Cervical alignment in the obese population following posterior cervical fusion for cervical myelopathy.

STUDY DESIGN: Retrospective cohort study OBJECTIVE: The aim of this study was to investigate the effect of body mass index (BMI) on the reoperation rate and cervical sagittal alignment of patients who underwent posterior cervical decompression and fusion for cervical spondylotic myelopathy (CSM). SUMMARY OF BACKGROUND DATA: Cervical sagittal balance has been correlated with postoperative clinical outcomes. Previous studies have shown worse postoperative sagittal alignment and higher reoperation rates in patients with high BMI undergoing anterior decompression and fusion. Similar evidence for the impact of obesity in postoperative sagittal alignment for patients with (CSM) undergoing posterior cervical decompression and fusion (PCF) is lacking. METHODS: A retrospective analysis of 198 patients who underwent PCF for cervical myelopathy due to degenerative spine disease was performed. Demographics, need for reoperation, and perioperative radiographic parameters were collected. Cervical lordosis (CL), C2-7 sagittal vertical axis (SVA), and T1 slope (T1S) was measured on standing lateral radiographs. Comparative analysis of the patient cohort was performed by stratifying the sample population into three BMI categories (<25, 25-30, ≥30). RESULT: Of the 198 patients that met inclusion criteria, 53 had BMI normal (<25), 65 were overweight (25-30), and 80 were obese (≥30). Mean SVA increased postoperatively in all groups, 4 mm in the normal group, 13 mm in the overweight group, and 13 mm in the obese group (p = 0.003). There was no significant difference in the postoperative change of cervical lordosis or T1 slope between the groups. Multivariate analysis demonstrated fusions involving the cervicothoracic junction and those involving 5 or more levels significantly affected alignment parameters. There were 27 complications requiring reoperation (14%) with no significant differences among the groups stratified by BMI (p = 0.386). CONCLUSIONS: Overweight patients (BMI>25) with CSM undergoing PCF had a greater increase in SVA than normal weight patients while reoperation rates were similar. In addition, preoperative CL increased with increasing BMI, although this trend was not Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation significant and there was not found to be a significant difference between the change in CL from baseline to post-fusion between BMI cohorts. This study further highlights the importance of considering BMI when attempting to optimize sagittal alignment in patients undergoing PCF.

Risk factors associated with reoperation in posterior cervical fusions: A large-scale retrospective analysis.

OBJECTIVES: To identify risk factors for reoperation in patients who have undergone posterior cervical fusion (PCF). PATIENTS AND METHODS: A retrospective cohort analysis was performed of patients undergoing PCF during a 12-year period at a single institution. Demographic and surgical characteristics were collected from electronic medical records. This study addressed reoperations, from all causes, of PCF. Different strategies, including the addition of anterior fusion, were also compared. RESULTS: Of the 370 patients meeting inclusion criteria there were 44 patients (11.9 %) that required a revision and of those 5 required a second revision. The most common reasons for revision were adjacent segment disease and infection, 13 (3.5 %) and 11 patients (3.0 %), respectively. There was not a higher revision rate (for any cause) for patients who had a subaxial fusion and compared with those that included C2 or those that failed to cross the cervicothoracic junction. Of patients who required reoperation, there was a statistically significant higher fraction of smokers (p =  0.023). CONCLUSION: The risks and benefits of posterior cervical instrumentation and fusion should be thoroughly discussed with patients. This report implicates smoking as a risk factor for all-cause reoperation in patients who have had this PCF and provides surgeons with additional data regarding this complication. When possible, preoperative optimization should include smoking cessation therapy.

Vertebral hemangiomas: Diagnosis and management. A single center experience.

