Initial Results of Precision Treatment of Postoperative Cerebrospinal Fluid Leak with Ultrasound-Guided Epidural Blood Patch.

BACKGROUND: Incidental durotomy, a known complication of spinal surgery, can lead to persistent cerebrospinal fluid leak and pseudomeningocele if unrecognized or incompletely repaired. We describe the use of ultrasound to visualize the site of durotomy, observe the aspiration of the pseudomeningocele, and guide the precise application of an ultrasound-guided epidural blood patch (US-EBP), under direct visualization in real time. METHODS: A retrospective review was performed to determine demographic, procedural, and outcome characteristics for patients who underwent US-EBP for symptomatic postoperative pseudomeningocele. RESULTS: Overall, 48 patients who underwent 49 unique episodes of care were included. The average age and body mass index were 60.5 (±12.6) years and 27.8 (±4.50) kg/m2, respectively. The most frequent index operation was laminectomy (24.5%), and 36.7% of surgeries were revision operations. Durotomy was intended or recognized in 73.4% of cases, and the median time from surgery to symptom development was 7 (interquartile range 4-16) days. A total of 61 US-EBPs were performed, with 51.0% of patients experiencing resolution of their symptoms after the first US-EBP. An additional 20.4% were successful with multiple US-EBP attempts. Complications occurred in 14.3% of cases, and the median clinical follow-up was 4.3 (interquartile range 2.4-14.5) months. CONCLUSIONS: This manuscript represents the largest series in the literature describing US-EBP for the treatment of postoperative pseudomeningocele. The success rate suggests that routine utilization of US-guided EBP may allow for targeted treatment of pseudomeningoceles, without the prolonged hospitalization associated with lumbar drains or the risks of general anesthesia and impaired wound healing associated with surgical revision.

Partial Costotransversectomy and Corpectomy for Thoracic Spinal Metastatic Disease: Operative Technique and Nuances: 2-Dimensional Operative Video.

We describe the operative approach and management for thoracic metastatic disease in a 78-yr-old man with worsening mechanical lower back and left-sided thoracic radicular pain. Imaging of the thoracic spine revealed an osteolytic T11 mass with destruction of the left T11 pedicle and transverse process. Biopsy confirmed spinal metastasis from the liver. Preoperative angiogram was completed for localization of the artery of Adamkewicz and microparticle embolization of the left T11 intercostal artery. Surgical resection was supplemented with electrophysiological monitoring and neuronavigation. The corpectomy was approached by resecting the medial aspect of the rib, transverse process, and pedicle, which were all invaded with tumor. The left T11 nerve root was isolated and sacrificed to allow for placement of the expandable corpectomy cage and also resulted in sustained relief of the patient's radicular pain. The patient recovered from surgery well, with postoperative improvement of his pain. This case highlights the complex technical nuances of this procedure, and the importance of a thorough preoperative evaluation, including angiography, as proper identification of the artery of Adamkewitz can prevent severe neurological deficit from a spinal cord stroke. The patient consented to the procedure.

Redirecting pedicle screws: a revision spinal fusion strategy using three-dimensional image guidance.

BACKGROUND: Pedicle screws are a preferred method for spinal fixation because of their three-column support and rigid posterior stabilization. The purpose of this study was to evaluate the outcome of patients requiring pedicle screw redirection, and to describe a technique using cone-beam computed tomography (cbCT). METHODS: A retrospective review of 30 patients undergoing revision spinal fusion with redirection of pedicle screws was performed. Fifty pedicle screws were redirected in these patients using cbCT-based 3D image guidance. They were graded pre- and post-operatively using an established grading system. RESULTS: No complications occurred in this study as a result of redirection. No pedicle breach was noted in all of the redirected pedicle screws. CONCLUSION: Redirection of misplaced pedicle screws using cbCT-based 3D image guidance seems to be safe and accurate in our experience. Further studies are needed to establish its safety, accuracy, fusion rate, and clinical outcome compared with other methods. Copyright © 2016 John Wiley & Sons, Ltd.

Radiographic comparison of cross-sectional lumbar pedicle fill when placing screws with navigation versus free-hand technique.

