Minimally Invasive Placement of Spinal Cord Stimulator Paddle Electrodes Is Associated With Improved Perioperative and Long-Term Experience Among Neuropathic Pain Patients.

STUDY DESIGN: Prospective, observational cohort study. OBJECTIVE: This study compared in-hospital and long-term outcomes among spinal cord stimulation (SCS) patients undergoing paddle insertion by open or minimally invasive surgery (MIS) approaches. SUMMARY OF BACKGROUND DATA: Patients with treatment-refractory extremity neuropathic pain may benefit from SCS. Conventional placement of surgical paddles for an external neurostimulation trial is through open laminectomy, but MIS techniques may offer advantages. METHODS: Twenty SCS patients were prospectively assessed. Open patients underwent caudal thoracic laminectomy for multicolumnar electrode paddle placement. MIS patients underwent paddle placement through interlaminar flavectomy using tubular retractors. Demographic data included age, sex, underlying diagnosis, and preoperative visual analog scale (VAS) extremity scores. Intraoperative data included operative duration, blood loss, and number of device passages to achieve final position. Perioperative data included VAS back pain scores; trial data included time-to-trial and time-to-decision. Postoperative data included 1 month VAS back pain scores and 1 year follow-up device complications. RESULTS: No demographic differences were observed among surgical cohorts. MIS procedures had shorter operative duration (P = 0.03), less blood loss (P < 0.001), and similar median number of device passages (2 vs 1.5, P = 0.71). MIS patients reported less perioperative surgical back pain (P < 0.05). External neurostimulation trials began sooner among MIS patients who also made sooner decision whether to implant the SCS device (2.8 ±â€Š1.4 vs 4.3 ±â€Š1.0 days, P = 0.013). Similar 1 month back pain scores were reported between surgical cohorts (P = 0.08). CONCLUSION: MIS techniques for SCS surgical paddle implantation is associated with less perioperative morbidity and surgical site back pain, shorter external neurostimulator trial duration, and long-term device stability benefits. LEVEL OF EVIDENCE: 2.

Systemic Inflammatory and Th17 Immune Activation among Patients Treated for Lumbar Radiculopathy Exceeds that of Patients Treated for Persistent Postoperative Neuropathic Pain.

BACKGROUND: The pathophysiology of lumbar radiculopathy includes both mechanical compression and biochemical irritation of apposed neural elements. Inflammatory and immune cytokines have been implicated, induced by systemic exposure of immune-privileged intervertebral disc tissue. Surgical intervention provides improved symptoms and quality of life, but persistent postoperative neuropathic pain (PPNP) afflicts a significant fraction of patients. OBJECTIVE: To compare the inflammatory and immune phenotypes among patients undergoing structural surgery for lumbar radiculopathy and spinal cord stimulation for neuropathic pain. METHODS: Consecutive patients undergoing surgical intervention for lumbar radiculopathy or neuropathic pain were studied. Demographic data included age, gender, and VAS and neuropathic pain scores. Serum was evaluated for cytokine levels (IL-6, Il-17, TNF-α) and cellular content [white blood cell (WBC)/differential, lymphocyte subtypes]. The primary analysis differentiated molecular and cellular profiles between radiculopathy and neuropathic pain patients. Subgroup analysis within the surgical radiculopathy population compared those patients achieving relief of symptoms and those with PPNP. RESULTS: Heightened IL-6, Il-17, and TNF-α levels were observed for the lumbar radiculopathy group compared with the neuropathic pain group. This was complemented by higher WBC count and a greater fraction of Th17 lymphocytes among radiculopathy patients. In the lumbar discectomy subgroup, pain relief was seen among patients with preoperatively elevated IL-17 levels. Those patients with PPNP refractory to surgical discectomy exhibited normal cytokine levels. CONCLUSION: Differences in Th17 immune activation are seen among radiculopathy and neuropathic pain patients. These cellular and molecular profiles may be translated into biomarkers to improve patient selection for structural spine surgery.

The Advancing Role of Neuromodulation for the Management of Chronic Treatment-Refractory Pain.

