Markedly Elevated Intracranial Pressure Treated With Cranial Vault Expansion, Instead of CSF Shunting, in a Child With Hurler-Scheie Syndrome and Multiple Suture Craniosynostosis.

Despite a known association of mucopolysaccharidoses (MPS) and craniosynostosis, treatment of elevated intracranial pressure (ICP) in these patients is primarily cerebrospinal fluid (CSF) shunting. We present a unique case of Hurler-Scheie syndrome with multisuture craniosynostosis and elevated ICP, without ventriculomegaly, where elevated ICP was successfully treated with extensive cranial vault expansion and shunt placement was avoided. Patients with MPS should be evaluated for craniosynostosis, and calvarial vault expansion may be considered as a viable treatment alternative to CSF shunting for elevated ICP in select patients.

Biomechanical study of rod stress after pedicle subtraction osteotomy versus anterior column reconstruction: A finite element study.

BACKGROUND: In an effort to minimize rod fractures and nonunion in pedicle subtraction osteotomy (PSO) constructs, surgeons have adopted multirod constructs and interbody cages. Anterior column realignment (ACR) with posterior column osteotomies is a minimally invasive alternative to PSO in sagittal balance correction, however, there is a paucity of evidence with respect to rod survival. METHODS: Three-dimensional (3D) finite-element-model of a T12-sacrum spine segment was used to compare a 25° PSO at L3 and an ACR with a posterior column osteotomy and 30° hyperlordotic interbody cage at L3-4. The amount of overall T12-S1 lordosis correction was the same for each condition. Each simulation included cobalt chromium alloy primary rods with: (1) PSO; (2) PSO with an interbody cage (IB) at L2-3 (PSO+IB); (3) PSO with accessory (A) rods and IB at L2-3 (PSO+IB+A); (4) PSO with satellite (S) rods and IB at L2-3 (PSO+IB+2S); (5) ACR; 6) ACR with satellite rods (ACR + 2S). A 400 N follower preload was simulated for each condition. RESULTS: PSO condition had the largest rod stress of 286 MPa in flexion. Adding interbody support reduced the rod stress by 15%. The 4-rod constructs further reduced rod stress, with the satellite rod condition facilitating the largest reduction. The rod stress in the ACR+2S was equivalent to the PSO+2S, with 50% reduction in rod stress. CONCLUSION: The rod stress with an ACR was comparable to a PSO coupled with interbody support. These results suggest an ACR is a viable MIS alternative to a PSO without the need for a large posterior osteotomy.

Indirect decompression and reduction of lumbar spondylolisthesis does not result in higher rates of immediate and long term complications.

Nerve root decompression and spondylolisthesis reduction is typically reserved for open surgery. MIS techniques have been thought to be associated with higher rates of neurological complications. This study aims to report acute and chronic neurologic complications encountered with MIS surgery for spondylolisthesis, specifically, the incidence of nerve root injury and clinical and radiographic outcomes. A retrospective review of 269 patients who underwent MIS LIF or ALIF treatment for lumbar degenerative or isthmic grade 1 or 2 spondylolisthesis was conducted. Immediate and long-term complication rates were the primary outcome. Only patients who had symptomatic anterolisthesis and 2-year outcome data were included in the study. 52 patients met inclusion criteria with 54 lumbar spondylolisthesis levels treated. Five patients (9.6%) experienced postoperative anterior thigh numbness, which completely resolved within 3months. There were no permanent neurologic deficits; however, 2 patients (3.8%) suffered a transient foot weakness that resolved with physical therapy by 3months follow-up. There was one incidence of wound breakdown that required revision and one incidence of L5/S1 endplate/sacral promontory fracture and relisthesis 3months postoperatively. Overall fusion rate was 98% at 6months. Indirect decompression and closed anatomical reduction for treatment of low-grade spondylolisthesis using ALIF and LIF with posterior percutaneous fixation was not associated with an increased risk of neurologic deficit. This study suggests that this technique is safe, reproducible, durable, and provides adequate fusion rates.

Contralateral psoas hematoma after minimally invasive, lateral retroperitoneal transpsoas lumbar interbody fusion: a multicenter review of 3950 lumbar levels.

