Anne Louise Oaklander
Kunal P. Raygor, Khoi D. Than, Dean Chou, and Praveen V. Mummaneni
Spinal tumor resection has historically been performed via open approaches, although minimally invasive approaches have recently been found to be effective in small cohort series. The authors compare surgical characteristics and clinical outcomes of surgery in patients undergoing mini-open and open approaches for intradural-extramedullary tumor resection.
The authors retrospectively reviewed 65 consecutive intradural-extramedullary tumor resections performed at their institution from 2007 to 2014. Patients with cervical tumors or pathology demonstrating neurofibroma were excluded (n = 14). The nonparametric Mann-Whitney U-test and Pearson chi-square test were used to compare continuous and categorical variables, respectively. Statistical analyses were performed using SPSS, with significance set at p < 0.05.
Fifty-one thoracolumbar intradural-extramedullary tumor resections were included; 25 were performed via the minimally invasive transspinous approach. There were no statistically significant differences in age, sex, body mass index, preoperative American Spinal Injury Association (ASIA) score, preoperative symptom duration, American Society of Anesthesiologists (ASA) physical status class, tumor size, or tumor location. There was no statistically significant difference between groups with respect to the duration of the operation or extent of resection, but the mean estimated blood loss was significantly lower in the minimally invasive surgery (MIS) cohort (142 vs 320 ml, p < 0.05). In each group, the 2 most common tumor pathologies were schwannoma and meningioma. There were no statistically significant differences in length of hospitalization, ASIA score improvement, complication rate, or recurrence rate. The mean duration of follow-up was 2 years for the MIS group and 1.6 years for the open surgery group.
This is one of the largest comparisons of minimally invasive and open approaches to the resection of thoracolumbar intradural-extramedullary tumors. With well-matched cohorts, the minimally invasive transspinous approach appears to be as safe and effective as the open technique, with the advantage of significantly reduced intraoperative blood loss.
Kevin S. Chen, Khoi D. Than, Frank LaMarca, and Paul Park
This video describes a minimally invasive approach for treatment of symptomatic grade I spondylolisthesis and high-grade spinal stenosis. In this procedure, a unilateral approach for bilateral decompression is utilized in conjunction with a modified transforaminal lumbar interbody fusion and percutaneous pedicle screw fixation. The key steps in the procedure are outlined, and include positioning, fluoroscopic positioning/guidance, exposure with tubular retractor system, technique for ipsilateral and contra-lateral decompression, disc space preparation and interbody grafting, percutaneous pedicle screw and rod placement, and closure.
The video can be found here: http://youtu.be/QTymO4Cu4B0.
Kevin S. Chen, Khoi D. Than, Frank LaMarca, and Paul Park
This video details a minimally invasive treatment of symptomatic adult kyphoscoliosis. Both anterior and posterior approaches are used to obtain sagittal and coronal balance. In addition, improved lumbar lordosis is achieved to closely match the patient's pelvic incidence. The key steps for the lateral transpsoas procedure are detailed in the first portion of the video and include positioning, fluoroscopic localization, exposure with tubular retractor placement, interbody preparation and grafting, and closure. The second portion of the video shows positioning, fluoroscopic positioning/guidance, exposure for percutaneous pedicle screw placement, rod insertion, and closure.
The video can be found here: http://youtu.be/cHkTMtSXZ8A.
Kelly J. Bridges, Carli L. Bullis, Ajay Wanchu, and Khoi D. Than
Pseudogout is a form of acute calcium pyrophosphate deposition (CPPD) disease that typically afflicts the elderly. CPPD commonly involves larger joints, such as the knees, wrists, shoulders, and hips, and has been known to involve the spine.
The authors report the case of a 66-year-old woman with a recent history of lumbar laminectomy and fusion who presented 5 weeks postprocedure with a clinical and radiographic picture consistent with multilevel skip lesions involving the cervical and thoracic spine, thoracic discitis, and epidural abscess. Serial blood cultures and repeat biopsy samples were sterile. Subsequent wrist and ankle erythema, pain, and swelling led to synovial fluid analysis, and pseudogout was diagnosed. She was treated with an interleukin-1 inhibitor with immediate symptom relief.
To the authors’ knowledge, this is only the second report of spinal pseudogout presenting with a clinical and radiographic picture consistent with discitis and epidural abscess. This report is the first to report skip lesions of pseudogout occurring throughout the spine that are uniquely remote from a recent lumbar surgery.
Hardik Sardana, Roshan Sahu, and Shweta Kedia
Arnold B. Etame, Anthony C. Wang, Khoi D. Than, Frank La Marca, and Paul Park
Symptomatic cervical kyphosis can result from a variety of causes. Symptoms can include pain, neurological deficits, and functional limitation due to loss of horizontal gaze.
The authors review the long-term functional and radiographic outcomes following surgery for symptomatic cervical kyphosis by performing a PubMed database literature search.
Fourteen retrospective studies involving a total of 399 patients were identified. Surgical intervention included ventral, dorsal, or circumferential approaches. Analysis of the degree of deformity correction and functional parameters demonstrated significant postsurgical improvement. Overall, patient satisfaction appeared high. Five studies reported mortality with rates ranging from 3.1 to 6.7%. Major medical complications after surgery were reported in 5 studies with rates ranging from 3.1 to 44.4%. The overall neurological complication rate was 13.5%.
Although complications are not insignificant, surgery appears to be an effective option when conservative measures fail to provide relief.
