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.

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.

Survival following stereotactic radiosurgery for newly diagnosed and recurrent glioblastoma multiforme: a multicenter experience.

Despite decades of clinical trials investigating new treatment modalities for glioblastoma multiforme (GBM), there have been no significant treatment advances since the 1980s. Reported median survival times for patients with GBM treated with current modalities generally range from 9 to 19 months. The purpose of the current study is to retrospectively review the ability of CyberKnife (Accuray Incorporated, Sunnyvale, CA, USA) radiosurgery to provide local tumor control of newly diagnosed or recurrent GBM. Twenty patients (43.5%) underwent CyberKnife treatment at the time of the initial diagnosis and/or during the first 3 months of their initial clinical management. Twenty-six patients (56.5%) were treated at the time of tumor recurrence or progression. CyberKnife was performed in addition to the traditional therapy. The median survival from diagnosis for the patients treated with CyberKnife as an initial clinical therapy was 11.5 months (range, 2-33) compared to 21 months (range, 8-96) for the patients treated at the time of tumor recurrence/progression. This difference was statistically significant (Kaplan-Meier analysis, P = 0.0004). The median survival from the CyberKnife treatment was 9.5 months (range, 0.25-31 months) and 7 months (range, 1-34 months) for patients in the newly diagnosed and recurrent GBM groups (Kaplan-Meier analysis, P = 0.79), respectively. Cox proportional hazards survival regression analysis demonstrated that survival time did not correlate significantly with treatment parameters (Dmax, Dmin, number of fractions) or target volume. Survival time and recursive partitioning analysis class were not correlated (P = 0.07). Patients with more extensive surgical interventions survived longer (P = 0.008), especially those who underwent total tumor resection vs. biopsy (P = 0.004). There is no apparent survival advantage in using CyberKnife in initial management of glioblastoma patients, and it should be reserved for patients whose tumors recur or progress after conventional therapy.

The safety of instrumented outpatient anterior cervical discectomy and fusion.

BACKGROUND CONTEXT: Reported hospitalization times after an anterior cervical discectomy and fusion (ACDF) procedure range between 20 hours to 4 days. Reasons for this wide variation are manifold, but the safety of an instrumented ACDF in the setting of a hostile medical-legal climate is most likely the primary concern influencing such a discrepancy. PURPOSE: The purpose of this study was to evaluate the safety and feasibility of performing single, two- and three-level ACDF with instrumentation on an outpatient or 23-hour observation period basis in order to potentially diminish the additional cost of hardware without compromising the purported benefits of surgery. STUDY DESIGN/SETTING: A retrospective chart review of patients undergoing instrumented ACDF on an outpatient basis was performed. PATIENT SAMPLE: A total of 103 patients with neck pain and/or radiculopathy undergoing ACDF were enrolled into this study. OUTCOME MEASURES: Included the evaluation of intraoperative and perioperative complications, which were reported for a total of 6 months after surgery. Clinical examination and radiographical assessment, including plain radiographs and computed tomography and magnetic resonance imaging (when required), were performed to assess complications. METHODS: Complications were divided into two groups: major and minor. Major complications included vertebral fracture and dehydration resulting in readmission. Minor complications included allergic reactions to medications that did not require hospitalization, and transient (< or = 3 months) neurologic deficit. A comprehensive literature search and meta-analysis was performed to generate a large comparison group in order to compare the complication rates in our outpatient series to those reported in the literature. RESULTS: A total of 99 patients (96.1%) undergoing single and two-level ACDF were discharged less than 15 hours after their surgeries (median time: 8 hours; range: 2-15 hours), and 4 patients (3.9%) were discharged after a 23-hour observation period following three-level ACDF. The overall complication rate in our outpatient series was 3.8% (n=4), including 1.9% (n=2) major and 1.9% (n=2) minor complications. The overall complication rate in the 633 patient meta-analysis derived comparison group was 0.95% (n=6). The difference between overall complication rates was not found to be significantly different (p = .12). The hardware-related complication rate in the meta-analysis comparison group was 0.5% (n=3), and was not found to be significantly different from our rate of 0% (p < or = 1). CONCLUSION: Performing ACDF with instrumentation on an outpatient basis is feasible, and it is not associated with higher overall or hardware-related complication rates as compared with complication rates reported in the literature, suggesting that this procedure is safe to perform on an outpatient basis.