OBJECTIVE Minimally invasive lateral lumbar interbody fusion (LLIF) via the retroperitoneal transpsoas approach is a technically demanding procedure with a multitude of potential complications. A relatively unknown complication is the contralateral psoas hematoma. The authors speculate that injury occurs from segmental vessel injury at the time of contralateral annulus release; however, this is not fully understood. In this multicenter retrospective review, the authors report the incidence of this contralateral complication and its neurological sequelae. METHODS This study was a retrospective chart review of all minimally invasive LLIF performed at participating institutions from 2008 to 2014. Exclusion criteria included an underlying diagnosis of trauma or neoplasia as well as lateral corpectomies or anterior column releases. Single-level, multilevel, and stand-alone constructs were included. All patients underwent preoperative MRI. Follow-up was at least 12 months. All complications and clinical outcomes were self-reported by each surgeon. RESULTS There were 3950 lumbar interbody cages placed via the retroperitoneal transpsoas approach, with 7 cases (0.18% incidence) of symptomatic contralateral psoas hematoma, 3 of which required reoperation for hematoma evacuation. Neurological outcome did not improve after reoperation. Reoperation occurred an average of 1 month after the initial operation due to a delay in diagnosis. In 1 case, segmental artery injury was confirmed at the time of surgery; in the others, segmental vessel injury was suspected, although it could not be confirmed. Neurological deficits persisted in 3 patients while the others remained neurologically intact. Two patients were receiving antiplatelet therapy prior to the procedure. CONCLUSIONS The contralateral psoas hematoma is a rare complication suspected to occur from segmental vessel injury during contralateral annulus release. Detailed review of preoperative imaging for aberrant vessel anatomy may prevent injury and subsequent neurological deficit.

The Potentially Fatal Ogilvie's Syndrome in Lateral Transpsoas Access Surgery: A Multi-Institutional Experience with 2930 Patients.

BACKGROUND: Ogilvie's syndrome (OS) is a relatively uncommon pathology characterized by significant colonic dilation in the absence of mechanical obstruction. If unrecognized and untreated, cecal perforation resulting in a mortality rate of 25%-71% may occur. It is a potentially underdiagnosed condition in the lateral transpsoas approach population because of its uncommon nature and imitation of other well-known pathologies. METHODS: Two thousand nine hundred and thirty patients from 6 separate institutions were retrospectively reviewed since 2007 and screened for OS. All patients underwent a minimum of single-level lateral transpsoas fusion. Diagnostic criteria included signs of a postoperative paralytic ileus combined with abdominal computed tomography showing a cecal diameter greater than 9 cm. Treatment modalities and outcomes were recorded. RESULTS: Eight cases (0.22%) of OS were diagnosed at 6 separate institutions. Most institutions recorded more than 350 lateral access procedures. Four cases were initially diagnosed as a routine postoperative ileus; however, they failed conservative therapy and underwent abdominal CT imaging. Neostigmine treatment was required for 1 patient in the intensive care unit setting, and 3 patients were managed conservatively without complications. Four other patients demonstrated bowel perforation at least 48 hours after surgery and required laparotomy with diversion ileostomy. CONCLUSION: Ogilvie's syndrome is a rare but potentially fatal complication that can mimic a postoperative ileus. It is likely underdiagnosed in the lateral transpsoas approach population because of its uncommon nature and a high index of suspicion should remain. Neostigmine can be administered safely under close observation with immediate and successful outcomes. Patients with perforation require urgent laparotomy and primary repair.

Effects of intradiscal vacuum phenomenon on surgical outcome of lateral interbody fusion for degenerative lumbar disease.

