The effect of intraoperative intrathecal opioid administration on the length of stay and postoperative pain control for patients undergoing lumbar interbody fusion.

PURPOSE: In an effort to control postoperative pain more effectively in spinal fusion patients, intraoperative intrathecal morphine (ITM) administration is gaining popularity and acceptance with clinicians. This study seeks to determine the impact of intraoperative intrathecal opioid (ITO) administration following lumbar fusion surgery on postoperative pain and length of hospitalization as primary outcomes. Secondary outcomes will investigate postoperative opioid intake and side effects. METHODS: The retrospective analysis of collected data was performed. The study compared patients undergoing one- or two-level transforaminal interbody fusions between 2019 and 2021 who intraoperatively received two different ITO doses (n = 89) vs. the reference group (n = 48) that did not receive ITO. The patients in the ITO group received either 0.2 mg (n = 44) of duramorph or 0.2 mg duramorph + 50 mcg fentanyl (n = 45). The effect of ITO was evaluated for the first four postoperative days (POD) on pain scores (visual analog scale), length of stay (LOS, hours) and opioid requirement (MED, morphine equivalent dose). RESULTS: In the ITO group, a significant reduction of postoperative pain scores (t(99) = 4.3, p < 0.001) and opioid intake (t(70) = 2.49, p = 0.015) was noted on POD1. Cohen's d effect sizes were 0.76 and 0.50, meaning that postoperative pain and MED intake were reduced by about ¾ to ½ standard deviations (SD) in the ITO group. Further, multivariate regression models revealed that ITO administration predicted lower postoperative pain scores for the two PODs (ß = - 0.83, p < 0.001; ß = - 0.63, p = 0.022) and MED intake for the first two PODs (ß = - 20.8, p = 0.047; ß = - 16.4, p = 0.030). Mean LOS was 15.4 h less in the ITO group (mean ± SD, 63.4 ± 37.1 vs. 78.8 ± 39.6, p = 0.10). CONCLUSIONS: In conclusion, our study provides results in a large sample of patients undergoing transforaminal lumbar fusions. The results demonstrated that ITO administration is effective in reducing POD1 pain scores and POD1-2 opioid requirement while not increasing the risk of any opioid-related side effects.

Medical complications and mortality in octogenarians undergoing elective spinal fusion surgeries.

BACKGROUND: The consequences of suffering postoperative complications in elderly undergoing spinal surgeries may be different compared to younger patients. The primary objective of this study was to identify the types and frequency of medical complications and mortality rates in patients 80 years of age or older undergoing elective spinal fusion surgeries for degenerative spinal disease. METHODS: A prospective observational study with a retrospective chart review was performed, which included all consecutive patients ≥80 years old undergoing elective spinal fusion surgeries from May 2012 to August 2015. We identified a total of 95 patients, of which 39 cervical and 56 lumbar surgeries were performed. There were 41 female and 54 male patients with the mean age of 82.8 years (range, 80-91). The perioperative complications were allocated into the following categories: infection, pulmonary, cardiac, gastrointestinal, hematologic, urologic, neurovascular, thromboembolic, and other. Baseline and postoperative clinical outcome scores were compared to evaluate efficacy. RESULTS: The mean follow-up time was 14.8 months (range, 5 days to 37 months) with an overall mortality rate of 8.4%. The 30-day, 90-day, and 1-year mortality rates were 2.1, 2.1, and 4.2%, respectively. There were 53.9 and 71.4% patients with complications in the cervical and lumbar patient groups, respectively. The presence of general comorbidities and the number of intervertebral levels predicted the occurrence of perioperative complications. Also, longer OR times were associated with a higher number of complications per patient and the occurrence of a UTI. Dysphagia was a significant predictor in developing pneumonia and atelectasis. CONCLUSIONS: The incidence of perioperative medical complications and mortality rates in octogenarians undergoing elective spinal surgeries are quite high. The benefits of having surgery must be weighed against the risks of not only surgical but also adverse medical events. An informed decision-making process should include discussion of potential postoperative morbidity specific to this patient population in order to guide patient's acceptance of higher risks and expectations postoperatively. It is also important to identify potential complications and adapt preventive measures in order to help minimize them in this patient population.

Preliminary results on feasibility of outpatient instrumented transforaminal lumbar interbody fusion.

