Distinctive Characteristics of Thoracolumbar Junction Region Stenosis

STUDY DESIGN

Retrospective case series and systemic literature meta-analysis.

BACKGROUND

Thoracolumbar junction region stenosis produces spinal cord compression just above the conus and may manifest with symptoms that are not typical of either thoracic myelopathy or neurogenic claudication from lumbar stenosis.

OBJECTIVE

As few studies describe its specific pattern of presenting symptoms and neurological deficits, this investigation was designed to improve understanding of this pathology.

METHODS

A retrospective review assessed surgically treated cases of T10-L1 degenerative stenosis. Clinical outcomes were evaluated with the thoracic Japanese Orthopedic Association score. In addition, a systematic review and meta-analysis was performed in accordance with guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Of 1069 patients undergoing laminectomy at 1477 levels, 31 patients (16M/15F) were treated at T10-L1 a mean age 64.4 (SD=11.8). Patients complained of lower extremity numbness in 29/31 (94%), urinary dysfunction 11/31 (35%), and back pain 11/31 (35%). All complained about gait difficulty and objective motor deficits were detected in 24 of 31 (77%). Weakness was most often seen in foot dorsiflexion 22/31 (71%). Deep tendon reflexes were increased in 10 (32%), decreased in 11 (35%), and normal 10 (32%); the Babinski sign was present 8/31 (26%). Mean thoracic Japanese Orthopedic Association scores improved from 6.4 (SD=1.8) to 8.4 (SD=1.8) ( P <0.00001). Gait subjectively improved in 27/31 (87%) numbness improved in 26/30 (87%); but urinary function improved in only 4/11 (45%).

CONCLUSIONS

Thoracolumbar junction stenosis produces distinctive neurological findings characterized by lower extremity numbness, weakness particularly in foot dorsiflexion, urinary dysfunction, and inconsistent reflex changes, a neurological pattern stemming from epiconus level compression and the myelomeres for the L5 roots. Surgery results in significant clinical improvement, with numbness and gait improving more than urinary dysfunction. Many patients with thoracolumbar junction stenosis are initially misdiagnosed as being symptomatic from lumbar stenosis, thus delaying definitive surgery.

Intramedullary Spinal Hemorrhage in Behcet's Syndrome: A Case Report and Systematic Review

Acute neurological manifestations in patients with Behcet's syndrome are rare yet may lead to devastating outcomes. Distinguishing primary neurological deficits from spontaneous hemorrhagic insults is of particular importance for the prognosis of patients with Behcet's syndrome. Here, we investigate the clinical characteristics, management, and outcomes of nontraumatic hemorrhagic injury in patients with Bechet's syndrome. Following the case presentation, a systematic review of the literature identified cases of spontaneous hemorrhage among patients with Behcet's syndrome. Variables of interest were collected from each article to characterize patient demographics, clinical manifestations, management, and reported outcomes. Additionally, a rare case of nontraumatic intramedullary spinal bleeding in a young male with Behcet's syndrome is presented. Including our case, we analyzed 12 cases of spontaneous bleeding associated with Behcet's syndrome in 12 articles. Patient age ranged from 16 to 71 (median = 36), with a male predominance (n = 11, 91.7%). Involvement of cardiothoracic structures (n = 3, 25%), pulmonary (n = 4, 33.3%), and gastrointestinal or genitourinary vasculature (n = 3, 25%) was most common, followed by extracranial (n = 2, 16.7%) and central nervous system vasculature (n = 1, 8.3%). Clinical presentation varied depending on which specific systems or anatomical structures were involved. Anticoagulation or antiplatelet therapy was mentioned in three cases (27.3%). Erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) were noted to be elevated in six cases (54.5%). Most cases were managed surgically (n = 8, 66.7%); four cases were managed conservatively (33.3%). In our case, the patient's intramedullary bleed was allowed to dissolve without further manipulation. Of the reported outcomes, major recovery was achieved in 10 patients (83.3%), and two patients died from aneurysm or pseudoaneurysm rupture (16.7%). New-onset neurological findings in patients with Behcet's syndrome should raise suspicion for possible spontaneous hemorrhage. Our case presents the first reported instance of an abrupt onset of neurological injury secondary to intramedullary spinal cord bleed in Behcet's syndrome. A systematic review of the literature demonstrates no difference in mortality for patients managed conservatively compared to those who undergo surgical treatment.

Treatment of Chiari malformations with craniovertebral junction anomalies: Where do we stand today?

Background

Chiari malformation type 1 (CM-1) is characterized by cerebellar tonsil herniation through the foramen magnum and can be associated with additional craniovertebral junction anomalies (CVJA). The pathophysiology and treatment for CM-1 with CVJA (CM-CVJA) is debated.

Objective

To evaluate the trends and outcomes of surgical interventions for patients with CM-CVJA.

Methods

A systematic review of the literature was performed to obtain articles describing surgical interventions for patients with CM-CVJA. Articles included were case series describing surgical approach; reviews were excluded. Variables evaluated included patient characteristics, approach, and postoperative outcomes.

Results

The initial query yielded 403 articles. Twelve articles, published between 1998-2020, met inclusion criteria. From these included articles, 449 patients underwent surgical interventions for CM-CVJA. The most common CVJAs included basilar invagination (BI) (338, 75.3%), atlantoaxial dislocation (68, 15.1%) odontoid process retroflexion (43, 9.6%), and medullary kink (36, 8.0%). Operations described included posterior fossa decompression (PFD), transoral (TO) decompression, and posterior arthrodesis with either occipitocervical fusion (OCF) or atlantoaxial fusion. Early studies described good results using combined ventral and posterior decompression. More recent articles described positive outcomes with PFD or posterior arthrodesis in combination or alone. Treatment failure was described in patients with PFD alone that later required posterior arthrodesis. Additionally, reports of treatment success with posterior arthrodesis without PFD was seen.

Conclusion

Patients with CM-CVJA appear to benefit from posterior arthrodesis with or without decompressive procedures. Further definition of the pathophysiology of craniocervical anomalies is warranted to identify patient selection criteria and ideal level of fixation.

Superior discrimination of the Risk Analysis Index compared with the 5-item modified frailty index in 30-day outcome prediction after anterior cervical discectomy and fusion

OBJECTIVE

The objective of this paper was to compare the predictive ability of the recalibrated Risk Analysis Index (RAI-rev) with the 5-item modified frailty index-5 (mFI-5) for postoperative outcomes of anterior cervical discectomy and fusion (ACDF).

METHODS

This study was performed using data of adult (age > 18 years) ACDF patients obtained from the National Surgical Quality Improvement Program database during the years 2015-2019. Multivariate modeling and receiver operating characteristic (ROC) curve analysis, including area under the curve/C-statistic calculation with the DeLong test, were performed to evaluate the comparative discriminative ability of the RAI-rev and mFI-5 for 5 postoperative outcomes.

RESULTS

Both the RAI-rev and mFI-5 were independent predictors of increased postoperative mortality and morbidity in a cohort of 61,441 ACDF patients. In the ROC analysis for 30-day mortality prediction, C-statistics indicated a significantly better performance of the RAI-rev (C-statistic = 0.855, 95% CI 0.852-0.858) compared with the mFI-5 (C-statistic = 0.684, 95% CI 0.680-0.688) (p < 0.001, DeLong test). The results were similar for postoperative ACDF morbidity, Clavien-Dindo grade IV complications, nonhome discharge, and reoperation, demonstrating the superior discriminative ability of the RAI-rev compared with the mFI-5.

CONCLUSIONS

The RAI-rev demonstrates superior discrimination to the mFI-5 in predicting postoperative ACDF mortality and morbidity. To the authors' knowledge, this is the first study to document frailty as an independent risk factor for postoperative mortality after ACDF. The RAI-rev has conceptual fidelity to the frailty phenotype and may be more useful than the mFI-5 in preoperative ACDF risk stratification. Prospective validation of these findings is necessary, but patients with high RAI-rev scores may benefit from knowing that they might have an increased surgical risk for ACDF morbidity and mortality.

Thecal sac ligation in the setting of thoracic spondyloptosis with complete cord transection

Background

Traumatic spondyloptosis (TS) with complete spinal cord transection and unrepairable durotomy is particularly rare and can lead to a difficult-to-manage cerebrospinal fluid (CSF) leak.

Methods

We performed a systematic review of the literature on TS and discuss the management strategies and outcomes of TS with cord transection and significant dural tear. We also report a novel case of a 26-year-old female who presented with thoracic TS with complete spinal cord transection and unrepairable durotomy with high-flow CSF leak.

Results

Of 93 articles that resulted in the search query, 13 described cases of TS with complete cord transection. The approach to dural repair was only described in 8 (n = 20) of the 13 articles. The dura was not repaired in two (20%) of the cases. Ligation of the proximal end of the dural defect was done in 15 (75%) of the cases, all at the same institution. One (5%) case report describes ligation of the distal end; one (5%) case describes the repair of the dura with duraplasty; and another (5%) case describes repair using muscle graft to partially reconstruct the defect.

Conclusion

Suture ligation of the thecal sac in the setting of traumatic complete spinal cord transection with significant dural disruption has been described in the international literature and is a safe and successful technique to prevent complications associated with persisting high-flow CSF leakage. To the best of our knowledge, this is the first report of thecal sac ligation of the proximal end of the defect from the United States.

Dural Closure Techniques and Cerebrospinal Fluid Leak Incidence After Resection of Primary Intradural Spinal Tumors: A Systematic Review

STUDY DESIGN

This is a systematic review of primary intradural spinal tumors (PIDSTs) and the frequency of postoperative cerebrospinal fluid (CSF) leaks.

