Complex Wound Closure in Adult Spinal Deformity Surgery Reduces Complications in High-Risk Patients.

BACKGROUND: Adult spinal deformity (ASD) surgery is becoming increasingly prevalent. Soft tissue defects arising from revision closure and impaired healing can predispose to wound complications including dehiscence and infection. Soft tissue coverage with local muscle flaps has been shown to minimize wound complications in high-risk patients. In this study we evaluate the role of complex wound closure in preventing wound complications in high-risk spinal deformity patients. METHODS: The authors retrospectively reviewed charts of patients who underwent ASD surgery. Patients were stratified into muscle flap advancement (by neurosurgery or plastic surgery) closure versus primary approximation by neurosurgery. Relevant patient and operative factors were collected and summarized using descriptive statistics. Outcomes of interest included wound complication and revision surgery. RESULTS: Ninety-four cases met inclusion criteria including 56 wounds closed by neurosurgery and 38 wounds closed by plastic surgery (PRS). Of the neurosurgery wounds, 31 and 25 were closed by primary approximation and muscular flap advancement, respectively. Patients operated on by PRS were higher risk than all patients operated on only by neurosurgery (P = 0.0037) but were not significantly higher risk than the neurosurgery performed flap cohort (P = 0.4914). In subgroup analysis, despite similar levels of risk, the PRS population experienced lower rates of any wound complication (P = 0.028) and specifically dehiscence (P = 0.029) compared with the neurosurgery performed flap closure cohort. CONCLUSIONS: Prophylactic involvement of plastic surgery in ASD surgery wound closure may improve wound outcomes in higher risk patients. A multidisciplinary approach with plastic and spine surgeons may lessen the risk of wound complications in high-risk spine surgeries.

Surgical Management of Postradiation, Dropped Head Spinal Deformity in Patients with Head and Neck Cancer.

BACKGROUND: Dropped head syndrome is a morbid condition that affects daily functionality, causing pain and dysphagia and respiratory compromise. Reported causes of dropped head syndrome include neuromuscular disorders, iatrogenic from cervical spine surgery, and idiopathic and postradiation for head and neck cancers. Management of this spinal disorder remains challenging, as the complication rates are high. We present our series of 7 patients who underwent surgical correction of dropped head syndrome, all resulting from radiation for head and neck cancers. METHODS: This was a retrospective review of 7 patients who underwent surgery between 2016 and 2019 for dropped head syndrome secondary to postradiation cervical spine deformity. Clinical variables were obtained from medical records. Radiographic parameters pre- and postsurgery including T1 slope, sagittal vertical axis, and C2-C7 cervical lordosis were examined. RESULTS: Seven patients were included in the study, with an average age 69 years. Two patients underwent traction preoperatively. Five patients had posterior fixation and fusion only and 2 patients had a combined anterior and posterior fixation and fusion. Overall, there was improvement in average pre/postoperative sagittal vertical axis (6.96 cm to 3.04 cm), T1 slope (33.61° to 24.34°), and C2-C7 lordosis (-21.65° to -0.03°). CONCLUSIONS: Surgical correction of postradiation dropped head spinal deformity involving anterior and posterior fixation with osteotomies provides improvement in functional and radiographic outcomes as shown in our series. These cases are technically challenging and have a high rate of perioperative complications. Approaches must be tailored to the patient with attention to their specific surgical and radiation history.

Failure in Cervical Spinal Fusion and Current Management Modalities.

Failed fusion in the cervical spine is a multifactorial problem stemming from a combination of patient and surgical factors. Patient-related risk factors such as steroid use, poor bone quality, and smoking can be optimized preoperatively. Age, prior radiation, prior surgery, and underlying genetics are nonmodifiable patient-centered risk factors. Surgical risks for failed fusion include the number of segments fused, anterior versus posterior approach for fusion, the type of bone graft, and the instrumentation utilized. Many symptomatic cases of failed fusion (pseudarthrosis) result in pain, neurological deficits, or loosened hardware necessitating a revision surgery consisting of extending the prior construct and utilizing additional allografts or autografts to augment the fusion. Given the relatively mobile nature of the cervical spine, pseudoarthrosis (either known or anticipated) must be recognized by the spine surgeon, and steps should be considered to optimize the likelihood of future fusion. This consists of both performing a rigid fixation and using appropriate bone graft to enhance the environment for arthrodesis. Vascularized bone grafts are a useful tool to augment fusion and provide added structural stability in cases at high risk of pseudoarthrosis.

