ENDOCRINE OUTCOMES OF TRANSSPHENOIDAL SURGERY FOR PITUITARY APOPLEXY VERSUS ELECTIVE SURGERY FOR PITUITARY ADENOMA.

Objective: To determine the rate of hormone replacement therapy (HRT) after transsphenoidal surgery (TSS) for pituitary apoplexy (PA) versus elective resection of a null cell (NC) macroadenoma. Methods: A retrospective cohort study was performed. Data was collected on all consecutive patients who underwent TSS from December 31, 2000 to December 31, 2016. Patients were split into two groups: (1) patients that presented with PA, and (2) patients that underwent elective TSS for NC macroadenoma. Postoperative pituitary function was determined by examining HRT, hormone lab values, and an evaluation by an endocrinologist for each patient. The odds ratio (OR) was calculated to determine if there was an association between PA and the need for HRT after surgery when compared to elective resection of a NC macroadenoma. Results: The need for HRT was significantly higher following surgery for PA compared to resection of a NC macroadenoma (14.7% versus 2.9%, OR = 5.690; 95% confidence interval (CI) = 1.439 to 22.500; P = .013). Conclusion: There is an increased need for hormone replacement therapy after surgery in patients with PA versus patients undergoing elective resection of a NC macroadenoma. Further studies are warranted to strengthen this data and help determine further predictors of the need for HRT. Abbreviations: BNP = brain natriuretic peptide; CI = confidence interval; DDAVP = desmopressin acetate; GH = growth hormone; HRT = hormone replacement therapy; MRI = magnetic resonance imaging; NC = null cell (adenoma); OR = odds ratio; PA = pituitary apoplexy; TSS = transsphenoidal surgery.

Incisional Hernia After Minimally Invasive Lateral Retroperitoneal Surgery: Case Series and Review of the Literature.

BACKGROUND: Minimally invasive lateral retroperitoneal (lateral-MIS) approaches to the spine involve traversing the lateral abdominal wall musculature and fascia. Incisional hernia is an uncommon approach-related complication. OBJECTIVE: To review the incidence, treatment, and preventative measures of incisional hernia after lateral-MIS approaches. METHODS: This is a retrospective review of cases performed by a single surgeon from 2011 to 2016. All patients who underwent lateral-MIS approaches at this institution were included. Patients with a postoperative diagnosis of lateral hernia on physical exam and corroborating advanced imaging findings were included in this study. Cases of flank bulge due to peripheral nerve injury were excluded. RESULTS: Three-hundred three patients underwent lateral-MIS approaches to the spine. Three (1%) patients with incisional hernia were identified. Two patients presented with a clinically symptomatic incisional hernia, while 1 patient was diagnosed incidentally after a routine abdominal magnetic resonance imaging for an unrelated reason. No patients suffered bowel entrapment or strangulation. CONCLUSION: Incisional hernia after lateral-MIS approaches is rare. Patients with incisional hernias may be susceptible to bowel incarceration and ischemia, though the incidence of this is probably low. Meticulous closure of the fascia is critical to avoiding this complication.

Development of Proximal Junctional Kyphosis After Minimally Invasive Lateral Anterior Column Realignment for Adult Spinal Deformity.

BACKGROUND: Development of proximal junctional kyphosis (PJK) after correction of adult spinal deformity (ASD) undermines sagittal alignment. Minimally invasive anterior column realignment (ACR) is a powerful tool for correction of ASD; however, long-term PJK rates are unknown. OBJECTIVE: To characterize PJK after utilization of ACR in ASD correction. METHODS: A retrospective multi-institution cohort analysis per STROBE criteria was conducted of all patients who underwent lateral lumbar interbody fusion (LLIF) or ACR for ASD from 2010 to 2015. All patients obtained preoperative and follow-up upright radiographs, assessing spinal alignment and development of PJK. Patients without proper imaging or minimum 1-yr follow-up were excluded. RESULTS: A total of 73 of 112 patients who underwent either LLIF or ACR for ASD met inclusion criteria. Mean follow-up was 22.8 mo. There was significant improvement of all spinopelvic parameters. Overall, PJK and proximal junctional failure (PJF) rates were 20.5% and 11%, respectively. The incidence of PJK increased with greater corrective surgery (0% LLIF, 30% ACR, 42.9% ACR + posterior column osteotomy (PCO); P < .001). PJF rates increased (0% LLIF, 11% ACR, 40% ACR + PCO; P = .005). Risk factors included location of the upper-instrumented vertebra at T10-L1 vs L2-L4 (P = .007), age (P = .029), severity of ASD, and overcorrection of sagittal imbalance. CONCLUSION: The incidence of PJK after minimally invasive ACR is slightly lower than reported after open surgery but greater than in LLIF only and increases with PCO utilization. The PJK rate increases when crossing the TL junction, sagittal imbalance severity, and overcorrection. Elderly patients are at an increased risk, suggesting need for age appropriate correction goals.

Anterior Column Release/Realignment.

Lateral anterior column release (ACR) is a powerful extension of the minimally invasive lateral lumbar interbody fusion procedure that incorporates division of the anterior longitudinal ligament to allow manipulation of the anterior and middle spinal columns. The resulting surgical control permits restoration of significant segmental lordosis that, when combined with varying posterior column releases, can achieve global sagittal realignment on par with traditional 3-column osteotomies. As a result, ACR is a factor in the growth of minimally invasive strategies for the correction of spinal deformities.

Minimally Invasive Lateral Transpsoas Interbody Fusion at the L4/5 Level: A Review of 61 Consecutive Cases.

BACKGROUND: Reported complication rates for minimally invasive lateral transpsoas interbody fusion (MIS-LIF) vary widely. The risk of lumbar plexus injury is particularly concerning at the L4-5 disc space. We report our experience with MIS-LIF at L4-5, and discuss the risk profile of transpsoas approaches at this level. OBJECTIVE: To evaluate safety of MIS-LIF at the L4/5 level. METHODS: This was a retrospective, IRB-approved cohort study performed at a single institution from 2011 to 2016. Patients who underwent MIS-LIF at L4-5 were included. Patients with multilevel fusions were excluded. We analyzed postoperative sensory and motor deficits, the date of resolution, health-related quality-of-life scores, and rate of fusion. RESULTS: Over a 5-yr period, 303 patients underwent MIS-LIF at our institution. Sixty-one patients had surgery only at the L4-5 level (20.1%). Twelve of these patients (19.6%) had postoperative neurological deficits including 2 motor deficits (2/61 = 3.2%) and 11/61 (18%) sensory deficits. At 12-mo follow-up, 3 of the deficits persisted for a long-term complication rate of 3/61 (4.9%), motor complication 2/61 (3.2%). Hospital stay and follow-up averaged 2.1 d and 15 mo. Average Oswestry Disability Index improved from 51.1 to 31.1 (P < .00001). Visual Analog Scale (VAS) improved from 7.4 to 3.9 (P < .016). There were no reoperations secondary to hardware failure or pseudoarthrosis. Fusion rate was 89% at 12 mo. CONCLUSION: MIS-LIF is a safe and effective approach for interbody fusion at L4-5 with low rate of lumbar plexus injury. Most immediate postoperative deficits will resolve over time.