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Sharfman ZT, Clark AJ, Gupta MC, Theologis AA. Coronal Alignment in Adult Spine Surgery. J Am Acad Orthop Surg 2024; 32:417-426. [PMID: 38354413 DOI: 10.5435/jaaos-d-23-00961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 12/28/2023] [Indexed: 02/16/2024] Open
Abstract
Coronal realignment is an important goal in adult spine surgery that has been overshadowed by emphasis on the sagittal plane. As coronal malalignment drives considerable functional disability, a fundamental understanding of its clinical and radiographic evaluation and surgical techniques to prevent its development is of utmost importance. In this study, we review etiologies of coronal malalignment and their radiographic and clinical assessments, risk factors for and functional implications of postoperative coronal malalignment, and surgical strategies to optimize appropriate coronal realignment in adult spine surgery.
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Affiliation(s)
- Zachary T Sharfman
- From the Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, CA (Sharfman and Theologis), Department of Neurological Surgery, UCSF, San Francisco, CA (Clark), Department of Orthopaedic Surgery, Washington University in St. Louis, St. Louis, MO (Gupta)
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Hung NJ, McClellan RT, Hsu W, Hu SS, Clark AJ, Theologis AA. Timelines for Return to Different Sports Types After Eight Cervical Spine Fractures in Recreational and Elite Athletes: A Survey of the Association for Collaborative Spine Research. Clin Spine Surg 2024:01933606-990000000-00282. [PMID: 38531829 DOI: 10.1097/bsd.0000000000001607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Accepted: 01/22/2024] [Indexed: 03/28/2024]
Abstract
STUDY DESIGN Prospective cross-sectional survey. OBJECTIVE To identify timelines for when athletes may be considered safe to return to varying athletic activities after sustaining cervical spine fractures. BACKGROUND While acute management and detection of cervical spine fractures have been areas of comprehensive investigation, insight into timelines for when athletes may return to different athletic activities after sustaining such fractures is limited. METHODS A web-based survey was administered to members of the Association for Collaborative Spine Research that consisted of surgeon demographic information and questions asking when athletes (recreational vs elite) with one of 8 cervical fractures would be allowed to return to play noncontact, contact, and collision sports treated nonoperatively or operatively. The third part queried whether the decision to return to sports was influenced by the type of fixation or the presence of radiculopathy. RESULTS Thirty-three responses were included for analysis. For all 8 cervical spine fractures treated nonoperatively and operatively, significantly longer times to return to sports for athletes playing contact or collision sports compared with recreational and elite athletes playing noncontact sports, respectively (P< 0.05), were felt to be more appropriate. Comparing collision sports with contact sports for recreational and elite athletes, similar times for return to sports for nearly all fractures treated nonoperatively or operatively were noted. In the setting of associated radiculopathy, the most common responses for safe return to play were "when only motor deficits resolve completely" and "when both motor and sensory deficits resolve completely." CONCLUSIONS In this survey of spine surgeons from the Association for Collaborative Spine Research, reasonable timeframes for return to play for athletes with 8 different cervical spine fractures treated nonoperatively or operatively varied based on fracture subtype and level of sporting physicality.
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Affiliation(s)
- Nicole J Hung
- Department of Orthopaedic Surgery, David Geffen School of Medicine, University of California-Los Angeles (UCLA), Los Angeles
| | - Robert Trigg McClellan
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), San Francisco, CA
| | - Wellington Hsu
- Department of Orthopaedic Surgery, Northwestern University, Chicago, IL
| | - Serena S Hu
- Department of Orthopaedic Surgery, Stanford University, Stanford
| | - Aaron J Clark
- Department of Neurological Surgery, UCSF, San Francisco, CA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), San Francisco, CA
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Kondapavulur S, Scheer JK, Safaee MM, Clark AJ. Completely Minimally Invasive Implant Removal and Transforaminal Lumbar Interbody Fusion for Adjacent Segment Disease: Case Series and Operative Video. Oper Neurosurg (Hagerstown) 2024:01787389-990000000-01086. [PMID: 38451097 DOI: 10.1227/ons.0000000000001121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/16/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Adjacent segment disease is a relatively common late complication after lumbar fusion. If symptomatic, certain patients require fusion of the degenerated adjacent segment. Currently, there are no posterior completely minimally invasive techniques described for fusion of the adjacent segment above or below a previous fusion. We describe here a novel minimally invasive technique for both implant removal (MIS-IR) and adjacent level transforaminal lumbar interbody fusion (MIS-TLIF) for lumbar stenosis. METHODS Demographic, surgical, and radiographic outcome data were collected for patients with lumbar stenosis and previous lumbar fusion, who were treated with MIS-IR and MIS-TLIF through the same incision. Radiographic outcomes were assessed postoperatively and complications were assessed at the primary end point of 3 months. RESULTS A total of 14 patients (7 female and 7 male), with average age 64.6 years (SD 13.4), were included in this case series. Nine patients had single-level MIS-IR with single-level MIS-TLIF. Three patients had 2-level MIS-IR with single-level MIS-TLIF. Two patients had single-level MIS-IR with 2-level MIS-TLIF. Only 1 patient had a postoperative complication-hematoma requiring same-day evacuation. There were no other complications at the primary end point and no fusion failure at the hardware removal levels to date (average follow-up, 11 months). Average increases in posterior disk height and foraminal height after MIS-TLIF were 4.44, and 2.18 mm, respectively. CONCLUSION Minimally invasive spinal IR can be successfully completed along with adjacent level TLIF through the same incisions, via an all-posterior approach.
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Affiliation(s)
- Sravani Kondapavulur
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Justin K Scheer
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Michael M Safaee
- Department of Neurological Surgery, University of Southern California, Los Angeles, California, USA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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Khela M, Kasir R, Lokken RP, Clark AJ, Theologis AA. Bilateral dual iliac screw pelvic fixation for adult spinal deformity: a case report of a superior gluteal artery pseudoaneurysm secondary to aberrant iliac screw trajectory. Spine Deform 2024; 12:501-505. [PMID: 37882967 PMCID: PMC10867056 DOI: 10.1007/s43390-023-00774-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/03/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE To present a case of a pseudoaneurysm of a branch of the left superior gluteal artery (SGA) secondary to lateral wall perforation from an iliac screw and its subsequent evaluation and management. METHODS Case report. RESULTS A 67-year-old female with a history of degenerative flatback and scoliosis and pathological fractures of T12 and L1 secondary to osteodisciitis underwent a single0stage L5-S1 ALIF and T9-pelvis posterior instrumented fusion with bilateral dual iliac screw fixation, revision T11-S1 decompression, and T12 and L1 irrigation and debridement and partial corpectomies. During the operation, non-pulsatile bleeding was encountered after creating an initial trajectory for the more proximal of the two left iliac screws. While the initial post-operative course was benign, the patient was readmitted for hypotension and anemia. Computed tomography of the abdomen/pelvis demonstrated a pseudoaneurysm (2.3 cm × 2.1 cm × 2.3 cm) of a branch of the left SGA. Diagnostic angiogram confirmed a pseudoaneurysm off of one of the branches of the left SGA. Endovascular embolization using multiple coils resulted in a complete cessation of blood flow in the pseudoaneurysm. At 2 years follow-up, no symptoms suggestive of recurrence of the pseudoaneurysm were reported. CONCLUSIONS A pseudoaneurysm of a branch of the left superior gluteal artery as a result of lateral wall perforation from an aberrantly placed iliac screw during an adult spinal deformity operation involving dual screw pelvic fixation is reported. Prompt recognition, multidisciplinary collaboration, and appropriate intervention were key in achieving a successful outcome and preventing further morbidity.
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Affiliation(s)
- Monty Khela
- School of Medicine, Creighton University, Omaha, NE, USA
| | - Rafid Kasir
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
| | - R Peter Lokken
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, USA
| | - Aaron J Clark
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA.
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Cummins DD, Clark AJ, Gupta MC, Theologis AA. Anterior lumbar interbody fusion versus transforaminal lumbar interbody fusion for correction of lumbosacral fractional curves in adult (thoraco)lumbar scoliosis: A systematic review. N Am Spine Soc J 2024; 17:100299. [PMID: 38193108 PMCID: PMC10772279 DOI: 10.1016/j.xnsj.2023.100299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 11/25/2023] [Accepted: 11/27/2023] [Indexed: 01/10/2024]
Abstract
Background Anterior lumbar interbody fusion (ALIF) or transforaminal lumbar interbody fusion (TLIF) may be used to correct the lumbosacral fractional curve (LsFC) in de novo adult (thoraco) lumbar scoliosis. Yet, the relative benefits of ALIF and TLIF for LsFC correction remain largely undetermined. Purpose To compare the currently available data comparing radiographic correction of the LsFC provided by ALIF and TLIF of LsFC in adult (thoraco)lumbar scoliosis. Methods A systematic review was performed on original articles discussing fractional curve correction of lumbosacral spinal deformity (using search criteria: "lumbar" and "fractional curve"). Articles which discussed TLIF or ALIF for LsFC correction were presented and radiographic results for TLIF and ALIF were compared. Results Thirty-one articles were returned in the original search criteria, with 7 articles included in the systematic review criteria. All 7 articles presented radiographic results using TLIF for LsFC correction. Three of these articles also discussed results for patients whose LsFC were treated with ALIFs; 2 articles directly compared TLIF and ALIF for LsFC correction. Level III and level IV evidence indicated ALIF as advantageous for reducing the coronal Cobb angle of the LsFC. There were mixed results on relative efficacy of ALIF and TLIF in the LsFC for restoration of adequate global coronal alignment. Conclusions Limited level III and IV evidence suggests ALIF as advantageous for reducing the coronal Cobb angle of the LsFC in de novo adult (thoraco) lumbar scoliosis. Relative efficacy of ALIF and TLIF in the LsFC for restoration of global coronal alignment may be dictated by several factors, including directionality and magnitude of preoperative coronal deformity. Given the limited and low-quality evidence, additional research is warranted to determine the ideal interbody support strategies to address the LsFC in adult (thoraco) lumbar scoliosis.
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Affiliation(s)
- Daniel D. Cummins
- Department of Orthopaedic Surgery, University of California — San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143 United States
| | - Aaron J. Clark
- Department of Neurological Surgery, UCSF, 400 Parnassus Ave, Eighth Floor, San Francisco, CA 94143, United States
| | - Munish C. Gupta
- Department of Orthopaedic Surgery, Washington University, Campus Box 8233, 660 Euclid Avenue, Saint Louis, MO 63110, United States
| | - Alekos A. Theologis
- Department of Orthopaedic Surgery, University of California — San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143 United States
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Lim P, Clark AJ, Deviren V, Berven SH, Burch S, Ames CP, Theologis AA. Odontoid fractures above C2 to pelvis posterior instrumented fusions: a single center's 11-year experience. Spine Deform 2024; 12:463-471. [PMID: 38157096 PMCID: PMC10866802 DOI: 10.1007/s43390-023-00800-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/25/2023] [Indexed: 01/03/2024]
Abstract
PURPOSE To define the prevalence, characteristics, and treatment approach for proximal junction failure secondary to odontoid fractures in patients with prior C2-pelvis posterior instrumented fusions (PSF). METHODS A single institution's database was queried for multi-level fusions (6+ levels), including a cervical component. Posterior instrumentation from C2-pelvis and minimum 6-month follow-up was inclusion criteria. Patients who sustained dens fractures were identified; each fracture was subdivided based on Anderson & D'Alonzo and Grauer's classifications. Comparisons between the groups were performed using Chi-square and T tests. RESULTS 80 patients (71.3% female; average age 68.1 ± 8.1 years; 45.0% osteoporosis) were included. Average follow-up was 59.8 ± 42.7 months. Six patients (7.5%) suffered an odontoid fracture post-operatively. Cause of fracture in all patients was a mechanical fall. Average time to fracture was 23 ± 23.1 months. Average follow-up after initiation of fracture management was 5.84 ± 4 years (minimum 1 year). Three patients sustained type IIA fractures one of which had a concomitant unilateral C2 pars fracture. Three patients sustained comminuted type III fractures with concomitant unilateral C2 pars fractures. Initial treatment included operative care in 2 patients, and an attempt at non-operative care in 4. Non-operative care failed in 75% of patients who ultimately required revision with proximal extension. All patients with a concomitant pars fracture had failure of non-operative care. Patients with an intact pars were more stable, but 50% required revision for pain. CONCLUSIONS In this 11-year experience at a single institution, the prevalence of odontoid fractures above a C2-pelvis PSF was 7.5%. Fracture morphology varied, but 50% were complex, comminuted C2 body fractures with concomitant pars fractures. While nonoperative management may be suitable for type II fractures with simple patterns, more complex and unstable fractures likely benefit from upfront surgical intervention to prevent fracture displacement and neural compression. As all fractures occurred secondary to a mechanical fall, inpatient and community measures aimed to minimize risk and prevent mechanical falls would be beneficial in this high-risk group.
