Search Results

You are looking at 1 - 9 of 9 items for

  • Author or Editor: Sunil Kukreja x
Clear All Modify Search
Restricted access

Vibhu K. Viswanathan, Sunil Kukreja, Amy J. Minnema and H. Francis Farhadi

OBJECTIVE

Proximal junctional kyphosis (PJK) can progress to proximal junctional failure (PJF), a widely recognized early and serious complication of multisegment spinal instrumentation for the treatment of adult spinal deformity (ASD). Sublaminar band placement has been suggested as a possible technique to prevent PJK and PJF but carries the theoretical possibility of a paradoxical increase in these complications as a result of the required muscle dissection and posterior ligamentous disruption. In this study, the authors prospectively assess the safety as well as the early clinical and radiological outcomes of sublaminar band insertion at the upper instrumented vertebra (UIV) plus 1 level (UIV+1).

METHODS

Between August 2015 and February 2017, 40 consecutive patients underwent either upper (T2–4) or lower (T8–10) thoracic sublaminar band placement at the UIV+1 during long-segment thoracolumbar arthrodesis surgery. Outcome measures were prospectively collected and uploaded to a web-based REDCap database specifically designed to include demographic, clinical, and radiological data. All patients underwent clinical assessment, as well as radiological assessment with anteroposterior and lateral 36-inch whole-spine standing radiographs both pre- and postoperatively.

RESULTS

Forty patients (24 women and 16 men) were included in this study. Median age at surgery was 64.0 years with an IQR of 57.7–70.0 years. Median follow-up was 12 months (IQR 6–15 months). Three procedure-related complications were noted, including 2 intraoperative cerebrospinal spinal fluid leaks and 1 transient neurological deficit. Median visual analog scale (VAS) scores for back pain significantly improved after surgery (preoperatively: 8.0, IQR 6.0–10.0; 1-year follow-up: 2.0, IQR 0.0–6.0; p = 0.001). Median Oswestry Disability Index (version 2.1a) scores also significantly improved after surgery (preoperatively: 56.0, IQR 45.0–64.0; 1-year follow-up: 46.0, IQR 22.2–54.0; p < 0.001). Sagittal vertical axis (preoperatively: 9.0 cm, IQR 5.3–11.6 cm; final follow-up: 4.7 cm, IQR 2.0–6.6 cm; p < 0.001), pelvic incidence-lumbar lordosis mismatch (24.7°, IQR 11.2°–31.2°; 7.7°, IQR −1.2° to 19.5°; p < 0.001), and pelvic tilt (28.7°, IQR 20.4°–32.6°; 17.1°, IQR 10.8°–25.2°; p < 0.001) were all improved at the final follow-up. While proximal junctional (PJ) Cobb angles increased overall at the final follow-up (preoperatively: 4.2°, IQR 1.9°–7.4°; final follow-up: 8.0°, IQR 5.8°–10.3°; p = 0.002), the significant increase was primarily noted starting at the immediate postoperative time point (7.2°, IQR 4.4°–11.8°; p = 0.001) and not beyond. Three patients (7.5%) developed radiological PJK (mean ΔPJ Cobb 15.5°), while there were no instances of PJF in this cohort.

CONCLUSIONS

Sublaminar band placement at the UIV+1 during long-segment thoracolumbar instrumented arthrodesis is relatively safe and is not associated with an increased rate of PJK. Moreover, no subjects developed PJF. Prospective large-scale and long-term analysis is needed to define the potential benefit of sublaminar bands in reducing the incidence of PJK and PJF following surgery for ASD.

Clinical trial registration no.: NCT02411799 (clinicaltrials.gov)

Full access

Impact of body habitus on fluoroscopic radiation emission during minimally invasive spine surgery

Presented at the 2014 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves

Sunil Kukreja, Justin Haydel, Anil Nanda and Anthony H. Sin

OBJECT

Minimally invasive spine surgeries (MISSs) have gained immense popularity in the last few years. Concern about the radiation exposure has also been raised. The purpose of this study was to demonstrate the impact of body habitus on the radiation emission during various MISS procedures. The authors also aim to evaluate the effect the surgeon's experience has on the amount of radiation exposure during MISS especially with regard to patient size.

METHODS

The authors conducted a retrospective analysis of 332 patients who underwent 387 MISS procedures performed at their institution from January 2010 to August 2013 by a single surgeon. The dose of radiation emission available from the fluoroscopic equipment was recorded from the electronic database. The authors analyzed mainly 3 procedure groups: microdiscectomy/decompression (MiDD, n = 211) and transforaminal lumbar interbody fusion (TLIF) either with unilateral instrumentation (UnTLIF, n = 106) or bilateral instrumentation (BiTLIF, n = 70). The patients in each procedure group were divided into 6 categories based on the WHO criteria for obesity: underweight (body mass index [BMI] < 18.50), normal (18.50–24.99), overweight (25.00–29.99), Class 1 obese (30.00–34.99), Class 2 obese (35.00– 39.99), and Class 3 obese (> 40.00).

