Minimally invasive surgery for synchronous, same-level lumbar intradural-extramedullary neoplasm and acute disc herniation.

Schwannomas are the most common intradural-extramedullary spinal tumors, with an estimated incidence of 3 to 10 cases per 100,000 people. With continued advances in minimally invasive surgery (MIS) over recent years, MIS techniques have been utilized by spine surgeons in the resection of intradural spinal neoplasms with favorable surgical results and clinical outcomes. This video demonstrates a rare case of symptomatic, synchronous, same-level lumbar intradural-extramedullary neoplasm and acute disc herniation, both of which were successfully treated using a single MIS approach. Surgical pearls and nuances are discussed to better delineate technique and minimize potential complications. The video can be found here: http://youtu.be/78ibbicBRUk.

Single-level anterior cervical discectomy and fusion versus minimally invasive posterior cervical foraminotomy for patients with cervical radiculopathy: a cost analysis.

OBJECT: Patients suffering from cervical radiculopathy in whom a course of nonoperative treatment has failed are often candidates for a single-level anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF). The objective of this analysis was to identify any significant cost differences between these surgical methods by comparing direct costs to the hospital. Furthermore, patient-specific characteristics were also considered for their effect on component costs. METHODS: After obtaining approval from the medical center institutional review board, the authors conducted a retrospective cross-sectional comparative cohort study, with a sample of 101 patients diagnosed with cervical radiculopathy and who underwent an initial single-level ACDF or minimally invasive PCF during a 3-year period. Using these data, bivariate analyses were conducted to determine significant differences in direct total procedure and component costs between surgical techniques. Factorial ANOVAs were also conducted to determine any relationship between patient sex and smoking status to the component costs per surgery. RESULTS: The mean total direct cost for an ACDF was $8192, and the mean total direct cost for a PCF was $4320. There were significant differences in the cost components for direct costs and operating room supply costs. It was found that there was no statistically significant difference in component costs with regard to patient sex or smoking status. CONCLUSIONS: In the management of single-level cervical radiculopathy, the present analysis has revealed that the average cost of an ACDF is 89% more than a PCF. This increased cost is largely due to the cost of surgical implants. These results do not appear to be dependent on patient sex or smoking status. When combined with results from previous studies highlighting the comparable patient outcomes for either procedure, the authors' findings suggest that from a health care economics standpoint, physicians should consider a minimally invasive PCF in the treatment of cervical radiculopathy.

Disseminated spinal myxopapillary ependymoma in an adult at initial presentation: a case report and review of the literature.

Disseminated spinal myxopapillary ependymoma (MPE) is extremely rare in adults. We report a 63-year-old man with chronic low-back pain found to have multiple MPEs in the thoracic, lumbar and sacral spine. Diagnostic and management strategies of disseminated MPE are discussed with a review of pertinent literature.

Upstream Effects: Intraoperative Migration of Intradural Extramedullary Tumor After Non-Adjacent Level Stenosis Decompression.

A 74-year-old man with back pain, foot numbness, and hip/thigh radiculopathy was found to have an L1-L2 intradural extramedullary neoplasm and severe L4-L5 stenosis. L4-L5 minimally invasive laminectomy for decompression and concomitant L1-L2 minimally invasive laminectomy for tumor resection were planned. L4-L5 laminectomy was completed first followed by the L1-L2 laminectomy. On extensive intradural exploration at L1-L2, no neoplasm was found. Immediate postoperative imaging showed that the intradural extramedullary tumor had migrated caudally by nearly a complete spinal level, presumably due to changes in cerebrospinal fluid pressure and resultant shift in intradural contents after the L4-L5 laminectomy. Successful resection of the intradural extramedullary tumor was performed, with improvement in the patient's symptoms.

Mycobacterium xenopi vertebral osteomyelitis in a patient with systemic lupus erythematosus: illustrative case.

