Laterally placed expandable interbody spacers with and without adjustable lordosis improve patient outcomes: A preliminary one-year chart review.

BACKGROUND/OBJECTIVES: Minimally invasive lateral lumbar interbody fusion (MIS LLIF) has been employed to treat degenerative disc disease, with reduced complication profiles in comparison to other open anterior and posterior techniques. The technique permits the use of larger, coronal-spanning interbody spacers to restore height and alignment. However, large static spacers have historically been associated with iatrogenic complications during trialing and insertion. Developments in expandable technology have the potential for incrementally larger increases in both height and lordosis in a controlled expansion in situ, minimizing endplate violation. However, further clinical and radiographic data are needed to investigate the effect of expansion technology. METHODS: A retrospective, single-surgeon chart review was performed on 103 consecutive patients, all of whom underwent MIS LLIF surgery at 1-2 contiguous level(s) with expandable spacers [66/103 patients were implanted with lordotically actuated (adjustable lordosis) spacers, and 37/103 with non-adjustable lordosis spacers]. Clinical and radiographic functional outcomes were collected and compared at both preoperative and postoperative time points up to 12-month follow-up. Parametric and nonparametric tests were utilized when they were appropriate, with a P value < 0.05 being significant. RESULTS: One-hundred twenty-five levels were instrumented on 103 consecutive cases. Average age was 58.2 ± 12.1 years; 42.1% (45/107) were female; 78.6% (81/103) were 1-level cases; 21.4% (22/103) were 2-level cases; 44.8% (56/125) were performed at L4-L5 and 34.4% (43/125) at L3-4. Average estimated blood loss was 24.6 ± 12.3cc. Mean operative time was 61.0 ± 19.1 min, and mean fluoroscopic time was 28.2 ± 14.6 s. Visual Analog Scale (VAS) back and leg pain scores decreased significantly by an average of 6.5 ± 1.3 points at 12 months (P < 0.001). Oswestry Disability Index (ODI) scores significantly decreased at final follow-up by a mean of 62.0 ± 12.4 points (P < 0.001). Lumbar lordosis significantly improved by a mean of 3.1 ± 8.8°, while segmental lordosis significantly improved by 3.9 ± 3.1° at 12 months (P < 0.001). Anterior, middle, and posterior disc heights all experienced significant increases at 12 months by averages of 5.1 ± 3.1, 4.5 ± 2.9, and 2.4 ± 2.2 mm, respectively (P < 0.001). Neuroforaminal height significantly increased at 12 months by a mean of 3.7 ± 3.7 mm (P < 0.001). There was 99% fusion at all levels, with no findings of radiolucency and 1% pseudarthrosis observed. Only 1 (1/125, 0.8%) case of subsidence and 7 (7/125, 5.6%) cases of suspected, asymptomatic radiographic adjacent segment degeneration were reported, with no secondary revision surgeries through 12-month follow-up. CONCLUSION: Significant improvement of disc height, neuroforaminal height, segmental lordosis, and indirect decompression was achieved and maintained up to 1-year follow-up from baseline. Clinical outcomes were significantly improved based on appreciable decreases in VAS pain and ODI scores at final follow-up. Minimal complications were reported, with significant radiographic and patient reported outcomes observed. The use of expandable spacers, with and without adjustable lordosis, was shown to improve outcomes for the studied patient population.

Expandable Technology Improves Clinical and Radiographic Outcomes of Minimally Invasive Lateral Lumbar Interbody Fusion for Degenerative Disc Disease.

BACKGROUND: Static interbody spacers are standard of care for minimally invasive lateral lumbar interbody fusion (MIS LLIF). However, placement of large static interbody spacers typically requires multiple trialing, endplate preparation, and forceful impaction. A lateral expandable interbody spacer with adjustable lordosis can be inserted at a reduced height, to optimize the endplate-to-endplate fit. This study describes radiographic and clinical outcomes in patients treated using lateral titanium expandable interbody spacers with adjustable lordosis using MIS LLIF. METHODS: This is a single-surgeon, retrospective, institutional review board-exempt chart review of 24 consecutive patients who underwent MIS LLIF at 1-2 contiguous level(s) using expandable spacers with adjustable lordosis. Radiographic and clinical functional outcomes were collected and compared at preoperative and postoperative time points up to 24 months. Parametric and nonparametric tests were used when appropriate. Statistical results were significant if P < .05. RESULTS: Twenty-four consecutive patients were evaluated with an average age of 57.8 ± 12.6 years; 45.8% were female. Visual analog scale for back pain improved by 7.3 ± 1.0 points, whereas Oswestry Disability Index scores improved by a mean of 67.5 ± 11.3 points at 24 months (P < .001). Lumbar lordosis improved by a mean of 6.3 ± 10.1° at 24 months (P < .001). There were 29 spinal levels, with 41.4% at L4-5 and 34.5% at L3-4. Anterior, middle, and posterior disc height significantly increased at 24 months by means of 4.5 ± 2.9 mm, 4.0 ± 2.8 mm, and 2.6 ± 1.9 mm, respectively (P < .001). Neuroforaminal height significantly improved by 3.3 ± 3.9 mm at 24 months (P < .001). Segmental lordosis improved by 3.6 ± 3.0° at 24 months. CONCLUSIONS: This study showed significant positive clinical and radiographic outcomes for patients who underwent MIS LLIF using expandable interbody spacers with adjustable lordosis. Correction of sagittal alignment was achieved and maintained up to 2-year follow-up. The use of expandable spacers with adjustable lordosis was shown to be safe and effective in this cohort. LEVEL OF EVIDENCE: 3.

