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Rod J. Oskouian and J. Patrick Johnson


The purpose of this investigation was to evaluate surgical and neurological outcomes in thoracic disc surgery in a prospective fashion.


Quantifiable outcome data such as operating time, blood loss, duration of chest tube drainage, narcotic drug use, length of hospital stay (LOS), and long-term follow up of neurological function and pain-related symptoms were collected prospectively.

In patients with myelopathy there was an improvement of two Frankel grades in the thoracoscopic discectomy group and one Frankel grade in the patients treated with thoracotomy; however, patients in the thoracotomy group were significantly worse preoperatively. None of the patients experienced worsened pain, and pain related to radiculopathy was improved by 75% in the thoracoscopic group.


Thoracoscopic discectomy yields acceptable surgical results and has several distinct advantages, with reduced postoperative pain, morbidity, and LOS.

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Rod J. Oskouian and J. Patrick Johnson

Object. The purpose of this clinical study was to evaluate prospectively surgical and neurological outcomes after endoscopic thoracic disc surgery.

Methods. The authors assessed the following quantifiable outcome data in 46 patients: operative time, blood loss, duration of chest tube insertion, narcotic use, hospital length of stay (LOS), and long-term follow-up neurological function and pain-related symptoms.

In patients who presented with myelopathy there was a postoperative improvement of two Frankel grades. Pain related to radiculopathy was improved by 75% and in one patient it worsened postoperatively. The authors also present operative data, surgical outcomes, and complications.

Conclusions. Thoracoscopic discectomy can be used to achieve acceptable results. It has several distinct advantages such as reduced postoperative pain, morbidity, and LOS compared with traditional open procedures.

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Rod J. Oskouian Jr. and J. Patrick Johnson

Object. Anterior approaches in thoracic and lumbar spinal surgery have potentially serious vascular injury—related complications. In this study the authors evaluate the incidence of vascular complications in anterior approaches to the thoracic and lumbar spine in cases requiring reconstructive surgery.

Methods. The authors retrospectively reviewed the medical records of 207 patients who underwent anterior thoracic and lumbar spinal reconstructive surgery during the period from 1992 through 1999 to determine the incidence, causes, and management of vascular complications.

Overall, the incidence of vascular complications following reconstructive spinal surgery was 5.8% (12 patients) and the mortality rate was 1% (two patient deaths). In seven patients (3.4%), direct vascular injuries developed as a result of surgical techniques or error; one patient died as a result. Five patients (2.4%) developed deep venous thromboses, and one patient in this subgroup died of pulmonary embolism.

Conclusions. Vascular injury to the great vessels is a known and potentially serious complication associated with anterior spinal reconstructive procedures. The authors found, however, that the incidence is relatively low in cases in which venous injuries occurred acutely and arterial injuries presented in a delayed fashion.

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Namath S. Hussain, David Hanscom and Rod J. Oskouian Jr.

Injury to the lymphatic channels is a rare and relatively unknown complication of anterior approaches to the lumbar spine and can cause fluid to build up in the retroperitoneal space, resulting in a lymphocele. If they enlarge sufficiently, these collections of chyle in the abdomen can cause pain and bowel ischemia, and can compress nearby organs. The authors report 4 cases in which anterior approaches to the lumbar spine were complicated by a postoperative retroperitoneal chylous fluid collection. They describe the anatomy of the lymphatic system and pathophysiology of this disease entity, review the sparse literature on this subject, and recommend a treatment algorithm. Maintaining a high index of suspicion for this clinical entity in patients who have recently undergone an anterior approach to the thoracic or lumbar spine is vital to avoid delays in diagnosis and treatment.

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Rod J. Oskouian, Richard Whitehill, Amir Samii, Mark E. Shaffrey, J. Patrick Johnson and Christopher I. Shaffrey

Both total hip and knee arthroplasty have demonstrated outstanding clinical results. The functional spinal unit composed of the intervertebral disc and facet joints is at least as complex. The intricacies of the coupled motions of the functional spinal unit have made development of an artificial disc a challenge. There have been several failed attempts to create a disc replacement that recapitulates normal motion while providing significant longevity and a low incidence of complications.

Better understanding of the biomechanics of the intervertebral disc complex and improvements in implant material have made successful intervertebral disc replacement a likely reality, now that several artificial discs have completed Food and Drug Administration clinical trials. In this manuscript the authors detail the biomaterials used in disc arthroplasty and discuss joint wear and the host response to wear debris.

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Aaron S. Dumont, Rod J. Oskouian Jr., Michael M. Chow and Neal F. Kassell

The basilar artery (BA) bifurcation is the most common site for aneurysms arising from the posterior circulation. Their inhospitable location, nested within the narrow confines of the interpeduncular fossa anterior to the brainstem, coupled with the rich network of adjacent critical thalamoperforating arteries irrigating the midbrain and thalamus, pose difficult anatomical obstacles for the surgeon.

The age old adage that the only cure for intracranial aneurysms remains exclusion from circulation before rupture still holds true. Although management of unruptured aneurysms in general is still controversial, unruptured aneurysms of the BA bifurcation can be treated surgically with acceptable rates of morbidity. The clinician must gather and weigh all clinical, pathological, and radiological data when formulating recommendations for the individual patient.

