Chronic C1-C2 Rotatory Subluxation Reduced by C1 Lateral Mass Screws and C2 Translaminar Screws: A Case Report.

BACKGROUND: C1-C2 rotatory subluxation can result from a variety or etiologies. Pediatric patients are particularly susceptible to C1-C2 rotatory subluxation. If left untreated the condition is termed an atlantoaxial rotatory fixation (AARF) and chronic neck pain and deformity can result. Patients failing conservative treatment or those with recurrent or chronic rotatory subluxation may require halo treatment or surgical intervention. This illustrative case report is about a patient with chronic C1-C2 AARF who was treated with C1 lateral mass screws and C2 translaminar screws, a treatment that has not been addressed by this technique in a pediatric population. METHODS: This is a retrospective case review. RESULTS: After an unsuccessful attempt at reduction, an 11-year-old girl underwent surgery to treat her C1-C2 AARF. Through an all posterior approach, screws were placed bilaterally into the C1 lateral masses followed by the placement of C2 translaminar screws bilaterally. A small amount of distraction was applied through the screw construct to open up the C1-C2 articulation and the AARF was open reduced and fused. A detailed postoperative computed tomographic scan focused on the occiput C1-C2 joint confirmed the anatomical reduction of the joint complex. CONCLUSIONS: The patient had cosmetically pleasing relief of her torticollis and was doing well at 60 months after surgery. LEVEL OF EVIDENCE: Level IV.

Uniplanar Versus Fixed Pedicle Screws in the Correction of Thoracic Kyphosis in the Treatment of Adolescent Idiopathic Scoliosis (AIS).

BACKGROUND: The aim of surgical treatment of scoliosis is to obtain fusion of the spinal column, balanced in the coronal and sagittal planes. Great success has been attained with coronal correction; however, the sagittal profile has received less attention, resulting in little correction of sagittal plane alignment. The purpose of this study was to compare uniplanar and fixed pedicle screws in the correction of the thoracic sagittal alignment in the treatment of adolescent idiopathic scoliosis (AIS). METHODS: The sagittal profile of 2 groups of patients undergoing posterior spinal fusion (PSF) for AIS was compared. One group had uniplanar screws (n=16) as bone anchors, and the second group had fixed screws (n=20). Consecutive patients with AIS treated by PSF during 2004 to 2006 with fixed screws; and those treated in 2008 with uniplanar screws were included in the study. Data included: patient demographics, medical conditions, curve type, Risser stage, coronal and sagittal curve magnitude, curve flexibility, osteotomies, fusion levels, type and location of instrumentation, curve magnitude at the initial postoperative visit and at final follow-up. ANOVA and χ testing was completed. A P<0.05 was considered significant. RESULTS: Both groups were comparable demographically, medically, in relation to the curve characteristics and the surgical treatment. Immediate postcorrection sagittal curvature measurements were greater using the uniplanar than fixed screws, 36 versus 26 degrees and was also statistically significant at final follow-up (P=0.006). There was no difference between groups with respect to coronal thoracic deformity. In the Lenke 1 and Lenke 2 curve population, similar results were found. CONCLUSIONS: In patients undergoing PSF for AIS, uniplanar screws achieved superior correction of the sagittal thoracic alignment than fixed screws. This advantage was maintained in the postoperative follow-up period. The ability of the uniplanar screws to adapt to variable sagittal orientation appears to contribute to better radiographic outcomes. LEVEL OF EVIDENCE: This is a level III respective review study conducted at a single center from a single, pediatric spine surgeon.

Retroperitoneal fluid collection following anterior spine surgery--differential and management.

Iatrogenic ureteral injuries are rare and must be accurately identified to minimizing the risk for additional complications. Anterior lumbar interbody fusion (ALIF) is a valuable technique utilized in spine surgery, with its own unique set of complications. For example, retroperitoneal fluid collections, following ALIF surgery are rare and may result in back pain, radicular pain, nausea, and even death. It is important to rapidly identify the nature of the fluid collection to clarify appropriate management options. The purpose of this case report is to present a differential diagnosis for a delayed presentation of an extremely large retroperitoneal fluid collection following anterior lumbar surgery, as well as to provide discussion on this rare complication. Specifically, a 51-year-old female with a history of numerous previous abdominal surgeries underwent an L3-S1 ALIF through a paramedian retroperitoneal approach. Postoperatively, she developed a large retroperitoneal fluid collection heralded by unilateral left lower extremity swelling and paresthesias. Fluid aspiration suggested a urine leak, but no specific injury was identified on retrograde pyelogram, most likely due to hardware obscuration in the area of presumed injury. A presumptive ureteral injury resulted in a ureteral stent placement, with resolution of the fluid collection and hydronephrosis. A high index of suspicion allowed for proper treatment, healing, and ultimately, a satisfactory outcome.

