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Paul Marcotte, Curtis A. Dickman, Volker K. H. Sonntag, Dean G. Karahalios and Janine Drabier

✓ Eighteen patients with atlantoaxial instability were treated with posterior atlantoaxial facet screws to obtain immediate rigid fixation of C1–2. Of these 18 patients, instability occurred due to trauma in nine, rheumatoid arthritis in six, neoplasms in two, and os odontoideum in one. Four patients presented with nonunion after failed C1–2 wire and graft procedures. In all cases in this series the screw fixations were augmented with an interspinous C1–2 strut graft which was wired in place to provide three-point stabilization and to facilitate bone fusion. In every case fixation was satisfactory, and C1–2 alignment and stability were restored without complications due to instrumentation. One patient died 3 months postoperatively from metastatic tumor; the spinal fixation was intact. All 17 surviving patients have developed osseous unions (mean follow-up period 12 months, range 6 to 16 months). Posterior atlantoaxial facet screw fixation provides immediate multidirectional rigid fixation of C1–2 that is mechanically superior to wiring or clamp fixation. This technique maximizes success without the need for a supplemental rigid external orthosis, and is particularly useful for pseudoarthrosis.

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John A. Boockvar, Matthew F. Philips, Albert E. Telfeian, Donald M. O'Rourke and Paul J. Marcotte

Object. Stabilization of the cervicothoracic junction (CTJ) requires special attention to the operative approach and biomechanical requirements of the fixation construct. In this study the authors assess the morbidity associated with the anterior approach to the CTJ and define risks that may lead to construct failure after anterior CTJ surgery.

Methods. Data obtained for 14 patients (six men and eight women, mean age 50.1 years) who underwent surgical stabilization of the CTJ via an anterior cervical approach were retrospectively reviewed to assess the anterior approach—related morbidity and the risks of construct failure. The mean follow-up period was 21.1 months. Four patients (29%) had previously undergone CTJ surgery; in 11 patients (64%) more than one motion segment was involved (two levels, six patients; three levels, four patients; four levels, one patient); allograft was placed in three (21%) of 14 graft sites; and anterior plates were used for reconstruction augmentation in eight patients (57%). Postoperatively all patients improved, although four patients had residual deficits or pain. Graft/plate failure, requiring surgical revision and/or halo placement, occurred in five patients (36%). One patient experienced transient recurrent laryngeal nerve palsy. Postoperatively, the authors classified patients into one of two groups: those in whom surgery was successful (nine cases) and those in whom it had failed (five cases). Analysis of the characteristics of these two groups revealed that male sex (p < 0.0365), multiple levels of involvement (p < 0.0378), and the use of allograft as compared with autograft (p < 0.0088) were significant risk factors for construct failure. Prior CTJ surgery (p < 0.053) tended to be associated with graft failure.

Conclusions: Findings of this study, in the setting of these factors, indicate that anterior reconstruction alone may not meet the biomechanical needs of this spinal region and that supplementary fixation may be considered to augment stabilization for fusion success.

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Albert E. Telfeian, G. Timothy Reiter, Susan R. Durham and Paul Marcotte

Object. The diagnosis, treatment, and postoperative care of morbidly obese patients undergoing spinal surgery require modifications for body habitus. With a growing percentage of the United States population becoming morbidly obese, the surgeon may need elective or emergency treatment plans that address the special needs of these patients. The authors retrospectively reviewed the diagnosis, treatment, and postoperative care of the severely obese patient undergoing spinal surgery.

Methods. To assess the associated results and complications of management that required modification for body habitus, 12 patients were included in the study (nine females); the mean age was 50 years and mean weight was 320 lb. Cases of cervical (two cases), thoracic (four cases), and lumbar surgeries (six cases) were included. The follow-up period ranged from 6 months to 2 years. Patients presented with myelopathy (five cases), radicular pain and weakness (four cases), radiculopathy (two cases), and cauda equina syndrome (one patient). Chronic progressive neurological deterioration secondary to spinal cord compression was demonstrated in nine patients and acute pain and/or weakness secondary to nerve root compression was observed in three patients.