Vascularized Bone Grafts for Spinal Fusion-Part 1: The Iliac Crest.

BACKGROUND: Iliac crest autograft has been the gold standard for harvest of fusion materials in spine surgery. The benefits of a vascularized version of this bone graft-including delivery of stem cells, ability to deliver antibiotics to the fusion bed, and relative ease of harvest-make this technique superior to free bone transfer in the achievement of augmented spinal fusion. OBJECTIVE: To present a brief summary of similar existing concepts before describing the novel technique of this vascularized posterior iliac crest bone graft. METHODS: Vascularized posterior iliac crest bone graft can be harvested from the same midline lumbar incision used for thoracolumbar spinal fusion, through lateral dissection around the paraspinals to the iliac crest. Recipient sites in the posterolateral bony spinal gutters may be as rostral as T12 and caudal as the sacrum. The ability to cover multiple lumbar levels can be achieved with desired lengths of the donor iliac crest. RESULTS: Over 14 vascularized iliac crest bone grafts have been performed to augment lumbar fusion for salvage after pseudoarthrosis. Operative time and bleeding are reduced compared to free flap procedures, and no patients have experienced any complications related to these grafts. Indocyanine green (ICG) angiography has been utilized in a novel way to ensure the vascularity of the bone graft prior to arthrodesis. CONCLUSION: While long-term follow-up will be required to fully characterize fusion rates and patient morbidity, this innovative surgical option augments spinal fusion in patients with, or at increased risk for, pseudoarthrosis.

Solitary Fibrous tumor of the lumbar spine mimicking a sequestered disc fragment.

Solitary fibrous tumor in the lumbar spine is a rare pathology with non-specific radiographic features, sometimes resulting in misdiagnosis. Our patient was a 41-year old female who presented with low back pain and bilateral leg pain. Initial MRI showed a lesion misdiagnosed for a sequestered disc at the mid L4-5 level, which was subsequently characterized appropriately and treated surgically, with resolution of symptoms. Pathologic diagnosis was most consistent with a solitary fibrous tumor due to STAT 6 and CD 34 reactivity. Long-term follow up is recommended in these patients to monitor tumor recurrence and evidence of metastasis.

Osteomyelitis-Discitis at the Thoracolumbar Junction and the Development of Postinfectious Spinal Deformity: A Surgical Case Series.

BACKGROUND: Progressive spinal deformity and neural compromise are the main indications for surgical management of vertebral osteomyelitis-discitis. However, when such pathology presents at the thoracolumbar (TL) junction, it remains unclear what the appropriate intervention is. The therapeutic dilemmas of decompression with or without instrumented fusion, the need for circumferential decompression and reconstruction, as well as the prognostic factors for progression of kyphosis, all remained ill-defined in the literature. The objective of this study is to evaluate risk factors for instrumentation at TL junction in spinal osteomyelitis-discitis. METHODS: A review of patients at a single center with osteomyelitis-discitis at the TL junction between 2014 and 2018 was performed. Patients were 18 years or older with infectious pathologies at T10 to L2. RESULTS: Sixteen patients were included. Indication for instrumentation included progression of kyphosis following prior laminectomy/medical management. Of the 16 patients, 4 patients received laminectomy at initial treatment versus 12 patients receiving medical management alone. All 4 patients receiving laminectomy experienced progressive kyphosis requiring revision with instrumented fusion versus only 4 of 12 of the medically managed. Laminectomy, epidural compression, and vertebral body collapse were significant risk factors for kyphosis progression requiring instrumentation. The average time to surgical intervention for the indication of progressive kyphosis was 2.6 months after prior laminectomy and 6 months after initiation of medical management. CONCLUSIONS: Given the proclivity for kyphotic deformity at the TL junction, patients may benefit from long segment instrumentation in addition to decompression at the initial surgery. Laminectomy alone may hasten kyphosis progression.