STUDY DESIGN: A retrospective chart review study was performed. OBJECTIVE: The primary objective of this study was to analyze our preliminary results to examine whether it is safe and effective to perform instrumented lumbar interbody fusions on an outpatient basis by comparing 2 groups of patients who were discharged the same day versus those who stayed overnight. The secondary objective was to identify the need for prolonged observation for complications that may occur in the immediate postoperative period. SUMMARY OF BACKGROUND DATA: There is currently no information in the literature on the safety and complication rates of instrumented transforaminal lumbar interbody fusions performed in an ambulatory surgery setting. METHODS: Surgeries were performed at an ambulatory surgery center (n=27) or hospital outpatient departments (n=25). The mean age of patients was 49.8 years (range, 19-72 y). The safety of outpatient lumbar fusions was assessed by analyzing complications that occurred from the moment of discharge up to the seventh postoperative day (0-7 POD), as well as all complications that occurred up to 6 months postoperatively (>7 POD). The efficacy of surgical intervention was also evaluated by assessing change in pain, patient satisfaction scores, and fusion rates. RESULTS: There were no cases of pneumonia, urinary tract infection, or thromboembolic complications. Four patients (14%) who had surgeries performed at an ambulatory surgery center had complications within 7 days postoperatively compared with 1 (4%) patient who had surgery performed at a hospital outpatient department. This difference was not statistically significant (P=0.36, Fisher exact test). Lower back and leg pain was significantly (P<0.0001) decreased postoperatively. The average postoperative back pain was 18.8 (range, 0-90) compared with 74.5 (range, 0-100) preoperatively as measured on a 0-100 visual analog scale. The average postoperative leg pain was 9.1 (range, 0-60) compared with 54.2 (range, 0-100) preoperatively. CONCLUSIONS: Although further confirmation is needed, this study discusses the possibility of performing instrumented lumbar interbody fusions with the transforaminal lumbar interbody fusion technique as an outpatient procedure. These results support a future prospective randomized study with a well-defined patient selection criteria.

Comparing vertebral body reconstruction implants for the treatment of thoracic and lumbar metastatic spinal tumors: a consecutive case series of 37 patients.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To compare different interbody reconstruction implants after corpectomy in metastatic spine tumors. SUMMARY OF BACKGROUND DATA: Vertebral body reconstruction after corpectomy is common for patients with metastatic spine tumors. Although various implants are reported individually in the literature, no study to-date has compared them with one another directly. METHODS: Thirty-seven consecutive patients with metastatic tumors of the thoracic or lumbar spine underwent single or multilevel corpectomy with subsequent interbody reconstruction. Longevity of interbody graft was primarily evaluated in this study as defined by the need for any revision surgeries or complications after surgery. Data was collected retrospectively. RESULTS: Twenty-seven, 5, and 5 patients underwent reconstruction with metal implants, bone implants, and polymethylmethacrylate (PMMA), respectively. Twenty-three patients had metastatic tumor involvement of the thoracic spine and 14 patients had tumor involvement of the lumbar spine. Three patients (8.1%) required additional surgery: 1 wound infection, 1 hardware revision, and 1 for resection of an intradural, intramedullary tumor not identified at the first operation. Overall complication rate was 43.2% (16 patients) and 2 patients died within 30 days of their index spine surgery. Postoperative complication rates were more than double in the metal implant group (52%) compared with an equal number of complications in bone (20%) and PMMA (20%) implant group. The rate of revision surgery was highest in the bone group (40%) compared with none in the PMMA and only 3.7% in the metal interbody groups. CONCLUSIONS: Vertebral body reconstruction after corpectomy for patients with metastatic tumors to the thoracic and lumbar spine can be performed effectively with metal, bone, or cement implants. Although metal implants are used in the majority of reconstruction cases, they seem to have a higher rate of overall complications, with bone interbody constructs showing a higher rate of revision surgery.

A Rare Case of Brain Metastases in an Elderly Patient With Primary Pancreatic Cancer.

Pancreatic adenocarcinoma is an extremely aggressive cancer with a low survival rate. Common sites for metastases include the liver and lungs, while brain metastases are considered extremely rare, especially in elderly patients. We present an elderly female patient who developed brain metastases 51 months after the initial diagnosis of pancreatic cancer and was treated with gross tumor resection, chemotherapy, and stereotactic radiosurgery. The treatment completely resolved her neurological symptoms but did not result in improved survival for this patient. The patient developed generalized tonic-clonic seizures, was diagnosed with leptomeningeal carcinomatosis, and died 5.5 months after tumor resection. The literature on pancreatic cancer with brain metastases is scarce, with limited guidelines for treatment strategies in this patient population. Adding this case report to the existing literature may provide additional guidance to clinicians managing patients with similar presentations.

