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Darryl Lau and Dean Chou

OBJECT

Spinal metastases most commonly affect the vertebral bodies of the spinal column, and spinal cord compression is an indication for surgery. Commonly, an open posterior approach is employed to perform a transpedicular costotransversectomy or lateral extracavitary corpectomy. Because of the short life expectancies in patients with metastatic spinal disease, decreasing the morbidity of surgical treatment and recovery time is critical. One potential approach to decreasing morbidity is utilizing minimally invasive surgery (MIS). Although significant advances have been made in MIS of the spine, data supporting the utility of MIS are still emerging. This study compared outcomes of patients who underwent mini-open versus traditional open transpedicular corpectomy for spinal metastases in the thoracic spine.

METHODS

A consecutive cohort from 2006 to 2013 of 49 adult patients who underwent thoracic transpedicular corpectomies for spinal metastases was retrospectively identified. Patients were categorized into one of 2 groups: open surgery and mini-open surgery. Mini-open transpedicular corpectomy was performed with a midline facial incision over only the corpectomy level of interest and percutaneous instrumentation above and below that level. The open procedure consisted of a traditional posterior transpedicular corpectomy. Chi-square test, 2-tailed t-test, and ANOVA models were employed to compare perioperative and follow-up outcomes between the 2 groups.

RESULTS

In the analysis, there were 21 patients who had mini-open surgery and 28 patients who had open surgery. The mean age was 57.9 years, and 59.2% were male. The tumor types encountered were lung (18.3%), renal/bladder (16.3%), breast (14.3%), hematological (14.3%), gastrointestinal tract (10.2%), prostate (8.2%), melanoma (4.1%), and other/unknown (14.3%). There were no significant intergroup differences in demographics, comorbidities, neurological status (American Spinal Injury Association [ASIA] grade), number of corpectomies performed, and number of levels instrumented. The open group had a mean operative time of 413.6 minutes, and the mini-open group had a mean operative time of 452.4 minutes (p = 0.329). Compared with the open group, the mini-open group had significantly less blood loss (917.7 ml vs 1697.3 ml, p = 0.019) and a significantly shorter hospital stay (7.4 days vs 11.4 days, p = 0.001). There was a trend toward a lower perioperative complication rate in the mini-open group (9.5%) compared with the open group (21.4%), but this was not statistically significant (p = 0.265). At follow-up, there were no significant differences in ASIA grade (p = 0.342), complication rate after the 30-day postoperative period (p = 0.999), or need for surgical revision (p = 0.803). The open approach had a higher overall infection rate of 17.9% compared with that in the mini-open approach of 9.5%, but this was not statistically significant (p = 0.409).

CONCLUSIONS

The mini-open transpedicular corpectomy is associated with less blood loss and shorter hospital stay compared with open transpedicular corpectomy. The mini-open corpectomy also trended toward lower infection and complication rates, but these did not reach statistical significance.

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Darryl Lau and Dean Chou

OBJECTIVE

During the mini-open posterior corpectomy, percutaneous instrumentation without fusion is performed above and below the corpectomy level. In this study, the authors' goal was to compare the perioperative and long-term implant failure rates of patients who underwent nonfused percutaneous instrumentation with those of patients who underwent traditional open instrumented fusion.

METHODS

Adult patients who underwent posterior thoracic corpectomies with cage reconstruction between 2009 and 2014 were identified. Patients who underwent mini-open corpectomy had percutaneous instrumentation without fusion, and patients who underwent open corpectomy had instrumented fusion above and below the corpectomy site. The authors compared perioperative outcomes and rates of implant failure requiring reoperation between the open (fused) and mini-open (unfused) groups.

RESULTS

A total of 75 patients were identified, and 53 patients (32 open and 21 mini-open) were available for followup. The mean patient age was 52.8 years, and 56.6% of patients were male. There were no significant differences in baseline variables between the 2 groups. The overall perioperative complication rate was 15.1%, and there was no significant difference between the open and mini-open groups (18.8% vs 9.5%; p = 0.359). The mean hospital stay was 10.5 days. The open group required a significantly longer stay than the mini-open group (12.8 vs 7.1 days; p < 0.001). Overall implant failure rates requiring reoperation were 1.9% at 6 months, 9.1% at 1 year, and 14.7% at 2 years. There were no significant differences in reoperation rates between the open and mini-open groups at 6 months (3.1% vs 0.0%, p = 0.413), 1 year (10.7% vs 6.2%, p = 0.620), and 2 years (18.2% vs 8.3%, p = 0.438). The overall mean follow-up was 29.2 months.

CONCLUSIONS

These findings suggest that percutaneous instrumentation without fusion in mini-open transpedicular corpectomies offers similar implant failure and reoperation rates as open instrumented fusion as far out as 2 years of follow-up.

