Search Results

You are looking at 1 - 5 of 5 items for

  • Author or Editor: Vaidya Govindarajan x
  • Refine by Access: all x
Clear All Modify Search
Free access

Vaidya Govindarajan, Jean-Paul Bryant, Roberto J. Perez-Roman, and Michael Y. Wang

OBJECTIVE

Cervical fractures in patients with ankylosing spondylitis can have devastating neurological consequences. Currently, several surgical approaches are commonly used to treat these fractures: anterior, posterior, and anterior-posterior. The relative rarity of these fractures has limited the ability of surgeons to objectively determine the merits of each. The authors present an updated systematic review and meta-analysis investigating the utility of anterior surgical approaches relative to posterior and anterior-posterior approaches.

METHODS

After a comprehensive literature search of the PubMed, Cochrane, and Embase databases, 7 clinical studies were included in the final qualitative and 6 in the final quantitative analyses. Of these studies, 6 compared anterior approaches with anterior-posterior and posterior approaches, while 1 investigated only an anterior approach. Odds ratios and 95% confidence intervals were calculated where appropriate.

RESULTS

A meta-analysis of postoperative neurological improvement revealed no statistically significant differences in gross rates of neurological improvement between anterior and posterior approaches (OR 0.40, 95% CI 0.10–1.59; p = 0.19). However, when analyzing the mean change in neurological function, patients who underwent anterior approaches had a significantly lower mean change in postoperative neurological function relative to patients who underwent posterior approaches (mean difference [MD] −0.60, 95% CI −0.76 to −0.45; p < 0.00001). An identical trend was seen between anterior and anterior-posterior approaches; there were no statistically significant differences in gross rates of neurological improvement (OR 3.05, 95% CI 0.84–11.15; p = 0.09). However, patients who underwent anterior approaches experienced a lower mean change in neurological function relative to anterior-posterior approaches (MD −0.46, 95% CI −0.60 to −0.32; p < 0.00001). There were no significant differences in complication rates between anterior approaches, posterior approaches, or anterior-posterior approaches, although complication rates trended lower in patients who underwent anterior approaches.

CONCLUSIONS

The results of this review and meta-analysis demonstrated the varying benefits of anterior approaches relative to posterior and anterior-posterior approaches in treatment of cervical fractures associated with ankylosing spondylitis. While reports demonstrated lower degrees of neurological improvement in anterior approaches, they may benefit patients with less-severe injuries if lower complication rates are desired.

Free access

Roberto J. Perez-Roman, Vaidya Govindarajan, Jean-Paul Bryant, and Michael Y. Wang

OBJECTIVE

Awake surgery has previously been found to improve patient outcomes postoperatively in a variety of procedures. Recently, multiple groups have investigated the utility of this modality for use in spine surgery. However, few current meta-analyses exist comparing patient outcomes in awake spinal anesthesia with those in general anesthesia. Therefore, the authors sought to present an updated systematic review and meta-analysis investigating the utility of spinal anesthesia relative to general anesthesia in lumbar procedures.

METHODS

Following a comprehensive literature search of the PubMed and Cochrane databases, 14 clinical studies were included in our final qualitative and quantitative analyses. Of these studies, 5 investigated spinal anesthesia in lumbar discectomy, 4 discussed lumbar laminectomy, and 2 examined interbody fusion procedures. One study investigated combined lumbar decompression and fusion or decompression alone. Two studies investigated patients who underwent discectomy and laminectomy, and 1 study investigated a series of patients who underwent transforaminal lumbar interbody fusion, posterolateral fusion, or decompression. Odds ratios, mean differences (MDs), and 95% confidence intervals were calculated where appropriate.

