bluuebunny/crossref_metadata_2025 huggingface dataset:
Metastatic Spine Tumor Surgery
Authors: Kumar Naresh , Malhotra Rishi , Maharajan Karthikeyan , Zaw Aye S. , Wu Pang Hung , Makandura Milindu C. , Po Liu Gabriel Ka , Thambiah Joseph , Wong Hee-Kit
Published: March 2018

Study Design:

Prospective cohort study.

Summary of Background Data:

Minimally invasive spinal surgery (MISS) has been gaining recognition in patients with metastatic spine disease (MSD). The advantages are reduction in blood loss, hospital stay, and postoperative morbidity. Most of the studies were case series with very few comparing the outcomes of MISS to open approaches.

Objective:

To evaluate and compare the clinical and perioperative outcomes of MISS versus open approach in patients with symptomatic MSD, who underwent posterior spinal stabilization and/or decompression.

Patients and Methods:

Our study included 45 MSD patients; 27 managed by MISS and 18 by open approach. All patients had MSD presenting with symptoms of neurological deficit, spinal instability, or both. Preoperative, intraoperative, and postoperative data were collected for comparison of the 2 approaches. All patients were followed up until the end of study period (maximum up to 4 years from time of surgery) or till their demise. The clinical outcome measures were pain control, neurological and functional status, whereas perioperative outcomes were blood loss, operative time, length of hospital stay, and time taken to initiate radiotherapy/chemotherapy after index surgery.

Results:

Majority of patients in both groups showed improvement in pain, neurological status, independent ambulation, and ECOG score in the postoperative period with no significant differences between the 2 groups. There was a significant reduction in intraoperative blood loss (621 mL less, P<0.001) in the MISS group. The average time to initiate radiotherapy after surgery was 13 days (range, 12–16 d) in MISS and 24 days (range, 16–40 d) in the open group. This difference was statistically significant (P<0.001). Operative time and duration of hospital stay were also favorable in the MISS group, although the differences were not significant.

Conclusions:

MISS is comparable with open approach demonstrating similar improvements in clinical outcomes, that is pain control, neurological and functional status. MISS approaches have also shown promising results due to lesser intraoperative blood loss and allowing earlier radiotherapy/chemotherapy.
Comparison of Long-term Differences in Dysphagia
Authors: Smucker Joseph D. , Bassuener Scott R. , Sasso Rick C. , Riew K. Daniel
Published: March 2018

Study Design:

Retrospective cohort study.

Objective:

This study investigates the incidence of long-term dysphagia in cervical disc arthroplasty, and anterior cervical discectomy and fusion (ACDF) patients.

Summary of Background Data:

No long-term comparison of dysphagia between cervical arthroplasty and fusion patients has been published. Widely variable short-term postsurgical dysphagia rates have been reported.

Materials and Methods:

Cohorts for this study are patients with single-level cervical degenerative disc disease previously enrolled in a randomized clinical trial comparing cervical arthroplasty and ACDF. Subjective modified Bazaz Dysphagia Severity questionnaires were distributed to each patient at a minimum of 5 years postoperative for the long-term assessment. Dysphagia severity data were pooled to compare the rate of patients with dysphagia (grade>1) to asymptomatic (grade=1).

Results:

In the arthroplasty cohort, 15 of 22 (68%) patients completed long-term swallowing questionnaires with no reports of dysphagia. Eighteen of 25 (72%) ACDF patients completed questionnaires, with 5 of 18 (28%) reporting dysphagia. This is a statistically significant difference (P=0.042) favoring lower rates of long-term dysphagia after cervical arthroplasty at an average interval of 7 years postoperative (range, 5.5–8.5 y). No significant difference between rates of self-reported short-term dysphagia was noted with 12% (3/25) and 9% (2/22) in the ACDF and arthroplasty groups, respectively (P=0.56). All short-term dysphagia cases in the arthroplasty cohort reported complete resolution of symptoms within 12 months postoperative. In the ACDF cohort, persistent symptoms at 7 years were noted in all responding patients. Three ACDF patients reported new late-onset, which was not noted in the arthroplasty cohort.

Conclusions:

To date, these findings represent the longest reported follow-up interval comparing rates of dysphagia between randomized cohorts of cervical arthroplasty and fusion patients. Our study suggests that cervical arthroplasty is less likely than ACDF to cause sustained long-term or late-presenting dysphagia.
“Inline” Axial Reconstructed CT Scans Provide a Significantly Larger Assessment of C2 Pedicle Diameter for Screw Placement Compared With “Standard” Axial Scans
Authors: Vizurraga David E. , Rhee John M. , Borden Timothy C. , Mansour Ashton S.
Published: March 2018

Study Design:

Radiologic analysis.

Objective:

The objective was to compare C2 pedicle diameter and screw feasibility on reconstructed axial computed tomography (CT) cuts created “Inline” (IL) with the intended pedicle screw tract versus unaltered “Standard” (STD) axial cuts.

Background Data:

Axial CT cuts through the C2 pedicle are commonly evaluated when planning pedicle screw fixation as medial aberrancies of the vertebral artery can significantly narrow pedicle diameter. STD axial CT cuts provided by radiology departments are typically formatted orthogonal to the long axis of the neck or the vertical plumb, which is often not IL with the axis of the intended C2 pedicle screw tract.

Materials and Methods:

A total of 89 cervical spine CT scans obtained by a single radiology department over 2 years (35 male, 54 female; mean age 64.9 y) were reviewed. STD axial cuts were not manipulated but were assessed as provided. IL axial cuts were created along the intended C2 pedicle screw tract using free, open-source DICOM viewer software. Inner and outer pedicle diameters were measured on axial cuts most closely approximating the isthmus of the intended tract.

