Jay D. Turner and Robert F. Spetzler
Dennis A. Turner, Jay Tracy, and Stephen J. Haines
✓ The long-term outcome following carotid endarterectomy for neurological symptoms was analyzed using a retrospective life-table approach in 212 patients who had undergone 243 endarterectomy procedures. The postoperative follow-up period averaged 38.9 ± 2.1 months (mean ± standard error of the mean). The endpoints of stroke and death were evaluated in these patients. Patient groups with the preoperative symptoms of amaurosis fugax, transient ischemic attack, and prior recovered stroke were similar in terms of life-table outcome over the follow-up period. Sixty-two percent of symptomatic patients were alive and free of stroke at 5 years. The late risk of stroke (after 30 days postoperatively) averaged 1.7% per year based on a linear approximation to the hazard at each life-table interval (1.3% per year for ipsilateral stroke). The trend of late stroke risk was clearly downward, however, and could be fitted more accurately by an exponential decay function with a half-life of 33 months. Thus, the risk of stroke following carotid endarterectomy for neurological symptoms was highest in the perioperative period, slowly declined with time, and occurred predominantly ipsilateral to the procedure.
The definition of a prospective medical control group remains crucial for a critical analysis of treatment modalities following the onset of premonitory neurological symptoms. In the absence of an adequate control group for this series, the calculated perioperative and postoperative stroke risk from this study was compared to data obtained from the literature on stroke risk in medically treated symptomatic patients. This uncontrolled comparison of treatment modalities suggests the combined perioperative and postoperative stroke risk associated with carotid endarterectomy to be modestly improved over medical treatment alone.
Eduardo Martinez-del-Campo, Jay D. Turner, Hector Soriano-Baron, Anna G. U. S. Newcomb, Samuel Kalb, and Nicholas Theodore
The authors assessed the rate of vertebral growth, curvature, and alignment for multilevel constructs in the cervical spine after occipitocervical fixation (OCF) in pediatric patients and compared these results with those in published reports of growth in normal children.
The authors assessed cervical spine radiographs and CT images of 18 patients who underwent occipitocervical arthrodesis. Measurements were made using postoperative and follow-up images available for 16 patients to determine cervical alignment (cervical spine alignment [CSA], C1–7 sagittal vertical axis [SVA], and C2–7 SVA) and curvature (cervical spine curvature [CSC] and C2–7 lordosis angle). Seventeen patients had postoperative and follow-up images available with which to measure vertebral body height (VBH), vertebral body width (VBW), and vertical growth percentage (VG%—that is, percentage change from postoperative to follow-up). Results for cervical spine growth were compared with normal parameters of 456 patients previously reported on in 2 studies.
Ten patients were girls and 8 were boys; their mean age was 6.7 ± 3.2 years. Constructs spanned occiput (Oc)–C2 (n = 2), Oc–C3 (n = 7), and Oc–C4 (n = 9). The mean duration of follow-up was 44.4 months (range 24–101 months). Comparison of postoperative to follow-up measures showed that the mean CSA increased by 1.8 ± 2.9 mm (p < 0.01); the mean C2–7 SVA and C1–7 SVA increased by 2.3 mm and 2.7 mm, respectively (p = 0.3); the mean CSC changed by −8.7° (p < 0.01) and the mean C2–7 lordosis angle changed by 2.6° (p = 0.5); and the cumulative mean VG% of the instrumented levels (C2–4) provided 51.5% of the total cervical growth (C2–7). The annual vertical growth rate was 4.4 mm/year. The VBW growth from C2–4 ranged from 13.9% to 16.6% (p < 0.001). The VBW of C-2 in instrumented patients appeared to be of a smaller diameter than that of normal patients, especially among those aged 5 to < 10 years and 10–15 years, with an increased diameter at the immediately inferior vertebral bodies compensating for the decreased width. No cervical deformation, malalignment, or detrimental clinical status was evident in any patient.
The craniovertebral junction and the upper cervical spine continue to present normal growth, curvature, and alignment parameters in children with OCF constructs spanning a distance as long as Oc–C4.
Eduardo Martinez-del-Campo, Jay D. Turner, Leonardo Rangel-Castilla, Hector Soriano-Baron, Samuel Kalb, and Nicholas Theodore
If left untreated, occipitocervical (OC) instability may lead to serious neurological injury or death. Open internal fixation is often necessary to protect the neurovascular elements. This study reviews the etiologies for pediatric OC instability, analyzes the radiographic criteria for surgical intervention, discusses surgical fixation techniques, and evaluates long-term postoperative outcomes based on a single surgeon's experience.