The Outcomes of Revision Anterior Cervical Decompression and Fusion Using a Stand-Alone Implant Versus Traditional Interbody Polyetheretherketone Cage, Titanium Plate, and Screw Instrumentation.

INTRODUCTION: Anterior cervical decompression and fusion (ACDF) is the standard surgical procedure for cervical radiculopathy and myelopathy, although ACDF includes risks of adjacent segment disease (ASD) and subsequent revision procedures. Various interbody cage, plate, and screw options can be utilized. Stand-alone devices were designed to overcome undesired complications of hardware prominence and associated dysphagia, soft tissue violation, and adjacent level encroachment. Implants include biomechanical structural support (cage) composed of various materials (polyetheretherketone (PEEK)/titanium) and integral fixation (screws/blades). The purpose was to compare intraoperative, short- and long-term outcomes of revision ACDF using a stand-alone implant (ACDF-ZP group) versus traditional interbody PEEK cage, titanium plate, and screw instrumentation (ACDF-CP group). METHODS: This was a retrospective, cohort study reviewing charts of patients who underwent revision ACDF. The primary outcome measure was the incidence of postoperative dysphagia. Secondary outcomes included intraoperative, short-term, and long-term outcomes and complications. RESULTS: Sixty-one patients were included (ACDF-ZP group = 50; ACDF-CP group = 11). In-hospital incidence of dysphagia was significantly less in the ACDF-CP group (P = 0.041). Thrity-one (62.0%) of the ACDF-ZP group reported dysphagia postoperatively, half resolved by 6 weeks, and two persisted for more than 6 months. Five (45.5%) of the ACDF-CP group reported dysphagia with most resolving within 6 weeks. There were no statistically significant differences between groups in short- or long-term complications, dysphonia, or reoperation rates. No statistical significance was seen in blood loss, operative time, hospital stay, local and global alignment, or cage subsidence. CONCLUSION: Rates of dysphagia were comparable between groups at short and long-term follow-up, despite a greater incidence of postoperative dysphagia in the ACDF-ZP group. All complications and occurrences of cage subsidence were observed in the ACDF-ZP group, which may be attributed to the larger sample size. Given these findings, zero-profile stand-alone implants and traditional interbody PEEK cage, titanium plate, and screw instrumentation appear to be both safe and effective options for revision ACDF.

The effectiveness of pre-contoured titanium alloy rods in inducing thoracic kyphosis after sequential spinal releases in an in vitro biomechanical model.

Purpose: Evaluate the ability of pre-contoured rods to induce thoracic kyphosis (TK) in human cadaveric spines and determine the effectiveness of sequential surgical adolescent idiopathic scoliosis (AIS) release procedures. Methods: Six thoracolumbar (T3-L2) spine specimens were instrumented with pedicle screws bilaterally (T4-T12). Over correction using pre-contoured rods was performed for intact condition and Cobb angle was measured. Rod radius of curvature (RoC) was measured pre- and post-reduction. The process was repeated following sequential release procedures of (1) interspinous and supraspinous ligaments (ISL); (2) ligamentum flavum; (3) Ponte osteotomy; (4) posterior longitudinal ligament (PLL); and (5) transforaminal discectomy. Cobb measurements determined the effective contribution of release on TK and RoC data displayed effects of reduction to the rods. Results: The intact TK (T4-12) was 38.0° and increased to 51.7° with rod reduction and over correction. Each release resulted in 5°-7°of additional kyphosis; the largest releases were ISL and PLL. All releases resulted in significant increases in kyphosis compared to intact with rod reduction and over correction. Regionally, kyphosis increased ∼2° for each region following successive releases. Comparing RoC before and after reduction showed significant 6° loss in rod curvature independent of release type. Conclusion: Kyphosis increased in the thoracic spine using pre-contoured and over corrected rods. Subsequent posterior releases provided a substantial, meaningful clinical change in the ability to induce additional kyphosis. Regardless of the number of releases, the ability of the rods to induce and over correct kyphosis was reduced following reduction.

Giant cell tumor of a lumbar vertebra in a 7-year-old child: a case report.

