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Karthik Madhavan, John Paul G. Kolcun, Lee Onn Chieng and Michael Y. Wang

Surgical robots have captured the interest—if not the widespread acceptance—of spinal neurosurgeons. But successful innovation, scientific or commercial, requires the majority to adopt a new practice. “Faster, better, cheaper” products should in theory conquer the market, but often fail. The psychology of change is complex, and the “follow the leader” mentality, common in the field today, lends little trust to the process of disseminating new technology. Beyond product quality, timing has proven to be a key factor in the inception, design, and execution of new technologies. Although the first robotic surgery was performed in 1985, scant progress was seen until the era of minimally invasive surgery. This movement increased neurosurgeons’ dependence on navigation and fluoroscopy, intensifying the drive for enhanced precision. Outside the field of medicine, various technology companies have made great progress in popularizing co-robots (“cobots”), augmented reality, and processor chips. This has helped to ease practicing surgeons into familiarity with and acceptance of these technologies. The adoption among neurosurgeons in training is a “follow the leader” phenomenon, wherein new surgeons tend to adopt the technology used during residency. In neurosurgery today, robots are limited to computers functioning between the surgeon and patient. Their functions are confined to establishing a trajectory for navigation, with task execution solely in the surgeon’s hands. In this review, the authors discuss significant untapped technologies waiting to be used for more meaningful applications. They explore the history and current manifestations of various modern technologies, and project what innovations may lie ahead.

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Angela Mae Richardson, Joanna Elizabeth Gernsback, John Paul G. Kolcun and Steven Vanni

The authors report on the first surgical treatment for traumatic interspinous ligament calcification, with significant radiographic and symptomatic improvements at long-term follow-up. Heterotopic ossification occurs following traumatic injury but does not typically affect the interspinous ligaments. While these ligaments can calcify with age, this is rarely seen in patients younger than 50 years of age. The authors present the unusual case of a 31-year-old man who suffered traumatic fractures of thoracic and lumbar spinous processes. He developed progressive low-back pain that failed to respond to conservative treatments. At presentation, he was neurologically intact. CT scanning demonstrated partial calcification of the interspinous ligaments at L2–3, L3–4, and L4–5 with significant hypertrophy of the spinous processes at those levels. He did not have significant disc pathology, and his symptoms were attributed to the limited range of motion caused by the enlarged spinous processes. Partial resection of the spinous processes and calcified interspinous ligaments was performed to remove the heterotopic bone. The patient was seen in follow-up at 5 months postoperatively for imaging, and he was interviewed at 1 and 2 years postoperatively. He is doing well with significant pain relief and an improved range of motion. His Oswestry Disability Index improved from 25 preoperatively to 18 at 2 years postoperatively.

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John Paul G. Kolcun, G. Damian Brusko, Gregory W. Basil, Richard Epstein and Michael Y. Wang

OBJECTIVE

Open spinal fusion surgery is often associated with significant blood loss, postoperative pain, and prolonged recovery times. Seeking to minimize surgical and perioperative morbidity, the authors adopted an endoscopic minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) technique performed without general anesthesia. In this report, they present data on the first 100 patients treated with this procedure.

METHODS

The authors conducted a retrospective review of the first 100 patients who underwent awake endoscopic MIS-TLIF at a single institution between 2014 and 2017. Surgery was performed while the patient was sedated but without intubation or the use of general anesthetic or narcotic agents. Long-lasting (liposomal) bupivacaine was used for local analgesia. The discectomy and placement of an expandable interbody graft were performed endoscopically, followed by percutaneous pedicle screw implantation. Inclusion criteria for the procedure consisted of diagnosis of degenerative disc disease with grade I or II spondylolisthesis and evidence of spinal stenosis or nerve impingement with intractable symptomatology.

RESULTS

Of the first 100 patients, 56 were female and 44 were male. Single-level fusion was performed in 84 patients and two-level fusion in 16 patients. The most commonly fused level was L4–5, representing 77% of all fused levels. The mean (± standard deviation) operative time was 84.5 ± 21.7 minutes for one-level fusions and 128.1 ± 48.6 minutes for two-level procedures. The mean intraoperative blood loss was 65.4 ± 76.6 ml for one-level fusions and 74.7 ± 33.6 ml for two-level fusions. The mean length of hospital stay was 1.4 ± 1.0 days. Four deaths occurred in the 100 patients; all four of those patients died from complications unrelated to surgery. In 82% of the surviving patients, 1-year follow-up Oswestry Disability Index (ODI) data were available. The mean preoperative ODI score was 29.6 ± 15.3 and the mean postoperative ODI score was 17.2 ± 16.9, which represents a significant mean reduction in the ODI score of −12.3 using a two-tailed paired t-test (p = 0.000001). In four cases, the surgical plan was revised to include general endotracheal anesthesia intraoperatively and was successfully completed. Other complications included two cases of cage migration, one case of osteomyelitis, and one case of endplate fracture; three of these complications occurred in the first 50 cases.

CONCLUSIONS

This series of the first 100 patients to undergo awake endoscopic MIS-TLIF demonstrates outcomes comparable to those reported in our earlier papers. This procedure can provide a safe and efficacious option for lumbar fusion with less morbidity than open surgery. Further refinements in surgical technique and technologies will allow for improved success.