Results:

On STD cuts, the mean outer and inner pedicle diameters were 5.05±1.45 and 2.01±1.31 mm, respectively. By contrast, IL measurements yielded significantly larger outer and inner diameters: 5.85±1.78 and 2.68±1.47 mm (P<0.01). IL measurement predicted a higher number of pedicles amenable to insertion of a 3.5 mm screw with safety margins of 1 to 3 mm.

Conclusions:

Reformatted IL axial cuts through the intended path of C2 pedicle screws provide significantly larger assessments of C2 pedicle diameter than those obtained on STD cuts. IL measurements predict C2 screw insertion feasibility in a substantially higher number of pedicles. As assessment of IL cuts may alter surgical decision-making at no added cost or radiation exposure, we suggest that they be obtained whenever considering C2 pedicle screw placement.
The Significance of the Trömner Sign in Cervical Spondylotic Myelopathy Patient
Authors: Chaiyamongkol Weera , Laohawiriyakamol Teeranan , Tangtrakulwanich Boonsin , Tanutit Pramot , Bintachitt Piyawat , Siribumrungwong Koopong
Published: March 2018

Study Design:

This study is a diagnostic analysis.

Objective:

To investigate the diagnostic accuracy of Trömner sign in cervical spondylotic myelopathy (CSM), and how its presence correlates with the severity of myelopathy.

Summary of Background Data:

A clinical presentation of myelopathy corresponding with image findings is a current standard to diagnose CSM. Trömner sign is an alternative of well-known Hoffmann sign to detect CSM. Little is known about its diagnostic accuracy and how its presence correlates with the severity of CSM.

Materials and Methods:

Consecutive patients with clinical diagnosis of CSM and other cervical spondylosis–related problems were enrolled in either CSM group, cervical spondylotic radiculopathy group, or axial pain group. Normal volunteers and patients without spine-related issues were used as a control. All participants were examined for the presence of myelopathic signs. Magnetic resonance imaging studies of all participants were reviewed by a radiologist.

Results:

There were 85 participants included in the study. Diagnostic sensitivity was 76%, 94%, 76%, and 36% for Hoffmann sign, Trömner sign, inverted radial reflex, and Babinski sign, respectively. Trömner sign had relatively high sensitivity (95%) despite of mild degree of myelopathy. Negative predictive value was 60%, 85%, 59%, and 38% for Hoffmann sign, Trömner sign, inverted radial reflex, and Babinski sign, respectively. There were 63%–71% of patients in either axial pain group or cervical spondylotic radiculopathy group had positive Trömner sign. Most of CSM patients with cord signal changed had positive myelopathic sign. Regarding CSM patient without cord signal change, most of tests were negative except Trömner sign.

Conclusions:

High sensitivity (94%) and relatively high negative predictive value (85%) for Trömner sign indicate the usefulness of Trömner sign in ruling out CSM. High incidence of positive Trömner sign in presymptomatic cervical cord compression patients suggests Trömner sign could have a useful role in early detection of presymptomatic patients.
Failure to Launch
Authors: Hart Robert A. , DePasse J. Mason , Daniels Alan H.
Published: March 2018

Study Design:

Spine surgeon survey.

Objective:

The objective was to investigate the failure of widespread adoption of lumbar total disk replacement (L-TDR) in the United States.

Summary of Background Data:

L-TDR has been available for use in the United States since 2005. L-TDR has not gained wide acceptance as a treatment for degenerative disk disease despite substantial investments in product development and positive results in randomized controlled trials.

Methods:

Estimates of the number of L-TDR procedures performed in the United States from 2005 to 2010 were calculated using the Nationwide Inpatient Sample database. Insurance policies were assessed for L-TDR coverage through Internet search. Finally, an 18-question survey regarding surgeons’ opinions toward L-TDR was distributed to the members of North American Spine Society.

Results:

The estimated number of primary L-TDR procedures performed in the United States decreased from 3650 in 2005 to 1863 in 2010, whereas revision L-TDR procedures increased from 420 to 499. Of 14 major insurers, 11 (78.6%) do not cover L-TDR. In total, 613 spine surgeons responded to the survey. Over half of respondents (51.1%, 313/612) have performed L-TDR, although only 44.6% (136/305) of initial adopters currently perform the surgery. However, 81.5% (106/130) of those currently performing L-TDR have been satisfied with the results. When asked about their perceptions of L-TDR, 65.0% (367/565) indicated a lack of insurance coverage for L-TDR in their region, 54.9% (310/565) worry about long-term complications, and 52.7% (298/565) worry about the technical challenges of revision.

Conclusions:

Despite early enthusiasm for L-TDR, wide adoption has not occurred. A primary reason for this failure seems to be a lack of insurance coverage, despite intermediate-term clinical success. In addition, surgeons continue to express concerns regarding long-term outcomes and the technical difficulties of revision. This case study of a failed surgical innovation may signal increasing involvement of payers in clinical decision-making and may be instructive to surgeons, policymakers, and manufacturers.
Unilateral Versus Bilateral Pedicle Screw Fixation in Transforaminal Lumbar Interbody Fusion
Authors: Liu Fubing , Feng Zhenzhou , Zhou Xiaogang , Liang Yun , Jiang Chun , Li Xilei , Li Zheng , Jiang Xiaoxing , Dong Jian
Published: March 2018

Study Design:

A retrospective clinical study.

