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Jacob R. Joseph, Brandon W. Smith, Frank La Marca and Paul Park

OBJECT

Minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) and lateral lumbar interbody fusion (LLIF) are 2 currently popular techniques for lumbar arthrodesis. The authors compare the total risk of each procedure, along with other important complication outcomes.

METHODS

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant studies (up to May 2015) that reported complications of either MI-TLIF or LLIF were identified from a search in the PubMed database. The primary outcome was overall risk of complication per patient. Secondary outcomes included risks of sensory deficits, temporary neurological deficit, permanent neurological deficit, intraoperative complications, medical complications, wound complications, hardware failure, subsidence, and reoperation.

RESULTS

Fifty-four studies were included for analysis of MI-TLIF, and 42 studies were included for analysis of LLIF. Overall, there were 9714 patients (5454 in the MI-TLIF group and 4260 in the LLIF group) with 13,230 levels fused (6040 in the MI-TLIF group and 7190 in the LLIF group). A total of 1045 complications in the MI-TLIF group and 1339 complications in the LLIF group were reported. The total complication rate per patient was 19.2% in the MI-TLIF group and 31.4% in the LLIF group (p < 0.0001). The rate of sensory deficits and temporary neurological deficits, and permanent neurological deficits was 20.16%, 2.22%, and 1.01% for MI-TLIF versus 27.08%, 9.40%, and 2.46% for LLIF, respectively (p < 0.0001, p < 0.0001, p = 0.002, respectively). Rates of intraoperative and wound complications were 3.57% and 1.63% for MI-TLIF compared with 1.93% and 0.80% for LLIF, respectively (p = 0.0003 and p = 0.034, respectively). No significant differences were noted for medical complications or reoperation.

CONCLUSIONS

While there was a higher overall complication rate with LLIF, MI-TLIF and LLIF both have acceptable complication profiles. LLIF had higher rates of sensory as well as temporary and permanent neurological symptoms, although rates of intraoperative and wound complications were less than MI-TLIF. Larger, prospective comparative studies are needed to confirm these findings as the current literature is of relative poor quality.

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Cheerag D. Upadhyaya, Paul Park and Frank La Marca

✓ Chyloretroperitoneum is an uncommon complication following spinal surgery. The authors present the case of a patient in whom conservative treatment and initial surgical measures failed to relieve varied symptoms of postsurgical chyloretroperitoneum. Following attempts at conservative management, a peritoneal window was surgically created to divert lymphatic flow from the retroperitoneal space into the peritoneal space, where it was resorbed. This unique surgical technique provides yet another option in the treatment of refractory chyloretroperitoneum following anterior lumbar spinal surgery. The authors describe their technique and review retroperitoneal lymphatic anatomy along with similar case reports in the literature.

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William R. Stetler Jr., Frank La Marca and Paul Park

Object

Ossification of the posterior longitudinal ligament (OPLL) is a pathological process of ectopic calcification with a preponderance for the cervical spine. Epidemiological and familial studies have both indicated predisposition; however, the genetic inheritance pattern and responsible genes for OPLL are still uncertain. The aim of this study was to evaluate and summarize the current understanding of the genetics underlying OPLL.

Methods

The authors reviewed epidemiological and genetic studies surrounding OPLL, with a particular focus on inheritance patterns and potential genes responsible for OPLL, using a PubMed database literature search.

Results

Despite an unclear inheritance pattern, there appears to be a strong familial link in patients with OPLL. Examination of these patterns using linkage analysis has shown multiple candidate genes that could be responsible for the inheritance of OPLL. Genes for collagen, nucleotide pyrophosphatase, transforming growth factors, and the vitamin D receptor have all been implicated. Additionally, multiple cytokines and growth factors, including bone morphogenetic proteins as well as other proteins and interleukins involved in bone development, have been shown to be abnormally expressed in patients with OPLL. In addition, multiple mechanical and metabolic factors such as hyperinsulinemia and obesity have been shown to be linked to OPLL.

Conclusions

Ossification of the posterior longitudinal ligament has a complex inheritance pattern. It does not appear that OPLL follows a simple, single-gene Mendelian inheritance pattern. Development of OPLL is more likely multifactorial in nature and develops in patients with a genetic predisposition from a variety of different mutations in various genes on various chromosomes. Additionally, environmental factors and interaction by other pathological disease processes, such as obesity and diabetes mellitus, may play a role in the development of OPLL in susceptible individuals.