Prospective, Randomized, Blinded Clinical Trial Comparing PEEK and Allograft Spacers in Patients Undergoing Anterior Cervical Discectomy and Fusion Surgeries.

STUDY DESIGN: Prospective, randomized, blinded clinical trial. OBJECTIVE: To examine clinical and radiological outcomes in patients undergoing anterior cervical discectomy and fusion (ACDF) surgeries randomized to receive either polyether-ether-ketone (PEEK) or structural bone allografts. SUMMARY OF BACKGROUND DATA: The biomechanical qualities as well as osteoconductive, osteogenic, and osteoinductive properties of various graft materials have been previously evaluated. There remain questions, however, as to whether there are any clinical and/or radiographic outcome differences in the selection of interbody graft types for ACDF. METHODS: Patients undergoing one- to three-level ACDF with single anterior plate fixation were randomized (1:1 ratio) to receive either cortical allograft or PEEK interbody spacers. Radiographic and clinical outcomes were assessed at 3, 6, 12, and 24 months with an additional postoperative radiographic assessment. RESULTS: A total of 120 patients were enrolled and randomized. Comparing clinical outcomes, no differences in arm or neck pain scores were noted; however, there was a statistically significant (≤0.041) improvement in SF-36 PCS scores for the allograft group at all follow-up time points and a tendency toward lower disability scores. Overall, evidence of radiographic fusion was achieved in 87 (91.6%) patients: five (10.2%) and three (6.5%) patients had pseudoarthrosis (P = 0.72) in the PEEK and allograft groups, respectively. At 24 months' follow-up time, any cervical or segmental alignment restoration achieved with surgery was lost and no statistically significant changes were detected when all levels of surgery were included. Likewise, there were no statistically significant differences between the groups for anterior or posterior body height measurements at the 24 months' follow-up. Approximately 20% of patients had anterior and posterior subsidence, all grade 0 regardless of the group assignment. CONCLUSION: Comparable radiographic outcomes were observed for patients undergoing one- to three-level PEEK versus allograft-assisted ACDF surgeries. Although MCID comparisons suggest that allograft and PEEK-treated patients have similar clinical outcomes, testing that incorporates the magnitude of the change suggests that there may be a statistically significant greater magnitude of improvement for the allograft group patients, but further studies with a larger sample size would be helpful to determine if a true effect exists.

Prospective, randomized, double-blinded clinical trial comparing PEEK and allograft spacers in patients undergoing transforaminal lumbar interbody fusion surgeries.

BACKGROUND CONTEXT: Allograft and polyether-ether-ketone (PEEK) radiographic, biomechanical, histological properties have been extensively studied and both spacers have their advantages and shortcomings. There are no comparative randomized or double-blinded spinal fusion clinical trials reported to date. PURPOSE: The study's primary objective was to prospectively investigate clinical and radiological outcomes in patients undergoing lumbar interbody fusions and randomized to receive either PEEK or structural bone allografts. STUDY DESIGN/ SETTING: A prospective, randomized, double-blinded clinical trial was initiated at a single center. PATIENT SAMPLE: A total of 138 patients were enrolled, randomized and 121 patients completed the study. OUTCOME MEASURES: The primary clinical outcome parameters were scored from standardized patient-reported questionnaires. The severity of lower back and leg pain was evaluated using the 11-point Visual Analog Scale (VAS). The Oswestry Disability Questionnaire was used to evaluate chronic disability and activities of daily living. Health-related quality of life and functional outcomes were assessed using Health-related Quality of Life Questionnaire (SF-36 v2). Two scores within the scoring algorithm were analyzed: Physical Component (PCS) and Mental Component Summary (MCS). The primary radiological outcomes included restoration and maintenance of vertebral body height, lumbar sagittal and segmental alignment, and fusion status. METHODS: All patients were followed for 2 years ± 2 months; radiographic and clinical outcomes were assessed at 3, 6, 12 and 24 months with an additional follow-up at 3 weeks for radiographic assessment. RESULTS: A total of 138 patients undergoing transforaminal lumbar interbody fusions (TLIF) were randomized (1:1) to receive either cortical allograft or PEEK interbody lordotic spacers. Although no differences were detected between the allograft and PEEK patient groups at any of the follow-up time points, there was a highly significant (p<.0001) improvement in all clinical outcome measures. Overall, evidence of radiographic fusion was achieved in 118 (97.5%) patients at the 24 months follow-up. Three patients, all in the allograft group, had pseudoarthrosis and underwent revision surgeries. Postoperative improvement of sagittal alignment, anterior (ABH) or posterior body height (PBH) was initially achieved, but it was mainly lost or reduced at the final follow-up and there were no statistically significant differences between the groups. At the end of the study, improvement and maintenance of lumbar lordosis were achieved in 43.3% and 49.2% patients and segmental alignment in 38.3% and 36.1% for the allograft and PEEK patient groups, respectively. Similarly, ABH was improved and maintained in 28.3% and 36.1% patients and PBH in 28.3% and 44.3% for the allograft and PEEK groups, respectively. CONCLUSIONS: Although allograft-assisted surgeries may have reduced fusion rates, the study findings demonstrated that TLIF surgery with two different types of cages and in conjunction with rhBMP-2 resulted in similar radiological or clinical outcomes and a highly statistically significant improvement in all clinical outcome measures at the end of the study regardless of the randomization group.

