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Shane M. Burke, Mina G. Safain, James Kryzanski and Ron I. Riesenburger

Lumbar nerve root anomalies are uncommon phenomena that must be recognized to avoid neural injury during surgery. The authors describe 2 cases of nerve root anomalies encountered during mini-open transforaminal lumbar interbody fusion (TLIF) surgery. One anomaly was a confluent variant not previously classified; the authors suggest that this variant be reflected in an amendment to the Neidre and Macnab classification system. They also propose strategies for identifying these anomalies and avoiding injury to anomalous nerve roots during TLIF surgery. Case 1 involved a 68-year-old woman with a 2-year history of neurogenic claudication. An MR image demonstrated L4–5 stenosis and spondylolisthesis and an L-4 nerve root that appeared unusually low in the neural foramen. During a mini-open TLIF procedure, a nerve root anomaly was seen. Six months after surgery this patient was free of neurogenic claudication. Case 2 involved a 60-year-old woman with a 1-year history of left L-4 radicular pain. Both MR and CT images demonstrated severe left L-4 foraminal stenosis and focal scoliosis. Before surgery, a nerve root anomaly was not detected, but during a unilateral mini-open TLIF procedure, a confluent nerve root was identified. Two years after surgery, this patient was free of radicular pain.

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Mina G. Safain, Shane M. Burke, Ron I. Riesenburger, Vasilios Zerris and Steven W. Hwang

OBJECT

The standard surgical release of a tethered cord may result in recurrent scar formation and occasionally be associated with retethering. The application of spinal shortening procedures to this challenging problem potentially can reduce tension on the retethered spinal cord while minimizing the difficulties inherent in traditional lumbosacral detethering revision. Although spinal shortening procedures have proven clinical benefit in patients with a recurrent tethered cord, it is unclear how much shortening is required to achieve adequate reduction in spinal cord tension or what impact these osteotomies have on dural buckling.

METHODS

The authors calculated mean values from 4 human cadavers to evaluate the effect of 3 different spinal shortening procedures—Smith-Petersen osteotomy (SPO), pedicle subtraction osteotomy (PSO), and vertebral column resection (VCR)—on spinal cord tension and dural buckling. Three cadavers were dedicated to the measurement of spinal cord tension, and 3 other cadavers were devoted to myelography to measure dural buckling parameters.

RESULTS

The SPO was associated with a maximal decrease in spinal cord tension of 16.1% from baseline and no dural buckling with any degree of closure. The PSO led to a mean maximal decrease in spinal cord tension of 63.1% from baseline at 12 mm of closure and demonstrated a direct linear relationship between dural buckling and increasing osteotomy closure. Finally, VCR closure correlated with a mean maximal decrease in spinal cord tension of 87.2% from baseline at 10 mm of closure and also showed a direct linear relationship between dural buckling and increases in osteotomy closure.

CONCLUSIONS

In this cadaveric experiment, the SPO did not lead to appreciable tension reduction, while a substantial response was seen with both the PSO and VCR. The rate of tension reduction may be steeper for the VCR than the PSO. Adequate tension relief while minimizing dural buckling may be optimal with 12–16 mm of posterior osteotomy closure based on this cadaveric experiment.

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Tofey J. Leon, Elizabeth N. Kuhn, Anastasia A. Arynchyna, Burkely P. Smith, R. Shane Tubbs, James M. Johnston, Jeffrey P. Blount, Curtis J. Rozzelle, W. Jerry Oakes and Brandon G. Rocque

OBJECTIVE

There are sparse published data on the natural history of “benign” Chiari I malformation (CM-I)—i.e., Chiari with minimal or no symptoms at presentation and no imaging evidence of syrinx, hydrocephalus, or spinal cord signal abnormality. The purpose of this study was to review a large cohort of children with benign CM-I and to determine whether these children become symptomatic and require surgical treatment.

