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Camilo Molina, C. Rory Goodwin, Nancy Abu-Bonsrah, Benjamin D. Elder, Rafael De la Garza Ramos and Daniel M. Sciubba

Surgical interventions for spinal metastasis are commonly performed for mechanical stabilization, pain relief, preservation of neurological function, and local tumor reduction. Although multiple surgical approaches can be used for the treatment of metastatic spinal lesions, posterior approaches are commonly performed. In this study, the role of posterior surgical procedures in the treatment of spinal metastases was reviewed, including posterior laminectomy with and without instrumentation for stabilization, transpedicular corpectomy, and costotransversectomy. A review of the literature from 1980 to 2015 was performed using Medline, as was a review of the bibliographies of articles meeting preset inclusion criteria, to identify studies on the role of these posterior approaches among adults with spinal metastasis. Thirty-four articles were ultimately analyzed, including 1 randomized controlled trial, 6 prospective cohort studies, and 27 retrospective case reports and/or series. Some of the reviewed articles had Level II evidence indicating that laminectomy with stabilization can be recommended for improvement in neurological outcome and reduction of pain in selected patients. However, the use of laminectomy alone should be carefully considered. Additionally, transpedicular corpectomy and costotransversectomy can be recommended with the expectation of improving neurological outcomes and reducing pain in properly selected patients with spinal metastases. With improvements in the treatment paradigms for patients with spinal metastasis, as well as survival, surgical therapy will continue to play an important role in the management of spinal metastasis. While this review presents a window into determining the utility of posterior approaches, future prospective studies will provide essential data to better define the roles of the various options now available to surgeons in treating spinal metastases.

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Taylor E. Purvis, C. Rory Goodwin, Camilo A. Molina, Steven M. Frank and Daniel M. Sciubba

OBJECTIVE

The aim of this study was to characterize the association between percentage change in hemoglobin (ΔHb)—i.e., the difference between preoperative Hb and in-hospital nadir Hb concentration—and perioperative adverse events among spine surgery patients.

METHODS

Patients who underwent spine surgery at the authors’ institution between December 4, 2008, and June 26, 2015, were eligible for this retrospective study. Patients who underwent the following procedures were included: atlantoaxial fusion, subaxial anterior cervical fusion, subaxial posterior cervical fusion, anterior lumbar fusion, posterior lumbar fusion, lateral lumbar fusion, excision of intervertebral disc, and excision of spinal cord lesion. Data on intraoperative transfusion were obtained from an automated, prospectively collected, anesthesia data management system. Data on postoperative hospital transfusions were obtained through an Internet-based intelligence portal. Percentage ΔHb was defined as: ([preoperative Hb − nadir Hb]/preoperative Hb) × 100. Clinical outcomes included in-hospital morbidity and length of stay associated with percentage ΔHb.

RESULTS

A total of 3949 patients who underwent spine surgery were identified. Of these, 1204 patients (30.5%) received at least 1 unit of packed red blood cells. The median nadir Hb level was 10.6 g/dl (interquartile range 8.7–12.4 g/dl), yielding a mean percentage ΔHb of 23.6% (SD 15.4%). Perioperative complications occurred in 234 patients (5.9%) and were more common in patients with a larger percentage ΔHb (p = 0.017). Hospital-related infection, which occurred in 60 patients (1.5%), was also more common in patients with greater percentage ΔHb (p = 0.001).

CONCLUSIONS

Percentage ΔHb is independently associated with a higher risk of developing any perioperative complication and hospital-related infection. The authors’ results suggest that percentage ΔHb may be a useful measure for identifying patients at risk for adverse perioperative events.

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Benjamin D. Elder, Wataru Ishida, C. Rory Goodwin, Ali Bydon, Ziya L. Gokaslan, Daniel M. Sciubba, Jean-Paul Wolinsky and Timothy F. Witham

OBJECTIVE

With the advent of new adjunctive therapy, the overall survival of patients harboring spinal column tumors has improved. However, there is limited knowledge regarding the optimal bone graft options following resection of spinal column tumors, due to their relative rarity and because fusion outcomes in this cohort are affected by various factors, such as radiation therapy (RT) and chemotherapy. Furthermore, bone graft options are often limited following tumor resection because the use of local bone grafts and bone morphogenetic proteins (BMPs) are usually avoided in light of microscopic infiltration of tumors into local bone and potential carcinogenicity of BMP. The objective of this study was to review and meta-analyze the relevant clinical literature to provide further clinical insight regarding bone graft options.

