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Krishn Khanna and Sigurd H. Berven

Vascular complications are an important adverse event that can be associated with spinal reconstructive surgery. Direct injury of vessels, or indirect traction or compression of vessels, can cause both arterial and venous injury. Indirect compression of the mesenteric vessels is a well-recognized complication of bracing and surgical care of children with spinal deformity (superior mesenteric artery syndrome), but the complication is not common or well recognized in the adult population with spinal deformity. The purpose of this case report is to detail the case of postoperative mesenteric ischemia in a 63-year-old man in whom a posterior approach was used to perform spinal deformity correction. Preoperatively, the patient had had significant lumbar hypolordosis. The reconstructive surgery with the use of posterior-based osteotomies resulted in a shortening of the posterior column of the spine but a relative lengthening of structures anterior to the spine. The significant lordosis achieved by the surgery led to an acute worsening of the mesenteric stenosis suffered by the patient. He required a vascular surgery intervention to restore perfusion to the bowel. Recognition of severe vasculopathy is important in anticipating potential postoperative vascular insufficiency. This case report will inform surgeons and clinicians to have a higher index of suspicion for the exacerbation of vascular insufficiency, including mesenteric pathology, in patients undergoing surgery that involves significant realignment of the spine. Preoperative recognition of vascular insufficiency and treatment of symptomatic disease may limit the occurrence of postoperative vascular complications in spinal reconstructive surgery.

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Cheerag D. Upadhyaya, Sigurd Berven and Praveen V. Mummaneni

Pedicle subtraction osteotomy (PSO) is a powerful technique for correcting a fixed sagittal plane deformity. The authors report the case of a 51-year-old man with a history of multiple prior lumbar operations, flat-back syndrome, thoracic kyphosis, and radiculopathy, who underwent deformity correction surgery with T3–S1 pedicle screw fixation and L-3 PSO. Progressive spondylolisthesis of the PSO segment associated with rod fracture then developed. The patient subsequently underwent anterior and posterior revision surgery. This case is a rare instance of spondylolisthesis following PSO.

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Junichi Ohya, Todd D. Vogel, Sanjay S. Dhall, Sigurd Berven and Praveen V. Mummaneni

S-2 alar iliac (S2AI) screw fixation has recently been recognized as a useful technique for pelvic fixation. The authors demonstrate two cases where S2AI fixation was indicated: one case was a sacral insufficiency fracture following a long-segment fusion in a patient with a transitional S-1 vertebra; the other case involved pseudarthrosis following lumbosacral fixation. S2AI screws offer rigid fixation, low profile, and allow easy connection to the lumbosacral rod. The authors describe and demonstrate the surgical technique and nuances for the S2AI screw in a case with transitional S-1 anatomy and in a case with normal S-1 anatomy.

The video can be found here: https://youtu.be/Sj21lk13_aw.

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John E. Ziewacz, Sigurd H. Berven, Valli P. Mummaneni, Tsung-Hsi Tu, Olaolu C. Akinbo, Russ Lyon and Praveen V. Mummaneni

Object

The purpose of this study was to provide an evidence-based algorithm for the design, development, and implementation of a new checklist for the response to an intraoperative neuromonitoring alert during spine surgery.

Methods

The aviation and surgical literature was surveyed for evidence of successful checklist design, development, and implementation. The limitations of checklists and the barriers to their implementation were reviewed. Based on this review, an algorithm for neurosurgical checklist creation and implementation was developed. Using this algorithm, a multidisciplinary team surveyed the literature for the best practices for how to respond to an intraoperative neuromonitoring alert. All stakeholders then reviewed the evidence and came to consensus regarding items for inclusion in the checklist.

Results

A checklist for responding to an intraoperative neuromonitoring alert was devised. It highlights the specific roles of the anesthesiologist, surgeon, and neuromonitoring personnel and encourages communication between teams. It focuses on the items critical for identifying and correcting reversible causes of neuromonitoring alerts. Following initial design, the checklist draft was reviewed and amended with stakeholder input. The checklist was then evaluated in a small-scale trial and revised based on usability and feasibility.

Conclusions

The authors have developed an evidence-based algorithm for the design, development, and implementation of checklists in neurosurgery and have used this algorithm to devise a checklist for responding to intraoperative neuromonitoring alerts in spine surgery.

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Bruce M. McCormack, Rafael C. Bundoc, Mario R. Ver, Jose Manuel F. Ignacio, Sigurd H. Berven and Edward F. Eyster

Object

The authors present 1-year results in 60 patients with cervical radiculopathy due to spondylosis and stenosis that was treated with a bilateral percutaneous facet implant. The implant consists of a screw and washer that distracts and immobilizes the cervical facet for root decompression and fusion. Clinical and radiological results are analyzed.