Objective:

This study sought to retrospectively compare the mid-term to long-term outcomes between unilateral pedicle screw (UPS) and bilateral pedicle screw (BPS) augmented transforaminal lumbar interbody fusion (TLIF) in lumbar degenerative diseases.

Summary of Background Data:

Recently, UPS fixation has been applied in TLIF, for its satisfactory clinical outcome, less implants and less invasiveness. However, only short-term outcome has been reported, the mid-term to long-term outcome has not been well characterized.

Materials and Methods:

From June 2007 to February 2011, 215 of 348 consecutive patients suffering from lumbar degenerative diseases were operated in our hospital and accomplished a minimum of 4-year follow-up. These patients were divided into 2 groups according to the operative techniques: UPS group (n=109), and bilateral pedicle screw group (n=106). Operative time, blood loss, length of hospital stay, hospital bill, fusion status, and complications were recorded and analyzed statistically. Visual analog scale, Oswestry disability index, and Japanese Orthopaedic Association scores were used to assess the preoperative and postoperative pain and functional outcome.

Results:

The mean follow-up duration was 52.2 months. A significant decrease occurred in operative time, blood loss, and hospital bill in unilateral group, compared with bilateral group (P<0.05). The average postoperative visual analog scale, Oswestry disability index, and Japanese Orthopaedic Association scores improved significantly in each group than the preoperative counterparts (P<0.05); however, there were no significant difference between groups at any follow-up time point (P>0.05). No statistically difference was detected regarding fusion rate and complication rate between the 2 groups (P>0.05), except the cage migration rate (P<0.05).

Conclusions:

UPS fixation could achieve satisfactory clinical outcome similar to bilateral fixation in TLIF at a mid-term to long-term follow-up. To avoid cage migration, bullet-shaped cages should not be used in the unilateral group.
The Role of Incentives in Changing the Behavior of Spinal Care Providers
Authors: Sharan Alok D. , Schroeder Gregory D. , West Michael E. , Vaccaro Alexander R.
Published: March 2018

As spinal care transitions from individual practitioners working in a volume-based reimbursement system toward multidisciplinary health care organizations working in a population-based model with value-based reimbursement, it is critical that insurance companies, administrators, and spine care provider have a clear understanding of how incentives change physician behavior. This article will introduce the concept of behavior economics, and discuss 9 principles relevant to physician decision-making.
Degenerative Spondylolisthesis in the Fifth Lumbar Vertebra and Radiographic Parameters
Authors: Chen Qian , Cao Lu , Bian Chong , Wang Hui-Ren , Lin Hong , Li Xi-Lei , Jiang Yun-Qi , Dong Jian
Published: March 2018

Study Design:

A retrospective study.

Objective:

This study aimed to analyze the relationships between degenerative spondylolisthesis in the fifth lumbar vertebra (L5-DS) and radiographic parameters and to further determine the radiographic predictors of the development of L5-DS.

Summary of Background Data:

Degenerative lumbar spondylolisthesis (DLS) is a common degenerative disease of the spine; however, the correlations between L5-DS and radiographic parameters remain controversial.

Patients and Methods:

This retrospective case-control study was conducted in our hospital. Between 2011 and 2014, a total of 84 subjects with L5-DS were enrolled in the DLS group, and 56 healthy volunteers were recruited to the control group. A series of radiographic parameters, including the bone mineral density, disk degenerative index, disk height, L5 vertebral size (L5-VS), lumbar lordosis angle (LL), sacral slope angle (SS), pelvic incidence (PI), facet joint angulations (FJA) of the cephalad and caudad portions, and asymmetry of the FJA, were measured in both groups by 3 examiners.

Results:

The bone mineral density, disk degenerative index, disk height, L5-VS, LL, SS, PI, and FJA exhibited significant differences (P=0.014–0.045) between the DLS and control groups. Significant changes in the FJA of the cephalad and caudad portions in the L4–L5 and L5–S1 segments were observed between the 2 groups (P=0.00, 0.00), whereas no significant differences in the asymmetries of FJA were observed in the L4–L5 or L5–S1 segments (P=0.605–0.972). Among all of the parameters, the L5-VS (P=0.025), SS (P=0.020), LL (P=0.031), PI (P=0.014), and FJA (P=0.022) were identified as being associated with the DLS group by multiple logistic regression analysis.

Conclusions:

In this study, SS, LL, PI, and a more sagittal FJA were proven to be risk factors for L5-DS, whereas L5-VS was found to be a likely protective factor against L5-DS. These parameters should be considered predictors of L5-DS.
Impact of Inpatient Venous Thromboembolism Continues After Discharge
Authors: Li Alexander Y. , Azad Tej D. , Veeravagu Anand , Bhatti Inderpreet , Li Amy , Cole Tyler , Desai Atman , Ratliff John K.
Published: March 2018

Study Design:

Propensity score matched retrospective study using a nationwide longitudinal database.

Objective:

To quantify the longitudinal economic impact of venous thromboembolism (VTE) complications in spinal fusion patients.

Summary of Background Data:

VTE is a rare and serious complication that may occur after spine surgery. The long-term socioeconomic impact understanding of these events has been limited by small sample sizes and a lack of longitudinal follow-up. We provide a comparative economic outcomes analysis of these complications.

Methods:

We identified 204,308 patients undergoing spinal fusion procedures in a national billing claims database (MarketScan) between 2006 and 2010. Cohorts were balanced using 50:1 propensity score matching and outcome measures compared at 6, 12, and 18 months postoperation.