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Giacomo Pacchiarotti, Michael Y. Wang, John Paul G. Kolcun, Ken Hsuan-kan Chang, Motasem Al Maaieh, Victor S. Reis and Dao M. Nguyen

Solitary paravertebral schwannomas in the thoracic spine and lacking an intraspinal component are uncommon. These benign nerve sheath tumors are typically treated using complete resection with an excellent outcome. Resection of these tumors is achieved by an anterior approach via open thoracotomy or minimally invasive thoracoscopy, by a posterior approach via laminectomy, or by a combination of both approaches. These tumors most commonly occur in the midthoracic region, for which surgical removal is usually straightforward. The authors of this report describe 2 cases of paravertebral schwannoma at extreme locations of the posterior mediastinum, one at the superior sulcus and the other at the inferior sulcus of the thoracic cavity, for which the usual surgical approaches for safe resection can be challenging. The tumors were completely resected with robot-assisted thoracoscopic surgery. This report suggests that single-stage anterior surgery for this type of tumor in extreme locations is safe and effective with this novel minimally invasive technique.

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S. Shelby Burks, Juan S. Uribe, John Paul G. Kolcun, Adisson Fortunel, Jakub Godzik, Konrad Bach and Michael Y. Wang

OBJECTIVE

Minimally invasive techniques are increasingly used in adult deformity surgery as surgeon familiarity improves and long-term data are published. Concerns raised in such cases include pseudarthrosis at levels where interbody grafts are not utilized. Few previous studies have specifically examined the thoracolumbar component of long surgical constructs, which is commonly instrumented without interbody or intertransverse fusion.

METHODS

A retrospective analysis was performed on all patients who underwent hybrid minimally invasive deformity corrections in two academic spine centers over a 9-year period. Inclusion criteria were at least 2 rostral levels instrumented percutaneously, ranging from T8 to L1 as the upper end of the construct. Fusion assessment was made using CT when possible or radiography. Common radiographic parameters and clinical variables were assessed pre- and postoperatively.

RESULTS

A total of 36 patients fit the inclusion criteria. Baseline characteristics included a 1:1.8 male/female ratio, average age of 65.7 years, and BMI of 30.2 kg/m2. Follow-up imaging was obtained at a mean of 35.7 months. The average number of levels fused was 7.5, with an average of 3.4 instrumented percutaneously between T8 and L1, representing a total of 120 rostral levels instrumented percutaneously. Fusion assessment was performed using CT in 69 levels and radiography in 51 levels. Among the 120 rostral levels instrumented percutaneously, robust fusion was noted in 25 (20.8%), with 53 (44.2%) exhibiting some evidence of fusion. Pseudarthrosis was noted in 2 rostral segments (1.7%). There were no instances of proximal hardware revision. Eight patients exhibited radiographic proximal junctional kyphosis (PJK; 22.2%), none of whom underwent surgical intervention.

CONCLUSIONS

In the present series of adult patients with scoliosis undergoing thoracolumbar deformity correction, rostral segments instrumented percutaneously have a very low rate of pseudarthrosis, with radiographic evidence of bone fusion occurring in more than 60% of patients. The rate of PJK was acceptable and similar to other published series.

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G. Damian Brusko, John Paul G. Kolcun, Julie A. Heger, Allan D. Levi, Glen R. Manzano, Karthik Madhavan, Timur Urakov, Richard H. Epstein and Michael Y. Wang

OBJECTIVE

Lumbar fusion is typically associated with high degrees of pain and immobility. The implementation of an enhanced recovery after surgery (ERAS) approach has been successful in speeding the recovery after other surgical procedures. In this paper, the authors examined the results of early implementation of ERAS for lumbar fusion.

METHODS

Beginning in March 2018 at the authors’ institution, all patients undergoing posterior, 1- to 3-level lumbar fusion surgery by any of 3 spine surgeons received an intraoperative injection of liposomal bupivacaine, immediate single postoperative infusion of 1-g intravenous acetaminophen, and daily postoperative visits from the authors’ multidisciplinary ERAS care team. Non–English- or non–Spanish-speaking patients and those undergoing nonelective or staged procedures were excluded. Reviews of medical records were conducted for the ERAS cohort of 57 patients and a comparison group of 40 patients who underwent the same procedures during the 6 months before implementation.

RESULTS

Groups did not differ significantly with regard to sex, age, or BMI (all p > 0.05). Length of stay was significantly shorter in the ERAS cohort than in the control cohort (2.9 days vs 3.8 days; p = 0.01). Patients in the ERAS group consumed significantly less oxycodone-acetaminophen than the controls on postoperative day (POD) 0 (408.0 mg vs 1094.7 mg; p = 0.0004), POD 1 (1320.0 mg vs 1708.4 mg; p = 0.04), and POD 3 (1500.1 mg vs 2105.4 mg; p = 0.03). Postoperative pain scores recorded by the physical therapy and occupational therapy teams and nursing staff each day were lower in the ERAS cohort than in controls, with POD 1 achieving significance (4.2 vs 6.0; p = 0.006). The total amount of meperidine (8.8 mg vs 44.7 mg; p = 0.003) consumed was also significantly decreased in the ERAS group, as was ondansetron (2.8 mg vs 6.0 mg; p = 0.02). Distance ambulated on each POD was farther in the ERAS cohort, with ambulation on POD 1 (109.4 ft vs 41.4 ft; p = 0.002) achieving significance.

CONCLUSIONS

In this very initial implementation of the first phase of an ERAS program for short-segment lumbar fusion, the authors were able to demonstrate substantial positive effects on the early recovery process. Importantly, these effects were not surgeon-specific and could be generalized across surgeons with disparate technical predilections. The authors plan additional iterations to their ERAS protocols for continued quality improvements.