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Editorial: Incremental cost-effectiveness of adult spinal deformity surgery

Christopher I. Shaffrey and Justin S. Smith

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Editorial: Stabilization of the sacroiliac joint

Christopher I. Shaffrey and Justin S. Smith

Lower back pain and pain involving the area of the posterior iliac spine are extremely common. Degeneration of the sacroiliac joint (SIJ) is one potential cause for lower back pain and pain radiating into the groin or buttocks. Degenerative changes to the lumbar spine and sacroiliac joints are common. A recent study evaluating SIJ abnormalities in a primary low back pain population demonstrated 31.7% of patients demonstrated SI joint abnormalities. 4 As is the case for the evaluation and management of isolated lower back pain, the evaluation, management, and role for surgical intervention in SIJ pain is very controversial.

Many patients have degenerative changes of the disc, facet joints, and SIJs. A recent systematic review performed to determine the diagnostic accuracy of tests available to clinicians to identify the disc, facet joint, or SIJ as the source of low back pain concluded that tests do exist that change the probability of the disc or SIJ (but not the facet joint) as the source of low back pain. 3 It was also concluded that the usefulness of these tests in clinical practice, particularly for guiding treatment selection, remains unclear. 3

Although there is general agreement that SIJ pathological changes are a potential cause of pain, there is far less agreement about the optimal management of these conditions. A variety of conditions can cause SIJ dysfunction including degenerative and inflammatory arthritis, trauma, prior lumbosacral fusion, hip arthritis, limb length inequality, infections, and neoplasia. 8 There is increasing evidence that image intensifier-guided single periarticular injection can correctly localize pain to the SIJ but the optimal management strategy remains controversial. Recent publications have compared surgical versus injection treatments and fusion versus denervation procedures. 1,8 A systematic review found improvement regardless of the treatment, with most studies reporting over 40% improvement in pain as measured by VAS or NRS scores. 8 It cautioned that one of the studies reported 17.6% of patients experiencing mild/no pain compared with 82.4% experiencing marked/severe pain at 39 months after SIJ fusion procedures. 6,8 This systematic review also noted that despite improvements in reported pain, less than half of patients who had work status reported as returning to work. 8

Because of the functional and socioeconomic consequences of chronic lower back pain, numerous surgical treatments to improve this condition have been attempted by spinal surgeons through the years. Arthrodesis of the SIJ is a surgical procedure with a long history dating to the beginnings of spinal surgery. 7 Poor results, high complication rates and the need for additional surgical procedures have generally diminished the enthusiasm for this procedure until recently. 6

A variety of “minimally invasive” procedures have been recently introduced that have rekindled enthusiasm for the surgical management of SIJ pathology. The technique demonstrated in the “Stabilization of the SIJ with SI-Bone” is one of these new techniques. There has been a recent publication detailing the very short term clinical outcomes with this technique that reported encouraging results. 5 In this series of 50 patients, quality of life questionnaires were available for 49 patients preoperatively, 41 patients at 3 months, 40 at 6 months and only 27 at 12 months, complicating the ability to accurately assess true outcomes.

Although the focus of this video by Geisler is on the surgical technique, there should have been more information provided on the expected surgical outcomes and potential complications of SIJ fusion. 2 The video only gives minimal information on how to appropriately select patients with potential SIJ pathology for surgical intervention. There are insufficient recommendations on the clinical and radiographic follow-up needed for this procedure. A concern with this implant is whether the porous plasma spray coating on the implant actually results in bone growth across the SIJ or only serves as a stabilizer. If true fusion does not result, deterioration in the clinical result could occur over time.

This video nicely demonstrates the surgical technique of stabilization of the SIJ with SI-Bone product. There are numerous unanswered questions regarding patient selection for SIJ fusion or stabilization. There are an increasing number of surgical techniques for treating SIJ pathology and it is not clear which method may provide the best outcomes. Without prospective trials with nonconflicted surgeons and standardized selection criteria, the true role for SIJ fusion procedures in the management of chronic lower back pain will remain murky. The consequences of the unsupported enthusiasm for the surgical management of discogenic back pain still negatively impacts the public perception of spinal surgeons. Much more high quality information is needed regarding the surgical management of SIJ pathology before widespread use of this technique should be adopted.

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Minimally invasive posterior thoracic fusion

Justin S. Smith, Alfred T. Ogden, and Richard G. Fessler

Thoracic spine fusion may be indicated in the surgical treatment of a wide range of pathologies, including trauma, deformity, tumor, and infection. Conventional open procedures for surgical treatment of thoracic spine disease can be associated with significant approach-related morbidity, which has motivated the development of minimally invasive approaches. Thoracoscopy and, later, video-assisted thoracoscopic surgery were developed to address diseases of the thoracic cavity and subsequently adapted for thoracic spine surgery. Although video-assisted thoracoscopic surgery has been used to treat a variety of thoracic spine diseases, its relatively steep learning curve and high rate of pulmonary complications have limited its widespread use. These limitations have motivated the development of minimally invasive posterior approaches to address thoracic spine pathology without the added risk of morbidity involved in surgically entering the chest. Many of these advances are ongoing and represent the forefront of minimally invasive spine surgery. As these techniques are developed and applied, it will be important to assess their equivalence or superiority in comparison with standard open techniques using prospective trials. In this paper the authors focus on minimally invasive posterior thoracic procedures that include fusion, and provide a review of the current literature, a discussion of future pathways for development, and case examples. The topic is divided by pathology into sections including trauma, deformity, spinal column tumors, and osteomyelitis.