Methods

Between 2009 and 2011, 60 patients were treated with the DTRAX Facet System in a multicenter prospective single-arm study. All patients had symptomatic clinical radiculopathy, and conservative management had failed. The majority of patients had multilevel radiographically confirmed disease. Only patients with single-level radiculopathy confirmed by history, physical examination, and in some cases confirmatory nerve blocks were included. Patients were assessed preoperatively with Neck Disability Index, visual analog scale, quality of life questionnaire (Short Form-12 version 2), CT scans, MRI, and dynamic radiographs. Surgery was percutaneous posterior bilateral facet implants consisting of a screw and expandable washer and iliac crest bone aspirate. Patients underwent postoperative assessments at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year with validated outcome questionnaires. Alterations of segmental and overall cervical lordosis, foraminal dimensions, device retention and fusion criteria were assessed for up to 1 year with CT reconstructions and radiographs. Fusion criteria were defined as bridging trabecular bone between the facets, translational motion < 2 mm, and angular motion < 5°.

Results

All patients were followed to 1 year postoperatively. Ages in this cohort ranged from 40 to 75 years, with a mean of 53 years. Forty-two patients were treated at C5–6, 8 at C6–7, 7 at C4–5, and 3 at C3–4. Fifty-six had bilateral implants; 4 had unilateral implants due to intraoperative facet fracture (2 patients) and inability to access the facet (2 patients). The Neck Disability Index, Short Form-12 version 2, and visual analog scale scores were significantly improved at 2 weeks and remained significantly improved up to 1 year. At the treated level, 93% had intrafacet bridging trabecular bone on CT scans, translational motion was < 2 mm in 100% and angular movement was < 5° in 83% at the 1-year follow-up. There was no significant change in overall cervical lordosis. There was a 1.6° loss of segmental lordosis at the treated level at 1 year that was significant. Foraminal width, volume, and posterior disc height was significantly increased at 6 months and returned to baseline levels at 1 year. There was no significant decrease in foraminal width and height at adjacent levels. There were no reoperations or surgery- or device-related complications, including implant failure or retained hardware.

Conclusions

Results indicate that the DTRAX Facet System is safe and effective for treatment of cervical radiculopathy.

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Dominic Amara, Praveen V. Mummaneni, Christopher P. Ames, Bobby Tay, Vedat Deviren, Shane Burch, Sigurd H. Berven and Dean Chou

OBJECTIVE

Many options exist for the surgical management of adult spinal deformity. Radiculopathy and lumbosacral pain from the fractional curve (FC), typically from L4 to S1, is frequently a reason for scoliosis patients to pursue surgical intervention. The purpose of this study was to evaluate the outcomes of limited fusion of the FC only versus treatment of the entire deformity with long fusions.

METHODS

All adult scoliosis patients treated at the authors’ institution in the period from 2006 to 2016 were retrospectively analyzed. Patients with FCs from L4 to S1 > 10° and radiculopathy ipsilateral to the concavity of the FC were eligible for study inclusion and had undergone three categories of surgery: 1) FC only (FC group), 2) lower thoracic to sacrum (LT group), or 3) upper thoracic to sacrum (UT group). Primary outcomes were the rates of revision surgery and complications. Secondary outcomes were estimated blood loss, length of hospital stay, and discharge destination. Spinopelvic parameters were measured, and patients were stratified accordingly.

RESULTS

Of the 99 patients eligible for inclusion in the study, 27 were in the FC group, 46 in the LT group, and 26 in the UT group. There were no significant preoperative differences in age, sex, smoking status, prior operation, FC magnitude, pelvic tilt (PT), sagittal vertical axis (SVA), coronal balance, pelvic incidence–lumbar lordosis (PI-LL) mismatch, or proportion of well-aligned spines (SVA < 5 cm, PI-LL mismatch < 10°, and PT < 20°) among the three treatment groups. Mean follow-up was 30 (range 12–112) months, with a minimum 1-year follow-up. The FC group had a lower medical complication rate (22% [FC] vs 57% [LT] vs 58% [UT], p = 0.009) but a higher rate of extension surgery (26% [FC] vs 13% [LT] vs 4% [UT], p = 0.068). The respective average estimated blood loss (592 vs 1950 vs 2634 ml, p < 0.001), length of hospital stay (5.5 vs 8.3 vs 8.3 days, p < 0.001), and rate of discharge to acute rehabilitation (30% vs 46% vs 85%, p < 0.001) were all lower for FC and highest for UT.

CONCLUSIONS

Treatment of the FC only is associated with a lower complication rate, shorter hospital stay, and less blood loss than complete scoliosis treatment. However, there is a higher associated rate of extension of the construct to the lower or upper thoracic levels, and patients should be counseled when considering their options.

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Junichi Ohya, David P. Bray, Stephen T. Magill, Todd D. Vogel, Sigurd Berven and Praveen V. Mummaneni

Elderly patients with diffuse idiopathic skeletal hyperostosis are at high risk for falls, and 3-column unstable fractures present multiple challenges. Unstable fractures across the cervicothoracic junction are associated with significant morbidity and require fixation, which is commonly performed through a posterior open or percutaneous approach. The authors describe a novel, navigated, mini-open anterior approach using intraoperative cone-beam CT scanning to place lag screws followed by an anterior plate in a 97-year-old patient. This approach is less invasive and faster than an open posterior approach and can be considered as an option for management of cervicothoracic junction fractures in elderly patients with high perioperative risk profile who cannot tolerate being placed prone during surgery.