RESULTS

A meta-analysis of the total anesthesia time showed that time was significantly less in patients who received spinal anesthesia for both lumbar discectomies (MD −26.53, 95% CI −38.16 to −14.89; p = 0.00001) and lumbar laminectomies (MD −11.21, 95% CI −19.66 to −2.75; p = 0.009). Additionally, the operative time was significantly shorter in patients who underwent spinal anesthesia (MD −14.94, 95% CI −20.43 to −9.45; p < 0.00001). Similarly, when analyzing overall postoperative complication rates, patients who received spinal anesthesia were significantly less likely to experience postoperative complications (OR 0.29, 95% CI 0.16–0.53; p < 0.0001). Furthermore, patients who received spinal anesthesia had significantly lower postoperative pain scores (MD −2.80, 95% CI −4.55 to −1.06; p = 0.002). An identical trend was seen when patients were stratified by lumbar procedures. Patients who received spinal anesthesia were significantly less likely to require postoperative analgesia (OR 0.06, 95% CI 0.02–0.25; p < 0.0001) and had a significantly shorter hospital length of stay (MD −0.16, 95% CI −0.29 to −0.03; p = 0.02) and intraoperative blood loss (MD −52.36, 95% CI −81.55 to −23.17; p = 0.0004). Finally, the analysis showed that spinal anesthesia cost significantly less than general anesthesia (MD −226.14, 95% CI −324.73 to −127.55; p < 0.00001).

CONCLUSIONS

This review has demonstrated the varying benefits of spinal anesthesia in awake spine surgery relative to general anesthesia in patients who underwent various lumbar procedures. The analysis has shown that spinal anesthesia may offer some benefits when compared with general anesthesia, including reduction in the duration of anesthesia, operative time, total cost, and postoperative complications. Large prospective trials will elucidate the true role of this modality in spine surgery.

Free access

Joshua D. Burks, Turki Elarjani, Aria M. Jamshidi, Vaidya Govindarajan, and Allan D. Levi

OBJECTIVE

Vertebral compression fractures are common in multiple myeloma (MM). Modern treatment paradigms place emphasis on treatment with radiation, with surgery reserved for cases involving frank instability or severe neural compression. However, experience at the authors’ institution has led them to suspect a more prominent role for surgical intervention in some settings. The authors undertook the present study to better understand the incidence of MM in undiagnosed patients who require urgent surgery for pathological vertebral fracture.

METHODS

The authors reviewed a prospectively collected database of all patients who underwent surgery with the senior author at their main hospital between June 1, 1998, and June 30, 2020. Patients admitted from the emergency room or after transfer from another hospital who then underwent surgery for pathological fracture during the same admission were included in the final analysis. Patients scheduled for elective surgery and those with previous cancer diagnoses were excluded.

RESULTS

Forty-three patients were identified as having undergone urgent surgical decompression and/or stabilization for pathological fracture. Histopathology confirmed diagnosis of MM in 22 (51%) patients, lung metastasis in 5 (12%) patients, and breast metastasis in 4 (9%) patients. Twelve (28%) patients were diagnosed with other types of metastatic carcinoma or undifferentiated disease. Sixteen of 29 (55%) men and 6 of 14 (42%) women were diagnosed with MM (p = 0.02). Seventeen of 34 (50%) patients who underwent surgery for neurological deficit, 5 of 6 (83%) patients who underwent surgery for spinal instability, and 0 (0%) patients who underwent surgery for pain with impending spinal cord injury were diagnosed with MM (p = 0.12).

CONCLUSIONS

A majority of patients presenting to the authors’ hospital with no history of malignancy who required urgent surgery for pathological compression fracture were found to have MM or plasmacytoma. This disease process may affect a significant portion of patients requiring decompressive or stabilizing surgery for compression fracture in academic medical centers.

Free access

Vaidya Govindarajan, Anthony Diaz, Roberto J. Perez-Roman, S. Shelby Burks, Michael Y. Wang, and Allan D. Levi

OBJECTIVE

Bisphosphonates and teriparatide are the most common therapies used in the treatment of osteoporosis. Their impact on fusion rates in osteoporotic patients following spinal fusion has yet to be concretely defined, with previous systematic reviews focusing heavily on bisphosphonates and lacking clinical insight on the utility of teriparatide. Herein the authors present an updated meta-analysis of the utility of both bisphosphonates and teriparatide in improving spinal fusion outcomes in osteoporotic patients.

METHODS

After a comprehensive search of the English-language literature in the PubMed and Embase databases, 11 clinical studies were included in the final qualitative and quantitative analyses. Of these studies, 9 investigated bisphosphonates, 7 investigated teriparatide, and 1 investigated a combination of teriparatide and denosumab. Odds ratios and 95% confidence intervals were calculated where appropriate.