BACKGROUND: Pedicle screws are often used for spinal fixation. Increasing the percentage of pedicle that is filled with the screw presumably yields greater fixation. It has not been shown whether spinal navigation helps surgeons more completely fill their instrumented pedicles. METHODS: Fifty consecutive patients from each arm (navigated and free-hand) were retrospectively reviewed. The cross-sectional area of each instrumented lumbar pedicle and screw were measured using an automatic area calculation tool. The coronal images and measurements were blinded to the surgeons. RESULTS: The instrumented pedicles in the navigated patients were significantly more filled by screws than the pedicles in the non-navigated patients (P < 0.001). CONCLUSION: Obtaining a higher cross-sectional percentage fill of the pedicle with a screw is expected to provide greater spinal fixation in instrumented fusion surgery. This study shows that utilizing spinal navigation helps to more completely fill the pedicles that are being instrumented. Copyright © 2015 John Wiley & Sons, Ltd.

A case series on the technical use of three-dimensional image guidance in subaxial anterior cervical surgery.

BACKGROUND: Three dimensional (3D) image guidance has been used to improve the safety of complex spine surgeries, but its use has been limited in anterior cervical spine approaches. METHODS: Twenty-two patients underwent complex anterior cervical spine surgeries in which 3D image guidance provided intraoperative assistance with the dissection, decompression and implant placement. One of two paired systems, the BrainLAB (BrainLAB, Westchester, Illinois) system, or Stealth (Medtronic Inc., Littleton, Massachusetts) system was used for 3D image guidance in this study. RESULTS: Image guidance was able to reliably locate pertinent anatomical structures in complex anterior cervical spine surgery involving re-exploration, dissection around vertebral arteries or deformity correction. No complications occurred, and no patients required a revision anterior surgery. CONCLUSION: This technical note describes the setup and technique for the use of cone beam computed tomography (cbCT)-based, 3D image guidance in subaxial anterior cervical surgery. The authors have found this technique to be a useful adjunct in revision anterior cervical procedures, as well as anterior cervical procedures involving corpectomy or tumor removal.

Migration to the ICD-10 coding system: A primer for spine surgeons (Part 1).

BACKGROUND: On 1 October 2015, a new federally mandated system goes into effect requiring the replacement of the International Classification of Disease-version 9-Clinical Modification (ICD-9-CM) with ICD-10-CM. These codes are required to be used for reimbursement and to substantiate medical necessity. ICD-10 is composite with as many as 141,000 codes, an increase of 712% when compared to ICD-9. METHODS: Execution of the ICD-10 system will require significant changes in the clinical administrative and hospital-based practices. Through the transition, diminished productivity and practice revenue can be anticipated, the impacts of which the spine surgeon can minimizeby appropriate education and planning. RESULTS: The advantages of the new system include increased clarity and more accurate definitions reflecting patient condition, information relevant to ambulatory and managed care encounters, expanded injury codes, laterality, specificity, precise data for safety and compliance reporting, data mining for research, and finally, enabling pay-for-performance programs. The disadvantages include the cost per physician, training administrative staff, revenue loss during the learning curve, confusion, the need to upgrade hardware along with software, and overall expense to the healthcare system. CONCLUSIONS: With the deadline rapidly approaching, gaps in implementation result in delayed billing, delayed or diminished reimbursements, and absence of quality and outcomes data. It is thereby essential for spine surgeons to understand their role in transitioning to this new environment. Part I of this article discusses the background, coding changes, and costs as well as reviews the salient features of ICD-10 in spine surgery.

Implementation and impact of ICD-10 (Part II).