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Affiliation(s)
- Perry Lim
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3 Floor, San Francisco, CA, 94143, USA
| | - Aaron J Clark
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
| | - Vedat Deviren
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3 Floor, San Francisco, CA, 94143, USA
| | - Sigurd H Berven
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3 Floor, San Francisco, CA, 94143, USA
| | - Shane Burch
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3 Floor, San Francisco, CA, 94143, USA
| | | | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California-San Francisco (UCSF), 500 Parnassus Ave, MUW 3 Floor, San Francisco, CA, 94143, USA.
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Collins AP, Clark AJ, Ames CP, Theologis AA. Proximal Junctional Fracture and Kyphosis: Correction With Posterior Vertebral Column Resection and the "Rail Technique": 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2024; 26:237. [PMID: 37819085 DOI: 10.1227/ons.0000000000000952] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 08/22/2023] [Indexed: 10/13/2023] Open
Affiliation(s)
- Andrew P Collins
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington , USA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California - San Francisco (UCSF), San Francisco , California , USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California - San Francisco (UCSF), San Francisco , California , USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, UCSF, San Francisco , California , USA
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Collins AP, Freise CE, Hiramoto J, Clark AJ, Theologis AA. Abdominal lymphocele following multi-level anterior lumbar interbody fusion (ALIF) managed with a laparoscopic peritoneal window: case report and review of the literature. Eur Spine J 2023:10.1007/s00586-023-08072-x. [PMID: 38147084 DOI: 10.1007/s00586-023-08072-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 10/14/2023] [Accepted: 11/29/2023] [Indexed: 12/27/2023]
Abstract
PURPOSE Lymphocele formation following anterior lumbar interbody fusion (ALIF) is not common, but it can pose diagnostic and treatment challenges. The purpose of this case is to report for the first time the treatment of a postoperative lymphocele following a multi-level ALIF using a peritoneal window made through a minimally invasive laparoscopic approach. METHODS Case report. RESULTS A 74-year-old male with a history of prostatectomy and pelvic radiation underwent a staged L3-S1 ALIF (left paramedian approach) and T10-pelvis posterior instrumented with L1-5 decompression/posterior column osteotomies for degenerative scoliosis and neurogenic claudication. Three weeks after surgery, swelling of the left abdomen and entire left leg was reported. Computed tomography of the abdomen/pelvis demonstrated a large (19.2 × 12.0 × 15.4 cm) retroperitoneal fluid collection with compression of the left ureter and left common iliac vein. Fluid analysis (80% lymphocytes) was consistent with a lymphocele. Percutaneous drainage for 4 days was ineffective at clearing the lymphocele. For more definitive management, the patient underwent an uncomplicated laparoscopic creation of a peritoneal window to allow passive drainage of lymphatic fluid into the abdomen. Three years after surgery, he had no back or leg pain, had achieved spinal union, and had no abdominal swelling or left leg swelling. Advanced imaging also confirmed resolution of the lymphocele. CONCLUSIONS In this case report, creation of a peritoneal window minimally invasively via a laparoscope allowing passive drainage of lymphatic fluid into the abdomen was safe and effective for management of an abdominal lymphocele following a multi-level ALIF.
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Affiliation(s)
- Andrew P Collins
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, USA
| | - Christopher E Freise
- Division of Transplant Surgery, Department of Surgery, University of California - San Francisco (UCSF), San Francisco, CA, USA
| | - Jade Hiramoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, UCSF, San Francisco, CA, USA
| | - Aaron J Clark
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California - San Francisco, 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA.
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Goodarzi A, Arora A, Burch S, Clark AJ, Theologis AA. Navigated Hybrid Open/Muscle-sparing Approach to 2-level Cement Augmentation of the UIV and UIV+1 for Prevention of Proximal Junctional Failure: Supplemental Manuscript to Operative Video. Clin Spine Surg 2023; 36:451-457. [PMID: 37448146 DOI: 10.1097/bsd.0000000000001485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023]
Abstract
STUDY DESIGN Operative video and supplemental manuscript. OBJECTIVE To present a cement augmentation technique of the upper instrumented vertebra (UIV) and UIV+1 for prevention of proximal junctional fractures (PJFs) in multi-level thoracolumbar posterior instrumented fusions. SUMMARY OF BACKGROUND DATA PJFs are unfortunately a common occurrence after multi-level thoracolumbar instrumented fusions to the pelvis for adult spinal deformity that can result in significant functional disability and often require costly revision operations. As such, their prevention is key. METHODS A surgical video illustrates the nuances of a 2-level cement augmentation technique, consisting of an open vertebroplasty of the UIV through fenestrated screws and a muscle-sparing kyphoplasty of the UIV+1. RESULTS Utility of performing an open vertebroplasty of the UIV through fenestrated screws and muscle-sparing kyphoplasty of the UIV+1 lies in its ability to minimize soft-tissue disruption at the adjacent segment while providing additional structural support to the anterior column at this high-risk zone. CONCLUSIONS Cement augmentation of the UIV and UIV+1 consisting of a hybrid open vertebroplasty and muscle-sparing kyphoplasty can be an effective strategy to decrease the incidence of PJF after multi-level posterior thoracolumbar instrumented fusions to the pelvis for adult spinal deformity.
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Affiliation(s)
| | | | | | - Aaron J Clark
- Neurological Surgery, University of California-San Francisco (UCSF), San Francisco, CA
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Arora A, Sharfman ZT, Clark AJ, Theologis AA. Proximal Junctional Kyphosis and Failure: Strategies for Prevention. Neurosurg Clin N Am 2023; 34:573-584. [PMID: 37718104 DOI: 10.1016/j.nec.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Proximal junctional kyphosis (PJK) and proximal junctional failure/fractures (PJF) are common complications following long-segment posterior instrumented fusions for adult spinal deformity. As progression to PJF involves clinical consequences for patients and requires costly revisions that may undermine the utility of surgery and are ultimately unsustainable for health care systems, preventative strategies to minimize the occurrence of PJF are of tremendous importance. In this article, the authors present a detailed outline of PJK and PJF with a focus on surgical strategies aimed at preventing their occurrence..
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Affiliation(s)
- Ayush Arora
- Department of Orthopaedic Surgery, UCSF, 500 Parnassus Avenue, MUW 3Road Floor, San Francisco, CA 94143, USA
| | - Zachary T Sharfman
- Department of Orthopaedic Surgery, UCSF, 500 Parnassus Avenue, MUW 3Road Floor, San Francisco, CA 94143, USA
| | - Aaron J Clark
- Department of Neurological Surgery, UCSF, 521 Parnassus Avenue, 6307, San Francisco, CA 94117, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, UCSF, 500 Parnassus Avenue, MUW 3Road Floor, San Francisco, CA 94143, USA.
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Scheer JK, Clark AJ, Mitsunaga K, Tan LA, Theologis AA. Lumbar Pedicle Subtraction Osteotomy (PSO): A Novel Surgical Technique for Correction of Sagittal and Coronal Imbalance Using Laterally Based Satellite Rods. Clin Spine Surg 2023; 36:317-322. [PMID: 37482632 DOI: 10.1097/bsd.0000000000001486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 06/19/2023] [Indexed: 07/25/2023]
Abstract
STUDY DESIGN Operative video and supplemental manuscript. OBJECTIVE To present a novel step-by-step approach to performing a lumbar pedicle subtraction osteotomy (PSO) using laterally based satellite rods. SUMMARY OF BACKGROUND DATA Multi-rod constructs have demonstrated paramount for decreasing rates of pseudarthrosis after PSOs. Multi-rods constructs can be achieved using either "satellite" rods (rods not connected to the primary rods) and/or "accessory rods" (rods connected to the primary rods). METHODS A step-by-step approach to performing a lumbar PSO using a laterally based satellite rod configuration is provided through a case example and surgical technique video. RESULTS Lateral satellite rods can be particularly useful from a surgical perspective, as they provide temporary stabilization while the PSO is being performed, facilitate closure of the osteotomy site (symmetric and/or asymmetric), and serve as the final fixation rods across the PSO without needing to be exchanged. CONCLUSIONS Use of laterally based satellite rods is a useful technique for lumbar PSOs, as they provide temporary stabilization while the PSO is being performed, facilitate closure of the osteotomy site, and serve as the final fixation rods across the PSO without needing to be exchanged.
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Affiliation(s)
- Justin K Scheer
- Department of Neurological Surgery, University of California-San Francisco (UCSF), San Francisco, CA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California-San Francisco (UCSF), San Francisco, CA
| | - Kyle Mitsunaga
- The Queen's Medical Center Orthopedic Spine Center, Honolulu, HI
| | - Lee A Tan
- Department of Neurological Surgery, University of California-San Francisco (UCSF), San Francisco, CA
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Semonche A, Scheer JK, Shah VN, Fung M, Tan LA, Chou D, Mummaneni PV, Berven SH, Ames CP, Deviren V, Theologis AA, Clark AJ. Duration of neurological deficit and outcomes in the surgical treatment of spinal coccidioidomycosis. J Neurosurg Spine 2023; 39:419-426. [PMID: 37243554 DOI: 10.3171/2023.4.spine221210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 04/17/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Vertebral osteomyelitis is a rare complication of coccidioidomycosis infection. Surgical intervention is indicated when there is failure of medical management or presence of neurological deficit, epidural abscess, or spinal instability. The relationship between timing of surgical intervention and recovery of neurological function has not been previously described. The purpose of this study was to investigate if the duration of neurological deficits at presentation affects neurological recovery after surgical intervention. METHODS This was a retrospective study of all patients diagnosed with coccidioidomycosis involving the spine at a single tertiary care center between 2012 and 2021. Data collected included patient demographics, clinical presentation, radiographic information, and surgical intervention. The primary outcome was change in neurological examination after surgical intervention, quantified according to the American Spinal Injury Association Impairment Scale. The secondary outcome was the complication rate. Logistic regression was used to test if the duration of neurological deficits was associated with improvement in the neurological examination after surgery. RESULTS Twenty-seven patients presented with spinal coccidioidomycosis between 2012 and 2021; 20 of these patients had vertebral involvement on spinal imaging with a median follow-up of 8.7 months (IQR 1.7-71.2 months). Of the 20 patients with vertebral involvement, 12 (60.0%) presented with a neurological deficit with a median duration of 20 days (range 1-61 days). Most patients presenting with neurological deficit (11/12, 91.7%) underwent surgical intervention. Nine (81.2%) of these 11 patients had an improved neurological examination after surgery and the other 2 had stable deficits. Seven patients had improved recovery sufficient to improve by 1 grade according to the AIS. The duration of neurological deficits on presentation was not significantly associated with neurological improvement after surgery (p = 0.49, Fisher's exact test). CONCLUSIONS The duration of neurological deficits on presentation should not deter surgeons from operative intervention in cases of spinal coccidioidomycosis.
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Affiliation(s)
| | | | | | - Monica Fung
- 3Department of Medicine, Division of Infectious Diseases, University of California, San Francisco, California
| | | | | | | | - Sigurd H Berven
- 4Orthopaedic Surgery, University of California, San Francisco; and
| | | | - Vedat Deviren
- 4Orthopaedic Surgery, University of California, San Francisco; and
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Clark AJ, Drullinsky D, Pradella M, Mehta CK. Aortic arch and frozen elephant trunk repair of a right-sided aortic arch with pseudoaneurysm rupture. J Vasc Surg Cases Innov Tech 2023; 9:101258. [PMID: 37520168 PMCID: PMC10382922 DOI: 10.1016/j.jvscit.2023.101258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 06/05/2023] [Indexed: 08/01/2023] Open
Abstract
A 53-year-old man with a history of vascular ring repair secondary to a right-sided aortic arch with a retroesophageal subclavian artery and ligamentum arteriosum to the descending thoracic aorta presented to our institution with a large aortic pseudoaneurysm of the distal aortic arch. Computed tomography demonstrated a right-sided aortic arch with a 5.8-cm pseudoaneurysm arising from the distal arch with concern for rupture. The patient underwent successful two-stage repair, including a left carotid artery to subclavian artery bypass, followed by total arch replacement with the frozen elephant trunk technique. He recovered well postoperatively, and computed tomography showed complete, successful repair of the pseudoaneurysm.