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Juan Santiago Uribe, Edwin Ramos-Zapata and Fernando Luis Vale

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Darryl Lau, Matthew R. Leach, Frank La Marca and Paul Park

Object

Surgery for spinal metastasis is considered palliative, and postoperative survival is often less than a year. Recurrence of metastatic lesions is quite common, and it remains unclear whether repeat surgery is effective. In this study, the authors assessed independent predictors for survival at 6 months, 1 year, and 2 years after surgery, and examined whether repeat surgery for recurrence of spinal metastasis influenced survival rates.

Methods

Retrospective review of the electronic medical records was performed to identify a consecutive population of adult patients who underwent surgery for spinal metastasis during the period 2005–2011. Utilizing a Cox proportional hazard regression model, the authors assessed independent predictors and risk factors for survival at 6 months, 1 year, and 2 years after surgery. In addition, the impact of repeat surgery on survival was specifically assessed via multivariable analysis.

Results

A total of 99 patients were included in the final analysis. The overall mean postoperative duration of survival was 9.6 months. In addition to previously identified predictors of survival (preoperative ambulation, Karnofsky Performance Status [KPS], radiotherapy, primary cancer type, presence of extraspinal metastasis, and number of spinal segments with metastasis), pain on presentation and body mass index (BMI) of 25–30 were both independently associated with survival. Patients with recurrence who underwent repeat surgery had longer mean survival times than patients with recurrence who did not undergo repeat surgery (19.6 months vs 12.8 months, respectively). Repeat surgery was also independently associated with higher survival rates on multivariate analysis. Follow-up KPS was significantly higher in patients who underwent repeat surgery as well.

Conclusions

In addition to confirming previously identified predictors of survival following surgery for spinal metastasis, the authors identified BMI and pain on presentation as independent predictors of survival. They also found that repeat surgery may be a viable option in patients with metastatic recurrence and may offer prolonged survival, likely due to improved functionality, mitigating complications associated with immobility.

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Sangala Jaypal Reddy, Frank La Marca and Paul Park

Heat shock proteins (HSPs) are normal intracellular proteins that are produced in greater amounts when cells are subjected to stress or injury. These proteins have been shown to play a key role in the modulation of the secondary injury that occurs after the initial spinal cord injury (SCI). Heat shock proteins normally act as molecular chaperones and are called protein guardians because they act to repair partially damaged proteins. Normally intracellular, HSPs can also be liberated into the systemic circulation to act as important inflammatory mediators. In the setting of SCI, HSP induction has been shown to be beneficial. These proteins are liberated primarily by acutely stressed microglial, endothelial, and ependymal cells. Heat shock proteins have also been shown to assist in the protection of motor neurons and to prevent chronic inflammation after SCI. In animal models, several experimental drugs have shown neuroprotective effects in the spinal cord and appear to function by modulating HSPs.

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Anthony C. Wang, Khoi D. Than, Arnold B. Etame, Frank La Marca and Paul Park

Object

Transcranial motor evoked potential (TcMEP) monitoring is frequently used in complex spinal surgeries to prevent neurological injury. Anesthesia, however, can significantly affect the reliability of TcMEP monitoring. Understanding the impact of various anesthetic agents on neurophysiological monitoring is therefore essential.

Methods

A literature search of the National Library of Medicine database was conducted to identify articles pertaining to anesthesia and TcMEP monitoring during spine surgery. Twenty studies were selected and reviewed.

Results

Inhalational anesthetics and neuromuscular blockade have been shown to limit the ability of TcMEP monitoring to detect significant changes. Hypothermia can also negatively affect monitoring. Opioids, however, have little influence on TcMEPs. Total intravenous anesthesia regimens can minimize the need for inhalational anesthetics.

Conclusions

In general, selecting the appropriate anesthetic regimen with maintenance of a stable concentration of inhalational or intravenous anesthetics optimizes TcMEP monitoring.