The charts of all patients < 18 years old who underwent internal OC fixation conducted by the senior author were retrospectively reviewed. Forty consecutive patients were identified for analysis. Patient demographic data, OC junction pathology, radiological diagnostic tools, surgical indications, and outcomes are reported.
The study population consisted of 20 boys and 20 girls, with a mean age of 7.3 years. Trauma (45% [n = 18]) was the most common cause of instability, followed by congenital etiologies (37.5% [n = 15]). The condyle-C1 interval had a diagnostic sensitivity of 100% for atlantooccipital dislocation. The median number of fixated segments was 5 (occiput–C4). Structural bone grafts were used in all patients. Postsurgical neurological improvement was seen in 88.2% (15/17) of patients with chronic myelopathy and in 25% (1/4) of patients with acute myelopathy. Preoperatively, 42.5% (17/40) of patients were neurologically intact and remained unchanged at last follow-up, 42.5% (17/40) had neurological improvement, 12.5% (5/40) remained unchanged, and 2.5% (1/40) deteriorated. All patients had successful fusion at 1-year follow-up. The complication rate was 7.5% (3/40), including 1 case of vertebral artery injury.
Occipitocervical fixation is safe in children and provides immediate immobilization, with excellent survival and arthrodesis rates. Of the radiographic tools evaluated, the condyle-C1 interval was the most predictive of atlantooccipital dislocation.
Adib A. Abla, Jay D. Turner, Alim P. Mitha, Gregory Lekovic, and Robert F. Spetzler
Brainstem cavernous malformations (CMs) are low-flow vascular lesions in eloquent locations. Their presentation is often marked with symptomatic hemorrhages that appear to occur more frequently than hemorrhage from supratentorial cavernomas. Brainstem CMs can be removed using 1 of the 5 standard skull-base approaches: retrosigmoid, suboccipital (with or without telovelar approach), supracerebellar infratentorial, orbitozygomatic, and far lateral.
Patients being referred to a tertiary institution often have lesions that are aggressive with respect to bleeding rates. Nonetheless, the indications for surgery, in the authors' opinion, are the same for all lesions: those that are symptomatic, those that cause mass effect, or those that abut a pial surface. Patients often have relapsing and remitting courses of symptoms, with each hemorrhage causing a progressive and stepwise decline. Many patients experience new postoperative deficits, most of which are transient and resolve fully. Despite the risks associated with operating in this highly eloquent tissue, most patients have had favorable outcomes in the authors' experience. Surgical treatment of brainstem CMs protects patients from the potentially devastating effects of rehemorrhage, and the authors believe that the benefits of intervention outweigh the risks in patients with the appropriate indications.
Alim P. Mitha, Jay D. Turner, Adib A. Abla, A. Giancarlo Vishteh, and Robert F. Spetzler
The management of intramedullary spinal cord cavernous malformations (CMs) is controversial. At Barrow Neurological Institute, the authors selectively offer surgical treatment for symptomatic spinal cord CMs. The purpose of this paper is to review the clinical outcomes in patients after resection of these lesions based on a single-center experience over a 25-year period.
The records of 80 patients who underwent resection of pathologically confirmed spinal cord CMs from January 1985 to May 2010 were analyzed retrospectively. Preoperative clinical status and imaging findings were evaluated as well as immediate and long-term postoperative outcomes.
Compared with their preoperative Frankel grade, 11% of patients were worse, 83% were the same, and 6% improved immediately after surgery. At a mean follow-up interval of 5 years, 10% of patients were worse, 68% were the same, and 23% were improved compared with their preoperative status. Five percent of patients underwent reoperation for resection of a symptomatic residual or recurrent lesion. Immediate complications were encountered in 6% of patients, including CSF leakage and deep venous thrombosis. Long-term complications were encountered in 14% of patients and included kyphotic deformity, stenosis, and spinal cord tethering. A significant correlation was found between long-term outcome and anteroposterior length of the lesion (p = 0.01).
The resection of intramedullary spinal cord CMs can be achieved with good long-term outcomes and an acceptable risk of immediate or delayed complications.
Tyler S. Cole, Kaith K. Almefty, Jakub Godzik, Amy H. Muma, Randall J. Hlubek, Eduardo Martinez-del-Campo, Nicholas Theodore, U. Kumar Kakarla, and Jay D. Turner
Cervical spondylotic myelopathy (CSM) is the primary cause of adult spinal cord dysfunction. Diminished hand strength and reduced dexterity associated with CSM contribute to disability. Here, the authors investigated the impact of CSM severity on hand function using quantitative testing and evaluated the response to surgical intervention.