OBJECTIVE

This study aimed to compare CSF leak rates among techniques for dural watertight closure (WTC) after the resection of PIDSTs.

SUMMARY OF BACKGROUND DATA

Resection of PIDSTs may result in persistent CSF leak. This complication is associated with infection, wound dehiscence, increased length of stay, and morbidity. Dural closure techniques have been developed to decrease the CSF leak rate.

METHODS

A PubMed search was performed in 2022 with these inclusion criteria: written in English, describe PIDST patients, specify the method of dural closure, report rates of CSF leak, and be published between 2015 and 2020. Articles were excluded if they had <5 patients. We used standardized toolkits to assess the risk of bias. We assessed patient baseline characteristics, tumor pathology, CSF leak rate, and dural closure techniques; analysis of variance and a 1-way Fisher exact test were used.

RESULTS

A total of 4 studies (201 patients) satisfied the inclusion criteria. One study utilized artificial dura (AD) and fibrin glue to perform WTC and CSF diversion, with lumbar drainage as needed. The rate of CSF leak was different among the 4 studies (P=0.017). The study using AD with dural closure adjunct (DCA) for WTC was associated with higher CSF leak rates than those using native dura (ND) with DCA. There was no difference in CSF leak rate between ND-WTC and AD-DCA, or with any of the ND-DCA studies.

CONCLUSIONS

After resection of PIDSTs, the use of autologous fat grafts with ND resulted in lower rates of CSF leak, while use of fibrin glue and AD resulted in the highest rates. These characteristics suggest that a component of hydrophobic scaffolding may be required for WTC. A limitation included articles with low levels of evidence. Continued investigation to understand mechanisms for WTC is warranted.

LEVEL OF EVIDENCE

Level 3.

Adult Trauma Patients With Thoracolumbar Injury Classification and Severity Score of 4: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

Evaluate characteristics of patients with thoracolumbar injury classification and severity (TLICS) score of 4 (To4) severity traumatic thoracolumbar injury.

SUMMARY OF BACKGROUND DATA

The TLICS score is used to predict the need for operative versus nonoperative management in adult patients with traumatic thoracolumbar injury. Ambiguity exists in its application and score categorization.

METHODS

A systematic review of the literature was performed. The databases of MEDLINE, Embase, Web of Science, and Cochrane Review were queried. Studies included adults with traumatic thoracolumbar injury with assigned TLICS score and description of management strategy.

RESULTS

A total of 16 studies met inclusion criteria representing 1911 adult patients with traumatic thoracolumbar injury. There were 503 (26.32%) patients with To4, of which 298 (59.24%) were operative. Studies focusing on the thoracolumbar junction and AO Type A fracture morphology had To4 patient incidences of 11.15% and 52.94%, respectively. Multiple studies describe better quality of life, pain scores, and radiographic outcomes in To4 who underwent operative treatment patients.

CONCLUSION

To4 injuries are more commonly AO Type A and located in the thoracolumbar junction in adult patients with traumatic thoracolumbar injury. Despite ambiguous recommendations regarding treatment provided by TLICS, outcomes favor operative intervention in this subset of traumatic thoracolumbar injury patients.

Disparities in anterior cervical discectomy and fusion provision and outcomes for cervical stenosis

Background

Disparities in neurosurgical care have emerged as an area of interest when considering the impact of social determinants on access to health care. Decompression via anterior cervical discectomy and fusion (ACDF) for cervical stenosis (CS) may prevent progression towards debilitating complications that may severely compromise one's quality of life. This retrospective database analysis aims to elucidate demographic and socioeconomic trends in ACDF provision and outcomes of CS-related pathologies.

Methods

The Healthcare Cost and Utilization Project National Inpatient Sample database was queried between 2016 and 2019 using International Classification of Diseases 10th edition codes for patients undergoing ACDF as a treatment for spinal cord and nerve root compression. Baseline demographics and inpatient stay measures were analyzed.

Results

Patients of White race were significantly less likely to present with manifestations of CS such as myelopathy, plegia, and bowel-bladder dysfunction. Meanwhile, Black patients and Hispanic patients were significantly more likely to experience these impairments representative of the more severe stages of the degenerative spine disease process. White race conferred a lesser risk of complications such as tracheostomy, pneumonia, and acute kidney injury in comparison to non-white race. Insurance by Medicaid and Medicare conferred significant risks in terms of more advanced disease prior to intervention and negative inpatient. Patients in the highest quartile of median income consistently fared better than patients in the lowest quartile across almost every aspect ranging from degree of progression at initial presentation to incidence of complications to healthcare resource utilization. All outcomes for patients age > 65 were worse than patients who were younger at the time of the intervention.

Conclusions

Significant disparities exist in the trajectory of CS and the risks associated with ACDF amongst various demographic cohorts. The differences between patient populations may be reflective of a larger additive burden for certain populations, especially when considering patients' intersectionality.

Selecting the lowest instrumented vertebra in a multilevel posterior cervical fusion across the cervicothoracic junction: a biomechanical investigation

OBJECTIVE

Posterior cervical fusion is a common surgical treatment for patients with myeloradiculopathy or regional deformity. Several studies have found increased stresses at the cervicothoracic junction (CTJ) and significantly higher revision surgery rates in multilevel cervical constructs that terminate at C7. The purpose of this study was to investigate the biomechanical effects of selecting C7 versus T1 versus T2 as the lowest instrumented vertebra (LIV) in multisegmental posterior cervicothoracic fusion procedures.

METHODS

Seven fresh-frozen cadaveric cervicothoracic spines (C2-L1) with ribs intact were tested. After analysis of the intact specimens, posterior rods and lateral mass screws were sequentially added to create the following constructs: C3-7 fixation, C3-T1 fixation, and C3-T2 fixation. In vitro flexibility tests were performed to determine the range of motion (ROM) of each group in flexion-extension (FE), lateral bending (LB), and axial rotation (AR), and to measure intradiscal pressure of the distal adjacent level (DAL).

RESULTS

In FE, selecting C7 as the LIV instead of crossing the CTJ resulted in the greatest increase in ROM (2.54°) and pressure (29.57 pound-force per square inch [psi]) at the DAL in the construct relative to the intact specimen. In LB, selecting T1 as the LIV resulted in the greatest increase in motion (0.78°) and the lowest increase in pressure (3.51 psi) at the DAL relative to intact spines. In AR, selecting T2 as the LIV resulted in the greatest increase in motion (0.20°) at the DAL, while selecting T1 as the LIV resulted in the greatest increase in pressure (8.28 psi) in constructs relative to intact specimens. Although these trends did not reach statistical significance, the observed differences were most apparent in FE, where crossing the CTJ resulted in less motion and lower intradiscal pressures at the DAL.

CONCLUSIONS

The present biomechanical cadaveric study demonstrated that a cervical posterior fixation construct with its LIV crossing the CTJ produces less stress in its distal adjacent discs compared with constructs with C7 as the LIV. Future clinical testing is necessary to determine the impact of this finding on patient outcomes.

Characteristics of Patients Selected for Surgical Treatment of Spinal Meningioma

BACKGROUND

Spinal meningiomas are benign extra-axial tumors that can present with neurological deficits. Treatment partly depends on the degree of disability as there is no agreed-upon patient selection algorithm at present. We aimed to elucidate general patient selection patterns in patients undergoing surgery for spinal meningioma.

METHODS

Data for patients with spinal tumors admitted between 2016 and 2019 were extracted from the U.S. Nationwide Inpatient Sample. We identified patients with a primary diagnosis of spinal meningioma (using International Classification of Disease, 10^th revision codes) and divided them into surgical and nonsurgical treatment groups. Patient characteristics were evaluated for intergroup differences.

RESULTS

Of 6395 patients with spinal meningioma, 5845 (91.4%) underwent surgery. Advanced age, nonwhite race, obesity, diabetes mellitus, chronic renal failure, and anticoagulant/antiplatelet use were less prevalent in the surgical group (all P < 0.001). The only positive predictor of surgical treatment was elective admission status (odds ratio, 3.166; P < 0.001); negative predictors were low income, Medicaid insurance, anxiety, obesity, and plegia. Patients with bowel-bladder dysfunction, plegia, or radiculopathy were less likely to undergo surgical treatment. The surgery group was less likely to experience certain complications (deep vein thrombosis, P < 0.001; pulmonary embolism, P = 0.002). Increased total hospital charges were associated with nonwhite race, diabetes, depression, obesity, myelopathy, plegia, and surgery.

CONCLUSIONS

Patients treated surgically had a decreased incidence of complications, comorbidities, and Medicaid payer status. A pattern of increased utilization of health care resources and spending was also observed in the surgery group. The results indicate a potentially underserved population of patients with spinal meningioma.

Cervical fusion for adult patients with atlantoaxial rotatory subluxation

BACKGROUND

Atlantoaxial rotatory subluxation (AARS) is a rare injury of the C1/C2 junction. It is often associated with trauma in adults. Treatment may depend on the duration of symptoms and clinical presentation, but there is no consensus regarding the ideal management of these injuries. Our objective is to ascertain the prevalence of neurological deficit, complications, and outcomes of patients diagnosed with AARS undergoing cervical fusion (CF) versus those treated without CF.

METHODS

The 2016-2019 National Inpatient Sample (NIS) was queried using International Classification of Diseases, 10th revision (ICD-10) for adult patients with C1/C2 subluxation. Patients undergoing CF were defined through ICD-10 procedure codes. Baseline health and acute illness severity was calculated using the 11-point modified frailty index (mFI-11). Presenting characteristics, treatment complications, and outcomes were evaluated of CF vs. non-CF patients.