Congenital Fusion of Dens to T3 Vertebra in Klippel-Feil Syndrome.

BACKGROUND: Patients with Klippel-Feil syndrome may present with neurologic complaints such as neck pain, radiculopathy and gait instability. Here we describe surgical management of a patient with congenital fusion of the occipital-cervical region and also block circumferential fusion of dens to T3 with spinal cord compression. This report is the first of its kind with such extensive fusion. CASE DESCRIPTION: Our patient was a 56 year-old female, who presented with neck pain and tingling in all extremities. On exam, she had a short neck, prominent jaw with extremely limited range of motion in neck and features of myelopathy. CT showed fusion of the dens to T3 vertebrae. Patient underwent sub-occipital craniectomy, C1 laminectomy and Occiput to T5 posterior fixation and fusion with neurologic improvement. CONCLUSION: This is the first reported case of Klippel-Feil syndrome with fusion of all cervical vertebrae down to T3. We recommend surgery for advanced cases of myelopathy or radiculopathy due to stenosis and spinal instability.

The minimally invasive paramedian approach for foraminal disc herniation.

Foraminal disc herniation presents with an operative challenge, as it often requires facetectomy, which can result in segmental instability. The intraforaminal approach includes partial pars resection and medial facetectomy and allows for direct visualization of the nerve roots and herniated disc in the foramen without violating the joint, with good clinical outcomes. Herein, we describe a retrospective series of patients that underwent minimally invasive paramedian approach with hemilaminectomy, partial medial pars resection, medial facetectomy for foraminal disc herniation. Demographics and clinical outcomes were obtained from medical records. Improvement in functional outcomes was evaluated using the pre and post-operative Visual Analog Scale (VAS) and Oswestry Disability Index (ODI). A total of 23 patients were included in this study. The average age was 56.47 ± 9.4 yrs and body mass index was 31.92 ± 7.7 kg/m2. 47.8% of cases were L4-5 FDH. The estimated blood loss was 31.32 ± 19.8 ml. The average length of hospital stay was 1.11 ± 0.3 days. All patients were discharged home. Overall, there was a significant improvement in the VAS (pre-op: 8.21 ± 2.1; post-op: 2.59 ± 2.7; p-value: <0.0001) and ODI (pre-op: 57.16 ± 13.2; post-op: 21.47 ± 9.9; p-value: <0.0001). The minimally invasive paramedian approach provides satisfactory outcomes as a safe strategy in the treatment of foraminal disc herniation. Herein, there was a significant improvement in pain and functional outcomes, minimal blood loss and decreased hospital stay.

Practical Application of Recent Advances in Diagnostic, Prognostic, and Therapeutic Modalities for Spinal Cord Injury.

OBJECTIVE: Spinal cord injury remains a highly morbid entity, with limited treatment modalities in both acute and chronic settings. Clinical research efforts to improve therapeutic guidelines are confounded by initial evaluation inaccuracies, as presentations are frequently complicated by trauma and objective diagnostic and prognostic methods are poorly defined. The purpose of our study was to review recent practical advances for further delineation of these injuries and how such classification may benefit the development of novel treatments. METHODS: A review was carried out of recent studies reported within the last 5 years for prognostic and diagnostic modalities of acute spinal cord injury. RESULTS: Substantial efforts have been made to improve the timeliness and accuracy of the initial assessment, not only for the purpose of enhancing prognostication but also in determining the efficacy of new treatments. Whether it be applying traumatic brain injury principles to limit injury extent, external stimulators used for chronic pain conditions to enhance the effects of physical therapy, or creative algorithms incorporating various nerve or muscle transfer techniques, innovative and practical solutions continue to be developed in lieu of definitive treatment. Further development will benefit from enhanced stratification of injury from accurate and practical assessment modalities. CONCLUSIONS: Recent advances in accurate, timely, and practical classification methods of acute spinal cord injury will assist in the development of novel treatment approaches for both acute and chronic injury alike.

Giant Symptomatic Meningocele as a Delayed, Adult Complication of Lipomyelomeningocele.

