Cervical dystonia is a psychologically and physically disabling disease that has intrigued clinicians since the early history of surgery. Because of its elusive etiology, its operative treatment has had an extended evolutionary voyage. Early surgical approaches involved resection of the sternocleidomastoid muscle. Later recognition of more diffuse involvement of the posterior neck muscles led to the introduction of new techniques with more effective results. A review of available surgical patient records at The Johns Hopkins Hospital from around the turn of the 20th century provided a glimpse of the early history of the operative treatment for torticollis through the work of some of the leaders of surgery, including Halsted, Cushing, and specifically Finney. Here, the authors present a segment of history on the surgical treatment of this disease as it relates to the introduction of myotomy and denervation techniques.
Todd D. Vogel, Courtney Pendleton, Alfredo Quinoñes-Hinojosa, and Aaron A. Cohen-Gadol
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.
Daniel H. Fulkerson, Todd D. Vogel, Abdul A. Baker, Neal B. Patel, Laurie L. Ackerman, Jodi L. Smith, and Joel C. Boaz
The optimal treatment of symptomatic posterior fossa arachnoid cysts is controversial. Current options include open or endoscopic resection, fenestration, or cyst-peritoneal shunt placement. There are potential drawbacks with all options. Previous authors have described stenting a cyst into the ventricular system for supratentorial lesions. The current authors have used a similar strategy for posterior fossa cysts.
The authors performed a retrospective review of 79 consecutive patients (1993–2010) with surgically treated intracranial arachnoid cysts.
The authors identified 3 patients who underwent placement of a stent from a posterior fossa arachnoid cyst to a supratentorial ventricle. In 2 patients the stent construct consisted of a catheter placed into a posterior fossa arachnoid cyst and connecting to a lateral ventricle catheter. Both patients underwent stent placement as a salvage procedure after failure of open surgical fenestration. In the third patient a single-catheter cyst-ventricle stent was stereotactically placed. All 3 patients improved clinically. Two patients remained asymptomatic, with radiographic stability in a follow-up period of 1 and 5 years, respectively. The third patient experienced initial symptom resolution with a demonstrable reduction of intracystic pressure. However, he developed recurrent headaches after 2 years.
Posterior fossa cyst–ventricle stenting offers the benefits of ease of surgical technique and a low morbidity rate. It may also potentially reduce the incidence of shunt-related headaches by equalizing the pressure between the posterior fossa and the supratentorial compartments. While fenestration is considered the first-line therapy for most symptomatic arachnoid cysts, the authors consider cyst-ventricle stenting to be a valuable additional strategy in treating these rare and often difficult lesions.
Todd D. Vogel, Charles G. Kulwin, Andrew J. DeNardo, Troy D. Payner, Joel C. Boaz, and Daniel H. Fulkerson
Aneurysms in children are rare and potentially devastating lesions. The authors report the case of a 16-year-old girl with a complicated medical history related to a chiasmal glioma diagnosed at 18 months of age. She had previously received multiple modalities of radiation treatment, including external beam, proton therapy, and Gamma Knife. She presented with hemorrhage centered in the tumor and extending into the ventricular space. There was no subarachnoid blood. Magnetic resonance imaging demonstrated the hemorrhage and tumor anatomy. Magnetic resonance angiography revealed an aneurysm at the internal carotid artery bifurcation, but the lesion was more clearly delineated on CT angiography. A comparison MR imaging study obtained 6 months earlier, even in retrospect, did not show evidence of an aneurysm. This case illustrates the salient point that the clinician must search for vascular lesions in the patient with spontaneous “tumor bleeding,” especially if that patient has risk factors for aneurysm formation. The authors also suggest that a CT angiogram is better at radiographically demonstrating an intratumoral aneurysm than an MR angiogram in this scenario.
Andrew K. Chan, Arnau Benet, Junichi Ohya, Xin Zhang, Todd D. Vogel, Daniel W. Flis, Ivan H. El-Sayed, and Praveen V. Mummaneni
The microscopic transoral, endoscopic transnasal, and endoscopic transoral approaches are used alone and in combination for a variety of craniovertebral junction (CVJ) pathologies. The endoscopic transoral approach provides a more direct exposure that is not restricted by the nasal cavity, pterygoid plates, and palate while sparing the potential morbidities associated with extensive soft-tissue dissection, palatal splitting, or mandibulotomy. Concerns regarding the extent of visualization afforded by the endoscopic transoral approach may be limiting its widespread adoption.
A dissection of 10 cadaver heads was undertaken. CT-based imaging guidance was used to measure the working corridor of the endoscopic transoral approach. Measurements were made relative to the palatal line. The built-in linear measurement tool was used to measure the superior and inferior extents of view. The superolateral extent was measured relative to the midline, as defined by the nasal process of the maxilla. The height of the clivus, odontoid tip, and superior aspect of the C-1 arch were also measured relative to the palatal line. A correlated clinical case is presented with video.
The CVJ was accessible in all cases. The superior extent of the approach was a mean 19.08 mm above the palatal line (range 11.1–27.7 mm). The superolateral extent relative to the midline was 15.45 mm on the right side (range 9.6–23.7 mm) and 16.70 mm on the left side (range 8.1–26.7 mm). The inferior extent was a mean 34.58 mm below the palatal line (range 22.2–41.6 mm). The mean distances were as follows: palatal line relative to the odontoid tip, 0.97 mm (range −4.9 to 3.7 mm); palatal line relative to the height of the clivus, 4.88 mm (range −1.5 to 7.3 mm); and palatal line relative to the C-1 arch, −2.75 mm (range −5.8 to 0 mm).