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Primary brachial plexus tumors: imaging, surgical, and pathological findings in 25 patients

Devin K. Binder, Justin S. Smith, and Nicholas M. Barbaro

Object

The authors report on the treatment of primary brachial plexus tumors in 25 patients at the University of California, San Francisco. They compare their findings with those obtained in similar series.

Methods

The authors reviewed the electronic and medical records, radiological images, operative reports, and pathological findings in 25 consecutive cases of primary brachial plexus tumors. Cases of metastatic lesions or adjacent neoplasms extending into and involving the brachial plexus were excluded.

At presentation patients ranged in age from 19 to 71 years (mean 47 ±15 years), and neurofibromatosis was present in eight patients (32%). Presenting signs and symptoms included palpable mass (60%), numbness/paresthesias (44%), radiating pain (44%), local pain (16%), and weakness (12%). Duration of symptoms ranged from 2 months to 10 years. Neuroimaging revealed lesions ranging widely in size (volume ~1 to >100 ml). Pathological diagnoses included schwannoma (15 [60%]), neurofibroma (five [20%]), malignant peripheral nerve sheath tumor (four [16%]), and desmoid tumor (one [4%]).

Conclusions

Primary tumors arising in the brachial plexus are rare. Careful workup, surgical technique, and attention to pathological diagnosis optimize management.

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Editorial: Recombinant human bone morphogenetic protein–2

Christopher I. Shaffrey and Justin S. Smith

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Editorial: Depression and outcome

Christopher I. Shaffrey and Justin S. Smith

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Editorial: Minimally invasive spinal deformity surgery

Christopher I. Shaffrey and Justin S. Smith

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Spontaneous regression of a discal cyst

Case report

Dean Chou, Justin S. Smith, and Cynthia T. Chin

✓The authors describe a case of a discal cyst that resolved almost completely without direct intervention. Discal cysts are rare, with the authors of only a few case reports describing this entity. These reports all identify at least some intervention performed for alleviation of the symptoms, including open surgery, minimally invasive surgery, or percutaneous puncture with aspiration. The authors report on a 35-year-old man with radiculopathy who presented with a discal cyst and was treated with a routine epidural injection and selective nerve root block. Within 5 months, the discal cyst showed dramatic regression on magnetic resonance imaging and the patient’s symptoms improved. The natural history of this pathological entity is unknown, and to the authors’ knowledge this is the first detailed report of the regression of a discal cyst without surgery or aspiration.

Open access

Introduction. Expanding lateral access spine surgery

Laura A. Snyder, Melissa Erickson, Justin S. Smith, and Praveen V. Mummaneni

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Association between absence of epidermal growth factor receptor immunoreactivity and poor prognosis in patients with atypical meningioma

Justin S. Smith, Anita Lal, Miranda Harmon-Smith, Andrew W. Bollen, and Michael W. McDermott

Object

The clinical behavior of meningiomas is variable. Because multiple growth factor receptors have been identified in these tumors, the authors sought to assess the capacity of the expression patterns of a subset of these receptors to stratify meningioma cases.

Methods

Eighty-four meningiomas were analyzed, including 36 benign, 29 atypical, and 19 malignant lesions. Immunohistochemical staining was performed for epidermal growth factor receptor (EGFR), platelet-derived growth factor receptor (PDGFR)–β, basic fibroblast growth factor receptor (BFGFR), and MIB-1. Survival analyses were performed using follow-up data obtained in patients with newly diagnosed tumors.

Immunoreactivity for EGFR was observed in 47% of benign, 48% of atypical, and 42% of malignant tumors. Staining for BFGFR was identified in 89% of benign, 97% of atypical, and 95% of malignant lesions. Immunostaining for PDGFR-β was evident in all the lesions assessed. Mean MIB-1 indices for benign, atypical, and malignant cases were 3.6 (range 0.5–15.3), 8.2 (range 1.5–23.1) and 18.3 (range 1.0–55.8), respectively. Overall mean follow-up duration was 9.0 years (range 5.1–18.8 years). Lack of EGFR immunoreactivity was identified as a strong predictor of shorter overall survival in patients with atypical meningioma (p = 0.003, log-rank test). This association was not evident in cases of benign or malignant meningiomas.

Conclusions

There is a significant association between EGFR immunoreactivity and prolonged survival in patients with atypical meningioma. Given the variable behavior of atypical meningiomas, EGFR assessment could improve existing strategies for patient stratification and treatment.