Letter to the Editor: The Brain and Spinal Injury Center score
Sandeep S. Bhangoo
Mini-open removal of extradural foraminal tumors of the lumbar spine
Daniel C. Lu, Sanjay S. Dhall, and Praveen V. Mummaneni
Spinal extradural foraminal neoplasms are uncommon lesions that are traditionally resected via an open laminectomy and facetectomy approach. In this paper the authors present their mini-open approach for the removal of 3 such tumors. The authors retrospectively reviewed 3 patients with extradural schwannoma who underwent mini-open resection and fusion between June 2006 and July 2007. Clinical data, tumor characteristics, and outcomes were analyzed. All 3 patients underwent successful mini-open treatment of their spinal neoplasms. Postoperative MR imaging demonstrated complete resection in 2 cases and subtotal resection in 1 case. Extradural foraminal neoplasms can be safely and effectively treated with mini-open techniques. Reductions in blood loss, hospitalization, and tissue disruption may be potential benefits of this approach.
Clinical and radiographic comparison of mini–open transforaminal lumbar interbody fusion with open transforaminal lumbar interbody fusion in 42 patients with long-term follow-up
Sanjay S. Dhall, Michael Y. Wang, and Praveen V. Mummaneni
As minimally invasive approaches gain popularity in spine surgery, clinical outcomes and effectiveness of mini–open transforaminal lumbar interbody fusion (TLIF) compared with traditional open TLIF have yet to be established. The authors retrospectively compared the outcomes of patients who underwent mini–open TLIF with those who underwent open TLIF.
Between 2003 and 2006, 42 patients underwent TLIF for degenerative disc disease or spondylolisthesis; 21 patients underwent mini–open TLIF and 21 patients underwent open TLIF. The mean age in each group was 53 years, and there was no statistically significant difference in age between the groups (p = 0.98). Data were collected perioperatively. In addition, complications, length of stay (LOS), fusion rate, and modified Prolo Scale (mPS) scores were recorded at routine intervals.
No patient was lost to follow-up. The mean follow-up was 24 months for the mini-open group and 34 months for the open group. The mean estimated blood loss was 194 ml for the mini-open group and 505 ml for the open group (p < 0.01). The mean LOS was 3 days for the mini-open group and 5.5 days for the open group (p < 0.01). The mean mPS score improved from 11 to 19 in the mini-open group and from 10 to 18 in the open group; there was no statistically significant difference in mPS score improvement between the groups (p = 0.19). In the mini-open group there were 2 cases of transient L-5 sensory loss, 1 case of a misplaced screw that required revision, and 1 case of cage migration that required revision. In the open group there was 1 case of radiculitis as well as 1 case of a misplaced screw that required revision. One patient in the mini-open group developed a pseudarthrosis that required reoperation, and all patients in the open group exhibited fusion.
Mini–open TLIF is a viable alternative to traditional open TLIF with significantly reduced estimated blood loss and LOS. However, the authors found a higher incidence of hardware-associated complications with the mini–open TLIF.
Spinal intradural clear cell meningioma following resection of a suprasellar clear cell meningioma
Case report and recommendations for management
Sanjay S. Dhall, Luis M. Tumialán, Daniel J. Brat, and Daniel L. Barrow
✓ The authors report on 32-year-old woman with a history of a previously resected suprasellar clear cell meningioma (CCM), who returned to their institution after 3 years suffering from progressively worsening leg and back pain associated with leg weakness and bowel and bladder dysfunction. A magnetic resonance image of the thoracic and lumbar spine demonstrated a homogeneously enhancing intradural mass that filled and expanded the thecal sac. The patient underwent multiple-level laminectomies for resection of the lesion. Results of pathological studies confirmed distant recurrence of a CCM.
Since its initial recognition as a rare but aggressive histological variant of meningothelial tumors, the body of literature on CCMs has grown to include more than 40 cases. Nevertheless, the natural history of this neoplastic entity remains ill defined, as are the recommendations for management. Of particular concern is the treatment of patients who have undergone subtotal resection or present with recurrence. To the authors' knowledge, the present case represents the sixth distant recurrence of CCM reported in the literature. The radiographic and histological studies are reviewed along with the current literature on this subtype of meningioma. Recommendations for surveillance and treatment are made.
