Video-Assisted Thoracoscopic Lateral Interbody Fusion for Symptomatic Pseudarthrosis in Neurofibromatosis 1-Associated Spinal Deformity.

BACKGROUND: The treatment of symptomatic pseudarthrosis via posterior-only approaches in the setting of neurofibromatosis 1 (NF1) is challenging due to dural ectasias, resulting in erosion of the posterior elements. The purpose of this report is to illustrate a minimally invasive method for performing anterior thoracic fusion for pseudarthrosis in a patient with NF1-associated scoliosis and dysplastic posterior elements. To the best of our knowledge, this is the first documented case of using video-assisted thoracoscopic lateral interbody fusion to treat pseudarthrosis for NF1-associated spinal deformity. CASE DESCRIPTION: The patient underwent video-assisted thoracoscopic anterior spinal fusion via a direct lateral interbody approach with interbody cage placement at T10-T11 and T11-T12, followed by revision of his posterior spinal fusion and instrumentation. The patient had an uneventful postoperative course. At 6 months of follow-up, the patient had complete resolution of his preoperative symptoms and had returned to full-time work with no complaints. At 3 years postoperatively, the patient reported being satisfied with the operation and had continued to work full-time without restrictions. CONCLUSIONS: To the best of our knowledge, this is the first report of pseudarthrosis in the setting of NF1-associated scoliosis treated via minimally invasive anterior thoracic fusion facilitated by video-assisted thoracoscopic surgery. This is a powerful technique that allows for safe access for anterior thoracic fusion in the setting of dysplastic posterior anatomy and poor posterior bone stock.

Is spinopelvic mismatch associated with increased disability at 2 years following short-segment lumbar fusions?

OBJECTIVE: This study aimed to investigate the impact of pelvic incidence (PI) and lumbar lordosis (LL) matching on health-related quality of life (HRQOL) outcomes in patients undergoing one- or two-level lumbar fusions for degenerative pathology. The study also examined changes in alignment and HRQOL over a 24-month follow-up period. METHODS: A retrospective cohort study used data from a multicenter, prospectively collected database. Radiographic parameters were measured preoperatively and at 3-month and 24-month postoperative time points. Patients were categorized as having alignment (PI-LL ≤ 10°) or malalignment (PI-LL > 10°) at all time points. The Oswestry Disability Index scores were collected at the same time points. Statistical analyses assessed differences in HRQOL scores and radiographic parameters between the aligned and malaligned groups. RESULTS: Seventy-six patients were included. Both the aligned and malaligned groups showed improved HRQOL scores after surgery, but patients with proper alignment (PI-LL ≤ 10°) had significantly better HRQOL scores at the 24-month follow-up. Alignment remained stable from 3 months to 24 months postoperatively, with minimal movement between the aligned and malaligned groups. CONCLUSIONS: Proper PI-LL matching in one- and two-level lumbar fusions for degenerative pathology leads to improved HRQOL outcomes at the 24-month follow-up. Patients with maintained proper alignment after surgery experience continued improvement in disability levels. Surgeons should consider longer follow-up for patients who do not achieve proper alignment initially, as 24 months is crucial for assessing the consequences of malalignment in short-segment lumbar fusions.

Trans-sacral interbody fixation in long fusions to the sacrum for adult spinal deformity: complications and fusion rates at minimum two years follow-up.

PURPOSE: This study aims to investigate the fusion rate and complications associated with trans-sacral interbody fusion (TSIF) in long fusions to the sacrum for adult spinal deformity (ASD) over a two year follow-up period. Potential predictor variables associated with pseudarthrosis were also examined. METHODS: A retrospective clinical review was conducted on a consecutive series of ASD patients who underwent long fusions to the sacrum, with TSIF performed as a same-day or staged procedure. Patient demographics, bone mineral density, operative details, perioperative and late complications, and fusion rates were reviewed. Univariate analysis was used to identify the risk factors associated with pseudarthrosis. RESULTS: The study included 43 patients with an average age of 55.3 ± 8.9 years. The perioperative complication rate was 28%, with 12% of the complications directly related to TSIF. The late complication rate was 33%, with 16% related to TSIF. The most common complications were pseudarthrosis (14%) and postoperative ileus (7%). The overall radiographic fusion rate at two years was 86%. Univariate analysis revealed that revision surgery was significantly associated with pseudarthrosis (p = 0.027). Over the follow-up period, patients who underwent TSIF during long posterior fusions to the sacrum showed improvement in overall SRS scores, ODI scores, and SF-36 physical health and mental health (p < 0.05). CONCLUSION: TSIF is a relatively safe and minimally invasive method for achieving interbody fusion at the lumbosacral junction in the treatment of ASD, with acceptable fusion rates and a low complication rate. However, TSIF is not recommended for revision reconstruction in ASD.

