Combined Incisional Negative Pressure Wound Therapy and Subfascial Suction Drainage: The Suction Taco Approach.

An 18-year-old male with T4-L3 adult idiopathic scoliosis was treated with posterior spinal fusion followed by the application of a combined incisional negative pressure wound therapy (NPWT) and subfascial suction drainage system. In this report, we describe a novel technique that incorporates subfascial drains into an NPWT incisional vacuum system leading to a single exiting suction line. This effectively mitigates drain burden, maintains a sterile environment during the in-hospital postoperative period, provides NPWT to the drain exiting and incisional sites, and provides negative pressure-assisted deep space closure.

Transpedicular-Transdiscal Cement Augmentation Treatment of Thoracolumbar Fusion Proximal Junctional Failure.

BACKGROUND: Long instrumented fusions for adult deformity have a proximal junction kyphosis rate between 20% and 40%. When symptomatic, proximal junctional failure (PJF) often requires revision surgery and is associated with significant morbidity. Vertebral cement augmentation (VCA) has been used for prophylaxis against PJF but has not been previously described as treatment after onset of PJF has occurred. We describe a series of patients with PJF of long posterior spinal fusions that were treated at our institution using a novel VCA technique. METHODS: Three patients with PJF above thoracolumbopelvic fusions were retrospectively reviewed following treatment with transpedicular-transdiscal VCA. The medical record was reviewed for demographic data, outcomes scores, and radiographic images. RESULTS: Mean age was 69.3 years. Mean follow-up was 13.3 months. Mean preprocedure visual analog scale score was 8.67, and postprocedure visual analog scale score was 4.00. Mean preprocedure sagittal balance was 9.7 cm, and postprocedure sagittal balance was 5.8 cm. No patients required revision surgery for PJF in the follow-up period. CONCLUSIONS: Transpedicular-transdiscal VCA treatment for PJF is safe and may have the potential to prevent the need for revision surgery. LEVEL OF EVIDENCE: 4.

Mini-open sacroiliac joint fusion with direct bone grafting and minimally invasive fixation using intraoperative navigation.

BACKGROUND: Describe a novel technique for sacroiliac arthrodesis using intraoperative navigation, direct bone grafting, and minimally invasive implants. Report on the outcomes of the first cohort of these patients. METHODS: Institutional review board (IRB) approved, single center, two surgeon, retrospective study. RESULTS: All patients were 18 years or older, primary sacroiliac fusions, and underwent novel technique described. Fifty patients underwent 57 surgeries. Twelve male/38 female patients. All received three sacroiliac implants. Average blood loss 42.8 mL. Average length of stay 1.9 nights. Average follow-up 13.96±13 months. Statistically significant improvements in Visual Analogue Scale (VAS) scores (<0.001) for all time periods 6 weeks, 3 months, 6 months, 12 months compared to preop. Other outcomes scores [Oswestry Disability Index (ODI), and Denver Sacroiliac Joint Questionnaire (DSIJQ)] also showed a general trend for clinical improvement at all postoperative time periods. Of 2/57 (3.5%) complications were identified. No patients required surgical revision within the study window. CONCLUSIONS: Limited open sacroiliac arthrodesis using minimally invasive implants, intraoperative navigation, and direct open bone grafting is safe and demonstrates clinical benefit, similar to other techniques for minimally invasive sacroiliac arthrodesis. There is potential for improved long-term outcomes from increased union rates. KEYWORDS: Sacroiliac dysfunction; minimally invasive sacroiliac fusion; open sacroiliac fusion; navigation.

Outcomes Following Multilevel Cervical Disc Arthroplasty in the Young Active Population.

BACKGROUND: Cervical radiculopathy is a common disorder that portends significant morbidity. The presence of radiculopathy can have a debilitating effect on patients as well as a significant economic impact. Active duty military patients with increased physical occupational demands can be significantly impacted by cervical disease. The resulting disability can have a strong negative impact on operational readiness. Several studies have demonstrated comparably good functional outcomes between cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion for single-level disease. To date, no study has specifically evaluated the functional and occupational outcomes following adjacent 2-level CDA in a young, active patient population as represented by the active duty military population. PURPOSE: To evaluate functional and occupational outcomes following adjacent 2-level CDA for cervical radiculopathy in the U.S. military population. We hypothesized that this population would have excellent symptomatic relief at the cost of a low return to duty rate. METHODS: We performed a case series with prospective follow-up of all patients who underwent adjacent two-level CDA at a single institution from 2011 to 2014. Each patient completed the Neck Disability Index questionnaire to assess functional outcome. Primary outcomes of interest were return to active military duty and complications. RESULTS: Follow-up was available for 18 of 21 (85.7%) patients. At an average follow-up of 21.4 ± 11.1 months, 12 patients (66.7%) reported complete symptomatic relief and were able to return to preoperative levels of function. Average self-reported pain score improved from 8.3 preoperatively to 1.1 postoperatively, and average postoperative Neck Disability Index score was 15.5 compared to 37.0 for those who medically retired. Radiographic analysis did not show any evidence of subsidence, migration of hardware, or heterotopic ossification. The average return to duty time was 9.6 weeks. DISCUSSION: We demonstrate that adjacent two-level CDA is capable of providing predictable symptomatic relief and maintenance of a high-demand preoperative level of function for cervical radiculopathy among a population of young and highly active individuals. Adjacent two-level CDA offers significant relief of symptoms with low risk of complication in a young, active, and high-demand cohort such as the U.S. military. Adjacent two-level CDA can be performed with the expectation of improving function, relieving symptoms, returning to preoperative levels of activity, and maintaining operational readiness.