BACKGROUND: Mycobacterium xenopi is a common nontuberculous Mycobacterium (NTM) that is slow growing and an infrequent cause of infection. When infections do occur, it is by exposure to contaminated soil or water or to infectious aerosols. Nontuberculous mycobacterial infections in the spine are exceedingly rare. Risk factors can include immunosuppression, particularly human immunodeficiency virus; however, other systemic diseases such as systemic lupus erythematosus (SLE) have been reported. OBSERVATIONS: The authors report a case of cord compression due to M. xenopi vertebral osteomyelitis with an epidural abscess in a patient with SLE on hydroxychloroquine and recent steroid use. The authors explore the presentation of a patient who developed acute neurological deficits concerning for spinal pathology secondary to NTM. Although considered a rare occurrence, patients with autoimmune pathologies are susceptible to infection by unusual organisms. Standard treatment of autoimmune diseases can predispose patients to infection and warrant surgical correction to prevent long-term neurological deficits. LESSONS: There is still much work and research to be done in the exploration and understanding of nontuberculous mycobacterial infection, pathophysiology, and treatment in the immunocompetent population and in patients with autoimmune disorders.

Postoperative Adjacent Segment Disease in Minimally Invasive Transforaminal Lumbar Interbody Fusion with Adjacent Laminectomy for Grade I-II Spondylolisthesis and Adjacent Spinal Stenosis.

BACKGROUND AND OBJECTIVES: Studies have demonstrated increased risk of adjacent segment disease (ASD) after open fusion with adjacent-level laminectomy, with rates ranging from 16%-47%, potentially related to disruption of the posterior ligamentous complex. Minimally invasive surgical (MIS) approaches may offer a more durable result. We report institutional outcomes of simultaneous MIS transforaminal lumbar interbody fusion (MISTLIF) and adjacent-level laminectomy for patients with low grade spondylolisthesis and ASD. METHODS: Retrospective analysis was performed on patients who underwent MISTLIF with adjacent level laminectomy to treat grade I-II spondylolisthesis with adjacent stenosis at a single institution from 2007-2022. RESULTS: A total of 34 patients met criteria, with mean follow-up of 23.1 months. In total, 37 levels were fused and 45 laminectomies performed. In this group, 21 patients received a single level laminectomy and single-level MISTLIF, 10 patients received a 2-level laminectomy and single-level MISTLIF, 2 patients received a single-level laminectomy and 2-level MISTLIF, and 1 patient received a 2-level laminectomy and 2-level MISTLIF. Three (8.8%) patients experienced clinically significant postoperative ASD requiring reoperation. Three other patients required reoperation for other reasons. Multiple logistic regression did not reveal any association between development of ASD and surgical covariates. CONCLUSION: MISTLIF with adjacent-level laminectomy demonstrated a favorable safety profile with rates of postoperative ASD lower than published rates after open fusion and on par with the published rates of ASD from MISTLIF alone. Future prospective studies may better elucidate the durability of adjacent-level laminectomies when performed alongside MISTLIF, but retrospective data suggests it is safe and durable.

The Impact of L4-L5 Minimally Invasive Transforaminal Lumbar Interbody Fusion on 2-Year Adjacent-level Parameters.