In the present report the authors describe their current technique for the surgical management of unruptured BA bifurcation aneurysms; this represents the culmination of the senior author's (N.K.) experience in the management of both ruptured and unruptured BA bifurcation aneurysms. A modified, right-sided subtemporal transtentorial approach has been adopted in all cases of isolated unruptured BA bifurcation aneurysms. Technical nuances are described.

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Rod J. Oskouian Jr., John A. Jane Sr., Aaron S. Dumont, Jonas M. Sheehan, Jeffrey J. Laurent and Paul A. Levine

Esthesioneuroblastoma is a rare and malignant upper nasal cavity neoplasm involving the anterior skull base. Treatment includes surgery, radiotherapy, chemotherapy, or a combination. The ideal treatment modality has yet to be determined. Esthesioneuroblastoma often lies in proximity to the optic nerves, optic chiasm, and the orbit. Resection risks damaging these critical structures, and radiotherapeutic techniques, similar to those applied for paranasal sinus tumors, may damage these vital structures and result in late sequelae such as blindness and cortical necrosis.

Management strategies for this neoplasm lack uniformity, and there is no universally accepted staging system. In this paper the authors discuss the clinical presentation, radiological and pathological features, and treatment of this rare, malignant skull base neoplasm, as well as review the literature. They also present their results and treatment regimen, which includes preoperative radio- and chemotherapy or 1) craniofacial resection if the lesion has a significant intrac-erebral component, or 2) frontal sinus resection if little intracranial extension exists.

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Alan T. Villavicencio, Rod J. Oskouian, Cliff Roberson, John Stokes, Jongsoo Park, Christopher I. Shaffrey and J. Patrick Johnson


Metastatic spinal tumors continue to represent a major problem for patients and treating physicians. The purpose of this study was to assess quantitatively the functional outcome, quality of life, and survival rates of patients after major reconstructive spine surgery.


A prospective database was established and 58 patients were identified who had undergone thoracolum-bar vertebral reconstruction for metastatic spinal tumors between March 1993 and October 1999. Surgical indications included disabling pain (92%) and/or progressive neurological dysfunction (60%).

Forty-nine patients (85%) had clinical improvement in pain as determined based on the Oswestry pain scale (p < 0.05); 60% demonstrated improvement in their neurological status. The mean neurological improvement in Frankel grade was 1.2 (p < 0.05). The 12-month survival rate was 65%, and all patients who were ambulatory after surgery remained so until the time of death. Instrumentation failure requiring repeated operation occurred in two patients (3.5%), and in 12 patients (21%) local tumor recurrence necessitated repeated surgery. There were no cases of neurological deficit or death related to surgery.


Major anterior thoracolumbar vertebral reconstruction is an effective treatment for local tumor control. More importantly, the authors have demonstrated that surgical treatment can significantly improve the quality of life by improvement of pain control and maintenance of ambulation during the patient's remaining life span.

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Wyatt L. Ramey, Alexander von Glinski, Andrew Jack, Ronen Blecher, Rod J. Oskouian and Jens R. Chapman


The surgical treatment of osteomyelitis and discitis of the spine often represents a challenging clinical entity for a multitude of reasons, including progression of infection despite debridement, development of spinal deformity and instability, bony destruction, and seeding of hardware. Despite advancement in spinal hardware and implantation techniques, these aforementioned challenges not uncommonly result in treatment failure, especially in instances of heavy disease burden with enough bony endplate destruction as to not allow support of a modern titanium cage implant. While antibiotic-infused polymethylmethacrylate (aPMMA) has been used in orthopedic surgery in joints of the extremities, its use has not been extensively described in the spine literature. Herein, the authors describe for the first time a series of patients treated with a novel surgical technique for the treatment of spinal osteomyelitis and discitis using aPMMA strut grafts with posterior segmental fusion.


Over the course of 3 years, all patients with spinal osteomyelitis and discitis at a single institution were identified and included in the retrospective cohort if they were surgically treated with spinal fusion and implantation of an aPMMA strut graft at the nidus of infection. Basic demographics, surgical techniques, levels treated, complications, and return to the operating room for removal of the aPMMA strut graft and placement of a traditional cage were examined. The surgical technique consisted of performing a discectomy and/or corpectomy at the level of osteomyelitis and discitis followed by placement of aPMMA impregnated with vancomycin and/or tobramycin into the cavity. Depending on the patient’s condition during follow-up and other deciding clinical and radiographic factors, the patient may return to the operating room nonurgently for removal of the PMMA spacer and implantation of a permanent cage with allograft to ultimately promote fusion.


Fifteen patients were identified who were treated with an aPMMA strut graft for spinal osteomyelitis and discitis. Of these, 9 patients returned to the operating room for aPMMA strut graft removal and insertion of a cage with allograft at an average of 19 weeks following the index procedure. The most common infections were methicillin-sensitive Staphylococcus aureus (n = 6) and methicillin-resistant S. aureus (n = 5). There were 13 lumbosacral infections and 1 each of cervical and thoracic infection. Eleven patients were cured of their infection, while 2 had recurrence of their infection; 2 patients were lost to follow-up. Three patients required unplanned return trips to the operating room, two of which were for wound complications, with the third being for recurrent infection.


In cases of severe infection with considerable bony destruction, insertion of an aPMMA strut graft is a novel technique that should be considered in order to provide strong anterior-column support while directly delivering antibiotics to the infection bed. While the active infection is being treated medically, this structural aPMMA support bridges the time it takes for the patient to be converted from a catabolic to an anabolic state, when it is ultimately safe to perform a definitive, curative fusion surgery.