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Faris Shweikeh, Lutfi Al-Khouja, Miriam Nuño, J. Patrick Johnson, Doniel Drazin and Matthew A. Adamo

OBJECT

Tethered cord syndrome (TCS) is a common spinal abnormality. In this study, the authors analyzed demographics, complications, and outcomes in children and adolescents who underwent surgery for TCS.

METHODS

Using the national Kids' Inpatient Database (KID), the authors retrospectively identified patients with a primary diagnosis of TCS who were treated with spinal laminectomy and discharged in 2000, 2003, 2006, and 2009. Descriptive analysis was provided for patient- and hospital-level characteristics. Mortality, complications, non-routine discharges, in-hospital length of stay (LOS), and total charges were documented for the entire cohort and age-specific cohorts (0–5, 6–10, 11–15, and 16–20 years). Comparisons by complications and age groups were conducted.

RESULTS

A total of 7397 children and adolescents met the criteria in the 4 studied years. The mean age was 5.7 years; 55.3% of patients were younger than 5 years, 21.5% were 6–10 years, and 16.2% were 11–15 years. Most surgeries were performed in patients who were female (55.0%) and white (64.4%) and were performed at large (49.8%), teaching (94.2%), and urban (99.1%) children's (89.3%) hospitals. The trend showed an increase in prevalence from 2000 (19.9%) to 2009 (29.6%). Common comorbidities included anomalies in spinal curvature (16.7%), urinary or bladder dysfunction (14.3%), and spinal stenosis/spondylosis (1.4%). Non-routine discharges (3.3%) were significantly higher with advancing age, increasing from 2.2% in those younger than 5 years to 9.0% in those older than 15 years (p < 0.0001). There was a similar increasing trend for complications (6.8% to 13.9%, respectively, p < 0.0001) and average LOS (3.5 to 5.1 days, respectively, p < 0.0001). Hospital charges increased with age from an average of $28,521 in those younger than 5 years to $36,855 in those older than 15 years (p < 0.0001).

CONCLUSIONS

There was a steady trend of increasing operative treatment for TCS over the more recent years. The nationwide analysis was also indicative of an existing disparity, based on age, in complications, outcomes, and charges following TCS surgical correction. Older children tended to have more complications, longer LOS, more non-routine discharges, and higher hospital costs. The results are highly supportive of surgery at a younger age for this condition. Future research should investigate this correlation, especially considering the efforts to control and reduce health care costs.

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Lutfi T. Al-Khouja, Eli M. Baron, J. Patrick Johnson, Terrence T. Kim and Doniel Drazin

Object

Medical care has been evolving with the increased influence of a value-based health care system. As a result, more emphasis is being placed on ensuring cost-effectiveness and utility in the services provided to patients. This study looks at this development in respect to minimally invasive spine surgery (MISS) costs.

Methods

A literature review using PubMed, the Cost-Effectiveness Analysis (CEA) Registry, and the National Health Service Economic Evaluation Database (NHS EED) was performed. Papers were included in the study if they reported costs associated with minimally invasive spine surgery (MISS). If there was no mention of cost, CEA, cost-utility analysis (CUA), quality-adjusted life year (QALY), quality, or outcomes mentioned, then the article was excluded.

Results

Fourteen studies reporting costs associated with MISS in 12,425 patients (3675 undergoing minimally invasive procedures and 8750 undergoing open procedures) were identified through PubMed, the CEA Registry, and NHS EED. The percent cost difference between minimally invasive and open approaches ranged from 2.54% to 33.68%—all indicating cost saving with a minimally invasive surgical approach. Average length of stay (LOS) for minimally invasive surgery ranged from 0.93 days to 5.1 days compared with 1.53 days to 12 days for an open approach. All studies reporting EBL reported lower volume loss in an MISS approach (range 10–392.5 ml) than in an open approach (range 55–535.5 ml).