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Affiliation(s)
- Aaron J. Clark
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David Drullinsky
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Maurice Pradella
- Department of Radiology, Northwestern Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Christopher K. Mehta
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
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Burke JF, Garcia JH, Safaee MM, Wong C, Gill SA, Chou D, Mummaneni PV, Deviren V, Ames CP, Clark AJ. Patient Frailty Influences Outcome After Open, But Not Minimally Invasive, Transforaminal Interbody Fusion: A Case Series of 115 Patients With Lumbar Degenerative Disease. Oper Neurosurg (Hagerstown) 2023; 24:565-571. [PMID: 36897093 PMCID: PMC10586842 DOI: 10.1227/ons.0000000000000665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Accepted: 12/22/2022] [Indexed: 03/11/2023] Open
Abstract
BACKGROUND For transforaminal lumbar interbody fusion (TLIF), there are equally good open and minimally invasive surgery (MIS) options. OBJECTIVE To determine if frailty has a differential effect on outcome for open vs MIS TLIF. METHODS We performed a retrospective review of 115 TLIF surgeries (1-3 levels) for lumbar degenerative disease performed at a single center; 44 MIS transforaminal interbody fusions and 71 open TLIFs were included. All patients had at least a 2-year follow up, and any revision surgery during that time was recorded. The Adult Spinal Deformity Frailty Index (ASD-FI) was used to separate patients into nonfrail (ASD-FI < 0.3) and frail (ASD-FI > 0.3) cohorts. The primary outcome variables were revision surgery and discharge disposition. Univariate analyses were performed to reveal associations in demographic, radiographic, and surgical data with the outcome variables. Multivariate logistic regression was used to assess independent predictors of outcome. RESULTS Frailty uniquely predicted both reoperation (odds ratio 8.1, 95% CI 2.5-26.1, P = .0005) and discharge to a location other than home (odds ratio 3.9, 95% CI 1.2-12.7, P = .0239). Post hoc analysis indicated that frail patients undergoing open TLIF had a higher revision surgery rate (51.72%) compared with frail patients undergoing MIS-TLIF (16.7%). Nonfrail patients undergoing open and MIS TLIF had a revision surgery rate of 7.5% and 7.7%, respectively. CONCLUSION Frailty was associated with increased revision rate and increased probability to discharge to a location other than home after open transforaminal interbody fusions, but not MIS transforaminal interbody fusions. These data suggest that patients with high frailty scores may benefit from MIS-TLIF procedures.
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Affiliation(s)
- John F. Burke
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Joseph H. Garcia
- School of Medicine, University of California, San Francisco, California, USA
| | - Michael M. Safaee
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Christopher Wong
- College of Osteopathic Medicine, Touro University California, Vallejo, California, USA
| | - Sabraj A. Gill
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Praveen V. Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, California, USA
| | - Christopher P. Ames
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Aaron J. Clark
- Department of Neurological Surgery, University of California, San Francisco, California, USA
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15
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Clark AJ. Expanding the scope of Endocrine Connections. Endocr Connect 2023; 12:e230051. [PMID: 36780221 PMCID: PMC10083673 DOI: 10.1530/ec-23-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 02/14/2023]
Affiliation(s)
- A J Clark
- Endocrine Connections Editor-in-Chief, Emeritus Professor of Endocrinology, University of London, London, United Kingdom of Great Britain and Northern Ireland
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16
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Callander JK, Clark AJ, Dillon W, Ryan WR. Spondylodiscitis and Spinal Epidural Abscess After Transoral Robotic Surgery Radical Tonsillectomy. OTO Open 2023; 7:e61. [PMID: 37351270 PMCID: PMC10284497 DOI: 10.1002/oto2.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/14/2023] [Accepted: 05/27/2023] [Indexed: 06/24/2023] Open
Affiliation(s)
- Jacquelyn K. Callander
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUnited States
| | - Aaron J. Clark
- Department of Neurological SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUnited States
| | - William Dillon
- UCSF Department of RadiologyNeuroradiology Section, University of California San FranciscoSan FranciscoCaliforniaUnited States
| | - William R. Ryan
- Department of Otolaryngology–Head and Neck SurgeryUniversity of California San FranciscoSan FranciscoCaliforniaUnited States
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17
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Arora A, Demb J, Cummins DD, Callahan M, Clark AJ, Theologis AA. Predictive models to assess risk of extended length of stay in adults with spinal deformity and lumbar degenerative pathology: development and internal validation. Spine J 2023; 23:457-466. [PMID: 36892060 DOI: 10.1016/j.spinee.2022.10.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/13/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND CONTEXT Postoperative recovery after adult spinal deformity (ASD) operations is arduous, fraught with complications, and often requires extended hospital stays. A need exists for a method to rapidly predict patients at risk for extended length of stay (eLOS) in the preoperative setting. PURPOSE To develop a machine learning model to preoperatively estimate the likelihood of eLOS following elective multi-level lumbar/thoracolumbar spinal instrumented fusions (≥3 segments) for ASD. STUDY DESIGN/SETTING Retrospectively from a state-level inpatient database hosted by the Health care cost and Utilization Project. PATIENT SAMPLE Of 8,866 patients of age ≥50 with ASD undergoing elective lumbar or thoracolumbar multilevel instrumented fusions. OUTCOME MEASURES The primary outcome was eLOS (>7 days). METHODS Predictive variables consisted of demographics, comorbidities, and operative information. Significant variables from univariate and multivariate analyses were used to develop a logistic regression-based predictive model that use six predictors. Model accuracy was assessed through area under the curve (AUC), sensitivity, and specificity. RESULTS Of 8,866 patients met inclusion criteria. A saturated logistic model with all significant variables from multivariate analysis was developed (AUC=0.77), followed by generation of a simplified logistic model through stepwise logistic regression (AUC=0.76). Peak AUC was reached with inclusion of six selected predictors (combined anterior and posterior approach, surgery to both lumbar and thoracic regions, ≥8 level fusion, malnutrition, congestive heart failure, and academic institution). A cutoff of 0.18 for eLOS yielded a sensitivity of 77% and specificity of 68%. CONCLUSIONS This predictive model can facilitate identification of adults at risk for eLOS following elective multilevel lumbar/thoracolumbar spinal instrumented fusions for ASD. With a fair diagnostic accuracy, the predictive calculator will ideally enable clinicians to improve preoperative planning, guide patient expectations, enable optimization of modifiable risk factors, facilitate appropriate discharge planning, stratify financial risk, and accurately identify patients who may represent high-cost outliers. Future prospective studies that validate this risk assessment tool on external datasets would be valuable.
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Affiliation(s)
- Ayush Arora
- Department of Orthopedic Surgery, University of California - San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA
| | - Joshua Demb
- Division of Gastroenterology, Department of Medicine, University of California - San Diego, La Jolla, 9500 Gilman Drive, La Jolla, CA 92093, CA, USA
| | - Daniel D Cummins
- Department of Orthopedic Surgery, University of California - San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA
| | - Matt Callahan
- Department of Orthopedic Surgery, University of California - San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA
| | - Aaron J Clark
- Department of Neurological Surgery, UCSF, 400 Parnassus Ave, San Francisco, CA 94143, San Francisco, CA, USA
| | - Alekos A Theologis
- Department of Orthopedic Surgery, University of California - San Francisco (UCSF), 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA.
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18
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Haddad AF, Safaee MM, Pereira MP, Oh JY, Lau D, Tan LA, Clark AJ, Chou D, Mummaneni PV, Ames CP. Posterior-based resection of spinal meningiomas: an institutional experience of 141 patients with an average of 28 months of follow-up. J Neurosurg Spine 2023; 38:139-146. [PMID: 36152326 DOI: 10.3171/2022.7.spine211603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 07/06/2022] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Spinal meningiomas pose unique challenges based on the location of their dural attachment. However, there is a paucity of literature investigating the role of dural attachment location on outcomes after posterior-based approach for spinal meningioma resection. The aim of this study was to investigate any differences in outcomes between dural attachment location subgroups in spinal meningioma patients who underwent posterior-based resection. METHODS This was a single-institution review of patients who underwent resection of a spinal meningioma from 1997 to 2017. Surgical, oncological, and neurological outcomes were compared between patients with varying dural attachments. Multivariate analysis was utilized. RESULTS A total of 141 patients were identified. The mean age was 62 years, and 110 women were included. The sites of dural attachments were as follows: 16 (11.3%) dorsal, 31 (22.0%) dorsolateral, 17 (12.1%) lateral, 40 (28.4%) ventral, and 37 (26.2%) ventrolateral. Most meningiomas were WHO grade I (92.2%) and in the thoracic spine (61.0%). All patients underwent a posterior approach for tumor resection. There were no differences between subgroups in terms of largest diameter of tumor resected (p = 0.201), gross-total resection (GTR) or subtotal resection (p = 0.362), Simpson grade of resection, perioperative complications (p = 0.116), long-term neurological deficit (p = 0.100), or postoperative radiation therapy (p = 0.971). Cervical spine location was associated with reduced incidence of GTR (OR 0.271, 95% CI 0.108-0.684, p = 0.006) on multivariate analysis. The overall incidence of recurrence/progression was 4.6%, with no difference (p = 0.800) between subgroups. Similarly, the average length of follow-up was 28.1 months, with no difference between subgroups (p = 0.413). CONCLUSIONS Posterior-based approaches for resection of spinal meningiomas are safe and effective, regardless of dural attachment location, with similar surgical, oncological, and neurological outcomes. Comparison of long-term recurrence rates between dural attachment subgroups is required.
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Affiliation(s)
- Alexander F Haddad
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Michael M Safaee
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Matheus P Pereira
- 2Medical Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina; and
| | - Jun Yeop Oh
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Darryl Lau
- 3Department of Neurosurgery, New York University, New York, New York
| | - Lee A Tan
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Aaron J Clark
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Dean Chou
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco, California
| | - Christopher P Ames
- 1Department of Neurological Surgery, University of California, San Francisco, California
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19
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Choy W, Garcia J, Safaee MM, Rubio RR, Loftus PA, Clark AJ. Superior Laryngeal Nerve Palsy After Anterior Cervical Diskectomy and Fusion: A Case Report and Cadaveric Description. Oper Neurosurg (Hagerstown) 2022; 23:e152-e155. [PMID: 35838480 DOI: 10.1227/ons.0000000000000276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 03/06/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Superior laryngeal nerve (SLN) injury after high cervical dissection can result in changes in vocal pitch due to cricothyroid denervation and dysphagia with aspiration risk because of decreased sensation of the supraglottic larynx. CLINICAL PRESENTATION We describe a 69-year-old singer with cervical spondylotic myelopathy who underwent elective C3/4 and C4/5 anterior cervical diskectomy and fusion. Postoperatively, the patient reported changes in his voice, most noticeable with higher registers. A number of studies confirmed severe right superior laryngeal neuropathy. A cadaveric description included to highlight anatomic relationships critical in minimizing risk of SLN injury during an anterior cervical diskectomy and fusion approach. CONCLUSION The SLN is a critical structure vulnerable to iatrogenic injury during high cervical dissections for anterior approaches to the spine. Therefore, it is critical for spine surgeons to have a firm understanding of SLN anatomy for these approaches.