OBJECTIVE: Vertebral hemangiomas (VH) are common benign lesions involving the spine. Owing to the multiplicity of treatments, the management of VH has not always been consistent. In this retrospective review of a single center experience, indications and options available for the treatment of VH are outlined. PATIENTS AND METHODS: This is a retrospective review of 71 cases of VH managed at our institution between 2005 and 2019. Sixty of these cases were managed non-operatively, with 11 cases undergoing operative intervention. Of the 11 cases that underwent surgery, there were 2 cervical cases and 9 in the thoracic spine. Ten cases were symptomatic, and 1 incidental. Three patients presented with localized pain, and the remaining 7 had neurological deficit. Decompression with maximal resection of the hemangioma was undertaken in 10 cases, and vertebroplasty in 1. RESULTS: Of the 60 patients who were managed non-operatively, 13 patients had presented with back/neck pain, with the remaining 47 patients being asymptomatic and diagnosed incidentally. Among the 13 symptomatic patients, all were offered surgical intervention for pain management, but given lack of severity of symptoms, all had opted for conservative approaches of pain control. In the 11 patients who underwent surgery, the preoperative diagnosis of VH was accurate in all but 1 case. There were 2 cervical cases treated with corpectomy. One patient was treated with vertebroplasty, and the remaining 8 with decompression. Radiation was used in 2 cases. Of the 10 patients undergoing decompression, 7 patients had improvement of the neurologic deficit, with resolution of pain in the remaining 3. None of our cases demonstrated deterioration. CONCLUSION: VH are often discovered incidentally during evaluation of spinal pain. Except in rare cases, the diagnosis of VH is made correctly from the radiographic and MRI studies. Observation for the asymptomatic lesion is appropriate. For VH presenting with deficit or intractable pain, decompressive surgery is recommended. Radiation is appropriate in cases of recurrent VH.

Differences and characteristics of symptoms by tumor location, size, and degree of spinal cord compression: a retrospective study on 53 surgically treated, symptomatic spinal meningiomas.

OBJECTIVE: The differences in symptoms of spinal meningiomas have rarely been discussed from the perspective of tumor characteristics. The main purpose of this paper was to define the differences, if any, in symptoms in patients with spinal meningiomas with respect to tumor size, location, and degree of spinal cord compression. The authors also sought the threshold of spinal cord compression that causes motor weakness. METHODS: The authors conducted a retrospective study of 53 cases of spinal meningiomas that were surgically treated from 2013 to 2018. Symptoms related to the tumor were classified as motor weakness, sensory disturbance, pain, and bowel/bladder dysfunction. Based on MR images, tumor location was classified by spinal level and by its attachment to the dura mater. Tumor dimensions were also measured. Occupation ratios of the tumors to the spinal canal and degree of spinal cord flattening were sought from the axial MR images that showed the highest degree of spinal cord compression. RESULTS: Motor weakness and sensory disturbance were significantly more common in thoracic spine meningiomas than in cervical spine meningiomas (p < 0.001 and p = 0.013, respectively), while pain was more common in meningiomas at the craniovertebral junction (p < 0.001). The attachment, height, width, depth, and volume of the tumor showed no significant difference irrespective of the presence or absence of each symptom. In cases of motor weakness and sensory disturbance, occupation ratios and spinal cord flattening ratios were significantly larger. However, these ratios were significantly smaller in the presence of pain. Multivariate logistic regression analysis revealed that occupation ratio independently contributed to motor weakness (OR 1.14, p = 0.035) and pain (OR 0.925, p = 0.034). Receiver operating characteristic curve analysis suggested that occupation ratio with a value of 63.678% is the threshold for the tumor to cause motor weakness. CONCLUSIONS: The study showed the difference in clinical presentation of spinal meningiomas by spinal level, occupation ratio, and spinal cord flattening ratio. An occupation ratio of approximately 64% could be utilized as the threshold value of tumor growth to cause motor weakness. Tumor growth in the cervical spine might cause pain symptoms before causing motor weakness. The relationship between the tumor and its symptomatology should be discussed with respect to tumor size relative to the surrounding spinal canal.

Survival after reoperation for recurrent glioblastoma.

Determining which patients will benefit from reoperation for recurrent glioblastoma remains difficult and the impact of the volume of FLAIR signal hyperintensity is not well known. The primary purpose of this study is to analyze the impact of preoperative volume of FLAIR hyperintensity on prognosis. 37 patients who underwent a reoperation for recurrent glioblastoma after initial gross total resection followed by standard chemoradiation were retrospectively reviewed. Volumetric analysis of preoperative MR images from the initial and second surgery was performed and correlated with clinical data. Survival probabilities were estimated using the Kaplan-Meier method and Cox regression to assess the effect of risk factors on time to reoperation (TTR), progression-free survival (PFS) after reoperation, and overall survival (OS). The volumes of FLAIR signal hyperintensity prior to the initial surgery and reoperation were not associated with prognosis. TTR and OS were significantly affected by the preoperative enhancement volume at the initial surgery, with increasing volumes yielding poorer prognosis. Patients with tumor in critical/eloquent areas were found to have a worse prognosis. Median TTR was 11 months, median PFS after reoperation was 3 months, and OS in patients undergoing a reoperation was 21 months. The results suggest FLAIR signal change seen in patients with glioblastoma does not influence time to reoperation, progression-free survival, or overall survival. These findings suggest the amount of FLAIR signal change should not greatly influence a surgeon's decision to perform a second surgical resection compare to other factors, and when appropriate, aggressive surgical intervention should be considered.