OBJECTIVE The authors investigated whether the presence of intradiscal vacuum phenomenon (IVP) results in greater correction of disc height and restoration of segmental lordosis (SL). METHODS A retrospective chart review was performed on every patient at the University of South Florida's Department of Neurosurgery treated with lateral lumbar interbody fusion between 2011 and 2015. From these charts, preoperative plain radiographs and CT images were reviewed for the presence of IVP. Preoperative and postoperative posterior disc height (PDH), anterior disc height (ADH), and SL were measured at disc levels with IVP and compared with those at disc levels without IVP using the t-test. Linear regression was used to evaluate the factors that predict changes in PDH, ADH, and SL. RESULTS One hundred forty patients with 247 disc levels between L-1 and L-5 were treated with lateral lumbar interbody fusion. Among all disc levels treated, the mean PDH increased from 3.69 to 6.66 mm (p = 0.011), the mean ADH increased from 5.45 to 11.53 mm (p < 0.001), and the mean SL increased from 9.59° to 14.55° (p < 0.001). Significantly increased PDH was associated with the presence of IVP, addition of pedicle screws, and lack of cage subsidence; significantly increased ADH was associated with the presence of IVP, anterior longitudinal ligament (ALL) release, addition of pedicle screws, and lack of subsidence; and significantly increased SL was associated with the presence of IVP and ALL release. CONCLUSIONS IVP in patients with degenerative spinal disease remains grossly underreported. The data from the present study suggest that the presence of IVP results in increased restoration of disc height and SL.

Anterior Longitudinal Ligament Release From the Minimally Invasive Lateral Retroperitoneal Transpsoas Approach: Technical Note.

BACKGROUND: The technique for minimally invasive anterior longitudinal ligament release is a major advancement in lateral access surgery. This method provides hypermobility of lumbar segments to allow for aggressive lordosis restoration while maintaining the benefits of indirect decompression and minimally invasive access. OBJECTIVE: To provide video demonstration of the lateral retroperitoneal transpsoas approach with anterior longitudinal ligament sectioning. METHODS: A detailed surgical technique of the minimally invasive anterior column release is described and illustrated in an elderly patient with adult spinal deformity and low back pain (visual analog scale, 8 of 10) refractory to conservative measures. The 3-foot standing radiographs demonstrated a lumbar lordosis of 54.4°, pelvic incidence of 63.7°, and pelvic tilt of 17.5°. Computed tomography and magnetic resonance imaging showed generalized lumbar spondylosis and degenerative disc changes from L2 to L5. RESULTS: The patient underwent a multilevel minimally invasive deformity correction with an anterior longitudinal ligament release at the L3/L4 level through the lateral retroperitoneal transpsoas approach. Lumbar lordosis increased from 54.4° to 77° with a global improvement in sagittal vertical axis from 4.37 cm to 0 cm. Total blood loss was less than 25 mL, and there were no major neurological or vascular complications. CONCLUSION: The anterior longitudinal ligament release using the minimally invasive lateral approach allows for deformity correction without the morbidity and blood loss encountered by traditional open posterior approaches. However, the risk of major vascular/visceral complication warrants only experts in minimally invasive lateral surgery to attempt this technique.

Complications associated with bacitracin powder in surgical wounds.

OBJECT: There has been renewed interest in the application of concentrated antibiotic powder to surgical wounds as a method to decrease infection rates. While there is substantial medical literature describing the effectiveness and complications associated with vancomycin and gentamycin powders, very little has been reported regarding the safety and effectiveness of bacitracin powder in surgical wounds. In this paper the authors report their detailed analysis of potential bacitracin powder-related complications in a population of pediatric patients who underwent shunt surgery. METHODS: A detailed retrospective analysis was completed of all CSF shunt surgeries performed by the corresponding author at a large children's hospital between 2001 and 2013. This cohort consisted of many patients who were the subject of a previous report that showed the use of bacitracin powder in shunt wounds potentially decreased infection rates. Data were collected regarding the most common known complications of bacitracin, i.e., anaphylaxis, wound healing difficulties, and renal dysfunction. Data were stratified by typical demographic, medical, and surgical variables, including whether bacitracin powder was applied to wounds prior to closure. RESULTS: A total of 597 patients were reviewed in the analysis: 389 underwent surgery without bacitracin powder and 208 had concentrated bacitracin powder applied to the wounds prior to closure. The application of bacitracin powder was not associated with anaphylaxis (n = 0 both groups) or with an increase in wound breakdown (n = 5 in the control group, n = 0 in the bacitracin powder group) or renal dysfunction (creatinine/estimated glomerular filtration rate) using both comparative and multivariate analyses between the 2 groups. The sample size evaluating renal function was significantly lower (range 6-320) than that of anaphylaxis and wound breakdown analysis because only clinical values acquired during the routine care of these patients were available for analysis. The only significant difference in demographics was the more frequent use of intrathecal vancomycin and gentamycin in patients who received bacitracin powder (n = 1 for controls, n = 21 for bacitracin powder). In the multivariate analysis, only 1 factor, surgery performed on a premature infant within the first 3 months of life, was independently associated with a change in creatinine at 3 months (creatinine decreased by 0.18) compared with the level before surgery (p < 0.0001). Bacitracin powder was not a significant factor. CONCLUSIONS: To the authors' knowledge, this is the first study to systematically analyze the potential complications of concentrated bacitracin powder applied to surgical wounds. The use of topical bacitracin powder in CSF shunt wounds was not associated with anaphylaxis, wound breakdown, or renal dysfunction. Further study using standardized protocols is necessary before widespread use can be recommended.