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Affiliation(s)
- Winward Choy
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Joseph Garcia
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Roberto R Rubio
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Patricia A Loftus
- Department of Otolaryngology, Head and Neck Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
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20
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Mendelis JR, Hung NJ, Deviren V, Ames CP, Clark AJ, Theologis AA. Proximal Junctional Spondylodiscitis Following Adult Spinal Deformity Surgery: Case Series and Review of the Literature. Int J Spine Surg 2022; 16:1054-1060. [PMID: 35831064 PMCID: PMC9807054 DOI: 10.14444/8327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Proximal junctional failure (PJF) following multilevel thoracolumbar instrumented to the pelvis for adult spinal deformity (ASD) is relatively uncommon but considerably disabling. While the leading etiology is mechanical, other rarer etiologies can play a role in its development. The purpose of this study was to present a case series of ASD patients who experienced PJF secondary to proximal junctional spondylodiscitis (PJS) after long-segment thoracolumbar posterior instrumented fusions. METHODS Adult patients who underwent posterior instrumented fusions at a single academic center between 2017 and 2020 and subsequently developed PJS were retrospectively reviewed. Patient demographics, operative details, clinical presentation, culture data, and management approach were evaluated. RESULTS Three patients developed PJS and were included for analysis (mean age 67 years [range, 58-76]; women: 2). Indication for all index operations was symptomatic ASD after failed conservative management. Clinical presentation ranged from mild back pain to severe neurological compromise. Average time to infection and PJF after the index procedure was 11 months (range, 3 months-2 years). All 3 patients were successfully managed with urgent revision surgery including surgical debridement and postoperative antibiotics. CONCLUSION PJS is a rare yet potentially devastating complication following long-segment posterior thoracolumbar instrumented fusions for ASD. It is critical that surgeons maintain a high index of suspicion of infection when managing PJF given the potential neurological morbidity of PJS. CLINICAL RELEVANCE This report highlights a rare but important cause of PJF following ASD surgery. It is critical that one maintains a high index of suspicion of infection when managing PJF. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- Joseph R. Mendelis
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Nicole J. Hung
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Vedat Deviren
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Christopher P. Ames
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Aaron J. Clark
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Alekos A. Theologis
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, USA, Alekos A. Theologis, Department of Orthopedic Surgery, University of California - San Francisco, 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA 94143, USA;
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21
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Buren MA, Theologis A, Zuraek A, Behrends M, Clark AJ, Leung JM. Lidocaine Infusion for the Management of Postoperative Pain and Delirium (LIMPP): protocol for a randomised control trial. BMJ Open 2022; 12:e059416. [PMID: 35667730 PMCID: PMC9171272 DOI: 10.1136/bmjopen-2021-059416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Postoperative delirium is a frequent adverse event following elective non-cardiac surgery. The occurrence of delirium increases the risk of functional impairment, placement to facilities other than home after discharge, cognitive impairment at discharge, as well as in-hospital and possibly long-term mortality. Unfortunately, there is a dearth of effective strategies to minimise the risk from modifiable risk factors, including postoperative pain control and the analgesic regimen. Use of potent opioids, currently the backbone of postoperative pain control, alters cognition and has been associated with an increased risk of postoperative delirium. Literature supports the intraoperative use of lidocaine infusions to decrease postoperative opioid requirements, however, whether the use of postoperative lidocaine infusions is associated with lower opioid requirements and subsequently a reduction in postoperative delirium has not been investigated. METHODS AND ANALYSIS The Lidocaine Infusion for the Management of Postoperative Pain and Delirium trial is a randomised, double-blinded study of a postoperative 48-hour infusion of lidocaine at 1.33 mg/kg/hour versus placebo in older patients undergoing major reconstructive spinal surgery at the University of California, San Francisco. Our primary outcome is incident delirium measured daily by the Confusion Assessment Method in the first three postoperative days. Secondary outcomes include delirium severity, changes in cognition, pain scores, opioid use, incidence of opioid related side effects and functional benefits including time to discharge and improved recovery from surgery. Lidocaine safety will be assessed with daily screening questionnaires and lidocaine plasma levels. ETHICS AND DISSEMINATION This study protocol has been approved by the ethics board at the University of California, San Francisco. The results of this study will be published in a peer-review journal and presented at national conferences as poster or oral presentations. Participants wishing to know the results of this study will be contacted directly on data publication. TRIAL REGISTRATION NUMBER NCT05010148.
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Affiliation(s)
- Marc Alan Buren
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Alekos Theologis
- Orthopedic Surgery, University of California San Francisco, San Francisco, California, USA
| | - Ariadne Zuraek
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Matthias Behrends
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
| | - Aaron J Clark
- Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Jacqueline M Leung
- Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA
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Cummins D, Georgiou S, Burch S, Tay B, Berven SH, Ames CP, Deviren V, Clark AJ, Theologis AA. RAPT score and preoperative factors to predict discharge location following adult spinal deformity surgery. Spine Deform 2022; 10:639-646. [PMID: 34773631 DOI: 10.1007/s43390-021-00439-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Accepted: 10/30/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess factors, including RAPT score, predictive of non-home discharges following adult spinal deformity (ASD) operations. METHODS Adults who underwent thoracolumbar instrumented fusions to the pelvis for ASD (1/2019-1/2020) were reviewed. Patient demographics, RAPT metrics, hospital length of stay (LOS), operative details, and complications were compared between patients discharged home and non-home. Univariate and multivariate analyses were performed using logistic regression to determine the relative risk of non-home discharge. Area Under the Receiver Operating Characteristic curve (AUROC) for RAPT score and non-home discharge was also determined. RESULTS Ninety-nine patients (average age 68 ± 9 years; female-64; average RAPT 8.6 ± 2.2) were analyzed. Operations had the following characteristics: average # levels fused 11 ± 3, revisions 54%, anterior-posterior 70%, 3-column osteotomies 23%. Average LOS was 8.5 ± 3.6 days. The majority of patients (75.8%) had non-home discharges. Non-home discharges had significantly lower RAPT scores (8.3 vs. 9.6; p = 0.02), more advanced age (70 vs. 63 years; p = 0.01), and higher Charlson Comorbidity Index (CCI) scores (3.6 vs. 2.5; p < 0.01) compared to home discharges. On univariate analysis, factors significantly associated with non-home discharge were older age [relative risk (RR) 1.09, p < 0.01], higher CCI (RR 1.73, p = 0.01), total # levels fused (RR 1.24, p = 0.04), and lower RAPT scores (RR 0.71, p = 0.01). RAPT score < 8 was most predictive of non-home discharge (RR 4.87, p = 0.04). An AUROC relating RAPT scores and non-home discharge was 0.7. CONCLUSIONS Non-home discharges after ASD operations are common. Of the four factors associated with non-home discharges (elderly age, higher CCI, total number of levels fused, RAPT score), a RAPT score < 8 was most predictive. The RAPT score holds promising utility for pre-operative patient counseling and discharge planning for adults undergoing operations for spinal deformity.
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Affiliation(s)
- Daniel Cummins
- Department of Orthopaedic Surgery, University of California - San Francisco, 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
| | - Stephen Georgiou
- Department of Orthopaedic Surgery, University of California - San Francisco, 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
| | - Shane Burch
- Department of Orthopaedic Surgery, University of California - San Francisco, 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
| | - Bobby Tay
- Department of Orthopaedic Surgery, University of California - San Francisco, 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
| | - Sigurd H Berven
- Department of Orthopaedic Surgery, University of California - San Francisco, 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
| | | | - Vedat Deviren
- Department of Orthopaedic Surgery, University of California - San Francisco, 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA
| | - Aaron J Clark
- Department of Neurological Surgery, UCSF, San Francisco, CA, USA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California - San Francisco, 500 Parnassus Ave, MUW 3rd Floor, San Francisco, CA, 94143, USA.
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23
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Cummins D, Callahan M, Clark AJ, Theologis AA. Lower Neurological Risk with Anterior Operations Compared to Posterior Operations for Thoracic Disc Herniations: Analysis of 697 Patients. Spine (Phila Pa 1976) 2022; 47:E94-E100. [PMID: 34381003 DOI: 10.1097/brs.0000000000004196] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE Compare rates of postoperative neural deficits between surgical approaches for thoracic disc herniations (TDHs). SUMMARY OF BACKGROUND DATA Anterior and posterior approaches for TDH carry high reported neurological risk, albeit comparative risk is not well defined. METHODS Health Care Utilization Project (HCUP) state inpatient databases (NY, FL, CA; 2005-2014) were queried for patients who underwent TDH operation. Demographics, operative details, surgical approach, neural injury, length of stay (LOS), and discharge location were assessed. Multivariate linear regression was used to determine relative risk of neural deficit and skilled nursing facility (SNF) discharge. RESULTS Six hundred ninety-seven patients (mean age 52.0 yrs, 194 institutions) met inclusion. Majority of operations were elective (76.0%) and one to two levels (80.5%). Overall neural injury rate was 9.0%. Anterior operations had significantly lower rates of neural injury compared with posterior operations on univariate analysis (4.6% vs. 11.4%; P < 0.01). All multilevel operations had similarly high rates of neural injury. On multivariate analysis, posterior approaches (RR 1.78; P = 0.12) and combined approaches (RR 2.15; P = 0.17) had higher neural risk compared with anterior approaches after controlling for younger age, higher Charlson Comorbidity Index, and nonelective admissions. Combined approaches had similar neural injury rates (13.8%) to posterior operations (11.4%) and significantly longer LOS and SNF discharges compared with single approaches. Neural deficit was associated with discharge to SNF (With = 87.3%; Without = 23.7%; P < 0.01) and increased LOS (With = 12.5 days; Without = 6.9 days; P < 0.01). CONCLUSION Overall rate of neural deficit after operation for TDH was 9.0%. While anterior approach was associated with a lower neural injury rate, this association was confounded by age, Charlson Comorbidity Index, and admission type. After correcting for these confounders, a nonsignificant trend remained that favored the anterior approach. Neural deficit was associated with increased LOS and discharge to SNF postoperatively.Level of Evidence: 4.
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Affiliation(s)
- Daniel Cummins
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, CA
| | - Matthew Callahan
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, CA
| | - Aaron J Clark
- Department of Neurological Surgery, UCSF, San Francisco, CA
| | - Alekos A Theologis
- Department of Orthopaedic Surgery, University of California - San Francisco (UCSF), San Francisco, CA
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Garcia JH, Haddad AF, Patel A, Safaee MM, Pennicooke B, Mummaneni PV, Clark AJ. Management of Malpositioned Cervical Interfacet Spacers: An Institutional Case Series. Cureus 2021; 13:e20450. [PMID: 35070522 PMCID: PMC8763025 DOI: 10.7759/cureus.20450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/05/2022] Open
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Chan AK, Badiee RK, Rivera J, Chang CC, Robinson LC, Mehra RN, Tan LA, Clark AJ, Dhall SS, Chou D, Mummaneni PV. Crossing the Cervicothoracic Junction During Posterior Cervical Fusion for Myelopathy Is Associated With Superior Radiographic Parameters But Similar Clinical Outcomes. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa241_s035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Lu AY, Blitstein JS, Talbott JF, Chan AK, Dhall SS, El Naga AN, Tan LA, Clark AJ, Chou D, Mummaneni PV, DiGiorgio AM. Single versus dual operative spine fractures in ankylosing spondylitis. Neurosurg Focus 2021; 51:E6. [PMID: 34598123 DOI: 10.3171/2021.7.focus21329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 07/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Ankylosing spondylitis, the most common spondyloarthritis, fuses individual spinal vertebrae into long segments. The unique biomechanics of the ankylosed spine places patients at unusually high risk for unstable fractures secondary to low-impact mechanisms. These injuries are unique within the spine trauma population and necessitate thoughtful management. Therefore, the authors aimed to present a richly annotated data set of operative AS spine fractures with a significant portion of patients with simultaneous dual noncontiguous fractures. METHODS Patients with ankylosing spondylitis with acute fractures who received operative management between 2012 and 2020 were reviewed. Demographic, admission, surgical, and outcome parameters were retrospectively collected and reviewed. RESULTS In total, 29 patients were identified across 30 different admissions. At admission, the mean age was 71.7 ± 11.8 years. The mechanism of injury in 77% of the admissions was a ground-level fall; 30% also presented with polytrauma. Of admissions, 50% were patient transfers from outside hospitals, whereas the other half presented primarily to our emergency departments. Fifty percent of patients sustained a spinal cord injury, and 35 operative fractures were identified and treated in 32 surgeries. The majority of fractures clustered around the cervicothoracic (C4-T1, 48.6%) and thoracolumbar (T8-L3, 37.11%) junctions. Five patients (17.2%) had simultaneous dual noncontiguous operative fractures; these patients were more likely to have presented with a higher-energy mechanism of injury such as a bicycle or motor vehicle accident compared with patients with a single operative fracture (60% vs 8%, p = 0.024). On preoperative MRI, 56.3% of the fractures had epidural hematomas (EDHs); 25% were compressive of the underlying neural elements, which dictated the number of laminectomy levels performed (no EDH, 2.1 ± 2.36; noncompressive EDH, 2.1 ± 1.85; and compressive EDH, 7.4 ± 4 [p = 0.003]). The mean difference in instrumented levels was 8.7 ± 2.6 with a mean estimated blood loss (EBL) of 1183 ± 1779.5 mL. Patients on a regimen of antiplatelet therapy had a significantly higher EBL (2635.7 mL vs 759.4 mL, p = 0.015). Overall, patients had a mean hospital length of stay of 15.2 ± 18.5 days; 5 patients died during the same admission or after transfer to an outside hospital. Nine of 29 patients (31%) had died by the last follow-up (the mean follow-up was 596.3 ± 878.9 days). CONCLUSIONS Patients with AS who have been found to have unstable spine fractures warrant a thorough diagnostic evaluation to identify secondary fractures as well as compressive EDHs. These patients experienced prolonged inpatient hospitalizations with significant morbidity and mortality.