Gout-Induced Cervical Deformity and Progressive Myelopathy Mimicking Infection Requiring Cervical Reconstruction.

BACKGROUND: This study describes a rare case where gout, a condition primarily associated with joint inflammation, initially manifested as a progressive cervical kyphotic deformity, mimicking infection and causing myelopathy. The patient, a previously healthy 56-year-old woman, presented with severe jaw pain and a temporomandibular joint abscess, alongside 2 months of worsening balance and arm/hand tingling. Extensive clinical and radiographic assessments revealed a severe cervical kyphotic deformity with bony erosion at multiple vertebral levels, raising suspicion of an infectious cause of compressive myelopathy. METHODS: The patient underwent an urgent staged surgical intervention involving multilevel cervical decompression and fusion, coupled with cervical deformity correction. RESULTS: Post surgery, she received antibiotics for 7 days, during which pathologic analysis unveiled collections of macrophages reacting to urate crystal deposition in a pattern consistent with gouty tophus. This unexpected diagnosis marked a novel case of undiagnosed gout-induced severe cervical deformity presenting with myelopathic symptoms and successfully managed through cervical spine deformity correction. CONCLUSIONS: This report underscores the significance of considering gout as a potential cause when encountering unusual spinal pathologies, especially in cases where gout-related symptoms are atypical. The presented 540-degree surgical approach effectively addressed both the cervical deformity and gout-induced myelopathic symptoms. To the best of our knowledge, this study represents the first documented instance of a patient with undiagnosed gout-induced severe cervical deformity successfully treated through cervical spine deformity correction, emphasizing the importance of vigilance and innovative management approaches in such rare clinical scenarios. As of the 2-year follow-up, the patient exhibited significant symptom improvement and overall well-being.

Personalized Medicine in Orthopaedic Surgery: The Case of Spine Surgery.

Personalized medicine has made a tremendous impact on patient care. Although initially, it revolutionized pharmaceutical development and targeted therapies in oncology, it has also made an important impact in orthopaedic surgery. The field of spine surgery highlights the effect of personalized medicine because the improved understanding of spinal pathologies and technological innovations has made personalized medicine a key component of patient care. There is evidence for several of these advancements to support their usage in improving patient care. Proper understanding of normative spinal alignment and surgical planning software has enabled surgeons to predict postoperative alignment accurately. Furthermore, 3D printing technologies have demonstrated the ability to improve pedicle screw placement accuracy compared with free-hand techniques. Patient-specific, precontoured rods have shown improved biomechanical properties, which reduces the risk of postoperative rod fractures. Moreover, approaches such as multidisciplinary evaluations tailored to specific patient needs have demonstrated the ability to decrease complications. Personalized medicine has shown the ability to improve care in all phases of surgical management, and several of these approaches are now readily available to orthopaedic surgeons.

What is the fate of the adjacent segmental angles 6 months after single-level L3-4 or L4-5 lateral lumbar interbody fusion?

