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Michael S. Turner

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Michael F. O'Brien, David Peterson and H. Alan Crockard

✓ Extreme-lateral lumbar disc herniations present a surgical challenge because the conventional posterior approach requires bone resection for complete visualization of the pathology. The authors have identified constant anatomical landmarks in cadaveric dissections that facilitate access to the intervertebral foramen when combined with a posterolateral approach, as described by Watkins, for lumbar spinal fusion. The authors describe a technique that allows rapid localization and safe excision of these extreme-lateral lumbar disc herniations without the need for bone resection.

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Kristian Aquilina, Donncha F. O’Brien, Michael A. Farrell and Ciaran Bolger

✓The authors report on the case of a craniopharyngioma arising in the cerebellopontine angle (CPA) in a patient with Gardner syndrome. Although familial adenomatous polyposis (FAP) is associated with intracranial neoplasms, the current case is only the third reported craniopharyngioma in a patient with Gardner syndrome. Two of these tumors, including that of the current case, originated in the CPA, an unusual location for craniopharyngiomas. The literature concerning FAP and its associations with intracranial neoplasia, as well as the pathogenesis of craniopharyngiomas in the posterior fossa, is discussed.

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Michael A. Murphy, Terence J. O'Brien, Kevin Morris and Mark J. Cook

Object. The aim of this study was to review seizure outcome, imaging modalities used, and complications following surgery in patients with epilepsy who had undergone multimodality image-guided surgery at our institution.

Methods. Data from patients with epilepsy who had undergone surgery between April 1999 and October 2001 were reviewed. During this time period, 116 operations were performed in 109 patients with medically refractory epilepsy. Among these patients, 22 were selected to undergo multimodality image-guided surgery primarily on the basis of whether they had no lesion visible on conventional magnetic resonance (MR) imaging sequences, multiple lesions, or one very large lesion that could not be completely resected without the risk of significant postoperative morbidity. A fourth group of patients in whom there was a single lesion in the eloquent cortex, a location associated with a significant risk of postoperative morbidity, was also included in the analysis. This latter group was assessed with the aid of intracranial grid electrodes that were coregistered to the MR image and were used intraoperatively to minimize electrode position error. Other imaging modalities used included positron emission tomography (PET), fluid-attenuated inversion recovery (FLAIR) MR imaging, and subtracted ictal–interictal single-photon positron emission computerized tomography (SPECT) coregistered with MR imaging (SISCOM). After coregistration, images were then downloaded onto an image-guided surgical system and the epileptogenic area was then resected.

The mean patient age was 33 years (range 17–46 years), and there was a mean follow up of 27 months (range 14–41 months). Multimodality coregistrations used were as follows: nine PET scans, seven subdural electrode grids, four SISCOM studies, one FLAIR MR image, and one combined PET/subdural grid. Seizure outcome was excellent in 17 patients (77%) and not excellent in five (23%), or favorable in 19 (86%) and unfavorable in three (14%). Six patients (27%) had a transient neurological deficit, one patient (5%) a permanent major deficit, and three patients (15%) a permanent minor deficit. Five patients (24%) had a transient psychiatric problem postoperatively.

Conclusions. Multimodality image-guided surgery offers a new perspective in surgery for epilepsy. Functional imaging modalities previously lateralized and often localized a seizure focus, but did not provide enough anatomical information to resect the epileptogenic zone confidently and safely. The coregistration of these modalities to a volumetric MR image and their incorporation into an image-guided system has allowed surgeons to offer surgery to patients who may not previously have been considered eligible, with outcomes comparable to those in patients with more straightforward lesional epilepsy.

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Laura A. Snyder, Harry Shufflebarger, Michael F. O'Brien, Harjot Thind, Nicholas Theodore and Udaya K. Kakarla

Object

Isthmic spondylolysis can significantly decrease functional abilities, especially in adolescent athletes. Although treatment can range from observation to surgery, direct screw placement through the fractured pars, or Buck's procedure, may be a more minimally invasive procedure than the more common pedicle screw-hook construct.

Methods

Review of surgical databases identified 16 consecutive patients treated with Buck's procedure from 2004 to 2010. Twelve patients were treated at Miami Children's Hospital and 4 at Barrow Neurological Institute. Demographics and clinical and radiographic outcomes were recorded and analyzed retrospectively.