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Affiliation(s)
- Alex Y Lu
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Jacob S Blitstein
- 2Touro University California, College of Osteopathic Medicine, Vallejo
| | - Jason F Talbott
- 3Department of Radiology, University of California, San Francisco; and
| | - Andrew K Chan
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Sanjay S Dhall
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Ashraf N El Naga
- 4Department of Orthopedic Surgery, University of California, San Francisco, California
| | - Lee A Tan
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Aaron J Clark
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Dean Chou
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Anthony M DiGiorgio
- 1Department of Neurological Surgery, University of California, San Francisco
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Haddad AF, Burke JF, Mummaneni PV, Chan AK, Safaee MM, Knightly JJ, Mayer RR, Pennicooke BH, Digiorgio AM, Weinstein PR, Clark AJ, Chou D, Dhall SS. Telemedicine in Neurosurgery: Standardizing the Spinal Physical Examination Using A Modified Delphi Method. Neurospine 2021; 18:292-302. [PMID: 34218612 PMCID: PMC8255762 DOI: 10.14245/ns.2040684.342] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/29/2021] [Indexed: 11/26/2022] Open
Abstract
Objective The use of telemedicine has dramatically increased due to the coronavirus disease 2019 pandemic. Many neurosurgeons are now using telemedicine technologies for preoperative evaluations and routine outpatient visits. Our goal was to standardize the telemedicine motor neurologic examination, summarize the evidence surrounding clinical use of telehealth technologies, and discuss financial and legal considerations.
Methods We identified a 12-member panel composed of spine surgeons, fellows, and senior residents at a single institution. We created an initial telehealth strength examination protocol based on published data and developed 10 agree/disagree statements summarizing the protocol. A blinded Delphi method was utilized to build consensus for each statement, defined as > 80% agreement and no significant disagreement using a 2-way binomial test (significance threshold of p < 0.05). Any statement that did not meet consensus was edited and iteratively resubmitted to the panel until consensus was achieved. In the final round, the panel was unblinded and the protocol was finalized.
Results After the first round, 4/10 statements failed to meet consensus (< 80% agreement, and p = 0.031, p = 0.031, p = 0.003, and p = 0.031 statistical disagreement, respectively). The disagreement pertained to grading of strength of the upper (3/10 statements) and lower extremities (1/10 statement). The amended statements clarified strength grading, achieved consensus (> 80% agreement, p > 0.05 disagreement), and were used to create the final telehealth strength examination protocol.
Conclusion The resulting protocol was used in our clinic to standardize the telehealth strength examination. This protocol, as well as our summary of telehealth clinical practice, should aid neurosurgical clinics in integrating telemedicine modalities into their practice.
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Affiliation(s)
- Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - John F Burke
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | | | - Rory R Mayer
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Brenton H Pennicooke
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Anthony M Digiorgio
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Philip R Weinstein
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
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Oh T, Avalos LN, Burke JF, Mummaneni N, Safaee M, Gupta N, Clark AJ. A Type II Split Cord Malformation in an Adult Patient: An Operative Case Report. Oper Neurosurg (Hagerstown) 2021; 20:E148-E151. [PMID: 33294923 DOI: 10.1093/ons/opaa334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/11/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Split cord malformations (SCMs) are rare conditions in which the spinal cord is split into two hemicords within either a single thecal sac or two separate thecal sacs. The hemicords are typically split by a bony or fibrous structure. We present an adult patient who presented with a type II SCM with tethered cord. This is the first case of such a presentation with an accompanying intraoperative video. Unusual features of the case were the presence of an incomplete fibrous septum and lack of a discrete filum terminale. CLINICAL PRESENTATION A 50-yr-old woman presented with back pain, radiculopathy, urinary urgency, and episodic fecal incontinence. Her exam was notable for weakness of the right extensor hallicus longus. Imaging showed an SCM extending from L3 to S1, a fibrous septum located at L4-5, and a low-lying conus at S4. She was treated with a decompressive L3-S4 laminectomy and disconnection of all the dural attachment points. She required lumbar drain placement postoperatively and reoperation for wound dehiscence and persistent pseudomeningocele. At the time of last follow-up, she was neurologically intact with improvement in bowel/bladder function. CONCLUSION SCM is an uncommon presentation in adults and is often accompanied by findings of skin stigmata, tethered cord, and other central nervous system/skeletal anomalies. Obtaining full multimodal imaging is critical to understanding subtle anatomic variations that can pose operative challenges. We report the treatment of an adult patient with type II SCM, and provide an intraoperative video demonstrating the removal of an incomplete midline fibrous septum.
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Affiliation(s)
- Taemin Oh
- Division of Pediatric Neurosurgery, UCSF Benioff Children's Hospital, San Francisco, California
| | - Lauro Nathaniel Avalos
- Division of Pediatric Neurosurgery, UCSF Benioff Children's Hospital, San Francisco, California
| | - John Frederick Burke
- Division of Pediatric Neurosurgery, UCSF Benioff Children's Hospital, San Francisco, California
| | - Nikhil Mummaneni
- Division of Pediatric Neurosurgery, UCSF Benioff Children's Hospital, San Francisco, California
| | - Michael Safaee
- Division of Pediatric Neurosurgery, UCSF Benioff Children's Hospital, San Francisco, California
| | - Nalin Gupta
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Division of Pediatric Neurosurgery, UCSF Benioff Children's Hospital, San Francisco, California
| | - Aaron J Clark
- Division of Pediatric Neurosurgery, UCSF Benioff Children's Hospital, San Francisco, California
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Denk JA, Michel E, Clark AJ, Thinh Pham D, Mehta CK. Veno-Venous Extracorporeal Rewarming Using Dual-Lumen Cannula in Accidental Hypothermia. ASAIO J 2021; 68:e53-e55. [PMID: 33769347 DOI: 10.1097/mat.0000000000001424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Accidental hypothermia with a core temperature below 28°C is associated with an increased risk of hemodynamic instability. It is difficult to predict which patients will survive with a favorable neurologic outcome; therefore, decision-making regarding extracorporeal support is not straightforward. We report a case of rewarming using veno-venous dual-lumen cannula as an alternative to veno-arterial support with full recovery and normal neurologic examination. In centers where extracorporeal membrane oxygenation is available, rewarming using veno-venous dual-lumen extracorporeal support may be a useful strategy to mitigate the risks associated with veno-arterial extracorporeal support.
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Affiliation(s)
- Jennifer A Denk
- From the Division of Anesthesiology, Bluhm Cardiovascular Institute, Northwestern Medicine and Northwestern University Feinberg School of Medicine, Chicago, Illinois Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine and Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Herrmann JL, Clark AJ, Colgate C, Rodefeld MD, Hoyer MH, Turrentine MW, Brown JW. Surgical Valvuloplasty Versus Balloon Dilation for Congenital Aortic Stenosis in Pediatric Patients. World J Pediatr Congenit Heart Surg 2021; 11:444-451. [PMID: 32645785 DOI: 10.1177/2150135120918774] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND For children with congenital aortic stenosis (AS) who are candidates for biventricular repair, valvuloplasty can be achieved by surgical aortic valvuloplasty (SAV) or by transcatheter balloon aortic dilation (BAD). We aimed to evaluate the longer term outcomes of SAV versus BAD at our institution. METHODS We retrospectively reviewed the outcomes of 2 months to 18 years old patients who underwent SAV or BAD at our institution between January 1990 and July 2018. Baseline and follow-up characteristics were assessed by echocardiography. Long-term survival, freedom from reintervention, freedom from aortic valve replacement (AVR), and aortic regurgitation were evaluated. RESULTS A total of 212 patients met inclusion criteria (SAV = 123; BAD = 89). Age, sex, aortic insufficiency (AI), and aortic valve gradient were similar between the groups. At 10 years, 27.9% (19/68) of SAV patients and 58.3% (28/48) of BAD patients had moderate or worse AI (P = .001), and reintervention occurred in 39.2% (29/74) of SAV patients and 78.6% (44/56) of BAD patients (P < .001). Kaplan-Meier analysis revealed overall survival was 96.8% (119/123) for SAV and 95.5% (85/89) for SAV (P = .87). At 10 years, 35% (23/66) of SAV patients and 54% (23/43) of BAD patients underwent AVR (P = .213). CONCLUSIONS Surgical aortic valvuloplasty demonstrated greater gradient reduction, less postoperative and long-term AI, and a lower reintervention rate at 10 years than BAD. There was no difference in survival or AVR reintervention rate. Surgical aortic valvuloplasty is a durable and efficacious intervention and should continue to be considered a favorable choice for palliation of valvular AS.
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Affiliation(s)
- Jeremy L Herrmann
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - Aaron J Clark
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Cameron Colgate
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark D Rodefeld
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - Mark H Hoyer
- Riley Children's Health at IU Health, Indianapolis, IN, USA.,Section of Pediatric Cardiology, Department of Pediatrics, Indianapolis, IN, USA
| | - Mark W Turrentine
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - John W Brown
- Division of Thoracic and Cardiovascular Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.,Riley Children's Health at IU Health, Indianapolis, IN, USA
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Safaee MM, Tenorio A, Haddad AF, Wu B, Hu SS, Tay B, Burch S, Berven SH, Deviren V, Dhall SS, Chou D, Mummaneni PV, Eichler CM, Ames CP, Clark AJ. Anterior Lumbar Interbody Fusion With Cage Retrieval for the Treatment of Pseudarthrosis After Transforaminal Lumbar Interbody Fusion: A Single-Institution Case Series. Oper Neurosurg (Hagerstown) 2021; 20:164-173. [PMID: 33035339 DOI: 10.1093/ons/opaa303] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/08/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The treatment of pseudarthrosis after transforaminal lumbar interbody fusion (TLIF) can be challenging, particularly when anterior column reconstruction is required. There are limited data on TLIF cage removal through an anterior approach. OBJECTIVE To assess the safety and efficacy of anterior lumbar interbody fusion (ALIF) as a treatment for pseudarthrosis after TLIF. METHODS ALIFs performed at a single academic medical center were reviewed to identify cases performed for the treatment of pseudarthrosis after TLIF. Patient demographics, surgical characteristics, perioperative complications, and 1-yr radiographic data were collected. RESULTS A total of 84 patients were identified with mean age of 59 yr and 37 women (44.0%). A total of 16 patients (19.0%) underwent removal of 2 interbody cages for a total of 99 implants removed with distribution as follows: 1 L2/3 (0.9%), 6 L3/4 (5.7%), 37 L4/5 (41.5%), and 55 L5/S1 (51.9%). There were 2 intraoperative venous injuries (2.4%) and postoperative complications were as follows: 7 ileus (8.3%), 5 wound-related (6.0%), 1 rectus hematoma (1.1%), and 12 medical complications (14.3%), including 6 pulmonary (7.1%), 3 cardiac (3.6%), and 6 urinary tract infections (7.1%). Among 58 patients with at least 1-yr follow-up, 56 (96.6%) had solid fusion. There were 5 cases of subsidence (6.0%), none of which required surgical revision. Two patients (2.4%) required additional surgery at the level of ALIF for pseudarthrosis. CONCLUSION ALIF is a safe and effective technique for the treatment of TLIF cage pseudarthrosis with a favorable risk profile.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Alexander Tenorio
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Alexander F Haddad
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Bian Wu
- Department of Vascular Surgery, University of California, San Francisco, San Francisco, California
| | - Serena S Hu
- Department of Orthopedic Surgery, Stanford University, Stanford, California
| | - Bobby Tay
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Shane Burch
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Sigurd H Berven
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Charles M Eichler
- Department of Vascular Surgery, University of California, San Francisco, San Francisco, California
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Safaee M, Tenorio A, Haddad AF, Wu B, Hu S, Tay B, Burch S, Berven S, Deviren V, Dhall SS, Chou D, Mummaneni PV, Eichler C, Ames CP, Clark AJ. Anterior Lumbar Interbody Fusion With Cage Retrieval for the Treatment of Pseudarthrosis After Transforaminal Lumbar Interbody Fusion. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Safaee M, Chang D, Hillman J, Shah SS, Wadhwa H, Ames CP, Clark AJ. Implementation of Outpatient Anterior Cervical Discectomy and Fusion at an Academic Medical Center Without Dedicated Ambulatory Surgery Centers. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Safaee M, Chang D, Hillman J, Shah SS, Garcia J, Wadhwa H, Ames CP, Clark AJ. Implementation of Outpatient Minimally Invasive Lumbar Decompression at an Academic Medical Center Without Ambulatory Surgery Centers. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Safaee MM, Chang D, Hillman JM, Shah SS, Garcia J, Wadhwa H, Ames CP, Clark AJ. Implementation of Outpatient Minimally Invasive Lumbar Decompression at an Academic Medical Center without Ambulatory Surgery Centers: A Cost Analysis and Systematic Review. World Neurosurg 2020; 146:e961-e971. [PMID: 33248311 DOI: 10.1016/j.wneu.2020.11.044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Lumbar decompressions are increasingly performed at ambulatory surgery centers (ASCs). We sought to compare costs of open and minimally invasive (MIS) lumbar decompressions performed at a university without dedicated ASCs. METHODS Lumbar decompressions performed at a tertiary academic hospital or satellite university hospital dedicated to outpatient surgery were retrospectively reviewed. Care pathways were same-day, overnight observation, or inpatient admission. Patient demographics, American Society of Anesthesiologists classification, Charlson Comorbidity Index, surgical characteristics, 30-day readmission, and costs were collected. A systematic review of lumbar decompression cost literature was performed. RESULTS A total of 354 patients, mean age 55 years with 128 women (36.2%), were reviewed. There was no significant difference in age, gender, body mass index, American Society of Anesthesiologists classification, or Charlson Comorbidity Index between patients treated with open and minimally invasive surgery. Open decompression was associated with higher total cost ($21,280 vs. $14,407; P < 0.001); however, this was driven by care pathway and length of stay. When stratifying by care pathway, there was no difference in total cost between open versus minimally invasive surgery among same-day ($10,609 vs. $11,074; P = 0.556), overnight observation ($14,097 vs. $13,992; P = 0.918), or inpatient admissions ($24,507 vs. $27,929; P = 0.311). CONCLUSIONS When accounting for care pathway, the cost of open and MIS decompression were no different. Transition from a tertiary academic hospital to a university hospital specializing in outpatient surgery was not associated with lower costs. Academic departments may consider transitioning lumbar decompressions to a dedicated ASC to maximize cost savings; however, additional studies are needed.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Diana Chang
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - John M Hillman
- Adult Business Line Finance, University of California Medical Center, San Francisco, California, USA
| | - Sumedh S Shah
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Joseph Garcia
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Harsh Wadhwa
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA.
