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

Object

Symptomatic cervical kyphosis can result from a variety of causes. Symptoms can include pain, neurological deficits, and functional limitation due to loss of horizontal gaze.

Methods

The authors review the long-term functional and radiographic outcomes following surgery for symptomatic cervical kyphosis by performing a PubMed database literature search.

Results

Fourteen retrospective studies involving a total of 399 patients were identified. Surgical intervention included ventral, dorsal, or circumferential approaches. Analysis of the degree of deformity correction and functional parameters demonstrated significant postsurgical improvement. Overall, patient satisfaction appeared high. Five studies reported mortality with rates ranging from 3.1 to 6.7%. Major medical complications after surgery were reported in 5 studies with rates ranging from 3.1 to 44.4%. The overall neurological complication rate was 13.5%.

Conclusions

Although complications are not insignificant, surgery appears to be an effective option when conservative measures fail to provide relief.

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Frank La Marca, Geoffrey Zubay, Thomas Morrison III, and Dean Karahalios

Object

The occipital condyle has never been studied as a viable structure that could permit bone purchase by fixation devices for occipitocervical fusion. The authors propose occipital condyle screw placement as a possible alternative to conventional occipitocervical fixation techniques.

Methods

Six adult cadaver heads (12 total occipital condyles) were studied, and the StealthStation image-guidance system was used for preoperative planning of occipital condyle screw placement. Morphometric studies of the occipital condyle were performed. A 3.5-mm Vertex screw was then placed in the occipital condyle with image-guided assistance in 3 specimens. Operations in the remaining 3 specimens proceeded using anatomical markers and calculated degrees of angulation for screw placement with a free-hand technique. Postoperatively the cadaver heads were rescanned and reanalyzed to determine the success of screw placement and its effect on hypoglossal canal volume.

Results

All screws were successfully placed with no sign of lateral or medial cortical breach. Two screws had bicortical purchase. There was no change in hypoglossal canal volume in any specimen.

Conclusions

Occipital condyle screw placement is a safe and viable option for occipitocervical fixation and could be a preferred procedure in selected cases. However, further biomechanical studies are required to compare its reliability to other more established techniques.

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Dushyanth Srinivasan, Samuel W. Terman, Mai Himedan, Domenico Dugo, Frank La Marca, and Paul Park

Object

Bacterial spinal infections are infrequent but may lead to significant morbidity and death. Apart from neurological complications, infections may also lead to bone destruction resulting in deformity of the spine. However, the incidence of spinal deformities and risk factors is not well characterized in the literature.

Methods

A retrospective cohort study was conducted using electronic medical records at a single institution. All patients were over 18 years of age and had a clinically and radiologically documented spinal infection that was treated surgically during the period 2006–2013. Infections were classified according to anatomical location including disc, bone, and/or epidural space. Deformities included kyphosis and/or subluxation. The authors analyzed risk factors for developing at least 1 deformity between the time of infection and operation using the Fisher exact test and chi-square test. Change in visual analog scale (VAS) scores preoperatively versus postoperatively was also analyzed using the paired t-test.

Results

The study included 48 patients. The most common types of spinal infections were osteomyelitis and discitis (31%); osteomyelitis, discitis, and spinal epidural abscess (SEA; 27%); SEA only (15%); and osteomyelitis only (13%). Overall, 21 (44%) of 48 patients developed a spinal deformity. Anatomical location of infection (bone and/or disc and/or epidural space) was significantly associated with development of deformity (p < 0.001). In particular, patients with SEA had lower odds of deformity compared with patients without SEA (odds ratio 0.2, 95% confidence interval 0.05–0.9; p < 0.001). No other factor was significantly associated with deformity. Pain measured by VAS score tended to improve by a mean of 1.7 ± 2.7 points (p < 0.001) when comparing preoperative to postoperative scores.

Conclusions

In this cohort of patients, 44% developed at least 1 deformity, predominantly kyphosis. The only variable significantly associated with deformity was infection location. Patients with SEA alone demonstrated lower odds of developing a deformity compared with patients without SEA. Other analyzed variables, including age, body mass index, time from initial diagnosis to surgery, and comorbidities, were not found to be associated with development of deformity. Surgical intervention resulted in pain improvement.