STUDY DESIGN: This case provides a rare occurrence of a giant cell tumor (GCT) in posterior elements of a lumbar vertebra in a 7-year-old child with successful outcome after surgical excision and regular follow-ups. OBJECTIVE: To present a unique case report of a pediatric GCT in the vertebral column and results. SUMMARY OF BACKGROUND DATA: GCT is a rare bone tumor seen in 3% to 5% of primary bone neoplasm. Approximately 7% of GCTs are found in the vertebral column. GCT of the spine is found in only 5% to 7% of cases and can occur in any region of the spine but are believed to be predominantly in the sacrum. Despite its benign nature, expansion in a confined space makes early detection of spinal GCTs important to prevent occurrence of compressive myelopathy/radiculopathy. The presence of a GCT in a child younger than 10 years of age, in posterior elements of a lumbar vertebral body, has not been reported earlier. METHODS: On the basis of the clinical history, radiograph of the thoracolumbar spine, computed tomography of lumbar spine, and magnetic resonance imaging, a preliminary diagnosis of osteoblastoma was made. RESULTS: The patient presented with a lytic lesion with involvement of posterior elements, 1 side the pedicle extending into the body of a lumbar vertebra (L3) and had extension into the paraspinal muscles. Intraoperative exploration and frozen section showed the presence of a typical histologic picture of a GCT. Ipsilateral pedicle, posterior elements, and the superior articular facet were excised. En bloc resection was found not to be feasible due to the friable nature of the tumor and involvement of the soft tissues. In addition, fusion was avoided with consideration of the young age of the patient. CONCLUSIONS: The patient has been free of any recurrence as of his last follow-up visit.

Comparison of operative implications between adolescent and young adult idiopathic scoliosis patients from scoliosis research society mortality and morbidity database.

PURPOSE: To compare the operative implications between adolescent idiopathic scoliosis patients (10-18 years) and young adult idiopathic scoliosis (YAdIS) patients (19-30 years). METHODS: This was a retrospective study querying the SRS M&M database for AIS (10-18 years) and YAdIS (19-30 years) cases enrolled between 2009 and 2015. Demographic and surgical parameters (Lenke curve classification, preoperative curve magnitude, approach type, osteotomy type, estimated blood volume (EBV), levels of fusion and ASA scores) were evaluated and compared between groups. RESULTS: N = 690: AIS (n = 607) and YAdIS (n = 83). Lenke curve classification distributions in AIS and YAdIS cases were: main thoracic, 293 vs. 34; double thoracic, 42 vs. 5; double major, 159 vs. 15; triple major, 15 vs. 5; thoracolumbar, 85 vs. 17; and lumbar, 5 vs. 6, respectively. Patients with a coronal curve > 90° were significantly greater in YAdIS vs. AIS patients, p = 0.008. Anterior and combined surgery rates were significantly higher in YAdIS, p = 0.028. Two-staged surgeries were significantly higher for YAdIS cohort, p = 0.01. Osteotomy rate was similar between groups, p = 0.42, but proportion of 3-column osteotomies was significantly higher for YAdIS, p < 0.001. ASA (severe systemic disease and some functional limitation) score 3 patients' rate was higher in YAdIS cohort, p = 0.01. EBV was significantly higher in YAdIS, p = 0.01. Average number of levels of fusions between cohorts was not significant, p = 0.87. CONCLUSIONS: The operative implications observed with young adult idiopathic scoliosis patients may potentially result in more complex surgical procedures and operative-associated complications than their adolescent counterparts. Further studies are required and should include a larger number of cases, be prospective in nature and verifiable data. LEVEL OF EVIDENCE: II.

Evaluation of shoulder balance in early onset scoliosis after definitive fusion and comparison with adolescent idiopathic scoliosis shoulder balance.