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Safaee MM, Chang D, Hillman JM, Shah SS, Wadhwa H, Ames CP, Clark AJ. Cost Analysis of Outpatient Anterior Cervical Discectomy and Fusion at an Academic Medical Center without Dedicated Ambulatory Surgery Centers. World Neurosurg 2020; 146:e940-e946. [PMID: 33217594 DOI: 10.1016/j.wneu.2020.11.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) are increasingly performed at ambulatory surgical centers (ASCs). Academic centers lacking dedicated ASCs must perform these at large university hospitals, which pose unique challenges to cost savings and efficiency. OBJECTIVE To describe the safety and cost of outpatient ACDF at a major academic medical center without a dedicated ASC. METHODS ACDFs performed from 2015 to 2018 were retrospectively reviewed. Cases were performed at the major tertiary university hospital or a satellite university hospital dedicated to outpatient surgery. Patient demographics, surgical characteristics, perioperative complications, fusion at 12 months, and cost were collected. RESULTS A total of 470 patients were included. The mean age was 56 years, with 255 women (54.3%). When comparing same-day discharge, overnight observation, or inpatient admission, there were no differences in age, gender, or number of levels fused. Same-day and overnight observation cases were associated with shorter procedure duration and less estimated blood loss. There were no differences in perioperative complications, 30-day readmissions, or fusion at 12 months. Direct and total costs were lowest for same-day cases, followed by overnight observation and inpatient admissions (P < 0.001). CONCLUSION Academic centers without dedicated ASCs can safely perform ACDF as a same-day or overnight observation procedure with significant reductions in cost. The lack of a dedicated ASC should not preclude academic centers from allocating appropriately selected patients into same-day or overnight observation care pathways. This strategy can improve resource utilization and preserve precious hospital resources for the most critically ill patients while also allowing these centers to build viable outpatient spine practices.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Diana Chang
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - John M Hillman
- Adult Business Line Finance, University of California Medical Center, San Francisco, California, USA
| | - Sumedh S Shah
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Harsh Wadhwa
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, California, USA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, California, USA.
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Safaee MM, Tenorio A, Osorio JA, Choy W, Amara D, Lai L, Hu SS, Tay B, Burch S, Berven SH, Deviren V, Dhall SS, Chou D, Mummaneni PV, Eichler CM, Ames CP, Clark AJ. The effect of anterior lumbar interbody fusion staging order on perioperative complications in circumferential lumbar fusions performed within the same hospital admission. Neurosurg Focus 2020; 49:E6. [PMID: 32871562 DOI: 10.3171/2020.6.focus20296] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 06/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Anterior lumbar interbody fusion (ALIF) is a powerful technique that provides wide access to the disc space and allows for large lordotic grafts. When used with posterior spinal fusion (PSF), the procedures are often staged within the same hospital admission. There are limited data on the perioperative risk profile of ALIF-first versus PSF-first circumferential fusions performed within the same hospital admission. In an effort to understand whether these procedures are associated with different perioperative complication profiles, the authors performed a retrospective review of their institutional experience in adult patients who had undergone circumferential lumbar fusions. METHODS The electronic medicals records of patients who had undergone ALIF and PSF on separate days within the same hospital admission at a single academic center were retrospectively analyzed. Patients carrying a diagnosis of tumor, infection, or traumatic fracture were excluded. Demographics, surgical characteristics, and perioperative complications were collected and assessed. RESULTS A total of 373 patients, 217 of them women (58.2%), met the inclusion criteria. The mean age of the study cohort was 60 years. Surgical indications were as follows: degenerative disease or spondylolisthesis, 171 (45.8%); adult deformity, 168 (45.0%); and pseudarthrosis, 34 (9.1%). The majority of patients underwent ALIF first (321 [86.1%]) with a mean time of 2.5 days between stages. The mean number of levels fused was 2.1 for ALIF and 6.8 for PSF. In a comparison of ALIF-first to PSF-first cases, there were no major differences in demographics or surgical characteristics. Rates of intraoperative complications including venous injury were not significantly different between the two groups. The rates of postoperative ileus (11.8% vs 5.8%, p = 0.194) and ALIF-related wound complications (9.0% vs 3.8%, p = 0.283) were slightly higher in the ALIF-first group, although the differences did not reach statistical significance. Rates of other perioperative complications were no different. CONCLUSIONS In patients undergoing staged circumferential fusion with ALIF and PSF, there was no statistically significant difference in the rate of perioperative complications when comparing ALIF-first to PSF-first surgeries.
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Affiliation(s)
| | | | | | | | | | | | - Serena S Hu
- 2Department of Orthopedic Surgery, Stanford University, Palo Alto, California
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Safaee MM, Shah V, Tenorio A, Uribe JS, Clark AJ. Minimally Invasive Pedicle Screw Fixation With Indirect Decompression by Ligamentotaxis in Pathological Fractures. Oper Neurosurg (Hagerstown) 2020; 19:210-217. [PMID: 32255471 DOI: 10.1093/ons/opaa045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Accepted: 01/13/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The spine is the most common site of bony metastases. Associated pathological fractures can result in pain, neurological deficit, biomechanical instability, and deformity. OBJECTIVE To present a minimally invasive technique for indirect decompression by ligamentotaxis in pathological fractures. METHODS A minimally invasive approach was utilized to perform percutaneous pedicle screw fixation in patients who required stabilization for pathological fractures. Preoperative and postoperative computed tomography and magnetic resonance imaging were used to compare spinal canal area and midsagittal canal diameter. RESULTS Two patients with newly diagnosed pathological fractures underwent minimally invasive treatment. Each presented with minimal epidural disease and a chief complaint of intractable back pain without neurological deficit. They underwent minimally invasive pedicle screw fixation with indirect decompression by ligamentotaxis. In each case, postoperative imaging demonstrated an increase in spinal canal area and midsagittal canal diameter by an independent neuroradiologist. There were no perioperative complications, and each patient was neurologically stable without evidence of hardware failure at their 5- and 6-mo follow-up visits. CONCLUSION Minimally invasive percutaneous fixation can be used to stabilize pathological fractures and provide indirect decompression by ligamentotaxis. This procedure is associated with minimal blood loss, low morbidity, and rapid initiation of radiation therapy. Only patients with minimal epidural disease, stenosis caused primarily by bony retropulsion, and mild-to-moderate deformity should be considered candidates for this approach.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California
| | - Vinil Shah
- Division of Neuroradiology, Department of Radiology, University of California-San Francisco, San Francisco, California
| | - Alexander Tenorio
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California
| | | | - Aaron J Clark
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California
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Xi Z, Mummaneni PV, Wang M, Ruan H, Burch S, Deviren V, Clark AJ, Berven SH, Chou D. The association between lower Hounsfield units on computed tomography and cage subsidence after lateral lumbar interbody fusion. Neurosurg Focus 2020; 49:E8. [DOI: 10.3171/2020.5.focus20169] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 05/13/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVEOne vexing problem after lateral lumbar interbody fusion (LLIF) surgery is cage subsidence. Low bone mineral density (BMD) may contribute to subsidence, and BMD is correlated with Hounsfield units (HUs) on CT. The authors investigated if lower HU values correlated with subsidence after LLIF.METHODSA retrospective study of patients undergoing single-level LLIF with pedicle screw fixation for degenerative conditions at the University of California, San Francisco, by 6 spine surgeons was performed. Data on demographics, cage parameters, preoperative HUs on CT, and postoperative subsidence were collected. Thirty-six–inch standing radiographs were used to measure segmental lordosis, disc space height, and subsidence; data were collected immediately postoperatively and at 1 year. Subsidence was graded using a published grade of disc height loss: grade 0, 0%–24%; grade I, 25%–49%; grade II, 50%–74%; and grade III, 75%–100%. HU values were measured on preoperative CT from L1 to L5, and each lumbar vertebral body HU was measured 4 separate times.RESULTSAfter identifying 138 patients who underwent LLIF, 68 met the study inclusion criteria. All patients had single-level LLIF with pedicle screw fixation. The mean follow-up duration was 25.3 ± 10.4 months. There were 40 patients who had grade 0 subsidence, 15 grade I, 9 grade II, and 4 grade III. There were no significant differences in age, sex, BMI, or smoking. There were no significant differences in cage sizes, cage lordosis, and preoperative disc height. The mean segmental HU (the average HU value of the two vertebrae above and below the LLIF) was 169.5 ± 45 for grade 0, 130.3 ± 56.2 for grade I, 100.7 ± 30.2 for grade II, and 119.9 ± 52.9 for grade III (p < 0.001). After using a receiver operating characteristic curve to establish separation criteria between mild and severe subsidence, the most appropriate threshold of HU value was 135.02 between mild and severe subsidence (sensitivity 60%, specificity 92.3%). After univariate and multivariate analysis, preoperative segmental HU value was an independent risk factor for severe cage subsidence (p = 0.017, OR 15.694, 95% CI 1.621–151.961).CONCLUSIONSLower HU values on preoperative CT are associated with cage subsidence after LLIF. Measurement of preoperative HU values on CT may be useful when planning LLIF surgery.
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Affiliation(s)
- Zhuo Xi
- Departments of 1Neurosurgery and
- 3Department of Neurosurgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
| | | | | | | | - Shane Burch
- 2Orthopedic Surgery, University of California, San Francisco, California; and
| | - Vedat Deviren
- 2Orthopedic Surgery, University of California, San Francisco, California; and
| | | | - Sigurd H. Berven
- 2Orthopedic Surgery, University of California, San Francisco, California; and
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Chan AK, Badiee RK, Rivera J, Chang CC, Robinson LC, Mehra RN, Tan LA, Clark AJ, Dhall SS, Chou D, Mummaneni PV. Crossing the Cervicothoracic Junction During Posterior Cervical Fusion for Myelopathy Is Associated With Superior Radiographic Parameters But Similar Clinical Outcomes. Neurosurgery 2020; 87:1016-1024. [DOI: 10.1093/neuros/nyaa241] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 04/05/2020] [Indexed: 11/13/2022] Open
Abstract
AbstractBackgroundFor laminectomy and posterior spinal fusion (LPSF) surgery for cervical spondylotic myelopathy (CSM), the evidence is unclear as to whether fusions should cross the cervicothoracic junction (CTJ).ObjectiveTo compare LPSF outcomes between those with and without lower instrumented vertebrae (LIV) crossing the CTJ.MethodsA consecutive series of adults undergoing LPSF for CSM from 2012 to 2018 with a minimum of 12-mo follow-up were identified. LPSF with subaxial upper instrumented vertebrae and LIV between C6 and T2 were included. Clinical and radiographic outcomes were compared.ResultsA total of 79 patients were included: 46 crossed the CTJ (crossed-CTJ) and 33 did not. The mean follow-up was 22.2 mo (minimum: 12 mo). Crossed-CTJ had higher preoperative C2-7 sagittal vertical axis (cSVA) (33.3 ± 16.0 vs 23.8 ± 12.4 mm, P = .01) but similar preoperative cervical lordosis (CL) and CL minus T1-slope (CL minus T1-slope) (P > .05, both comparisons). The overall reoperation rate was 3.8% (crossed-CTJ: 2.2% vs not-crossed: 6.1%, P = .37). In adjusted analyses, crossed-CTJ was associated with superior cSVA (β = –9.7; P = .002), CL (β = 6.2; P = .04), and CL minus T1-slope (β = –6.6; P = .04), but longer operative times (β = 46.3; P = .001). Crossed- and not-crossed CTJ achieved similar postoperative patient-reported outcomes [Visual Analog Scale (VAS) neck pain, VAS arm pain, Nurick Grade, Modified Japanese Orthopedic Association Scale, Neck Disability Index, and EuroQol-5D] in adjusted multivariable analyses (adjusted P > .05). For the entire cohort, higher postoperative CL was associated with lower postoperative arm pain (adjusted Pearson's r –0.1, P = .02). No postoperative cervical radiographic parameters were associated with neck pain (P > .05).ConclusionSubaxial LPSF for CSM that crossed the CTJ were associated with superior radiographic outcomes for cSVA, CL, and CL minus T1-slope, but longer operative times. There were no differences in neck pain or reoperation rate.