Neck pain in multisport athletes.

OBJECT: The sport of triathlon is very physically demanding and has experienced rapid growth in recent years. The number of triathletes seen for spine disorders at neurosurgery clinics is increasing. Neck pain and overuse injuries have not been adequately studied in multisport athletes. The authors undertook an epidemiological study to establish the lifetime incidence of neck pain and the prevalence of possible discogenic pain, and to identify risk factors among triathletes in the Boulder, Colorado area. METHODS: An online questionnaire was developed to collect information about physical characteristics, training habits, athletic status, number of races completed, and neck pain among triathletes. The incidence of possible cervical discogenic pain was defined according to the duration of symptoms for the most recent pain episode. RESULTS: One hundred and sixty-four athletes responded to the questionnaire. The lifetime incidence of neck pain was 47.6% (78 athletes), with 15.4% possibly being of discogenic origin based on the duration of symptoms. Approximately 64% of responding athletes reported that their neck pain was sports related. Although the number of previous triathlons was not predictive of neck pain, total years in the sport (p = 0.029) and number of previous sports-related injuries (p < 0.0001) were. CONCLUSIONS: Two major risk factors for long-term spinal problems in triathletes are sports-related injuries and overuse. This report is one of the first comprehensive studies of neck pain and overuse injury in multisport athletes.

Prediction based on preoperative opioid use of clinical outcomes after transforaminal lumbar interbody fusions.

OBJECTIVE Opioid analgesics have become some of the most prescribed drugs in the world, despite the lack of long-term studies evaluating the benefits of opioid medications versus their risks associated with chronic use. In addition, long-term opioid use may be associated with worse long-term clinical outcomes. The primary objective of this study was to evaluate whether preoperative opioid use predicted inferior clinical outcomes among patients undergoing transforaminal lumbar interbody fusion (TLIF) for symptomatic lumbar degenerative disc disease. METHODS The authors of this observational study prospectively enrolled 93 patients who underwent 1-level to 2-level TLIFs in 2011-2014; the patient cohort was divided into 2 groups according to preoperative opioid use or no such use. Visual analog scale (VAS) scores for low-back pain and leg pain, Oswestry Disability Index scores, and the scores of the mental component summary (MCS) and physical component summary (PCS) on the 36-Item Short Form Health Survey were used to assess pain, disability, and health-related quality of life outcomes, respectively. The clinical scores for the 2 groups were determined preoperatively and at a 12-month follow-up examination. RESULTS In total, 60 (64.5%) patients took prescribed opioid medications preoperatively. Compared with those not taking opioids preoperatively, these patients had significantly higher VAS scores for low-back pain (p = 0.016), greater disability (p = 0.013), and lower PCS scores (p = 0.03) at the 12-month follow-up. The postoperative MCS scores were also significantly lower (p = 0.035) in the opioid-use group, but these lower scores were due to significantly lower baseline MCS scores in this group. A linear regression analysis did not detect opioid dose-related effects on leg and back pain, disability, and MCS and PCS scores, suggesting that poorer outcomes are not significantly correlated with higher opioid doses taken by the patients. CONCLUSIONS The use of opioid medications to control pain before patients underwent lumbar fusion for degenerative lumbar conditions was associated with less favorable clinical outcomes postoperatively. This is the first study that has demonstrated this association in a homogeneous cohort of patients undergoing TLIF; this association should be studied further to evaluate the conclusions of the present study. Clinical trial registration no.: NCT01406405 ( clinicaltrials.gov ).