STUDY DESIGN: The Children Spine Study Group registry was queried for early onset scoliosis (EOS) patients who had final definitive spinal fusion after their scoliosis was managed with either growing rods or VEPTR. The Harms Study Group registry was queried for adolescent idiopathic scoliosis (AIS) patients who had definitive fusion OBJECTIVE: The goal is to assess shoulder alignment in EOS patients after a definitive fusion and how these radiographic outcomes relate to the more familiar situation of post-definitive fusions shoulder alignment in AIS patients. BACKGROUND: EOS is a challenging pathology to manage. Numerous components are important in the success of spinal surgery for this population. Shoulder balance is a one of the components that is easily seen by the patient. Recently, the importance of its relationship to patient satisfaction has received greater attention. METHODS: Sample size: n = 145 (EOS (n = 34) and AIS (n = 111)). Shoulder balance parameters (SBP) of clavicular angle (CA), coracoid height difference (CHD), clavicular tilt angle difference (CTAD), and clavicle-rib cage intersection difference (CRID) measurements were measured from the reviewed radiographs and documented pre-definitive, post-definitive and 2-year follow-up measures. Shoulder balance parameters were compared between EOS and AIS cohorts at documented intervals. RESULTS: EOS mean pre-definitive fusion SBPs (CA, CTAD, CRID, CHD) were significantly higher compared to AIS, p = 0.004, 0.003, < 0.001, < 0.001, respectively. Significant post-definitive fusion corrections were noticed for CTAD (0.01), CHD (0.01), nearly significant CA (0.07), non-significant CRID in EOS patients. In AIS patients, no significant corrections were noticed for CA, CTAD, CHD and but significant for CRID (0.02). At post-definitive and 2-year follow-up, CA, CRID, CHD were not significant between cohorts, but CTAD (< 0.01) was significantly higher in EOS cohort at final follow-up. CONCLUSION: Post-definitive and 2-year follow-up shoulder balance for EOS patients was not significantly different from AIS patients. LEVEL OF EVIDENCE: III.

Impact of liberal intraoperative allogeneic blood transfusion on postoperative morbidity and mortality in major thoracic and lumbar posterior spine instrumentation surgeries.

PURPOSE: To investigate the impact of intraoperative blood transfusion on outcomes in patients who had major thoracic and lumber posterior spine instrumentation surgery. METHODS: Retrospective study included patients who underwent major spine surgery between 2013 and 2017. Patients' demographics, surgical charts, anesthesia charts, discharge charts and follow-up outpatient charts were reviewed. Data collection included: age, gender, BMI, Charlson Co-morbidity Index (CCI) scores, American Society of Anesthesiologists (ASA) scores, amount of estimated blood loss [% estimated blood volume (%EBV)], amount of blood transfused during surgery and post-surgery before discharge, number of fusion levels, pre- and postoperative hemoglobin (Hb) levels, and length of hospital stay. Also collected in-hospital postoperative complications (cardiovascular, pulmonary, infections and deaths). Patients' postoperative intubation status data documented. Reviewed follow-up charts to document any complications. RESULTS: Sample size = 289; No transfusion = 92; transfusion = 197. Transfused patients were significantly older, p < 0.001, higher average BMIs (p < 0.001); ASA scores (p < 0.001); CCI scores (p < 0.001), mean postoperative Hb level (p = 0.004), average intraoperative %EBV loss (p < 0.001), longer hospital stays (p = 0.003). Non-transfusion cohort had significantly higher proportion of patients (p < 0.001) extubated immediately after surgery. Seventeen patients had at least one in-hospital complication, p = 0.05. Complications were not significant among groups. CONCLUSION: Intraoperative blood transfusions and high volume intraoperative allogeneic blood transfusions did not increase risk for in-hospital complications or surgical site infections. Delayed extubations noticed in patients who received higher volumes of intraoperative allogeneic blood transfusions. High-volume intraoperative blood transfusions increased length of hospital stays. High post-hospital surgical infections associated with high volume intraoperative blood transfusions. Results should be interpreted cautiously due to small sample size.

CT based bone mineral density as a predictor of proximal junctional fractures.

Background: Proximal junctional fractures (PJFr) can be a catastrophic complication associated with adult spinal deformity surgery. Osteoporosis can be a major risk factor for the cause of PJFr. Recent studies suggest using surrogate computed tomography (CT) scans in place of spinal dual-energy x-ray absorptiometry (DEXA) scores for bone mineral density (BMD). Investigate the feasibility of using preoperative CT based bone mineral density at upper instrumented vertebrae (UIV) and one level proximally (UIV+1) and distally (UIV-1) to predict the possibility of PJFr risk. Methods: Retrospective two-academic center case-controlled study, reviewed consecutive adult spinal deformity surgeries; included constructs encompassing at least five fusion levels and fusions to pelvis. Examined demographic, surgical, and radiographic data preoperatively, postoperatively, and final follow-up. Formed groups based on type of proximal junctional deformity (PJD): Control (no PJD), proximal junctional kyphosis (PJK) and PJFr. Preoperative CT BMD values measured in Hounsfield units (HU) for sagittal and axial planes at UIV, UIV+1, and UIV-1 and compared between groups. Results: N=92 patients. Preoperative CT scan BMD values were significantly lower in PJFr vs. control at: UIV+1 in sagittal (p=0.007), axial (p=0.02) planes; UIV sagittal (p=0.04) and axial (p=0.03) planes; and UIV-1 sagittal (p=0.05) plane. Similarly, lower CT scan BMD values noted in PJFr vs. PJK at: UIV+1 in sagittal (p=0.04) and axial (p=0.03) planes. Trend seen with lower CT scan BMD values at UIV+1 level in PJFr vs. PJK in sagittal (p=0.12) and axial (p=0.10) planes. Preoperative global sagittal imbalance measurements significantly lower in control, but comparable between PJK and PJFr. Conclusions: Higher preoperative global sagittal imbalance with lower preoperative CT BMD values at UIV and UIV+1 vertebral body may increase the risk of proximal junctional fractures after adult spine deformity surgery. Proximal junctional hooks may supplement the pathogenesis. Readers should note the small sample size.Level of Evidence: 3.

