definitions of complications in spinal surgery are not clear. Therefore, the authors assessed a group of practicing spine surgeons and, through the surgeons' responses to an online and emailed survey, developed a simple definition of operative complications due to spinal surgery. To validate this assessment, the authors revised their survey to make it appropriate for a lay audience and repeated the assessment with a cohort of patients who underwent spine surgery.
The authors surveyed a cohort of practicing spine surgeons via email and a web-based survey. Surgeons were presented with various complication scenarios and were asked to grade the presence or absence of a complication as well as complication severity, with responses limited to “major complication” and “minor complication/adverse event.” The authors administered a similar assessment, modified for lay persons, to patients in a spinal surgery clinic.
Complete responses were obtained from 229 surgeons; orthopedic surgeons comprised the majority of respondents (73%). The authors obtained completed surveys from 197 patients. Overall, there was consistent agreement between physicians and patients regarding the presence or absence of a complication in the majority of scenarios (8 [73%] of 11 scenarios with agreement that a complication was present). The overall kappa value, evaluating major versus minor complication, and presence or absence of a complication over the entire cohort, was fair (κ = 0.21). The authors found greater variation between the cohorts when evaluating complication severity. Patients were consistently more critical than physicians in the majority of scenarios in which a difference was evident. In 4 scenarios, patients were more likely than surgeons to deem the scenario a complication and to grade the complication as major versus minor (p < 0.01). In 3 additional scenarios, patients were more likely than physicians to grade a major complication as opposed to minor complication (p < 0.01). In only 1 scenario were patients less likely than physicians to report a complication (p < 0.001).
Comparing responses of spine surgeons and patients who underwent spinal surgery in assessing a group of common postoperative events, the authors found significant agreement on perception of presence of a complication in the majority of scenarios reviewed. However, patients were consistently more critical than surgeons when differences in reporting were found. The authors' data underscore the importance of reconciling differing opinions regarding complications through open discussions between physicians and patients to ensure accurate patient expectations of planned medical or surgical interventions.