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Robert Heary

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Darryl Lau, Andrew K. Chan, Alexander A. Theologis, Dean Chou, Praveen V. Mummaneni, Shane Burch, Sigurd Berven, Vedat Deviren and Christopher Ames

OBJECTIVE

Because the surgical strategies for primary and metastatic spinal tumors are different, the respective associated costs and morbidities associated with those treatments likely vary. This study compares the direct costs and 90-day readmission rates between the resection of extradural metastatic and primary spinal tumors. The factors associated with cost and readmission are identified.

METHODS

Adults (age 18 years or older) who underwent the resection of spinal tumors between 2008 and 2013 were included in the study. Patients with intradural tumors were excluded. The direct costs of index hospitalization and 90-day readmission hospitalization were evaluated. The direct costs were compared between patients who were treated surgically for primary and metastatic spinal tumors. The independent factors associated with costs and readmissions were identified using multivariate analysis.

RESULTS

A total of 181 patients with spinal tumors were included (63 primary and 118 metastatic tumors). Overall, the mean index hospital admission cost for the surgical management of spinal tumors was $52,083. There was no significant difference in the cost of hospitalization between primary ($55,801) and metastatic ($50,098) tumors (p = 0.426). The independent factors associated with higher cost were male sex (p = 0.032), preoperative inability to ambulate (p = 0.002), having more than 3 comorbidities (p = 0.037), undergoing corpectomy (p = 0.021), instrumentation greater than 7 levels (p < 0.001), combined anterior-posterior approach (p < 0.001), presence of a perioperative complication (p < 0.001), and longer hospital stay (p < 0.001). The perioperative complication rate was 21.0%. Of this cohort, 11.6% of patients were readmitted within 90 days, and the mean hospitalization cost of that readmission was $20,078. Readmission rates after surgical treatment for primary and metastatic tumors were similar (11.1% vs 11.9%, respectively) (p = 0.880). Prior hospital stay greater than 15 days (OR 6.62, p = 0.016) and diagnosis of lung metastasis (OR 52.99, p = 0.007) were independent predictors of readmission.

CONCLUSIONS

Primary and metastatic spinal tumors are comparable with regard to the direct costs of the index surgical hospitalization and readmission rate within 90 days. The factors independently associated with costs are related to preoperative health status, type and complexity of surgery, and postoperative course.

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Takahito Fujimori, Shinichi Inoue, Hai Le, William W. Schairer, Sigurd H. Berven, Bobby K. Tay, Vedat Deviren, Shane Burch, Motoki Iwasaki and Serena S. Hu

Object

Despite increasing numbers of patients with adult spinal deformity, it is unclear how to select the optimal upper instrumented vertebra (UIV) in long fusion surgery for these patients. The purpose of this study was to compare the use of vertebrae in the upper thoracic (UT) versus lower thoracic (LT) spine as the upper instrumented vertebra in long fusion surgery for adult spinal deformity.

Methods

Patients who underwent fusion from the sacrum to the thoracic spine for adult spinal deformity with sagittal imbalance at a single medical center were studied. The patients with a sagittal vertical axis (SVA) ≥ 40 mm who had radiographs and completed the 12-item Short-Form Health Survey (SF-12) preoperatively and at final follow-up (≥ 2 years postoperatively) were included.

Results

Eighty patients (mean age of 61.1 ± 10.9 years; 69 women and 11 men) met the inclusion criteria. There were 31 patients in the UT group and 49 patients in the LT group. The mean follow-up period was 3.6 ± 1.6 years. The physical component summary (PCS) score of the SF-12 significantly improved from the preoperative assessment to final follow-up in each group (UT, 34 to 41; LT, 29 to 37; p = 0.001). This improvement reached the minimum clinically important difference in both groups. There was no significant difference in PCS score improvement between the 2 groups (p = 0.8). The UT group had significantly greater preoperative lumbar lordosis (28° vs 18°, p = 0.03) and greater thoracic kyphosis (36° vs 18°, p = 0.001). After surgery, there was no significant difference in lumbar lordosis or thoracic kyphosis. The UT group had significantly greater postoperative cervicothoracic kyphosis (20° vs 11°, p = 0.009). The UT group tended to maintain a smaller positive SVA (51 vs 73 mm, p = 0.08) and smaller T-1 spinopelvic inclination (−2.6° vs 0.6°, p = 0.06). The LT group tended to have more proximal junctional kyphosis (PJK), although the difference did not reach statistical significance. Radiographic PJK was 32% in the UT group and 41% in the LT group (p = 0.4). Surgical PJK was 6.4% in the UT group and 10% in the LT group (p = 0.6).

Conclusions

Both the UT and LT groups demonstrated significant improvement in clinical and radiographic outcomes. A significant difference was not observed in improvement of clinical outcomes between the 2 groups.