BACKGROUND CONTEXT: Lateral lumbar interbody fusion (LLIF) is an effective technique for fusion and sagittal alignment correction/maintenance. Studies have investigated the impact on the segmental angle and lumbar lordosis (and pelvic incidence-lumbar lordosis mismatch), however not much is documented regarding the immediate compensation of the adjacent angles. PURPOSE: To evaluate acute adjacent and segmental angle as well as lumbar lordosis changes in patients undergoing a L3-4 or L4-5 LLIF for degenerative pathology. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients included in this study were analyzed pre- and post-LLIF performed by one of three fellowship-trained spine surgeons, 6 months following surgery. OUTCOME MEASURES: Patient demographics (including body mass index, diabetes diagnosis, age, and sex) as well as VAS and ODI scores were measured. Lateral lumbar radiograph parameters: lumbar lordosis (LL), segmental lordosis (SL), infra and supra-adjacent segmental angle, and pelvic incidence (PI). METHODS: Multiple regressions were applied for the main hypothesis tests. We examined any interactive effects at each operative level and used the 95% confidence intervals to determine significance: a confidence interval excluding zero indicates a significant effect. RESULTS: We identified 84 patients who underwent a single level LLIF (61 at L4-5, 23 at L3-4). For both the overall sample and at each operative level, the operative segmental angle was significantly more lordotic postop compared to preop (all ps≤.01). Adjacent segmental angles were significantly less lordotic postop compared to pre-op overall (p=.001). For the overall sample, greater lordotic change at the operative segment led to more compensatory reduction of lordosis at the supra-adjacent segment. At L4-5, more lordotic change at the operative segment led to more compensatory lordosis reduction at the infra-adjacent segment. CONCLUSION: The present study demonstrated that LLIF resulted in significant increase in operative level lordosis and a compensatory decrease in supra- and infra-adjacent level lordosis, and subsequently no significant impact on spinopelvic mismatch.

Incidence, etiology and time course of delays to adult spinal deformity surgery: a single-center experience.

PURPOSE: We sought to determine the incidence, origin, and timeframe of delays to adult spinal deformity surgery so that institutions using preoperative multidisciplinary patient assessment teams might better anticipate and address these potential delays. METHODS: Complex spine procedures for treatment of adult spinal deformity from 1/1/18 to 8/31/21 were identified. Procedures for infection, tumor, and urgent/emergent cases were excluded. Operations delayed due to COVID or those that were performed outside of our established perioperative care pathway were also excluded. The electronic health record was used to identify the etiology and timeline of all pre- and peri-operative delays. RESULTS: Of 235 patients scheduled for complex spine surgery, 193 met criteria for inclusion. Of these patients, 35 patients experienced a surgical delay (18.1%) with a total of 41 delays recorded. Reasons for delay include medically unoptimized (25.6%), intraoperative complication (17.9%), patient directed delay (17.9%), patient illness/injury (15.4%), scheduling complication (10.3%), insurance delay/denial (5.1%), and unknown (2.6%). Twenty-four delays experienced by 22 individuals occurred within 7 days of their scheduled surgery date. CONCLUSION: At a single multidisciplinary center, most delays to adult spinal deformity surgery occur before a patient is admitted to the hospital, and for recommendations of additional medical workup/clearance. We suspect that the preoperative protocol might increase pre-admission delays for unoptimized patients, as the protocol is intended to ensure patients receive surgery only when they are medically ready. Further research is needed to determine the economic and system impact of delays related to a preoperative optimization protocol weighed against the reduction in adverse events these protocols can provide.

Anterior Cervical Corpectomy and Fusion for Degenerative Cervical Spondylotic Myelopathy: Case Presentation With Surgical Technique Demonstration and Review of Literature.

Anterior cervical corpectomy and fusion (ACCF) provides an extensive decompression and provides a large surface area for fusion in patients presenting with cervical spondylotic myelopathy. Unfortunately, this procedure is a more difficult spinal surgery to perform (compared with a traditional anterior cervical discectomy and fusion) and has a higher incidence of overall complications. In literature, ACCF has functional outcomes that seem clinically equivalent to those for multilevel anterior cervical discectomy and fusion, especially when contained to 1 vertebral body level, and in cases, for which both posterior and anterior procedures would be appropriate surgical options, may provide greater long-term clinical benefit than posterior fusion or laminoplasty. In this manuscript, we summarize the indications and outcomes following ACCF for degenerative cervical spondylotic myelopathy. We then describe a case presentation and associated surgical technique with a discussion of complication avoidance with this procedure.