Spinal deformity surgery is accompanied by serious complications: report from the Morbidity and Mortality Database of the Scoliosis Research Society from 2013 to 2020.

PURPOSE: The Morbidity and Mortality (M&M) report of the Scoliosis Research Society (SRS) has been collected since 1965 and since 1968 submission of complications has been required of all members. Since 2009, the SRS has collected information on death, blindness, and neurological deficit, with acute infection being added in 2012 and unintentional return to the operating room (OR) being added in 2017. In this report, we use the most recent data submitted to the SRS M&M database to determine the rate of neurological deficit, blindness, acute infection, unintentional return to the OR, and death, while also comparing this information to previous reports. METHODS: The SRS M&M database was queried for all cases from 2013 to 2020. The rates of death, vision loss, neurological deficit, acute infection, and unintentional return to the OR were then calculated and analyzed. The rates were compared to previously published data if available. Differences in complication rates between years were analyzed with Poisson regression with significance set at α = 0.05. RESULTS: The total number of cases submitted per year varied with a maximum of 49,615 in 2018 and a minimum of 40,464 in 2020. The overall reported complication rate from 2013 to 2020 was 2.86%. The overall mortality rate ranged from 0.09% in 2018 to 0.14% in 2015. The number of patients with visual impairment ranged from 4 to 13 between 2013 and 2015 (no data on visual impairment were collected after 2015). The overall infection rate varied from 0.95 in 2020 to 1.30% in 2015. When the infection rate was analyzed based on spinal deformity group, the neuromuscular scoliosis group consistently had the highest infection rate ranging from 3.24 to 3.94%. The overall neurological deficit rate ranged from 0.74 to 0.94%, with the congenital kyphosis and dysplastic spondylolisthesis groups having the highest rates. The rates of unintentional return to the OR ranged from 1.60 to 1.79%. Multiple groups showed a statistically significant decreasing trend for infection, return to the operating room, neurologic deficit, and death. CONCLUSIONS: Neuromuscular scoliosis had the highest infection rate among all spinal deformity groups. Congenital kyphosis and dysplastic spondylolisthesis had the highest rate of neurological deficit postoperatively. This is similar to previously published data. Contrary to previous reports, neuromuscular scoliosis did not have the highest annual death rate. Multiple groups showed a statistically significant decreasing trend in complication rates during the reporting period, with only mortality in degenerative spondylolisthesis significantly trending upwards. LEVEL OF EVIDENCE: Level III.

Pediatric disk herniation.

Pediatric disk herniation is a rare condition that should be considered in the differential diagnosis of the child with back pain or radiating leg pain. Because pediatric disk herniation is relatively uncommon, there is typically a delay in diagnosis compared with time to diagnosis of adult disk herniation. Pediatric disk herniations are often recalcitrant to nonsurgical care, but such measures should be attempted in patients who present with isolated pain symptoms and have a normal neurologic examination. Twenty-eight percent of adolescent disk herniations involve apophyseal fractures; this presentation has a higher rate of surgical intervention than do herniations without fracture. Surgical management of pediatric disk herniation involves laminotomy and fragment excision. Short-term data demonstrate excellent pain relief, with 1% of children requiring repeat surgery for lumbar disk pathology in the first year. Long-term data suggest that 20% to 30% of patients will require additional surgery later in life.