BACKGROUND: The transition from the International Classification of Disease-9(th) clinical modification to the new ICD-10 was all set to occur on 1 October 2015. The American Medical Association has previously been successful in delaying the transition by over 10 years and has been able to further postpone its introduction to 2015. The new system will overcome many of the limitations present in the older version, thus paving the way to more accurate capture of clinical information. METHODS: The benefits of the new ICD-10 system include improved quality of care, potential cost savings, reduction of unpaid claims, and improved tracking of healthcare data. The areas where challenges will be evident include planning and implementation, the cost to transition, a shortage of qualified coders, training and education of the healthcare workforce, and a loss of productivity when this occurs. The impacts include substantial costs to the healthcare system, but the projected long-term savings and benefits will be significant. Improved fraud detection, accurate data entry, ability to analyze cost benefits with procedures, and enhanced quality outcome measures are the most significant beneficial factors with this change. RESULTS: The present Current Procedural Terminology and Healthcare Common Procedure Coding System code sets will be used for reporting ambulatory procedures in the same manner as they have been. ICD-10-PCS will replace ICD-9 procedure codes for inpatient hospital services. The ICD-10-CM will replace the clinical code sets. Our article will focus on the challenges to execution of an ICD change and strategies to minimize risk while transitioning to the new system. CONCLUSION: With the implementation deadline gradually approaching, spine surgery practices that include multidisciplinary health specialists have to anticipate and prepare for the ICD change in order to mitigate risk. Education and communication is the key to this process in spine practices.

A retrospective study of iliac crest bone grafting techniques with allograft reconstruction: do patients even know which iliac crest was harvested? Clinical article.

OBJECT: Considerable biological research has been performed to aid bone healing in conjunction with lumbar fusion surgery. Iliac crest autograft is often considered the gold standard because it has the vital properties of being osteoconductive, osteoinductive, and osteogenic. However, graft site pain has been widely reported as the most common donor site morbidity. Autograft site pain has led many companies to develop an abundance of bone graft extenders, which have limited proof of efficacy. During the surgical consent process, many patients ask surgeons to avoid harvesting autograft because of the reported pain complications. The authors sought to study postoperative graft site pain by simply asking patients whether they knew which iliac crest was grafted when a single skin incision was made for the fusion operation. METHODS: Twenty-five patients underwent iliac crest autografting with allograft reconstruction during instrumented lumbar fusion surgery. In all patients the autograft was harvested through the same skin incision but with a separate fascial incision. At various points postoperatively, the patients were asked if they could tell which iliac crest had been harvested, and if so, how much pain did it cause (10-point Numeric Rating Scale). RESULTS: Most patients (64%) could not correctly determine which iliac crest had been harvested. Of the 9 patients who correctly identified the side of the autograft, 7 were only able to guess. The 2 patients who confidently identified the side of grafting had no pain at rest and mild pain with activity. One patient who incorrectly guessed the side of autografting did have significant sacroiliac joint degenerative pain bilaterally. CONCLUSIONS: Results of this study indicate the inability of patients to clearly define their graft site after iliac crest autograft harvest with allograft reconstruction of the bony defect unless they have a separate skin incision. This simple, easily reproducible pilot study can be expanded into a larger, multiinstitutional investigation to provide more definitive answers regarding the ideal, safe, and cost-effective bone graft material to be used in spinal fusions.

Intraoperative image-guided spinal navigation: technical pitfalls and their avoidance.

Spinal instrumentation has made significant advances in the last two decades, with transpedicular constructs now widely used in spinal fixation. Pedicle screw constructs are routinely used in thoracolumbar-instrumented fusions, and in recent years, the cervical spine as well. Three-column fixations with pedicle screws provide the most rigid form of posterior stabilization. Surgical landmarks and fluoroscopy have been used routinely for pedicle screw insertion, but a number of studies reveal inaccuracies in placement using these conventional techniques (ranging from 10% to 50%). The ability to combine 3D imaging with intraoperative navigation systems has improved the accuracy and safety of pedicle screw placement, especially in more complex spinal deformities. However, in the authors' experience with image guidance in more than 1500 cases, several potential pitfalls have been identified while using intraoperative spinal navigation that could lead to suboptimal results. This article summarizes the authors' experience with these various pitfalls using spinal navigation, and gives practical tips on their avoidance and management.

Radiographic fusion rate after implantation of facet bone dowels.