Conclusions. The authors found that although morbidly obese patients may present late in the course of their symptoms and require modifications in the use of standard neuroimaging, operative facilities, and treatment plans, open mindedness and persistence can yield satisfactory results in most cases.

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Shabbar F. Danish and Paul J. Marcotte

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Matthew R. Sanborn, Jayesh P. Thawani, Robert G. Whitmore, Michael Shmulevich, Benjamin Hardy, Conrad Benedetto, Neil R. Malhotra, Paul Marcotte, William C. Welch, Stephen Dante and Sherman C. Stein

Object

There is considerable variation in the use of adjunctive technologies to confirm pedicle screw placement. Although there is literature to support the use of both neurophysiological monitoring and isocentric fluoroscopy to confirm pedicle screw positioning, there are no studies examining the cost-effectiveness of these technologies. This study compares the cost-effectiveness and efficacy of isocentric O-arm fluoroscopy, neurophysiological monitoring, and postoperative CT scanning after multilevel instrumented fusion for degenerative lumbar disease.

Methods

Retrospective data were collected from 4 spine surgeons who used 3 different strategies for monitoring of pedicle screw placement in multilevel lumbar degenerative disease. A decision analysis model was developed to analyze costs and outcomes of the 3 different monitoring strategies. A total of 448 surgeries performed between 2005 and 2010 were included, with 4 cases requiring repeat operation for malpositioned screws. A sample of 64 of these patients was chosen for structured interviews in which the EuroQol-5D questionnaire was used. Expected costs and quality-adjusted life years were calculated based on the incidence of repeat operation and its negative effect on quality of life and costs.

Results

The decision analysis model demonstrated that the O-arm monitoring strategy is significantly (p < 0.001) less costly than the strategy of postoperative CT scanning following intraoperative uniplanar fluoroscopy, which in turn is significantly (p < 0.001) less costly than neurophysiological monitoring. The differences in effectiveness of the different monitoring strategies are not significant (p = 0.92).

Conclusions

Use of the O-arm for confirming pedicle screw placement is the least costly and therefore most cost-effective strategy of the 3 techniques analyzed.

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Peter Syre III, Leonardo Rodriguez-Cruz, Rajiv Desai, Karl A. Greene, Robert Hurst, James Schuster, Neil R. Malhotra and Paul Marcotte

Object

Gunshot wounds to the atlantoaxial spine are uncommon injuries and rarely require treatment, as a bullet traversing this segment often results in a fatal injury. Additionally, these injuries are typically biomechanically stable. The authors report a series of 10 patients with gunshot wounds involving the lateral mass and/or bodies of the atlantoaxial complex. Their care is discussed and conclusions are drawn from these cases to identify the optimal treatment for these injuries.

Methods

A retrospective review was conducted of patients presenting to the emergency rooms of 3 institutions with gunshot wounds involving the atlantoaxial spine. Mechanism of injury and neurological status were obtained, as was the extent of the osteoligamentous, vascular, and neurological injuries. Nonoperative and operative treatment, complications, and clinical and radiographic outcome were recorded. The data were then analyzed to determine the neurological and biomechanical prognosis of these injuries, the utility of the various diagnostic modalities in the acute management of the injuries, and the nature and effectiveness of the nonoperative and operative treatment modalities.

Results

Ten patients with gunshot wounds involving the lateral mass and/or bodies of the atlantoaxial complex were identified. All but 2 patients sustained a vertebral artery injury. Each patient was evaluated using cervical radiographs, CT scans, and vascular imaging, 8 in the form of digital subtraction angiography and 2 with high-resolution CT angiography. Uncomplicated patients were treated conservatively using cervical collar immobilization, local wound care, and antibiotics. One patient was treated using a halo for instability and 1 underwent posterior fusion following a posterolateral decompression for delayed myelopathy. One patient underwent transoral resection of a bullet fragment. One patient underwent embolization for a symptomatic arteriovenous fistula and a second patient underwent a neck exploration and a jugular vein ligation. None of the patients received anticoagulation therapy. The mean follow-up duration was 13 months. All but 2 patients regained their previous functional status and all ultimately attained a mechanically stable spine.