BACKGROUND: An expanding cohort of patients with spina bifida live well into adulthood and pose complex management challenges due to unique combinations of adult health issues overlying congenital problems. CASE DESCRIPTION: We present a case of a 45-year-old woman with an expanding, disfiguring, painful lumbar meningocele more than 40 years after her only surgery as a 3-year-old child. A team of pediatric and adult neurosurgeons as well as plastic/reconstructive surgeons successfully performed surgery to obliterate the meningocele, with preservation of her baseline functional status, and no evidence of recurrence after more than 1 year of follow-up. CONCLUSIONS: Symptomatic meningocele may present in a long-delayed fashion in adult patients with a history of spina bifida. Surgical treatment may provide symptomatic benefit.

A somatic mutation in MEN1 gene detected in periventricular nodular heterotopia tissue obtained from depth electrodes.

Periventricular nodular heterotopia (PNH) is a common structural malformation of cortical development. Mutations in the filamin A gene are frequent in familial cases with X-linked PNH. However, many cases with sporadic PNH remain genetically unexplained. Although medically refractory epilepsy often brings attention to the underlying PNH, patients are often not candidates for surgical resection. This limits access to neuronal tissue harboring causal mutations. We evaluated a patient with PNH and medically refractory focal epilepsy who underwent a presurgical evaluation with stereotactically placed electroencephalographic (SEEG) depth electrodes. Following SEEG explantation, we collected trace tissue adherent to the electrodes and extracted the DNA. Whole-exome sequencing performed in a Clinical Laboratory Improvement Amendments-approved genetic diagnostic laboratory uncovered a de novo heterozygous pathogenic variant in novel candidate PNH gene MEN1 (multiple endocrine neoplasia type 1; c.1546dupC, p.R516PfsX15). The variant was absent in an earlier exome profiling of the venous blood-derived DNA. The MEN1 gene encodes the ubiquitously expressed, nuclear scaffold protein menin, a known tumor suppressor gene with an established role in the regulation of transcription, proliferation, differentiation, and genomic integrity. Our study contributes a novel candidate gene in PNH generation and a novel practical approach that integrates electrophysiological and genetic explorations of epilepsy.

Minimally Invasive Transforaminal Versus Direct Lateral Lumbar Interbody Fusion: Effect on Return to Work, Narcotic Use, and Quality of life.

BACKGROUND: Direct lateral (DLIF) and transforaminal (TLIF) lumbar interbody fusions have been shown to produce satisfactory clinical outcomes with significant reduction in pain and functional disability. Despite their increasing use in complex spinal deformity surgeries, there is a paucity of data comparing outcome measures, which this study addresses. METHODS: This is a retrospective, comparative study of patients who underwent minimally invasive, 1-level TLIF or DLIF between 2013 and 2015. Only patients 18 years and older were included. Preoperative and demographic variables were collected, and clinical outcome measures were compared between cohorts. RESULTS: In total, 46 patients were included (DLIF: 17 patients; TLIF: 29 patients). Preoperatively, there was no difference in visual analog scale pain score or Oswestry Disability Index. Overall, there was a significant improvement in the postoperative visual analog scale score and Oswestry Disability Index in the separate cohorts, without significant difference when compared. The duration of postoperative narcotic use was similar in both cohorts (DLIF: 4.8 ± 4.7 months vs. TLIF: 5.2 ± 5.1 months, P = 0.82). Significantly more patients in DLIF cohort were cleared for work after surgery. Patients who underwent MIS TLIF had a significantly longer time to return to work (7.1 ± 4.8 months) compared with patients undergoing DLIF (2.3 ± 1.3, P = 0.006). There was a greater incidence of reoperation in the TLIF cohort. CONCLUSIONS: Both MIS TLIF and DLIF provide long-term improvement in pain andfunctional outcomes, with an overall reduction in postoperative narcotic requirement. However, there was a significantly longer time to return to work and a greater incidence of reoperation in the TLIF cohort compared with the patients who underwent DLIF.

Bone Morphogenetic Protein Usage in Anterior Lumbar Interbody Fusion: What Else Can Go Wrong?

