A Comparative Study of Thumb Metacarpal Morphology and Shape Categorization.

PURPOSE: To describe the shape of a biplanar thumb metacarpal (MC) head and identify how it differs morphologically from previously described flat and round MC heads. METHODS: Lateral radiographs of the thumb were collected retrospectively from our patient database. Patients were included in the study if they had an appropriate lateral radiograph, met the age criteria (range; 18-75 years), and did not have severe metacarpophalangeal (MCP) joint arthritis. Metacarpal heads were categorized as flat or round by dividing the distance measured from the volar to the dorsal edge of the articular surface by the radius of curvature of the articular surface. A ratio of 1.7 or greater indicated a round MC head, whereas a ratio of less than 1.7 indicated a flat MC head. RESULTS: Among the 210 study participants, 110 were female and the average age was 47.3 years. During the measurement and classification process, it was determined by a board-certified hand surgeon that a subset of MCs did not meet the criteria for being categorized as either flat or round because of the inability to appropriately measure the radius of curvature of the MCP joint. Of the participants 113, 79, and 18, were classified as having either round, flat, or biplanar MC head shapes, respectively. CONCLUSIONS: We have identified a third, biplanar MC head shape. The biplanar head shape is more triangular and has two distinct planes on the articular surface that converge into an apex. CLINICAL RELEVANCE: The shape of the MC head has been shown to influence the range of motion of the MCP joint which may have an influence on the types of injuries that occur at the MCP joint. Further studies are required to understand how shape classification of MC heads may be useful and relevant to range of motion and risk of injury.

Airway Management for Emergency Spinal Epidural Hematoma Evacuation With Awake Spine Surgery: Case Report and Literature Review.

BACKGROUND: Postoperative spinal epidural hematomas (pSEHs) are a rare complication of microdiscectomy surgery. The hematoma may be unnoticed intraoperatively, but timely treatment may prevent permanent neurologic impairment. Airway management in patients with a full stomach is generally performed with rapid sequence intubation and general anesthesia. Awake spine surgery without intravenous analgesia or sedation may be beneficial in patients with a full stomach who are at higher risk for pulmonary aspiration with general anesthesia due to a loss of non-per-oral (NPO) status. The authors propose that it can also be performed in cases of urgent/emergent postsurgical epidural hematoma evacuation. METHODS: We present the airway management of a 41-year-old man who underwent a minimally invasive microdiscectomy with normal strength immediately after surgery but developed progressive weakness with right foot dorsiflexion, right extensor hallucis longus muscle weakness, and progressive right lower extremity ascending numbness over the course of the first 2 hours after surgery due to an epidural hematoma. RESULTS: The patient underwent urgent awake epidural hematoma evacuation with a spinal anesthetic. Afterward, the patient recovered neurological function and was discharged the following morning. CLINICAL RELEVANCE: pSEHs are a rare complication of microdiscectomy surgery. The purpose of this article is to describe the novel use of awake spine surgery in emergent epidural hematoma evacuation and demonstrate its feasibility. CONCLUSIONS: In emergencies, when a patient is not NPO, awake spine surgery can safely be performed with no sedation, ensuring the patient can protect their airway and avoid the risk of aspiration.

Minimally-invasive trans-facet lumbar interbody fusion using a dual-dimension expandable cage: preliminary results of a multi-institutional retrospective study.

Background: Minimally-invasive trans-facet lumbar interbody fusion (LIF) is an emerging technique that offers the advantages of being safe, enabling decompression, and facilitating patient recovery. An innovative cage that expands in two dimensions has been introduced to restore segmental lordosis and disc height while minimizing the risk of cage subsidence. This study aimed to report our surgical technique of trans-facet LIF utilizing the innovative cag and to report the early clinical outcomes. Methods: We retrospectively reviewed the medical records and radiographs of patients who underwent trans-facet LIF with dual-dimension expandable cages from two institutions: Duke University Hospital and Vail-Summit Orthopaedics and Neurosurgery. The analysis covered patient demographics, Oswestry Disability Index (ODI), visual analogue scale (VAS) for back pain, surgical data, complications, and radiographic parameters. Clinical outcomes were compared between pre- and one year post-operation, while radiographic outcomes were compared between pre- and three months post-operation. Results: Twenty patients with a mean age of 61.2 years were included. Seventeen patients (85.0%) had spondylolisthesis, and L4/5 (68.2%) was the most common pathology level. Twelve patients (60.0%) underwent awake surgery, and the mean operative time was 164.5±36.1 minutes, with an estimated blood loss of 64.0±39.5 mL and a hospital stay of 1.75±1.2 days. Four patients (20.0%) experienced cage subsidence; however, none required additional surgery. The VAS score significantly improved from a preoperative average of 7.3±2.7 to 2.6±1.6 one year post-operation (P=0.02). The ODI score also showed a significant decrease, from 48.7±22.9 preoperatively to 16.4±11.1 one year postoperatively (P=0.03). Notably, 80% and 83.3% of patients achieved the minimum clinically important difference in VAS and ODI scores, respectively. The degree of spondylolisthesis was significantly reduced from a median of 5.9 mm preoperatively to 0 mm postoperatively (P<0.001). Additionally, both anterior and posterior disc heights significantly increased after surgery, from 9.8±4.7 to 15.1±2.6 mm (anterior) and from 4.9±3.3 to 10.5±2.2 mm (posterior) (P<0.001 for both). The mean segmental lordosis increased by 2.9 degrees and was associated with cage height (P=0.03), while spinopelvic parameters remained unchanged. Conclusions: Minimally-invasive trans-facet LIF with dual-dimension expandable cages demonstrates a substantial capacity for spondylolisthesis reduction and disc height restoration, and provides good short-term clinical outcomes. It may be the most appropriate method for deploying this large cage as it allows for a large, unobstructed pathway to the disc. However, future studies are needed to determine the long-term outcomes, including the arthrodesis rate.

Ultrasound-guided bilateral erector spinae plane nerve blocks: a novel application for the management of acute postoperative pain in awake spine surgery. Illustrative case.

BACKGROUND: Postoperative pain management is a limiting factor for early ambulation and discharge following spine fusion surgery. Awake spinal surgery, when combined with minimally invasive transforaminal lumbar interbody fusion, is associated with enhanced recovery in well-selected patients. Some neurosurgeons have recently aimed to further improve outcomes by utilizing erector spinae plane block catheters, allowing for a continuous infusion of local anesthetic to improve the management of acute postoperative pain following minimally invasive transforaminal lumbar interbody fusion. OBSERVATIONS: A patient who underwent a minimally invasive transforaminal lumbar interbody fusion with perioperatively placed erector spinae plane catheters at the T12 level ambulated 30 minutes after surgery and was discharged the same day (length of stay, 4.6 hours). The total amount of narcotics administered during the hospital stay was 127.5 morphine milligram equivalents. LESSONS: The placement of bilateral erector spine plane nerve block catheters at the T12 level with an ambulatory infusion pump may help to improve acute postoperative pain management for patients undergoing lumbar spinal fusion.