Local Retropharyngeal Space Anesthetic for Dysphagia Reduction after Anterior Cervical Discectomy and Fusion Surgery: A Single-Center, Prospective, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial.

OBJECTIVE: The main objective of this study was to analyze the ability of local anesthetic instillation into the retropharyngeal space to reduce dysphagia symptoms and occurrence rates in patients undergoing anterior cervical discectomy and fusion (ACDF) procedures. METHODS: A single-center, prospective, randomized, double-blinded, and placebo-controlled clinical study was performed. We enrolled patients undergoing one- or two-level ACDF procedures for cervical degenerative disc disease with disc herniation, radiculopathy and/or myelopathy symptoms. The patients were randomly assigned (1:1 ratio) to receive either 0.5% bupivacaine hydrochloride or 0.9% NaCl solution. RESULTS: Forty-three (74%) and 41 (77%) of patients reported dysphagia symptoms at the time of discharge in the investigational and control groups, respectively. There were no statistically significant differences in duration of dysphagia symptoms, Swallowing-Quality of Life (SWAL-QOL) survey or pain scores between the investigational and control patient groups at any of the follow-up time points. Controlling for independent variables, only younger age significantly predicted dysphagia symptoms at discharge, 2-week, and 3-month follow-ups (P ≤ 0.03; R ≥ -0.038; OR 0.96, 95% CI 0.93-0.99. Female sex was associated with lower SWAL-QOL scores at discharge (P = 0.046; R = 0.87; OR 2.38, 95% CI 1.02-5.56). A total of 8 (13.8%) and 6 (11.3%) patients in the investigational and control groups, respectively, were referred to a specialist or underwent speech therapy for their dysphagia symptoms. There were no adverse reactions to the study drug observed. CONCLUSIONS: Local retropharyngeal space anesthetic instillation did not reduce dysphagia symptoms or occurrence rates in patients undergoing anterior discectomy and fusion surgeries.

Comparison of perioperative oral multimodal analgesia versus IV PCA for spine surgery.

STUDY DESIGN: A preintervention and postintervention design was used to examine a total of 200 patients. OBJECTIVE: After successful implementation at our institution of a perioperative oral multimodal analgesia protocol in major joint arthroplasty, a modified regimen was provided to patients undergoing spine procedures. SUMMARY OF BACKGROUND DATA: A proactive, multimodal approach is currently recommended for the management of acute postoperative pain. Inadequate postoperative analgesia can negatively influence surgical outcome and duration of rehabilitation. Routine use of intravenous patient controlled analgesia (IV PCA) after surgery can result in substantial functional interference, side effects, and lead to untoward events as a result of programming errors. METHODS: A preintervention and postintervention design was used to compare a historical control group of spine surgery patients who received conventional IV PCA (N=100) with a prospective group who received some form of perioperative oral multimodal analgesia (N=100). The new regimen included preoperative and postoperative scheduled extended-release oxycodone, gabapentin, and acetaminophen, intraoperative dolasetron and as-needed postoperative short-acting oral oxycodone. Patient surveys and chart audits were used to measure pain intensity, functional interference from pain, opioid consumption, analgesic-related side effects, and patient satisfaction over the first 24 hours postoperatively. RESULTS: Patients who received the new perioperative multimodal oral regimen had significantly less opioid consumption (P<0.001), lower ratings of Least Pain (P<0.01), and experienced less nausea (P<.001), drowsiness (P<0.05), interference with walking (P=0.05), and coughing and deep breathing (P<0.05) compared with the IV PCA group. CONCLUSIONS: This quality improvement study shows some safety and significant advantages of a multimodal perioperative oral analgesic regimen compared with standard IV PCA after spine surgery.