BACKGROUND CONTEXT: Achieving a posterolateral fusion in conjunction with performing decompressive laminectomies can prevent recurrence of stenosis or worsening of spondylolisthesis. Facet bone dowels have been introduced and marketed as a less invasive alternative to pedicle screws. Surgeons have been placing them during lumbar laminectomy surgery and coding for intervertebral biomechanical device and posterolateral fusion. These bone dowels have also been placed percutaneously in outpatient surgery centers and pain clinics for facet-mediated back pain. PURPOSE: To describe fusion outcomes in patients who underwent facet bone dowel placement. STUDY DESIGN/SETTING: Retrospective analysis of a single center's experience. PATIENT SAMPLE: Ninety-six patients comprise the entire cohort of patients who underwent facet bone dowel implantation at our institution with adequate postoperative imaging to determine fusion status. OUTCOME MEASURES: Fusion rates as determined on postoperative computed tomography (CT) scans and dynamic lumbar X-rays if CT is not available. METHODS: Threaded facet bone dowels in this study were placed according to the manufacturer's recommended methods. The bone dowels were placed after open exploration of the facet complex or percutaneously through a tubular retractor on the contralateral side from a microdiscectomy or synovial cyst resection. The most recent available postoperative imaging was reviewed to determine fusion status. RESULTS: Of 96 patients in our series, 6 (6.3%) had a fusion seen on CT and 4 did not exhibit any movement on dynamic lumbar X-rays for a total fusion rate of 10.4% (10/96). Eighty-six (89.6%) patients were shown on imaging to not have a solid fusion either by visualizing a patent facet joint on CT or measurable movement between the flexion and the extension lumbar X-rays. CONCLUSIONS: This article is mainly intended to question whether the implantation of facet bone dowels can produce a solid fusion radiographically. In our experience, the placement of facet bone dowels does not equal the time, skill, or attention to detail that is necessary for a posterolateral lumbar arthrodesis, and our follow-up radiographic studies clearly demonstrate an inadequate fusion rate.

Operating room radiation exposure in cone beam computed tomography-based, image-guided spinal surgery: clinical article.

OBJECT: Surgeon and operating room (OR) staff radiation exposure during spinal surgery is a concern, especially with the increasing use of multiplanar fluoroscopy in minimally invasive spinal surgery procedures. Cone beam computed tomography (cbCT)-based, 3D image guidance does not involve the use of active fluoroscopy during instrumentation placement and therefore decreases radiation exposure for the surgeon and OR staff during spinal fusion procedures. However, the radiation scatter of a cbCT device can be similar to that of a standard 64-slice CT scanner and thus could expose the surgeon and OR staff to radiation during image acquisition. The purpose of the present study was to measure radiation exposure at several unshielded locations in the OR when using cbCT in conjunction with 3D image-guided spinal surgery in 25 spinal surgery cases. METHODS: Five unshielded badge dosimeters were placed at set locations in the OR during 25 spinal surgery cases in which cbCT-based, 3D image guidance was used. The cbCT device (O-ARM) was used in conjunction with the Stealth S7 image-guided platform. The radiology department analyzed the badge dosimeters after completion of the last case. RESULTS: Fifty high-definition O-ARM spins were performed in 25 patients for spinal registration and to check instrumentation placement. Image-guided placement of 124 screws from C-2 to the ileum was accomplished without complication. Badge dosimetry analysis revealed minimal radiation exposure for the badges 6 feet from the gantry in the area of the anesthesiology equipment, as well as for the badges located 10-13 feet from the gantry on each side of the room (mean 0.7-3.6 mrem/spin). The greatest radiation exposure occurred on the badge attached to the OR table within the gantry (mean 176.9 mrem/spin), as well as on the control panel adjacent to the gantry (mean 128.0 mrem/spin). CONCLUSIONS: Radiation scatter from the O-ARM was minimal at various distances outside of and not adjacent to the gantry. Although the average radiation exposure at these locations was low, an earlier study, undertaken in a similar fashion, revealed no radiation exposure when the surgeon stood behind a lead shield. This simple precaution can eliminate the small amount of radiation exposure to OR staff in cases in which the O-ARM is used.

Placement of thoracic transvertebral pedicle screws using 3D image guidance.