The endoscopic transoral approach can reliably access the CVJ. This approach avoids the dissections and morbidities associated with a palate-splitting technique (velopharyngeal insufficiency) and the expanded endonasal approach (mucus crusting, sinusitis, and potential lacerum or cavernous-paraclival internal carotid artery injury). For appropriately selected lesions near the palatal line, the endoscopic transoral approach appears to be the preferred approach.
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.
Rishi K. Wadhwa, Junichi Ohya, Todd D. Vogel, Leah Y. Carreon, Anthony L. Asher, John J. Knightly, Christopher I. Shaffrey, Steven D. Glassman, and Praveen V. Mummaneni
The aim of this paper was to use a prospective, longitudinal, multicenter outcome registry of patients undergoing surgery for lumbar degenerative disease in order to assess the incidence and factors associated with 30-day reoperation and 90-day readmission.
Prospectively collected data from 9853 patients from the Quality and Outcomes Database (QOD; formerly known as the N2QOD [National Neurosurgery Quality and Outcomes Database]) lumbar spine registry were retrospectively analyzed. Multivariate binomial regression analysis was performed to identify factors associated with 30-day reoperation and 90-day readmission after surgery for lumbar degenerative disease. A subgroup analysis of Medicare patients stratified by age (< 65 and ≥ 65 years old) was also performed. Continuous variables were compared using unpaired t-tests, and proportions were compared using Fisher’s exact test.
There was a 2% reoperation rate within 30 days. Multivariate analysis revealed prolonged operative time during the index case as the only independent factor associated with 30-day reoperation. Other factors such as preoperative diagnosis, body mass index (BMI), American Society of Anesthesiologists (ASA) class, diabetes, and use of spinal implants were not associated with reoperations within 30 days. Medicare patients < 65 years had a 30-day reoperation rate of 3.7%, whereas those ≥ 65 years had a 30-day reoperation rate of 2.2% (p = 0.026). Medicare beneficiaries younger than 65 years undergoing reoperation within 30 days were more likely to be women (p = 0.009), have a higher BMI (p = 0.008), and have higher rates of depression (p < 0.0001). The 90-day readmission rate was 6.3%. Multivariate analysis demonstrated that higher ASA class (OR 1.46 per class, 95% CI 1.25–1.70) and history of depression (OR 1.27, 95% CI 1.04–1.54) were factors associated with 90-day readmission. Medicare beneficiaries had a higher rate of 90-day readmissions compared with those who had private insurance (OR 1.43, 95% CI 1.17–1.76). Medicare patients < 65 years of age were more likely to be readmitted within 90 days after their index surgery compared with those ≥ 65 years (10.8% vs 7.7%, p = 0.017). Medicare patients < 65 years of age had a significantly higher BMI (p = 0.001) and higher rates of depression (p < 0.0001).
In this analysis of a large prospective, multicenter registry of patients undergoing lumbar degenerative surgery, multivariate analysis revealed that prolonged operative time was associated with 30-day reoperation. The authors found that factors associated with 90-day readmission included higher ASA class and a history of depression. The 90-day readmission rates were higher for Medicare beneficiaries than for those who had private insurance. Medicare patients < 65 years of age were more likely to undergo reoperation within 30 days and to be readmitted within 90 days after their index surgery.
Khoi D. Than, Praveen V. Mummaneni, Kelly J. Bridges, Stacie Tran, Paul Park, Dean Chou, Frank La Marca, Juan S. Uribe, Todd D. Vogel, Pierce D. Nunley, Robert K. Eastlack, Neel Anand, David O. Okonkwo, Adam S. Kanter, and Gregory M. Mundis Jr.
High-quality studies that compare outcomes of open and minimally invasively placed pedicle screws for adult spinal deformity are needed. Therefore, the authors compared differences in complications from a circumferential minimally invasive spine (MIS) surgery and those from a hybrid surgery.
A retrospective review of a multicenter database of patients with spinal deformity who were treated with an MIS surgery was performed. Database inclusion criteria included an age of ≥ 18 years and at least 1 of the following: a coronal Cobb angle of > 20°, a sagittal vertical axis of > 5 cm, a pelvic incidence–lumbar lordosis angle of > 10°, and/or a pelvic tilt of > 20°. Patients were propensity matched according to the levels instrumented.
In this database, a complete data set was available for 165 patients, and after those who underwent 3-column osteotomy were excluded, 137 patients were available for analysis; 76 patients remained after propensity matching (MIS surgery group 38 patients, hybrid surgery group 38 patients). The authors found no difference in demographics, number of levels instrumented, or preoperative and postoperative radiographic results. At least 1 complication was suffered by 55.3% of patients in the hybrid surgery group and 44.7% of those in the MIS surgery group (p = 0.359). Patients in the MIS surgery group had significantly fewer neurological, operative, and minor complications than those in the hybrid surgery group. The reoperation rates in both groups were similar. The most common complication category for the MIS surgery group was radiographic and for the hybrid surgery group was neurological. Patients in both groups experienced postoperative improvement in their Oswestry Disability Index and visual analog scale (VAS) back and leg pain scores (all p < 0.05); however, MIS surgery provided a greater reduction in leg pain according to VAS scores.
Overall complication rates in the MIS and hybrid surgery groups were similar. MIS surgery resulted in significantly fewer neurological, operative, and minor complications. Reoperation rates in the 2 groups were similar, and despite complications, the patients reported significant improvement in their pain and function.