Clinical outcomes of nitinol staples for preventing curve progression in idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA: Although bracing for idiopathic scoliosis is moderately successful, its efficacy has been called into question and it carries associated psychosocial ramifications. In this study we report the background, rationale, indications, surgical techniques, and early results of vertebral body stapling (VBS) in patients with idiopathic scoliosis. METHODS: We reviewed the literature on growth modulation of the growing spine and the concepts behind the use of VBS as a fusionless strategy. The indications are derived from retrospectively reviewed patients with idiopathic scoliosis treated with VBS followed for a minimum of 2 years. Indications for staple use included: (a) age <13 years in girls and 15 in boys, (b) Risser 0 or 1 and/or 1 year of growth remaining on wrist radiograph, (c) coronal curve <45 degrees with minimal rotation and flexible to <25 degrees on a side bending radiograph, and (d) sagittal thoracic curve <40 degrees. RESULTS: Thoracic curves measuring <35 degrees had a success rate of 77.7%. Curves which reached ≤ 20 degrees on first erect radiograph had a success rate of 85.7%. Thoracic curves greater than 35 degrees were not successful and require alternative treatments. Lumbar curves demonstrated a success rate of 86.7%. CONCLUSIONS: Some patients with idiopathic scoliosis with moderate curves (25 to 45 degrees) and high risk of progression can be safely treated with VBS as an alternative to bracing. LEVEL OF EVIDENCE: Level III.

Distal Ventral Iliac Pathway for Spinopelvic Fixation: Technique Description and Case Series.

BACKGROUND: Pelvic fixation improves the stability of spinal instrumentation and can be used in high-grade degenerative disease, trauma, deformity, and destabilizing invasive pathologies, such as infection and tumor. Classic techniques for spinopelvic fixation include traditional iliac screws and S2-Alar-Iliac screws. We present a case series describing the distal ventral iliac pathway (DVIP) for spinopelvic fixation and discuss surgical indications and merits of this technique. We describe the use of the DVIP for spinopelvic fixation in the setting of degenerative and traumatic pathologies, compare this technique with existing approaches, and summarize literature to support this approach. METHODS: One hundred twenty-eight cases of DVIP screws were identified at 1 academic medical center, and 3 cases were chosen as representative examples for technique demonstration. RESULTS: Patient ages ranged from 19 to 81 (mean 62) years. Intraoperative and postoperative complications include 12 incidental durotomies, 3 suprafascial infections, and 2 compressive hematomas. There were 22 instances of hardware failure and 8 instances of pseudoarthrosis. Overall, 26 patients underwent revision surgery. Mean estimated blood loss, operative time, and time under fluoroscopy were 1959 mL, 386 minutes, and 3.19 minutes, respectively. CONCLUSIONS: The DVIP is both safe and effective as a treatment for patients with degenerative and traumatic lumbosacral pathology. Spinopelvic fixation provides improved soft tissue coverage and fewer hardware complications at minimum of 1 year follow up. This case series demonstrates a novel surgical technique for spinopelvic fixation in the setting of numerous spinal pathologies. LEVEL OF EVIDENCE: 4. CLINICAL RELEVANCE: This surgical technique is less technically challenging than current approaches, minimizes radiation exposure, and obviates the need for horizontal connector rods. In addition, in highly destabilizing pathologies, this technique also allows for multiple screw placement within the ilium, while maintaining the ability to connect to a single rod construct. This technique is safe, technically approachable, and broadly applicable to an array of spinopelvic pathologies.

Comparison of adverse events between cervical disc arthroplasty and anterior cervical discectomy and fusion: a 10-year follow-up.