Comparative Effectiveness of Laterally Placed Expandable versus Static Interbody Spacers: A 1-Year Follow-Up Radiographic and Clinical Outcomes Study.

STUDY DESIGN: Retrospective chart review. PURPOSE: This study compared the clinical and radiographic outcomes of patients treated with expandable and static interbody spacers following minimally invasive lateral lumbar interbody fusion (MIS-LLIF) with 12-month follow-up. OVERVIEW OF LITERATURE: A common surgical option for the treatment of degenerative disk disease (DDD) is MIS-LLIF using static or expandable spacers to restore disk height (DH), neuroforaminal height (NH), and segmental lordosis. Static spacers may require excessive trialing and aggressive impaction, potentially leading to endplate disruption and subsidence. Expandable spacers allow for in situ expansion to help address complications associated with static spacers. METHODS: This is an Institutional Review Board-exempt review of 69 patients (static, n=32; expandable, n=37) diagnosed with DDD who underwent MIS-LLIF at 1-2 contiguous level(s) using static or expandable spacers. Radiographic and clinical outcomes were collected and compared at pre- and postoperative time points up to 12 months. RESULTS: The expandable group had a significantly higher mean change in Visual Analog Scale (VAS) scores at 6 weeks, 6 months, and 12 months vs. static (∆VAS at 12 months: expandable, 6.7±1.3; static, 5.1±2.6). Mean improvement of Oswestry Disability Index (ODI) scores at 3, 6, and 12 months were significantly better for the expandable group vs. static (∆ODI at 12 months: expandable, 63.2±13.2; static, 29.8±23.4). Mean DH and NH significantly increased at final follow-up for both groups, with no significant difference in DH improvement between groups. The expandable mean NH improvement at 6 weeks and 6 months was significantly greater vs. static. Segmental lordosis significantly improved in the expandable group at all time intervals vs static. Subsidence rate at 12 months was significantly lower in the expandable group (1/46, 2.2%) vs. static (12/37, 32.4%). CONCLUSIONS: Expandable spacers resulted in a significantly lower subsidence rate, improve segmental lordosis, and VAS and ODI outcomes at 12 months vs. static.

Descriptive Analysis of 1972 Cervical Corpectomy Patients and 30-Day Postoperative Outcomes.

BACKGROUND: There exists no large, multi-institutional analysis of patients undergoing cervical corpectomy for common degenerative spinal disease, including patient demographics and comorbidities as well as postoperative complications. METHODS: Using Current Procedural Terminology and International Classification of Diseases codes, 1972 patients who underwent a cervical corpectomy for degenerative spinal disease were identified from the American College of Surgeons National Surgical Quality Improvement Program data sets from 2012 to 2015. A descriptive analysis of the patients who underwent the procedure as well as 30-day outcomes and adverse events were collected. Multivariate logistic regression models were used to determine the effect of any preoperative factors identified from a univariate logistic regression analysis (variables with P < .10) of complications. RESULTS: The total complication rate, defined as major or minor adverse event, mortality, unplanned readmission, unplanned reoperation, or admission >30 days, was 13.28%. The percentage of patients who had ≥1 major or minor adverse events was 5.02%. Several factors commonly associated with an increased risk of perioperative complications, including smoking and diabetes, were found not to be independently associated with complications in this cohort. CONCLUSIONS: This study is the largest analysis of cervical corpectomies. The results of the multivariate analysis provide guidance on risk factors associated with perioperative complications. These data could help develop risk-appropriate strategies for minimizing the effects of certain preoperative factors on perioperative complications.

Retrospective Review of Revision Surgery After Image-guided Instrumented Spinal Surgery Compared With Traditional Instrumented Spinal Surgery.

