Osteoblastomas are primary bone tumors with an affinity for the spine. They typically involve the posterior elements, although extension through the pedicles into the vertebral body is not uncommon. Histologically, they are usually indistinguishable from osteoid osteomas. However, there are different variants of osteoblastomas, with the more aggressive type causing more pronounced bone destruction, soft-tissue infiltration, and epidural extension. A bone scan is the most sensitive radiographic examination used to evaluate osteoblastomas. These osseous neoplasms usually present in the 2nd decade of life with dull aching pain, which is difficult to localize. At times, they can present with a painful scoliosis, which usually resolves if the osteoblastoma is resected in a timely fashion. Neurological manifestations such as radiculopathy or myelopathy do occur as well, most commonly when there is mass effect on nerve roots or the spinal cord itself. The mainstay of treatment involves surgical intervention. Curettage has been a surgical option, although marginal excision or wide en bloc resection are preferred options. Adjuvant radiotherapy and chemotherapy are generally not undertaken, although some have advocated their use after less aggressive surgical maneuvers or with residual tumor. In this manuscript, the authors have aimed to systematically review the literature and to put forth an extensive, comprehensive overview of this rare osseous tumor.
Michael A. Galgano, Carlos R. Goulart, Hans Iwenofu, Lawrence S. Chin, William Lavelle, and Ehud Mendel
William F. Lavelle, Nathaniel R. Ordway, Ali Araghi, Rudolph A. Buckley, and Amir H. Fayyazi
This purpose of this study was to objectively evaluate and assess the efficacy and efficiency of discectomy and endplate preparation during transforaminal lumbar interbody fusion (TLIF) using traditional manual instrumentation versus a novel suction discectomy curette. Transforaminal lumbar interbody fusion is the most widely used approach for lumbar arthrodesis, and its success depends on the ability to achieve fusion. Complete preparation of intervertebral disc space (removal of the nucleus, endplate cartilage, and margin of inner annulus) is the surgical goal. Performing an adequate discectomy requires numerous instrument passes, increasing surgical time and the risk of complications.
Four experienced spinal surgeons performed transforaminal discectomies from T-12 to S-1 on 5 whole-body cadavers. Each level (n = 26) was randomly assigned to either a control group using traditional instruments (12 levels) or to a suction curette group (14 levels). The time required to perform the discectomy and the number of passes through the annulus were recorded. Motion segments were dissected and analyzed by digital photogrammetric analysis. The intervertebral disc and the discectomy cross-sectional areas were measured on both superior and inferior images of each dissected surgical level. Areas were divided into 4 quadrants based on a midsagittal and midcoronal axis and analyzed for regional efficiency. In addition, a cross-sectional area of bony endplate (the area still covered with cartilage) and an area of endplate perforation were evaluated.
There was no significant difference in surgical time between the techniques (7:51 ± 2:43 minutes in the manual discectomy [MD] group and 7:06 ± 3:33 minutes in the suction curette discectomy [SD] group). There were significantly fewer (p < 0.01) instrument passes in the SD group (13 passes) compared with the MD group (43 passes). For both techniques, the amount of disc removed depended upon the anatomical region, with the posterior-contralateral side having the least amount of disc material removed. There was significantly less (p < 0.01) disc material removed in the MD group (38%) compared with the SD group (48%). The amount of disc material removed was significantly more (p < 0.05) in each quadrant when comparing the SD and MD groups, with the anterior regions showing the largest difference. For both techniques, the preparation of the endplate within the discectomy area resulted in a mostly cartilaginous interface (50% MD, 48% SD); a smaller amount of bony interface area (31% MD, 38% SD); and a smaller amount of perforation to the interface area (19% MD, 13% SD). There were no significant differences between the groups in terms of endplate preparation.
The improved discectomy observed with the suction curette device could potentially improve the clinical fusion rate.