Analyzing the Correlation Between Surgeon Experience and Patient Length of Hospital Stay.

Introduction  Many clinical, social, and even economic factors have been extensively analyzed in the literature and shown to influence the length of stay (LOS) after spinal procedures. However, surgeon's experience was mostly examined relative to a learning curve and not regarding the time in practice. The primary objective of this study was to determine the effect of one surgeon's experience on the LOS in patients undergoing one- to two-level transforaminal lumbar interbody fusions (TLIFs). Materials and Methods  The study design was a retrospective cohort study of hospital discharge data. The cohort was comprised of 240 consecutive patients who had undergone open one- or two-level elective TLIF procedures for lumbar degenerative disc disease. The primary predictor was the surgeon's experience based upon the years of practice. The primary outcome was LOS, which was controlled by the discharge criteria that remained consistent throughout the study. Results  Based on the Poisson regression model, it can be inferred that the LOS is not significantly associated with a surgeon's experience (Pr(>|t|) = 0.8985, CI: -0.5825 to 0.5114) while controlling for all other variables. Other independent factors did seem to significantly influence patients' LOS, including the admission type (Pr(>|t|) = 9.637-08, CI: -0.8186 to -0.3786), the number of TLIF levels (Pr(>|t|) = 1.721-06, CI: 0.0606 to 0.1446), the Clavien-Dindo ( Pr(>|t|) = 0, CI: 0.1489 to 0.1494), the American Society of Anesthesiologists (ASA) physical status classification scores (Pr(>|t|) = 4.878-3, CI: 0.0336 to 0.1880), and being discharged to skilled nursing facility (Pr(>|t|) = 3.44-2, CI: 0.0127 to 0.3339). Conclusions Based upon the years in practice, surgeon experience was not associated with length of hospitalization and estimated blood loss during surgery in patients undergoing one- and two-level TLIF surgeries. However, while controlling for all other variables, the surgeon's experience and surgical time had a highly significant correlation. The study results clearly demonstrated efficiency, but we did not identify a clear correlation between LOS and surgeon experience overtime suggesting that other factors are likely contributing to such outcome. The average LOS is a complex measure of healthcare resource use and hospital discharge policy or other variables are likely having more effect on LOS than individual surgeons' preferences.

Unplanned 30-Day readmission rates after spine surgery in a community-based Hospital setting.

OBJECTIVE: Unplanned readmissions after spinal surgery adversely affect not only healthcare costs but also the quality of delivered care. The primary objective of this study was to identify the rates and predicting factors of unplanned 30-day readmissions at a community-based hospital. PATIENTS AND METHODS: This study is a retrospective review of a single-center community-based hospital administrative and clinical records identifying unplanned readmissions. Risk factors for readmissions due to surgical site infections, pain, medical vs. procedure-related complications, and the number of readmissions were studied using multiple logistic regression analysis. RESULTS: A total overall readmission rate was 7.3 % (79 readmissions for 1077 patients). The readmission rates for thoracolumbar and cervical surgeries were 5.5 % and 1.8 %, respectively. The mean duration to primary readmission was 11.4 + 8.5 days. The most common procedure-related complication diagnosed at readmittance was wound-related complications (26 readmissions, 32.9 %). The most common non-surgical complication was a drug reaction or overdose (10.1 %). Multivariate logistic regression analyses revealed that longer hospitalization was a highly significant predictor of wound-related complications, followed by discharge to home or home care, and lower ASA scores (all <0.048). A younger age predicted readmissions due to pain (p = 0.014) and longer OR time did not reach statistical significance (p = 0.079). Higher ASA scores predicted readmissions due to medical vs. surgical complications (p = 0.028). There were no statistically significant predictors identified for more than one readmission during the 30-day post-discharge period. CONCLUSIONS: The overall rate of 30-day unplanned readmissions at a community-based hospital was 7.3 % for patients undergoing spinal surgeries and was similar to the rates reported by larger academic tertiary care institutions and registry-based studies. The study suggests that surgical site infections was the most common reason for readmissions, which was predictive by longer hospitalization, discharge disposition, and lower ASA scores.

Spinal Epidural Capillary Hemangioma With Intrathoracic Extension: Case Report and Review of the Literature.