RESULTS

Of 990 adult patients with AARS, 720 were treated without CF and 270 were treated with CF. CF patients were more often myelopathic. Patients that had undergone CF treatment were negatively associated with having had extensive trauma. Patients undergoing CF experienced significantly longer length of stay (LOS), increased healthcare resource utilization, and decreased inpatient mortality. Sepsis had a negative association with patients that underwent CF treatment while pneumonia had a positive association.

CONCLUSIONS

Adult patients undergoing CF for AARS demonstrated an increase in healthcare resource utilization but also a significant decrease in mortality. Extent of acute injury appears to have a strong influence on decision making for CF. Further study of decision making for treatment of this rare injury in adults is warranted.

Intraoperative navigation in surgical management of traumatic spine injury: a propensity score matching analysis

BACKGROUND

Traumatic spinal injury (TSI) can lead to severe morbidity and significant health care resource utilization. Intraoperative navigation (ION) systems have been shown to improve outcomes in some populations. However, controversy about the benefit of ION remains. To our knowledge, there is no large database analysis studying the outcomes of ION on TSI patients. Here we hope to compare complications and outcomes in patients with TSI undergoing spinal fusion of 3 or more levels with or without the use of ION.

METHODS

The 2015-2019 National Surgical Quality Improvement Program (NSQIP) database was queried for cases of posterior spinal instrumentation of 3 or more levels. This population was then selected for postoperative diagnosis consistent with TSI. The effect of prolonged operative time was analyzed for all patients. Propensity score matching analysis was performed to create ION case and non-ION control groups. Baseline demographic characteristics, complications, and outcome data were collected and compared between ION and non-ION groups.

RESULTS

A total of 1,034 patients were included in the propensity matched analysis. Among comorbidities, only obesity was significantly more likely in the non-ION group. There was no difference in case complexity between the two groups. ION was associated with higher incidence of prolonged operative time but was a negative independent predictor for sepsis. Prolonged operative time was a significant independent predictor for pulmonary embolism and requirement of transfusion in all patients. Discharge to home, readmission, and reoperation rates did not differ between TSI patients with or without ION.

CONCLUSIONS

Use of ION during posterior spinal fusion of 3 or more levels in TSI patients is not associated with worse outcomes. Prolonged operative time, rather than ION, appears to have a higher influence on the rate of complications in this population. Evaluation of ION in the context of specific populations and pathology is warranted to optimize its use.

Development of cerebral vasospasm following traumatic intracranial hemorrhage: incidence, risk factors, and clinical outcomes

OBJECTIVE

Limited evidence exists characterizing the incidence, risk factors, and clinical associations of cerebral vasospasm following traumatic intracranial hemorrhage (tICH) on a large scale. Therefore, the authors sought to use data from a national inpatient registry to investigate these aspects of posttraumatic vasospasm (PTV) to further elucidate potential causes of neurological morbidity and mortality subsequent to the initial insult.

METHODS

Weighted discharge data from the National (Nationwide) Inpatient Sample from 2015 to 2018 were queried to identify patients with tICH who underwent diagnostic angiography in the same admission and, subsequently, those who developed angiographically confirmed cerebral vasospasm. Multivariable logistic regression analysis was performed to identify significant associations between clinical covariates and the development of vasospasm, and a tICH vasospasm predictive model (tICH-VPM) was generated based on the effect sizes of these parameters.

RESULTS

Among 5880 identified patients with tICH, 375 developed PTV corresponding to an incidence of 6.4%. Multivariable adjusted modeling determined that the following clinical covariates were independently associated with the development of PTV, among others: age (adjusted odds ratio [aOR] 0.98, 95% CI 0.97–0.99; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.80, 95% CI 1.12–2.90; p = 0.015), intraventricular hemorrhage (aOR 6.27, 95% CI 3.49–11.26; p < 0.001), tobacco smoking (aOR 1.36, 95% CI 1.02–1.80; p = 0.035), cocaine use (aOR 3.62, 95% CI 1.97–6.63; p < 0.001), fever (aOR 2.09, 95% CI 1.34–3.27; p = 0.001), and hypokalemia (aOR 1.62, 95% CI 1.26–2.08; p < 0.001). The tICH-VPM achieved moderately high discrimination, with an area under the curve of 0.75 (sensitivity = 0.61 and specificity = 0.81). Development of vasospasm was independently associated with a lower likelihood of routine discharge (aOR 0.60, 95% CI 0.45–0.78; p < 0.001) and an extended hospital length of stay (aOR 3.53, 95% CI 2.78–4.48; p < 0.001), but not with mortality.

CONCLUSIONS

This population-based analysis of vasospasm in tICH has identified common clinical risk factors for its development, and has established an independent association between the development of vasospasm and poorer neurological outcomes.

Acute communicating hydrocephalus after intracranial arachnoid cyst decompression: A report of two cases

Background:

Arachnoid cysts (AC) may cause hydrocephalus and neurological symptoms, necessitating surgical intervention. Cyst drainage may result in postoperative complications, however, these interventions are not normally associated with the subsequent development of acute hydrocephalus. Herein, we present two unique cases of AC drainage with postoperative development of acute communicating hydrocephalus.

Case Description:

Case 1. A 75-year-old female presented with progressive headaches, cognitive decline, and questionable seizures. Her neurological examination was non-focal, but a head computed tomography scan (CT) identified a large right frontal AC with mass effect. She subsequently underwent craniotomy and decompression of the cyst. Postoperatively, her neurological examination deteriorated, and a head CT demonstrated new communicating hydrocephalus. The opening pressure was elevated upon placement of an external ventricular drain. Her hydrocephalus improved on follow-up imaging, but her neurological examination failed to improve, and she ultimately expired. Case 2. A 61-year-old female presented with headache and seizures attributed to a left parietal AC. She underwent open craniotomy for fenestration of the cyst into the Sylvian fissure. Postoperatively, her neurologic examination deteriorated, and she developed acute communicating hydrocephalus. She was initially managed with external ventricular drainage (EVD). The hydrocephalus resolved after several days, and the EVD was subsequently removed. Late follow-up imaging at 2 years showed that the regression of the AC was maintained.

Conclusion:

Acute development of hydrocephalus is a potential complication of intracranial AC fenestration. A better understanding of intracranial cerebrospinal fluid flow dynamics may better inform as to the underlying cause of this complication.

Correction of Sagittal Balance With Resection of Kissing Spines

Kissing spines syndrome, also known as Baastrup’s disease, is a common yet underdiagnosed disorder involving close approximation of adjacent spinous processes. These painful pseudoarticulations may be secondary to the compensatory mechanisms that result from sagittal imbalance. Conventional operative correction of sagittal balance includes a wide range of procedures from facetectomies to vertebral column resection. Resection of kissing spines for the operative management of sagittal imbalance is a treatment modality not extensively discussed in the literature but may offer improved patient outcomes with shorter operative times, lower risk, and reduced length of stay.

A 67-year old male with a history of degenerative disk disease and scoliosis presented with neurogenic claudication and severe back pain that worsened with walking and improved with sitting. X-ray imaging of the lumbar spine revealed straightening of the normal lumbar lordotic curvature with mild rotoscoliosis. There was also evidence of retrolisthesis of L2 on L3 that worsened with flexion. The patient had Baastrup’s disease at the L3-4 and L4, 5 levels that contributed to his reduced range of motion on extension imaging. Operative treatments including long-segment fusion with interbody cages to correct sagittal balance were considered with a discussion of possible debilitating and high-risk post-surgical outcomes. Instead, the patient underwent a simple decompression surgery involving laminectomies and resection of kissing spines to correct his sagittal imbalance. Postoperative follow-up imaging demonstrated significant improvement in sagittal balance, and the patient expressed relief of back and leg pain.

Although underdiagnosed, consideration of kissing spines syndrome in the surgical correction of sagittal imbalance may offer an improvement over conventional operations. Our case presents a unique surgical perspective on the treatment of spinal stenosis with kissing spines with particular regard to correcting the sagittal imbalance, avoiding debilitating procedures, and providing better immediate postoperative outcomes.

Surgical Outcomes for Upper Lumbar Disc Herniations: A Systematic Review and Meta-analysis

STUDY DESIGN

Systematic review and meta-analysis.

OBJECTIVE

To conduct a literature review on outcomes of discectomy for upper lumbar disc herniations (ULDH), estimate pooled rates of satisfactory outcomes, compare open laminectomy/microdiscectomy (OLM) versus minimally invasive surgical (MIS) techniques, and compare results of disc herniations at L1-3 versus L3-4.

METHODS

A systematic review of articles reporting outcomes of nonfusion surgical treatment of L1-2, L2-3, and/or L3-4 disc herniations was performed. The inclusion and exclusion of studies was performed according to the latest version of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

RESULTS

A total of 20 articles were included in the quantitative meta-analysis. Pooled proportion of satisfactory outcome (95% CI) was 0.77 (0.70, 0.83) for MIS and 0.82 (0.78, 0.84) for OLM. There was no significant improvement with MIS techniques compared with standard OLM, odds ratio (OR) = 0.86, 95% CI (0.42, 1.74), P = .66. Separating results by levels revealed a trend of higher satisfaction with L3-4 versus L1-3 with OLM surgery, OR = 0.46, 95% CI (0.19, 1.12), P = .08.

CONCLUSION

Our analysis reveals that discectomy for ULDH has an overall success rate of approximately 80% and has not improved with MIS. Discectomy for herniations at L3-4 trends toward better outcomes compared with L1-2 and L2-3, but was not significant.