The Mini-Open transpedicular thoracic discectomy: surgical technique and assessment
John H. Chi, Sanjay S. Dhall, Adam S. Kanter, and Praveen V. Mummaneni
Thoracic disc herniations can be surgically treated with a number of different techniques and approaches. However, surgical outcomes comparing the various techniques are rarely reported in the literature. The authors describe a minimally invasive technique to approach thoracic disc herniations via a transpedicular route with the use of tubular retractors and microscope visualization. This technique provides a safe method to identify the thoracic disc space and perform a decompression with minimal paraspinal soft tissue disruption. The authors compare the results of this approach with clinical results after open transpedicular discectomy.
The authors performed a retrospective cohort study comparing results in 11 patients with symptomatic thoracic disc herniations treated with either open posterolateral (4 patients) or mini-open transpedicular discectomy (7 patients). Hospital stay, blood loss, modified Prolo score, and Frankel score were used as outcome variables.
Patients who underwent mini-open transpedicular discectomy had less blood loss and showed greater improvement in modified Prolo scores (p = 0.024 and p = 0.05, respectively) than those who underwent open transpedicular discectomy at the time of early follow-up within 1 year of surgery. However, at an average of 18 months of follow-up, the Prolo score difference between the 2 surgical groups was not statistically significant. There were no major or minor surgical complications in the patients who received the minimally invasive technique.
The mini-open transpedicular discectomy for thoracic disc herniations results in better modified Prolo scores at early postoperative intervals and less blood loss during surgery than open posterolateral discectomy. The authors' technique is described in detail and an intraoperative video is provided.
Perioperative morbidity and mortality comparison in circumferential cervical fusion for osteomyelitis versus cervical spondylotic myelopathy
Rishi Wadhwa, Praveen V. Mummaneni, Darryl Lau, Hai Le, Dean Chou, and Sanjay S. Dhall
The most common indications for circumferential cervical decompression and fusion are cervical spondylotic myelopathy (CSM) and cervical osteomyelitis (COM). Currently, the informed consent process prior to circumferential cervical fusion surgery is not different for these two groups of patients, as details of their diagnosis-specific risk profiles have not been quantified. The authors compared two patient cohorts with either CSM or COM treated using circumferential fusion. They sought to quantify perioperative morbidity and postoperative mortality in these two groups to assist with a diagnosis-specific informed consent process for future patients undergoing this type of surgery.
Perioperative and follow-up data from two cohorts of patients who had undergone circumferential cervical decompression and fusion were analyzed. Estimated blood loss (EBL), length of stay (LOS), perioperative complications, hospital readmission, 30-day reoperation rates, change in Nurick grade, and mortality were compared between the two groups.
Twenty-two patients were in the COM cohort, and 24 were in the CSM cohort. Complications, hospital readmission, 30-day reoperation rates, EBL, and mortality were not statistically different, although patients with COM trended higher in each of these categories. There was a significantly greater LOS (p < 0.001) in the COM group and greater improvement in Nurick grade in the CSM group (p < 0.001).
When advising patients undergoing circumferential fusion about perioperative risk factors, it is important for those with COM to know that they are likely to have a higher rate of complications and mortality than those with CSM who are undergoing similar surgery. Furthermore, COM patients have less neurological improvement than CSM patients after surgery. This information may be useful to surgeons and patients in providing appropriate informed consent during preoperative planning.
Letter to the Editor: Minimum clinically important difference
Tobias A. Mattei and Daniel R. Fassett
Treatment of cervical stenotic myelopathy: a cost and outcome comparison of laminoplasty versus laminectomy and lateral mass fusion
Jason M. Highsmith, Sanjay S. Dhall, Regis W. Haid Jr., Gerald E. Rodts Jr., and Praveen V. Mummaneni
Cervical stenotic myelopathy due to spondylosis or ossification of the posterior longitudinal ligament is often treated with laminoplasty or cervical laminectomy (with fusion). The goal of this study was to compare outcomes, radiographic results, complications, and implant costs associated with these 2 treatments.
The authors analyzed the records of 56 patients (age range 42–81 years) who were surgically treated for cervical stenosis. Of this group, 30 underwent laminoplasty and 26 underwent laminectomy with fusion. Patients who had cervical kyphosis or spondylolisthesis were excluded. An average of 4 levels were instrumented in the laminoplasty group and 5 levels in the fusion group (p < 0.01). Forty-two percent of the fusions crossed the cervicothoracic junction, but no laminoplasty instrumentation crossed the cervicothoracic junction, and it only reached C-7 in one-third of the cases. Preoperative and postoperative Nurick grades and modified Japanese Orthopaedic Association (mJOA) scores were obtained. Outcomes were also assessed with neck pain visual analog scale (VAS) scores and the Odom outcome criteria. Postoperative length of stay, complications, and implant costs were calculated.