Results

The 16 patients had a median age of 16 years, and 14 were 20 years or younger at the time of treatment. Symptoms included axial back pain in 100% of patients with concomitant radiculopathy in 38%. Pars defects were bilateral in 81% and unilateral in 19% for a total of 29 pars defects treated using Buck's procedure. Autograft or allograft augmented with recombinant human bone morphogenetic protein as well as postoperative bracing was used in all cases. Postoperatively, symptoms resolved completely or partially in 15 patients (94%). Of 29 pars defects, healing was observed in 26 (89.6%) prior to 1 revision surgery, and an overall fusion rate of 97% was observed at last radiological follow-up. There were no implant failures. All 8 athletes in this group had returned to play at last follow-up.

Conclusions

Direct screw repair of the pars interarticularis defect as described in this series may provide a more minimally invasive treatment of adolescent patients with satisfactory clinical and radiological outcomes, including return to play of adolescent athletes.

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Justin K. Scheer, Jessica A. Tang, Justin S. Smith, Eric Klineberg, Robert A. Hart, Gregory M. Mundis Jr., Douglas C. Burton, Richard Hostin, Michael F. O'Brien, Shay Bess, Khaled M. Kebaish, Vedat Deviren, Virginie Lafage, Frank Schwab, Christopher I. Shaffrey, Christopher P. Ames and the International Spine Study Group

Object

Complications and reoperation for surgery to correct adult spinal deformity are not infrequent, and many studies have analyzed the rates and factors that influence the likelihood of reoperation. However, there is a need for more comprehensive analyses of reoperation in adult spinal deformity surgery from a global standpoint, particularly focusing on the 1st year following operation and considering radiographic parameters and the effects of reoperation on health-related quality of life (HRQOL). This study attempts to determine the prevalence of reoperation following surgery for adult spinal deformity, assess the indications for these reoperations, evaluate for a relation between specific radiographic parameters and the need for reoperation, and determine the potential impact of reoperation on HRQOL measures.

Methods

A retrospective review was conducted of a prospective, multicenter, adult spinal deformity database collected through the International Spine Study Group. Data collected included age, body mass index, sex, date of surgery, information regarding complications, reoperation dates, length of stay, and operation time. The radiographic parameters assessed were total number of levels instrumented, total number of interbody fusions, C-7 sagittal vertical axis, uppermost instrumented vertebra (UIV) location, and presence of 3-column osteotomies. The HRQOL assessment included Oswestry Disability Index (ODI), 36-Item Short Form Health Survey physical component and mental component summary, and SRS-22 scores. Smoking history, Charlson Comorbidity Index scores, and American Society of Anesthesiologists Physical Status classification grades were also collected and assessed for correlation with risk of early reoperation. Various statistical tests were performed for evaluation of specific factors listed above, and the level of significance was set at p < 0.05.

Results

Fifty-nine (17%) of a total of 352 patients required reoperation. Forty-four (12.5%) of the reoperations occurred within 1 year after the initial surgery, including 17 reoperations (5%) within 30 days.

Two hundred sixty-eight patients had a minimum of 1 year of follow-up. Fifty-three (20%) of these patients had a 3-column osteotomy, and 10 (19%) of these 53 required reoperation within 1 year of the initial procedure. However, 3-column osteotomy was not predictive of reoperation within 1 year, p = 0.5476). There were no significant differences between groups with regard to the distribution of UIV, and UIV did not have a significant effect on reoperation rates. Patients needing reoperation within 1 year had worse ODI and SRS-22 scores measured at 1-year follow-up than patients not requiring operation.

Conclusions

Analysis of data from a large multicenter adult spinal deformity database shows an overall 17% reoperation rate, with a 19% reoperation rate for patients treated with 3-column osteotomy and a 16% reoperation rate for patients not treated with 3-column osteotomy. The most common indications for reoperation included instrumentation complications and radiographic failure. Reoperation significantly affected HRQOL outcomes at 1-year follow-up. The need for reoperation may be minimized by carefully considering spinal alignment, termination of fixation, and type of surgical procedure (presence of osteotomy). Precautions should be taken to avoid malposition or instrumentation (rod) failure.