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Lara W. Massie, Hesham Mostafa Zakaria, Lonni R. Schultz, Azam Basheer, Morenikeji Ayodele Buraimoh and Victor Chang

OBJECTIVE

The inability to significantly improve sagittal parameters has been a limitation of minimally invasive surgery for transforaminal lumbar interbody fusion (MIS TLIF). Traditional cages have a limited capacity to restore lordosis. This study evaluates the use of a crescent-shaped articulating expandable cage (Altera) for MIS TLIF.

METHODS

This is a retrospective review of 1- and 2-level MIS TLIF. Radiographic outcomes included differences in segmental and lumbar lordosis, disc height, evidence of fusion, and any endplate violations. Clinical outcomes included the numeric rating scale for leg and back pain and the Oswestry Disability Index (ODI) for low-back pain.

RESULTS

Thirty-nine patients underwent single-level MIS TLIF, and 5 underwent 2-level MIS TLIF. The mean age was 63.1 years, with 64% women. On average, spondylolisthesis was corrected by 4.3 mm (preoperative = 6.69 mm, postoperative = 2.39 mm, p < 0.001), the segmental angle was improved by 4.94° (preoperative = 5.63°, postoperative = 10.58°, p < 0.001), and segmental height increased by 3.1 mm (preoperative = 5.09 mm, postoperative = 8.19 mm, p < 0.001). At 90 days after surgery the authors observed the following: a smaller postoperative sagittal vertical axis was associated with larger changes in back pain at 90 days (r = −0.558, p = 0.013); a larger decrease in spondylolisthesis was associated with greater improvements in ODI and back pain scores (r = −0.425, p = 0.043, and r = −0.43, p = 0.031, respectively); and a larger decrease in pelvic tilt (PT) was associated with greater improvements in back pain (r = −0.548, p = 0.043). For the 1-year PROs, the relationship between the change in PT and changes in ODI and numeric rating scale back pain were significant (r = 0.612, p = 0.009, and r = −0.803, p = 0.001, respectively) with larger decreases in PT associated with larger improvements in ODI and back pain. Overall for this study there was a 96% fusion rate.

Fourteen patients were noted to have endplate violation on intraoperative fluoroscopy during placement of the cage. Only 3 of these had progression of their subsidence, with an overall subsidence rate of 6% (3 of 49) visible on postoperative CT.

CONCLUSIONS

The use of this expandable, articulating, lordotic, or hyperlordotic interbody cage for MIS TLIF provides a significant restoration of segmental height and segmental lordosis, with associated improvements in sagittal balance parameters. Patients treated with this technique had acceptable levels of fusion and significant reductions in pain and disability.

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Mohamed Macki, Azam Basheer, Ian Lee, Ryan Kather, Ilan Rubinfeld and Muwaffak M. Abdulhak

OBJECTIVE

In the past, spine surgeons have avoided the transoral approach to the atlantoaxial segment because of concerns for unacceptable patient morbidity. The objective of this study was to measure 30-day postoperative complications, especially surgical site infection (SSI), after transoral versus posterior approach to atlantoaxial fusion.

METHODS

The source population was provided by the American College of Surgeons National Surgical Quality Improvement Program database, which was queried for all patients who underwent atlantoaxial fusion for degenerative/spondylotic disease and/or trauma between 2005 and 2014. To eliminate bias from unequal sample sizes, patients who underwent the transoral approach were matched with patients who underwent the posterior approach (generally 1:5 ratio) based on age ± 5 years and modified frailty index score (a measure of preoperative comorbidity burden). Because of rare SSI incidence, adjusted odds ratios (ORadj) of SSI were calculated using penalized maximum likelihood estimation.

RESULTS

A total of 318 patients were included in the study. There were no statistically significant differences between the transoral cohort (n = 56) and the posterior cohort (n = 262) in terms of 30-day postoperative individual complications, including SSI (1.79% vs 1.91%; p = 0.951) and composite complications (10.71% vs 6.87%; p = 0.323). Controlling for sex and smoking, the odds of SSI in the transoral approach were almost equal to the odds in the posterior approach (ORadj 1.17; p = 0.866). While the unplanned reoperation rate of 5.36% after transoral surgery was higher than the 1.53% rate after posterior surgery, the difference approached, but did not reach, statistical significance (p = 0.076).

CONCLUSIONS

Transoral versus posterior surgery for atlantoaxial fusion did not differ in 30-day unexpected outcomes. Therefore, spinal pathology, rather than concern for postoperative complications, should adjudicate the technical approach to the atlantoaxial segment.

Free access

Hesham Mostafa Zakaria, Azam Basheer, David Boyce-Fappiano, Erinma Elibe, Lonni Schultz, Ian Lee, Farzan Siddiqui, Brent Griffith and Victor Chang

OBJECTIVE

Predicting the survival rate for patients with cancer is currently performed using the TNM Classification of Malignant Tumors (TNM). Identifying accurate prognostic markers of survival would allow better treatment stratification between more aggressive treatment strategies or palliation. This is especially relevant for patients with spinal metastases, who all have identical TNM staging and whose surgical decision-making is potentially complex. Analytical morphometrics quantifies patient frailty by measuring lean muscle mass and can predict risk for postoperative morbidity after lumbar spine surgery. This study evaluates whether morphometrics can be predictive of survival in patients with spinal metastases.

