Pseudomeningocele is a rare but well-known complication of lumbar spine surgery, which arises in 0.068%–0.1% of individuals in large series of patients undergoing laminectomy and in up to 2% of patients with postlaminectomy symptoms. In symptomatic pseudomeningoceles, surgical reexploration and repair of the dural defect are typically necessary. Whereas the goals of pseudomeningocele repair, which are extirpation of the pseudomeningocele cavity and elimination of extradural dead space, can typically be achieved by primary closure performed using nonabsorbable sutures, giant pseudomeningoceles (> 8 cm) can require more elaborate repair in which fibrin glues, dural substitute, myofascial flaps, or all of the above are used. The authors present 2 cases of postsurgical symptomatic giant pseudomeningoceles that were repaired using a fast-resorbing polymer mesh–supported reconstruction technique, which is described here for the first time.
Carlos M. Alvarez, Timur M. Urakov and Steven Vanni
Timur M. Urakov and Michael Y. Wang
Timur M. Urakov, Ken Hsuan-kan Chang, S. Shelby Burks and Michael Y. Wang
Spine surgery is complex and involves various steps. Current robotic technology is mostly aimed at assisting with pedicle screw insertion. This report evaluates the feasibility of robot-assisted pedicle instrumentation in an academic environment with the involvement of residents and fellows.
The Renaissance Guidance System was used to plan and execute pedicle screw placement in open and percutaneous consecutive cases performed in the period of December 2015 to December 2016. The database was reviewed to assess the usability of the robot by neurosurgical trainees. Outcome measures included time per screw, fluoroscopy time, breached screws, and other complications. Screw placement was assessed in patients with postoperative CT studies. The speed of screw placement and fluoroscopy time were collected at the time of surgery by personnel affiliated with the robot’s manufacturer. Complication and imaging data were reviewed retrospectively.
A total of 306 pedicle screws were inserted in 30 patients with robot guidance. The average time for junior residents was 4.4 min/screw and for senior residents and fellows, 4.02 min/screw (p = 0.61). Among the residents dedicated to spine surgery, the average speed was 3.84 min/screw, while nondedicated residents took 4.5 min/screw (p = 0.41). Evaluation of breached screws revealed some of the pitfalls in using the robot.
No significant difference regarding the speed of pedicle instrumentation was detected between the operators’ years of experience or dedication to spine surgery, although more participants are required to investigate this completely. On the other hand, there was a trend toward improved efficiency with more cases performed. To the authors’ knowledge, this is the first reported academic experience with robot-assisted spine instrumentation.
G. Damian Brusko, John Paul G. Kolcun, Julie A. Heger, Allan D. Levi, Glen R. Manzano, Karthik Madhavan, Timur Urakov, Richard H. Epstein and Michael Y. Wang
Lumbar fusion is typically associated with high degrees of pain and immobility. The implementation of an enhanced recovery after surgery (ERAS) approach has been successful in speeding the recovery after other surgical procedures. In this paper, the authors examined the results of early implementation of ERAS for lumbar fusion.
Beginning in March 2018 at the authors’ institution, all patients undergoing posterior, 1- to 3-level lumbar fusion surgery by any of 3 spine surgeons received an intraoperative injection of liposomal bupivacaine, immediate single postoperative infusion of 1-g intravenous acetaminophen, and daily postoperative visits from the authors’ multidisciplinary ERAS care team. Non–English- or non–Spanish-speaking patients and those undergoing nonelective or staged procedures were excluded. Reviews of medical records were conducted for the ERAS cohort of 57 patients and a comparison group of 40 patients who underwent the same procedures during the 6 months before implementation.
Groups did not differ significantly with regard to sex, age, or BMI (all p > 0.05). Length of stay was significantly shorter in the ERAS cohort than in the control cohort (2.9 days vs 3.8 days; p = 0.01). Patients in the ERAS group consumed significantly less oxycodone-acetaminophen than the controls on postoperative day (POD) 0 (408.0 mg vs 1094.7 mg; p = 0.0004), POD 1 (1320.0 mg vs 1708.4 mg; p = 0.04), and POD 3 (1500.1 mg vs 2105.4 mg; p = 0.03). Postoperative pain scores recorded by the physical therapy and occupational therapy teams and nursing staff each day were lower in the ERAS cohort than in controls, with POD 1 achieving significance (4.2 vs 6.0; p = 0.006). The total amount of meperidine (8.8 mg vs 44.7 mg; p = 0.003) consumed was also significantly decreased in the ERAS group, as was ondansetron (2.8 mg vs 6.0 mg; p = 0.02). Distance ambulated on each POD was farther in the ERAS cohort, with ambulation on POD 1 (109.4 ft vs 41.4 ft; p = 0.002) achieving significance.
In this very initial implementation of the first phase of an ERAS program for short-segment lumbar fusion, the authors were able to demonstrate substantial positive effects on the early recovery process. Importantly, these effects were not surgeon-specific and could be generalized across surgeons with disparate technical predilections. The authors plan additional iterations to their ERAS protocols for continued quality improvements.