Conclusions

There are currently an insufficient number of studies published reporting the costs of MISS. Of the studies published, none have followed a standardized method of reporting and analyzing cost data. Preliminary findings analyzing the 14 studies showed both cost saving and better outcomes in MISS compared with an open approach. However, more Level I CEA/CUA studies including cost/QALY evaluations with specifics of the techniques utilized need to be reported in a standardized manner to make more accurate conclusions on the cost effectiveness of minimally invasive spine surgery.

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Doniel Drazin, Neil Bhamb, Lutfi T. Al-Khouja, Ari D. Kappel, Terrence T. Kim, J. Patrick Johnson and Earl Brien

OBJECTIVE

The aim of this study was to identify and discuss operative nuances utilizing image guidance in the surgical management of aggressive sacral tumors.

METHODS

The authors report on their single-institution, multi-surgeon, retrospective case series involving patients with pathology-proven aggressive sacral tumors treated between 2009 and 2016. They also reviewed the literature to identify articles related to aggressive sacral tumors, their diagnosis, and their surgical treatment and discuss the results together with their own experience. Information, including background, imaging, treatment, and surgical pearls, is organized by tumor type.

RESULTS

Review of the institutional records identified 6 patients with sacral tumors who underwent surgery between 2009 and 2016. All 6 patients were treated with image-guided surgery using cone-beam CT technology (O-arm). The surgical technique used is described in detail, and 2 illustrative cases are presented. From the literature, the authors compiled information about chordomas, chondrosarcomas, giant cell tumors, and osteosarcomas and organized it by tumor type, providing a detailed discussion of background, imaging, and treatment as well as surgical pearls for each tumor type.

CONCLUSIONS

Aggressive sacral tumors can be an extremely difficult challenge for both the patient and the treating physician. The selected surgical intervention varies depending on the type of tumor, size, and location. Surgery can have profound risks including neural compression, lumbopelvic instability, and suboptimal oncological resection. Focusing on the operative nuances for each type can help prevent many of these complications. Anecdotal evidence is provided that utilization of image-guided surgery to aid in tumor resection at our institution has helped reduce blood loss and the local recurrence rate while preserving function in both malignant and aggressive benign tumors affecting the sacrum.

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Rani Nasser, Doniel Drazin, Jonathan Nakhla, Lutfi Al-Khouja, Earl Brien, Eli M. Baron, Terrence T. Kim, J. Patrick Johnson and Reza Yassari

OBJECTIVE

The use of intraoperative stereotactic navigation has become more available in spine surgery. The authors undertook this study to assess the utility of intraoperative CT navigation in the localization of spinal lesions and as an intraoperative tool to guide resection in patients with spinal lesions.

METHODS

This was a retrospective multicenter study including 50 patients from 2 different institutions who underwent biopsy and/or resection of spinal column tumors using image-guided navigation. Of the 50 cases reviewed, 4 illustrative cases are presented. In addition, the authors provide a description of surgical technique with image guidance.

RESULTS

The patient group included 27 male patients and 23 female patients. Their average age was 61 ± 17 years (range 14–87 years). The average operative time (incision to closure) was 311 ± 188 minutes (range 62–865 minutes). The average intraoperative blood loss was 882 ± 1194 ml (range 5–7000 ml). The average length of hospitalization was 10 ± 8.9 days (range 1–36 days). The postoperative complications included 2 deaths (4.0%) and 4 radiculopathies (8%) secondary to tumor burden.

CONCLUSIONS

O-arm 3D imaging with stereotactic navigation may be used to localize lesions intraoperatively with real-time dynamic feedback of tumor resection. Stereotactic guidance may augment resection or biopsy of primary and metastatic spinal tumors. It offers reduced radiation exposure to operating room personnel and the ability to use minimally invasive approaches that limit tissue injury. In addition, acquisition of intraoperative CT scans with real-time tracking allows for precise targeting of spinal lesions with minimal dissection.