BACKGROUND CONTEXT: Cervical disc arthroplasty (CDA) has been advocated as an alternative to anterior cervical discectomy and fusion (ACDF) with the added potential to reduce the risk of adjacent level disc degeneration and segmental instability. However, the long-term adverse events of arthroplasty have yet to be fully reported. PURPOSE: To investigate the 10-year follow-up adverse events rates between CDA and ACDF. STUDY DESIGN/SETTING: The study was a randomized, prospective, multicenter Investigational Device Exemption (IDE) trial and its continued follow-up as a postapproval study (PAS). Single level surgeries were performed for cervical disc pathologies between May 2002 and October 2004. PATIENT SAMPLE: n=463 patients. OUTCOME MEASURES: Adverse events comparison of CDA and ACDF from self-reported and physiologic measures. METHODS: At each evaluation time point, subjects were queried for adverse events since their last visit; and all adverse events were documented, regardless of whether or not they appeared related to the surgery or device. Adverse events were recorded, categorized, and assessed for severity and relationship to the study device and/or surgical procedure. The 10-year cumulative rates for each type of adverse events were summarized using a life-table method for the time-to-event analysis. A log-rank test was used to compare the two treatment groups. RESULTS: A total of 242 patients received CDA and 221 patients received ACDF. At 10-year follow-up, 54% (130/242) of CDA patients and 47% (104/221) of the ACDF subjects were evaluated. At up to 10-year follow-up, 231 patients in the CDA group (cumulative rate 98.4%) and 199 patients in the ACDF group (cumulative rate 98.7%) had at least one adverse event. Overall, the difference in the cumulative rate of all adverse events over 10 years was not statistically different (p=0.166). The cumulative rates of the following adverse events were not different between the two groups for cancer, cardiovascular, death, dysphonia/dysphagia, gastrointestinal, infection, urogenital, respiratory, implant displacement/loosening, implant malposition, neck and arm pain, neurological, other pain, spinal events, and intraoperative vascular injury. However, there were more adverse events in the CDA group resulting from trauma (p=.012) and more spinal events at the index level (p=.006). The ACDF group had significantly more nonunion events (p=.019), and nonunion outcome pending (p=.034), adjacent level spinal events (p=.033), and events that fell into the "other" category (p=.015). CONCLUSIONS: The cumulative rates of patients who had any adverse events were not different between the artificial cervical disc and the anterior cervical arthrodesis groups. In addition, the cumulative rates were not different between the two groups for the majority of categories as well.

Epidural analgesia for postoperative pain control after adolescent spinal fusion procedures which violated the epidural space.

STUDY DESIGN: Retrospective chart review. OBJECTIVE: To determine the effectiveness of epidural analgesia in scoliosis patients with an opened (violated) spinal canal. BACKGROUND: Postoperative continuous epidural analgesia using local anesthetics and/or opioids has been described with good success after posterior scoliosis correction. One of the concerns with the use of epidural catheters for pain control is the reliability and distribution of analgesic medication when the epidural space is violated intraoperatively by Smith-Petersen osteotomies or placement of multiple sublaminar wires. METHODS: The medical records of 55 patients who underwent pediatric deformity surgery for scoliosis at a single university center over 1-year period (January 2007 to January 2008) were reviewed. Patient demographic, surgical, and postoperative data were collected. A chi test was used to make comparisons on the basis of categorical data, whereas analysis of variance tests were used to make comparisons on the basis of means. Statistical significance was defined as a probability value of <0.5. RESULTS: Twenty-nine patients were managed with epidural analgesia, whereas 26 patients were managed with intravenous patient-controlled analgesia (IV PCA). Seven of the 29 patients with epidural analgesia had a violation of their epidural space during their surgery, which did not alter the efficacy of their postoperative analgesia with an epidural. Epidural analgesia provided a lower mean pain score (P=0.022) over the first 24 hours and fewer pain scores over 4 (P=0.050) during that same time period than IV PCA for all patients as well as those with a violated spinal canal. There was no statistical difference in the rates of pruritus, nausea, ileus, constipation, urinary retention, change in neurologic examination, or rate of infection between the patients with a violated spinal canal and those with an intact spinal canal. CONCLUSIONS: Overall, patients managed with an epidural had significantly lower pain scores than those managed with IV PCA despite violation of the epidural space.

Outcomes of Negative Pressure Wound Therapies in the Management of Spine Surgical Site Wound Infections.

BACKGROUND: Many studies report benefits using negative pressure wound therapy (NPWT) in surgical site infections (SSIs). We measured and compared efficacy and complications associated with NPWT for traditional versus suprafascial vacuum-assisted closures (VACs). METHODS: This is a retrospective chart review of consecutive SSIs managed with negative wound therapy after spinal procedures between 2012 and 2015 from a single, academic center. Patients were collected through International Classification of Diseases, Ninth Revision, procedure codes. Inclusion criteria were patients with spine SSIs managed by irrigation and debridement with a VAC device; infection occurring after spinal surgeries; and age over 18. A total of 23 consecutive patients met the criteria. We reviewed demographic data, surgical data, infectious disease data, discharge summaries, and postoperative follow-up charts. We compared and analyzed demographics, duration of VAC therapy, and reoperation rates between VAC groups. Statistical analysis was completed using analysis of variance and χ2 tests; P ≤ 0.05 was considered statistically significant. RESULTS: A total of 7 patients had traditional VACs (Group 1), and 16 patients had suprafascial VACs (Group 2). Average blood loss and number of levels involved during index surgery were not statistically significant between groups. Locations of infection occurrence were cervical spine = 3, thoracic spine = 1, and lumbar spine = 19. Reoperation rate after initial wound VAC placement was 34%, with rates significantly higher for Group 1 (71%) than Group 2 (16%), P = 0.02. Average duration of wound therapy was longer in Group 1 (77 days) than Group 2 (33 days), P = 0.08. Average number of operating room visits after initial wound VAC implantation were 0.7 for Group 1 and 0.3 for Group 2, P = 0.26, before obtaining a clean wound closure. CONCLUSIONS: Small sample size and retrospective nature were limitations. Negative pressure wound therapy may be useful for managing spinal infections, and suprafascial VAC had less time duration, lower risk of sponge fragment retainment, and fewer procedures to ultimately achieve wound closure. LEVEL OF EVIDENCE: 3.