Use of Cannulated Reamers to Facilitate Thoracic Diskectomy Using a Minimally Invasive Retropleural Thoracotomy Approach-Surgical Technique.

BACKGROUND: The surgical treatment of symptomatic thoracic disk herniations is technically challenging. In the past decade, a minimally invasive retropleural thoracotomy approach has become more popular to treat this pathology. However, efficient bone removal to safely perform the diskectomy and spinal cord decompression is difficult with this technique because of the small incision size and long working distance in the thoracic cavity and the proximity of the compressed thoracic cord. OBJECTIVE: To describe a novel surgical technique for performing a thoracic diskectomy using a minimally invasive lateral approach using cannulated reamers to facilitate bone removal. METHODS: This technique was used in 7 consecutive patients who presented with thoracic myelopathy from a thoracic disk herniation. First, a standard lateral minimally invasive retropleural approach to the thoracic spine was performed. Partially threaded guide wires were placed in the posterior aspect of the vertebral bodies adjacent to the affected disk space, and sequential cannulated reamers were passed over the guidewires to perform partial corpectomies. The posterior annulus, posterior longitudinal ligament, and herniated disk material were then resected using Penfield dissectors and Kerrison rongeurs to complete the decompression. RESULTS: All 7 patients who underwent thoracic diskectomy using this approach had stable or improved neurologic function postoperatively. There were no complications related to the use of the cannulated reamer technique. CONCLUSION: The use of cannulated reamers provides a simple and efficient method for safe bone removal to facilitate minimally invasive thoracic diskectomy using a lateral approach. This is an easily reproducible technique using commonly available equipment.

Defining Cervical Sagittal Plane Deformity - When Are Sagittal Realignment Procedures Necessary in Patients Presenting Primarily With Radiculopathy or Myelopathy?

OBJECTIVE: It remains unclear whether cervical sagittal deformity (CSD) should be defined by radiographic parameters alone versus both clinical and radiographic factors, and whether radiographic malalignment by itself warrants a CSD corrective surgery in patients who present primarily with neurologic symptoms. METHODS: We administered a survey to a group of expert surgeons to evaluate whether radiographic parameters alone were sufficient to diagnose CSD, and in which scenarios surgeons recommend a CSD realignment procedure versus addressing the neurologic symptoms alone. RESULTS: No single radiographic criteria reached a 50% threshold as being sufficient to establish the diagnosis of CSD. When asymptomatic radiographic malalignment was present, a sagittal deformity correction was more likely to be recommended in patients with myelopathy versus those with radiculopathy alone. The majority of surgeons recommended deformity correction when symptoms of cervical deformity were present in addition to radiographic malalignment (85% with deformity symptoms and radiculopathy, 93% with deformity symptoms and myelopathy). CONCLUSION: There is no consensus on which radiographic and/or clinical criteria are necessary to define the presence of CSD. We recommend that symptoms of cervical deformity, in addition to radiographic parameters, be considered when deciding whether to perform deformity correction in patients who present primarily with myelopathy or radiculopathy.

Team Approach: Safety and Value in the Practice of Complex Adult Spinal Surgery.

Surgical management of complex adult spinal deformities is of high risk, with a substantial risk of operative mortality. Current evidence shows that potential risk and morbidity resulting from surgery for complex spinal deformity may be minimized through risk-factor optimization. The multidisciplinary team care model includes neurosurgeons, orthopaedic surgeons, physiatrists, anesthesiologists, hospitalists, psychologists, physical therapists, specialized physician assistants, and nurses. The multidisciplinary care model mimics previously described integrated care pathways designed to offer a structured means of providing a comprehensive preoperative medical evaluation and evidence-based multimodal perioperative care. The role of each team member is illustrated in the case of a 66-year-old male patient with previous incomplete spinal cord injury, now presenting with Charcot spinal arthropathy and progressive vertebral-body destruction resulting in lumbar kyphosis.

Helping spine surgeons detect pre-surgical psychological distress in complex spine patients: an observational pilot study.