METHODS

A web-based MEDLINE search was conducted in accordance with preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines, which yielded 27 articles with 383 patients. Information on baseline characteristics, tumor histology, adjunctive treatments, reconstruction methods, bone graft options, fusion rates, and time to fusion were collected. Pooled fusion rates (PFRs) and I2 values were calculated in meta-analysis. Meta-regression analyses were also performed if each variable appeared to affect fusion outcomes. Furthermore, data on 272 individual patients were available, which were additionally reviewed and statistically analyzed.

RESULTS

Overall, fusion rates varied widely from 36.0% to 100.0% due to both inter- and intrastudy heterogeneity, with a PFR of 85.7% (I2 = 36.4). The studies in which cages were filled with morselized iliac crest autogenic bone graft (ICABG) and/or other bone graft options were used for anterior fusion showed a significantly higher PFR of 92.8, compared with the other studies (83.3%, p = 0.04). In per-patient analysis, anterior plus posterior fusion resulted in a higher fusion rate than anterior fusion only (98.8% vs 86.4%, p < 0.001). Although unmodifiable, RT (90.3% vs 98.6%, p = 0.03) and lumbosacral tumors (74.6% vs 97.9%, p < 0.001) were associated with lower fusion rates in univariate analysis. The mean time to fusion was 5.4 ± 1.4 months (range 3–9 months), whereas 16 of 272 patients died before the confirmation of solid fusion with a mean survival of 3.1 ± 2.1 months (range 0.5–6 months). The average time to fusion of patients who received RT and chemotherapy were significantly longer than those who did not receive these adjunctive treatments (RT: 6.1 months vs 4.3 months, p < 0.001; chemotherapy: 6.0 months vs 4.3 months, p = 0.02).

CONCLUSIONS

Due to inter- and intrastudy heterogeneity in patient, disease, fusion criteria, and treatment characteristics, the optimal surgical techniques and factors predictive of fusion remain unclear. Clearly, future prospective, randomized studies will be necessary to better understand the issues surrounding bone graft selection following resection of spinal column tumors.

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Sharif Vakili, Dane Moran, Alice Hung, Benjamin D. Elder, Lee Jeon, Hugo Fialho, Eric W. Sankey, Ignacio Jusué-Torres, C. Rory Goodwin, Jennifer Lu, Jamie Robison and Daniele Rigamonti

OBJECTIVE

A growing body of evidence suggests that longer durations of preoperative symptoms may correlate with worse postoperative outcomes following cerebrospinal fluid (CSF) diversion for treatment of idiopathic normal pressure hydrocephalus (iNPH). The aim of this study is to determine whether the duration of preoperative symptoms alters postoperative outcomes in patients treated for iNPH.

METHODS

The authors conducted a retrospective review of 393 cases of iNPH involving patients treated with ventriculoperitoneal (VP) shunting. The duration of symptoms prior to the operative intervention was recorded. The following outcome variables were assessed at baseline, 6 months postoperatively, and at last follow-up: gait performance, urinary continence, and cognition.

RESULTS

The patients' median age at shunt placement was 74 years. Increased symptom duration was significantly associated with worse gait outcomes (relative risk (RR) 1.055 per year of symptoms, p = 0.037), and an overall absence of improvement in any of the classic triad symptomology (RR 1.053 per year of symptoms, p = 0.033) at 6 months postoperatively. Additionally, there were trends toward significance for symptom duration increasing the risk of having no 6-month postoperative improvement in urinary incontinence (RR 1.049 per year of symptoms, p = 0.069) or cognitive symptoms (RR 1.051 per year of symptoms, p = 0.069). However, no statistically significant differences were noted in these outcomes at last follow-up (median 31 months). Age stratification by decade revealed that prolonging symptom duration was significantly associated with lower Mini-Mental Status Examination scores in patients aged 60–70 years, and lack of cognitive improvement in patients aged 70–80 years.

CONCLUSIONS

Patients with iNPH with longer duration of preoperative symptoms may not receive the same short-term benefits of surgical intervention as patients with shorter duration of preoperative symptoms. However, with longer follow-up, the patients generally reached the same end point. Therefore, when managing patients with iNPH, it may take longer to see the benefits of CSF shunting when patients present with a longer duration of preoperative symptoms.

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Rafael De la Garza Ramos, C. Rory Goodwin, Nancy Abu-Bonsrah, Ali Bydon, Timothy F. Witham, Jean-Paul Wolinsky and Daniel M. Sciubba

OBJECTIVE

The aim of this study was to investigate the incidence of spinal tuberculosis (TB) in the US between 2002 and 2011.