Patient factors, comorbidities, and surgical characteristics that increase mortality and complication risk after spinal arthrodesis: a prognostic study based on 5,887 patients.

BACKGROUND CONTEXT: The impact of patient factors and medical comorbidities on the risk of mortality and complications after spinal arthrodesis has not been well described. Prior works have been limited by small sample size, single center data, or the inability to be broadly generalized. PURPOSE: To determine if there is an association between the patient demographic factors, comorbidities, nutritional status, and surgical characteristics and the occurrence of mortality and complications after spinal arthrodesis. STUDY DESIGN: Retrospective review of prospectively collected data in the National Surgical Quality Improvement Program (NSQIP). PATIENT SAMPLE: Patients who underwent spinal arthrodesis and had data registered with the NSQIP between 2005 and 2010. OUTCOME MEASURES: Primary outcomes were death or any complication after spinal arthrodesis. Secondary measures were the development of a specific complication, including wound infection, thromboembolic disease, or cardiac arrest/myocardial infarction. METHODS: The data set of the NSQIP from 2005 to 2010 was queried to identify all patients who underwent spinal arthrodesis. Demographic information, body mass index (BMI), medical comorbidities, arthrodesis procedure, operative time, American Society of Anesthesiologists (ASA) classification, and preoperative albumin were recorded for all patients identified. Mortality, the development of postoperative complications, and the presence of specific complications were also abstracted. Risk factors for mortality and complications were initially evaluated using chi-square and univariate logistic regression analyses. The risk factors that maintained p values less than .2 in univariate analysis were then combined in a multivariate fashion that identified significant, independent, predictors of mortality and complications while controlling for other factors present in the model. Sensitivity analysis was also performed, discriminating between the impact of risk factors on major and minor complications and the relative contribution to overall risk of morbidity. Multivariate analysis resulted in odds ratios (ORs) with 95% confidence intervals (CIs) for each risk factor. Only those predictors with ORs and 95% CI exclusive of 1.0 and p values less than .05 were considered statistically significant. RESULTS: In all, 5,887 patients who underwent spinal arthrodesis were identified. The average age of patients was 55.9 (±14.5) years. Twenty-five (0.42%) patients died after surgery, whereas 608 (10%) sustained a complication. Wound infection was the most common specific complication occurring in 2% of the cohort. Age (p=.03) and pulmonary conditions (p=.002) were found to have a significant association with the risk of mortality. Age exceeding 80 years was found to carry the highest risk of mortality. Age, pulmonary conditions, BMI, history of infection, ASA classification more than 2, neurologic conditions, resident (i.e., trainee) involvement, and procedural times exceeding 309 minutes increased the risk of complications. Body mass index, ASA classification more than 2, resident involvement, and procedural times exceeding 309 minutes were associated with the risk of infection. Although limited to univariate analysis, serum albumin 3.5 g/dL or less increased the risk of mortality, complications, wound infection, and thromboembolic disease. The OR for postoperative mortality among patients with albumin 3.5 g/dL or less was 13.8 (95% CI, 4.6-41.6; p<.001). CONCLUSIONS: Several factors, including patients' age, BMI, ASA classification more than 2, pulmonary conditions, procedural times, and nutritional status likely influence the risk of postoperative morbidity to varying degrees. The risk factors identified here may be more generalizable to the American population as a whole because of the design and methodology of the NSQIP in comparison with previously published studies.

Characterization of spinal injuries sustained by American service members killed in Iraq and Afghanistan: a study of 2,089 instances of spine trauma.

BACKGROUND: This study sought to characterize spine injuries among soldiers killed in Iraq or Afghanistan whose autopsy results were stored by the Armed Forces Medical Examiner System. METHODS: The Armed Forces Medical Examiner System data set was queried to identify American military personnel who sustained a spine injury in conjunction with wounds that resulted in death during deployment in Iraq or Afghanistan from 2003 to 2011. Demographic and injury-specific characteristics were abstracted for each individual identified. The raw incidence of spinal injuries was calculated and correlations were drawn between the presence of spinal trauma and military specialty, mechanism and manner of injury, and wounds in other body regions. Significant associations were also sought for specific injury patterns, including spinal cord injury, atlantooccipital injury, low lumbar vertebral fractures, and lumbosacral dissociation. Statistical calculations were performed using χ statistic, z test, t test with Satterthwaite correction, and multivariate logistic regression. RESULTS: Among 5,424 deceased service members, 2,089 (38.5%) were found to have sustained at least one spinal injury. Sixty-seven percent of all fatalities with spinal injury were caused by explosion, while 15% occurred by gunshot. Spinal fracture was the most common type of injury (n = 2,328), while spinal dislocations occurred in 378, and vertebral column transection occurred in 223. Fifty-two percent sustained at least one cervical spine injury, and spinal cord injury occurred in 40%. Spinal cord injuries were more likely to occur as a result of gunshot (p < 0.001), while atlantooccipital injuries (p < 0.001) and low lumbar fractures (p = 0.01) were significantly higher among combat specialty soldiers. No significant association was identified between spinal injury risk and the periods 2003 to 2007 and 2008 to 2011, although atlantooccipital injuries and spinal cord injury were significantly reduced beginning in 2008 (p < 0.001). CONCLUSION: The results of this study indicate that the incidence of spinal trauma in modern warfare seems to be higher than previously reported. LEVEL OF EVIDENCE: Epidemiologic study, level III.