Neuropathic pain is a common cause of disability and health care utilization. While judicious pharmacotherapy and management of comorbid psychological distress can provide for improved quality of life, some patients with treatment-refractory disease require more invasive therapies. Spinal cord stimulation can provide for improvement in pain and decrease in medication utilization, with level 1 evidence supporting its use across various pain etiologies including persistent postoperative neuropathic pain, complex regional pain syndrome, chronic inoperable limb ischemia, treatment refractory angina, and painful diabetic neuropathy. These procedures can be done with acceptably low morbidity and provide a cost-effective solution for those patients in whom medical therapies have failed. Technological innovation in lead design, implantable pulse generator capability, and stimulation algorithms and parameters may further enhance the success of this therapy. Neuromodulation of distal targets such as dorsal root ganglion may permit greater anatomic specificity of the therapy, whereas subthreshold stimulation with high-frequency or burst energy delivery may eliminate noxious and off-target paresthesiae. Such new technologies should be subject to rigorous evaluation as their mechanisms of action and long-term outcomes remain hitherto undefined.

Recent and Emerging Advances in Spinal Deformity.

BACKGROUND: Over the last several decades, significant advances have occurred in the assessment and management of spinal deformity. OBJECTIVE: The primary focus of this narrative review is on recent advances in adult thoracic, thoracolumbar, and lumbar deformities, with additional discussions of advances in cervical deformity and pediatric deformity. METHODS: A review of recent literature was conducted. RESULTS: Advances in adult thoracic, thoracolumbar, and lumbar deformities reviewed include the growing applications of stereoradiography, development of new radiographic measures and improved understanding of radiographic alignment objectives, increasingly sophisticated tools for radiographic analysis, strategies to reduce the occurrence of common complications, and advances in minimally invasive techniques. In addition, discussion is provided on the rapidly advancing applications of predictive analytics and outcomes assessments that are intended to improve the ability to predict risk and outcomes. Advances in the rapidly evolving field of cervical deformity focus on better understanding of how cervical alignment is impacted by thoracolumbar regional alignment and global alignment and how this can affect surgical planning. Discussion is also provided on initial progress toward development of a comprehensive cervical deformity classification system. Pediatric deformity assessment has been substantially improved with low radiation-based 3-D imaging, and promising clinical outcomes data are beginning to emerge on the use of growth-friendly implants. CONCLUSION: It is ultimately through the reviewed and other recent and ongoing advances that care for patients with spinal deformity will continue to evolve, enabling better informed treatment decisions, more meaningful patient counseling, reduced complications, and achievement of desired clinical outcomes.

Prevention of Surgical Site Infection in Spine Surgery.

BACKGROUND: Spine surgery is complicated by an incidence of 1% to 9% of surgical site infection (SSI). The most common organisms are gram-positive bacteria and are endogenous, that is are brought to the hospital by the patient. Efforts to improve safety have been focused on reducing SSI using a bundle approach. The bundle approach applies many quality improvement efforts and has been shown to reduce SSI in other surgical procedures. OBJECTIVE: To provide a narrative review of practical solutions to reduce SSI in spine surgery. METHODS: Literature review and synthesis to identify methods that can be used to prevent SSI. RESULTS: SSI prevention starts with proper patient selection and optimization of medical conditions, particularly reducing smoking and glycemic control. Screening for staphylococcus organisms and subsequent decolonization is a promising method to reduce endogenous bacterial burden. Preoperative warming of patients and timely administration of antibiotics are critical to prevent SSI. Skin preparation using chlorhexidine and alcohol solutions are recommended. Meticulous surgical technique and maintenance of sterile techniques should always be performed. Postoperatively, traditional methods of tissue oxygenation and glycemic control remain essential. Newer wound care methods such as silver impregnation dressing and wound-assisted vacuum dressing are encouraging but need further investigation. CONCLUSION: Significant reduction of SSIs is possible, but requires a systems approach involving all stakeholders. There are many simple and low-cost components that can be adjusted to reduce SSIs. Systematic efforts including understanding of pathophysiology, prevention strategies, and system-wide quality improvement programs demonstrate significant reduction of SSI.

Emerging Techniques in Degenerative Thoracolumbar Surgery.