Thirty-three patients undergoing surgical treatment of CSM were prospectively enrolled in the study. An occupational therapist conducted 3 functional hand tests: 1) palmar dynamometry to measure grip strength, 2) hydraulic pinch gauge test to measure pinch strength, and 3) 9-hole peg test (9-HPT) to evaluate upper extremity dexterity. Tests were performed preoperatively and 6–8 weeks postoperatively. Test results were expressed as 1) a percentile relative to age- and sex-stratified norms and 2) achievement of a minimum clinically important (MCI) difference. Patients were stratified into groups (mild, moderate, and severe myelopathy) based on their modified Japanese Orthopaedic Association (mJOA) score. The severity of stenosis on preoperative MRI was graded by three independent physicians using the Kang classification.
The primary presenting symptoms were neck pain (33%), numbness (21%), imbalance (12%), and upper extremity weakness (12%). Among the 33 patients, 61% (20) underwent anterior approach decompression, with a mean (SD) of 2.9 (1.5) levels treated. At baseline, patients with moderate and low mJOA scores (indicating more severe myelopathy) had lower preoperative pinch (p < 0.001) and grip (p = 0.01) strength than those with high mJOA scores/mild myelopathy. Postoperative improvement was observed in all hand function domains except pinch strength in the nondominant hand, with MCI differences at 6 weeks ranging from 33% of patients in dominant-hand strength tests to 73% of patients in nondominant-hand dexterity tests. Patients with moderate baseline mJOA scores were more likely to have MCI improvement in dominant grip strength (58.3%) than those with low mJOA scores/severe myelopathy (30%) and high mJOA scores/mild myelopathy (9%, p = 0.04). Dexterity in the dominant hand as measured by the 9-HPT ranged from < 1 in patients with cord signal change to 15.9 in patients with subarachnoid effacement only (p = 0.03).
Patients with CSM achieved significant improvement in strength and dexterity postoperatively. Baseline strength measures correlated best with the preoperative mJOA score; baseline dexterity correlated best with the severity of stenosis on MRI. The majority of patients experienced MCI improvements in dexterity. Baseline pinch strength correlated with postoperative mJOA MCI improvement, and patients with moderate baseline mJOA scores were the most likely to have improvement in dominant grip strength postoperatively.
Eduardo Martinez-del-Campo, Samuel Kalb, Hector Soriano-Baron, Jay D. Turner, Matthew T. Neal, Timothy Uschold, and Nicholas Theodore
Atlantooccipital dislocation (AOD) in adults cannot be diagnosed with adequate specificity and sensitivity using only CT or plain radiography, and the spine literature offers no guidelines. In children, the most sensitive and specific radiographic measurement for the diagnosis of AOD is the CT-based occipital condyle–C1 interval (CCI). The goal of the current study was to identify the normal CCI in healthy adults and compare it with the CCI in adults with AOD to establish a highly sensitive and specific cutoff value for the neuroimaging diagnosis of AOD.
A total of 81 patients, 59 without AOD and 22 with AOD, were included in this study. Measurements obtained from thin-slice CT scans of the craniovertebral joint to assess atlantooccipital dislocation included the CCI, condylar sum, the Wholey and Harris intervals, Powers and Sun ratios, Wackenheim line, and Lee X-lines.
The group of patients without AOD included 30 men (50.8%) and 29 women (49.2%) with a mean age of 42.4 ± 16 years (range 19–87 years). The group of patients with AOD included 10 men (45.5%) and 12 women (54.5%) with a mean age of 38.2 ± 9.7 years (range 20–56 years). Interrater reliabilities within a 95% CI were all greater than 0.98 for CCI measurements. A total of 1296 measurements of the CCI were made in 81 patients. The mean CCI for non-AOD patients was 0.89 ± 0.12 mm, the single largest CCI measurement was 1.4 mm, and the largest mean for either right or left CCI was 1.2 mm. The mean condylar sum was 1.8 ± 0.2 mm, and the largest condylar sum value was 2.2 mm. Linear regression with age predicted an increase in CCI of 0.001 mm/year (p < 0.05). The mean CCI in AOD patients was 3.35 ± 0.18 mm (range 1.5 mm–6.4 mm). The shortest single CCI measurements in the AOD patients were 1.1 mm and 1.2 mm. The mean condylar sum for all 22 AOD patients was 6.7 ± 2.7 mm and the shortest condylar sums were 3.0 mm. Cutoff values for AOD were set at 1.5 mm for the CCI and 3.0 mm for the condylar sum, both with a sensitivity of 1 and false-negative rate of 0. Sensitivity for the Powers, Wholey, Harris, Sun, Wackenheim, and Lee criteria were determined to be 0.55, 0.46, 0.27, 0.23, 0.41, and 0.41, respectively.
The CCI is shorter in adult patients as opposed to the pediatric population. The revised CCI (1.5 mm) and condylar sum (3.0 mm) cutoff values have the highest sensitivity and specificity for the diagnosis of AOD in the adult population.
