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Michael P. Wemhoff, Kevin Swong, Daphne Li, Neal Mugve, Lisa A. Gramlich and Russ P. Nockels

A case of cervical spinal cord injury in 12-year-old angular craniopagus twins is presented, with a description of the planning and execution of surgical treatment along with subsequent clinical outcome. The injury occurred following a fall from a standing position, resulting in quadriparesis in one of the twins. Imaging revealed severe craniocervical stenosis resulting from a C1–2 dislocation, and T2-weighted hyperintensity of the cervical spinal cord. After custom halo fixation was obtained, a posterior approach was utilized to decompress and instrument the occiput, cervical, and upper thoracic spine with intraoperative reduction of the dislocation. Early neurological improvement was noted during the acute postoperative phase, and 27 months of follow-up demonstrated intact instrumentation with continued neurological improvement to near baseline. The complexity of managing such an injury, inclusive of the surgical, anesthetic, biomechanical, and ethical considerations, is described in detail.

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Michael J. Strong, Timothy J. Yee, Siri Sahib S. Khalsa, Yamaan S. Saadeh, Kevin N. Swong, Osama N. Kashlan, Nicholas J. Szerlip, Paul Park and Mark E. Oppenlander

OBJECTIVE

The lateral lumbar interbody fusion (LLIF) technique is used to treat many common spinal degenerative pathologies including kyphoscoliosis. The use of spinal navigation for LLIF has not been broadly adopted, especially in adult spinal deformity. The purpose of this study was to evaluate the feasibility as well as the intraoperative and navigation-related complications of computer-assisted 3D navigation (CaN) during multiple-level LLIF for spinal deformity.

METHODS

Retrospective analysis of clinical and operative characteristics was performed for all patients > 18 years of age who underwent multiple-level CaN LLIF combined with posterior instrumentation for adult spinal deformity at the University of Michigan between 2014 and 2020. Intraoperative CaN-related complications, LLIF approach–related postoperative complications, and medical postoperative complications were assessed.

RESULTS

Fifty-nine patients were identified. The mean age was 66.3 years (range 42–83 years) and body mass index was 27.6 kg/m2 (range 18–43 kg/m2). The average coronal Cobb angle was 26.8° (range 3.6°–67.0°) and sagittal vertical axis was 6.3 cm (range −2.3 to 14.7 cm). The average number of LLIF and posterior instrumentation levels were 2.97 cages (range 2–5 cages) and 5.78 levels (range 3–14 levels), respectively. A total of 6 intraoperative complications related to the LLIF stage occurred in 5 patients. Three of these were CaN-related and occurred in 2 patients (3.4%), including 1 misplaced lateral interbody cage (0.6% of 175 total lateral cages placed) requiring intraoperative revision. No patient required a return to the operating room for a misplaced interbody cage. A total of 12 intraoperative complications related to the posterior stage occurred in 11 patients, with 5 being CaN-related and occurring in 4 patients (6.8%). Univariate and multivariate analyses revealed no statistically significant risk factors for intraoperative and CaN-related complications. Transient hip weakness and numbness were found to be in 20.3% and 22.0% of patients, respectively. At the 1-month follow-up, weakness was observed in 3.4% and numbness in 11.9% of patients.

CONCLUSIONS

Use of CaN in multiple-level LLIF in the treatment of adult spinal deformity appears to be a safe and effective technique. The incidence of approach-related complications with CaN was 3.4% and cage placement accuracy was high.

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Yamaan S. Saadeh, Clay M. Elswick, Eleanor Smith, Timothy J. Yee, Michael J. Strong, Kevin Swong, Brandon W. Smith, Mark E. Oppenlander, Osama N. Kashlan and Paul Park

OBJECTIVE

Age is known to be a risk factor for increased complications due to surgery. However, elderly patients can gain significant quality-of-life benefits from surgery. Lateral lumbar interbody fusion (LLIF) is a minimally invasive procedure that is commonly used to treat degenerative spine disease. Recently, 3D navigation has been applied to LLIF. The purpose of this study was to determine whether there is an increased complication risk in the elderly with navigated LLIF.

METHODS

Patients who underwent 3D-navigated LLIF for degenerative disease from 2014 to 2019 were included in the analysis. Patients were divided into elderly and nonelderly groups, with those 65 years and older categorized as elderly. Ninety-day medical and surgical complications were recorded. Patient and surgical characteristics were compared between groups, and multivariate regression analysis was used to determine independent risk factors for complication.

RESULTS

Of the 115 patients included, 56 were elderly and 59 were nonelderly. There were 15 complications (25.4%) in the nonelderly group and 10 (17.9%) in the elderly group, which was not significantly different (p = 0.44). On multivariable analysis, age was not a risk factor for complication (p = 0.52). However, multiple-level LLIF was associated with an increased risk of approach-related complication (OR 3.58, p = 0.02).

CONCLUSIONS

Elderly patients do not appear to experience higher rates of approach-related complications compared with nonelderly patients undergoing 3D navigated LLIF. Rather, multilevel surgery is a predictor for approach-related complication.

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Stephen J. Johans, Kevin N. Swong, Daniel J. Burkett, Michael P. Wemhoff, Sean M. Lew, Chirag R. Patel and Anand V. Germanwala

Superficial siderosis (SS) of the CNS is a rare and often unrecognized condition. Caused by hemosiderin deposition from chronic, repetitive hemorrhage in the subarachnoid space, it results in parenchymal damage in the subpial layers of the brain and spinal cord. T2-weighted MRI shows the characteristic hypointensity of hemosiderin deposition, classically occurring around the cerebellum, brainstem, and spinal cord. Patients present with progressive gait ataxia and sensorineural hearing impairment. Although there have been several studies, case reports, and review articles over the years, the clear pathophysiology of subarachnoid space hemorrhage remains to be elucidated. The proposed causes include prior intradural surgery, prior trauma, tumors, vascular abnormalities, nerve root avulsion, and dural abnormalities.

Surgical repair of a dural defect associated with SS has been shown to be efficacious at preventing symptomatic progression. There have been several reports of dural defects within the spinal canal treated with surgery. Here, the authors present the first known case of a dural defect of the ventral skull base, namely a clival meningocele, presumed to be causing SS. In this case report, a 10-year-old girl with a history of head trauma at the age of 3 years was found to have a clival meningocele 3 years after her original trauma. On follow-up imaging, the patient was found to have radiographic growth of the meningocele along with evidence of SS of the CNS. The patient was treated conservatively until she began to have progressive hearing loss. It was presumed that the growing meningocele was the source of her SS. An endoscopic endonasal transclival approach with a multilayer dural reconstruction was performed to fix the dural defect and repair the meningocele in hopes of mitigating the progression of her symptoms. At her 12-month postoperative follow-up, she was doing well, with audiometry showing a slightly decreased hearing threshold in the left ear but improved speech discrimination bilaterally. Postoperative MRI showed a stable level of hemosiderin deposition and meningocele repair. Long-term follow-up will be necessary to evaluate for continued clinical stabilization or possible improvement.