Results:

A total of 1196 (0.6%) patients developed postoperative VTE, predominantly occurring following lumbar fusion (69.7%). Postoperative VTE patients demonstrated an increase in hospital length of stay (7.8 vs. 3.3 d, P<0.001) and a decreased likelihood of being discharged home (71% vs. 85%, P<0.001). A $26,306 increase in total hospital payments (P<0.001) was observed, with a disproportionate increase seen in hospital payments ($22,103, P<0.001), relative to physician payments ($1766, P=0.001).

At 6, 12, and 18 months postfusion, increased rates of readmission and follow-up clinic visits were observed. Delayed readmissions were associated with decreased length of stay (3.6 vs. 4.6 d, P<0.001), but increased total payments, averaging at $21,270 per readmission. VTE patients generated greater cumulative outpatient service payments, costing $8075, $11,134, and $13,202 more at 6, 12, and 18 months (P<0.001).

Conclusions:

VTEs are associated with longer hospitalizations, a decreased likelihood of being discharged home, and overall increases of hospital resource utilization and cost in inpatient and outpatient settings. VTE patients generate greater charges in the outpatient setting and are more likely to become readmitted at 6, 12, and 18 months after surgery, demonstrating a significant socioeconomic impact long after occurrence.

Level of Evidence:

Level III—therapeutic.
The Utility of Routinely Obtaining Postoperative Laboratory Studies Following a Minimally Invasive Transforaminal Lumbar Interbody Fusion
Authors: Ahn Junyoung , Massel Dustin H. , Mayo Benjamin C. , Hijji Fady Y. , Narain Ankur S. , Aboushaala Khaled , Bohl Daniel D. , Elboghdady Islam M. , DiBattista Jacob V. , Singh Kern
Published: March 2018

Study Design:

This is a retrospective analysis.

Objective:

To test the hypothesis that there is limited utility in routinely obtaining postoperative laboratory values following minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

Background Data:

At many institutions, it is routine to obtain a complete blood count and basic metabolic profile (BMP) following a MIS TLIF. However, the utility of this practice has not been well characterized.

Methods:

A total of 332 consecutive patients who underwent a primary, 1-level MIS TLIF for degenerative spinal pathology between 2007 and 2013 were identified. Patients were stratified into low-risk and high-risk cohorts based upon risk for postoperative laboratory abnormalities. Inclusion criteria for the high-risk cohort were malignancy, complicated diabetes, renal failure, liver disease, hematologic disease, or significant intraoperative blood loss (>300 mL). Preoperative and postoperative hemoglobin (Hb), hematocrit, and BMP values were compared. Any interventions that were potentially related to laboratory values were identified.

Results:

Totals of 270 low-risk and 62 high-risk patients were identified. Mean postoperative Hb, hematocrit, blood urea nitrogen, sodium, potassium, and calcium values were decreased compared with preoperative values (P<0.001 for each) in both cohorts. Similar changes from preoperative levels were demonstrated in each cohort. No patients received blood product transfusion. Eleven low-risk (4.1%) and 5 high-risk patients (8.1%) received oral potassium supplementation. All patients who received potassium supplementation were asymptomatic. Most patients who were given potassium replacement consumed medications known to decrease serum potassium levels. No other interventions were performed in either group.

Conclusions:

Despite a significant decrease in mean Hb concentration following surgery, no patients required a transfusion. In total, 16 patients received potassium supplementation likely related to medication-related potassium deficits. Overall, these findings suggest that the utility of routinely obtaining a complete blood count or BMP following uncomplicated MIS TLIF may be limited except in the setting of select preoperative comorbidities and/or perioperative risk factors or events.

Level of Evidence:

Level III.
A Retrospective Cohort Study Comparing the Safety and Efficacy of Minimally Invasive Versus Open Surgical Techniques in the Treatment of Spinal Metastases
Authors: Hikata Tomohiro , Isogai Norihiro , Shiono Yuta , Funao Haruki , Okada Eijiro , Fujita Nobuyuki , Iwanami Akio , Watanabe Kota , Tsuji Takashi , Nakamura Masaya , Matsumoto Morio , Ishii Ken
Published: March 2018

Study Design:

A retrospective cohort study.

Objective:

This study was conducted to assess the invasiveness, efficacy, and safety of minimally invasive spine stabilization (MISt) for metastatic spinal tumor patients with short life expectancy.

Summary of Background Data:

Conventional open surgery for metastatic spinal tumors has the disadvantages of significant blood loss, potential infection, damage to back muscles, and extended hospital stays. The minimally invasive spine surgery has changed the treatment of metastatic spinal tumors radically and fundamentally.

Materials and Methods:

We retrospectively reviewed data from 50 consecutive patients registered with the Keio Spine Research Group (KSRG) who underwent posterior palliative surgery for metastatic spinal tumors from January 2009 to June 2015. Of these, 25 patients underwent MISt surgery (M group), and 25 underwent conventional open surgery (C group). The patients were assessed by demographic data, surgical invasiveness, complications, pain improvement, and neurological recovery.

Results:

The 2 groups did not differ significantly in baseline characteristics. The M group had significantly less blood loss (M, 340.1 mL; C, 714.3 mL; P=0.005), less postoperative drainage (M, 136.0 mL; C, 627.0 mL; P<0.001), lower rates of red blood cell transfusion (M, 3 cases; C, 10 cases; P=0.029), and a shorter postoperative period of bed rest (M, 2.0 d; C, 3.6 d; P<0.001), compared with the C group. The perioperative complication rates were significantly lower (P=0.012) in the M group (3 patients, 12%) than in the C group (11 patients, 44%). Neurological deficits and pain improved significantly and comparably in the 2 groups after surgery.

