Minimally invasive lateral corpectomy for thoracolumbar traumatic burst fractures.

OBJECTIVE: The need for anterior column reconstruction after thoracolumbar burst fractures remains controversial. Here, the authors present their experience with minimally invasive lateral thoracolumbar corpectomies for traumatic fractures. METHODS: Between 2012 and 2019, 59 patients with 65 thoracolumbar fractures underwent 65 minimally invasive lateral corpectomies (MIS group). This group was compared to 16 patients with single-level thoracolumbar fractures who had undergone open lateral corpectomies with the assistance of general surgery between 2007 and 2011 (open control group). Comparisons of the two groups were made with regard to operative time, estimated blood loss, time to ambulation, and fusion rates at 1 year postoperatively. The authors further analyzed the MIS group with regard to injury mechanism, fracture characteristics, neurological outcome, and complications. RESULTS: Patients in the MIS group had a significantly shorter mean operative time (228.3 ± 27.9 vs 255.6 ± 34.1 minutes, p = 0.001) and significantly shorter mean time to ambulation after surgery (1.8 ± 1.1 vs 5.0 ± 0.8 days, p < 0.001) than the open corpectomy group. Mean estimated blood loss did not differ significantly between the two groups, though the MIS group did trend toward a lower mean blood loss. There was no significant difference in fusion status at 1 year between the MIS and open groups; however, this comparison was limited by poor follow-up, with only 32 of 59 patients (54.2%) in the MIS group and 8 of 16 (50%) in the open group having available imaging at 1 year. Complications in the MIS group included 1 screw misplacement requiring revision, 2 postoperative femoral neuropathies (one of which improved), 1 return to surgery for inadequate posterior decompression, 4 pneumothoraces requiring chest tube placement, and 1 posterior wound infection. The rate of revision surgery for the failure of fusion in the MIS group was 1.7% (1 of 59 patients). CONCLUSIONS: The minimally invasive lateral thoracolumbar corpectomy approach for traumatic fractures appears to be relatively safe and may result in shorter operative times and quicker mobilization as compared to those with open techniques. This should be considered as a treatment option for thoracolumbar spine fractures.

The increasing frequency of intravenous drug abuse-associated spinal epidural abscesses: a case series.

OBJECTIVEFew studies have been published specifically examining intravenous drug abuse (IVDA)-associated spinal epidural abscesses (SEAs), an unfortunate sequela of the opioid crisis in the United States. Here, the authors examined a series of patients with IVDA-associated SEAs in order to shed light on this challenging disease entity.METHODSThis study is a retrospective chart review of patients presenting with IVDA-associated SEAs at the authors' institution from 2013 to 2018, spanning the statewide implementation of opioid-prescribing restrictions.RESULTSA total of 45 patients presented with IVDA-associated SEAs; 46.5% presented with a neurological deficit. Thirty-one patients underwent surgery for neurological deficit, failure of medical therapy, or both. Nineteen surgical patients underwent a fusion procedure along with decompression. The complication rate was 41.9%, and the mortality rate was 6.7%. The average length of stay was 27.6 days. Patients who underwent surgery within 24 hours of onset of neurological symptoms trended toward more improvement in their American Spinal Cord Association Impairment Scale grade than those who did not (0.5 vs -0.2, p = 0.068). Methicillin-resistant Staphylococcus aureus was isolated as the causative pathogen in 57.8% of patients. Twenty-three patients (51.5%) kept their scheduled clinic follow-up appointments. Of the fusion patients with adequate follow-up, 5 showed bony arthrodesis and 3 had pseudarthrosis. The rate of IVDA-associated SEAs increased after opioid-prescribing restrictions were put in place, from 0.54 cases per month to 1.15 cases per month (p = 0.017).CONCLUSIONSPatients with IVDA-associated SEAs are challenging to treat, with high complication rates and poor follow-up. This disease is increasing in frequency, and opioid-prescribing restrictions did not slow that rise. Community outreach to promote prevention, early medical attention, and medication compliance would benefit this largely publicly funded patient population.

A case series of penetrating spinal trauma: comparisons to blunt trauma, surgical indications, and outcomes.