Reduction in CSF shunt infection over a 10-year period associated with the application of concentrated topical antibiotic powder directly to surgical wounds prior to closure.

OBJECT: The application of concentrated topical antibiotic powder directly to surgical wounds has been associated with a reduction in wound infection in cardiac, spinal, and deep brain stimulator surgery. As a result of these findings, the corresponding author began systematically applying concentrated bacitracin powder directly to wounds during shunt surgery more than 5 years ago. The object of this study was to evaluate the effectiveness of concentrated bacitracin powder applied directly to wounds prior to closure during cranial shunt surgery and to evaluate the association between shunt infection and other risk factors. A single surgeon's cranial shunt surgery experience, equally divided between periods during which antibiotic powder was and was not applied, was studied to assess the effect of concentrated bacitracin powder application on shunt infection rates. METHODS: This retrospective cohort study included all patients who underwent a cranial shunting procedure at All Children's Hospital performed by a single surgeon (G.F.T.) from 2001 to 2013. The surgeon applied bacitracin powder to all shunt wounds prior to closure between 2008 and 2013, whereas no antibiotic powder was applied to wounds prior to 2008. Both initial and revision shunting procedures were included, and all procedures were performed at a large children's hospital (All Children's Hospital). The primary outcome measure was shunt infection, which was defined using clinical criteria previously used by the Hydrocephalus Clinical Research Network. The association between bacitracin powder use and shunt infection was estimated using hazard ratios (HRs) and 95% CIs from Cox proportional hazard regression models. RESULTS: A total of 47 infections out of 539 shunt operations occurred during the study period, resulting in an overall infection rate of 8.7%. Procedures performed before the use of concentrated bacitracin powder was instituted resulted in a 13% infection rate, whereas procedures performed after systematic use of bacitracin powder had been adopted experienced a 1% infection rate. Bacitracin powder use was associated with a reduced risk of shunt infection in univariate analysis (HR 0.11, 95% CI 0.03-0.34, p = 0.0002) and also in multivariate analysis (HR 0.12, 95% CI 0.04-0.41, p = 0.0006) when controlling for covariates that were associated with infection from the univariate analysis. The presence of a tracheostomy or a gastrostomy tube was also found to be independently associated with shunt infection in multivariate analysis (HR 3.15, 95% CI 1.05-9.50, p = 0.04, and HR 2.82, 95% CI 1.33-5.96, p = 0.007, respectively). CONCLUSIONS: This study suggests, for the first time, that the systematic application of concentrated bacitracin powder to surgical wounds prior to closure during shunt surgery may be associated with a reduction in cranial shunt infection. This initial finding requires validation in a large prospective study before widespread application can be advocated.

Percutaneous Minimally Invasive (MIS) Guide Wire-less Self-Tapping Pedicle Screw Placement in the Thoracic and Lumbar Spine: Safety and Initial Clinical Experience: Technical Note.