METHODS

The Nationwide Inpatient Sample database from 2002 to 2011 was used to identify patients with a discharge diagnosis of TB and spinal TB. Demographic and hospital data were obtained for all admissions, and included age, sex, race, comorbid conditions, insurance status, hospital location, hospital teaching status, and hospital region. The incidence rate of spinal TB adjusted for population growth was calculated after application of discharge weights.

RESULTS

A total of 75,858 patients with a diagnosis of TB were identified, of whom 2789 had a diagnosis of spinal TB (3.7%); this represents an average of 278.9 cases per year between 2002 and 2011. The incidence of spinal TB decreased significantly—from 0.07 cases per 100,000 persons in 2002 to 0.05 cases per 100,000 in 2011 (p < 0.001), corresponding to 1 case per 2 million persons in the latter year. The median age for patients with spinal TB was 51 years, and 61% were male; 11.6% were patients with diabetes, 11.4% reported recent weight loss, and 8.1% presented with paralysis. There were 619 patients who underwent spinal surgery for TB, with the most common location being the thoracolumbar spine (61.9% of cases); 50% of patients had instrumentation of 3 or more spinal segments.

CONCLUSIONS

During the examined 10-year period, the incidence of spinal TB was found to significantly decrease over time in the US, reaching a rate of 1 case per 2 million persons in 2011. However, the absolute reduction was relatively small, suggesting that although it is uncommon, spinal TB remains a public health concern and most commonly affects male patients approximately 50 years of age. Approximately 20% of patients with spinal TB underwent surgery, most commonly in the thoracolumbar spine.

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Chikezie I. Eseonu, C. Rory Goodwin, Xin Zhou, Debebe Theodros, Matthew T. Bender, Dimitrios Mathios, Chetan Bettegowda and Michael Lim

OBJECT

Calcium phosphate cement provides a biomaterial that can be used for calvarial reconstruction in a retrosigmoid craniectomy for microvascular decompression (MVD). This study evaluates the outcomes of postoperative CSF leak and wound infection for patients undergoing a complete cranioplasty using calcium phosphate cement versus incomplete cranioplasty using polyethylene titanium mesh following a retrosigmoid craniectomy for MVD.

METHODS

The authors evaluated 211 cases involving patients who underwent first-time retrosigmoid craniectomies performed by a single attending surgeon fortrigeminal neuralgia from October 2008 to June 2014. From this patient population, 111 patients underwent calvarial reconstruction after retrosigmoid craniectomy using polyethylene titanium mesh, and 100 patients had reconstructions using calcium phosphate cement. A Pearson’s chi-square test was used to compare postoperative complications of CSF leak and wound infection in these 2 types of cranioplasties.

RESULTS

The polyethylene titanium mesh group included 5 patients (4.5%) with postoperative CSF leak or pseudomeningocele and 3 patients (2.7%) with wound infections. In the calcium phosphate cement group, no patients had a CSF leak, and 2 patients (2%) had wound infections. This represented a statistically significant reduction of postoperative CSF leak in patients who underwent calcium phosphate reconstructions of their calvarial defect compared with those who underwent polyethylene titanium mesh reconstructions (p = 0.03). No significant difference was seen between the 2 groups in the number of patients with postoperative wound infections.

CONCLUSIONS

Calcium phosphate cement provides a viable alternative biomaterial for calvarial reconstruction of retrosigmoid craniectomy defects in patients who have an MVD. The application of this material provides a biocompatible barrier that reduces the incidence of postoperative CSF leaks.

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C. Rory Goodwin, Pablo F. Recinos, Xin Zhou, Jesse X. Yang and George I. Jallo

Object

Cerebrospinal fluid leakage following durotomy in spinal surgery can lead to significant patient morbidity and mortality, including meningitis and even death. Usage of a polyethylene glycol (PEG) sealant in combination with standard closure techniques has been shown to be effective in preventing CSF leaks in animal models and adult patients, but the results of its use have not been reported in the pediatric population.

Methods

A retrospective analysis was performed of pediatric neurosurgery patients (0–18 years of age) treated at The Johns Hopkins Hospital from 2003 to 2010. There were 93 spinal surgery patients identified in whom PEG was applied. The incidence of CSF leakage, meningitis, and neurological injury was recorded. There were 54 males and 39 females in this study with an average age of 8.7 years. Of the identified patients, 16.1%, 28%, and 55.9% underwent surgery in the cervical region, thoracic region, and lumbar region, respectively.