4-Point C2 Fixation for Occipitocervical Fusion: Technical Case Report

BACKGROUND

Occipitocervical fusion is an important surgical procedure to treat instability of the upper cervical and craniocervical junction. Fixation to the dense cortical bone of the occiput, contemporaneously typically accomplished with a plate and screws, is known to be strong and durable, but there are many competing methods used to secure an adequate number of fixation points of sufficient strength at the cervical end. Extension of hardware to the midcervical region to acquire additional fixation points, however, results in loss of subaxial motion segments and additional potential morbidity. The C2 vertebra is unique in that its morphology and dimensions permit fixation with longer screws than are typically possible to place in the midcervical lateral masses. Translaminar and pars screw techniques, both commonly used to achieve C2 fixation, are not mutually exclusive, as their respective trajectories are considerably different and engage different portions of the bony anatomy.

METHODS

We describe a novel, 4-point C2 fixation technique for OC fusion that may avoid the need to extend fusion to the subaxial spine.

RESULTS

This technical note illustrates how 4-point C2 fixation can be employed in occiptocervical fusion.

CONCLUSIONS

4-point fixation of C2 combining translaminar and pars screw placement is technically feasible and may be a suitable strategy to spare subaxial motion segments in OC fusion procedures. Futher investigation may establish its applicability to additional surgical procedures.

A Multidisciplinary Spine Surgical Indications Conference Leads to Alterations in Surgical Plans in a Significant Number of Cases: A Case Series

STUDY DESIGN

Case series.

OBJECTIVE

To evaluate the impact of a multidisciplinary spine surgery indications conference (MSSIC) on surgical planning for elective spine surgeries.

SUMMARY OF BACKGROUND DATA

Identifying methods for pairing the proper patient with the optimal intervention is of the utmost importance for improving spine care and patient outcomes. Prior studies have evaluated the utility of multidisciplinary spine conferences for patient management, but none have evaluated the impact of a MSSIC on surgical planning and decision making.

METHODS

We implemented a mandatory weekly MSSIC with all spine surgeons at our institution. Each elective spine surgery in the upcoming week is presented. Subsequently, a group consensus decision is achieved regarding the best treatment option based on the expertise and opinions of the participating surgeons. We reviewed cases presented at the MSSIC from September 2019 to December 2019. We compared the surgeon's initial proposed surgery for a patient with the conference attendees' consensus decision on the best treatment and measured compliance rates with the group's recommended treatment.

RESULTS

The conference reviewed 100 patients scheduled for elective spine surgery at our indications conference during the study period. Surgical plans were recommended for alteration in 19 cases (19%) with the proportion statistically significant from zero indicated by a binomial test (P < 0.001). The median absolute change in the invasiveness index of the altered procedures was 3 (interquartile range [IQR] 1-4). Participating surgeons complied with the group's recommendation in 96.5% of cases.

CONCLUSION

In conjunction with other multidisciplinary methods, MSSICs can lead to surgical planning alterations in a significant number of cases. This could potentially result in better selection of surgical candidates and procedures for particular patients. Although long-term patient outcomes remain to be evaluated, this care model will likely play an integral role in optimizing the care spine surgeons provide patients.

LEVEL OF EVIDENCE

4.

Prolonged length of stay and discharge disposition to rehabilitation facilities following single-level posterior lumbar interbody fusion for acquired spondylolisthesis

Background

Acquired lumbar spondylolisthesis is often treated with interbody fusion. However, few studies have evaluated predictors for prolonged length of stay (LOS) and disposition to rehabilitation facilities after posterior single-level lumbar interbody fusion for acquired spondylolisthesis.

Methods

The American College of Surgeons National Quality Improvement Program database was queried for adults with acquired spondylolisthesis who underwent single-level lumbar interbody fusion through a posterior approach (posterior lumbar interbody fusion (PLIF) or transforaminal lumbar interbody fusion [TLIF]). We utilized multivariate logistic regression analysis to identify predictors of prolonged LOS and disposition in this patient population.

Results

Among 2080 patients identified, 700 (33.7%) had a prolonged LOS (≥4 days), and 306 (14.7%) were discharged postoperatively to rehabilitation facilities. Predictors for prolonged LOS included: American Society of Anesthesiologist (ASA) class ≥3, anemia, prolonged operative time, perioperative blood transfusion, pneumonia, urinary tract infections, and return to the operating room. The following risk factors predicted discharge to postoperative rehabilitation facilities: age ≥65 years, male sex, ASA class ≥3, modified frailty score ≥2, perioperative blood transfusion, and prolonged LOS.

Conclusion

Multiple partial-overlapping risk factors predicted prolonged LOS and discharge to rehabilitation facilities after single-level TLIF/PLIF performed for acquired spondylolisthesis.

A safe, reliable, inexpensive and novel technique to localize in the mid thoracic spine in the prone position: Proof of concept and technical illustration

Intraoperative localization within the thoracic spine in the prone position may be particularly difficult on account of absence of common landmarks such as the sacrum or the C2 vertebra, thus increasing the potential for wrong-level surgery that may lead to patient morbidity and potential litigation. Some current localization methods involve implantation of markers that are invasive and serve to add to procedural expense while yet still failing to entirely eliminate errors. We describe a novel, non-invasive, and inexpensive technique for intraoperative localization of the thoracic spine in the prone position using an esophageal temperature probe. Following patient positioning, anteroposterior fluoroscopy is used to localize the radiopaque tip of the esophageal probe relative to the thoracic spine. After determining the probe tip's location, it becomes the counting reference for all subsequent intraoperative fluoroscopic localizations during surgery. As the probe tip is generally visible in the same fluoroscopic image as the surgical level, error from parallax created when moving the fluoroscopy machine from an anatomic landmark either above or below is avoided and a shorter fluoroscopy time is needed. Use of an esophageal temperature probe as a landmark in localizing spinal level may serve as a reliable and It offers a safe, reliable, and inexpensive technique for proper localization of thoracic spine levels.

Intraoperative Thrombolysis of Massive Pulmonary Embolus During Spine Surgery: Case Report of Survival Complicated by Massive Bleeding and Review of the Literature

BACKGROUND

Pulmonary embolism (PE) is a known risk of lumbar spinal fusion surgery that can lead to sudden and unexpected death. Treatment often involves systemic anticoagulation when the risk of potentially fatal hemodynamic deterioration is judged to outweigh the risk of epidural hematoma and paralysis. Acute massive PE with obstruction of more than 50% of the pulmonary arterial tree causes right heart failure, hypotension, and often rapid death, and may require aggressive medical intervention with thrombolytic agents, such as alteplase, although in the postoperative period this entails an extremely high risk of bleeding and the associated potential neurologic morbidity.

CASE DESCRIPTION

We report the first case, to our knowledge, of intraoperative thrombolytic therapy during spine surgery in a 68-year-old woman who developed a massive PE with cardiac arrest while undergoing lumbar instrumented fusion surgery in the prone position and detail the postoperative course that was complicated by severe bleeding.

CONCLUSIONS

Our experience is that chemical thrombolysis can be a lifesaving option to address pending circulatory arrest, but that severe bleeding is a likely consequence. If used to treat an intraoperative emergency, a smaller than standard dose of thrombolytic should be considered.

Neurologic Complications of Preoperative Embolization of Spinal Metastasis: A Systemic Review of the Literature Identifying Distinct Mechanisms of Injury

BACKGROUND

Preoperative embolization of spinal metastases may improve outcomes of resection by reducing surgical blood loss and operative time. Neurologic complications are rarely reported and the mechanisms leading to injury are poorly described.

METHODS

We present 2 illustrative cases of embolization-related neurologic injury from distinct mechanisms and the findings of a systemic literature review of similar complications according to the PRISMA guidelines.

RESULTS

A 77-year-old man with a history of renal cell carcinoma presented with gait dyscoordination and arm pain/weakness. Magnetic resonance imaging showed a C7/T1 mass causing severe compression of the C7/T1 roots and spinal cord. After embolization and tumor resection/fusion, lethargy prompted imaging showing multiple posterior circulation infarcts believed to be secondary to reflux of embolic particles. A 75-year-old man with renal cell carcinoma presented with L1 level metastasis causing conus compression and experienced paraplegia after superselective particle embolization presumed to be secondary to flow disruption of the artery of Adamkiewicz. Analysis of the literature yielded 6 articles reporting instances of cranial infarction/ischemia occurring in 10 patients, 12 articles reporting spinal cord ischemia/infarction occurring in 17 patients, and 5 articles reporting symptomatic postembolization tumoral swelling in 5 patients.

CONCLUSIONS

Neurologic injury is a risk of preoperative embolization of spinal metastasis from either compromise of spinal cord vascular supply or cranial stroke from reflux of embolic particles. Postprocedural tumor swelling rarely leads to clinical deficit. Awareness of these complications and the presumed mechanisms of injury may aid clinicians in implementing interventions and in counseling patients before treatment.

Telemedicine During COVID-19 and Beyond: A Practical Guide and Best Practices Multidisciplinary Approach for the Orthopedic and Neurologic Pain Physical Examination

BACKGROUND

The COVID pandemic has impacted almost every aspect of human interaction, causing global changes in financial, health care, and social environments for the foreseeable future. More than 1.3 million of the 4 million cases of COVID-19 confirmed globally as of May 2020 have been identified in the United States, testing the capacity and resilience of our hospitals and health care workers. The impacts of the ongoing pandemic, caused by a novel strain of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), have far-reaching implications for the future of our health care system and how we deliver routine care to patients. The adoption of social distancing during this pandemic has demonstrated efficacy in controlling the spread of this virus and has been the only proven means of infection control thus far. Social distancing has prompted hospital closures and the reduction of all non-COVID clinical visits, causing widespread financial despair to many outpatient centers. However, the need to treat patients for non-COVID problems remains important despite this pandemic, as care must continue to be delivered to patients despite their ability or desire to report to outpatient centers for their general care. Our national health care system has realized this need and has incentivized providers to adopt distance-based care in the form of telemedicine and video medicine visits. Many institutions have since incorporated these into their practices without financial penalty because of Medicare's 1135 waiver, which currently reimburses telemedicine at the same rate as evaluation and management codes (E/M Codes). Although the financial burden has been alleviated by this policy, the practitioner remains accountable for providing proper assessment with this new modality of health care delivery. This is a challenge for most physicians, so our team of national experts has created a reference guide for musculoskeletal and neurologic examination selection to retrofit into the telemedicine experience.