The Timing of Surgery and Symptom Resolution in Patients Undergoing Transforaminal Lumbar Interbody Fusion for Lumbar Degenerative Disk Disease and Radiculopathy.

OBJECTIVE: Success rates of surgical interventions for lumbar disorders vary significantly depending on multiple factors and, among them, the duration of symptoms. It is not clear whether there is a "cutoff" time when decompression and fusion surgery becomes less effective in the conditions with chronic nerve root compression symptomatology. The main objective of this study was to analyze whether duration of symptoms has any effect on clinical outcomes and primarily resolution of radicular pain symptoms due to degenerative disk disease and stenosis with spondylolisthesis in patients undergoing transforaminal lumbar interbody fusion (TLIF). METHODS: The prospective observational study was performed. Eighty-four patients with radicular symptoms due to degenerative disk disease and stenosis with spondylolisthesis with no previous fusion surgeries and undergoing 1- to 3-level TLIF surgery were enrolled. Fifteen patients (18%) were lost to follow-up and were excluded from this analysis leaving a total of 69 patients. Standardized questionnaires were used to analyze clinical outcomes and were administered preoperatively within 3 months of scheduled surgery, and postoperatively at 3, 6, 12, and 24 months. To emphasize the change in clinical outcome scores, the relevant scores were calculated as the ratio of minimal clinically important difference values and change scores. The change scores were calculated by subtracting the postoperative scores from the baseline scores. Multiple regression analyses were conducted to examine the relationship of the duration of symptoms and relevant minimal clinically important difference ratio values while controlling for independent variables. Further, a comparison between 2 groups of patients was performed to analyze the changes of clinical outcomes for the patients who underwent fusion within <24 months versus ≥24 months. RESULTS: It was determined that the duration of symptoms was a significant predictor of better leg pain resolution (P=0.018), but not back pain resolution (P=0.27), or improvement in ODI (P=0.10) and SF-36 PCS scores (P=0.19). The patients with shorter duration of symptoms had significantly better radicular symptom resolution (P=0.032) compared with patients who waited at least 24 months or longer to undergo fusion. CONCLUSIONS: A shorter duration of symptoms was found to be a statistically significant predictor for better resolution of radicular symptoms in patients undergoing TLIF for painful degenerative disk disease and stenosis with spondylolisthesis.

Back and neck pain in triathletes.

OBJECT: As the sport of triathlon has continued to grow, increasing numbers of triathletes have presented in the neurosurgery clinics with various spinal disorders. This epidemiological study was undertaken to establish the lifetime incidence of neck and back pain, to gauge the prevalence of discogenic pain, and to identify risk factors among triathletes in the Boulder, Colorado, area. METHODS: A live online questionnaire was developed that was used to collect information about physical characteristics, training habits, athletic status, number of races completed, and back pain among triathletes. The incidence of cervical and/or lumbar discogenic back pain was defined according to the duration of symptoms for the most recent pain episode. The lifetime incidence of low-back pain was 67.8%, with 23.7% of cases possibly being discogenic in origin. The number of triathlons in which the respondents had participated and the presence of previous sports-related injuries were predictive of low-back pain (p = 0.02 and p < 0.00001, respectively). The lifetime incidence of neck pain was 48.3%, with 21.4% of cases being consistent with intervertebral disc involvement. The number of previous sports-related injuries was predictive of neck pain (p < 0.00001), and a strong tendency toward neck pain was observed for athletes with more total years of participation in sports (p = 0.06). CONCLUSIONS: The two main risk factors for long-term spinal problems include sports-related injuries and overuse. The study results definitely support the influence of both mechanisms for low-back pain. Neck pain was associated with an injury event, and a strong (although not statistically significant) tendency toward neck pain was observed in respondents with overuse injuries.

RhBMP-2-induced radiculitis in patients undergoing transforaminal lumbar interbody fusion: relationship to dose.