Ron I. Riesenburger, Tejaswy Potluri, Nikhil Kulkarni, William Lavelle, Marie Roguski, Vijay K. Goel, and Edward C. Benzel
Both ventral and dorsal operative approaches have been used to treat unilateral cervical facet injuries. The gold standard ventral approach is anterior cervical discectomy and fusion. There is, however, no clear gold standard dorsal operation. In this study, the authors tested the stability of multiple posterior constructs, including unilateral lateral mass fixation supplemented by an interspinous cable.
Six fresh human cervical spine specimens (C3–T1) were tested by applying pure moments to the C-3 vertebral body in increments of 0.5 Nm from 0 Nm to 2.0 Nm. Each specimen was tested in the following 8 conditions (in the order shown): 1) intact; 2) after destabilization via injury to the C5–6 facet; 3) with bilateral C5–6 lateral mass screws and rods; 4) after further destabilization by creating a right unilateral lateral mass fracture of C-5 (which rendered secure screw placement into the right C-5 lateral mass impossible); 5) with unilateral left C5–6 lateral mass screws and rod; 6) with unilateral C5–6 lateral mass screws and rod supplemented with an interspinous cable; 7) with a bilateral multilevel dorsal construct C4–6; and 8) after a C5–6 anterior cervical discectomy and fusion (ACDF) procedure with a polyetheretherketone graft and plate.
The bilateral C5–6 lateral mass construct reduced the range of C5–6 motion to 33.6% of normal. The unilateral C5–6 lateral mass construct resulted in an increased range of motion to 110.1% of normal. The unilateral lateral mass construct supplemented by an interspinous cable reduced the C5–6 range of motion to 89.4% of normal. The bilateral C4–6 lateral mass construct reduced the C5–6 range of motion to 44.2% of normal. The C5–6 ACDF construct reduced the C5–6 range of motion to 62.6% of normal.
The unilateral lateral mass construct supplemented by an interspinous cable does reduce range of motion compared with an intact specimen, but is significantly inferior to a C4–6 bilateral lateral mass construct. When using a dorsal approach, the unilateral construct with a cable should only be considered in selected instances.
Matthew A. Howard III, Matthew B. Dobbs, Tereasa M. Simonson, William E. LaVelle, and Mark A. Granner
✓ As computer-interactive technologies become more widely used in neurosurgery, radiology, and radiation therapy, the need for an optimum skull fiducial marker system increases. In the past, intracranial localization methods required precisely machined metal frames and rigid pin fixation to the skull. Recently, this function has been performed using “frameless” computer-based systems that calculate brain position relative to a series of external reference points, the most accurate of which are screwed directly into the skull. A penetrating fiducial marker system, however, is not well suited for applications requiring multiple volume registrations over an extended time period. We describe a new skull fiducial marker system that attaches to the maxillary teeth and can be used repeatedly on different occasions. A curved bar, known as a Banana Bar (BB) extends backward from a custom mouthpiece around the side of the patient's head; the bar contains sites of attachment for screw-in radiographic fiducial markers. Repositioning accuracy was quantitated using a photographic technique. A BB prototype was constructed and tested in three subjects. The BB weighs less than 100 g and can be comfortably held in position for up to 30 minutes. It takes less than 1 minute to screw in the mouthpiece and only seconds to secure the BB to the teeth. One hundred twenty photographic measurements were analyzed from 60 repositionings over a minimum 3-week period. Standard deviations for the measurement series ranged from 0.29 to 0.86 mm. Results suggest that the BB may be an inexpensive, efficient, and accurate method for providing the external reference points needed for a wide range of emerging computer-interactive applications.