Conclusions:

MISt is a less invasive and effective alternative surgery to conventional open surgery for metastatic spinal tumors. MISt should be considered as a valid option for the treatment of metastatic spinal tumor patients with a short life expectancy.

Level of Evidence:

Level 3.
Database Research in Spine Surgery
Authors: Sebastian Arjun S.
Published: March 2018

With the introduction of several publicly available national databases to study surgical outcomes, the use of such databases for spine surgery research has increased dramatically. These databases allow researchers to retrospectively examine data from a large sample of patients. This rise in the use of national databases to study surgical outcomes parallels an increasing reliance by administrators, payers, and third-party graders to evaluate surgical quality with the use of large administrative databases. A good understanding of the most commonly utilized databases for spine surgery is important for critical assessment of this growing body of literature.
Prevention and Management of Postoperative Delirium in Elderly Patients Following Elective Spinal Surgery
Authors: Nazemi Alireza K. , Gowd Anirudh K. , Carmouche Jonathan J. , Kates Stephen L. , Albert Todd J. , Behrend Caleb J.
Published: March 2018

Study Design:

This study is a systematic review.

Objective:

Propose an evidence-based algorithm for prevention, diagnosis, and management of postoperative delirium in geriatric patients undergoing elective spine surgery.

Summary of Background Data:

Delirium is associated with longer stays after elective surgery, increased risk of readmission, and $6.9 billion annually in medical costs. Early diagnosis and treatment of delirium can reduce length of stay (LOS), in-hospital morbidity, and health care costs. After spinal surgery, postoperative delirium increases average LOS to >7 days and is diagnosed in 12.5%–24.3% of geriatric patients. Currently, studies for management of postoperative delirium after elective spinal procedures are not available.

Methods:

A literature review was performed for observational studies, randomized controlled trials, and systematic reviews between 1990 and 2015.

Results:

Risk factors for delirium after elective spinal surgery include age, functional impairment, preexisting dementia, general anesthesia, surgical duration >3 hours, intraoperative hypercapnia and hypotension, greater blood loss, low hematocrit and albumin, preoperative affective dysfunction, and postoperative sleep disorders. Postoperatively, decreasing the use of methylprednisolone and promoting movement with an appropriate orthosis can reduce delirium incidence (P=0.0091). Polypharmacy is an independent risk factor for delirium (P=0.01) and decreasing use of delirium-inducing medications may reduce incidence. The delirium observation screening scale diagnoses and monitors delirium and is rated by nurses as easier to use than the NEECHAM Confusion Scale (P<0.003). Haloperidol is used widely to treat postoperative delirium. Randomized controlled trials show that adding quetiapine results in delirium resolution an average of 3.5 days faster than haloperidol alone (P=0.001) and decreases agitation and LOS (P=0.02; P=0.05).

Conclusions:

An evidence-based algorithm is proposed to prevent, diagnose, and manage postoperative delirium that can be used clinically for geriatric patients undergoing elective spine surgery. Prevention and diagnosis involve efforts from the anesthesiologist and postoperative clinical care team. Treatment may include a therapeutic regimen of low-dose neuroleptic medications as needed.

Level of Evidence:

Level II.
Sensitivity of Computed Tomography Compared With that of Magnetic Resonance Myelography in the Presurgical Diagnosis of Foraminal or Extraforaminal Entrapment at the Lumbosacral Junction
Authors: Lee Sung Ho , Lee Sang-Ho , Kim Soo-Beom , Park Eun Soo , Kim Soo-Nyung , Moon Ki-Hyoung
Published: March 2018

Study Design:

This is a retrospective analysis.

Objective:

To investigate and compare the sensitivities of computed tomography (CT) and magnetic resonance myelography (MRM) in the presurgical diagnosis of foraminal or extraforaminal entrapment of the L5 nerve.

Summary of Background Data:

CT is more clinically available than MRM. Foraminal or extraforaminal entrapment at the lumbosacral junction may cause L5 radiculopathy but is difficult to diagnose. Asymmetric enlargement of the anterior primary division (APD) of the L5 nerve on preoperative CT and dorsal root ganglion (DRG) swelling and abnormal L5 nerve course on MRM coronal images have been examined in cases of foraminal or extraforaminal L5 nerve entrapment, but have not been compared directly.

Materials and Methods:

Ninety-five patients (mean age 63 y; 28–85 y) with L5 nerve entrapment at the lumbosacral junction who underwent preoperative CT and MRM, and microsurgical decompression by a single surgeon (K.-H.M.) from January 2010 to June 2014 were included. Symptomatic sites were diagnosed by confirming L5 nerve entrapment intraoperatively. Two spinal surgeons independently compared the bilateral APD diameters of the L5 nerve on CT and the L5 nerve courses and DRG swelling on MRM coronal images.

Results:

The interobserver agreement of asymmetric APD swelling on CT and abnormal nerve course and DRG swelling on MRM were excellent (κ=0.808, 0.811, and 0.849, respectively), and the sensitivities were 81%, 84%, and 82% on the right, and 86%, 92%, and 90% on the left sides, respectively. There was no statistically significant difference in the sensitivity between APD swelling on CT and an abnormal nerve course or DRG swelling on MRM on the right (P=1.000 and 0.789) and left (P=0.727 and 1.000) sides, respectively.

Conclusions:

CT has comparable sensitivity to MRM for the presurgical diagnosis of L5 nerve entrapment at the lumbosacral junction.