BACKGROUND CONTEXT: Recombinant human bone morphogenetic protein-2 (rhBMP-2) remains the primary synthetic osteoinductive material used in spinal fusion surgery today. The early inflammation reaction to rhBMP-2 manifesting with radicular symptoms has been previously reported in patients undergoing transforaminal lumbar interbody fusion (TLIF). There is a disagreement with regard to the factors affecting its occurrence and whether such symptoms are dose dependent. PURPOSE: The purpose of this analysis was to determine the incidence of rhBMP-2-induced radiculitis and its relationship to dose. STUDY DESIGN/SETTING: A retrospective cohort analysis was performed of the prospectively collected data. PATIENT SAMPLE: All consecutive patients (n=204) who underwent one- or two-level TLIF and instrumented posterolateral fusion with an off-label rhBMP-2 use were included in this analysis. OUTCOME MEASURES: The patients who developed new radicular symptoms after initial improvement postoperatively and had sterile fluid collections indicative of inflammatory process, or in the absence of any structural abnormalities that would explain these symptoms on imaging studies, were deemed to have rhBMP-2-induced radiculitis. METHODS: Magnetic resonance imaging (MRI) scans were obtained for all patients who developed postoperative radicular symptoms. Correlations between the total rhBMP-2 dose, dose per spinal level, and incidence of radiculitis were evaluated while controlling for age, sex, number of TLIF levels, and surgeon. RESULTS: The incidence of postoperative radiculitis was 11.3% (23 out of 204). The average total rhBMP-2 dose was 4.9 mg (range=2.1-12) and the average dose per spinal level was 3.8 mg (range=1.05-12). Logistic regression analysis did not identify any significant correlations between the rhBMP-2 doses and the incidence of radiculitis (p=.6). CONCLUSION: The incidence of rhBMP-2-induced radiculitis in patients undergoing TLIF is quite high, but there were no dose-related correlations found. The study, however, cannot rule out a possibility that a larger variation in bone morphogenetic protein (BMP) doses could still be a factor in the development of rhBMP-2-associated radiculitis.

Case Series of Anterior Intervertebral Graft Extrusions in Transforaminal Lumbar Interbody Fusion Surgeries.

BACKGROUND: According to the published reports, revision surgery is sometimes recommended even in patients with asymptomatic anterior lumbar intervertebral graft migrations. The main purpose of this chart review study was to report on the clinical course and outcomes of patients who had anterior intervertebral graft extrusions after transforaminal lumbar interbody fusion (TLIF). METHODS: From July 2002 to July 2014, 1259 consecutive TLIF surgeries were performed. These were reviewed, and patients who had anterior intervertebral graft extrusions were identified. RESULTS: The incidence of graft extrusion was 0.6% (7 of 1259 patients). There were 6 female patients and 1 male patient with an average age of 65.7 years (range, 44-80 years). All patients underwent TLIF with bilateral pedicle screw fixation, and 6 received recombinant human bone morphogenetic protein-2. Graft migrations were diagnosed between 5 days and 8 months postoperatively except for 2 cases in which migration occurred intraoperatively. The patients were closely followed for an average of 27.4 months (range, 12-43 months). All patients remained asymptomatic during the follow-up period and had solid fusion despite extrusions with an average time to fusion of 13 months (range, 10-18 months). No other adverse events occurred during the follow-up period. CONCLUSIONS: The risks of additional and highly invasive revision surgery should be weighed against the potential short-term and long-term complications associated with graft extrusions or migrations. It was demonstrated that fusion may take longer but can be achieved, and close observation may be adequate for asymptomatic patients.

Post-Treatment Gliosarcoma Extension into the Pterygomaxillary Fossa: Literature Review and Case Report.

Only four primary gliosarcoma case reports are described in the literature with transcranial (intradural to extradural) penetration into the region of the infratemporal fossa. This is the first report of a primary glioblastoma (GBM) that evolved into secondary or post-treatment gliosarcoma without evidence of a second de novo tumor and with extension into the left pterygomaxillary fossa.