The mean duration of follow-up, average patient age, and length of hospital stay were similar for both groups. The mean Nurick scores were also similar in the 2 groups and improved an average of 1.4 points in both (p < 0.01 for preoperative-postoperative comparison in each group). The mean mJOA scores improved 2.7 points in laminoplasty patients and 2.8 points in fusion patients (p < 0.01 for each group). The mean VAS scores for neck pain did not change significantly in the laminoplasty cohort (3.2 ± 2.8 [SD] preoperatively vs 3.4 ± 2.6 postoperatively, p = 0.50). In the fusion cohort, the mean VAS scores improved from 5.8 ± 3.2 to 3.0 ± 2.3 (p < 0.01). Excellent or good Odom outcomes were observed in 76.7% of the patients in the laminoplasty cohort and 80.8% of those in the fusion cohort (p = 0.71). In the fusion group, complications were twice as common and implant costs were nearly 3 times as high as in the laminoplasty group. When cases involving fusions crossing the cervicothoracic junction were excluded, analysis showed similar complication rates in the 2 groups.
Patients treated with laminoplasty and patients treated with laminectomy and fusion had similar improvements in Nurick scores, mJOA scores, and Odom outcomes. Patients who underwent fusion typically had higher preoperative neck pain scores, but their neck pain improved significantly after surgery. There was no significant change in the neck pain scores of patients treated with laminoplasty. Our series suggests cervical fusion significantly reduces neck pain in patients with stenotic myelopathy, but that the cost of the implant and rate of reoperation are greater than in laminoplasty.
Circumferential fusion for cervical kyphotic deformity
Praveen V. Mummaneni, Sanjay S. Dhall, Gerald E. Rodts, and Regis W. Haid
The treatment of cervical kyphotic deformity is challenging. Few prior reports have examined combined anterior/posterior correction methods, and fusion rates and standardized outcomes are rarely cited in literature examining these techniques. The authors present their midterm results with cervical kyphosis correction.
The authors retrospectively reviewed the charts of 30 patients with cervical kyphotic deformity who underwent circumferential spine surgery between 2001 and 2007. The causes of the deformity included chronic fracture in 17 patients, degenerative disease in 10, and tumor in 3. Anterior procedures included discectomies and corpectomies/osteotomies at 1 or more levels with fusion. Posterior operations included decompression and/or osteotomies with lateral mass or pedicle fixation. Preoperative and postoperative Ishihara kyphosis indices, modified Japanese Orthopaedic Association (mJOA) scores, and Nurick grades were analyzed. Arthrodesis was assessed via dynamic radiographs, and CT scans were used to assess fusion in questionable cases.
One patient was lost to follow-up. Two patients died within 1 month of surgery. The follow-up period in the remaining 27 patients ranged from 1 to 6.4 years (mean 2.6 years). Ishihara indices improved from a preoperative mean of −17.7 to a postoperative mean of +11.4. The mean Nurick grades improved from 3.2 preoperatively to 1.3 postoperatively. The mJOA scores improved from a preoperative mean of 10 to 15 postoperatively. All surviving patients who underwent follow-up showed postoperative fusion except 1 patient with renal failure and osteoporosis (95% fusion rate). The overall rate of complications (major and minor) was 33.3%.
In cases of cervical kyphosis, management with decompression, osteotomy, and stabilization from both anterior and posterior approaches can restore cervical lordosis. Furthermore, such surgical techniques can produce measurable improvements in neurological function (as measured with Nurick grades and mJOA scores) and achieve high fusion rates. However, there is a significant rate of complications.
Minimally invasive approach to extraforaminal disc herniations at the lumbosacral junction using an operating microscope: case series and review of the literature
Stephen M. Pirris, Sanjay Dhall, Praveen V. Mummaneni, and Adam S. Kanter
Surgical access to extraforaminal lumbar disc herniations is complicated due to the unique anatomical constraints of the region. Minimizing complications during microdiscectomies at the level of L5–S1 in particular remains a challenge. The authors report on a small series of patients and provide a video presentation of a minimally invasive approach to L5–S1 extraforaminal lumbar disc herniations utilizing a tubular retractor with microscopic visualization.