Conclusions

These 10 patients represent a rare form of cervical spine penetrating injury. Unilateral gunshot wounds to the atlantoaxial complex are usually stable and the need for acute surgical intervention is rare. Unilateral vertebral artery injury is well tolerated and any information provided by angiography does not alter the acute management of the patient. Vascular complications from gunshot wounds can be managed effectively by endovascular techniques.

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Implications of anesthetic approach, spinal versus general, for the treatment of spinal disc herniation

Presented at the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Nikhil Sharma, Matthew Piazza, Paul J. Marcotte, William Welch, Ali K. Ozturk, H. Isaac Chen, Zarina S. Ali, James Schuster and Neil R. Malhotra

OBJECTIVE

Healthcare costs continue to escalate. Approaches to care that have comparable outcomes and complications are increasingly assessed for quality improvement and, when possible, cost containment. Efforts to identify components of care to reduce length of stay (LOS) have been ongoing. Spinal anesthesia (SA), for select lumbar spine procedures, has garnered interest as an alternative to general anesthesia (GA) that might reduce cost and in-hospital LOS and accelerate recovery. While clinical outcomes with SA or GA have been studied extensively, few authors have looked at the cost-analysis in relation to clinical outcomes. The authors’ objectives were to compare the clinical perioperative outcomes of patients who received SA and GA, as well as the direct costs associated with each modality of care, and to determine which, in a retrospective analysis, can serve as a dominant procedural approach.

METHODS

The authors retrospectively analyzed a homogeneous surgical population of 550 patients who underwent hemilaminotomy for disc herniation and who received either SA (n = 91) or GA (n = 459). All clinical and billing data were obtained via each patient’s chart and the hospital’s billing database, respectively. Additionally, the authors prospectively assessed patient-reported outcome measures for a subgroup of consecutively treated patients (n = 75) and compared quality-adjusted life year (QALY) gains between the two cohorts. Furthermore, the authors performed a propensity score–matching analysis to compare the two cohorts (n = 180).

RESULTS

Direct hospital costs for patients receiving SA were 40% higher, in the hundreds of dollars, than for patients who received GA (p < 0.0001). Furthermore, there was a significant difference with regard to LOS (p < 0.0001), where patients receiving SA had a considerably longer hospital LOS (27.6% increase in hours). Patients undergoing SA had more comorbidities (p = 0.0053), specifically diabetes and hypertension. However, metrics of complications, including readmission (p = 0.3038) and emergency department (ED) visits at 30 days (p = 1.0), were no different. Furthermore, in a small pilot group, QALY gains were statistically no different (n = 75, p = 0.6708). Propensity score–matching analysis demonstrated similar results as the univariate analysis: there was no difference between the cohorts regarding 30-day readmission (p = 1.0000); ED within 30 days could not be analyzed as there were no patients in the SA group; and total direct costs and LOS were significantly different between the two cohorts (p < 0.0001 and p = 0.0126, respectively).

CONCLUSIONS

Both SA and GA exhibit the qualities of a good anesthetic, and the utilization of these modalities for lumbar spine surgery is safe and effective. However, this work suggests that SA is associated with increased LOS and higher direct costs, although these differences may not be clinically or fiscally meaningful.

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Zarina S. Ali, Tracy M. Flanders, Ali K. Ozturk, Neil R. Malhotra, Lena Leszinsky, Brendan J. McShane, Diana Gardiner, Kristin Rupich, H. Isaac Chen, James Schuster, Paul J. Marcotte, Michael J. Kallan, M. Sean Grady, Lee A. Fleisher and William C. Welch

OBJECTIVE

Enhanced recovery after surgery (ERAS) protocols address pre-, peri-, and postoperative factors of a patient’s surgical journey. The authors sought to assess the effects of a novel ERAS protocol on clinical outcomes for patients undergoing elective spine or peripheral nerve surgery.

METHODS

The authors conducted a prospective cohort analysis comparing clinical outcomes of patients undergoing elective spine or peripheral nerve surgery after implementation of the ERAS protocol compared to a historical control cohort in a tertiary care academic medical center. Patients in the historical cohort (September–December 2016) underwent traditional surgical care. Patients in the intervention group (April–June 2017) were enrolled in a unique ERAS protocol created by the Department of Neurosurgery at the University of Pennsylvania. Primary objectives were as follows: opioid and nonopioid pain medication consumption, need for opioid use at 1 month postoperatively, and patient-reported pain scores. Secondary objectives were as follows: mobilization and ambulation status, Foley catheter use, need for straight catheterization, length of stay, need for ICU admission, discharge status, and readmission within 30 days.