Guideline summary review: An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis.

BACKGROUND CONTEXT: The North American Spine Society's (NASS) Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Degenerative Lumbar Spondylolisthesis features evidence-based recommendations for diagnosing and treating degenerative lumbar spondylolisthesis. The guideline updates the 2008 guideline on this topic and is intended to reflect contemporary treatment concepts for symptomatic degenerative lumbar spondylolisthesis as reflected in the highest quality clinical literature available on this subject as of May 2013. The NASS guideline on this topic is the only guideline on degenerative lumbar spondylolisthesis included in the Agency for Healthcare Research and Quality's National Guideline Clearinghouse (NGC). PURPOSE: The purpose of this guideline is to provide an evidence-based educational tool to assist spine specialists when making clinical decisions for patients with degenerative lumbar spondylolisthesis. This article provides a brief summary of the evidence-based guideline recommendations for diagnosing and treating patients with this condition. STUDY DESIGN: A systematic review of clinical studies relevant to degenerative spondylolisthesis was carried out. METHODS: This NASS spondyolisthesis guideline is the product of the Degenerative Lumbar Spondylolisthesis Work Group of NASS' Evidence-Based Guideline Development Committee. The methods used to develop this guideline are detailed in the complete guideline and technical report available on the NASS website. In brief, a multidisciplinary work group of spine care specialists convened to identify clinical questions to address in the guideline. The literature search strategy was developed in consultation with medical librarians. Upon completion of the systematic literature search, evidence relevant to the clinical questions posed in the guideline was reviewed. Work group members used the NASS evidentiary table templates to summarize study conclusions, identify study strengths and weaknesses, and assign levels of evidence. Work group members participated in webcasts and in-person recommendation meetings to update and formulate evidence-based recommendations and incorporate expert opinion when necessary. The draft guidelines were submitted to an internal peer review process and ultimately approved by the NASS Board of Directors. Upon publication, the Degenerative Lumbar Spondylolisthesis guideline was accepted into the NGC and will be updated approximately every 5 years. RESULTS: Twenty-seven clinical questions were addressed in this guideline update, including 15 clinical questions from the original guideline and 12 new clinical questions. The respective recommendations were graded by strength of the supporting literature, which was stratified by levels of evidence. Twenty-one new or updated recommendations or consensus statements were issued and 13 recommendations or consensus statements were maintained from the original guideline. CONCLUSIONS: The clinical guideline was created using the techniques of evidence-based medicine and best available evidence to aid practitioners in the care of patients with degenerative lumbar spondylolisthesis. The entire guideline document, including the evidentiary tables, literature search parameters, literature attrition flow chart, suggestions for future research, and all of the references, is available electronically on the NASS website at https://www.spine.org/Pages/ResearchClinicalCare/QualityImprovement/ClinicalGuidelines.aspx and will remain updated on a timely schedule.

Intraoperative three-dimensional fluoroscopy-based computerized tomography guidance for percutaneous kyphoplasty.