OBJECTIVE: This study evaluates the impact of L4-L5 minimally invasive surgery (MIS)- transforaminal lumbar interbody fusion (TLIF) on adjacent-level parameters. METHODS: This is a retrospective study performed on consecutive patients between January 2015 and December 2019. The index- and adjacent-level segmental lordosis (SL) and disc angle (DA) were measured. Patient-reported outcomes (PROs) were collected preoperatively and at 3-24 months postoperatively. Factors influencing changes in adjacent-level parameters and the occurrence of adjacent segment degeneration (ASDeg) were assessed. RESULTS: A total of 117 adult patients, averaging 65.5 years of age and slight preponderance of female (56.4%), were analyzed. L4-L5 SL decreased at 2 years (P < 0.05), but L4-L5 DA significantly increased at all timepoints (P < 0.05). While L3-L4 SL and DA significantly decreased at all timepoints (P < 0.05), L5-S1 SL decreased at 3 and 12 months (P < 0.05) and L5-S1 DA only significantly decreased at 2 years (P < 0.05). All PROs improved significantly (P < 0.0001). The ASDeg rate was 19.7% at 2.2 years. Cephalad and caudal ASDeg rates were 12.0% and 10.3%, respectively. Eight patients (6.8%) required adjacent-level reoperations, mainly at L3-L4 (6 cases). The use of expandable cage significantly reduced the odds of caudal ASDeg (OR 0.15, P = 0.037), but had no significant effect on cephalad ASDeg. CONCLUSIONS: L4-L5 MIS-TLIF had a more consistent effect on L3-L4 than L5-S1. Although adjacent-level SL and DA decreased over time, their association with ASDeg appears limited, suggesting a multifactorial etiology. L4-L5 MIS-TLIF provides demonstrable clinical benefits with lasting PRO improvements and low adjacent-level reoperations.

Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures.

The Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures evidence-based clinical practice guideline was codeveloped by the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association. This guideline replaces the previous AAOS Information Statement, "Antibiotic Prophylaxis in Bacteremia in Patients With Joint Replacement," published in 2009. Based on the best current evidence and a systematic review of published studies, three recommendations have been created to guide clinical practice in the prevention of orthopaedic implant infections in patients undergoing dental procedures. The first recommendation is graded as Limited; this recommendation proposes that the practitioner consider changing the long-standing practice of routinely prescribing prophylactic antibiotic for patients with orthopaedic implants who undergo dental procedures. The second, graded as Inconclusive, addresses the use of oral topical antimicrobials in the prevention of periprosthetic joint infections. The third recommendation, a Consensus statement, addresses the maintenance of good oral hygiene.

Minimally invasive treatment of spinal dural arteriovenous fistula with the use of intraoperative indocyanine green angiography.

Spinal dural arteriovenous fistula (dAVF) is the most common vascular malformation of the spinal cord. Traditionally it is treated by the standard muscle-splitting midline approach with bilateral laminectomies extending from one level above to one level below the dAVF. We present a minimally invasive approach for ligation of dAVF with concurrent use of intraoperative indocyanine green (ICG) angiography. Minimally invasive watertight dural closure technique is also demonstrated and discussed. The minimally invasive approach with intraoperative ICG results in quicker recovery, early mobilization and shorter hospital stay compared to traditional open approach. The video can be found here: http://youtu.be/mNUeJKLxL3Q.

Comparison of Perioperative Complications After Anterior-Posterior Versus Posterior-Anterior-Posterior Cervical Fusion: A Retrospective Review of 153 Consecutive Cases.

BACKGROUND: Although published data support the utilization of circumferential fusion to treat select cervical spine pathologies, it is unclear whether the posterior-anterior-posterior (PAP) fusion has increased risks compared with the anterior-posterior fusion. OBJECTIVE: To evaluate the differences in perioperative complications between the 2 circumferential cervical fusion approaches. METHODS: One hundred fifty-three consecutive adult patients who underwent single-staged circumferential cervical fusion for degenerative pathologies from 2010 to 2021 were retrospectively reviewed. Patients were stratified into the anterior-posterior ( n = 116) and PAP ( n = 37) groups. The primary outcomes assessed were major complications, reoperation, and readmission. RESULTS: Although the PAP group was older ( P = .024), predominantly female ( P = .024), with higher baseline neck disability index ( P = .026), cervical sagittal vertical axis ( P = .001), and previous cervical operation rate ( P < .00001), the major complication, reoperation, and readmission rates were not significantly different from the 360° group. Although the PAP group had higher urinary tract infection ( P = .043) and transfusion ( P = .007) rates, higher estimated blood loss ( P = .034), and longer operative times ( P < .00001), these differences were insignificant after the multivariable analysis. Overall, operative time was associated with older age (odds ratio [OR] 17.72, P = .042), atrial fibrillation (OR 158.30, P = .045), previous cervical operation (OR 5.05, P = .051), and lower baseline C1 - 7 lordosis (OR 0.93, P = .007). Higher estimated blood loss was associated with older age (OR 1.13, P = .005), male gender (OR 323.31, P = .047), and higher baseline cervical sagittal vertical axis (OR 9.65, P = .022). CONCLUSION: Despite some differences in preoperative and intraoperative variables, this study suggests both circumferential approaches have comparable reoperation, readmission, and complication profiles, all of which are high.