Employment Status for the First Decade Following Randomization to Cervical Disc Arthroplasty Versus Fusion.

STUDY DESIGN: An analysis of employment status data up to 10 years following the Federal Drug Administration (FDA) Investigational Device Exemption (IDE) randomized trial and extension as post-approval study comparing BRYAN cervical disc (Medtronic, Minneapolis, MN) arthroplasty (CDA) versus single-level anterior cervical discectomy and fusion (ACDF) was performed. OBJECTIVE: Ten-year experience with the BRYAN disc arthroplasty trial provides opportunity to report patient employment data. SUMMARY OF BACKGROUND DATA: The long-term consequences of arthroplasty remain incomplete, including the occurrence of occupational compromise. METHODS: Patients' employment status were measured at regular intervals in both groups up to 10 years. RESULTS: The preoperative employment status proportion was comparable between investigational (BRYAN CDA) and control (ACDF) groups. In the investigational group, 49.2% returned to work at 6 weeks compared with 39.4% of the control group (P = 0.046). At 6 months and 2 years postoperatively, there was a similar likelihood of active employment in both groups. After 2 years at all time points, 10% drop-off seen in control group employment, but not in investigational group. At 10 years, 76.2% CDA patients were employed to 64.1% ACDF patients (P = 0.057). Preoperative variables influencing work status at 10 years following CDA included: preoperative work status, age, and SF-36 Mental Component Score (SF-36 MCS); whereas, no significant preoperative factor identified with ACDF. Time to return to work was influenced in both groups by preoperative work status; and in the ACDF group: reaching age 65 at 10-year visit, preoperative arm pain and NDI score had significant influences. CONCLUSION: More patients returned to work at 6 weeks after CDA compared with ACDF, although there was no difference by 6 months. After 2 years, a nonsignificant trend toward higher employment rates in the arthroplasty group was evident, but this difference could not be validated due to the very high rate of loss of patients to the follow-up. LEVEL OF EVIDENCE: 2.

Delayed quadriparesis after posterior spinal fusion for scoliosis: a case series.

STUDY DESIGN: A multicenter retrospective IRB exempt case series analyzing clinical and radiographical data of patients treated by three surgeons over the past two decades was conducted. OBJECTIVE: To examine the factors involved in the development of quadriparesis in patients who underwent posterior spinal fusion for scoliosis. Delayed spinal cord infarcts usually present at the region of instrumentation according to reports from the Scoliosis Research Society. Nonetheless, there is a lack of data regarding factors associated with delayed quadriparesis following posterior spinal fusion METHODS: Evaluated variables were age, Cobb angle, blood loss, and curve correction percentage. Postoperative imaging was also evaluated to determine factors indicative of the etiology of the quadriparesis. RESULTS: Eight patients presented delayed postoperative quadriparesis. All patients had a postoperative examination equal to that of baseline. The first patient deteriorated at 6 h postoperatively and the most delayed patient presented 4 days postoperatively. Six patients had neuromuscular disorders and 2 had adolescent idiopathic scoliosis. Mean age was 13.7, mean curve magnitude was 78.7°, mean percent curve correction was 71% and the mean estimated blood loss was 1185 cc. Seven of eight patients had documented peri- or postoperative hypotension. CONCLUSIONS: Cervical infarction is the likely cause of delayed quadriparesis after posterior spinal fusion. Even though the underlying etiology continues to be unclear, postoperative hypotension, curve magnitude, percent curve correction, and the presence of cervical kyphosis/stenosis may be contributory and need to be closely evaluated. LEVEL OF EVIDENCE: IV, Case Series.