Level of Evidence:

Level II.
The Influence of Histologic Subtype in Predicting Survival of Lung Cancer Patients With Spinal Metastases
Authors: Kumar Naresh , Tan Kimberly-Anne , Tan Jiong Hao , Zaw Aye S. , Hey Hwee Weng Dennis , Ruiz John , Stone Emily
Published: March 2018

Study Design:

Retrospective analysis.

Summary of Background Data:

Recent advancements in systemic treatment of lung cancer have significantly improved the survival of patients with certain histolopathologic and molecular subtypes. Existing prognostic scores do not account for this and patients with lung cancer spinal metastases are grouped together as poor prognostic candidates, and consequently, some may be inappropriately denied palliative spine surgery.

Objective:

The objective of the study was to study whether the expected survival in patients with lung cancer spinal metastases is affected by histolopathologic and molecular subtypes in the context of modern systemic therapy.

Materials and Methods:

We retrospectively reviewed all patients with histologically confirmed lung cancer treated for spinal metastases at our institution between 2001 and 2012. Patients’ demographics, histopathologic details, treatment modalities, and survival data were collected. The primary outcome was survival from time of spinal metastases diagnosis. The Cox regression analysis was used to evaluate the influence of tumor histology, molecular profile and treatment modality on survival. The Kaplan-Meier survival analysis was conducted to compare lung cancer subtypes, as well as various treatment regimens.

Results:

Out of 180 patients, 51 underwent surgery for spinal metastases. Female sex (P=0.019), absence of palsy (P=0.023), good Karnofsky performance scores (P<0.001), and non–small cell lung cancer (NSCLC) (P=0.002) were favorable prognostic factors. Patients who received systemic therapy, including tyrosine kinase inhibitors, platinum doublet chemotherapy, or both showed increased survival (P<0.01). The median survival time was 2.40 months [95% confidence interval (CI), 2.13–2.68] in the small cell lung cancer cohort, with no patients surviving past a year; 5.10 months (95% CI, 3.78–6.41) in the NSCLC cohort, with 25.9% 1-year survival; and 13.3 months (95% CI, 2.26–24.40) in adenocarcinoma patients who received both tyrosine kinase inhibitors and platinum doublet therapy, with 50.0% 1-year survival.

Conclusions:

NSCLC, systemic therapy, female sex, absence of palsy and good Karnofsky performance scores are all independent favorable prognostic factors for patients with lung cancer spinal metastases. These should be routinely considered during prognostication.
Posterior Vertebral Column Resection With Intraoperative Manual Retraction for the Treatment of Posttubercular Kyphosis in Upper Thoracic Spine or Cervicothoracic Junction
Authors: Chen Yuqiao , Lü Guohua , Wang Bing , Li Lei , Kuang Lei
Published: March 2018

Study Design:

This is a case-series.

Objective:

To evaluate the clinical and radiologic outcomes of posterior vertebral column resection (PVCR) for treatment of posttubercular kyphosis in upper thoracic spine and cervicothoracic junction (CTJ).

Summary of Background Data:

Surgical management of severe posttubercular kyphosis in upper thoracic spine or CTJ is challenging. A new technique that combines PVCR and intraoperative manual traction in a single procedure, was developed to maximize the correction rate and minimize the risk of dural buckling and spinal cord injury. However, the safety and effectiveness of the procedure is yet to be established.

Materials and Methods:

Ten patients with upper thoracic or CTJ posttubercular kyphosis, who underwent PVCR with intraoperative manual traction between December 2008 and 2013, were studied retrospectively. Data pertaining to operation time, blood loss, and perioperative complications were collected. Outcomes were evaluated using the visual analog scale; the 12-Item Short Form Health Survey (SF-12), Mental Component Summary, and SF-12 Physical Component Summary. Neurological status was assessed using American Spinal Injury Association (ASIA) impairment scale. Radiologic outcomes including fusion and deformity correction were assessed using plain radiography and computed tomography.

Results:

The average duration of follow-up was 53.6±7.2 months. Average operating time and blood loss were 263±35.3 minutes and 2490±569 mL, respectively. Visual analog scale score for back pain, SF-12 Mental Component Summary, and Physical Component Summary showed significant improvement postoperatively. Kyphosis improved from a preoperative average of 73.6±13.1 degrees to an average of 37.9±8.7 degrees at final follow-up (correction rate: 48.5%). No postoperative neurological deterioration was observed based on the ASIA score. As of the last follow-up, solid fusion was not achieved only in 1 patient.

Conclusions:

PVCR with intraoperative manual traction is a safe and effective procedure for treatment of upper thoracic or CTJ posttubercular kyphosis.

Level of Evidence:

Level 4.
Perioperative Complications of Spinal Metastases Surgery
Authors: Luksanapruksa Panya , Buchowski Jacob M. , Zebala Lukas P. , Kepler Christopher K. , Singhatanadgige Weerasak , Bumpass David B.
Published: March 2018

The incidence of symptomatic spinal metastasis has increased due to treatment improvements and longer patient survival. More patients with spinal tumors are choosing operative treatment with an associated increased rate of perioperative complications. Operative metastatic disease treatment complication rates have also increased with overall rates ranging from 5.3% to 76.20%. The common surgical-related complications are iatrogenic dural injury and wound complications. The most common postoperative medical complications are delirium, pneumonia, and deep vein thrombosis. Risk factors for perioperative complications after spinal metastatic surgery include older age, multilevel of spinal metastases, preoperative irradiation, low preoperative Karnofsky Performance Score (10–40) and multiple comorbidities. Charlson Comorbidity Index and New England Spinal Metastasis Score were significant predictor of 30-day complications. The reoperation rate is 10.7%, and the reoperation is most commonly performed in the same admission. In addition, the 30-day mortality rate in this patient population is ∼7% (0.9%–13%) and is influenced by the type of cancer, disease burden, and patient comorbidities. We reviewed the prevalence and risk factors of common perioperative complications that occur with surgical treatment of metastatic spine disease, in an effort to guide the spine surgeon in anticipating and potentially avoiding these complications.
Vertebral Body Hounsfield Units are Associated With Cage Subsidence After Transforaminal Lumbar Interbody Fusion With Unilateral Pedicle Screw Fixation
Authors: Mi Jie , Li Kang , Zhao Xin , Zhao Chang-Qing , Li Hua , Zhao Jie
Published: March 2018