RESULTS

A total of 201 patients underwent surgical care via an ERAS protocol and were compared to a total of 74 patients undergoing traditional perioperative care (control group). The 2 groups were similar in baseline demographics. Intravenous opioid medications postoperatively via patient-controlled analgesia was nearly eliminated in the ERAS group (0.5% vs 54.1%, p < 0.001). This change was not associated with an increase in the average or daily pain scores in the ERAS group. At 1 month following surgery, a smaller proportion of patients in the ERAS group were using opioids (38.8% vs 52.7%, p = 0.041). The ERAS group demonstrated greater mobilization on postoperative day 0 (53.4% vs 17.1%, p < 0.001) and postoperative day 1 (84.1% vs 45.7%, p < 0.001) compared to the control group. Postoperative Foley use was decreased in the ERAS group (20.4% vs 47.3%, p < 0.001) without an increase in the rate of straight catheterization (8.1% vs 11.9%, p = 0.51).

CONCLUSIONS

Implementation of this novel ERAS pathway safely reduces patients’ postoperative opioid requirements during hospitalization and 1 month postoperatively. ERAS results in improved postoperative mobilization and ambulation.

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Ashwin G. Ramayya, H. Isaac Chen, Paul J. Marcotte, Steven Brem, Eric L. Zager, Benjamin Osiemo, Matthew Piazza, Nikhil Sharma, Scott D. McClintock, James M. Schuster, Zarina S. Ali, Patrick Connolly, Gregory G. Heuer, M. Sean Grady, David K. Kung, Ali K. Ozturk, Donald M. O’Rourke and Neil R. Malhotra

OBJECTIVE

Although it is known that intersurgeon variability in offering elective surgery can have major consequences for patient morbidity and healthcare spending, data addressing variability within neurosurgery are scarce. The authors performed a prospective peer review study of randomly selected neurosurgery cases in order to assess the extent of consensus regarding the decision to offer elective surgery among attending neurosurgeons across one large academic institution.

METHODS

All consecutive patients who had undergone standard inpatient surgical interventions of 1 of 4 types (craniotomy for tumor [CFT], nonacute redo CFT, first-time spine surgery with/without instrumentation, and nonacute redo spine surgery with/without instrumentation) during the period 2015–2017 were retrospectively enrolled (n = 9156 patient surgeries, n = 80 randomly selected individual cases, n = 20 index cases of each type randomly selected for review). The selected cases were scored by attending neurosurgeons using a need for surgery (NFS) score based on clinical data (patient demographics, preoperative notes, radiology reports, and operative notes; n = 616 independent case reviews). Attending neurosurgeon reviewers were blinded as to performing provider and surgical outcome. Aggregate NFS scores across various categories were measured. The authors employed a repeated-measures mixed ANOVA model with autoregressive variance structure to compute omnibus statistical tests across the various surgery types. Interrater reliability (IRR) was measured using Cohen’s kappa based on binary NFS scores.

RESULTS

Overall, the authors found that most of the neurosurgical procedures studied were rated as “indicated” by blinded attending neurosurgeons (mean NFS = 88.3, all p values < 0.001) with greater agreement among neurosurgeon raters than expected by chance (IRR = 81.78%, p = 0.016). Redo surgery had lower NFS scores and IRR scores than first-time surgery, both for craniotomy and spine surgery (ANOVA, all p values < 0.01). Spine surgeries with fusion had lower NFS scores than spine surgeries without fusion procedures (p < 0.01).

CONCLUSIONS

There was general agreement among neurosurgeons in terms of indication for surgery; however, revision surgery of all types and spine surgery with fusion procedures had the lowest amount of decision consensus. These results should guide efforts aimed at reducing unnecessary variability in surgical practice with the goal of effective allocation of healthcare resources to advance the value paradigm in neurosurgery.