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Affiliation(s)
- Andrew K Chan
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ryan K Badiee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
- School of Medicine, University of California, San Francisco, San Francisco, California
| | - Joshua Rivera
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Chih-Chang Chang
- Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Leslie C Robinson
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Ratnesh N Mehra
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Lee A Tan
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Dean Chou
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Strohl MP, Choy W, Clark AJ, Mummaneni PV, Dhall SS, Tay BK, Loftus PA, El-Sayed IH, Russell MS. Immediate Voice and Swallowing Complaints Following Revision Anterior Cervical Spine Surgery. Otolaryngol Head Neck Surg 2020; 163:778-784. [PMID: 32482158 DOI: 10.1177/0194599820926133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To report on the incidence of dysphagia, dysphonia, and acute vocal fold motion impairment (VFMI) following revision anterior cervical spine surgery, as well as to identify risk factors associated with acute VFMI in the immediate postoperative period. STUDY DESIGN Retrospective cohort study. SETTING Tertiary care center. SUBJECTS AND METHODS All patients who underwent 2-team reoperative anterior cervical discectomy and fusion (ACDF) were retrospectively reviewed. Incidence of dysphonia, dysphagia, and acute VFMI was noted. Patient and operative factors were evaluated for association with risk of acute VFMI. RESULTS The incidence of postoperative dysphonia and dysphagia was 25% (18/72) and 52% (37/72), respectively. The incidence of immediate VFMI was 21% (15/72). Subjective postoperative dysphonia (odds ratio, [OR] 8; 95% CI, 2.2-28; P = .001) and dysphagia (OR, 22; 95% CI, 2.5-168; P = .005) were significantly associated with increased risk of VFMI. Three patients with VFMI required temporary injection medialization for voice complaints and/or aspiration. Infection (OR, 14; 95% CI, 1.4-147, P = .025) and level C7/T1 (OR, 5.5; 95% CI, 1.3-23, P = .02) were significantly associated with an increased risk of acute VFMI on multivariate logistic regression analysis. Number of prior surgeries, laterality of approach, side of approach relative to prior operations, and number of levels exposed were not significant. CONCLUSION Early involvement of an otolaryngologist in the care of a patient undergoing revision ACDF can be helpful to the patient in anticipation of voice and swallowing changes in the postoperative period. This may be particularly important in those being treated at C7/T1 or those with spinal infections.
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Affiliation(s)
- Madeleine P Strohl
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Winward Choy
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Aaron J Clark
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Praveen V Mummaneni
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Sanjay S Dhall
- Department of Neurological Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Bobby K Tay
- Department of Orthopedic Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Patricia A Loftus
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Ivan H El-Sayed
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
| | - Matthew S Russell
- Department of Otolaryngology-Head and Neck Surgery, University of California-San Francisco, San Francisco, California, USA
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Safaee MM, Tenorio A, Osorio JA, Choy W, Amara D, Lai L, Molinaro AM, Zhang Y, Hu SS, Tay B, Burch S, Berven SH, Deviren V, Dhall SS, Chou D, Mummaneni PV, Eichler CM, Ames CP, Clark AJ. The impact of obesity on perioperative complications in patients undergoing anterior lumbar interbody fusion. J Neurosurg Spine 2020; 33:1-10. [PMID: 32330881 DOI: 10.3171/2020.2.spine191418] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/27/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Anterior approaches to the lumbar spine provide wide exposure that facilitates placement of large grafts with high fusion rates. There are limited data on the effects of obesity on perioperative complications. METHODS Data from consecutive patients undergoing anterior lumbar interbody fusion (ALIF) from 2007 to 2016 at a single academic center were analyzed. The primary outcome was any perioperative complication. Complications were divided into those occurring intraoperatively and those occurring postoperatively. Multivariate logistic regression was used to assess the association of obesity and other variables with these complications. An estimation table was used to identify a body mass index (BMI) threshold associated with increased risk of postoperative complication. RESULTS A total of 938 patients were identified, and the mean age was 57 years; 511 were females (54.5%). The mean BMI was 28.7 kg/m2, with 354 (37.7%) patients classified as obese (BMI ≥ 30 kg/m2). Forty patients (4.3%) underwent a lateral transthoracic approach, while the remaining 898 (95.7%) underwent a transabdominal retroperitoneal approach. Among patients undergoing transabdominal retroperitoneal ALIF, complication rates were higher for obese patients than for nonobese patients (37.0% vs 28.7%, p = 0.010), a difference that was driven primarily by postoperative complications (36.1% vs 26.0%, p = 0.001) rather than intraoperative complications (3.2% vs 4.3%, p = 0.416). Obese patients had higher rates of ileus (11.7% vs 7.2%, p = 0.020), wound complications (11.4% vs 3.4%, p < 0.001), and urinary tract infections (UTI) (5.0% vs 2.5%, p = 0.049). In a multivariate model, age, obesity, and number of ALIF levels fused were associated with an increased risk of postoperative complication. An estimation table including 19 candidate cut-points, odds ratios, and adjusted p values found a BMI ≥ 31 kg/m2 to have the highest association with postoperative complication (p = 0.012). CONCLUSIONS Obesity is associated with increased postoperative complications in ALIF, including ileus, wound complications, and UTI. ALIF is a safe and effective procedure. However, patients with a BMI ≥ 31 kg/m2 should be counseled on their increased risks and warrant careful preoperative medical optimization and close monitoring in the postoperative setting.
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Affiliation(s)
- Michael M Safaee
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Alexander Tenorio
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Joseph A Osorio
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Winward Choy
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Dominic Amara
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Lillian Lai
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Annette M Molinaro
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Yalan Zhang
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Serena S Hu
- 2Department of Orthopedic Surgery, Stanford University, Palo Alto; and
| | - Bobby Tay
- Departments of3Orthopedic Surgery and
| | | | | | | | - Sanjay S Dhall
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Dean Chou
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Praveen V Mummaneni
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Charles M Eichler
- 4Vascular Surgery, University of California, San Francisco, California
| | - Christopher P Ames
- 1Department of Neurological Surgery, University of California, San Francisco
| | - Aaron J Clark
- 1Department of Neurological Surgery, University of California, San Francisco
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Chan AK, Ammanuel SG, Chan AY, Oh T, Skrehot HC, Edwards CS, Kondapavulur S, Miller CA, Nichols AD, Liu C, Dhall SS, Clark AJ, Chou D, Ames CP, Mummaneni PV. Chlorhexidine Showers are Associated With a Reduction in Surgical Site Infection Following Spine Surgery: An Analysis of 4266 Consecutive Surgeries. Neurosurgery 2020; 85:817-826. [PMID: 30590721 DOI: 10.1093/neuros/nyy568] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 11/05/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Surgical site infection (SSI) is a common complication following spinal surgery. Prevention is critical to maintaining safe patient care and reducing additional costs associated with treatment. OBJECTIVE To determine the efficacy of preoperative chlorhexidine (CHG) showers on SSI rates following fusion and nonfusion spine surgery. METHODS A mandatory preoperative CHG shower protocol was implemented at our institution in November 2013. A cohort comparison of 4266 consecutive patients assessed differences in SSI rates for the pre- and postimplementation periods. Subgroup analysis was performed on the type of spinal surgery (eg, fusion vs nonfusion). Data represent all spine surgeries performed between April 2012 and April 2016. RESULTS The overall mean SSI rate was 0.4%. There was no significant difference between the pre- (0.7%) and postimplementation periods (0.2%; P = .08). Subgroup analysis stratified by procedure type showed that the SSI rate for the nonfusion patients was significantly lower in the post- (0.1%) than the preimplementation group (0.7%; P = .02). There was no significant difference between SSI rates for the pre- (0.8%) and postimplementation groups (0.3%) for the fusion cohort (P = .21). In multivariate analysis, the implementation of preoperative CHG showers were associated with significantly decreased odds of SSI (odds ratio = 0.15, 95% confidence interval [0.03-0.55], P < .01). CONCLUSION This is the largest study investigating the efficacy of preoperative CHG showers on SSI following spinal surgery. In adjusted multivariate analysis, CHG showering was associated with a significant decrease in SSI following spinal surgery.
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Affiliation(s)
- Andrew K Chan
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Simon G Ammanuel
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Alvin Y Chan
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Taemin Oh
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Henry C Skrehot
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Caleb S Edwards
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Sravani Kondapavulur
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Catherine A Miller
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Amy D Nichols
- Department of Hospital Epidemiology and Infection Control, University of California, San Francisco, San Francisco, California
| | - Catherine Liu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Institute and Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington
| | - Sanjay S Dhall
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Aaron J Clark
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Dean Chou
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Christopher P Ames
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
| | - Praveen V Mummaneni
- Department of Neurosurgery, University of California, San Francisco, San Francisco, California
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Safaee MM, Pekmezci M, Deviren V, Ames CP, Clark AJ. Thoracolumbar Vertebral Column Resection With Rectangular Endplate Cages Through a Posterior Approach: Surgical Techniques and Early Postoperative Outcomes. Oper Neurosurg (Hagerstown) 2020; 18:329-338. [PMID: 31214704 DOI: 10.1093/ons/opz151] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Accepted: 03/04/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Thoracolumbar pathology can result in compression of neural elements, instability, and deformity. Circumferential decompression with anterior column reconstruction is often required to restore biomechanical stability and minimize the risk of implant failure. OBJECTIVE To assess the safety and viability of wide-footprint rectangular cages for vertebral column resection (VCR). METHODS We performed VCR with wide-footprint rectangular endplate cages, which were designed for transthoracic or retroperitoneal approaches. We present our technique using a single-stage posterior approach. RESULTS A total of 45 patients underwent VCR with rectangular endplate cages. Mean age was 58 yr. Diagnoses included 23 tumors (51%), 14 infections (31%), and 8 deformities (18%). VCRs were performed in 10 upper thoracic, 17 middle thoracic, 14 lower thoracic, and 4 lumbar levels. Twenty-four cases involved a single level VCR (53%) with 18 two-level (40%) and 3 three-level (7%) VCRs. Average procedure duration was 264 min with mean estimated blood loss of 1900 ml. Neurological outcomes were stable in 27 cases (60%), improved in 16 (36%), and worse in 2 (4%). There were 7 medical and 7 surgical complications in 11 patients. There were significant decreases in postoperative thoracic kyphosis (47° vs 35°, P = .022) and regional kyphosis (34° vs 10°, P < .001). There were 2 cases of cage subsidence due to intraoperative endplate violation, neither of which progressed on CT scan at 14 and 35 mo. CONCLUSION Posterior VCR with rectangular footprint cages is safe and feasible. This provides improved biomechanical stability without the morbidity of a lateral transthoracic or retroperitoneal approach.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
| | - Murat Pekmezci
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California.,Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Onwuharine EN, Clark AJ. Comparison of double inversion recovery magnetic resonance imaging (DIR-MRI) and dynamic contrast enhanced magnetic resonance imaging (DCE-MRI) in detection of prostate cancer: A pilot study. Radiography (Lond) 2020; 26:234-239. [PMID: 32052752 DOI: 10.1016/j.radi.2019.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/12/2019] [Accepted: 12/16/2019] [Indexed: 01/09/2023]
Abstract
INTRODUCTION DCE-MRI is established for detecting prostate cancer (PCa). However, it requires a gadolinium contrast agent, with potential risks for patients. The application of DIR-MRI is simple and may allow cancer detection without the use of an intravenous contrast agent by differentially nullifying signal from normal and abnormal prostate tissue, creating contrast between the cancer and background normal prostate. In this pilot study we gathered data from DIR-MRI and DCE-MRI of the prostate for an equivalence trial. We also looked at how the DIR-MRI appearance varies with the aggressiveness of PCa. METHOD DIR-MRI and DCE-MRI were acquired. The images were assessed by an experienced Consultant Radiologist and a novice reporter (Radiographer). The potential PCa lesions were quantified using a lesion to normal ratio (LNR). Radiological pathological correlation was made to identify the MRI lesions that represented significant PCa. A Wilcoxon sign rank was used to compare DCE-LNR and DIR-LNR for PCa containing lesions. Pearson's correlation was used to look at the relationship between DIR-LNR and PCa grade group (aggressiveness). RESULTS DCE-LNR and DIR-LNR were found to be significantly different (Z = -5.910, p < 0.001). However, a significant correlation was found between PCa grade group and DIR-LNR. CONCLUSION DIR and DCE sequences are not equivalent and significant cancer is more conspicuous on the DCE sequence. However, DIR-LNR does correlate with PCa aggressiveness. IMPLICATIONS FOR PRACTICE With the correlation of PCa grade group with DIR-LNR this may be a useful sequence in evaluation of the prostate; stratifying the risk of there being clinically significant PCa before biopsy is performed. Furthermore, given that DIR-LNR appears to predict PCa aggressiveness DIR might be used as part of a multiparametric MRI protocol designed to avoid biopsy.