Objective:

To assess the association between Hounsfield units (HU) measurement and cage subsidence after lumbar interbody fusion.

Background:

Transforaminal lumbar interbody fusion (TLIF) with unilateral fixation becomes a popular treatment modality for lumbar degenerative disease. Cage subsidence is a potentially devastating complication after lumbar interbody fusion with unilateral fixation. Recently, a new technique for assessing bone mineral density using HU values from computed tomography has been proposed. Bone quality is believed to be one of the important factors that cause cage subsidence after TLIF.

Materials and Methods:

Cage subsidence after single-level (L4/5) TLIF with unilateral fixation was prospectively documented at a single institution between 2013 and 2014. Patients with cage subsidence were matched 1:1 to a control cohort without cage subsidence on the basis of age and sex. HU values were measured from the preoperative computed tomography. All patients received computed tomographic scans at a minimum of 6 months postoperatively. Sagittal images were evaluated for evidence of cage subsidence.

Results:

Eighteen patients with cage subsidence were well matched 1:1 to a cohort without cage subsidence and had complete imaging data. The global lumbar HU values were significantly lower in patients with cage subsidence than in the controls (112.4±10.08 vs. 140.2±10.17; P=0.0015). Similarly, a regional assessment of HU across the fusion levels was significantly lower in patients with cage subsidence (113.4±10.47 vs. 127.9±8.13; P=0.0075). The areas under the receiver operating characteristic cure were 0.715 and 0.636 for global and regional assessment, respectively. The best cut-offs for global and regional assessment were 132 (sensitivity: 83.3%; specificity: 61.1%) and 122 (sensitivity: 72.2%; specificity: 55.6%), respectively.

Conclusions:

Lower preoperative HU values is associated with cage subsidence after TLIF with unilateral fixation. HU measurement may be used as a predictor of cage subsidence after unilateral fixation, which also should be incorporated in preoperative planning.
The Role of C2–C7 Angle in the Development of Dysphagia After Anterior and Posterior Cervical Spine Surgery
Authors: Tian Wei , Yu Jie
Published: March 2018

Study Design:

This is a retrospective clinical study.

Objective:

To analyze the relationship between cervical alignment and the development of dysphagia after anterior and posterior cervical (PC) spine surgery [anterior cervical discectomy and fusion (ACDF), cervical disk replacement (CDR), and PC].

Summary of Background Data:

Dysphagia is a known complication of cervical surgery and may be prolonged or occasionally serious. A previous study showed dysphagia after occipitocervical fusion was caused by oropharyneal stenosis resulting from O–C2 (upper cervical lordosis) fixation in a flexed position. However, there have been few reports analyzing the association between the C2–C7 angle (middle-lower cervical lordosis) and postoperative dysphagia.

Materials and Methods:

In total, 452 patients were reviewed in this study, including 172 patients who underwent the ACDF procedure, 98 patients who had the CDR procedure, and 182 patients who had the PC procedure between June 2007 and May 2010. The presence and duration of postoperative dysphagia were recorded via face-to-face questioning or telephone interview performed at least 1 year after the procedure. Plain cervical radiographs before and after surgery were collected. The O–C2 angle and C2–C7 angle were measured. The change of O–C2 angle and C2–C7 angle were defined as dO–C2 angle=postoperative O–C2 angle−preoperative O–C2 angle and dC2–C7 angle=postoperative C2–C7 angle−preoperative C2–C7 angle. The association between postoperative dysphagia with dO–C2 angle and dC2–C7 angle was studied.

Results:

A total of 12.8% ACDF, 5.1% CDR, and 9.4% PC patients reported dysphagia after cervical surgery. The dC2–C7 angle has considerable impact on postoperative dysphagia. When dC2–C7 angle is >5 degrees, the chance of developing postoperative dysphagia of this patient is significantly greater. The dO–C2 angle, age, sex, body mass index, operative time, blood loss, procedure type, revision surgery, most cephalic operative level, and number of operative levels did not significantly influence the incidence of postoperative dysphagia. No relationship was found between the dC2–C7 angle and the degree of dysphagia.

Conclusions:

Postoperative dysphagia is common after cervical surgery. The dC2–C7 angle may play an important role in the development of dysphagia in both anterior and PC spine surgery. Overenlargement of cervical lordosis should be avoided to reduce the development of postoperative dysphagia.
Anterior Versus Posterior Approaches for Odontoid Fracture Stabilization in Patients Older Than 65 Years
Authors: Patterson Joseph T. , Theologis Alexander A. , Sing David , Tay Bobby
Published: March 2018

Study Design:

Retrospective cohort analysis.

Objective:

To compare 30-day perioperative clinical outcomes of surgical odontoid stabilization by an anterior or posterior operative approach in elderly patients.