Results

At 90-day follow-up, 5 patients (5.4%) had a CSF leak, 4 patients (4.3%) required a reoperation, and 1 patient (1.1%) had meningitis within this time period. No deaths or associated neurological deficits were observed.

Conclusions

The use of a PEG sealant to augment dural closure in pediatric spine surgery appears to be a safe adjunct to standard dural closure in pediatric spine patients.

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C. Rory Goodwin, Pablo F. Recinos, Ibrahim Omeis, Eric N. Momin, Timothy F. Witham, Ali Bydon, Ziya L. Gokaslan and Jean-Paul Wolinsky

Sacral neoplasm resection is managed via partial or total sacrectomy that is performed via the Kraske approach. The combination of the patients positioning and the relatively long operative time required for this procedure increase the risk of pressure ulcers. Facial pressure ulcers can cause tissue necrosis and/or ulceration in a highly visible area, leading to a cosmetically disfiguring lesion. Here, the authors report the use of a Mayfield clamp in the positioning of patients undergoing sacral tumor resection to prevent facial pressure ulceration. After the patient is placed prone in the Kraske or Jackknife position, the hips and knees are flexed with arms to the side. Then while in the prone position, the patient is physically placed in pins, and the Mayfield clamp is fixated at the center of the metal arch via the Mayfield sitting adapter to the Andrews frame, suspending the head (and face) over the table. The authors find that this technique prevents the development of facial pressure ulcers, and it has the potential to be used in patients positioned in the Kraske position for other surgical procedures.

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A. Karim Ahmed, Zachary Pennington, Camilo A. Molina, Yuanxuan Xia, C. Rory Goodwin and Daniel M. Sciubba

Effective en bloc resection of primary spinal tumors necessitates careful consideration of adjacent anatomical structures in order to achieve negative margins and reduce surgical morbidity. This can be particularly challenging in the cervical spine, where vital neurovascular and connective tissues are present in the region. Early multidisciplinary surgical planning that includes clinicians and engineers can both optimize surgical planning and enable a more feasible resection with oncological margins. The aim of the current work was to demonstrate two cases that involved multidisciplinary surgical planning for en bloc resection of primary cervical spine tumors, successfully utilizing 3D-printed patient models and neoadjuvant therapies.

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Ann Liu, Eric W. Sankey, C. Rory Goodwin, Thomas A. Kosztowski, Benjamin D. Elder, Ali Bydon, Timothy F. Witham, Jean-Paul Wolinsky, Ziya L. Gokaslan and Daniel M. Sciubba

OBJECT

Spinal metastases from gynecological cancers are rare, with few cases reported in the literature. In this study, the authors examine a series of patients with spinal metastases from gynecological cancer and review the literature.

METHODS

The cases of 6 consecutive patients who underwent spine surgery for metastatic gynecological cancer between 2007 and 2012 at a single institution were retrospectively reviewed. The recorded demographic, operative, and postoperative factors were reviewed, and the functional outcomes were determined by change in Karnofsky Performance Scale and the American Spine Injury Association (ASIA) score during follow-up. A systematic review of the literature was also performed to evaluate outcomes for patients with similar gynecological metastases to the spine.

RESULTS

In this series, details regarding metastatic gynecological cancers to the spine are as follows: 2 patients with cervical cancer (both presented at age 46 years, mean postoperative survival of 32 months), 2 patients with endometrial cancer (mean age of 40 years, mean postoperative survival of 26 months), and 2 patients with leiomyosarcoma (mean age of 44 years, mean postoperative survival of 20 months). All patients presented with pain, and no complications were noted following surgery. All patients with known follow-up had stable or improved neurological outcomes, performance status, and improved pain, without local recurrence of tumor. Overall median survival after diagnosis of metastatic spine lesions for all cases in the literature as well as those treated by the authors was 15 months. When categorized by type, median survival of patients with cervical cancer (n = 2), endometrial cancer (n = 26), and leiomyosarcoma (n = 16) was 32, 10, and 22.5 months, respectively.

CONCLUSIONS

Gynecological cancers metastasizing to the spine are rare. In this series, overall survival following diagnosis of spinal metastasis and surgery was 27 months, with cervical cancer, endometrial cancer, and leiomyosarcoma survival being 32, 26, and 20 months, respectively. Combined with literature cases, survival differs depending on primary histology, with decreasing survival from cervical cancer (32 months) to leiomyosarcoma (22.5 months) to endometrial cancer (10 months). Integrating such information with other patient factors may more accurately guide decision making regarding management of such spinal lesions.