Jakub Godzik, Bernardo de Andrada Pereira, Anna G. U. Sawa, Jennifer N. Lehrman, Randall J. Hlubek, Brian P. Kelly, and Jay D. Turner
The objective of this study was to evaluate a novel connector design and compare it with traditional side connectors, such as a fixed-angle connector (FAC) and a variable-angle connector (VAC), with respect to lumbosacral stability and instrumentation strain.
Standard nondestructive flexibility tests (7.5 Nm) and compression tests (400 N) were performed using 7 human cadaveric specimens (L1–ilium) to compare range of motion (ROM) stability, posterior rod strain (RS), and sacral screw bending moment (SM). Directions of motion included flexion, extension, left and right lateral bending, left and right axial rotation, and compression. Conditions included 1) the standard 2-rod construct (2R); 2) the dual-tulip head (DTH) with 4-rod construct (4R); 3) FACs with 4R; and 4) VACs with 4R. Data were analyzed using repeated-measures ANOVA.
Overall, there were no statistically significant differences in ROM across the lumbosacral junction among conditions (p > 0.07). Compared with 2R, DTH and FAC significantly reduced RS in extension, left axial rotation, and compression (p ≤ 0.03). VAC significantly decreased RS compared with 2R in flexion, extension, left axial rotation, right axial rotation, and compression (p ≤ 0.03), and significantly decreased RS compared with DTH in extension (p = 0.02). DTH was associated with increased SM in left and right axial rotation compared with 2R (p ≤ 0.003) and in left and right lateral bending and left and right axial rotation compared with FAC and VAC (p ≤ 0.02). FAC and VAC were associated with decreased SM compared with 2R in right and left lateral bending (p ≤ 0.03).
RS across the lumbosacral junction can be high. Supplemental rod fixation with DTH is an effective strategy for reducing RS across the lumbosacral junction. However, the greatest reduction in RS and SM was achieved with a VAC that allowed for straight (uncontoured) accessory rod placement.
Corey T. Walker, S. Harrison Farber, Tyler S. Cole, David S. Xu, Jakub Godzik, Alexander C. Whiting, Cory Hartman, Randall W. Porter, Jay D. Turner, and Juan Uribe
Minimally invasive anterolateral retroperitoneal approaches for lumbar interbody arthrodesis have distinct advantages attractive to spine surgeons. Prepsoas or transpsoas trajectories can be employed with differing complication profiles because of the inherent anatomical differences encountered in each approach. The evidence comparing them remains limited because of poor quality data. Here, the authors sought to systematically review the available literature and perform a meta-analysis comparing the two techniques.
A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A database search was used to identify eligible studies. Prepsoas and transpsoas studies were compiled, and each study was assessed for inclusion criteria. Complication rates were recorded and compared between approach groups. Studies incorporating an analysis of postoperative subsidence and pseudarthrosis rates were also assessed and compared.
For the prepsoas studies, 20 studies for the complications analysis and 8 studies for the pseudarthrosis outcomes analysis were included. For the transpsoas studies, 39 studies for the complications analysis and 19 studies for the pseudarthrosis outcomes analysis were included. For the complications analysis, 1874 patients treated via the prepsoas approach and 4607 treated with the transpsoas approach were included. In the transpsoas group, there was a higher rate of transient sensory symptoms (21.7% vs 8.7%, p = 0.002), transient hip flexor weakness (19.7% vs 5.7%, p < 0.001), and permanent neurological weakness (2.8% vs 1.0%, p = 0.005). A higher rate of sympathetic nerve injury was seen in the prepsoas group (5.4% vs 0.0%, p = 0.03). Of the nonneurological complications, major vascular injury was significantly higher in the prepsoas approach (1.8% vs 0.4%, p = 0.01). There was no difference in urological or peritoneal/bowel injury, postoperative ileus, or hematomas (all p > 0.05). A higher infection rate was noted for the transpsoas group (3.1% vs 1.1%, p = 0.01). With regard to postoperative fusion outcomes, similar rates of subsidence (12.2% prepsoas vs 13.8% transpsoas, p = 0.78) and pseudarthrosis (9.9% vs 7.5%, respectively, p = 0.57) were seen between the groups at the last follow-up.
Complication rates vary for the prepsoas and transpsoas approaches owing to the variable retroperitoneal anatomy encountered during surgical dissection. While the risks of a lasting motor deficit and transient sensory disturbances are higher for the transpsoas approach, there is a reciprocal reduction in the risks of major vascular injury and sympathetic nerve injury. These results can facilitate informed decision-making and tailored surgical planning regarding the choice of minimally invasive anterolateral access to the spine.