There continue to be incremental advances in thoracolumbar spine surgery techniques in attempts to achieve more predictable outcomes, minimize risk of complications, speed recovery, and minimize the costs of these interventions. This paper reviews recent literature with regard to emerging techniques of interest in the surgical treatment of lumbar spinal stenosis, fusion fixation and graft material, degenerative lumbar spondylolisthesis, and thoracolumbar deformity and sacroiliac joint degeneration. There continue to be advances in minimal access options in these areas, although robust outcome data are heterogeneous in its support. The evidence in support of sacroiliac fusion appears to be growing more robust in the properly selected patient.

State of the Art in Degenerative Cervical Myelopathy: An Update on Current Clinical Evidence.

Degenerative cervical myelopathy (DCM) is a common cause of spinal cord dysfunction that confronts clinicians on a daily basis. Research performed over the past few decades has provided improved insight into the diagnosis, evaluation, and treatment of this disorder. We aim to provide clinicians with an update regarding the state of the art in DCM, focusing on more recent research pertaining to pathophysiology, natural history, treatment, consideration of the minimally symptomatic patient, surgical outcome prediction, and outcome measurement. Current concepts of pathophysiology focus on the combination of static and dynamic elements leading to breakdown of the blood-spinal cord barrier at the site of compression resulting in local inflammation, cellular dysfunction, and apoptosis. With respect to treatment, although there is a dearth of high-quality studies comparing surgical to nonoperative treatment, several large prospective studies have recently associated surgical management with clinically and statistically significant improvement in functional, disability, and quality of life outcome at long-term follow-up. When selecting the specific surgical intervention for a patient with DCM, anterior (discectomy, corpectomy, hybrid discectomy/corpectomy), posterior (laminectomy and fusion, laminoplasty), and combined approaches may be considered as options depending on the specifics of the patient in question; evidence supporting each of these approaches is reviewed in detail. Recently developed clinical prediction models allow for accurate forecasting of postoperative outcomes, permitting enhanced communication and management of patient expectations in the preoperative setting. Finally, an overview of outcome measures recommended for use in the assessment of DCM patients is provided.

Novel Osteobiologics and Biomaterials in the Treatment of Spinal Disorders.

Spinal osteobiologics have evolved substantially in this century after the development of many product categories such as growth factors, allograft, and stem cells. The indications for the use of novel biologics within spine surgery are rapidly expanding as the mechanism of each is elucidated. While the knowledge base of bone morphogenetic protein increases with each subsequent year, the application of new nanotechnology and cell-based strategies are being reported. This review will discuss the most recent data in novel osteobiologics, and where we could use future study.

Spontaneous Intracranial Hypotension: A Review and Introduction of an Algorithm For Management.

BACKGROUND: Spontaneous intracranial hypotension (SIH) is a condition of low cerebrospinal fluid volume and pressure caused by a leak of cerebrospinal fluid through a dural defect. Diagnosis and management can be difficult, often requiring coordination between multiple disciplines for myelography, blood patching, and possible surgical repair. Patients should be monitored closely, because they can deteriorate into a coma or even death. There are no widely accepted guidelines for the management of SIH. METHODS AND CONCLUSIONS: We review the existing SIH literature, illustrate management challenges via a case review, and propose an algorithm developed by neurosurgeons, radiologists, and anesthesiologists intended to simplify and streamline the management of SIH.

Patient Perspectives Regarding Ethics of Spinal Column Stimulators in the Surgical Management of Persistent Postoperative Neuropathic Pain.

OBJECTIVE: The aim of this study is to better understand perspectives of patients with persistent postoperative neuropathic pain (PPNP) and assess perceptions of the ethical issues surrounding their structural spinal surgeon also performing spinal cord stimulation (SCS). METHODS: Semistructured face-to-face interviews with 20 neurosurgical spine patients were conducted. Patients were recruited from the neurosurgery clinics at Toronto Western Hospital and were seen in consultation for PPNP. Interviews were transcribed and subjected to thematic analysis using open and axial coding. RESULTS: The range of the duration of participants' preoperative symptoms varied from one month to more than 20 years, and was primarily back dominant (13/20). The median time since patients most recently underwent spinal surgery was three years. The majority of patients (15/20) do not view their current condition of PPNP as a failure of their initial spine surgeon. The most commonly reported reason for this is that patients trusted their physician and clear communication between the physician and the patient, prior to their surgery, ensured an understanding of the goals of the procedure. Nearly unanimously (19/20), patients did not perceive an ethical problem with a surgeon performing a structurally corrective spinal surgery and subsequently also implanting a SCS device if the same patient that develops medically refractory PPNP. CONCLUSIONS: This is the first clinical qualitative study of values and ethical perceptions of patients with medically refractory PPNP. Our findings provide a framework for understanding the values of patients with PPNP and demonstrate that a strong surgeon-patient relationship can ameliorate concerns surrounding PPNP and SCS implantation.