Intraoperative Shoulder Traction as Cause of C5 Palsy: Magnetic Resonance Imaging Study.

OBJECTIVE: During surgery, shoulder traction is often used for better fluoroscopic imaging of the lower cervical spine. Traction on the C5 root has been implicated as a potential cause of C5 palsy after cervical spine surgery. Using magnetic resonance imaging, this study was undertaken to determine the impact of upper extremity traction on the C5 root orientation. METHODS: In this study, 5 subjects underwent coronal magnetic resonance imaging of the cervical spine and left brachial plexus. Using a wrist restraint, sequential traction on the left arm with 10, 20, and 30 lb. was applied. Measurements of the angle between the spinal axis and C5 nerve root and the angle between the C5 nerve root and the upper trunk of the brachial plexus were obtained. The measurements were taken by a trained neuroradiologist and analyzed for significance. RESULTS: The angle between the C5 nerve root and the vertical spinal axis remained within 3 and 4 degrees of the mean and was not found to be associated with increased traction weight (P = 0.753). The angle between the C5 root and the upper trunk increased with increasing weight and was found to be statistically significant (P = 0.003). CONCLUSIONS: While the cause of C5 palsy is likely multifactorial, this study provides evidence that, in the awake volunteer, upper extremity traction leads to C5 root and upper trunk tension. These results suggest that shoulder traction in the anesthetized patient could lead to tension of the C5 nerve root and subsequent injury and palsy.

Management of iatrogenic spinal cerebrospinal fluid leaks: A cohort of 124 patients.

OBJECTIVES: Cerebrospinal fluid leaks are a frequent complication of spinal surgery, with reported rates between 2 and 20%. Management is highly variable and dependent on comorbidities, complexity of the index procedure, and surgeons' experience. Treatment options include primary or delayed repair, with or without spinal drainage. Using a retrospective cohort, the authors aim to identify the appropriate management of iatrogenic spinal cerebrospinal fluid (CSF) leaks. PATIENTS AND METHODS: We queried our institutional database for postoperative spinal CSF leaks between 1/1/2007 and 3/14/2017 using Current Procedural Terminology (CPT) and International Classification of Disease (ICD) codes. Excluded were patients who had primarily intradural procedures such as tethered cord release, tumor resection, and posterior fossa decompression. Information regarding patient demographics, surgical characteristics, and postoperative course was gathered, including whether primary closure (with nonabsorbable suture) was achieved, lumbar drain placement at initial surgery, use of fibrin sealant, number of subsequent explorations, rate of infection, length of stay, and number of hospital admissions. RESULTS: Our cohort consisted of 124 patients who suffered intraoperative iatrogenic CSF leak out of 3965 procedures, for a rate of 3.1%. Primary dural closure (±lumbar drain) was attempted in 64 patients, with successful repair in 47 (73.4%). Lumbar drain placement (±primary closure) was performed in 49, with success in 43 (87.8%). Delayed exploration of the surgical wound was required in 34 patients. Patients in whom primary closure could not be achieved and did not have a lumbar drain placed had a 39.5% reexploration rate. Patients who were treated with delayed exploration had statistically significant increase in length of stay (19.6 vs. 7.8 days), hospital admissions (2.1 vs. 1.0), and infections (15 vs. 0). CONCLUSION: CSF leaks are fraught with complications requiring reexploration for repair in 27.4% of cases. Primary repair of the leak and use of fibrin sealant upon discovery, with consideration of lumbar drain, should be performed whenever possible, as they are associated with shorter hospital stays, fewer hospital admissions, and lower rates of reoperation and infection.