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Michael J. Cools, Wajd N. Al-Holou, William R. Stetler Jr., Frank La Marca and Juan M. Valdivia-Valdivia

Sacral fractures are rare and seldom result in formation of a sacral pseudomeningocele. Treatment of these pseudomeningoceles usually consists of conservative management with flat bedrest or open operative management. The authors describe the case of a 55-year-old woman with an anterior sacral pseudomeningocele that was successfully treated using a lumbar drain for temporary continuous CSF drainage. The patient first presented to an outside institution several days after sacral trauma from an ice skating fall. Initial symptoms included throbbing headaches relieved by lying flat. Head and cervical spine CT demonstrated no abnormality. As symptoms worsened, she presented to another institution where MRI of the lumbar spine indicated sacral fracture with pseudomeningocele. The patient subsequently transferred to the authors' facility, where symptoms included headaches and occasional mild sacral pain. Given her headaches and the authors' concern for CSF leak, another head CT scan was performed. This revealed no subdural hematoma or other abnormality. A subsequent CT myelogram revealed an anterior sacral pseudomeningocele at S3–4 with an anterior irregular linear filling defect, likely representing torn dura. Treatment included placement of a lumbar drain (10 ml/hr) and flat bedrest. Resolution of the CSF leak occurred on postprocedure Day 9. At the 4-week follow-up visit, the patient had no clinical symptoms of CSF leak and no neurological complaints. To our knowledge, this is the first description of temporary continuous CSF drainage used to treat a posttraumatic sacral pseudomeningocele. This technique may reduce the need for potentially complicated surgical repair of sacral fractures associated with CSF leak in select patients.

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Darryl Lau, Samuel W. Terman, Rakesh Patel, Frank La Marca and Paul Park

Object

A reported risk factor for adjacent-segment disease is injury to the superior facet joint from pedicle screw placement. Given that the facet joint is not typically visualized during percutaneous pedicle screw insertion, there is a concern for increased facet violation (FV) in minimally invasive fusion procedures. The purpose of this study was to analyze and compare the incidence of FV among patients undergoing minimally invasive transforaminal lumbar interbody fusion (MITLIF) and open transforaminal lumbar interbody fusion (TLIF). The impact of O-arm navigation compared with traditional fluoroscopy on FV in MITLIF is also assessed, as are risk factors for FV.

Methods

The authors identified a consecutive population of patients who underwent MITLIF with percutaneous pedicle screw placement, as well as a matched cohort of patients who underwent open TLIF. Postoperative CT imaging was assessed to determine intraarticular FV due to pedicle screw placement. Patients were stratified into minimally invasive and open TLIF groups. Within the MITLIF group, the authors performed a subanalysis of image guidance methods used in cases of FV. Two-tailed Student t-test, ANOVA, chi-square testing, and logistic regression were used for statistical analysis.

Results

A total of 282 patients were identified, with a total of 564 superior pedicle screw placements. The MITLIF group consisted of 142 patients with 284 screw insertions. The open TLIF group consisted of 140 patients with 280 screw insertions. Overall, 21 (7.4%) of 282 patients experienced FV. A total of 21 screws violated a facet joint for a screw-based FV rate of 3.7% (21 of 564 screws). There were no significant differences between the MITLIF and open TLIF groups in the percentage of patients with FV (6.3% vs 8.6%) and or the percentage of screws with FV (3.2% vs 4.3%) (p = 0.475 and p = 0.484, respectively). Further stratifying the MI group into O-arm navigation and fluoroscopic guidance subgroups, the patient-based rates of FV were 10.8% (4 of 37 patients) and 4.8% (5 of 105 patients), respectively, and the screw-based rates of FV were 5.4% (4 of 74 screws) and 2.4% (5 of 210 screws), respectively. There was no significant difference between the subgroups with respect to patient-based or screw-based FV rates (p = 0.375 and p = 0.442, respectively). The O-arm group had a significantly higher body mass index (BMI) (p = 0.021). BMI greater than 29.9 was independently associated with higher FV (OR 2.36, 95% CI 1.65–8.53, p = 0.039).

Conclusions

The findings suggest that minimally invasive pedicle screw placement is not associated with higher rates of FV. Overall violation rates were similar in MITLIF and open TLIF. Higher BMI, however, was a risk factor for increased FV. The use of O-arm fluoroscopy with computer-assisted guidance did not significantly decrease the rate of FV.