Capillary hemangiomas are hamartomatous congenital vascular malformations that are particularly uncommon in the spinal epidural space, and those with intrathoracic extensions are extremely rare. Although considered benign, capillary hemangiomas can cause rare hemorrhagic complications and risk of spinal cord compression or extension into the neural foramen. Therefore, surgery should be considered even in the absence of neurological symptoms. The literature reports three patients either underwent a partial resection or a complete tumor removal was achieved by accessing the lesion through a posterolateral approach and removing the costotransverse joint. The patient underwent a same-day, two-staged gross total resection of the tumor via combined posterior right-sided T7-T8 complete facetectomy and extradural mass resection with T7 nerve transection, followed by a posterolateral fusion of the T7-T8 vertebra. Stage 2 consisted of a video-assisted intrathoracic approach for the removal of the remaining tumor. The two-stage surgical procedure described in our case report allows for complete removal of intrathoracic and intraspinal portions of the mass with less morbidity.

The Impact of Preventative Multimodal Analgesia on Postoperative Opioid Requirement and Pain Control in Patients Undergoing Lumbar Fusions.

STUDY DESIGN: A prospective observational study with a historical reference group. OBJECTIVES: The main objectives of this study were to determine the impact of preventative multimodal analgesia (PMA) on postoperative opioid requirements and analgesic effectiveness in patients undergoing lumbar fusion surgery. SUMMARY OF BACKGROUND DATA: PMA addresses the multiple pathways of acute and chronic pain by interfering with peripheral and central sensitization and should provide a way to achieve safer and more effective pain management with reduced opioid medication use. MATERIALS AND METHODS: This study compared postoperative opioid requirement and analgesic effect in a total of 101 patients undergoing elective, 1-level or 2-level transforaminal lumbar interbody fusion surgeries for symptomatic lumbar degenerative disk disease. The PMA patient group included 51 consecutive patients who received 1000 mg of acetaminophen, 300-900 mg of gabapentin, and 200-400 mg of celecoxib 1 hour before their index procedure. The reference group included 50 patients who received 15 mg of morphine-equivalent dose (MED) preoperatively.Multiple linear regression was used to evaluate the effect of PMA on postoperative pain and MED over 4 postoperative days, while controlling for all variables likely to influence these outcomes, including age, sex, baseline opioid use, duration of surgery, postoperative intrathecal morphine use and the administration of muscle relaxants and anticonvulsants. RESULTS: The differences in opioid requirement and postoperative pain scores were statistically significant on all 4 postoperative days. The effect size varied from -0.54 to -0.99 (34.8%-54.2% MED reduction) for the postoperative opioid requirement and from -0.59 to -1.16 (28.9%-37.3% visual analog scale reduction) for postoperative pain indicating that these measures were reduced by about ½ to 1 SD in the PMA patient group. CONCLUSIONS: PMA is a highly effective and safe method for postoperative pain management in patients undergoing elective lumbar fusion surgeries by improving pain control and reducing opioid requirement. LEVEL OF EVIDENCE: Level III.

Minimally Invasive Sacroiliac Joint Fusion with Cylindrical Threaded Implants Using Intraoperative Stereotactic Navigation.

BACKGROUND: Significant progress in hardware and surgical techniques for sacroiliac joint (SIJ) fusion surgeries has facilitated safer and more efficacious procedures for patients. Triangular-shaped implants for SIJ fusions are the most-studied devices and have demonstrated good short-term and long-term clinical outcomes. Reports on cylindrical threaded implants are very limited. Owing to biomechanical differences in the implants and the surgical techniques required for their placement, previously reported results may not be applicable to cylindrical threaded implants. The aim of this study was to report preliminary clinical experience with minimally invasive SIJ fusion using intraoperative stereotactic navigation and the Rialto SI Fusion System. METHODS: We retrospectively reviewed 24 patients who underwent SIJ fusions between May 2015 and October 2017 performed by a single surgeon. RESULTS: Mean total satisfaction score was 89.0% ± 27.6%. A statistically significant reduction (P = 0.0028) in low back pain scores was noted from an average baseline score of 6.6 ± 2.4 to 3.7 ± 3.3 postoperatively. Leg pain scores decreased from 4.8 ± 3.8 to 1.5 ± 2.9 (P = 0.0034). Mean surgical time was 53.0 ± 13.9 minutes. It took significantly longer (P = 0.0089) to perform the initial 13 cases (59.9 ± 15.2 minutes) compared with subsequent cases (45.4 ± 7.3 minutes). Estimated blood loss was minimal (10.4 ± 5.2 mL). CONCLUSIONS: Minimally invasive SI joint fusion using cylindrical threaded implants can be safely performed with minimal morbidity and good clinical outcomes.