OBJECT: Transvertebral pedicle screws have successfully been used in the treatment of high-grade L5-S1 spondylolisthesis. An advantage of transvertebral pedicle screws is the purchase of multiple cortical layers across 2 vertebrae, thereby increasing the stability of the construct. At the lumbosacral junction, transvertebral pedicle screws have been shown to be biomechanically superior to pedicle screws placed in the standard fashion. The use of transvertebral pedicle screws at spinal levels other than L5-S1 has not been reported in the literature. The authors describe their technique of transvertebral pedicle screw placement in the thoracic spine using 3D image guidance. METHODS: Twelve patients undergoing cervicothoracic or thoracolumbar fusion had 41 thoracic transvertebral pedicle screws placed across 26 spinal levels using this technique. Indications for placement of thoracic transvertebral pedicle screws in earlier cases included osteoporosis and pedicle screw salvage. However, in subsequent cases screws were placed in patients undergoing multilevel thoracolumbar fusion without osteoporosis, particularly near the top of the construct. Image guidance in this study was accomplished using the Medtronic StealthStation S7 image guidance system used in conjunction with the O-arm. All patients were slated to undergo postoperative CT scanning at approximately 4-6 months for fusion assessment, which also allowed for grading of the transvertebral pedicle screws. RESULTS: No thoracic transvertebral pedicle screw placed in this study had to be replaced or repositioned after intraoperative review of the cone beam CT scans. Review of the postoperative CT scans revealed all transvertebral screws to be across the superior disc space with the tips in the superior vertebral body. Six pedicle screws were placed using the in-out-in technique in patients with narrow pedicles, leaving 35 screws that underwent breach analysis. No pedicle breach was noted in 34 of 35 screws. A Grade 1 (< 2 mm) medial breach was noted in 1 screw without clinical consequence. Solid fusion was observed across 25 of 26 spinal levels that underwent transvertebral screw placement including 7 spinal levels located at the top of a multilevel construct. CONCLUSIONS: This report describes the authors' initial in vivo experience with the 3D image-guided placement of 41 thoracic transvertebral pedicle screws. Advantages of thoracic transvertebral screws include the purchase of 2 vertebral segments across multiple cortical layers. A high fusion rate was observed across spinal levels in which transvertebral screws were placed. A formal biomechanical study is needed to assess the biomechanical advantages of this technique and is currently being planned.

Symptomatic pneumocephalus associated with lumbar dural tear and reverse trendelenburg positioning: a case report and review of the literature.

Symptomatic pneumocephalus is a rare complication of degenerative lumbar spine surgery. This is a case report of a patient who developed transient diplopia associated with pneumocephalus following lumbar spine surgery complicated by a dural tear. The diplopia improved as the pneumocephalus resolved. Factors involved in the development of pneumocephalus include an unintended durotomy and intraoperative reverse Trendelenburg positioning that was utilized to decrease the risk of postoperative vision loss. When encountering cerebrospinal fluid (CSF) leakage intraoperatively, spine surgeons should level the operating table until closure of the dural defect to prevent potential complications associated with pneumocephalus. If postoperative patients complain of severe headaches or display a focal cranial neurologic deficit, then a computed tomography (CT) scan of the brain should be ordered and evaluated. Consulting neurologists should be aware of the circumstances surrounding this rare complication.

Symptomatic postlaminectomy cerebrospinal fluid leak treated with 4-dimensional ultrasound-guided epidural blood patch.

BACKGROUND: A persistent cerebrospinal fluid leak after spinal surgery can be associated with both meningitis and/or pneumocephalus. Therefore, early active intervention is recommended with surgical exploration, lumbar subarachnoid drain, and less commonly epidural blood patch. In the absence of a ligamentum flavum, the use of high-resolution ultrasound (US) spine imaging enables real-time advancement of a Tuohy needle towards the dura and the precise injection of blood to cover the dural defect. METHODS: Six patients, after lumbar spine surgery with instrumentation and primary closure was complicated by incidental dural tears, developed severe symptomatic headaches that failed conservative therapy. All patients underwent US-guided epidural blood patch. Precise needle advancement to the dura was observed with US guidance, and 4-dimensional US scanning was used to confirm the expansion of blood over the dura in real time. RESULTS: All patients had symptomatic relief of their headaches and successful treatment of dural leaks using US-guided blood patch. CONCLUSIONS: Real-time US guidance allowed accurate positioning of the Tuohy needle and deposition of the epidural blood patch in the setting of a surgically removed ligamentum flavum. Further investigations are needed to confirm that an US-guided epidural blood patch may offer reliable symptomatic relief to postsurgical persistent cerebrospinal fluid leak and may serve as an intermediate step along a spectrum between conservative initial management and surgical reexploration.