OBJECTIVES

To describe and illustrate musculoskeletal and neurologic examination techniques that can be used effectively in telemedicine.

STUDY DESIGN

Consensus-based multispecialty guidelines.

SETTING

Tertiary care center.

METHODS

Literature review of the neck, shoulder, elbow, wrist, hand, lumbar, hip, and knee physical examinations were performed. A multidisciplinary team comprised of physical medicine and rehabilitation, orthopedics, rheumatology, neurology, and anesthesia experts evaluated each examination and provided consensus opinion to select the examinations most appropriate for telemedicine evaluation. The team also provided consensus opinion on how to modify some examinations to incorporate into a nonhealth care office setting.

RESULTS

Sixty-nine examinations were selected by the consensus team. Household objects were identified that modified standard and validated examinations, which could facilitate the examinations.The consensus review team did not believe that the modified tests altered the validity of the standardized tests.

LIMITATIONS

Examinations selected are not validated for telemedicine. Qualitative and quantitative analyses were not performed.

CONCLUSIONS

The physical examination is an essential component for sound clinical judgment and patient care planning. The physical examinations described in this manuscript provide a comprehensive framework for the musculoskeletal and neurologic examination, which has been vetted by a committee of national experts for incorporation into the telemedicine evaluation.

Effect of Cage Type on Short-Term Radiographic Outcomes in Transforaminal Lumbar Interbody Fusion

BACKGROUND

The effect of expandable versus static cage type on radiographic outcomes in transforaminal lumbar interbody fusion (TLIF) has not been well studied in the literature. We studied the effect of 3 cage types on change in foraminal height (FH), disk height (DH), subsidence, and segmental lordosis (SL).

METHODS

We conducted a retrospective review of patients who underwent TLIF in a single institution from 2014 to 2019. The following 3 cage types were identified: banana cage, bullet, and expandable cage. Computed tomography (CT) scans of the lumbar spine or lumbar radiographs (when CT scan was not available) with 6-week follow-up time were used for radiographic assessment.

RESULTS

One hundred patients with 133 fused segments were identified. The average age was 60.9 years, and 40% were men. A banana cage was used in 19 segments (14.3%), a bullet cage was used in 47 (35.4%), and an expandable cage was used in 67 segments (50.4%). There were no significant differences in FH (average increase, 0.7 mm; P = 0.771), subsidence (average, 2.3 mm; P = 0.554), DH (average decrease, 1.0 mm; P = 0.769), or clinically significant subsidence (>4 mm; P = 0.174). Expandable cages demonstrated a positive 1.2° gain in SL, whereas both other cages demonstrated a decrease in SL on average (P = 0.05). This result held up on multivariate analysis (P = 0.031).

CONCLUSIONS

The average increase in the foraminal height in TLIF is small (0.7 mm) and is not different between the cage types; therefore, direct decompression is crucially important in this procedure. Although TLIF is often considered to be a kyphotic procedure, an expandable cage demonstrated superiority in terms of segmental lordosis improvement.

Biomechanical evaluation comparing zero-profile devices versus fixed profile systems in a cervical hybrid decompression model: a biomechanical in vitro study

BACKGROUND CONTEXT

The use of zero-profile devices and the need for posterior fixation in conjunction with a cervical hybrid decompression model have yet to be investigated.

PURPOSE

To compare the biomechanics of zero-profile and fixed profile cervical hybrid constructs composed of anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF). Fixed profile devices included anterior plating, whereas zero-profile devices included integrated screws.

STUDY DESIGN

In vitro cadaveric biomechanical study.

METHODS

Twelve fresh-frozen cadaveric spines (C2-C7) were divided into two groups of equal bone mineral density, fixed profile versus zero profile (n=6). Groups were instrumented from C3-C6 with either (1) an expandable ACCF device and a static ACDF spacer with an anterior plate (Hybrid-AP) or (2) a zero-profile ACCF spacer with adjacent zero-profile ACDF spacer (Hybrid-Z). Motion was captured for the (1) intact condition, (2) a hybrid model with lateral mass screws (LMS), (3) a hybrid model without LMS, and (4) a hybrid model without LMS following simulated repetitive loading (fatigue).

RESULTS

Hybrid-AP with LMS reduced motion in flexion-extension (FE), lateral bending (LB), and axial rotation (AR) by 77%, 88%, and 82%, respectively, compared with intact. Likewise, Hybrid-Z with LMS exhibited the greatest reduction in motion relative to intact in FE, LB, and AR by 90%, 95%, and 66%, respectively. Following simulated in vivo fatiguing, an increase in motion was observed for both groups in all planes, particularly during Hybrid-Z postfatigue condition where motion increased relative to intact by 29%. Overall, biomechanical equivalency was observed between Hybrid-AP and Hybrid-Z groups (p>.05). Three (50%) of the Hybrid-Z group specimens exhibited signs of implant migration from the inferior endplate during testing.

CONCLUSIONS

Fixed profile systems using an anterior plate for supplemental fixation is biomechanically more favorable to maintain stability and prevent dislodgement. Dislodgement of 50% of the Hybrid-Z group without LMS emphasizes the necessity for posterior fixation in a zero-profile cervical hybrid decompression model.

Spinal cord ischemia/infarct after cauda equina syndrome from disc herniation - A case study and literature review

Background

Spinal cord infarction is rare and occurs in 12/100,000; it represents 0.3%-2% of central nervous system infarcts. Here, we present a patient who developed recurrent bilateral lower extremity paraplegia secondary to spinal cord infarction 1 day after a successful L4-5 microdiscectomy in a patient who originally presented with a cauda equina syndrome.

Case Description

A 56-year-old patient presented with an acute cauda equina syndrome characterized by severe lower back pain, a right foot drop, saddle anesthesia, and acute urinary retention. When the lumbar magnetic resonance imaging (MRI) revealed a large right paracentral lumbar disc herniation at the L4-L5 level, the patient underwent an emergency minimally invasive right-sided L4-5 discectomy. Immediately, postoperatively, the patient regained normal function. However, 1 day later, while having a bowel movement, he immediately developed the recurrent paraplegia. The new lumbar MRI revealed acute ischemia and an infarct involving the distal conus medullaris. Further, workup was negative for a spinal cord vascular malformation, thus leaving an inflammatory postsurgical vasculitis as the primary etiology of delayed the conus medullaris infarction.

Conclusions

Acute neurologic deterioration after spinal surgery which does not neurologically correlate with the operative level or procedure performed should prompt the performance of follow-up MR studies of the neuraxis to rule out other etiologies, including vascular lesions versus infarctions, as causes of new neurological deficits.

Perioperative Complications and Mortality Following Anterior Odontoid Screw Fixation in Elderly Patients: A National Database Analysis

OBJECTIVE

To identify predictors of short-term mortality and complications after anterior odontoid screw fixation.

METHODS

This was a retrospective analysis of a national database. The American College of Surgeons National Quality Improvement Database was queried using Current Procedural Terminology codes to identify patients aged ≥60 years who underwent surgery for anterior fixation of odontoid fracture admitted from 2007 to 2016. Univariate analysis and subsequent multivariate analysis were used to analyze risk factors for postoperative complications and 30-day postoperative mortality. Complications were defined as surgical-site infection, wound breakdown, pneumonia, venous thromboembolism, stroke, myocardial infarction, sepsis, renal progressive renal insufficiency/acute kidney injury, or cardiac arrest.

RESULTS

A total of 198 patients were identified. Mean age was 77.7 (±8.7) years and 60.6% were female. Overall mortality rate was 7.6%, and the complication rate was 9.1%. In multivariate analysis, dependent functional status (0.012; odds ratio [OR] 5.2; 95% confidence interval [CI] 1.42-18.72) and preoperative systemic inflammatory response syndrome (P = 0.011; OR 6.2; 95% CI 1.52-25.79) predicted mortality. Emergency case status (P = 0.033; OR 3.4; 95% CI 1.10-10.70) predicted perioperative complications. Age was not significantly associated with either complications or mortality in multivariate analysis.

CONCLUSIONS

Functional dependence and preoperative systemic inflammatory response syndrome predict mortality following odontoid screw placement. Although age often is considered a limiting factor in pursuing surgical intervention in patients with odontoid fracture, age did not independently increase odds of either complications or perioperative mortality in this analysis. Further studies are needed to explore these findings.

Multifocal Epidural Neurosarcoidosis Causing Spinal Cord Compression: A Case Report

We describe a rare case of multifocal extramedullary epidural neurosarcoidosis that presented with myelopathy without motor deficits and perform a literature review for previous cases of epidural neurosarcoidosis. A 46-year-old woman presented with lower back pain, urinary incontinence, gait disturbance, and sensory loss without motor deficits. Spine magnetic resonance imaging (MRI) showed multiple epidural lesions, the largest causing spinal cord compression at the T5 level. A computed tomography (CT)-guided biopsy of the dominant lesion showed noncaseating granulomas consistent with neurosarcoidosis. She was treated with a course of dexamethasone and discharged home after a 10-day hospital course. She was discharged home on oral prednisone taper over a four-month period. At her latest follow-up, she is neurologically intact and gainfully employed. This case demonstrates that certain cases of epidural neurosarcoidosis causing spinal cord compression may be treated with medical therapy alone in the absence of severe neurological deficits.