METHODS

Utilizing a retrospective registry of patients with spinal metastases who had undergone stereotactic body radiation therapy, the authors identified patients with primary lung cancer. Morphometric measurements were taken of the psoas muscle using CT of the lumbar spine. Additional morphometrics were taken of the L-4 vertebral body. Patients were stratified into tertiles based on psoas muscle area. The primary outcome measure was overall survival, which was measured from the date of the patient's CT scan to date of death.

RESULTS

A total of 168 patients were identified, with 54% male and 54% having multiple-level metastases. The median survival for all patients was 185.5 days (95% confidence interval [CI] 146–228 days). Survival was not associated with age, sex, or the number of levels of metastasis. Patients in the smallest tertile for the left psoas area had significantly shorter survival compared with a combination of the other two tertiles: 139 days versus 222 days, respectively, hazard ratio (HR) 1.47, 95% CI 1.06–2.04, p = 0.007. Total psoas tertiles were not predictive of mortality, but patients whose total psoas size was below the median size had significantly shorter survival compared with those greater than the median size: 146 days versus 253.5 days, respectively, HR 1.43, 95% CI 1.05–1.94, p = 0.025. To try to differentiate small body habitus from frailty, the ratio of psoas muscle area to vertebral body area was calculated. Total psoas size became predictive of mortality when normalized to vertebral body ratio, with patients in the lowest tertile having significantly shorter survival (p = 0.017). Left psoas to vertebral body ratio was also predictive of mortality in patients within the lowest tertile (p = 0.021). Right psoas size was not predictive of mortality in any calculations.

CONCLUSIONS

In patients with lung cancer metastases to the spine, morphometric analysis of psoas muscle and vertebral body size can be used to identify patients who are at risk for shorter survival. This information should be used to select patients who are appropriate candidates for surgery and for the tailoring of oncological treatment regimens.

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Morenikeji Buraimoh, Azam Basheer, Kevin Taliaferro, Jonathan H. Shaw, Sameah Haider, Gregory Graziano and Eugene Koh

Every day, spine surgeons call for instruments named after surgical pioneers. Few know the designers or the histories behind their instruments. In this paper the authors provide a historical perspective on the Penfield dissector, Leksell rongeur, Hibbs retractor, Woodson elevator, Kerrison rongeur, McCulloch retractor, Caspar pin retractor system, and Cloward handheld retractor, and a biographical review of their inventors. Historical data were obtained by searching the HathiTrust Digital Library, PubMed, Google Scholar, Google Books, and Google, and personal communications with relatives, colleagues, and foundations of the surgeon-designers. The authors found that the Penfield dissectors filled a need for delicate tools for manipulating the brain and that the Leksell rongeur increased surgical efficiency during war-related laminectomies. Hibbs’ retractor facilitated his spine fusion technique. Woodson was both a dentist and a physician whose instrument was adopted by spine surgeons. Kerrison rongeurs were developed in otology to decompress bone near the facial nerve. The McCulloch, Caspar, and Cloward retractors helped improve exposure during the emergence of new techniques, i.e., microdiscectomy and anterior cervical discectomy and fusion. The histories behind these eponymous instruments remind us that innovation sometimes begins in other specialties and demonstrate the role of innovation in improving patient care.

Full access

Kevin Reinard, David R. Nerenz, Azam Basheer, Rizwan Tahir, Timothy Jelsema, Lonni Schultz, Ghaus Malik, Ellen L. Air and Jason M. Schwalb

OBJECTIVE

A number of studies have documented inequalities in care and outcomes for a variety of clinical conditions. The authors sought to identify racial and socioeconomic disparities in the diagnosis and treatment of trigeminal neuralgia (TN), as well as the potential underlying reasons for those disparities, which could serve as areas of focus for future quality improvement initiatives.

METHODS

The medical records of patients with an ICD-9 code of 350.1, signifying a diagnosis of TN, at the Henry Ford Medical Group (HFMG) in the period from 2006 to 2012 were searched, and clinical and socioeconomic data were retrospectively reviewed. Analyses were conducted to assess potential racial differences in subspecialty referral patterns and the specific type of treatment modality undertaken for patients with TN.

RESULTS

The authors identified 652 patients eligible for analysis. Compared with white patients, black patients were less likely to undergo percutaneous ablative procedures, stereotactic radiosurgery, or microvascular decompression (p < 0.001). However, there was no difference in the likelihood of blacks and whites undergoing a procedure once they had seen a neurosurgeon (67% vs 70%, respectively; p = 0.712). Blacks and whites were equally likely to be seen by a neurologist or neurosurgeon if they were initially seen in either the emergency room (38% vs 37%, p = 0.879) or internal medicine (48% vs 50%, p = 0.806). Among patients diagnosed (268 patients) after the 2008 publication of the European Federation of Neurological Societies and the American Academy of Neurology guidelines for medical therapy for TN, fewer than 50% were on medications sanctioned by the guidelines, and there were no statistically significant racial disparities between white and black patients (p = 0.060).

CONCLUSIONS

According to data from a large database from one of the nation's largest comprehensive health care systems, there were significant racial disparities in the likelihood of a patient undergoing a procedure for TN. This appeared to stem from outside HFMG from a difference in referral patterns to the neurologists and neurosurgeons.