Perception of frailty in spinal metastatic disease: international survey of the AO Spine community.

OBJECTIVE: Frailty has not been clearly defined in the context of spinal metastatic disease (SMD). Given this, the objective of this study was to better understand how members of the international AO Spine community conceptualize, define, and assess frailty in SMD. METHODS: The AO Spine Knowledge Forum Tumor conducted an international cross-sectional survey of the AO Spine community. The survey was developed using a modified Delphi technique and was designed to capture preoperative surrogate markers of frailty and relevant postoperative clinical outcomes in the context of SMD. Responses were ranked using weighted averages. Consensus was defined as ≥ 70% agreement among respondents. RESULTS: Results were analyzed for 359 respondents, with an 87% completion rate. Study participants represented 71 countries. In the clinical setting, most respondents informally assess frailty and cognition in patients with SMD by forming a general perception based on clinical condition and patient history. Consensus was attained among respondents regarding the association between 14 preoperative clinical variables and frailty. Severe comorbidities, extensive systemic disease burden, and poor performance status were most associated with frailty. Severe comorbidities associated with frailty included high-risk cardiopulmonary disease, renal failure, liver failure, and malnutrition. The most clinically relevant outcomes were major complications, neurological recovery, and change in performance status. CONCLUSIONS: The respondents recognized that frailty is important, but they most commonly evaluate it based on general clinical impressions rather than using existing frailty tools. The authors identified numerous preoperative surrogate markers of frailty and postoperative clinical outcomes that spine surgeons perceived as most relevant in this population.

Chordoma of the thoracic spine in an 89-year-old.

STUDY DESIGN: Case report and literature review. OBJECTIVE: Report the highly unusual presentation of thoracic spine chordoma in an 89-year-old and review existing literature as it impacts treatment in the elderly. Chordomas are infrequent tumors of the spine that commonly present during mid-adulthood at the spheno-occipital or sacrococcygeal junctions. The mobile spine is affected in 10-15% of cases but chordomas are extremely rare in the thoracic spine. Chordoma rarely enters the differential diagnosis of spinal tumors in elderly patients, for whom metastases and multiple myeloma are by far the most common. METHODS: A case report is detailed of an 89-year-old male presenting with incapacitating pain and early signs of thoracic myelopathy. A lytic, expanding lesion of the T10 vertebral body with epidural spinal cord compression was identified. In the absence of evidence of other primary tumor, a CT-guided needle biopsy revealed chordoma. A literature review of reported thoracic spine chordomas was also performed. RESULTS: An intralesional posterolateral resection and reconstruction was performed with good results and no recurrence at 13 months' follow-up. 30 reports of thoracic spine chordomas were identified in the literature since 1902. Mean age of presentation at 35.7 years is earlier than for most chordomas. The oldest previously reported patient was 68-year-old. Neurological impairment at presentation is rare with the usual presenting symptom being pain. Response to radiation and chemotherapy is limited. 5-year survival rates range from 50 to 60%. CONCLUSION: Chordoma is a highly uncommon epidural neoplasm of the thoracic spine and is vanishingly rare in elderly patients. This report documents the oldest reported patient with thoracic spine chordoma at 89-year-old. Their locally aggressive behavior typically prompts consideration of aggressive surgical resection. When tailored to the individual patient, such procedures are feasible without excessive morbidity even in elderly patients.