Incidence and Predictors of Hardware Failure After Instrumentation for Spine Metastasis: A Single-Institutional Series

OBJECTIVE

We report a retrospective analysis of hardware failure in patients requiring instrumentation for spinal metastasis.

METHODS

In a retrospective study at a single institution, we identified 58 patients who underwent spinal instrumentation for metastasis from 2012 to 2018. Hardware failure was defined as screw pullout/loosening, cage migration, progressive kyphosis, or an otherwise-noticeable instrumentation deficit detectable on imaging. Risk factors for hardware failure with a P < 0.05 in in univariate were included in multivariate logistic regression models controlled for age, sex, and previously identified risk factors for hardware failure.

RESULTS

In total, 58 patients required instrumentation for metastatic spine disease. Median age was 60.2 years (interquartile range 49.0-66.3), 38 patients (65.5%) were male, and median follow-up was 8.1 months (interquartile range 3.1-20.7). Eight patients (13.8%) developed signs of hardware failure during follow-up, of whom 2 patients (3.4%) underwent operative revision. In univariate analysis, Eastern Cooperative Oncology Group performance status >2 (P = 0.049) and multiple myeloma lesions (P = 0.010) were significant predictors of failure. Both factors maintained significance in a multivariate logistic regression model controlled for age, sex, history of spine radiation, and number of fused levels with P = 0.047; odds ratio 12.7 (95% confidence interval 1.03-156.4) for Eastern Cooperative Oncology Group performance status over 2 and P = 0.012; odds ratio 31.5 (95% confidence interval 2.2-460.0) for multiple myeloma lesions.

CONCLUSIONS

The rate of hardware failure in this cohort was 13.8%, although operative revision rate was 3.4%. Spinal instrumentation in patients with poor preoperative functional status or multiple myeloma may be more likely to develop instrumentation failure.

The Effect of Cigarette Smoking on Wound Complications After Single-Level Posterolateral and Interbody Fusion for Spondylolisthesis

OBJECTIVE

To evaluate the impact of cigarette smoking on the development of wound complications, including wound dehiscence, superficial infection, deep infection, or organ space infection, within the first 30 postoperative days in patients undergoing surgery for spondylolisthesis.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the years 2012-2014 was used to identify adult patients who underwent single-level posterolateral fusion (PLF) or interbody fusion for spondylolisthesis. Wound complications occurring within 30 days were compared between current smokers and nonsmokers.

RESULTS

A total of 1688 patients who underwent single-level PLF or interbody fusion for spondylolisthesis were identified, among whom 271 were current smokers (16.1%). The overall wound complication rate was 3.3% for smokers versus 1.8% for nonsmokers (P = 0.095). When stratified by operative technique, the rate of wound complications was not significantly different between smokers and nonsmokers undergoing PLF (2.4% vs. 2.6%; P = 1.00); however, smokers who underwent interbody fusion were more likely to experience a wound complication compared with nonsmokers undergoing interbody fusion (3.7% vs. 1.3%; P = 0.028). On multivariate analysis, smoking was an independent predictor of organ/space infection irrespective of fusion technique used (odds ratio, 15.4; 95% confidence interval, 1.34-175.4; P = 0.028).

CONCLUSIONS

The rate of wound complications was not higher in smokers undergoing PLF alone, but was significantly higher in smokers who underwent interbody fusion. However, multivariate analysis identified smoking as an independent predictor of organ/space infection irrespective of fusion technique used.

Use of Bone Morphogenetic Protein-2 in Vertebral Column Tumor Surgery: A National Investigation

OBJECTIVE

To report the rate of bone morphogenetic protein-2 (BMP-2) use in vertebral column tumor surgery.

METHODS

The Nationwide Inpatient Sample database (2012-2014) was queried to identify patients who underwent spinal fusion for vertebral column tumors (primary benign, primary malignant, or metastatic). The rate of BMP-2 use was calculated, and patient and operative factors associated with its use were also investigated.

RESULTS

We identified 9375 patients who underwent fusion surgery for spinal tumors between 2012 and 2014, with 540 cases using BMP-2 (5.8%). Preoperative diagnosis revealed that the rate of BMP-2 use in primary benign tumor surgery was 4.9%, 7.6% for primary malignant tumors, and 5.7% for metastatic lesions (P = 0.607). The overall complication rate was 13.2% (13.4% in the NO-BMP-2 group vs. 11.1% in the BMP-2 group; P = 0.504). Patients who received this growth factor were less likely to have epidural spinal cord compression at presentation (37.0% vs. 49.2%; P = 0.014), and more likely to have elective surgery (53.7% vs. 37.7%; P < 0.001). Analysis of hospital location indicated that the highest use of BMP-2 was in the South (7.4% rate; P = 0.002). There was no statistical difference between age, sex, insurance status, comorbidities, the presence of a pathologic fracture, or the use of inpatient radiotherapy or chemotherapy between patients who received BMP-2 and controls.

CONCLUSIONS

BMP-2 has been used off-label to promote arthrodesis; however, its use in patients with spinal tumors is controversial. In this national study, BMP-2 use was highest in the South, in patients without epidural cord compression at presentation, and in elective cases.

Predicting critical care unit-level complications after long-segment fusion procedures for adult spinal deformity

Background

To identify predictive factors for critical care unit-level complications (CCU complication) after long-segment fusion procedures for adult spinal deformity (ASD).

Methods

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database [2010-2014] was reviewed. Only adult patients who underwent fusion of 7 or more spinal levels for ASD were included. CCU complications included intraoperative arrest/infarction, ventilation >48 hours, pulmonary embolism, renal failure requiring dialysis, cardiac arrest, myocardial infarction, unplanned intubation, septic shock, stroke, coma, or new neurological deficit. A stepwise multivariate regression was used to identify independent predictors of CCU complications.

Results

Among 826 patients, the rate of CCU complications was 6.4%. On multivariate regression analysis, dependent functional status (P=0.004), combined approach (P=0.023), age (P=0.044), diabetes (P=0.048), and surgery for over 8 hours (P=0.080) were significantly associated with complication development. A simple scoring system was developed to predict complications with 0 points for patients aged <50, 1 point for patients between 50-70, 2 points for patients 70 or over, 1 point for diabetes, 2 points dependent functional status, 1 point for combined approach, and 1 point for surgery over 8 hours. The rate of CCU complications was 0.7%, 3.2%, 9.0%, and 12.6% for patients with 0, 1, 2, and 3+ points, respectively (P<0.001).

Conclusions

The findings in this study suggest that older patients, patients with diabetes, patients who depend on others for activities of daily living, and patients who undergo combined approaches or surgery for over 8 hours may be at a significantly increased risk of developing a CCU-level complication after ASD surgery.

Minimally invasive transpedicular approach for the treatment of central calcified thoracic disc disease: a technical note

PURPOSE

To assess the utility of stereotactic navigation for the surgical treatment of ossified, paracentral thoracic discs via a minimally invasive (MI) transpedicular approach.

METHODS

The authors performed a retrospective review of cases with paracentral thoracic disc herniation resulting in myelopathy where a traditional MI approach would be difficult, who underwent a stereotactic assisted MI transpedicular approach via a tubular retractor system between 2011 and 2016. Five cases of patients over the age of 18 were selected. Collected data included patient age at surgery, sex, preoperative Nurick grade, number of levels treated, calcified disc presence, length of surgery, estimated blood loss (EBL), length of stay (LOS), complication rate, postoperative Nurick grade, and length of follow-up.

RESULTS

Five patients had a stereotaxic assisted MI transpedicular thoracic discectomy for paracentrally located calcified disc herniation. Intraoperative navigational images were acquired using intraoperative CT scans (O-arm) to plan and guide the surgical procedure, and real-time navigation was used for precise navigation around the cord to access and remove all fragments. MIS surgery was successfully performed in these otherwise contraindicated cases due to the use of intraoperative real-time stereotactic navigation. All patients had a successful decompression around the anterior aspect of the cord.

CONCLUSION

The traditional MI transpedicular thoracic discectomy approach can be further refined and enhanced by stereotactic navigation to expand the limitations of the MIS technique allowing for an increased number and types of patients eligible for minimally invasive surgery. Therefore, MIS via a tubular retractor system with stereotactic navigation is a novel, safe, and effective improvement in feasibility from the traditional minimally invasive transpedicular thoracic discectomy technique.

Effect of body mass index on surgical outcomes after posterior spinal fusion for adolescent idiopathic scoliosis

OBJECTIVE

Obesity is an increasing public health concern in the pediatric population. The purpose of this investigation was to examine the impact of body mass index (BMI) on 30-day outcomes after posterior spinal fusion for adolescent idiopathic scoliosis (AIS).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program Pediatric database (2013 and 2014) was reviewed. Patients 10–18 years of age who had undergone fusion of 7 or more spinal levels for AIS were included. Thirty-day outcomes (complications, readmissions, and reoperations) were compared based on patient BMI per age- and sex-adjusted growth charts as follows: normal weight (NW; BMI < 85th percentile), overweight (OW; BMI 85th–95th percentile), and obese (OB; BMI > 95th percentile).