METHODS

Patients were identified from institutional outpatient records using International Classification of Diseases, 9th Revision, diagnosis codes for CM-I from 1996 to 2016. After review of the medical records, patients were excluded if they 1) did not have a diagnosis of CM-I, 2) were not evaluated by a neurosurgeon, 3) had previously undergone posterior fossa decompression, or 4) had imaging evidence of syringomyelia at their first appointment. To include only patients with benign Chiari (without syrinx or classic Chiari symptoms that could prompt immediate intervention), any patient who underwent decompression within 9 months of initial evaluation was excluded. After a detailed chart review, patients were excluded if they had classical Chiari malformation symptoms at presentation. The authors then determined what changes in the clinical picture prompted surgical treatment. Patients were excluded from the multivariate logistic regression analysis if they had missing data such as race and insurance; however, these patients were included in the overall survival analysis.

RESULTS

A total of 427 patients were included for analysis with a median follow-up duration of 25.5 months (range 0.17–179.1 months) after initial evaluation. Fifteen patients had surgery at a median time of 21.0 months (range 11.3–139.3 months) after initial evaluation. The most common indications for surgery were tussive headache in 5 (33.3%), syringomyelia in 5 (33.3%), and nontussive headache in 5 (33.3%). Using the Kaplan-Meier method, rate of freedom from posterior fossa decompression was 95.8%, 94.1%, and 93.1% at 3, 5, and 10 years, respectively.

CONCLUSIONS

Among a large cohort of patients with benign CM-I, progression of imaging abnormalities or symptoms that warrant surgical treatment is infrequent. Therefore, these patients should be managed conservatively. However, clinical follow-up of such individuals is justified, as there is a low, but nonzero, rate of new symptom or syringomyelia development. Future analyses will determine whether imaging or clinical features present at initial evaluation are associated with progression and future need for treatment.

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Daniel B. Herrick, Joseph E. Tanenbaum, Marc Mankarious, Sagar Vallabh, Eitan Fleischman, Swamy Kurra, Shane M. Burke, Marie Roguski, Thomas E. Mroz, William F. Lavelle, Jeffrey E. Florman and Ron I. Riesenburger

OBJECTIVE

Use of surgical site drains following posterior cervical spine surgery is variable, and its impact on outcomes remains controversial. Studies of drain use in the lumbar spine have suggested that drains are not associated with reduction of reoperations for wound infection or hematoma. There is a paucity of studies examining this relationship in the cervical spine, where hematomas and infections can have severe consequences. This study aims to examine the relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery.

METHODS

This study is a multicenter retrospective review of 1799 consecutive patients who underwent posterior cervical decompression with instrumentation at 4 tertiary care centers between 2004 and 2016. Demographic and perioperative data were analyzed for associations with drain placement and return to the operating room.

RESULTS

Of 1799 patients, 1180 (65.6%) had a drain placed. Multivariate logistic regression analysis identified history of diabetes (OR 1.37, p = 0.03) and total number of levels operated (OR 1.32, p < 0.001) as independent predictors of drain placement. Rates of reoperation for any surgical site complication were not different between the drain and no-drain groups (4.07% vs 3.88%, p = 0.85). Similarly, rates of reoperation for surgical site infection (1.61% vs 2.58%, p = 0.16) and hematoma (0.68% vs 0.48%, p = 0.62) were not different between the drain and no-drain groups. However, after adjusting for history of diabetes and the number of operative levels, patients with drains had significantly lower odds of returning to the operating room for surgical site infection (OR 0.48, p = 0.04) but not for hematoma (OR 1.22, p = 0.77).

CONCLUSIONS

This large study characterizes current practice patterns in the utilization of surgical site drains during posterior cervical decompression and instrumentation. Patients with drains placed did not have lower odds of returning to the operating room for postoperative hematoma. However, the authors’ data suggest that patients with drains may be less likely to return to the operating room for surgical site infection, although the absolute number of infections in the entire population was small, limiting the analysis.