BACKGROUND: Bone morphogenetic protein (BMP) graft showed promising outcome during early phases of its use. However, unreported adverse events and off-label use shattered its safe profile and raised concerns regarding its indication. In 2008 the U.S. Food and Drug Administration prohibited its use in anterior cervical spine procedures due to the possibility of edema, hematoma, and need to intubate. At the molecular level, BMPs act as multifactorial growth factors playing a role in cartilage, heart, and bone formation. However, its unfavorable effect on bone overgrowth or heterotopic ossification post spine surgeries has been described. Reported cases in the literature were limited to epidural bone formation. CASE DESCRIPTION: We present a rare and interesting case of a 59-year-old female, in whom BMP caused intradural bone growth several years after an anterior lumbar interbody fusion surgery. CONCLUSION: Caution must be exercised while using BMPs because of inadvertent complications.

Is there a "July effect" in pediatric neurosurgery?

PURPOSE: The belief that July, when resident physicians' training year begins, may be associated with increased risk of patient morbidity and mortality is known as the "July effect." This study aimed to compare complication rates after pediatric neurosurgical procedures in the first versus last academic quarters in two national datasets. METHODS: Data were extracted from the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) database for year 2012 for 30-day complication events and the Kids' Inpatient Database (KID) for year 2012 for in-hospital complication events after pediatric neurosurgical procedures. Descriptive and analytic statistical methods were used to characterize the impact of seasonal variation between the first and last quarters on complications. RESULTS: Three thousand six hundred twenty-four procedures in the NSQIP-P dataset and 14,855 hospitalizations in KID were included in the study cohort. No significant difference was observed between the first and fourth quarters for these complication events: wound disruption/dehiscence, wound infection, nerve injury, bleeding requiring transfusion, central line-associated BSI, deep venous thrombosis/pulmonary embolism, urinary tract infection, renal failure, re-intubation/pulmonary failure, cardiac arrest, stroke, coma, and death. There was no difference in the average length of stay or average length of surgical time. In the NSQIP-P, the first quarter was associated with a significantly increased incidence of pneumonia and unplanned re-operation; there was a trend towards increased incidence of unplanned re-admission and sepsis. In KID, there was no difference in the rate of pneumonia or sepsis. CONCLUSION: For the majority of morbidity and mortality events, no significant difference was found in occurrence rates between the first and last quarters.

Back Muscle Morphometry: Effects on Outcomes of Spine Surgery.

BACKGROUND: This review seeks to synthesize emerging literature on the effects of back muscle size on outcomes in spine surgery. Risk factors that contribute to poor surgical outcomes continue to be an area of interest in spine surgery because proper risk stratification can result in reduction in morbidity and enhanced patient care. However, the impact of muscle size on spine surgical outcomes is an understudied avenue with paucity of data evaluating the relationship among back muscles and surgical outcomes, patient's quality of life, and functional improvement postoperatively. METHODS: This review was centered around identifying studies that assessed the impact of back muscle size on spine surgery outcomes. RESULTS: Five retrospective studies were selected for review. All studies set out to see if differences in muscle size existed in patients with disparate post-operative outcomes as a primary objective. The studies support the association between larger back muscles and improved outcomes. The size and relative cross sectional area of paraspinal muscles and the size of the psoas muscle were associated with functional outcomes, incidence of complications and also fusion rates. CONCLUSION: With reduction in surgical complications and improvement in postoperative functional outcomes, back muscle morphometry ought to be included in the preoperative surgical planning as a predictor of outcomes.

Predictive parameters for the antecedent development of hip pathology associated with long segment fusions to the pelvis for the treatment of adult spinal deformity.