RESULTS

Patients eligible for study numbered 2712 (80.1% female and 19.9% male) and had a mean age of 14.4 ± 1.8 years. Average BMI for the entire cohort was 21.9 ± 5.0 kg/m2; 2010 patients (74.1%) were classified as NW, 345 (12.7%) as OW, and 357 (13.2%) as OB. The overall complication rate was 1.3% (36/2712). For NW and OW patients, the complication rate was 0.9% in each group; for OB patients, the rate was 4.2% (p < 0.001). The 30-day readmission rate was 2.0% (55/2712) for all patients, 1.6% for NW patients, 1.2% for OW patients, and 5.0% for OB patients (p < 0.001). The 30-day reoperation rate was 1.4% (39/2712). Based on BMI, this reoperation rate corresponded to 0.9%, 1.2%, and 4.8% for NW, OW, and OB patients, respectively (p < 0.001). After controlling for patient age, number of spinal levels fused, and operative/anesthesia time on multiple logistic regression analysis, obesity remained a significant risk factor for complications (OR 4.61), readmissions (OR 3.16), and reoperations (OR 5.33; all p < 0.001).

CONCLUSIONS

Body mass index may be significantly associated with short-term outcomes after long-segment fusion procedures for AIS. Although NW and OW patients may have similar 30-day outcomes, OB patients had significantly higher wound complication, readmission, and reoperation rates and longer hospital stays than the NW patients. The findings of this study may help spine surgeons and patients in terms of preoperative risk stratification and perioperative expectations.

Minimally Invasive Separation Surgery with Intraoperative Stereotactic Guidance: A Feasibility Study

BACKGROUND

The treatment of spinal metastasis consists of algorithms combining surgical and radiation modalities. Recently the concept of separation surgery followed by stereotactic radiosurgery was shown to be a safe and effective treatment to achieve local tumor control.

OBJECTIVE

We examined a minimally invasive approach to separation surgery in a cadaveric study followed by a patient cohort with spinal metastasis using navigation to discuss our results and provide a technical note.

METHODS

A cadaveric study using minimally invasive access systems examined the feasibility of spinal cord decompression. Subsequently, 17 patients with spinal metastasis underwent minimally invasive separation surgery and instrumentation using navigation. All patients were at least 3/5 and pre- and post-operative CT scans were used to evaluate the decompression. Endpoints included neurologic function, operative time, estimated blood loss, duration of hospital stay, and complications.

RESULTS

The cadaveric study demonstrated adequate decompression of the spinal cord. For the operative cases, the post-operative imaging demonstrated excellent separation for safe stereotactic radiosurgery. The mean incision length was 4.9 cm. The average operative time was 6 hours and 48 minutes, the mean length of stay was 12.8 days and the mean surgical blood loss was 458 mL. The median Spine Instability Neoplastic Score score was 10 with a range of 6-16. All patients remained or improved their neurologic baseline with excellent pain control. One patient incurred a perioperative complication.

CONCLUSIONS

Minimally invasive separation surgery for spinal metastasis allows for circumferential decompression of the spinal cord and safe post-operative stereotactic radiosurgery. In addition, we demonstrated the efficacy of intra-operative navigation in guiding the resection.

Impact of body mass index on 30-day outcomes after spinopelvic fixation surgery

Background:

Obesity is one of the most prevalent chronic diseases associated with degenerative spinal disease. There is limited evidence regarding the short-term outcome of patients with elevated BMI following spinopelvic fixation surgery.

Methods:

We used the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2013 to 2014. Inclusion criteria included: adults, aged 18 and older, who underwent all-cause spinopelvic fixation surgery. Primary outcome measures were 30-day readmission, reoperation, and major complication rates. Logistic regression analysis was used to assess the effect of elevated body mass index (BMI) on 30-day outcome.

Results:

A total of 618 patients met inclusion criteria stratified into levels of BMI: 11.2% were Class 2 obese and 10.3% were Class 3 obese. Significant differences were found between the classes for the incidence of revision surgery, reoperations, and deep wound infections. However, there were no significant increases in readmissions and major complications rates, and only Class 3 obese patients had significantly higher odds of reoperation than those who were not obese.

Conclusion:

Significant differences between all classes of obesity regarding revision surgery, reoperation, and deep wound infection rates were found. Class 3 obese patients had significantly higher odds of reoperation, most likely attributed to the greater number/severity of preoperative comorbidities.

Glioblastoma multiforme presenting with an open ring pattern of enhancement on MR imaging

Background:

Intracerebral ring enhancing lesions can be the presentation of a variety of pathologies, including neoplasia, inflammation, and autoimmune demyelination. Use of a precise diagnostic algorithm is imperative in correctly treating these lesions and minimizing potential adverse treatment effects.

Case Description:

A 55-year-old patient presented to the hospital with complaints of a post-concussive syndrome and a non-focal neurologic exam. Imaging revealed a lesion with an open ring enhancement pattern, minimal surrounding vasogenic edema, and minimal mass effect. Given the minimal mass effect, small size of the lesion, and nonfocal neurological exam, we elected to pursue a comprehensive noninvasive neurologic workup because our differential ranged from inflammatory/infectious to neoplasm. Over the next 8 weeks, the patient's condition worsened, and repeat imaging showed marked enlargement of the lesion with a now closed ring pattern of enhancement with satellite lesions and a magnetic resonance (MR) spectroscopy and perfusion signature suggestive of neoplasm. The patient was taken to surgery for biopsy and debulking of the lesion. Surgical neuropathology examination revealed glioblastoma multiforme.

Conclusion:

The unique open ring enhancement pattern of this lesion on initial imaging is highly specific for a demyelinating process, however, high-grade glial neoplasms can also present with complex and irregular ring enhancement including an open ring sign. Therefore, other imaging modalities should be used, and close follow-up is warranted when the open ring sign is encountered.

Thirty-day readmission and reoperation rates after single-level anterior cervical discectomy and fusion versus those after cervical disc replacement

OBJECTIVE The goal of this study was to compare 30-day readmission and reoperation rates after single-level anterior cervical discectomy and fusion (ACDF) versus those after cervical disc replacement (CDR). METHODS The authors used the 2013-2014 American College of Surgeons National Surgical Quality Improvement Program database. Included were adult patients who underwent first-time single-level ACDF or CDR for cervical spondylosis or disc herniation. Primary outcome measures were readmission and/or reoperation within 30 days of the original surgery. Logistic regression analysis was used to assess the independent effect of the procedure (ACDF or CDR) on outcome, and results are presented as odds ratios with 95% confidence intervals. RESULTS A total of 6077 patients met the inclusion criteria; 5590 (92.0%) patients underwent single-level ACDF, and 487 (8.0%) patients underwent CDR. The readmission rates were 2.6% for ACDF and 0.4% for CDR (p = 0.003). When stratified according to age groups, only patients between the ages of 41 and 60 years who underwent ACDF had a significantly higher readmission rate than those who underwent CDR (2.5% vs 0.7%, respectively; p = 0.028). After controlling for patient age, sex, body mass index, smoking status, history of chronic obstructive pulmonary disease (COPD), diabetes, hypertension, steroid use, and American Society of Anesthesiologists (ASA) class, patients who underwent CDR were significantly less likely to undergo readmission within 30 days than patients who underwent ACDF (OR 0.23 [95% CI 0.06-0.95]; p = 0.041). Patients with a history of COPD (OR 1.97 [95% CI 1.08-3.57]; p = 0.026) or hypertension (OR 1.62 [95% CI 1.10-2.38]; p = 0.013) and those at ASA Class IV (OR 14.6 [95% CI 1.69-125.75]; p = 0.015) were significantly more likely to require readmission within 30 days. The reoperation rates were 1.2% for ACDF and 0.4% for CDR (p = 0.086), and multivariate analysis revealed that CDR was not associated with lower odds of reoperation (OR 0.60 [95% CI 0.14-2.55]; p = 0.492). However, increasing age was associated with a higher risk (OR 1.02 [95% CI 1.00-1.05]; p = 0.031) of reoperation; a 2% increase in risk per year of age was found. CONCLUSIONS Patients who underwent single-level ACDF had a higher readmission rate than those who underwent single-level CDR in this study. When stratified according to age, this effect was seen only in the 41- to 60-year age group. No significant difference in the 30-day single-level ACDF and single-level CDR reoperation rates was found. Although patients in the ACDF group were older and sicker, other unmeasured covariates might have accounted for the increased rate of readmission in this group, and further investigation is encouraged.

Radiographic Pearls in the Evaluation of an Extradural Thoracic Meningioma: A Case Report

Spinal meningiomas are the most common of adult spinal tumors. Spinal meningiomas account for up to 45% of all intradural spinal tumors in adults and up to 25% of all spinal tumors. While spinal meningiomas are traditionally classified as intradural lesions, up to 14% may have an extradural component. Preoperative evaluation and directed use of imaging techniques are key in these rare but observed cases, to accurately diagnose and direct therapy. In this report, the authors present a case of a 61-year-old female with an incidentally found, exclusively extradural thoracic meningioma treated with surgical resection, highlighting key radiographic pearls in the evaluation of these uncommon lesions.

Isolated synchondrosis fracture of the atlas presenting as rotatory fixation of the neck: Case report and review of literature

Background:

Exclusive to the pediatric population, cartilaginous fractures of the atlas are singularly rare. Rarer still are those fractures that produce a fixed, rotational deficit of the neck. Here, the authors present the case of a 4-year-old boy with an isolated fracture of the anterior synchondrosis of C1 with a rotational component following a fall, as well as a review of the literature. Management with serial bedside manipulation, which is unique to our report, helped conservatively correct the rotation of the patient's neck, and, coupled with rigid bracing, demonstrated a comprehensive management strategy that resulted in fracture ossification at 3 months.