Summary of Background Data:

Surgical stabilization of odontoid fractures is superior to nonoperative management in geriatric patients. How elderly patients with odontoid fractures fare after anterior and posterior approaches, however, is not well defined.

Materials and Methods:

Retrospective review of the prospectively collected American College of Surgeons National Surgical Quality Improvement Program database (2005–2013). Elderly patients (≥65 y) with odontoid fractures who underwent odontoid stabilization through anterior or posterior approaches were identified by International Classification of Diseases 9th Revision/Common Procedure Terminology codes. Exclusion criteria included concomitant subaxial spine surgery, instrumentation noncontiguous with the atlantoaxial interval, and combined approaches. Baseline demographics and perioperative details were compared. Adverse events, mortality, reoperation, discharge, and readmission rates within 30 days of operation were compared using bivariate and multivariate generalized linear regressions.

Results:

One hundred forty-one patients (male—81; female—60; average age: 77.8±6.5 y; anterior approach—48; posterior approach—93) were analyzed. Patients scheduled to have a posterior approach had significantly more nonunions preoperatively and higher body mass indices. Operative times for posterior surgeries were significantly longer. Age, comorbidities, functional dependence, time to surgery, and length of hospital stay were similar between groups. There were no significant differences in the relative risk (RR) of the composite outcome of “any adverse event” after adjusting for differences in baseline characteristics. Patients who underwent an anterior approach were more likely to have an unplanned hospital readmission (RR=8.95; 95% confidence interval, 2.21–36.29; P=0.002) and have significantly more revision operations (RR=19.51; 95% confidence interval, 2.49–152.62; P=0.005) than patients who had a posterior operation.

Conclusions:

An anterior approach for odontoid fracture stabilization in patients ≥65 years old were associated with shorter operative times and greater RRs of unplanned readmissions and revision operations within 30 days of surgery relative to a posterior approach.
The Assessment of Upright Cervical Spinal Alignment Using Supine MRI Studies
Authors: Karabag Hamza , Iplikcioglu Ahmet C.
Published: March 2018

Study Design:

This is a prospective, single-centre study.

Objective:

The purpose of this study is researching whether there is a correlation or not between the cervical alignment in the examinations of magnetic resonance imaging (MRI) in lying position and the alignment in the cervical direct radiography and whether the cervical alignment in standing position could be estimated or not through MRI measurements in the supine position.

Summary of Background Data:

Cervical spinal alignment is a parameter required for deciding the surgical procedure particularly in patients with cervical myelopathy and deformity. However, cervical alignment angles change according to lying and standing positions. Therefore, the direct standing radiograph is taken as basis for this examination.

Methods

Cervical alignments were measured with 3 different methods with the standing lateral radiographies and lying MRI of 51 patients with cervical disorder.

Results:

A high correlation was found between the measurements in standing and lying positions for the spinal alignments measured through the Cobb angle and posterior tangent method. It was found that standing Cobb angle (in plain graphy)=Cobb angle (in MRI)×0.489+7.13 and posterior tangent angle (in plain graphy)=posterior tangent angle (in MRI)×0.54+9.37.

Conclusions:

It is possible to estimate the spinal alignment in standing position with the measurements of cervical spinal alignment in the MRI at supine position. And this may render having cervical graphy in standing position unnecessary.
Preoperative Risk Factors of C5 Nerve Root Palsy After Laminectomy and Fusion in Patients With Cervical Myelopathy
Authors: Kang Kyung-Chung , Suk Kyung-Soo , Kim Hak-Sun , Moon Seong-Hwan , Lee Hwan-Mo , Seo Jung-Ho , Kim Sung-Min , Jin Sung-Yub , Mella Pierre
Published: March 2018

Study Design:

A retrospective study.

Objective:

To identify preoperative risk factors causing cervical fifth nerve root palsy (C5 palsy) after laminectomy and fusion (LF).

Summary of Background Data:

It is well known that postoperative C5 palsy is not rare after cervical surgery. Although there remains controversy, C5 palsy is considered to be more common in patients who had LF than in those who had laminoplasty. However, the reason for the higher incidence of C5 palsy in patients with LF has been poorly understood.

Methods:

A total of 70 consecutive patients (mean age: 60.3 y) who had LF due to cervical myelopathy were reviewed. Patients were divided on the basis of the presence (group P) or absence (group N) of C5 palsy. Among various risk factors for C5 palsy from previous reports, 6 risk factors were selected as follows: (1) preoperative low Japanese Orthopedic Association score, (2) postoperatively increased lordosis, (3) low Pavlov ratio, (4) high signal intensity in the cord at C3–C5, (5) anterior protruding mass lesion compressing the spinal cord, and (6) presence of C4–C5 foraminal stenosis. With these factors, the 2 groups were compared by statistical analysis.

Results:

C5 palsy occurred in 10 patients (14.3%). The mean onset time was 3.5 days (range, 1–8 d) and the mean recovery time was 3.4 months (range, 1–7 mo). There were no significant differences in the preoperative Japanese Orthopedic Association score, cervical lordosis, Pavlov ratio, high signal intensity, and anterior protruding mass between the 2 groups (P>0.05). However, C4–C5 foraminal stenosis was found in 80.0% (8/10) in group P and 21.7% (13/60) in group N. There were significant differences between the 2 groups in C4–C5 foraminal stenosis (P=0.004).

Conclusions:

In this study, a high occurrence rate and risk factor for C5 palsy were verified after LF. Among the various factors, C4–C5 foraminal stenosis was the only risk factor for C5 palsy. Preoperative warning for C5 palsy after LF seems to be imperatively necessary, especially in patients with C4–C5 foraminal stenosis.