RESULTS

Patients who underwent BiTLIF had the highest median radiation exposure (113 mGy, SD 9.44), whereas microdiscectomy required minimal exposure (12.62 mGy, SD 2.75 mGy). There was a significant correlation between radiation emission and BMI of the patients during all MISS procedures (p < 0.05). The median radiation exposure was substantially greater with larger patients (p ≤ 0.001). In the analyses within the procedure groups, radiation exposure was found to be significantly high in patients who were severely obese (Class 2 and Class 3 obesity). The radiation emission was lower during the surgeries performed in 2013 than during those performed in 2010 especially in obese patients; however, this observation was not statistically significant.

CONCLUSIONS

Body habitus of the patients has a substantial impact on radiation emission during MISS. Severe obesity (BMI ≥ 35) is associated with a significantly greater risk of radiation exposure compared with other weight categories. Surgical experience seems to be associated with lower radiation emission especially in cases in which patients have a higher BMI; however, further studies should be performed to examine this effect.

Full access

Shyamal C. Bir, Sudheer Ambekar, Sunil Kukreja and Anil Nanda

Julius Caesar Arantius is one of the pioneer anatomists and surgeons of the 16th century who discovered the different anatomical structures of the human body. One of his prominent discoveries is the hippocampus. At that time, Arantius originated the term hippocampus, from the Greek word for seahorse (hippos [“horse”] and kampos [“sea monster”]). Arantius published his description of the hippocampus in 1587, in the first chapter of his work titled De Humano Foetu Liber. Numerous nomenclatures of this structure, including “white silkworm,” “Ammon's horn,” and “ram's horn” were proposed by different scholars at that time. However, the term hippocampus has become the most widely used in the literature.

Free access

Piyush Kalakoti, Symeon Missios, Richard Menger, Sunil Kukreja, Subhas Konar and Anil Nanda

OBJECT

Because of the limited data available regarding the associations between risk factors and the effect of hospital case volume on outcomes after resection of intradural spine tumors, the authors attempted to identify these associations by using a large population-based database.

METHODS

Using the National Inpatient Sample database, the authors performed a retrospective cohort study that involved patients who underwent surgery for an intradural spinal tumor between 2002 and 2011. Using national estimates, they identified associations of patient demographics, medical comorbidities, and hospital characteristics with inpatient postoperative outcomes. In addition, the effect of hospital volume on unfavorable outcomes was investigated. Hospitals that performed fewer than 14 resections in adult patients with an intradural spine tumor between 2002 and 2011 were labeled as low-volume centers, whereas those that performed 14 or more operations in that period were classified as high-volume centers (HVCs). These cutoffs were based on the median number of resections performed by hospitals registered in the National Inpatient Sample during the study period.

RESULTS

Overall, 18,297 patients across 774 hospitals in the United States underwent surgery for an intradural spine tumor. The mean age of the cohort was 56.53 ± 16.28 years, and 63% were female. The inpatient postoperative risks included mortality (0.3%), discharge to rehabilitation (28.8%), prolonged length of stay (> 75th percentile) (20.0%), high-end hospital charges (> 75th percentile) (24.9%), wound complications (1.2%), cardiac complications (0.6%), deep vein thrombosis (1.4%), pulmonary embolism (2.1%), and neurological complications, including durai tears (2.4%). Undergoing surgery at an HVC was significantly associated with a decreased chance of inpatient mortality (OR 0.39; 95% CI 0.16−0.98), unfavorable discharge (OR 0.86; 95% CI 0.76−0.98), prolonged length of stay (OR 0.69; 95% CI 0.62−0.77), high-end hospital charges (OR 0.67; 95% CI 0.60−0.74), neurological complications (OR 0.34; 95% CI 0.26−0.44), deep vein thrombosis (OR 0.65; 95% CI 0.45−0.94), wound complications (OR 0.59; 95% CI 0.41−0.86), and gastrointestinal complications (OR 0.65; 95% CI 0.46−0.92).

CONCLUSIONS

The results of this study provide individualized estimates of the risks of postoperative complications based on patient demographics and comorbidities and hospital characteristics and shows a decreased risk for most unfavorable outcomes for those who underwent surgery at an HVC. These findings could be used as a tool for risk stratification, directing presurgical evaluation, assisting with surgical decision making, and strengthening referral systems for complex cases.

Full access

Sunil Kukreja, Sudheer Ambekar, Anthony Hunkyun Sin and Anil Nanda

Object

Reports of myxopapillary ependymomas (MPEs) of the spinal cord in pediatric patients are scarce. In the literature, various authors have shared their experiences with small groups of patients, which makes it difficult to create a consensus regarding the treatment approach for spinal MPEs in young patients. The aim of this study was to perform a survival analysis of patients in the first 2 decades of life whose cases were selected from the published studies, and to examine the influence of various factors on outcomes.