Surgeon radiation exposure in cone beam computed tomography-based, image-guided spinal surgery.

BACKGROUND: Radiation exposure to the surgeon is a concern in spinal surgery, especially with the increasing popularity of minimally invasive spinal surgery techniques. Three-dimensional (3D) image guidance used in conjunction with cone beam computed tomography (cbCT) has a theoretical advantage of decreased radiation exposure to the surgeon and operating room (OR) staff. Radiation scatter to the environment immediately surrounding a CT scanner during acquisition of a CT scan is a known entity. This in vivo study measures the radiation exposure to the surgeon when using cbCT registration in 3D image-guided spinal surgery. METHODS: Two badge dosimeters were worn by the surgeon (EWN), one on the right waistband of the surgeon's scrubs and the other located over the thyroid area during 25 consecutive spinal surgery cases in which cbCT was used in conjunction with 3D image guidance. No lead protection was worn by the surgeon. The cbCT device was used for registration of the anatomy and to confirm adequate instrumentation placement. The surgeon stood behind a clear lead shield in the same location during every spin of the cbCT device. After the 25th case, the badge dosimeters were sent to the radiology department for analysis. RESULTS: Overall, 63 cbCT spins were accomplished in 25 patients. A total of 228 screws were placed into spinal levels spanning from C2 to the ileum. No complications resulted from instrumentation placement or the use of image guidance.Analysis of both badge dosimeters revealed 0 millirem (mRem) exposure. CONCLUSIONS: Our study demonstrates that no radiation exposure to the surgeon occurs in cbCT-based, 3D image-guided spinal surgery procedures. Additionally, radiation scatter does not result in surgeon radiation exposure during patient registration if the surgeon stands behind a lead shield 10 feet from the cbCT device and not in direct line with the opening of the cbCT tube.

Patients' perspective on full disclosure and informed consent regarding postoperative visual loss associated with spinal surgery in the prone position.

OBJECTIVE: To determine patients' opinions regarding the person, method, and timing for disclosure of postoperative visual loss (POVL) associated with high-risk surgery. PATIENTS AND METHODS: On the basis of findings of a pilot study involving 219 patients at Mayo Clinic in Florida, we hypothesized that at least 80% of patients would prefer disclosure of POVL by the surgeon, during a face-to-face discussion, before the day of scheduled surgery. To test the hypothesis, we sent a questionnaire to 437 patients who underwent prolonged prone spinal surgical procedures at Mayo Clinic in Rochester, MN, or Mayo Clinic in Arizona from December 1, 2008, to December 31, 2009. RESULTS: Among the 184 respondents, 158 patients gave responses supporting the hypothesis vs 26 with at least 1 response not supporting it, for an observed incidence of 86%. The 2-sided 95% confidence interval is 80% to 91%. CONCLUSION: At least 80% of patients prefer full disclosure of the risk of POVL, by the surgeon, during a face-to-face discussion before the day of scheduled surgery. This finding supports development of a national patient-driven guideline for disclosing the risk of POVL before prone spinal surgery.

Subaxial cervical synovial cysts: report of 35 histologically confirmed surgically treated cases and review of the literature.