Social Media for Academic Neurosurgical Programs: The University of Toronto Experience.

BACKGROUND: There is a paucity of available strategies to increase visibility and engagement in social media (SM) within the neurosurgical community. The objective of this study was to investigate the possible factors for engagement and reach among SM users in neurosurgery. METHODS: Data from Facebook and Twitter accounts of our institution were collected. We extracted data on demographics and attributes of our current users, including sex, country, age group, device used, and language. Attributes of SM posts were also collected, including time of post, type and content of post, impressions, and engagements. Nonparametric analyses were conducted to evaluate differences in metrics. RESULTS: Metrics were obtained on 192 Facebook and Twitter posts, published online between October 1, 2013, and March 13, 2016. On both platforms, there was a greater representation of male users relative to female users. Facebook users were predominantly in the 18-34 years age range (83%), with most users being from outside of North America. Conversely, users from Canada and the United States comprised the highest proportion of Twitter users. On both platforms, posts containing photos or videos scored significantly higher in engagements and impressions (P < 0.05). Posts on weekdays and during work hours achieved higher visibility and engagements. Moreover, Facebook posts demonstrated higher SM metrics if they mentioned faculty with more than 16 years' experience (P < 0.05). CONCLUSIONS: The current study demonstrates that our SM users predominantly comprise a younger demographic and that content optimization with media materials may lead to higher visibility and engagement. The impact of high SM reach on academic neurosurgical programs remains to be determined.

How Best to Manage the Spinal Epidural Abscess? A Current Systematic Review.

BACKGROUND: A spinal epidural abscess is a medical emergency. Despite urgent surgical intervention and adjuvant antibiotic therapy, neurologic prognosis remains variable and guarded. The optimal approach to managing this condition is debated with substantial variability in clinical practice, dependent on patient demographic and pretreatment neurologic status as well as radiologic appearance. METHODS: A systematic search in MEDLINE and similar databases was conducted for literature published from 1990 to 2015 using the search term "spinal epidural abscess", limiting the search results to human studies published in the English language. Case series that consisted of fewer than 10 patients were excluded. The evidence strength was graded according to the Grades of Recommendation Assessment, Development, and Evaluation criteria. RESULTS: The search yielded 1843 patients from 34 retrospective case series. Ten studies compared surgical and medical management, with no significant difference in patients with good outcome (odds ratio, 0.65; P = 0.11) or neurologic improvement (odds ratio, 1.11; P = 0.69). However, failure rates after initial medical management requiring surgical intervention ranged from 10% to 50%. Three of 4 studies evaluating timing of surgery reported large effect sizes for neurologic outcome if early surgery was performed (P < 0.01). Other prognostic factors from a neurologic perspective included admission neurologic status, patient age, and diabetes mellitus. CONCLUSIONS: Surgery with adjuvant antibiotics remains the optimal treatment for the neurologically symptomatic patient with spinal epidural abscess. If antibiotic therapy alone is considered for the neurologically intact patient, we recommend interdisciplinary medical and surgical consultations with an in-depth dialogue on the potential for failure in isolated medical management and the recommendation for close neurologic monitoring.

Chronic infection of a Brindley sacral nerve root stimulator.

The Finetech-Brindley sacral anterior root stimulator (SARS) is implanted for the treatment of bladder dysfunction following spinal cord injury (SCI) and has been successful in improving micturition in many patients with SCI. This case describes a 62-year-old man who presented with a chronic Staphylococcus aureus infection of a Brindley SARS 26 years after implantation following a T5 American Spinal Injury Association A spinal cord injury (T5 ASIA A SCI). He presented with chronic sacral osteomyelitis with a history of periodic implant erosion through the skin. Following a series of interventions, definitive management involved removal of the intradural electrodes and epidural and intradural phlegmon, ligation of the thecal sac and flap reconstruction. In the case of delayed infection of a Brindley SARS, removal of the entire system should be considered, especially if extension of the infection to the intradural compartment is suspected.