Minimally Invasive Posterior Cervical Foraminotomy Versus Anterior Cervical Fusion and Arthroplasty: Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVES: Patients with lateral cervical disc and foraminal pathology can be treated with anterior and posterior approaches including anterior cervical discectomy and fusion(ACDF), cervical total disc arthroplasty(TDA), and minimally invasive posterior cervical foraminotomy(MIS-PCF). Although MIS-PCF may have some advantages over the anterior approaches, few comparative studies and meta-analyses have been done to assess superiority. METHODS: This study includes a systematic review of the literature and meta-analysis of studies directly comparing minimally invasive posterior cervical foraminotomy to either anterior cervical discectomy and fusion or cervical total disc arthroplasty. RESULTS: In comparing patients undergoing ACDF and MIS-PCF, operative time ranged from 68 to 97.8 minutes in the ACDF group compared to 28 to 93.9 minutes in the MIS-PCF group. Mean postoperative length of stay ranged from 33.84 to 112.8 hours in the ACDF group compared to 13.68 to 83.6 hours in the MIS-PCF group. The total complication rates were 3.72% in the ACDF group and 3.73% in the MIS-PCF group. A random-effects model meta-analysis was carried out which failed to show a statistically significant difference in the complication rate between the two procedures(OR .91; 95% CI 0.13, 6.43; P = .92, I2 = 59%). The total reoperation rate was 3.5% in the ACDF group and 5.4% in the MIS-PCF group. A random-effects model meta-analysis was carried out which failed to show a statistically significant difference in the reoperation rate between the two procedures(OR .66; 95% CI 0.33, 1.33; P = .25, I2 = 0). In comparing patients undergoing TDA and MIS-PCF, operative time ranged from 90.3 to 106.7 minutes in the TDA group compared to 77.4 to 93.9 minutes in the MIS-PCF group. Mean postoperative length of stay ranged from 103.2 to 165.6 hours in the TDA group and 93.6 to 98.4 hours in the MIS-PCF group. The complication rate ranged from 23.5 to 28.6% in the TDA group and 0 to 14.3% in the MIS-PCF group. The overall reoperation rates were 2.6% in the TDA group and 10.2% in the MIS-PCF group. CONCLUSIONS: There is no clear superiority between MIS-PCF and ACDF/TDA in terms of operative time, postoperative length of stay, or rate of complications/reoperations. Further studies with increased follow-up intervals >48 months, and higher sample sizes are necessary to determine the true superiority of MIS-PCF and anterior neck approaches in treatment of lateral disc and foraminal pathology.

Recurrent IgG4-Related Meningeal Disease of the Cervicothoracic Spine: A Case Report and Review of the Literature.

Background: IgG4-related disease is a rare, recently recognized chronic inflammatory disease. IgG4-related hypertrophic pachymeningitis (IgG4-RHP) of the central nervous system predominantly involves the cranial meninges. Spinal involvement remains rare. Objective: We report a case of recurrent cervicothoracic IgG4-RHP and review the surgical literature. Methods and Materials: A 35-year-old woman presented with a 6-month history of neck and right shoulder pain, progressive right triceps weakness and paresthesias in the right C8 and T1 dermatomes. MRI demonstrated a T2 hypointense epidural soft tissue mass extending from C6-T1. The patient underwent C6-T1 laminoforaminotomy and partial resection with near complete symptom resolution. Histopathology was consistent with diagnosis of IgG4-RHP. Eighteen months postoperatively, she experienced symptom recurrence necessitating re-operation and adjuvant postoperative prednisone with complete resolution at 40-months' follow-up. Results and Conclusions: Of the now nineteen confirmed cases of IgG4-RHP, fifteen underwent surgery. A majority achieved partial resection. Three surgical patients did not receive adjuvant therapy with symptomatic recurrence between 2 and 18 months.