STUDY DESIGN: Retrospective cohort series. OBJECTIVE: The objective of this study was to determine if the use of image-guided navigation offers a clinically significant advantage over fluoroscopy-assisted pedicle screw and non-navigated screw placement in reducing the risk of revision surgery for malpositioned screws in instrumented spinal surgery. SUMMARY OF BACKGROUND DATA: Use image-guided navigation has become increasingly commonplace in instrumented spine surgery, but there is a lack of information regarding differences in the rates of clinically relevant screw malposition with image-guided compared with non-navigated screw placement. MATERIALS AND METHODS: This is a retrospective cohort series of consecutive patients who underwent instrumented spinal surgery by the senior authors at 2 academic tertiary care centers in New York. RESULTS: A total of 663 instrumented spinal surgeries were analyzed, including 271 instances with image-guided navigation. For the image-guided navigation cohort, 110 of the patients underwent screw placement using O-Arm image-guidance, yielding data on 1115 screws. The remaining 161 surgeries utilizing image-guided screw placement were performed using Brainlab Spine Navigation, for a total of 1001 screws. A fluoroscopy-assisted technique or freehand technique was used in 419 instances, with a total of 3689 screws. Of the non-navigated cohort, 10 patients required a surgical revision of screw placement, for a total of 15 malpositioned screws. Amongst the image-guided navigation cohort, 1 patient in the O-Arm group and 2 in the Brainlab group required revision surgery, with 3 malpositioned screws in total. The rate of revision surgery for a malpositioned screw placed via non-navigated techniques was 2.39%. This risk was decreased to 1.11% with the use of the intraoperative image-guided navigation. However, no comparisons between non-navigated and image-guided screw placement reached statistical significance. CONCLUSION: Although not reaching statistical significance, these data suggest there may be an advantage offered by image-guided screw placement in instrumented spinal surgery.

Comparative Effectiveness of Expandable Versus Static Interbody Spacers via MIS LLIF: A 2-Year Radiographic and Clinical Outcomes Study.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The purpose of this study is to compare the radiographic and clinical outcomes of expandable interbody spacers to static interbody spacers. METHODS: This is a retrospective, institutional review board-exempt chart review of 62 consecutive patients diagnosed with degenerative disc disease who underwent minimally invasive spine surgery lateral lumbar interbody fusion (MIS LLIF) using static or expandable spacers. There were 27 patients treated with static spacers, and 35 with expandable spacers. Radiographic and clinical functional outcomes were collected. Statistical results were significant if P < .05. RESULTS: Mean improvement in visual analogue scale back and leg pain scores was significantly greater in the expandable group compared to the static group at 6 and 24 months by 42.3% and 63.8%, respectively (P < .05). Average improvement in Oswestry Disability Index scores was significantly greater in the expandable group than the static group at 3, 6, 12, and 24 months by 28%, 44%, 59%, 53%, and 89%, respectively (P < .05). For disc height, the mean improvement from baseline to 24 months was greater in the static group compared to the expandable group (P < .05). Implant subsidence was significantly greater in the static group (16.1%, 5/31 levels) compared with the expandable group (6.7%, 3/45 levels; P < .05). CONCLUSIONS: This study showed positive clinical and radiographic outcomes for patients who underwent MIS LLIF with expandable spacers compared to those with static spacers. Sagittal correction and pain relief was achieved and maintained through 24-month follow-up. The expandable group had a lower subsidence rate than the static group.

Risk factors and associated complications with unplanned intubation in patients with craniotomy for brain tumor.

Patients undergoing surgical resection of a brain tumor have the potential risk for beingintubated post-operatively, which may be associated with significant morbidity and/or mortality after surgery. This study was analyzed various preoperative patient characteristics, postoperative outcomes, and complications to identify risk factors for unplanned intubation (UI) in adult patients undergoing craniotomy for a brain tumor and created a risk score framework for that cohort. Patients undergoing surgery for a brain tumor were identified according to primary Current Procedural Terminology codes, and information found in The American College of Surgeons (ACS) National Surgical Quality Improvement Project (NSQIP) database from 2012 to 2015 was reviewed. A total of 18,642 adult brain tumor patients were included in the ACS-NSQIP. The rate of unplanned intubation in this cohort was 2.30% (4 2 8). The mortality rate of patients who underwent UI after surgical resection of brain tumor was 24.78% compared to an overall mortality of 2.46%. During the first 30 days after surgery, 33% of patients who underwent UI had an unplanned reoperation, compared to 4.76% of patients who did not undergo unplanned intubation. Bivariate and multivariate analyses identified several predictors and computed a risk score for UI. A risk score based on patient factors for those undergoing a craniotomy for a brain tumor predicts the postoperative UI rate. This could aid in surgical decision-making by identify patients at a higher risk of UI, while modifying perioperative management may help prevent UI.