Chronic hypertrophic nonunion of the Type II odontoid fracture causing cervical myelopathy: Case report and review of literature.

BACKGROUND: Complications of nonunited Type II odontoid fractures can range from neck pain to progressive neurological deficit from cervical myelopathy. Rarely, the hypertrophic nonunion requires both anterior transoral decompression and posterior decompression with instrumented fusion. We present a case and review literature around this entity. CASE DESCRIPTION: A 68-year-old female presented with rapidly progressive cervical myelopathy (from normal to moderate myelopathy modified Japanese Orthopedic Association [mJOA] 13) over 3 months. Her history was positive for a Type II odontoid fracture managed conservatively and lost to follow-up for 25 years. Spinal imaging studies revealed hypertrophic nonunion and craniocervical kyphotic deformity with significant subaxial stenosis and segmental kyphosis. The patient underwent anterior transoral decompression, followed by posterior occipitothoracic decompression and instrumented fusion. At follow-up, the cervical myelopathy has improved to near normalcy (mJOA 17) with no evidence or implant-related complication. CONCLUSION: Rarely, nonunion of Type II odontoid fractures may be hypertrophic where both instability and compression cause neurological morbidity. Such cases require anterior transoral decompression, posterior cervical decompression, and instrumented fusions.

Social Media Metrics and Bibliometric Profiles of Neurosurgical Departments and Journals: Is There a Relationship?

BACKGROUND: Social media plays an increasingly important role in dissemination of knowledge and raising awareness of selected topics among the general public and the academic community. OBJECTIVE: To investigate the relationship between social media metrics and academic indices of neurosurgical programs and journals. METHODS: A 2-step online search was performed to identify official social media accounts of neurosurgical departments that were accredited by the Accreditation Council for Graduate Medical Education and the Royal College of Physicians and Surgeons of Canada. Dedicated neurosurgery and spine journals' social media accounts also were identified through an online search on SCImago Journal and Country Rank portal. Nonparametric tests were performed with bootstrapping to compare groups and to look for correlations between social media and academic metrics. RESULTS: We identified 36 social media accounts officially affiliated with academic neurosurgical institutions. These accounts represented 22 of 119 neurosurgical programs in North America (18.4%). The presence of a social media account for neurosurgical departments was associated with statistically significant higher values of academic impact metrics (P < 0.05). Specific social media metrics for neurosurgical department accounts, however, did not correlate with any values of academic indices. For journals, there were 11 journals present on social media and had greater academic metrics compared with journals without social media presence (P < 0.05). CONCLUSIONS: Social media presence is associated with stronger academic bibliometrics profiles for both neurosurgical departments and journals. The impact of social media metrics on indices of scientific impact in neurosurgery is not known.

Neurosurgical patients' perceptions of the "surgeon+": a qualitative study.

OBJECTIVE: Neurosurgical patients bear a varying degree of anxiety when confronted with having to undergo surgery or even visit with a neurosurgeon in consultation. Previous studies have suggested that patient perceptions can heavily influence the patient-physician encounter. Accordingly, a better understanding of these perceptions can marshal our knowledge regarding strategies for improving patient-physician interactions during such an apprehensive time. The aim of the present study was to qualitatively examine patient values and preferences for a neurosurgeon who participates in extraclinical activities (i.e., a "neurosurgeon+") and understand the factors that influence these perceptions. METHODS: Semistructured face-to-face interviews with 47 neurosurgical patients were conducted. Patients were recruited from the Toronto Western Hospital neurosurgery clinics for cranial and spinal conditions. Descriptive summary statistics were used to characterize the study participants. Family members were encouraged to contribute to the interviews. Interviews were audio-recorded, transcribed, and subjected to thematic analysis by using open and axial coding. RESULTS: Patients generally indicated that they want to feel confident in their neurosurgeon. A number of factors contribute to this confidence, including a strong positive referral from another physician. Patients are inclined to search for information pertaining to the qualifications of neurosurgeons online, and a perception of the neurosurgeon's adeptness given his or her qualifications is important for patients. Although there were some differences in patient values between those in the cranial and spinal groups, overall, neurosurgical patients tend to positively view their neurosurgeon's involvement in extraclinical duties. CONCLUSIONS: This study details the first comprehensive clinical qualitative study of patient perceptions of neurosurgeons and provides a descriptive framework for understanding patient values in this clinical domain.