Comparison of Fusion versus Nonunion After 4-Level and 5-Level Anterior Cervical Diskectomy and Fusion With Anterior Plate Fixation.

BACKGROUND: Nonunion remains a concern in multilevel anterior cervical discectomy and fusion (ACDF), yet there are limited data on nonunion after 4 to 5-level ACDF. In fact, the largest series on 4-level or 5-level ACDF focused specifically on the swallowing outcomes. OBJECTIVE: To assess nonunion after 4 to 5-level ACDF. METHODS: Forty-one patients treated with 4 to 5-level ACDF with minimum of 12-month radiographic follow-up were retrospectively reviewed. Nonunion was found in 25 patients (61%) and 42 levels (25%) and complete fusion in 16 (39%) patients and 126 levels (75%). The 2 groups were further compared. RESULTS: One-level nonunion was by far the most common pattern compared with multilevel nonunion. Nonunion occurred more frequently at the caudal than the cranial or middle segments ( P < .0001). There were significantly more subsidence ( P < .0001) and screw fractures/pullouts ( P < .0001) in the nonunion compared with the fusion group. The symptomatic patients were significantly younger than the asymptomatic patients ( P = .044). The symptomatic levels were significantly more than asymptomatic levels ( P = .048). Equal proportion of patients implanted with allograft and polyetheretherketone had nonunion. However, there were markedly more nonunion than fused levels with allograft and more fused than nonunion levels with polyetheretherketone ( P = .023). The reoperation rate was 24.4% and mostly due to nonunion. There were no reoperations within 90 days of the primary surgery. CONCLUSION: The nonunion rate for 4-level and 5-level ACDF may be higher than previously reported. Symptomatic nonunion remains a major reason for reoperation after multilevel ACDF. Baseline characteristics that negatively affect fusion may be obviated by careful patient selection.

Clinical Outcomes After 4- and 5-Level Anterior Cervical Discectomy and Fusion for Treatment of Symptomatic Multilevel Cervical Spondylosis.

OBJECTIVE: There are limited patient-reported outcome measure (PROM) data on 4-level and 5-level anterior cervical discectomy and fusion (ACDF). The largest series to date solely focused on complications. This retrospective series evaluates PROMs after 4-level and 5-level ACDF. METHODS: Pertinent data from adult patients treated with a 4-level or 5-level ACDF in 2011-2019 were analyzed. PROMs and minimal clinically important differences (MCIDs) were assessed. Factors associated with favorable and unfavorable outcomes were identified. RESULTS: There were 34 patients (30 underwent 4-level and 4 underwent 5-level ACDFs) with a mean age of 59.6 years; 55.9% were women. At 3 months, there were significant improvements in PROMs except Short-Form 12-Item Survey (SF-12) mental component subscale, which showed modest improvement. At 12 months, there were significant improvements in PROMs except SF-12 physical component subscale (PCS), which showed moderate improvement. The proportions of patients who met the MCID cutoffs ranged from 35.3% (numeric rating scale [NRS]-neck) to 75% (Veteran RAND 12-Item Survey [VR-12] PCS) at 3 months and 38.2% (NRS-arm) to 65.5% (VR-12 mental component subscale) at 12 months. Shorter symptom duration was associated with significantly reduced postoperative pain and Neck Disability Index scores. Shorter length of stay was associated with significantly improved postoperative functional outcomes. patients undergoing 4-level compared with 5-level ACDF achieved better postoperative PROMs. Shorter procedure duration was associated with improved PROMs at 3 months. No patient returned to the operating room within 30 days. Patients who required reoperation achieved significantly inferior Neck Disability Index, NRS-neck, and SF-12 PCS scores at 3 months. CONCLUSIONS: This study showed satisfactory PROMs up to 12 months after 4-level and 5-level ACDF despite the complication rate. With thorough preoperative planning and meticulous technique, performing this procedure in carefully selected patients may be associated with acceptable PROMs.