OBJECTIVEWhile blunt spinal trauma accounts for the majority of spine trauma, penetrating injuries affect a substantial number of patients. The goal of this study was to examine the epidemiology of penetrating spine injuries compared with blunt injuries and review the operative interventions and outcomes in the penetrating spine injury group.METHODSThe prospectively maintained trauma database was queried for spinal fractures from 2012 to 2018. Charts from patients with penetrating spine trauma were reviewed.RESULTSA total of 1130 patients were evaluated for traumatic spinal fractures; 154 injuries (13.6%) were secondary to penetrating injuries. Patients with penetrating injuries were significantly younger (29.2 years vs 44.1 years, p < 0.001), more likely male (87.7% vs 69.2%, p < 0.001), and more commonly African American (80.5% vs 33.3%, p < 0.05). When comparing primary insurers, the penetrating group had a significantly higher percentage of patients covered by Medicaid (60.4% vs 32.6%, p < 0.05) or prison (3.9% vs 0.1%, p < 0.05) or being uninsured (17.5% vs 10.3%, p < 0.05). The penetrating group had a higher Injury Severity Score on admission (20.2 vs 15.6, p < 0.001) and longer hospital length of stay (20.1 days vs 10.3 days, p < 0.001) and were less likely to be discharged home (51.3% vs 65.1%, p < 0.05). Of the penetrating injuries, 142 (92.2%) were due to firearms. Sixty-three patients (40.9%) with penetrating injuries had a concomitant spinal cord or cauda equina injury. Of those, 44 (69.8%) had an American Spinal Injury Association Impairment Scale (AIS) grade of A. Ten patients (15.9%) improved at least 1 AIS grade, while 2 patients (3.2%) declined at least 1 AIS grade. Nine patients with penetrating injuries underwent neurosurgical intervention: 5 for spinal instability, 4 for compressive lesions with declining neurological examination results, and 2 for infectious concerns, with some patients having multiple indications. Patients undergoing neurosurgical intervention did not show a significantly greater change in AIS grade than those who did not. No patient experienced a complication directly related to neurosurgical intervention.CONCLUSIONSPenetrating spinal trauma affects a younger, more publicly funded cohort than blunt spinal trauma. These patients utilize more healthcare resources and are more severely injured. Surgery is undertaken for limiting progression of neurological deficit, stabilization, or infection control.

Management of cerebrospinal fluid leak from cervical gunshot wounds with external ventricular drainage: a small case series.

Historically, the surgical management of gunshot wounds to the spine has been controversial. Repair of a persistent cerebrospinal fluid (CSF) leak is a generally agreed upon indication. The management of such CSF leaks typically involves lumbar drainage or direct surgical repair. Here, the authors report two cases of CSF diversion with an external ventricular drain (EVD) in patients with cervical gunshot wounds. Both patients had spinal canal obliteration or physiologic myelographic block at or below the level of injury. To the best of the author's knowledge, these are the first two reports of successful EVD treatment of persistent CSF leaks related cervical gunshot wounds. The authors also propose a CSF treatment algorithm for cervical gunshot wounds that includes EVD.

Minimally Invasive Management of Civilian Gunshot Wounds to the Lumbar Spine: A Case Series and Technical Report.

BACKGROUND: Treatment of penetrating gunshot wounds (GSW) to the spine remains controversial. The decision to operate is often based on surgeon preference and experience. We present a case series of 7 patients who underwent minimally invasive thoracolumbar/sacral decompression and bullet removal at a level 1 trauma center. OBJECTIVE: To describe the use of minimally invasive techniques to achieve decompression and bullet removal for GSW to the spine. METHODS: From 2010 to 2017, 7 patients with spinal GSW underwent minimally invasive decompression and bullet removal at an academic level 1 trauma center. RESULTS: Patient ages ranged from 20 to 55 yr (mean: 31 yr). The mechanisms of injury were GSW to the abdomen/pelvis (n = 6) and direct GSW to the spine (n = 1). Based on the neurological examination, the injuries were characterized as complete (n = 1) or incomplete (n = 6). Decompression and bullet removal were performed using a tubular retractor system. All patients with incomplete injuries who had postdischarge follow-up demonstrated some neurologic recovery. There were no postoperative wound infections, cerebrospinal fluid (CSF) fistulas, or other complications related to the procedure. CONCLUSION: Minimally invasive decompression and bullet removal is a safe technique that may help reduce the risk of postoperative infections and CSF fistulas in patients with GSW to the lumbar spine compared to the standard open technique. This approach appears to be particularly beneficial in patients with incomplete injuries and neuropathic pain refractory to medical treatment.