STUDY DESIGN: Retrospective analysis. OBJECTIVE: Analysis of a standardized, pre-surgical psychological evaluation program for complex spine surgery. Adult spinal deformity (ASD) patients have a high rate of comorbid mental health conditions. Although there is a body of literature demonstrating the impact of psychological factors, including anxiety and depression, on spine surgery outcome, it is estimated that spine surgeons utilize a psychological assessment only about one third of the time prior to a patient's spine surgery. At this time, there is not a widely reported pre-surgical psychological evaluation program for ASD patients. METHODS: 129 consecutive complex spine surgery candidates receiving a pre-surgical psychological evaluation were analyzed between January 1st 2014 and December 31st 2018. Based on the available literature and professional experience in our facility, a color code for patients was developed from Green (low psychological or psychosocial co-morbidity) to Red (high psychological or psychosocial co-morbidity). Univariate analysis was used to evaluate between color grades and demographics, mental health disorders and outcomes. RESULTS: 83% of complex spine patients had at least one psychological disorder or psychosocial barrier. Only 17% had a combination of realistic expectations for surgery, a good support plan, and were without a history of mental illness. The pre-surgical psychological color criteria were validated in showing higher rates of major depression, anxiety disorder, and bipolar disorder in moderate to severe color grades (p < .001) in addition to higher PHQ-9 and GAD-7 scores (p < .001). Patients having a more severe color grade had lower rates of a discharge home and were taking higher morphine equivalent dosages (MEDs) at their six-month follow-up, though both did not reach statistical significance (p = .07 and p = .08; respectively). CONCLUSION: A comprehensive pre-surgical psychological evaluation may be beneficial to risk stratify and counsel patients being evaluated for surgical reconstruction of adult spinal deformities. LEVEL OF EVIDENCE: 3.

Postoperative Blood Salvage and Autotransfusion for Adult Spinal Deformity: A Randomized Controlled Trial.

STUDY DESIGN: Randomized controlled trial. OBJECTIVE: The aim of this study was to determine whether postoperative blood salvage and autotransfusion versus traditional closed suction drainage reduces the rate of homologous blood transfusions in patients undergoing surgery for adult spinal deformity. SUMMARY OF BACKGROUND DATA: The use of intraoperative blood salvage has become commonplace in spine surgery; however, the collection and reinfusion of blood drained from the wound postoperatively have not been employed routinely because of increased cost and questionable benefit. METHODS: Adult patients undergoing long posterior fusions were randomized to either a blood salvage and reinfusion system (OrthoPat - Group 1) or a standard subfascial closed suction drain (Group 2). Blood collected in Group 1 was reinfused according to the manufacturer's protocol. Reinfusion drains were converted to standard closed suction drains when output was <50 mL during 4 hours, and drains were removed when output was minimal. Patients received autologous or homologous blood transfusions when hemoglobin (Hg) <8 g/dL or they had symptomatic anemia. RESULTS: Thirty-four patients were randomized into Group 1 and 36 patients into Group 2. There were no differences in preoperative or intraoperative parameters. Patients in Group 1 had higher hemoglobin levels on postoperative day (POD) 2 and POD 3 compared to those in Group 2. However, there was no significant difference in the percentage of patients requiring homologous blood transfusion between the two groups (41% Group 1 vs. 60% Group 2, P = 0.17). Similarly a subgroup analysis in patients with estimated blood loss >2000 mL also showed no difference in homologous blood transfusion rates (67% Group 1 vs. 76% Group 2, P = 0.58). There were no differences in the rate or type of postoperative complications. CONCLUSION: Postoperative blood salvage and reinfusion result in a higher hemoglobin level in the early postoperative period, but does not significantly reduce the need for homologous blood transfusion. LEVEL OF EVIDENCE: 1.