BACKGROUND: Multiple methods for minimally invasive (MIS) thoracic and lumbar pedicle screw placement exist. The guide wire is almost universally used for most insertion techniques; however, its use is not without complication and potentially prolongs surgical procedures. OBJECTIVE: To evaluate the safety of percutaneous MIS guide wire-less pedicle screw placement in the thoracic and lumbar spine at a single institution over a 3-year experience. METHODS: Forty-one patients who underwent posterior instrumentation with 110 transpedicular MIS thoracic and lumbar screws by a single surgeon from 2011 to 2014 were analyzed. The mean age was 63 years at the time of surgery. Etiological diagnoses were adult spinal deformity, trauma, spondylosis/spondylolisthesis, and other spinal diseases. Pedicle screws were inserted with the use of a guide wire-free technique in which anatomy-specific entry sites and fluoroscopic landmarks were used to guide the surgeon. A square, sharp-tipped pedicle screw was carefully advanced under biplanar fluoroscopic image (anteroposterior and lateral) down the pedicle into the body. No tapping or any type of electromonitoring was performed. An independent spine surgeon using medical records and thoracic/lumbar computed tomography taken during the postoperative period reviewed all patients. RESULTS: The number of the screws inserted at each level was as follows: total, 110; thoracic, 30; and lumbar, 80. All screws were evaluated by computed tomography to assess screw position. Seven screws (6.3%) were inserted with moderate cortical perforation, including 3 screws (2.7%) that violated the medial wall. There were no neurological, vascular, or visceral complications with up to 3 years of follow-up. CONCLUSION: The percutaneous MIS guide wire-less technique of lumbar and thoracic pedicle screw placement performed using a biplanar fluoroscopic guidance in a stepwise, consistent manner is an accurate, safe, and reproducible method of insertion to treat a variety of spinal disorders.

Bucket and straw technique to facilitate passage of a ventriculoperitoneal shunt through the distal tunneling sheath.

Placement of a ventriculoperitoneal shunt (VPS) is a procedure comprising many small steps. Difficulties and delays can arise when passing the distal shunt tubing down the distal tunneling sheath during surgery. The authors of this report describe a simple technique for quickly passing the distal catheter of a VPS through the tunneler sheath, whereby the sheath is used as a fluid tube to allow the distal catheter to be drawn through the fluid tube under suction pressure. The plastic sheath that surrounds the shunt tunneler device is used as a fluid tube, or "straw," with the proximal aperture submerged into a bucket of sterile irrigation liquid containing the distal catheter. Suction pressure is placed against the distal aperture of the tunneler, and the shunt catheter is quickly drawn through the sheath. No special equipment is required. In time trials, the bucket and straw technique took an average of 0.43 seconds, whereas traditional passage methods took 32.3 seconds. The "bucket and straw" method for passing distal shunt tubing through the tunneler sheath is a technique that increases surgical efficiency and reduces manual contact with shunt hardware.

Median nerve branches to the pronator teres: cadaveric study with potential use in neurotization procedures to the radial nerve at the elbow.

OBJECT: Various donor nerves have been used for brachial plexus neurotization procedures. To the authors' knowledge, neurotization of median nerve branches to the pronator teres to the radial nerve at the elbow have not been explored. METHODS: In an attempt to identify an additional nerve donor candidate for neurotization procedures of the upper limb, 20 cadaveric upper limbs underwent dissection of the cubital fossa and identification of branches of the median nerve to the pronator teres. Measurements were made of such branches, and distal transection was then performed to determine the appropriate length so that the structure could be brought to the laterally positioned radial nerve via tunneling deep to the biceps brachii muscle. RESULTS: All specimens were found to have a median nerve branch to the pronator teres that was long enough to reach the radial nerve in the cubital fossa. Neural connections remained tension free with full pronation and supination. The mean length of these branches to the pronator teres was 3.6 cm. The overall mean diameter of these nerves was 1.5 mm. The mean proximal, midpoint, and distal diameters were 2.0, 1.8, and 1.5 mm, respectively. The mean distance between the origin of these branches to the pronator teres and the medial epicondyle of the humerus was 4.1 cm. CONCLUSIONS: Based on the results of our cadaveric study, the use of the branch of the median nerve to the pronator teres muscle may be considered for neurotization of the radial nerve in the cubital fossa.