Robert E. Harbaugh, Clinton Devin, Michelle B. Leavy, Zoher Ghogawala, Kristin R. Archer, Mohamad Bydon, Christine Goertz, Doron Dinstein, David R. Nerenz, Guy S. Eakin, William Lavelle, William O. Shaffer, Paul M. Arnold, Charles H. Washabaugh, and Richard E. Gliklich
The development of new treatment approaches for degenerative lumbar spondylolisthesis (DLS) has introduced many questions about comparative effectiveness and long-term outcomes. Patient registries collect robust, longitudinal data that could be combined or aggregated to form a national and potentially international research data infrastructure to address these and other research questions. However, linking data across registries is challenging because registries typically define and capture different outcome measures. Variation in outcome measures occurs in clinical practice and other types of research studies as well, limiting the utility of existing data sources for addressing new research questions. The purpose of this project was to develop a minimum set of patient- and clinician-relevant standardized outcome measures that are feasible for collection in DLS registries and clinical practice.
Nineteen DLS registries, observational studies, and quality improvement efforts were invited to participate and submit outcome measures. A stakeholder panel was organized that included representatives from medical specialty societies, health systems, government agencies, payers, industries, health information technology organizations, and patient advocacy groups. The panel categorized the measures using the Agency for Healthcare Research and Quality’s Outcome Measures Framework (OMF), identified a minimum set of outcome measures, and developed standardized definitions through a consensus-based process.
The panel identified and harmonized 57 outcome measures into a minimum set of 10 core outcome measure areas and 6 supplemental outcome measure areas. The measures are organized into the OMF categories of survival, clinical response, events of interest, patient-reported outcomes, and resource utilization.
This effort identified a minimum set of standardized measures that are relevant to patients and clinicians and appropriate for use in DLS registries, other research efforts, and clinical practice. Collection of these measures across registries and clinical practice is an important step for building research data infrastructure, creating learning healthcare systems, and improving patient management and outcomes in DLS.
The relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery: a multicenter retrospective study
Presented at the 2018 AANS/CNS Joint Section on Disorders of the Spine and Peripheral Nerves
Daniel B. Herrick, Joseph E. Tanenbaum, Marc Mankarious, Sagar Vallabh, Eitan Fleischman, Swamy Kurra, Shane M. Burke, Marie Roguski, Thomas E. Mroz, William F. Lavelle, Jeffrey E. Florman, and Ron I. Riesenburger
Use of surgical site drains following posterior cervical spine surgery is variable, and its impact on outcomes remains controversial. Studies of drain use in the lumbar spine have suggested that drains are not associated with reduction of reoperations for wound infection or hematoma. There is a paucity of studies examining this relationship in the cervical spine, where hematomas and infections can have severe consequences. This study aims to examine the relationship between surgical site drains and reoperation for wound-related complications following posterior cervical spine surgery.
This study is a multicenter retrospective review of 1799 consecutive patients who underwent posterior cervical decompression with instrumentation at 4 tertiary care centers between 2004 and 2016. Demographic and perioperative data were analyzed for associations with drain placement and return to the operating room.
Of 1799 patients, 1180 (65.6%) had a drain placed. Multivariate logistic regression analysis identified history of diabetes (OR 1.37, p = 0.03) and total number of levels operated (OR 1.32, p < 0.001) as independent predictors of drain placement. Rates of reoperation for any surgical site complication were not different between the drain and no-drain groups (4.07% vs 3.88%, p = 0.85). Similarly, rates of reoperation for surgical site infection (1.61% vs 2.58%, p = 0.16) and hematoma (0.68% vs 0.48%, p = 0.62) were not different between the drain and no-drain groups. However, after adjusting for history of diabetes and the number of operative levels, patients with drains had significantly lower odds of returning to the operating room for surgical site infection (OR 0.48, p = 0.04) but not for hematoma (OR 1.22, p = 0.77).
This large study characterizes current practice patterns in the utilization of surgical site drains during posterior cervical decompression and instrumentation. Patients with drains placed did not have lower odds of returning to the operating room for postoperative hematoma. However, the authors’ data suggest that patients with drains may be less likely to return to the operating room for surgical site infection, although the absolute number of infections in the entire population was small, limiting the analysis.