STUDY DESIGN: Retrospective study OBJECTIVE: The authors' aim of the present study is to report their experience with subaxial cervical synovial cysts hoping to provide further insight into these lesions including the presenting symptoms, possible mechanisms of cyst development associated with cervical level, surgical treatments and clinical outcomes. SUMMARY OF BACKGROUND DATA: Synovial cysts are relatively common in the lumbar spine and very uncommonly identified in the subaxial cervical spine. Several case reports and a few small series have been reported in the literature over the past four decades. METHODS: The authors retrospectively reviewed the cases of 35 patients who underwent surgical treatment for histologically confirmed symptomatic subaxial cervical synovial cysts between 1993 and 2009. The presenting symptoms, age, sex, cervical level, operation, complications and outcomes were analyzed in this cohort. Preoperative and postoperative neurologic assessments were done by staff neurologists independent of the operating surgeon. This study was approved by the Mayo Clinic institutional review board. RESULTS: Thirty-five patients underwent surgical treatment for their synovial cysts and follow-up for at least 12 months postoperatively. The mean follow-up time was 49 months (range, 12-134). There were no deaths associated with the surgery. There was one postoperative infection in a patient undergoing a decompressive laminectomy and posterior instrumented fusion. Patient outcomes were assessed using the Modified Rankin Score for 12 patients was 0, 17 patients was 1, 4 patients was 2, and 2 patients was 3. CONCLUSION: This series of 35 patients with subaxial cervical synovial cysts surgically treated over a period of 17 years illustrates the relative rarity of these lesions. Magnetic resonance imaging is currently the optimal radiographic study to identify these lesions. Surgical resection can be an effective treatment.

Three-dimensional image-guided placement of percutaneous pedicle screws without the use of biplanar fluoroscopy or Kirschner wires: technical note.

BACKGROUND: Percutaneous pedicle screws are commonly used in minimally invasive spinal procedures. Traditional techniques of percutaneous pedicle screw placement have employed the use of multiplanar fluoroscopy and Kirschner wires (K-wires). The use of multiplanar fluoroscopy for the placement of percutaneous pedicle screws likely increases radiation exposure to the surgeon when compared to open techniques. K-wires can break or become bent during the procedure, making it difficult to insert and remove instrumentation over them. Additionally, there is also a risk of visceral or vascular injury with the use of K-wires. The authors present a novel method of percutaneous pedicle screw placement utilizing three-dimensional (3D) fluoroscopy-based image guidance in which K-wires are not used and there is minimal to no radiation exposure to the surgeon and operating room staff. METHODS: Thirty-six screws were placed in 15 patients using this technique. An independent radiologist graded screw placement using computed tomographic (CT) scans and the breach rate of the percutaneous pedicle screws was compared to the breach rate of 33 pedicle screws placed contralaterally using the mini-open technique. RESULTS: No bony breach was noted by any screw in either group and no complications occurred in this study as a result of screw placement. CONCLUSIONS: Percutaneous pedicle screws can be placed accurately and safely using 3D image guidance without the use of K-wires. Little to no radiation exposure to the surgeon or OR staff occurs with this technique. No complications occurred in this study as a result of screw placement or image guidance.

Painful medial branch neuroma treated with minimally invasive medial branch neurectomy.

STUDY DESIGN: Case report. OBJECTIVE: To report an unusual complication following lumbar facet radiofrequency denervation and describe a successful, minimally invasive treatment of a presumed medial branch neuroma. SUMMARY OF BACKGROUND DATA: Radiofrequency medial branch neurotomy is a common procedure for the treatment of mechanical back pain. Deafferentation injury and neuroma formation is well known and reported following chemical, surgical, and cryoablation neurolysis; however, it is thought to be rare with radiofrequency ablation. When this problem is encountered, treatment options appear to be limited. Further radiofrequency ablations may be ineffective and indeed may cause further injury. METHODS: A 17-year-old male who sustained a traumatic fracture of the right L3-4 facet joint presented with increasing back pain after multiple radiofrequency ablations of the medial branches of the L2 and L3 dorsal rami. The description of the back pain, initially nociceptive in nature, had become progressively neuropathic with clear focal areas of allodynia and hyperesthesia. Further medial branch radiofrequency denervation was found to be ineffective. RESULTS: Diagnostic block of the right medial branch of the L2 dorsal ramus provided the patient with total relief of pain. This was followed by a minimally invasive open surgical ablation of the L2 medial branch neuroma using three-dimensional, fluoroscopy-based image guidance. At 7 months of follow-up, the patient reported complete resolution of pain, discontinuation of all pain medications, and return to all previous physical activities. CONCLUSION: Deafferentation injury is a rare but recognized complication of chemical, surgical, and thermal neuroablation. This case report presents a rare instance of presumed neuroma formation following multiple radiofrequency ablations for the treatment of facet-generated mechanical back pain. Open and minimally invasive medial branch neurectomy resulted in complete resolution of pain and return to baseline function.