RESULTS

A meta-analysis of the postoperative use of bisphosphonate demonstrated better odds of successful fusion as compared to that in controls during short-term monitoring (OR 3.33, 95% CI 1.72–6.42, p = 0.0003) but not long-term monitoring (p > 0.05). Bisphosphonate use was also shown to significantly reduce the likelihood of postoperative vertebral compression fracture (VCF; OR 0.07, 95% CI 0.01–0.59, p = 0.01) and significantly reduce Oswestry Disability Index scores (mean difference [MD] = −2.19, 95% CI −2.94 to −1.44, p < 0.00001) and visual analog scale pain scores (MD = −0.58, 95% CI −0.79 to −0.38, p < 0.00001). Teriparatide was found to significantly increase fusion rates at long-term postoperative periods as compared to rates after bisphosphonate therapy, with patients who received postoperative teriparatide therapy 2.05 times more likely to experience successful fusion (OR 2.05, 95% CI 1.17–3.59, p = 0.01).

CONCLUSIONS

The authors demonstrate the benefits of bisphosphonate and teriparatide therapy independently in accelerating fusion during the first 6 months after spinal fusion surgery in osteoporotic patients. In addition, they show that teriparatide may have superior benefits in spinal fusion during long-term monitoring as compared to those with bisphosphonates. Bisphosphonates may be better suited in preventing VCFs postoperatively in addition to minimizing postoperative disability and pain.

Restricted access

Jacob K. Greenberg, Stephen Shelby Burks, Christopher F. Dibble, Saad Javeed, Vivek P. Gupta, Alexander T. Yahanda, Roberto J. Perez-Roman, Vaidya Govindarajan, Andrew T. Dailey, Sanjay Dhall, Daniel J. Hoh, Daniel E. Gelb, Adam S. Kanter, Eric O. Klineberg, Michael J. Lee, Praveen V. Mummaneni, Paul Park, Charles A. Sansur, Khoi D. Than, Jon J. W. Yoon, Michael Y. Wang, and Wilson Z. Ray

OBJECTIVE

Minimally invasive surgery (MIS) techniques can effectively stabilize and decompress many thoracolumbar injuries with decreased morbidity and tissue destruction compared with open approaches. Nonetheless, there is limited direction regarding the breadth and limitations of MIS techniques for thoracolumbar injuries. Consequently, the objectives of this study were to 1) identify the range of current practice patterns for thoracolumbar trauma and 2) integrate expert opinion and literature review to develop an updated treatment algorithm.

METHODS

A survey describing 10 clinical cases with a range of thoracolumbar injuries was sent to 12 surgeons with expertise in spine trauma. The survey results were summarized using descriptive statistics, along with the Fleiss kappa statistic of interrater agreement. To develop an updated treatment algorithm, the authors used a modified Delphi technique that incorporated a literature review, the survey results, and iterative feedback from a group of 14 spine trauma experts. The final algorithm represented the consensus opinion of that expert group.

RESULTS

Eleven of 12 surgeons contacted completed the case survey, including 8 (73%) neurosurgeons and 3 (27%) orthopedic surgeons. For the 4 cases involving patients with neurological deficits, nearly all respondents recommended decompression and fusion, and the proportion recommending open surgery ranged from 55% to 100% by case. Recommendations for the remaining cases were heterogeneous. Among the neurologically intact patients, MIS techniques were typically recommended more often than open techniques. The overall interrater agreement in recommendations was 0.23, indicating fair agreement. Considering both literature review and expert opinion, the updated algorithm indicated that MIS techniques could be used to treat most thoracolumbar injuries. Among neurologically intact patients, percutaneous instrumentation without arthrodesis was recommended for those with AO Spine Thoracolumbar Classification System subtype A3/A4 (Thoracolumbar Injury Classification and Severity Score [TLICS] 4) injuries, but MIS posterior arthrodesis was recommended for most patients with AO Spine subtype B2/B3 (TLICS > 4) injuries. Depending on vertebral body integrity, anterolateral corpectomy or mini-open decompression could be used for patients with neurological deficits.

CONCLUSIONS

Spine trauma experts endorsed a range of strategies for treating thoracolumbar injuries but felt that MIS techniques were an option for most patients. The updated treatment algorithm may provide a foundation for surgeons interested in safe approaches for using MIS techniques to treat thoracolumbar trauma.