Case Description:

Our patient is a 4-year-old boy who fell from a bunk bed and complained of severe neck pain. The patient was brought to the emergency room and was found to have an isolated anterior fracture of the right frontal synchondrosis of the atlas. After conservative management with a hard collar and cautious manual reductions at the bedside, rotation of our patient's neck spontaneously resolved on day 3. After 3 months of rigid immobilization, the patient remained at neurological baseline and his fracture was healed. Literature review demonstrated age range between 2 and 6 years, with a subset of patients demonstrating rotational components to their fractures. Complete resolution of nearly all patients treated with rigid immobilization after fracture was documented, yet several patients experienced delayed diagnosis.

Conclusions:

Knowledge of the radiographic appearance of the C1 ossification centers as well as the normal timeline and sequence of ossification is essential in differentiating a true synchondrosis fracture from normal, nonossified cervical cartilage. With early diagnosis, immobilization, pain control, and muscle relaxants, patients can recover well with conservative management, can successfully ossify fracture sites, and can recover without sequelae.

Ultra-delayed lumbar surgical wound hematoma

Background:

There exists an inherent risk of increased venous thromboembolism (VTE) in surgical spine patients, which is independent of their existing risk factors. Prophylaxis and treatment of VTE is an imprecise practice and may have serious complications even well after the initial surgery. Furthermore, there are no clear guidelines on how to manage postoperative spine patients with regards to the timing of anticoagulation.

Case Description:

Here, we present the case of a middle-aged male, status post L2/3 laminectomy and discectomy who developed bilateral below the knee deep venous thrombosis. He was started on Enoxaparin and transitioned to Warfarin and returned with axial back pain, and was found to have a postoperative hematoma almost 3 weeks later in a delayed fashion.

Conclusion:

Delayed surgical wound hematoma with neural compression is an important complication to identify and should remain high on the differential diagnosis in patients on warfarin who present with axial spinal pain.

Postoperative urinary retention in patients undergoing elective spinal surgery

OBJECTIVE

Postoperative urinary retention (POUR) is a common problem leading to morbidity and an increased hospital stay. There are limited data regarding its baseline incidence in patients undergoing spinal surgery and the risk factors with which it may be associated. The purpose of this study was to evaluate the incidence of POUR in elective spine surgery patients and determine the factors associated with its occurrence.

METHODS

The authors retrospectively reviewed the records of patients who had undergone elective spine surgery and had been prospectively monitored for POUR during an 18-month period. Collected data included operative positioning, surgery duration, volume of intraoperative fluid, length of hospital stay, and patient characteristics such as age, sex, and medical comorbidities. Dialysis patients or those with complete urinary retention preoperatively were excluded from analysis.

RESULTS

Of the 397 patients meeting the study inclusion criteria, 35 (8.8%) developed POUR. An increased incidence of POUR was noted in those who underwent posterior lumbar surgery, those with benign prostatic hypertrophy (BPH), those with chronic constipation or prior urinary retention, and those using a patient-controlled analgesia pump postoperatively. An increased incidence of POUR was seen with a longer operative time but not with intraoperative intravenous fluid administration. A significant relationship between the female sex and POUR was noted after controlling for BPH, yet there was no association between POUR and diabetes or intraoperative instrumentation. Postoperative retention significantly prolonged the hospital stay. Three patients developed epidural hematomas necessitating operative reexploration, and while they experienced POUR, they also developed the full constellation of cauda equina syndrome.

CONCLUSIONS

Awareness of the risk factors for POUR may be useful in perioperative Foley catheter management and in identifying patients who need particular vigilance when they are due to void postprocedure. A greater understanding of POUR may also prevent longer hospital stays in select at-risk patients. Postoperative retention is rarely caused by a postoperative cauda equina syndrome due to epidural hematoma, which is also associated with saddle anesthesia, leg pain, and weakness, yet the delineation of isolated POUR from this urgent complication is necessary for optimal patient care.

The Impact of Hospital Teaching Status on Timing of Intervention, Inpatient Morbidity, and Mortality After Surgery for Vertebral Column Fractures with Spinal Cord Injury

OBJECTIVE

To investigate the impact of hospital teaching status on the timing of intervention and inpatient morbidity and mortality after surgery for acute spinal cord injury (SCI).

METHODS

Data from the Nationwide Inpatient Sample (2002-2011) were reviewed. Patients were included if they had a diagnosis of closed vertebral column fracture with SCI, underwent spine surgery, and were admitted urgently or emergently. Early intervention (the day of or the day after admission), inpatient morbidity and mortality rates were compared between patients admitted to teaching versus nonteaching hospitals. Multivariable regression analyses were performed.

RESULTS

A total of 9236 patients were identified (mean age 43 years, 82.6% male gender), with 78.7% admitted to a teaching hospital (n = 7,272) and 21.3% to a nonteaching hospital (n = 1,964). The most common mechanism of injury was a motor vehicle collision (43.9%), while the most common fracture location was between C5 and C7 (35.3%), and 22% of cases were complete SCIs. Following multivariable analysis, teaching hospital status was significantly associated with early intervention (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.01-1.25), but not with complication development (OR, 1.09; 95% CI, 0.98-1.23) or mortality (OR, 1.19; 95% CI, 0.91-1.56).

CONCLUSIONS

In this nationwide study, patients with vertebral column fractures with SCI who were admitted to teaching hospitals were more likely to receive early intervention compared to patients admitted to nonteaching hospitals. Future studies into the long-term implications of admission to teaching hospitals versus nonteaching hospitals for patients with SCI are encouraged.

Postoperative urinary retention in patients undergoing elective spinal surgery

OBJECTIVE Postoperative urinary retention (POUR) is a common problem leading to morbidity and an increased hospital stay. There are limited data regarding its baseline incidence in patients undergoing spinal surgery and the risk factors with which it may be associated. The purpose of this study was to evaluate the incidence of POUR in elective spine surgery patients and determine the factors associated with its occurrence. METHODS The authors retrospectively reviewed the records of patients who had undergone elective spine surgery and had been prospectively monitored for POUR during an 18-month period. Collected data included operative positioning, surgery duration, volume of intraoperative fluid, length of hospital stay, and patient characteristics such as age, sex, and medical comorbidities. Dialysis patients or those with complete urinary retention preoperatively were excluded from analysis. RESULTS Of the 397 patients meeting the study inclusion criteria, 35 (8.8%) developed POUR. An increased incidence of POUR was noted in those who underwent posterior lumbar surgery, those with benign prostatic hypertrophy (BPH), those with chronic constipation or prior urinary retention, and those using a patient-controlled analgesia pump postoperatively. An increased incidence of POUR was seen with a longer operative time but not with intraoperative intravenous fluid administration. A significant relationship between the female sex and POUR was noted after controlling for BPH, yet there was no association between POUR and diabetes or intraoperative instrumentation. Postoperative retention significantly prolonged the hospital stay. Three patients developed epidural hematomas necessitating operative reexploration, and while they experienced POUR, they also developed the full constellation of cauda equina syndrome. CONCLUSIONS Awareness of the risk factors for POUR may be useful in perioperative Foley catheter management and in identifying patients who need particular vigilance when they are due to void postprocedure. A greater understanding of POUR may also prevent longer hospital stays in select at-risk patients. Postoperative retention is rarely caused by a postoperative cauda equina syndrome due to epidural hematoma, which is also associated with saddle anesthesia, leg pain, and weakness, yet the delineation of isolated POUR from this urgent complication is necessary for optimal patient care.

Predictive parameters for the antecedent development of hip pathology associated with long segment fusions to the pelvis for the treatment of adult spinal deformity

BACKGROUND

The surgical treatment of adult scoliosis frequently involves long segment fusions across the lumbosacral joints that redistribute tremendous amounts of force to the remaining mobile spinal segments as well as to the pelvis and hip joints. Whether or not these forces increase the risk of femoral bone pathology remains unknown. The aim of this study is to determine the correlation between long segment spinal fusions to the pelvis and the antecedent development of degenerative hip pathologies as well as what predictive patient characteristics, if any, correlate with their development.

METHODS

A retrospective chart review of all long segment fusions to the pelvis for adult degenerative deformity operated on by the senior author at the Duke Spine Center from February 2008 to March 2014 was undertaken. Enrolment criteria included all available demographic, surgical, and clinical outcome data as well as pre and postoperative hip pathology assessment. All patients had prospectively collected outcome measures and a minimum 2-year follow-up. Multivariable logistic regression analysis was performed comparing the incidence of preoperative hip pain and antecedent postoperative hip pain as a function of age, gender, body mass index (BMI), and number of spinal levels fused.

RESULTS

In total, 194 patients were enrolled in this study. Of those, 116 patients (60%) reported no hip pain prior to surgery. Eighty-three patients (71.6%) remained hip pain free, whereas 33 patients (28.5%) developed new postoperative hip pain. Age, gender, and BMI were not significant among those who went on to develop hip pain postoperatively (P < 0.0651, 0.3491, and 0.1021, respectively). Of the 78 patients with preoperative hip pain, 20 patients (25.6%) continued to have hip pain postoperatively, whereas 58 patients reported improvement in the hip pain after long segment fusion for correction of their deformity, a 74.4% rate of reduction. Age, gender, and BMI were not significant among those who continued to have hip pain postoperatively (P < 0.4386, 0.4637, and 0.2545, respectively). Number of levels fused was not a significant factor in the development of hip pain in either patient population; patients without preoperative pain who developed pain postoperatively (P < 0.1407) as well as patients with preoperative pain who continued to have pain postoperatively (P < 0.0772).

CONCLUSION

This study demonstrates that long segment lumbosacral fusions are not associated with an increase in postoperative hip pathology. Age, gender, BMI, and levels fused do not correlate with the development of postoperative hip pain. The restoration of spinal alignment with long segment fusions may actually decrease the risk of developing femoral bone pathology and have a protective effect on the hip.