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Dmitry Ruban and John E. O'Toole

Object

Unintended durotomy is one of the most common complications in spine surgery that may lead to serious complications if not recognized or treated properly. There are few reports on the management of durotomies incurred during minimally invasive spine surgery (MISS). The authors describe their experience in a series of consecutive MISS patients with unintended durotomies.

Methods

All patients who underwent MISS by the senior author between August 2006 and February 2011 were retrospectively reviewed, and cases with unintended durotomies were identified. A case-control study was carried out comparing patient demographics and perioperative data between patients with and without durotomy. Surgical technique, including a proposed algorithm for management of durotomies, is described.

Results

Unintended durotomy occurred in 53 (9.4%) of 563 patients. The mean age at surgery was 60.7 years (range 30–85 years). Previous surgery at the same level was performed in 5 patients (9.4%). Two patients underwent posterior cervical surgery, and 51 patients underwent posterior lumbar surgery. Decompression alone was performed in 32 patients (60.4%), and fusion was performed in 21 patients (39.6%). The mean operative time was 105 minutes in the decompression group and 310 minutes in the fusion group (p < 0.001). Estimated blood loss was 60 ml in the decompression group and 381 ml in the fusion group (p < 0.001). The hospital length of stay was 52 hours in the decompression group and 106 hours in the fusion group (p < 0.001). The mean follow-up was 310 days, and there were no cases of cutaneous CSF fistula, pseudomeningocele, or other complications referable to durotomy in either group. Risk factors identified for durotomy included previous operation at the same level (p = 0.019) and operation in the lumbar spine region (p = 0.001).

Conclusions

In the authors' consecutive series of patients undergoing MISS, an unintended durotomy was associated with fewer complications than previously reported for open spinal surgery. The authors propose a simple management algorithm that includes early mobilization and results in excellent clinical outcomes with no incidence of postoperative cutaneous CSF fistula or other complications.

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John E. O'Toole and Vincent C. Traynelis

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Mazda K. Turel, Mena G. Kerolus, and John E. O’Toole

Ossification of the ligament flavum in the thoracic spine is an uncommon radiological finding in the Western population but can present with back pain, varying degrees of myelopathy, and even paraplegia on occasion. The authors here present the case of a 50-year-old woman with a history of progressive back pain and symptoms of spontaneous intracranial hypotension who was found to have an ossified ligamentum flavum of the thoracic spine resulting in a dural erosion cerebrospinal fluid leak. Surgery involved removal of the ossified ligament flavum at T10–11, facetectomy, ligation of the nerve root, and primary closure of the dura, which resulted in complete resolution of the patient’s symptoms. Radiological, clinical, and intraoperative findings are discussed to assist surgeons with an accurate diagnosis and treatment in the setting of this unusual presentation.

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Adam P. Smith, Michael J. Musacchio, and John E. O'toole

Tumor necrosis factor–α inhibitors are used to treat numerous chronic inflammatory and rheumatological diseases, such as Crohn disease, rheumatoid arthritis, and psoriatic arthritis. Because the mechanism of these inhibitors is to decrease the body's inflammatory response, the primary complication of treatment is infection. The authors present the first case of a spinal epidural abscess in a patient receiving long-term infliximab therapy for severe psoriatic arthritis. Infliximab and its side-effect profile are discussed, along with other associated complications.

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Ricardo B. Fontes, Lee A. Tan, and John E. O'Toole

Spinal dural arteriovenous fistula (dAVF) is the most common vascular malformation of the spinal cord. Traditionally it is treated by the standard muscle-splitting midline approach with bilateral laminectomies extending from one level above to one level below the dAVF. We present a minimally invasive approach for ligation of dAVF with concurrent use of intraoperative indocyanine green (ICG) angiography. Minimally invasive watertight dural closure technique is also demonstrated and discussed. The minimally invasive approach with intraoperative ICG results in quicker recovery, early mobilization and shorter hospital stay compared to traditional open approach.

The video can be found here: http://youtu.be/mNUeJKLxL3Q.

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Manish K. Kasliwal, Lee A. Tan, and John E. O'Toole

Spinal metastases are the most common of spinal neoplasms and occur predominantly in an extradural location. Their appearance in an intradural location is uncommon and is associated with a poor prognosis. Cerebrospinal fluid dissemination accounts for a significant number of intradural spinal metastases mostly manifesting as leptomeningeal carcinomatoses or drop metastases from intracranial tumors. The occurrence of local tumor dissemination intradurally following surgery for an extradural spinal metastasis has not been reported previously. The authors describe 2 cases in which local intradural and intramedullary tumor recurrences occurred following resection of extradural metastases that were complicated by unintended durotomy. To heighten clinical awareness of this unusual form of local tumor recurrence, the authors discuss the possible etiology and clinical consequences of this entity.

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Haley E. Mansfield, W. Jeffrey Canar, Carter S. Gerard, and John E. O'Toole

Object

Patients suffering from cervical radiculopathy in whom a course of nonoperative treatment has failed are often candidates for a single-level anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF). The objective of this analysis was to identify any significant cost differences between these surgical methods by comparing direct costs to the hospital. Furthermore, patient-specific characteristics were also considered for their effect on component costs.

Methods

After obtaining approval from the medical center institutional review board, the authors conducted a retrospective cross-sectional comparative cohort study, with a sample of 101 patients diagnosed with cervical radiculopathy and who underwent an initial single-level ACDF or minimally invasive PCF during a 3-year period. Using these data, bivariate analyses were conducted to determine significant differences in direct total procedure and component costs between surgical techniques. Factorial ANOVAs were also conducted to determine any relationship between patient sex and smoking status to the component costs per surgery.