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Dean Chou and Daniel C. Lu

Transpedicular corpectomies are frequently used to perform anterior surgery from a posterior approach. Minimally invasive thoracolumbar corpectomies have been previously described, but these are performed through a unilateral approach. Bilateral access must be obtained for a circumferential decompression when using such techniques. The authors describe a technique that allows for a mini-open transpedicular corpectomy, 360° decompression, and expandable cage reconstruction through a single posterior approach. This is performed using percutaneous pedicle screws, the trap-door rib-head osteotomy, and a single midline fascial exposure. The authors describe this technique with intraoperative photos and a video demonstrating the technique.

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Dean Chou and Vincent Y. Wang

Lateral extracavitary and costotransversectomy approaches have been well described, and they are useful for posterior thoracic corpectomies. However, these approaches require pleural dissection and are associated with welldocumented morbidities, including hemothorax, pneumothorax, and pneumonia. But without removing the rib head, the window through which an expandable cage can be placed from a posterior approach is narrow. Thus, smaller nonexpandable mesh cages or methylmethacrylate constructs are commonly used for anterior column reconstruction. The authors describe a technique of using a “trap-door” rib-head osteotomy that avoids pleural dissection, yet allows a large expandable cage to be placed from an entirely posterior approach.

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Darryl Lau, Dean Chou and Praveen V. Mummaneni

OBJECT

In the treatment of cervical spondylotic myelopathy (CSM), anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF) are effective decompressive techniques. It remains to be determined whether ACCF and ACDF offer equivalent outcomes for multilevel CSM. In this study, the authors compared perioperative, radiographic, and clinical outcomes between 2-level ACCF and 3-level ACDF.

METHODS

Between 2006 and 2012, all patients at the authors' hospital who underwent 2-level ACCF or 3-level ACDF performed by 1 of 2 surgeons were identified. Primary outcomes of interest were sagittal Cobb angle, adjacent-segment disease (ASD) requiring surgery, neck pain measured by visual analog scale (VAS), and Nurick score. Secondary outcomes of interest included estimated blood loss (EBL), length of stay, perioperative complications, and radiographic pseudarthrosis rate. Chi-square tests and 2-tailed Student t-tests were used to compare the 2 groups. A subgroup analysis of patients without posterior spinal fusion (PSF) was also performed.

RESULTS

Twenty patients underwent 2-level ACCF, and 35 patients underwent 3-level ACDF during a 6-year period. Preoperative Nurick scores were higher in the ACCF group (2.1 vs 1.1, p = 0.014), and more patients underwent PSF in the 2-level ACCF group compared with patients in the 3-level ACDF group (60.0% vs 17.1%, p = 0.001). Otherwise there were no significant differences in demographics, comorbidities, and baseline clinical parameters between the 2 groups. Two-level ACCF was associated with significantly higher EBL compared with 3-level ACDF for the anterior stage of surgery (382.2 ml vs 117.9 ml, p < 0.001). Two-level ACCF was also associated with a longer hospital stay compared with 3-level ACDF (7.2 days vs 4.9 days, p = 0.048), but a subgroup comparison of patients without PSF showed no significant difference in length of stay (3.1 days vs 4.4 days for 2-level ACCF vs 3-level ACDF, respectively; p = 0.267). Similarly, there was a trend toward more complications in the 2-level ACCF group (20.0%) than the 3-level ACDF group (5.7%; p = 0.102), but a subgroup analysis that excluded those who had second-stage PSF no longer showed the same trend (2-level ACCF, 0.0% vs 3-level ACDF, 3.4%; p = 0.594). There were no significant differences between the ACCF group and the ACDF group in terms of postoperative sagittal Cobb angle (7.2° vs 12.1°, p = 0.173), operative ASD (6.3% vs 3.6%, p = 0.682), and radiographic pseudarthrosis rate (6.3% vs 7.1%, p = 0.909). Both groups had similar improvement in mean VAS neck pain scores (3.4 vs 3.2 for ACCF vs ACDF, respectively; p = 0.860) and Nurick scores (0.8 vs 0.7, p = 0.925).

CONCLUSIONS

Two-level ACCF was associated with greater EBL and longer hospital stays when patients underwent a second-stage PSF. However, the length of stay was similar when patients underwent anterior-only decompression with either 2-level ACCF or 3-level ACDF. Furthermore, perioperative complication rates were similar in the 2 groups when patients underwent anterior decompression without PSF. Both groups obtained similar postoperative cervical lordosis, operative ASD rates, radiographic pseudarthrosis rates, neurological improvement, and pain relief.

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Dean Chou, Prakash Sampath and Henry Brem

Hemorrhagic vestibular schwannomas are rare entities, with only a few case reports in the literature during the last 25 years. The authors review the literature on vestibular schwannoma hemorrhage and the presenting symptoms of this entity, which include headache, nausea, vomiting, sudden cranial nerve dysfunction, and ataxia. A very unusual case is presented of a 36-year-old man, who unlike most of the patients reported in the literature, had clinically silent vestibular schwannoma hemorrhage. The authors also discuss the management issues involved in more than 1000 vestibular schwannomas treated at their institution during a 25-year period.