OBJECT: Percutaneous kyphoplasty is an established method for the treatment of pathological vertebral compression fractures (VCFs). This procedure is usually performed with the aid of biplanar fluoroscopic image guidance. There are currently no published clinical studies in which the use of three-dimensional (3D) image guidance to facilitate this technique has been evaluated. The purpose of this study was to evaluate the efficacy of isocentric fluoroscopy-based navigation for the kyphoplasty procedure, with special reference to operating time and the amount of radiation exposure. METHODS: A prospective clinical study was performed in which 11 consecutive patients with painful pathological VCFs that did not respond to conservative treatment underwent the kyphoplasty procedure. During this procedure, cannulation of the pedicle and vertebral body was performed with the aid of isocentric 3D fluoroscopy visualization. Total operating time and intraoperative fluoroscopy time for this group was compared with a cohort of nine patients who underwent the procedure prior to the availability of isocentric fluoroscopy (only biplanar fluoroscopy was used). Possible complications such as cement extravasations were evaluated during the procedure and on postoperative computerized tomography scans. The mean duration of surgery for the 3D isocentric fluoroscopic guidance group was 60 minutes (range 36-89 minutes) for one-level and 68.5 minutes (range 65-75 minutes) for two-level cases. Because of a learning curve with the equipment, the operating time for the initial cases was significantly longer than with the later ones. Even with the initial cases included, the mean operating time was shorter compared with the biplanar fluoroscopy-assisted procedures, which averaged 69.2 minutes (range 44-113 minutes) for one-level procedures. This difference was not statistically significant. The mean fluoroscopy exposure time was 41.3 seconds (range 25-62 seconds) in the isocentric fluoroscopy-assisted procedures, with an additional 40 seconds of fluoroscopy time used for the 3D fluoroscopy "spin," compared with 293.2 seconds (range 180-400 seconds) in the biplanar fluoroscopy-assisted procedures. The difference was statistically significant (p = 0.02). All pedicles were accessed without difficulty and no complications were encountered in either group of patients. CONCLUSIONS: The main advantage of isocentric fluoroscopy is the significant reduction in radiation exposure for the patient and surgical staff without an increase in the mean operating time. This technique is a significant advancement over biplanar fluoroscopy in this setting.

Thoracolumbar vertebral reconstruction after surgery for metastatic spinal tumors: long-term outcomes.

OBJECT: Metastatic spinal tumors continue to represent a major problem for patients and treating physicians. The purpose of this study was to assess quantitatively the functional outcome, quality of life, and survival rates of patients after major reconstructive spine surgery. METHODS: A prospective database was established and 58 patients were identified who had undergone thoracolumbar vertebral reconstruction for metastatic spinal tumors between March 1993 and October 1999. Surgical indications included disabling pain (92%) and/or progressive neurological dysfunction (60%). Forty-nine patients (85%) had clinical improvement in pain as determined based on the Oswestry pain scale (p < 0.05); 60% demonstrated improvement in their neurological status. The mean neurological improvement in Frankel grade was 1.2 (p < 0.05). The 12-month survival rate was 65%, and all patients who were ambulatory after surgery remained so until the time of death. Instrumentation failure requiring repeated operation occurred in two patients (3.5%), and in 12 patients (21%) local tumor recurrence necessitated repeated surgery. There were no cases of neurological deficit or death related to surgery. CONCLUSIONS: Major anterior thoracolumbar vertebral reconstruction is an effective treatment for local tumor control. More importantly, the authors have demonstrated that surgical treatment can significantly improve the quality of life by improvement of pain control and maintenance of ambulation during the patient's remaining life span.

CyberKnife radiosurgery for idiopathic trigeminal neuralgia.

OBJECT: Gamma knife surgery is an accepted treatment option for trigeminal neuralgia (TN). The safety and efficacy of CyberKnife radiosurgery as a treatment option for TN, however, has not been established. METHODS: Forty-one patients were treated between May 2002 and September 2004 for idiopathic TN at Stanford University and the Rocky Mountain CyberKnife Center. Patients with atypical pain, multiple sclerosis, or previous radiosurgical treatment or a follow-up duration of less than 6 months were excluded. Patients were evaluated for the level of pain control, response rate, time to pain relief, occurrence of hypesthesia, and time to pain recurrence with respect to the length of the nerve treated and the maximum and the minimum dose to the nerve margin. Thirty-eight patients (92.7%) experienced initial pain relief at a median of 7 days after treatment (range, 24 hours-4 months). Pain control was ranked as excellent in 36 patients (87.8%), moderate in two (4.9%), and three (7.3%) reported no change. Six (15.8%) of the 38 patients with initial relief experienced a recurrence of pain at a median of 6 months (range 2-8 months). Long-term response after a mean follow-up time of 11 months was found in 32 (78%) of 41. Twenty-one patients (51.2%) experienced numbness after treatment. CONCLUSIONS: CyberKnife radiosurgery for TN has high rates of initial pain control and short latency to pain relief compared with those reported for other radiosurgery systems. The doses used for treatment were safe and effective. Higher prescribed doses were not associated with improvement in pain relief or recurrence rate. The hypesthesia rate was related to the length of the trigeminal nerve treated.