Results

The mean total direct cost for an ACDF was $8192, and the mean total direct cost for a PCF was $4320. There were significant differences in the cost components for direct costs and operating room supply costs. It was found that there was no statistically significant difference in component costs with regard to patient sex or smoking status.

Conclusions

In the management of single-level cervical radiculopathy, the present analysis has revealed that the average cost of an ACDF is 89% more than a PCF. This increased cost is largely due to the cost of surgical implants. These results do not appear to be dependent on patient sex or smoking status. When combined with results from previous studies highlighting the comparable patient outcomes for either procedure, the authors' findings suggest that from a health care economics standpoint, physicians should consider a minimally invasive PCF in the treatment of cervical radiculopathy.

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John E. O'Toole, Kurt M. Eichholz, and Richard G. Fessler

Object

Postoperative surgical site infections (SSIs) have been reported after 2–6% of spinal surgeries in most large series. The incidence of SSI can be < 1% after decompressive procedures and > 10% after instrumented fusions. Anecdotal evidence has suggested that there is a lower rate of SSI when minimally invasive techniques are used.

Methods

A retrospective review of prospectively collected databases of consecutive patients who underwent minimally invasive spinal surgery was performed. Minimally invasive spinal surgery was defined as any spinal procedure performed through a tubular retractor system. All surgeries were performed under standard sterile conditions with preoperative antibiotic prophylaxis. The databases were reviewed for any infectious complications. Cases of SSI were identified and reviewed for clinically relevant details. The incidence of postoperative SSIs was then calculated for the entire cohort as well as for subgroups based on the type of procedure performed, and then compared with an analogous series selected from an extensive literature review.

Results

The authors performed 1338 minimally invasive spinal surgeries in 1274 patients of average age 55.5 years. The primary diagnosis was degenerative in nature in 93% of cases. A single minimally invasive spinal surgery procedure was undertaken in 1213 patients, 2 procedures in 58, and 3 procedures in 3 patients. The region of surgery was lumbar in 85%, cervical in 12%, and thoracic in 3%. Simple decompressive procedures comprised 78%, instrumented arthrodeses 20%, and minimally invasive intradural procedures 2% of the collected cases. Three postoperative SSIs were detected, 2 were superficial and 1 deep. The procedural rate of SSI for simple decompression was 0.10%, and for minimally invasive fusion/fixation was 0.74%. The total SSI rate for the entire group was only 0.22%.

Conclusions

Minimally invasive spinal surgery techniques may reduce postoperative wound infections as much as 10-fold compared with other large, modern series of open spinal surgery published in the literature.

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Lee A. Tan, Manish K. Kasliwal, Joshua Wewel, Ricardo B. V. Fontes, and John E. O'Toole

Schwannomas are the most common intradural-extramedullary spinal tumors, with an estimated incidence of 3 to 10 cases per 100,000 people. With continued advances in minimally invasive surgery (MIS) over recent years, MIS techniques have been utilized by spine surgeons in the resection of intradural spinal neoplasms with favorable surgical results and clinical outcomes. This video demonstrates a rare case of symptomatic, synchronous, same-level lumbar intradural-extramedullary neoplasm and acute disc herniation, both of which were successfully treated using a single MIS approach. Surgical pearls and nuances are discussed to better delineate technique and minimize potential complications.

The video can be found here: http://youtu.be/78ibbicBRUk.

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Ziev B. Moses, Seok Yoon Oh, Ricardo B. V. Fontes, Harel Deutsch, John E. O’Toole, and Richard G. Fessler

OBJECTIVE

The modified frailty index (mFI) is a simple tool that measures physiological reserve based on a thorough history and physical examination. Its use has been validated in several surgical specialties, including spinal deformity surgery. Prior research has suggested no significant differences in clinical outcomes between elderly and nonelderly patients undergoing posterior lumbar interbody fusion. The authors sought to investigate the use of the mFI in patients undergoing transforaminal lumbar interbody fusion (TLIF) and the relationship between frailty scores and clinical outcomes.

METHODS

A retrospective chart review was conducted on 198 patients who underwent a single-level TLIF over a 60-month period at a single institution. For all patients, an mFI score was computed incorporating a set of 11 clinical factors to assess preexisting comorbidities and functional status. Clinical follow-up and health-related quality-of-life (HRQOL) scores were obtained at baseline and regular intervals of 6 weeks, 6 months, and 1 year following surgery.

RESULTS

Patients were grouped according to their level of frailty: no frailty (mFI = 0), mild frailty (mFI = 0.09), moderate frailty (mFI = 0.18), and severe frailty (mFI ≥ 0.27). One-way ANOVA revealed increasing levels of frailty to be associated with an increased rate of complications, from 10.3% to 63.6%. In addition, increasing levels of frailty were associated with longer hospital length of stay (LOS), from 3.1 days to 6.5 days, and lower rates of disposition to home. At the 1-year follow-up, increased levels of frailty were associated with worse HRQOL measures.

CONCLUSIONS

Increasing mFI score was associated with higher morbidity, longer inpatient LOS, and a lower probability of discharge to home in patients undergoing single-level TLIF. Consideration of the mFI may help surgeons improve decision-making across the spectrum of patients who are at risk from frailty.