Methods

A comprehensive search of studies published in English was performed on PubMed. Patients whose age was ≤ 20 years were included for integrative analysis. Information about age, treatment characteristics, critical events (progression, recurrence, and death), time to critical events, and follow-up duration was recorded. The degree of association of the various factors with the survival outcome was calculated by using Kaplan-Meier estimator and Cox proportional hazard model techniques.

Results

A total of 95 patients were included in the analysis. The overall rate of recurrence (RR) was 34.7% (n = 33), with a median time to recurrence of 36 months (range 2–100 months). Progression-free survival (PFS) and overall survival rates at 5 years were 73.7% and 98.9%, respectively. Addition of radiotherapy (RT) following resection significantly improved PFS (log-rank test, p = 0.008). In patients who underwent subtotal resection (STR), administering RT (STR + RT) improved outcome with the lowest failure rates (10.3%), superior to patients who underwent gross-total resection (GTR) alone (RR 43.1%; log-rank test, p < 0.001). Addition of RT to patients who underwent GTR was not beneficial (log-rank test, p = 0.628). In patients who had disseminated tumor at presentation, adjuvant RT controlled the disease effectively. High-dose RT (≥ 50 Gy) did not change PFS (log-rank test, p = 0.710).

Conclusions

Routine inclusion of RT in the treatment protocol for spinal MPEs in young patients should be considered. Complete resection is always the goal of tumor resection. However, when complete resection does not seem to be possible in complex lesions, RT should be used as an adjunct to avoid aggressive resection and to minimize inadvertent injury to the surrounding neural tissues. High-dose RT (≥ 50 Gy) did not provide additional survival benefits, although this association needs to be evaluated by prospective studies.

Full access

Sunil Kukreja, Sudheer Ambekar, Mayur Sharma and Anil Nanda

The authors report the case of a spinal intradural schwannoma presenting with intracranial subarachnoid hemorrhage (SAH). Cerebral angiography did not show any intracranial lesion; however, MRI revealed two separate tumors in the lower segment of the spinal cord. The proximal lesion arising from the conus medullaris was well circumscribed and homogeneously enhanced, whereas the tumor in the cauda equina revealed hemorrhagic signals on MRI. This case also illustrates an unusual presentation of intracranial SAH simultaneously with intratumoral hemorrhage in a spinal cord schwannoma. The absence of hemorrhagic changes in the lesion arising proximal to the cauda equina region supports the mechanical theory proposed for the pathogenesis of hemorrhagic complications in spinal cord tumors.

Free access

Sunil Kukreja, Piyush Kalakoti, Richard Murray, Menarvia Nixon, Symeon Missios, Bharat Guthikonda and Anil Nanda

OBJECT

Incidence of C-2 fracture is increasing in elderly patients. Patient age also influences decision making in the management of these fractures. There are very limited data on the national trends of incidence, treatment interventions, and resource utilization in patients in different age groups with isolated C-2 fractures. The aim of this study is to investigate the incidence, treatment, complications, length of stay, and hospital charges of isolated C-2 fracture in patients in 3 different age groups by using the Nationwide Inpatient Sample (NIS) database. methods The data were obtained from NIS from 2002 to 2011. Data on patients with closed fractures of C-2 without spinal cord injury were extracted using ICD-9-CM diagnosis code 805.02. Patients with isolated C-2 fractures were identified by excluding patients with other associated injuries. The cohort was divided into 3 age groups: < 65 years, 65–80 years, and > 80 years. Incidence, treatment characteristics, inpatient/postoperative complications, and hospital charges (mean and total annual charges) were compared between the 3 age groups.

RESULTS

A total of 10,336 patients with isolated C-2 fractures were identified. The majority of the patients were in the very elderly age group (> 80 years; 42.3%) followed by 29.7% in the 65- to 80-year age group and 28% in < 65-year age group. From 2002 to 2011, the incidence of hospitalization significantly increased in the 65- to 80-year and > 80-year age groups (p < 0.001). However, the incidence did not change substantially in the < 65-year age group (p = 0.287). Overall, 21% of the patients were treated surgically, and 12.2% of the patients underwent nonoperative interventions (halo and spinal traction). The rate of nonoperative interventions significantly decreased over time in all age groups (p < 0.001). Regardless of treatment given, patients in older age groups had a greater risk of inpatient/postoperative complications, nonroutine discharges, and longer hospitalization. The mean hospital charges were significantly higher in older age groups (p < 0.001).

CONCLUSIONS

The incidence of hospitalization for isolated C-2 fractures is progressively increasing in older age groups. Simultaneously, there has been a steadily decreasing trend in the preference for nonoperative interventions. Due to more complicated hospital stay, longer hospitalizations, and higher rates of nonroutine discharges, the patients in older age groups seem to have a higher propensity for greater health care resource utilization.

Full access

Qingsong Fu, Guoxin Fan, Xinbo Wu, Guangfei Gu, Xiaofei Guan, Hailong Zhang, Xin Gu and Shisheng He