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Laurence A. G. Marshman

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Pregnancy-related vertebral hemangioma

Case report, review of the literature, and management algorithm

John H. Chi, Geoffrey T. Manley and Dean Chou

Pregnancy is a recognized risk factor for quiescent vertebral hemangiomas becoming symptomatic; this usually occurs during the 3rd month of gestation. The natural history of these lesions is poorly understood, and treatment practices must consider the overall safety of the mother and fetus. The authors report a case of cervical vertebral hemangioma presenting during the 24th week of pregnancy and review the current literature.

A 26-year-old woman in her 24th week of pregnancy presented with upper-back pain and progressive spastic paresis in the legs. Neuroimaging studies revealed a diffuse C-7 vertebral body lesion with extradural extension and compression of the spinal cord consistent with a vertebral hemangioma. Successful decompression was accomplished, and the fetus experienced no adverse effects from the surgery.

In a review of the literature, 23 cases of pregnancy-related vertebral hemangioma dating back to 1927 were identified. Prepartum surgical decompression was performed in eight patients, postpartum surgery was performed in 12, and surgery was not performed in four. Overall, patients experienced excellent neurological recovery, regardless of the severity and duration of spastic paresis.

Observation should be considered for symptomatic patients at greater than 32 weeks gestation. Surgery should be considered for patients with severe neurological deficits at less than 32 weeks of gestation.

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Daniel C. Lu, Dean Chou and Praveen V. Mummaneni

Object

Standard approaches to thoracic intradural tumors often involve a large incision and significant tissue destruction. Minimally invasive techniques have been applied successfully for a variety of surgical decompression procedures but have been rarely used for the removal of intradural thoracolumbar tumors. In this paper, the authors compare the clinical outcome of mini-open resection of intradural thoracolumbar tumors with a standard open technique.

Methods

The authors retrospectively reviewed their series of 18 consecutive mini-open thoracolumbar, intradural, tumor resection cases and compared the outcomes with a profile-matched cohort of 9 cases of open intradural tumor resection. Operative statistics, functional outcome, and complications were compared.

Results

Tumors were removed successfully using both approaches, except for 1 case in the mini-open cohort in which only biopsy was performed for a diffusely infiltrating tumor (glioblastoma). There was no statistically significant difference in operative duration, American Spinal Injury Association scale score improvement, or back pain visual analog scale score improvement between groups. However, the mini-open group demonstrated a significantly lower estimated blood loss (153 vs 372 ml, respectively) and a significantly shorter length of hospitalization (4.9 vs 8.2 days, respectively). There was 1 complication of pseudomeningocele formation in the mini-open cohort and 1 complication of cerebral infarction in the open cohort. Mean follow-up length was 16 months in the mini-open group compared with 20 months in the open group.

Conclusions

The mini-open approach allows for adequate treatment of intradural thoracolumbar tumors with comparable outcomes to standard, open approaches. The mini-open approach is associated with less blood loss and a shorter length of stay compared with standard open surgery.

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Darryl Lau, Dean Chou, John E. Ziewacz and Praveen V. Mummaneni

Object

Smoking is one of the leading causes of preventable morbidity and death in the US and has been associated with perioperative complications. In this study, the authors examined the effects of smoking on perioperative outcomes and pseudarthrosis rates following anterior cervical corpectomy.

Methods

All adult patients from 2006 to 2011 who underwent anterior cervical corpectomy were identified. Patients were categorized into 3 groups: patients who never smoked (nonsmokers), patients who quit for at least 1 year (quitters), and patients who continue to smoke (current smokers). Demographic, medical, and surgical covariates were collected. Multivariate analysis was used to define the relationship between smoking and blood loss, 30-day complications, length of hospital stay, and pseudarthrosis.

Results

A total of 160 patients were included in the study. Of the 160 patients, 49.4% were nonsmokers, 25.6% were quitters, and 25.0% were current smokers. The overall 30-day complication rate was 20.0%, and pseudarthrosis occurred in 7.6% of patients. Mean blood loss was 368.3 ml and mean length of stay was 6.5 days. Current smoking status was significantly associated with higher complication rates (p < 0.001) and longer lengths of stay (p < 0.001); current smoking status remained an independent risk factor for both outcomes after multivariate logistic regression analysis. The complications that were experienced in current smokers were mostly infections (76.5%), and this proportion was significantly greater than in nonsmokers and quitters (p = 0.013). Current smoking status was also an independent risk factor for pseudarthrosis at 1-year follow-up (p = 0.012).

Conclusions

Smoking is independently associated with higher perioperative complications (especially infectious complications), longer lengths of stay, and higher rates of pseudarthrosis in patients undergoing anterior cervical corpectomy.