Sepsis and septic shock after craniotomy: Predicting a significant patient safety and quality outcome measure.

OBJECTIVES: Sepsis and septic shock are important quality and patient safety metrics. This study examines incidence of Sepsis and/or septic shock (S/SS) after craniotomy for tumor resection, one of the most common neurosurgical operations. METHODS: Multicenter, prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was used to identify patients undergoing craniotomy for tumor (CPT 61510, 61521, 61520, 61518, 61526, 61545, 61546, 61512, 61519, 61575) from 2012-2015. Univariate and multivariate logistic regression models were used to identify risk factors for S/SS. RESULTS: There were 18,642 patients that underwent craniotomy for tumor resection. The rate of sepsis was 1.35% with a mortality rate of 11.16% and the rate of septic shock was 0.65% with a 33.06% mortality rate versus an overall mortality rate of 2.46% in the craniotomy for tumor cohort. The 30-day readmission rate was 50.54% with S/SS vs 10.26% in those without S/SS. Multiple factors were identified as statistically significant (p <0.05) for S/SS including ascites (OR = 33.0), ventilator dependence (OR = 4.5), SIRS (OR = 2.8), functional status (OR = 2.3), bleeding disorders (OR = 1.7), severe COPD (OR = 1.6), steroid use (OR = 1.6), operative time >310 minutes (OR = 1.5), hypertension requiring medication (OR = 1.5), ASA class ≥ 3 (OR = 1.4), male sex (OR = 1.4), BMI >35 (OR = 1.4) and infratentorial location. CONCLUSIONS: The data indicate that sepsis and septic shock, although uncommon after craniotomy for tumor resection, carry a significant risk of 30-day unplanned reoperation (35.60%) and mortality (18.21%). The most significant risk factors are ventilator dependence, ascites, SIRS and poor functional status. By identifying the risk factors for S/SS, neurosurgeons can potentially improve outcomes. Further investigation should focus on the creation of a predictive score for S/SS with integration into the electronic health record for targeted protocol initiation in this unique neurosurgical patient population.

What is the advance of extent of resection in glioblastoma surgical treatment-a systematic review.

Glioblastoma multiform (GBM) is the most common malignant brain tumor characterized by poor prognosis, increased invasiveness, and high relapse rates. The relative survival estimates are quite low in spite of the standard treatment for GBM in recent years. Now, it has been gradually accepted that the amount of tumor mass removed correlates with longer survival rates. Although new technique advances allowing intraoperative analysis of tumor and normal brain tissue and functional paradigms based on stimulation techniques to map eloquent areas have been used for GBM resection, visual identification of tumor margins still remains a challenge for neurosurgeons. This article attempts to review and summarize the evolution of surgical resection for glioblastomas.

Comparative Analysis of Decompression Versus Decompression and Fusion for Surgical Management of Lumbar Spondylolisthesis.

OBJECTIVE: When lumbar stenosis involves spondylolisthesis, many surgeons include fixation. Two recent trials have shown no consensus to definitive treatment. We aimed to add to the discourse of fusion versus decompression in patients with lumbar spondylolisthesis by providing a large-scale generalizable study. METHODS: We used multicenter, prospectively collected data from the American College of Surgeons National Surgical Quality Improvement Program database to compare 30-day outcomes for decompression alone versus combination decompression and fusion in the treatment of lumbar spondylolisthesis. Logistic regression models were used to analyze the effect of surgical type on multiple characteristics. Univariate 2-tailed χ2 analyses were used to identify further outcome differences. RESULTS: In total, 9606 patients with treated lumbar spondylolisthesis were identified (907 decompression only, 8699 decompression and fusion). The fusion group tended to be younger (P < 0.001) and was more likely to be smokers (P = 0.01). Unplanned return to surgery was 3.02% in the fusion group, compared with 1.02% (P = 0.011). Minor adverse events occurred in 12.8% of the fusion group versus 4.9% (P < 0.001). Major adverse events occurred in 4.5% of the fusion group versus 3.1% (P = 0.0498). There was no significant difference in 30-day mortality, prolonged admission, or 30-day readmission. CONCLUSIONS: Unplanned return to the operating room and major and minor adverse events were greater for patients undergoing fusion. This could influence future decision-making in lumbar spondylolisthesis. This study indicates that further investigation is warranted but that decompression may be associated with less morbidity in the properly selected patient.