Cervical Alignment Analysis Comparing Two-Level Cervical Disc Arthroplasty with Anterior Cervical Discectomy and Fusion with Anterior Plate Fixation.

OBJECTIVE: This study assesses cervical alignments after 2-level cervical disc arthroplasty (CDA) versus anterior cervical discectomy and fusion (ACDF) with anterior plate fixation. METHODS: Eighty-two patients who underwent 2-level CDA or ACDF in 2014-2019 were identified. Cervical alignment parameters were compared between the 2 cohorts. Subgroup analyses were performed to determine factors that differentiate alignment outcomes between the 2 procedures. RESULTS: Although both cohorts achieved significant focal lordosis (FL) and overall cervical lordotic (CL) gains, CDA cohorts achieved significantly greater 12-month FL gain (P = 0.022). However, in a multivariate analysis controlling for preoperative variables, FL gain was no longer significant. Although the CDA cervical sagittal vertical axis (cSVA) significantly improved at 3 (P = 0.030) and 12 (P = 0.007) months, these improvements were not superior to the ACDF cSVA. Male patients undergoing CDA achieved greater 12-month CL gain. Patients undergoing CDA with body mass index >25 kg/m2 achieved greater 12-month FL gain. Patients undergoing CDA with symptom duration >12 months achieved greater FL gain at 3 and 12 months. Patients undergoing CDA with high baseline T1 slope or cSVA achieved greater 12-month cSVA reduction. Clinical outcomes were comparable between the 2 cohorts. Unlike the ACDF group, CL gain in the CDA group was significantly correlated with the cSVA reduction, which was associated with significant improvement in the Neck Disability Index, arm pain, and 12-Item Short-Form Mental Component Scores. Heterotopic ossification was not found to significantly affect patient outcome and cervical alignment in both cohorts. CONCLUSIONS: ACDF and CDA are viable options for 2-level degenerative disc disease in carefully selected patients. Both approaches produced equivalent postoperative alignment changes in a 2-level operation.

Management of incidental durotomy in minimally invasive spine surgery.

OBJECT: Unintended durotomy is one of the most common complications in spine surgery that may lead to serious complications if not recognized or treated properly. There are few reports on the management of durotomies incurred during minimally invasive spine surgery (MISS). The authors describe their experience in a series of consecutive MISS patients with unintended durotomies. METHODS: All patients who underwent MISS by the senior author between August 2006 and February 2011 were retrospectively reviewed, and cases with unintended durotomies were identified. A case-control study was carried out comparing patient demographics and perioperative data between patients with and without durotomy. Surgical technique, including a proposed algorithm for management of durotomies, is described. RESULTS: Unintended durotomy occurred in 53 (9.4%) of 563 patients. The mean age at surgery was 60.7 years (range 30-85 years). Previous surgery at the same level was performed in 5 patients (9.4%). Two patients underwent posterior cervical surgery, and 51 patients underwent posterior lumbar surgery. Decompression alone was performed in 32 patients (60.4%), and fusion was performed in 21 patients (39.6%). The mean operative time was 105 minutes in the decompression group and 310 minutes in the fusion group (p < 0.001). Estimated blood loss was 60 ml in the decompression group and 381 ml in the fusion group (p < 0.001). The hospital length of stay was 52 hours in the decompression group and 106 hours in the fusion group (p < 0.001). The mean follow-up was 310 days, and there were no cases of cutaneous CSF fistula, pseudomeningocele, or other complications referable to durotomy in either group. Risk factors identified for durotomy included previous operation at the same level (p = 0.019) and operation in the lumbar spine region (p = 0.001). CONCLUSIONS: In the authors' consecutive series of patients undergoing MISS, an unintended durotomy was associated with fewer complications than previously reported for open spinal surgery. The authors propose a simple management algorithm that includes early mobilization and results in excellent clinical outcomes with no incidence of postoperative cutaneous CSF fistula or other complications.