Use of neuropathic pain questionnaires in predicting persistent postoperative neuropathic pain following lumbar discectomy for radiculopathy.

OBJECT Failed-back surgery syndrome has been historically used to describe extremity neuropathic pain in lumbar disease despite structurally corrective spinal surgery. It is unclear whether specific preoperative pain characteristics can help determine which patients may be susceptible to such postoperative disabling symptoms. METHODS This prospective study analyzed surgical microdiscectomy patients treated for lumbar, degenerative, painful radiculopathy. Clinical parameters included general demographics, preoperative and postoperative clinical examination status, self-reported pain and disability scores, and neuropathic pain scores. The screening tests for neuropathic pain were the Douleur Neuropathique 4 and Leeds Assessment of Neuropathic Symptoms and Signs, with correlation tested for ordinal score and screen positivity. Multiple logistic regression analysis was used to define predictors of postoperative symptomatology. RESULTS Twelve percent of the 250 patients with radiculopathy who underwent microdiscectomy experienced persistent postoperative neuropathic pain (PPNP) with only modest, if any, relief of leg pain. The condition was highly associated with abnormal preoperative screen results for neuropathic pain, but not sex, smoking status, or preoperative pain severity (α = 0.05). Good correlation was seen between the 2 screening tests used in this study for both absolute ordinal score (Spearman ρ = 0.84; p < 0.001) and the threshold for terming the patient as having neuropathic pain features (Spearman ρ = 0.48; p < 0.001). Younger age at treatment also correlated with a higher likelihood of developing PPNP (p = 0.03). CONCLUSIONS This population exhibited a low overall frequency of PPNP. Higher neuropathic pain screening scores correlated strongly with likelihood of significant postoperative leg pain. Further work is required to develop more accurate prognostication tools for radiculopathy patients undergoing structural spinal surgery.

The Association of Cervical Spine Alignment with Neurologic Recovery in a Prospective Cohort of Patients with Surgical Myelopathy: Analysis of a Series of 124 Cases.

BACKGROUND: Cervical spine sagittal malalignment has been demonstrated to correlate with the severity of disease in patients with cervical spondylotic myelopathy (CSM). The impact of spinal alignment on neurologic recovery has not been investigated thoroughly. The goal of this study was to evaluate the variable impact of preoperative sagittal alignment on neurologic recovery among surgical myelopathic patients. METHODS: An analysis of prospectively collected data was performed on surgical CSM patients treated at a tertiary neurosurgical center. Demographic data and preoperative and postoperative measures of neurologic disability (modified Japanese Orthopedic Association [mJOA] score, Nurick grade, Neck Disability Index) were analyzed for dependency on cervical spine alignment (kyphotic vs. lordotic) as well as preoperative disease severity and spinal cord magnetic resonance imaging. RESULTS: Thirty-four percent of 124 CSM patients had preoperative kyphosis. Surgical intervention was more frequently anterior or combined anterior/posterior among this group than those with preserved lordosis. Most patients exhibited postoperative neurologic improvement; however, the extent was dichotomous, with greater improvement among patients with preoperative lordosis (ΔmJOA 3.1) than with preoperative kyphosis (ΔmJOA 1.4, P = 0.02). More severe preoperative disease and quantitative magnetic resonance imaging T2 hyperintensity also predicted poorer recovery (α = 0.05). Lordotic patients exhibited similar improvement when approached anteriorly or posteriorly, whereas kyphotic patients exhibited greater improvement when approached by an anterior or combined approach. It is unclear whether restoring lordosis protects against adjacent segment disease. CONCLUSIONS: The majority of patients with CSM showed postoperative neurologic improvement. Patients with preoperative lordotic alignment exhibited greater improvement than those with preoperative kyphotic alignment. Furthermore, the choice of surgical approach impacted neurologic recovery among kyphotic patients, with those patients who were approached anteriorly or with a combined approach faring better.