The impact of BMI on operating room time, blood loss, and hospital stay in patients undergoing spinal fusion.

OBJECTIVE: Obesity affects not only the health of an individual but society as a whole and especially the healthcare system. Healthcare providers are faced with challenges to deliver adequate care in this resource-limited environment, assure safety, and accommodate the increasing population of overweight patients. The effects of increased body mass index (BMI) on clinical outcomes, complications, health care resource utilization, effectiveness of minimally invasive approaches, and perioperative parameters in spine surgeries have all been previously studied, but the majority of these findings are conflicting rather than conclusive. The main objective of this study was to analyze the impact of BMI on perioperative outcomes in patients undergoing one- to two-level elective TLIF procedures for degenerative spine conditions and to identify the need to modify internal hospital operational planning, team organization, and patient flow processes to accommodate patients who are overweight. PATIENTS AND METHODS: A single-center retrospective case-review study was completed. The study included 172 consecutive patients who underwent elective one- or two-level transforaminal lumbar interbody fusions (TLIF). The patients were categorized as obese if they had BMI value that was equal to or greater than 30 kg/m2. Outcome measures included surgical and non-operative operating room (OR) time, length of stay (LOS), and estimated blood loss (EBL). Multiple regression analyses were performed to determine if BMI had an effect on perioperative parameters while controlling for independent variables. RESULTS: BMI did not have a statistically significant effect on surgical (p = 0.13) and non-operative OR time (p = 0.82). Obese patients remained hospitalized on average 0.45 ± 0.25 days longer (p = 0.037) and lost 71.8 ± 26.3 mL more blood (p = 0.007). CONCLUSIONS: Obesity is associated with longer hospitalization and more intraoperative blood loss, but may have no impact on surgical and non-operative OR times in patients undergoing one- and two-level TLIFs.

The role of cation-dependent chloride transporters in neuropathic pain following spinal cord injury.

BACKGROUND: Altered Cl- homeostasis and GABAergic function are associated with nociceptive input hypersensitivity. This study investigated the role of two major intracellular Cl- regulatory proteins, Na+-K+-Cl- cotransporter 1 (NKCC1) and K+-Cl- cotransporter 2 (KCC2), in neuropathic pain following spinal cord injury (SCI). RESULTS: Sprague-Dawley rats underwent a contusive SCI at T9 using the MASCIS impactor. The rats developed hyperalgesia between days 21 and 42 post-SCI. Thermal hyperalgesia (TH) was determined by a decrease in hindpaw thermal withdrawal latency time (WLT) between days 21 and 42 post-SCI. Rats with TH were then treated with either vehicle (saline containing 0.25% NaOH) or NKCC1 inhibitor bumetanide (BU, 30 mg/kg, i.p.) in vehicle. TH was then re-measured at 1 h post-injection. Administration of BU significantly increased the mean WLT in rats (p < 0.05). The group administered with the vehicle alone showed no anti-hyperalgesic effects. Moreover, an increase in NKCC1 protein expression occurred in the lesion epicenter of the spinal cord during day 2-14 post-SCI and peaked on day 14 post-SCI (p < 0.05). Concurrently, a down-regulation of KCC2 protein was detected during day 2-14 post-SCI. The rats with TH exhibited a sustained loss of KCC2 protein during post-SCI days 21-42. No significant changes of these proteins were detected in the rostral region of the spinal cord. CONCLUSION: Taken together, expression of NKCC1 and KCC2 proteins was differentially altered following SCI. The anti-hyperalgesic effect of NKCC1 inhibition suggests that normal or elevated NKCC1 function and loss of KCC2 function play a role in the development and maintenance of SCI-induced neuropathic pain.

Chiari Malformation and Hydrocephalus Masking Neurocysticercosis.

BACKGROUND: Various diagnostic characteristics associated with neurocysticercosis have been well studied; however, their potential to be implicated in other differential diagnoses has not been well demonstrated. CASE DESCRIPTION: We report the case of a 55-year-old Hispanic man who underwent a Chiari decompression surgery, which was complicated with hydrocephalus. Despite a ventriculoperitoneal shunt placement, he continued to have headaches and was soon found to have several skull base subarachnoid lesions, which were later diagnosed as the sequelae of an active neurocysticercosis infection. CONCLUSION: This case report highlights the importance of overlapping symptoms between diseases in a short temporal context.

