A 65-year-old woman underwent an uneventful C3–4 anterior cervical discectomy and fusion for a large, symptomatic disc herniation. On postoperative Day 1 the patient suffered a sudden, acute respiratory compromise. Emergency fiberoptic intubation revealed significant anterior neck swelling with concern for physical obstruction of the airway. Computed tomography of the neck did not demonstrate an expanding hematoma. The patient was managed with surgical wound exploration and washout. Examination of the anterior neck after incision of the prior surgical site revealed a large volume of Surgifoam under high pressure, which was greater than the amount used during the initial surgery. Thorough washout of the surgical site did not reveal any swelling of the prevertebral soft tissues or hematoma, and the Hemovac drain did not appear to be occluded. The patient was extubated on the 2nd postoperative day and is symptom free 12 months after surgery. To the authors' knowledge, this report represents the first reported complication of acute respiratory failure from Surgifoam overexpansion after anterior cervical surgery.
Branko Skovrlj, Justin R. Mascitelli, Martin B. Camins, Amish H. Doshi and Sheeraz A. Qureshi
Yakov Gologorsky, Branko Skovrlj, Jeremy Steinberger, Max Moore, Marc Arginteanu, Frank Moore and Alfred Steinberger
Transforaminal lumbar interbody fusion (TLIF) with segmental pedicular instrumentation is a wellestablished procedure used to treat lumbar spondylosis with or without spondylolisthesis. Available biomechanical and clinical studies that compared unilateral and bilateral constructs have produced conflicting data regarding patient outcomes and hardware complications.
A prospective cohort study was undertaken by a group of neurosurgeons. They prospectively enrolled 80 patients into either bilateral or unilateral pedicle screw instrumentation groups (40 patients/group). Demographic data collected for each group included sex, age, body mass index, tobacco use, and Workers' Compensation/litigation status. Operative data included segments operated on, number of levels involved, estimated blood loss, length of hospital stay, and perioperative complications. Long-term outcomes (hardware malfunction, wound dehiscence, and pseudarthrosis) were recorded. For all patients, preoperative baseline and 6-month postoperative scores for Medical Outcomes 36-Item Short Form Health Survey (SF-36) outcomes were recorded.
Patient follow-up times ranged from 37 to 63 months (mean 52 months). No patients were lost to follow-up. The patients who underwent unilateral pedicle screw instrumentation (unilateral cohort) were slightly younger than those who underwent bilateral pedicle screw instrumentation (bilateral cohort) (mean age 42 vs 47 years, respectively; p = 0.02). No other significant differences were detected between cohorts with regard to demographic data, mean number of lumbar levels operated on, or distribution of the levels operated on. Estimated blood loss was higher for patients in the bilateral cohort, but length of stay was similar for patients in both cohorts. The incidence of pseudarthrosis was significantly higher among patients in the unilateral cohort (7 patients [17.5%]) than among those in the bilateral cohort (1 patient [2.5%]) (p = 0.02). Wound dehiscence occurred for 1 patient in the unilateral cohort. Reoperation was offered to 8 patients in the unilateral cohort and 1 patient in the bilateral cohort (p = 0.03). The physical component scores of the Medical Outcomes SF-36 outcomes improved significantly for all patients (p < 0.001).
Transforaminal lumbar interbody fusion with either unilateral or bilateral segmental pedicular instrumentation is an effective treatment for lumbar spondylosis. Because patients with unilateral constructs were 7 times more likely to experience pseudarthrosis and require reoperation, TLIF with bilateral constructs might be the biomechanically superior technique.