Safety of transforaminal lumbar interbody fusion and intervertebral recombinant human bone morphogenetic protein-2.

OBJECT: Recombinant human bone morphogenetic protein-2 (rhBMP-2) is being increasingly used for spinal fusion. There are few data regarding its clinical safety, effectiveness, and clinical outcome when applied on an absorbable collagen sponge (ACS) in conjunction with allograft for transforaminal lumbar interbody fusion (TLIF). METHODS: Seventy-four consecutive patients undergoing TLIF for degenerative disc disease were divided into five groups depending on whether the patient underwent a minimally invasive or open approach, as well as the number of spinal levels surgically treated. Surgery-related data, fusion results, complications, and clinical outcome were evaluated. The mean follow-up duration was 20.6 months (range 14-28 months). The radiographic fusion rate was 100% at 12 and 24 months after the surgery. No bone overgrowth or other complications related to BMP use were demonstrated. CONCLUSIONS: Analysis of the results demonstrated that TLIF combined with a BMP-2-soaked ACS is a feasible, effective, and safe method to promote lumbar fusion. There were no significant intergroup differences in clinical outcome between patients who underwent open compared with minimally invasive procedures. Patient satisfaction rates, however, were higher in the minimally invasive procedure group. The efficacy of BMP-2 was not dependent on which approach was used or the number of spinal levels that were treated.

The duration of symptoms and clinical outcomes in patients undergoing anterior cervical discectomy and fusion for degenerative disc disease and radiculopathy.

BACKGROUND CONTEXT: There have been controversial reports published in the literature on the duration of symptoms (DOS) and clinical outcome correlation in patients undergoing anterior cervical discectomy and fusion (ACDF) for painful degenerative disc disease and radiculopathy. PURPOSE: The primary purpose of this study was to analyze if the DOS has any effect on clinical outcomes. STUDY DESIGN/SETTING: A post hoc analysis was performed on an original prospective clinical study analyzing clinical outcomes and cervical sagittal alignment correlations. PATIENTS SAMPLE: Fifty-eight patients undergoing one- or two-level ACDF surgeries for cervical degenerative radiculopathy were analyzed. OUTCOME MEASURES: Standardized questionnaires were used to evaluate clinical outcomes. Neck and arm pain was evaluated using (Visual Analog Scale [VAS]). Two scales of Health-Related Quality-of-Life Questionnaire (Short-Form 36 Health Survey [SF-36]) were used for this study: the physical component summary (PCS) and mental component summary (MCS). Neck disability index (NDI) was used to evaluate chronic disability in activities of daily living. The patients completed a self-reported Patient Satisfaction with Results Survey. METHODS: Patients who had previous or redo surgeries, were diagnosed with myelopathy or had more than two-level ACDF surgeries were excluded, leaving a total of 58 patients. The mean follow-up was 37.2 months (range 12-54). Patients were divided into two groups for clinical outcome analyses according to the DOS: patients who had surgery within 6 months (n=29) or more than 6 months (n=29) after becoming symptomatic. RESULTS: There were no statistically significant differences in any demographic or clinical parameters among the patient groups. Controlling for preoperative scores, the patients who had surgery within 6 months reported significantly higher reduction (p=.04) in arm pain scores compared with the patients who waited more than 6 months. No significant differences were detected in postoperative neck pain VAS (p=.3), NDI (p=.06), SF-36 PCS (p=.08), and MCS (p=.8) scores. CONCLUSIONS: Neck and upper extremity pain can be successfully treated conservatively. In those cases, when surgical intervention is pursued, patients with shorter DOS have better improvement in radiculopathy symptoms that is statistically significant.