Outcomes of Fusions From the Cervical Spine to the Pelvis.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Determine the indications, complications, and clinical outcomes in patients requiring fusions from the cervical spine to the pelvis. Several investigators have examined fusions from the thoracic spine to the sacrum, but no similar study has been performed for cervical-to-pelvis fusions. METHODS: Patients from 2003 to 2014 with an upper instrumented vertebrae (UIV) in the cervical spine (any level) and a lower instrumented vertebrae (LIV) in the sacrum or pelvis were included in the study. Those with infectious or acute trauma-related deformities were excluded. Patient demographics, medical history, diagnosis, operative procedure, and health-related quality of life measures were analyzed. Student's t test, Kruskal-Wallis test, and χ2 test were used as appropriate; significance was set at P < .05 for all tests. RESULTS: Fifty-five patients met inclusion criteria for the study. Average follow-up was 2.8 years. Proximal junctional kyphosis was the most common indication for cervical-to-pelvis fusions (36%). The most common UIV was C2 (29%) followed by C7 (24%). There was an average 31° correction in maximum kyphosis and a 3.3 cm improvement in sagittal vertical axis. In adults, the rate of complication was 71.4%, with a major complication rate of 39.3% and reoperation rate of 53.6%. There was significant improvement in the Scoliosis Research Society (SRS-22r) score (3.0 to 3.5; P < .01). CONCLUSION: Proximal junctional kyphosis is the most common indication for patients requiring fusion to the cervical spine. Adult patients incur a significant risk of major complications and reoperations. However, significant improvement in SRS-22r outcomes are noted in these patients.

Erratum to Incidence and Risk Factors for Major Surgical Complications in Patients With Complex Spinal Deformity: A Report From an SRS GOP Site [Spine Deformity 3 (2015) 57-64].

The corresponding author regret that co-author name was incorrectly published as "Elias C. Papadopoulus" in the article. The correct name of the author should be displayed as "Elias C. Papadopoulos".

Lumbar computed tomography scans are not appropriate surrogates for bone mineral density scans in primary adult spinal deformity.

OBJECTIVE The authors examined the correlation between lumbar spine CT Hounsfield unit (HU) measurements and bone mineral density measurements in an adult spinal deformity (ASD) population. METHODS Patients with ASD were identified in the records of a single institution. Lumbar CT scans were reviewed, and the mean HU measurements from L1-4 were recorded. Bone mineral density (BMD) was assessed using femoral neck and lumbar spine dual-energy x-ray absorptiometry (DEXA). The number of patients who met criteria for osteoporosis was determined for each imaging modality. RESULTS Forty-eight patients underwent both preoperative DEXA and CT scanning. Forty-three patients were female and 5 were male. Forty-seven patients were Caucasian and one was African American. The mean age of the patients was 62.1 years. Femoral neck DEXA was more likely to identify osteopenia (n = 26) than lumbar spine DEXA (n = 8) or lumbar CT HU measurements (n = 6) (p < 0.001). There was a low-moderate correlation between lumbar spine CT and lumbar spine DEXA (r = 0.463, p < 0.001), and there was poor correlation between lumbar spine CT and femoral neck DEXA (r = 0.303, p = 0.036). CONCLUSIONS Despite the opportunistic utility of lumbar spine CT HU measurements in identifying osteoporosis in patients undergoing single-level fusion, these measurements were not useful in this cohort of ASD patients. The correlation between femoral neck DEXA and HU measurements was poor. DEXA assessment of BMD in ASD patients is essential to optimize the care of these complicated cases.

Adolescent Idiopathic Scoliosis: Update on Bracing, Surgical Techniques, and Patient Safety.

The primary goal in the management of adolescent idiopathic scoliosis is to prevent the progression of spinal deformity either with the use of a brace or with surgery. The goals of surgery, if indicated, are to correct the spinal deformity safely and to preserve overall spinal balance and as many motion segments as possible, which maximizes the long-term health of a patient's spine. Recently, tremendous advances have been made in the surgical techniques that are used to correct adolescent idiopathic scoliosis, and improved tools have allowed surgeons to perform spinal deformity surgery as safely and with as few complications as possible. Surgeons should be aware of recent evidence that demonstrates the efficacy of bracing in patients who have adolescent idiopathic scoliosis. In addition, surgeons should understand recent advances in spinal deformity surgery with regard to fusion level selection, implant placement, three-dimensional deformity correction, and techniques that are used to minimize perioperative complications.