Anthony C. Wang, Khoi D. Than, Arnold B. Etame, Frank La Marca, and Paul Park
Transcranial motor evoked potential (TcMEP) monitoring is frequently used in complex spinal surgeries to prevent neurological injury. Anesthesia, however, can significantly affect the reliability of TcMEP monitoring. Understanding the impact of various anesthetic agents on neurophysiological monitoring is therefore essential.
A literature search of the National Library of Medicine database was conducted to identify articles pertaining to anesthesia and TcMEP monitoring during spine surgery. Twenty studies were selected and reviewed.
Inhalational anesthetics and neuromuscular blockade have been shown to limit the ability of TcMEP monitoring to detect significant changes. Hypothermia can also negatively affect monitoring. Opioids, however, have little influence on TcMEPs. Total intravenous anesthesia regimens can minimize the need for inhalational anesthetics.
In general, selecting the appropriate anesthetic regimen with maintenance of a stable concentration of inhalational or intravenous anesthetics optimizes TcMEP monitoring.
Zoe E. Teton, Barry Cheaney II, James T. Obayashi, and Khoi D. Than
Common interbody graft options for anterior cervical discectomy and fusion (ACDF) include allograft and polyetheretherketone (PEEK). PEEK has gained popularity due to its radiolucent properties and a modulus of elasticity similar to that of bone. PEEK devices also result in higher billing costs than allograft, which may drive selection. A previous study found a 5-fold higher rate of pseudarthrosis with the use of PEEK devices compared with structural allograft in single-level ACDF. Here the authors report on the occurrence of pseudarthrosis with PEEK devices versus structural allograft in patients who underwent multilevel ACDF.
The authors retrospectively reviewed 81 consecutive patients who underwent a multilevel ACDF and had radiographic follow-up for at least 1 year. Data were collected on age, sex, BMI, tobacco use, pseudarthrosis, and rate of reoperation for pseudarthrosis. Logistic regression was used for data analysis.
Of 81 patients, 35 had PEEK implants and 46 had structural allograft. There were no significant differences between age, sex, smoking status, or BMI in the 2 groups. There were 26/35 (74%) patients with PEEK implants who demonstrated radiographic evidence of pseudarthrosis, compared with 5/46 (11%) patients with structural allograft (p < 0.001, OR 22.2). Five patients (14%) with PEEK implants required reoperation for pseudarthrosis, compared with 0 patients with allograft (p = 0.013).
This study reinforces previous findings on 1-level ACDF outcomes and suggests that the use of PEEK in multilevel ACDF results in statistically significantly higher rates of radiographic pseudarthrosis and need for revision surgery than allograft. Surgeons should consider these findings when determining graft options, and reimbursement policies should reflect these discrepancies.
Darryl Lau, Ethan A. Winkler, Khoi D. Than, Dean Chou, and Praveen V. Mummaneni
Cervical curvature is an important factor when deciding between laminoplasty and laminectomy with posterior spinal fusion (LPSF) for cervical spondylotic myelopathy (CSM). This study compares outcomes following laminoplasty and LPSF in patients with matched postoperative cervical lordosis.
Adults undergoing laminoplasty or LPSF for cervical CSM from 2011 to 2014 were identified. Matched cohorts were obtained by excluding LPSF patients with postoperative cervical Cobb angles outside the range of laminoplasty patients. Clinical outcomes and radiographic results were compared. A subgroup analysis of patients with and without preoperative pain was performed, and the effects of cervical curvature on pain outcomes were examined.
A total of 145 patients were included: 101 who underwent laminoplasty and 44 who underwent LPSF. Preoperative Nurick scale score, pain incidence, and visual analog scale (VAS) neck pain scores were similar between the two groups. Patients who underwent LPSF had significantly less preoperative cervical lordosis (5.8° vs 10.9°, p = 0.018). Preoperative and postoperative C2–7 sagittal vertical axis (SVA) and T-1 slope were similar between the two groups. Laminoplasty cases were associated with less blood loss (196.6 vs 325.0 ml, p < 0.001) and trended toward shorter hospital stays (3.5 vs 4.3 days, p = 0.054). The perioperative complication rate was 8.3%; there was no significant difference between the groups. LPSF was associated with a higher long-term complication rate (11.6% vs 2.2%, p = 0.036), with pseudarthrosis accounting for 3 of 5 complications in the LPSF group. Follow-up cervical Cobb angle was similar between the groups (8.8° vs 7.1°, p = 0.454). At final follow-up, LPSF had a significantly lower mean Nurick score (0.9 vs 1.4, p = 0.014). Among patients with preoperative neck pain, pain incidence (36.4% vs 31.3%, p = 0.629) and VAS neck pain (2.1 vs 1.8, p = 0.731) were similar between the groups. Similarly, in patients without preoperative pain, there was no significant difference in pain incidence (19.4% vs 18.2%, p = 0.926) and VAS neck pain (1.0 vs 1.1, p = 0.908). For laminoplasty, there was a significant trend for lower pain incidence (p = 0.010) and VAS neck pain (p = 0.004) with greater cervical lordosis, especially when greater than 20° (p = 0.011 and p = 0.018). Mean follow-up was 17.3 months.
For patients with CSM, LPSF was associated with slightly greater blood loss and a higher long-term complication rate, but offered greater neurological improvement than laminoplasty. In cohorts of matched follow-up cervical sagittal alignment, pain outcomes were similar between laminoplasty and LPSF patients. However, among laminoplasty patients, greater cervical lordosis was associated with better pain outcomes, especially for lordosis greater than 20°. Cervical curvature (lordosis) should be considered as an important factor in pain outcomes following posterior decompression for multilevel CSM.