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Saqib Hasan, Lynn B. McGrath Jr., Rajeev D. Sen, Jason K. Barber, and Christoph P. Hofstetter

OBJECTIVE

The management of lumbar spinal stenosis (LSS) with concurrent scoliosis and/or spondylolisthesis remains controversial. Full-endoscopic unilateral laminotomy for bilateral decompression (ULBD) facilitates neural decompression while preserving stabilizing osseoligamentous structures and may be uniquely suited for the treatment of LSS with concurrent mild to moderate degenerative deformity. The safety and efficacy of full-endoscopic versus minimally invasive surgery (MIS) ULBD in this patient population is studied here for the first time.

METHODS

A retrospective analysis of prospectively collected data was conducted on 45 consecutive LSS patients with concurrent scoliosis (≥ 10° coronal Cobb angle) and/or spondylolisthesis (≥ 3 mm). Patient demographics, operative details, complications, and imaging characteristics were reviewed. Outcomes were quantified using back and leg visual analog scale (VAS) scores and the Oswestry Disability Index (ODI) at 2 weeks, 3 months, and 1 year.

RESULTS

A total of 26 patients underwent full-endoscopic and 19 underwent MIS-ULBD with an average follow-up period of 12 months. The endoscopic cohort experienced a significantly shorter hospital length of stay (p = 0.014) and fewer adverse events (p = 0.010). Both cohorts experienced significant improvements in VAS and ODI scores at all time points (p < 0.001), but the endoscopic cohort demonstrated significantly better early ODI scores (p = 0.024).

CONCLUSIONS

Endoscopic and MIS-ULBD result in similar functional outcomes for LSS with mild to moderate deformity, while the endoscopic approach demonstrates a favorable rate of complications. Further studies are required to better delineate the characteristics of spinal deformities amenable to this approach and the durability of functional results.

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Chibawanye I. Ene, Anthony C. Wang, Kelly L. Collins, Robert H. Bonow, Lynn B. McGrath, Sharon J. Durfy, Jason K. Barber, and Richard G. Ellenbogen

OBJECTIVE

While a select population of pediatric patients with Chiari malformation type I (CM-I) remain asymptomatic, some patients present with tussive headaches, neurological deficits, progressive scoliosis, and other debilitating symptoms that necessitate surgical intervention. Surgery entails a variety of strategies to restore normal CSF flow, including increasing the posterior fossa volume via bone decompression only, or bone decompression with duraplasty, with or without obex exploration. The indications for duraplasty and obex exploration following bone decompression remain controversial. The objective of this study was to describe an institutional series of pediatric patients undergoing surgery for CM-I, performed by a single neurosurgeon. For patients presenting with a syrinx, the authors compared outcomes following bone-only decompression with duraplasty only and with duraplasty including obex exploration. Clinical outcomes evaluated included resolution of syrinx, scoliosis, presenting symptoms, and surgical complications.

METHODS

A retrospective review was conducted of the medical records of 276 consecutive pediatric patients with CM-I operated on at a single institution between 2001 and 2015 by the senior author. Imaging findings of tonsillar descent, associated syrinx (syringomyelia or syringobulbia), basilar invagination, and clinical assessment of CM-I–attributable symptoms and scoliosis were recorded. In patients presenting with a syrinx, clinical outcomes, including syrinx resolution, symptom resolution, and impact on scoliosis progression, were compared for three surgical groups: bone-only/posterior fossa decompression (PFD), PFD with duraplasty (PFDwD), and PFD with duraplasty and obex exploration (PFDwDO).

RESULTS

PFD was performed in 25% of patients (69/276), PFDwD in 18% of patients (50/276), and PFDwDO in 57% of patients (157/276). The mean follow-up was 35 ± 35 months. Nearly half of the patients (132/276, 48%) had a syrinx. In patients presenting with a syrinx, PFDwDO was associated with a significantly higher likelihood of syrinx resolution relative to PFD only (HR 2.65, p = 0.028) and a significant difference in time to symptom resolution (HR 2.68, p = 0.033). Scoliosis outcomes did not differ among treatment groups (p = 0.275). Complications were not significantly higher when any duraplasty (PFDwD or PFDwDO) was performed following bone decompression (p > 0.99).

CONCLUSIONS

In this series of pediatric patients with CM-I, patients presenting with a syrinx who underwent expansile duraplasty with obex exploration had a significantly greater likelihood of syrinx and symptom resolution, without increased risk of CSF-related complications, compared to those who underwent bone-only decompression.

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Ryan P. Morton, Isaac Josh Abecassis, Josiah F. Hanson, Jason K. Barber, Mimi Chen, Cory M. Kelly, John D. Nerva, Samuel N. Emerson, Chibawanye I. Ene, Michael R. Levitt, Michelle M. Chowdhary, Andrew L. Ko, and Randall M. Chesnut

OBJECTIVE

Despite their technical simplicity, cranioplasty procedures carry high reported morbidity rates. The authors here present the largest study to date on complications after cranioplasty, focusing specifically on the relationship between complications and timing of the operation.

METHODS

The authors retrospectively reviewed all cranioplasty cases performed at Harborview Medical Center over the past 10.75 years. In addition to relevant clinical and demographic characteristics, patient morbidity and mortality data were abstracted from the electronic medical record. Cox proportional-hazards models were used to analyze variables potentially associated with the risk of infection, hydrocephalus, seizure, hematoma, and bone flap resorption.

RESULTS

Over the course of 10.75 years, 754 cranioplasties were performed at a single institution. Sixty percent of the patients who underwent these cranioplasties were male, and the median follow-up overall was 233 days. The 30-day mortality rate was 0.26% (2 cases, both due to postoperative epidural hematoma). Overall, 24.6% percent of the patients experienced at least 1 complication including infection necessitating explantation of the flap (6.6%), postoperative hydrocephalus requiring a shunt (9.0%), resorption of the flap requiring synthetic cranioplasty (6.3%), seizure (4.1%), postoperative hematoma requiring evacuation (2.3%), and other (1.6%).

The rate of infection was significantly higher if the cranioplasty had been performed < 14 days after the initial craniectomy (p = 0.007, Holm-Bonferroni–adjusted p = 0.028). Hydrocephalus was significantly correlated with time to cranioplasty (OR 0.92 per 10-day increase, p < 0.001) and was most common in patients whose cranioplasty had been performed < 90 days after initial craniectomy. New-onset seizure, however, only occurred in patients who had undergone their cranioplasty > 90 days after initial craniectomy. Bone flap resorption was the least likely complication for patients whose cranioplasty had been performed between 15 and 30 days after initial craniectomy. Resorption was also correlated with patient age, with a hazard ratio of 0.67 per increase of 10 years of age (p = 0.001).

CONCLUSIONS

Cranioplasty performed between 15 and 30 days after initial craniectomy may minimize infection, seizure, and bone flap resorption, whereas waiting > 90 days may minimize hydrocephalus but may increase the risk of seizure.