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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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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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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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Jinping Liu, Pingguo Duan, Praveen V. Mummaneni, Rong Xie, Bo Li, Yinhui Dong, Sigurd Berven, and Dean Chou

OBJECTIVE

Conflicting reports exist about whether transforaminal lumbar interbody fusion (TLIF) induces lordosis or kyphosis, ranging from decreasing lordosis by 3.71° to increasing it by 18.8°. In this study, the authors’ aim was to identify factors that result in kyphosis or lordosis after TLIF.

METHODS

A single-center, retrospective study of open TLIF without osteotomy for spondylolisthesis with a minimum 2-year follow-up was undertaken. Preoperative and postoperative clinical and radiographic parameters and cage specifics were collected. TLIFs were considered to be “lordosing” if postoperative induction of lordosis was > 0° and “kyphosing” if postoperative induction of lordosis was ≤ 0°.

RESULTS

A total of 137 patients with an average follow-up of 52.5 months (range 24–130 months) were included. The overall postoperative disc angle (DA) and segmental lordosis (SL) increased by 1.96° and 1.88° (p = 0.003 and p = 0.038), respectively, whereas overall lumbar lordosis remained unchanged (p = 0.133). Seventy-nine patients had lordosing TLIFs with a mean SL increase of 5.72° ± 3.97°, and 58 patients had kyphosing TLIFs with a mean decrease of 3.02° ± 2.98°. Multivariate analysis showed that a lower preoperative DA, lower preoperative SL, and anterior cage placement were correlated with the greatest increase in postoperative SL (p = 0.040, p < 0.001, and p = 0.035, respectively). There was no difference in demographics, cage type or height, or spinopelvic parameters between the groups (p > 0.05). Linear regression showed that the preoperative DA and SL correlated with SL after TLIF (R2 = 0.198, p < 0.001; and R2 = 0.2931, p < 0.001, respectively).

CONCLUSIONS

Whether a TLIF induces kyphosis or lordosis depends on the preoperative DA, preoperative SL, and cage position. Less-lordotic segments became more lordotic postoperatively, and highly lordotic segments may lose lordosis after TLIF. Cages placed more anteriorly were associated with more lordosis.

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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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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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Ping-Guo Duan, Praveen V. Mummaneni, Minghao Wang, Andrew K. Chan, Bo Li, Rory Mayer, Sigurd H. Berven, and Dean Chou

OBJECTIVE

In this study, the authors’ aim was to investigate whether obesity affects surgery rates for adjacent-segment degeneration (ASD) after transforaminal lumbar interbody fusion (TLIF) for spondylolisthesis.

METHODS

Patients who underwent single-level TLIF for spondylolisthesis at the University of California, San Francisco, from 2006 to 2016 were retrospectively analyzed. Inclusion criteria were a minimum 2-year follow-up, single-level TLIF, and degenerative lumbar spondylolisthesis. Exclusion criteria were trauma, tumor, infection, multilevel fusions, non-TLIF fusions, or less than a 2-year follow-up. Patient demographic data were collected, and an analysis of spinopelvic parameters was performed. The patients were divided into two groups: mismatched, or pelvic incidence (PI) minus lumbar lordosis (LL) ≥ 10°; and balanced, or PI-LL < 10°. Within the two groups, the patients were further classified by BMI (< 30 and ≥ 30 kg/m2). Patients were then evaluated for surgery for ASD, matched by BMI and PI-LL parameters.

RESULTS

A total of 190 patients met inclusion criteria (72 males and 118 females, mean age 59.57 ± 12.39 years). The average follow-up was 40.21 ± 20.42 months (range 24–135 months). In total, 24 patients (12.63% of 190) underwent surgery for ASD. Within the entire cohort, 82 patients were in the mismatched group, and 108 patients were in the balanced group. Within the mismatched group, adjacent-segment surgeries occurred at the following rates: BMI < 30 kg/m2, 2.1% (1/48); and BMI ≥ 30 kg/m2, 17.6% (6/34). Significant differences were seen between patients with BMI ≥ 30 and BMI < 30 (p = 0.018). A receiver operating characteristic curve for BMI as a predictor for ASD was established, with an AUC of 0.69 (95% CI 0.49–0.90). The optimal BMI cutoff value determined by the Youden index is 29.95 (sensitivity 0.857; specificity 0.627). However, in the balanced PI-LL group (108/190 patients), there was no difference in surgery rates for ASD among the patients with different BMIs (p > 0.05).

CONCLUSIONS

In patients who have a PI-LL mismatch, obesity may be associated with an increased risk of surgery for ASD after TLIF, but in obese patients without PI-LL mismatch, this association was not observed.

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Ping-Guo Duan, Praveen V. Mummaneni, Jeremy M. V. Guinn, Joshua Rivera, Sigurd H. Berven, and Dean Chou

OBJECTIVE

The aim of this study was to investigate whether fat infiltration of the lumbar multifidus (LM) muscle affects revision surgery rates for adjacent-segment degeneration (ASD) after L4–5 transforaminal lumbar interbody fusion (TLIF) for degenerative spondylolisthesis.

METHODS

A total of 178 patients undergoing single-level L4–5 TLIF for spondylolisthesis (2006 to 2016) were retrospectively analyzed. Inclusion criteria were a minimum 2-year follow-up, preoperative MR images and radiographs, and single-level L4–5 TLIF for degenerative spondylolisthesis. Twenty-three patients underwent revision surgery for ASD during the follow-up. Another 23 patients without ASD were matched with the patients with ASD. Demographic data, Roussouly curvature type, and spinopelvic parameter data were collected. The fat infiltration of the LM muscle (L3, L4, and L5) was evaluated on preoperative MRI using the Goutallier classification system.

RESULTS

A total of 46 patients were evaluated. There were no differences in age, sex, BMI, or spinopelvic parameters with regard to patients with and those without ASD (p > 0.05). Fat infiltration of the LM was significantly greater in the patients with ASD than in those without ASD (p = 0.029). Fat infiltration was most significant at L3 in patients with ASD than in patients without ASD (p = 0.017). At L4 and L5, there was an increasing trend of fat infiltration in the patients with ASD than in those without ASD, but the difference was not statistically significant (p = 0.354 for L4 and p = 0.077 for L5).

CONCLUSIONS

Fat infiltration of the LM may be associated with ASD after L4–5 TLIF for spondylolisthesis. Fat infiltration at L3 may also be associated with ASD at L3–4 after L4–5 TLIF.