Upper cervical myelopathy due to arachnoiditis and spinal cord tethering from adjacent C-2 osteomyelitis. Case report and review of the literature.

Myelopathy caused by a spinal cord infection is typically related to an adjacent compressive lesion such as an epidural abscess. The authors report a case of progressive high cervical myelopathy from spinal cord tethering caused by arachnoiditis related to an adjacent C-2 osteomyelitis. This 70-year-old woman initially presented with a methicillin-sensitive Staphylococcus aureus osteomyelitis involving the C-2 odontoid process. She was treated with appropriate antibiotic therapy but, over the course of 4 weeks, she developed progressive quadriparesis. A magnetic resonance image revealed near-complete resolution of the C-2 osteomyelitis, but new ventral tethering of the cord was observed at the level of the odontoid tip. She subsequently underwent open surgical decompression and cord detethering. Postoperatively she experienced improvement in her symptoms and deficits, which continued to improve 1 year after her surgery. To the authors' knowledge, this is the first reported case of progressive upper cervical myelopathy due to arachnoiditis and cord tethering from an adjacent methicillin-sensitive S. aureus C-2 osteomyelitis.

Tethering tracts in spina bifida occulta: revisiting an established nomenclature.

OBJECT: The goal of the present study goal was to systematically confirm the previously recognized nomenclature for tethering tracts that are part of the spectrum of occult spinal dysraphic lesions. METHODS: The tethering tract in 20 patients with spina bifida occulta underwent histological examination with H & E staining and epithelial membrane antigen (EMA) immunolabeling, and additional selected specimens were stained with Masson trichrome. RESULTS: All tethering tracts contained fibrous connective tissue. Four tracts were lined with epithelial cells and either originated within a dermoid cyst, terminated at a skin dimple/sinus opening, or had both of these characteristics. No tethering tracts exhibited EMA positivity or meningeal elements. Although all tethering tracts originated in juxtaposition to the spinal cord, their termination sites were variable. CONCLUSIONS: Based on histological findings and presumed embryological origin, the authors broadly classified tethering tracts terminating within the dura mater, epidural space, or lamina as "short tethering tracts" (STTs). The STTs occurred mostly in conjunction with split cord malformations and had a purely fibrous composition. Tethering tracts terminating superficial to the overlying lamina were classified as "long tethering tracts" (LTTs), and the authors propose that these are embryologically distinct from STTs. The LTTs were of two varieties: epithelial and nonepithelial, the former being typically associated with a skin dimple or spinal cord (epi)dermoid cyst. In fact, analysis of the data suggested that not every tethering tract terminating in or on the skin should be classified as a dermal sinus tract without histological confirmation, and because no evidence of meningeal tissue-lined tracts was detected, the use of the term "meningocele manqué" may not be appropriate.

Tethered cord due to spina bifida occulta presenting in adulthood: a tricenter review of 61 patients.

OBJECT: Children with spina bifida occulta require early surgery to prevent neurological deficits. The treatment of patients with a congenitally tethered cord who present in adulthood remains controversial. METHODS: The authors studied the medical records of 61 adult patients who underwent surgical untethering for spina bifida occulta at three institutions between 1994 and 2003. Patients who had undergone prior myelomeningocele repair or tethered cord release surgery were excluded. The most common intraoperative findings were lipomyelomeningocele (41%) and a tight terminal filum (36%). The follow-up duration ranged from 10.8 to 149.5 months. Of the 34 patients with back pain, status improved in 65%, worsened in 3%, remained unchanged in 18%, and improved and later recurred in 15%. Lower-extremity pain improved in 16 patients (53%), remained unchanged in 23%, improved and then recurred in 17%, and worsened in 7%. Lower-extremity weakness improved in 47%, remained unchanged in 47%, and improved and then recurred in 5%. Finally, of the 17 patients with lower-extremity sensory changes, status improved in 35%, remained unchanged in 35%, and the information on five patients was unavailable. Surgical complications included three wound infections, one cerebrospinal fluid leak, and two pseudomeningoceles requiring surgical revision. One patient developed acute respiratory distress syndrome and sepsis postoperatively and died several days later. CONCLUSIONS: Adult-age presentation of a congenital tethered cord is unusual. Despite a slight increase in postoperative neurological injury in adults, surgery has relatively low risk and offers good potential for neurological improvement or stabilization. As they do in children, the authors recommend early surgery in adults with this disorder. The decision to undertake surgery, however, should be modulated by other factors such as a patient's general medical condition and risk posed by anesthesia.