BACKGROUND: The surgical treatment of adult scoliosis frequently involves long segment fusions across the lumbosacral joints that redistribute tremendous amounts of force to the remaining mobile spinal segments as well as to the pelvis and hip joints. Whether or not these forces increase the risk of femoral bone pathology remains unknown. The aim of this study is to determine the correlation between long segment spinal fusions to the pelvis and the antecedent development of degenerative hip pathologies as well as what predictive patient characteristics, if any, correlate with their development. METHODS: A retrospective chart review of all long segment fusions to the pelvis for adult degenerative deformity operated on by the senior author at the Duke Spine Center from February 2008 to March 2014 was undertaken. Enrolment criteria included all available demographic, surgical, and clinical outcome data as well as pre and postoperative hip pathology assessment. All patients had prospectively collected outcome measures and a minimum 2-year follow-up. Multivariable logistic regression analysis was performed comparing the incidence of preoperative hip pain and antecedent postoperative hip pain as a function of age, gender, body mass index (BMI), and number of spinal levels fused. RESULTS: In total, 194 patients were enrolled in this study. Of those, 116 patients (60%) reported no hip pain prior to surgery. Eighty-three patients (71.6%) remained hip pain free, whereas 33 patients (28.5%) developed new postoperative hip pain. Age, gender, and BMI were not significant among those who went on to develop hip pain postoperatively (P < 0.0651, 0.3491, and 0.1021, respectively). Of the 78 patients with preoperative hip pain, 20 patients (25.6%) continued to have hip pain postoperatively, whereas 58 patients reported improvement in the hip pain after long segment fusion for correction of their deformity, a 74.4% rate of reduction. Age, gender, and BMI were not significant among those who continued to have hip pain postoperatively (P < 0.4386, 0.4637, and 0.2545, respectively). Number of levels fused was not a significant factor in the development of hip pain in either patient population; patients without preoperative pain who developed pain postoperatively (P < 0.1407) as well as patients with preoperative pain who continued to have pain postoperatively (P < 0.0772). CONCLUSION: This study demonstrates that long segment lumbosacral fusions are not associated with an increase in postoperative hip pathology. Age, gender, BMI, and levels fused do not correlate with the development of postoperative hip pain. The restoration of spinal alignment with long segment fusions may actually decrease the risk of developing femoral bone pathology and have a protective effect on the hip.

Neuromonitoring for Intramedullary Spinal Cord Tumor Surgery.

BACKGROUND: Intramedullary spinal cord tumors (IMSCT) account for about 2%-4% of tumors of the central nervous system. Surgical resection continues to be the most effective treatment modality for most intramedullary tumors, with gross total resection leading to preserved neurologic function and improved survival. However, surgical treatment is often difficult and carries significant risk of postoperative neurologic complications. Intraoperative neuromonitoring has been shown to be of clinical importance in the surgical resection of IMSCT. The main monitoring modalities include somatosensory evoked potentials, transcranial motor evoked potentials via limb muscles or spinal epidural space (D-waves), and dorsal column mapping. These monitoring modalities have been shown to inform surgeons intraoperatively and in many cases, have led to alterations in operative decision. METHODS: We reviewed the literature on the usefulness of intraoperative neuromonitoring for intramedullary spinal tumor resection and its role in predicting postoperative neurologic deficits. A MEDLINE search was performed (2000-2015) and 13 studies were reviewed. Detailed information and data from the selected articles were assessed and compiled. Data were extracted showing the role of monitoring in outcomes of surgery. CONCLUSIONS: By using intraoperative somatosensory evoked potentials, transcranial motor evoked potentials, D-waves, and dorsal column mapping, spinal injury could be prevented in most cases, thereby improving postoperative neurologic functioning and outcome in patients undergoing surgery for IMSCT.

Fulminant spinal cord compression caused by postradiation inflammatory pseudotumor with rapid response to steroids: case report.

Radiation therapy continues to play an extremely valuable role in the treatment of malignancy. The effects of radiation therapy on normal tissue can present in a delayed fashion, resulting in localized damage with pseudomalignant transformation, producing a compressive effect on the spinal cord or exiting nerve roots. Infiltration of inflammatory cells and the subsequent fibrotic response can result in the development of an inflammatory pseudotumor (benign tumor-like lesion) with subsequent mass effect. Herein, the authors present a rare case of inflammatory pseudotumor with fulminant cervicothoracic cord compression, developing 7 years after radiation therapy for breast cancer. The lesion recurred following resection but subsequently displayed complete and rapid resolution following steroid therapy. To the best of the authors' knowledge, no previous studies have reported such an incident.