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Affiliation(s)
- E N Onwuharine
- Radiology Department, University Hospitals of North Midlands (UHNM) NHS Trust, UK.
| | - A J Clark
- Radiology Department, University Hospitals of North Midlands (UHNM) NHS Trust, UK.
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Lee LS, Clark AJ, Namburi N, Naum CC, Timsina LR, Corvera JS, Beckman DJ, Everett JE, Hess PJ. The presence of a dedicated cardiac surgical intensive care service impacts clinical outcomes in adult cardiac surgery patients. J Card Surg 2020; 35:787-793. [PMID: 32048378 DOI: 10.1111/jocs.14457] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Postoperative critical care management is an integral part of cardiac surgery that contributes directly to clinical outcomes. In the United States there remains considerable variability in the critical care infrastructure for cardiac surgical programs. There is little published data investigating the impact of a dedicated cardiac surgical intensive care service. METHODS A retrospective study examining postoperative outcomes in cardiac surgical patients before and after the implementation of a dedicated cardiac surgical intensive care service at a single academic institution. An institutional Society of Thoracic Surgeons database was queried for study variables. Primary endpoints were the postoperative length of stay, intensive care unit length of stay, and mechanical ventilation time. Secondary endpoints included mortality, readmission rates, and postoperative complications. The effect on outcomes based on procedure type was also analyzed. RESULTS A total of 1703 patients were included in this study-914 in the control group (before dedicated intensive care service) and 789 in the study group (after dedicated intensive care service). Baseline demographics were similar between groups. Length of stay, mechanical ventilation hours, and renal failure rate were significantly reduced in the study group. Coronary artery bypass grafting patients observed the greatest improvement in outcomes. CONCLUSIONS Implementation of a dedicated cardiac surgical intensive care service leads to significant improvements in clinical outcomes. The greatest benefit is seen in patients undergoing coronary artery bypass, the most common cardiac surgical operation in the United States. Thus, developing a cardiac surgical intensive care service may be a worthwhile initiative for any cardiac surgical program.
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Affiliation(s)
- Lawrence S Lee
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Aaron J Clark
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Niharika Namburi
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Chris C Naum
- Division of Pulmonary and Critical Care Medicine, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lava R Timsina
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Joel S Corvera
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Daniel J Beckman
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey E Everett
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Philip J Hess
- Division of Cardiothoracic Surgery, Indiana University Health Methodist Hospital, Indiana University School of Medicine, Indianapolis, Indiana
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Deng H, Chan AK, Ammanuel SG, Chan AY, Oh T, Skrehot HC, Edwards CS, Kondapavulur S, Nichols AD, Liu C, Yue JK, Dhall SS, Clark AJ, Chou D, Ames CP, Mummaneni PV. Risk factors for deep surgical site infection following thoracolumbar spinal surgery. J Neurosurg Spine 2020. [DOI: 10.3171/2019.8.spine19479] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVESurgical site infection (SSI) following spine surgery causes major morbidity and greatly impedes functional recovery. In the modern era of advanced operative techniques and improved perioperative care, SSI remains a problematic complication that may be reduced with institutional practices. The objectives of this study were to 1) characterize the SSI rate and microbial etiology following spine surgery for various thoracolumbar diseases, and 2) identify risk factors that were associated with SSI despite current perioperative management.METHODSAll patients treated with thoracic or lumbar spine operations on the neurosurgery service at the University of California, San Francisco from April 2012 to April 2016 were formally reviewed for SSI using the National Healthcare Safety Network (NHSN) guidelines. Preoperative risk variables included age, sex, BMI, smoking, diabetes mellitus (DM), coronary artery disease (CAD), ambulatory status, history of malignancy, use of preoperative chlorhexidine gluconate (CHG) showers, and the American Society of Anesthesiologists (ASA) classification. Operative variables included surgical pathology, resident involvement, spine level and surgical technique, instrumentation, antibiotic and steroid use, estimated blood loss (EBL), and operative time. Multivariable logistic regression was used to evaluate predictors for SSI. Odds ratios and 95% confidence intervals were reported.RESULTSIn total, 2252 consecutive patients underwent thoracolumbar spine surgery. The mean patient age was 58.6 ± 13.8 years and 49.6% were male. The mean hospital length of stay was 6.6 ± 7.4 days. Sixty percent of patients had degenerative conditions, and 51.9% underwent fusions. Sixty percent of patients utilized presurgery CHG showers. The mean operative duration was 3.7 ± 2 hours, and the mean EBL was 467 ± 829 ml. Compared to nonfusion patients, fusion patients were older (mean 60.1 ± 12.7 vs 57.1 ± 14.7 years, p < 0.001), were more likely to have an ASA classification > II (48.0% vs 36.0%, p < 0.001), and experienced longer operative times (252.3 ± 120.9 minutes vs 191.1 ± 110.2 minutes, p < 0.001). Eleven patients had deep SSI (0.49%), and the most common causative organisms were methicillin-sensitive Staphylococcus aureus and methicillin-resistant S. aureus. Patients with CAD (p = 0.003) or DM (p = 0.050), and those who were male (p = 0.006), were predictors of increased odds of SSI, and presurgery CHG showers (p = 0.001) were associated with decreased odds of SSI.CONCLUSIONSThis institutional experience over a 4-year period revealed that the overall rate of SSI by the NHSN criteria was low at 0.49% following thoracolumbar surgery. This was attributable to the implementation of presurgery optimization, and intraoperative and postoperative measures to prevent SSI across the authors’ institution. Despite prevention measures, having a history of CAD or DM, and being male, were risk factors associated with increased SSI, and presurgery CHG shower utilization decreased SSI risk in patients.
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Affiliation(s)
- Hansen Deng
- 1Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Andrew K. Chan
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Simon G. Ammanuel
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Alvin Y. Chan
- 3Department of Neurological Surgery, University of California, Irvine, California
| | - Taemin Oh
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Henry C. Skrehot
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Caleb S. Edwards
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Sravani Kondapavulur
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Amy D. Nichols
- 4Department of Hospital Epidemiology and Infection Control, University of California, San Francisco, California; and
| | - Catherine Liu
- 5Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Institute and Division of Allergy and Infectious Diseases, University of Washington, Seattle, Washington
| | - John K. Yue
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Sanjay S. Dhall
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Aaron J. Clark
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Dean Chou
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Christopher P. Ames
- 2Department of Neurological Surgery, University of California, San Francisco, California
| | - Praveen V. Mummaneni
- 2Department of Neurological Surgery, University of California, San Francisco, California
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Safaee MM, Ames CP, Deviren V, Clark AJ. Minimally Invasive Lateral Retroperitoneal Approach for Resection of Extraforaminal Lumbar Plexus Schwannomas: Operative Techniques and Literature Review. Oper Neurosurg (Hagerstown) 2019; 15:516-521. [PMID: 29351647 DOI: 10.1093/ons/opx304] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Accepted: 12/26/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Traditional approaches for retroperitoneal lumbar plexus schwannomas involve anterior open or laparoscopic resection. For select tumors, the lateral retroperitoneal approach provides a minimally invasive alternative. OBJECTIVE To describe a minimally invasive lateral transpsoas approach for the resection of retroperitoneal schwannomas. METHODS A lateral retroperitoneal transpsoas approach was used to resect a 3.1 × 2.7 × 4.1 cm schwannoma embedded within the psoas muscle. A minimally invasive retractor system allows for appropriate visualization and complete resection with the aid of the microscope. The patient tolerated the procedure without complication and was discharged on postoperative day 2 in good condition at her neurological baseline. RESULTS The lateral retroperitoneal approach provides a minimally invasive alternative for select retroperitoneal schwannomas. In theory, this procedure allows for faster recovery and less blood loss compared to traditional open anterior approaches. For a subset of tumors, anterior laparoscopy may provide better access, but the lateral approach is well known to most neurosurgeons who perform lateral interbody fusions and can be easily tailored to extraforaminal tumor resection. CONCLUSION Retroperitoneal schwannomas pose a challenge due to their deep location. The lateral retroperitoneal approach provides a useful alternative for resection of a subset of retroperitoneal schwannomas.
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Affiliation(s)
- Michael M Safaee
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, California.,Department of Orthopedic Surgery, University of California, San Francisco, California
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, California
| | - Aaron J Clark
- Department of Neurological Surgery, University of California, San Francisco, California
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Mu TS, Becker AM, Clark AJ, Batts SG, Murata LAM, Uyehara CFT. ECMO with vasopressor use during early endotoxic shock: Can it improve circulatory support and regional microcirculatory blood flow? PLoS One 2019; 14:e0223604. [PMID: 31600278 PMCID: PMC6786553 DOI: 10.1371/journal.pone.0223604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/24/2019] [Indexed: 11/24/2022] Open
Abstract
Introduction While extracorporeal membrane oxygenation (ECMO) is effective in preventing further hypoxemia and maintains blood flow in endotoxin-induced shock, ECMO alone does not reverse the hypotension. In this study, we tested whether concurrent vasopressor use with ECMO would provide increased circulatory support and blood flow, and characterized regional blood flow distribution to vital organs. Methods Endotoxic shock was induced in piglets to achieve a 30% decrease in mean arterial pressure (MAP). Measurements of untreated pigs were compared to pigs treated with ECMO alone or ECMO and vasopressors. Results ECMO provided cardiac support during vasodilatory endotoxic shock and improved oxygen delivery, but vasopressor therapy was required to return MAP to normotensive levels. Increased blood pressure with vasopressors did not alter oxygen consumption or extraction compared to ECMO alone. Regional microcirculatory blood flow (RBF) to the brain, kidney, and liver were maintained or increased during ECMO with and without vasopressors. Conclusion ECMO support and concurrent vasopressor use improve regional blood flow and oxygen delivery even in the absence of full blood pressure restoration. Vasopressor-induced selective distribution of blood flow to vital organs is retained when vasopressors are administered with ECMO.
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Affiliation(s)
- Thornton S. Mu
- Department of Pediatrics, Brooke Army Medical Center, San Antonio, Texas, United States of America
- * E-mail:
| | - Amy M. Becker
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, United States of America
| | - Aaron J. Clark
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, United States of America
| | - Sherreen G. Batts
- Department of Pediatrics, Tripler Army Medical Center, Honolulu, HI, United States of America
| | - Lee-Ann M. Murata
- Department of Clinical Investigation, Tripler Army Medical Center, Honolulu, HI, United States of America
| | - Catherine F. T. Uyehara
- Department of Clinical Investigation, Tripler Army Medical Center, Honolulu, HI, United States of America
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Safaee M, Tenorio A, Amara D, Lai L, Molinaro A, Hu S, Tay B, Burch S, Berven S, Deviren V, Dhall SS, Chou D, Mummaneni PV, Eichler CM, Ames CP, Clark AJ. Perioperative Complications in Obese Patients Undergoing Anterior Lumbar Interbody Fusion: Results From 938 Patients. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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