Prognosis of Significant Intraoperative Neurophysiologic Monitoring Events in Severe Spinal Deformity Surgery.

BACKGROUND: Intraoperative neurophysiologic monitoring has become a standard tool for mitigating neurologic injury during spinal deformity surgery. Significant monitoring changes during deformity correction are relatively uncommon. This study characterizes precipitating factors for neurologic injury and relates significant events and postoperative neurologic prognosis. METHODS: All spinal deformity surgeries at a West African hospital over a 12-month period were reviewed. Patients were included if complete operative reports, monitoring data, and postoperative neurologic examinations were available for review. Surgical and systemic triggers of monitoring events were recorded and neurologic status was followed for 6 weeks postoperatively. RESULTS: Eighty-eight patients met inclusion criteria. The average age was 14 years (3-28). The average kyphosis was 108° (54°-176°) and average scoliosis was 100° (48°-177°). There were 44 separate neurologic events in 34 patients (39%). The most common triggers were traction or positioning (16), posterior column osteotomies/vertebral column resections (9/1), and distraction, corrective maneuvers, or implant placement (12). On surgery completion, 100% (12/12) of events from non-osteotomy-related surgical procedures, 75% (12/16) of events from traction or positioning resolved; however, 0% (0/10) of events from osteotomies resolved completely. Eight percent (7/88) had new neurologic deficits postoperatively, all with intraoperative monitoring changes. In 6 of these 7 patients, the event was attributed to an osteotomy; in 1 patient the cause was not determined. At 6-week follow-up, all patients had some preserved motor function bilaterally with the ability to walk (ASIA D/E) or recovered completely. CONCLUSIONS: Intraoperative signal changes were most frequently from traction or positioning. However, the most common cause of persistent neurologic deterioration and the only cause of postoperative neurologic deficit was the performance of osteotomies. Unlike traction- or instrument-related correction, osteotomies produce irreversible changes, from canal intrusion or sudden localized deformity change. The incidence of postoperative neurologic deficit is very low when the inciting cause is reversed; however, osteotomy-related events are irreversible, with a high incidence of associated lasting neurologic injury.

Evaluating the Diagnostic Yield of Computed Tomography-Guided Aspirations in Suspected Post-operative Spine Infections.

BACKGROUND: Early detection of surgical site infection (SSI) following spinal surgery would allow for prompt treatment and would improve overall outcome, yet early diagnosis is a challenge. Computed tomography (CT) guided aspiration of fluid collections may aid in diagnosis, as its diagnostic utility has previously been demonstrated in the setting of hip SSI, knee SSI, and spontaneous diskitis. There is no literature on its use in post-operative spinal SSIs. QUESTIONS/PURPOSES: The current study aims to (1) determine the diagnostic value of CT-guided aspiration in evaluating suspected SSI; (2) identify the characteristics of the clinical presentation that are predictive of SSI; and (3) identify characteristics of the hematologic workup that are predictive of SSI. METHODS: Thirty patients who underwent CT-guided aspiration of paraspinal post-operative fluid collections and culture of aspirate fluid over the 6-year period from 2006 to 2011 were retrospectively reviewed. Aspirate fluid culture results were compared to intraoperative cultures, which were used as the "gold standard" for diagnosing SSI. The diagnostic value was evaluated by determining the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of aspirate fluid cultures. Clinical presentation, patient demographics, comorbidities, and laboratory values were reviewed for association with infection risk. RESULTS: Eleven of thirty patients undergoing CT-guided aspiration were subsequently confirmed to have SSI through positive cultures. Wound drainage, wound erythema, elevated ESR, and cloudiness of aspirate fluid were associated with SSI. The sensitivity and specificity of aspirate cultures were 36.4 and 89.5%, respectively, and the respective positive predictive value (PPV) and negative predictive value (NPV) were 66.7 and 70.8%. CONCLUSIONS: Cloudy aspirate fluid was highly suggestive of infection, while wound erythema, drainage, and elevated ESR were also suggestive of SSI. CT-guided aspirations are a useful adjunct tool in evaluating for SSI but further studies are necessary before it can be considered a stand-alone diagnostic procedure.