3D-Printed Spine Models for Planning Staged Minimally Invasive Transverse Process Resections for Bertolotti Syndrome: Technical Note.

Background: Three-dimensional (3D) printing has enabled numerous advances in spine surgery execution and education. However, few examples exist to outline how this technology can aid the performance of complex spine surgery using minimally invasive surgery (MIS) techniques. Therefore, we present a case that illustrates the benefits of 3D-printed spine model production before and after correction of a congenital lumbosacral anomaly using an MIS approach. Case Report: A 40-year-old woman with Bertolotti syndrome underwent a staged bilateral L6 MIS transverse process resection for the treatment of severe and progressive axial back pain which had repeatedly failed conservative management. 3D-printed spine models were used for pre- and post-operative surgical planning and patient counseling. Conclusion: 3D-printed spine models can aid in the planning of complex spine cases suited for an MIS approach.

Transfusion Guidelines in Traumatic Brain Injury: A Systematic Review and Meta-Analysis of the Currently Available Evidence.

Our study aims to provide a synthesis of the best available evidence on the hemoglobin (hgb) red blood cell (RBC) transfusion thresholds in adult traumatic brain injury (TBI) patients, as well as describing the risk factors and outcomes associated with RBC transfusion in this population. A systematic review and meta-analysis was conducted using PubMed, Google Scholar, and Web of Science electronic databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to assess articles discussing RBC transfusion thresholds and describe complications secondary to transfusion in adult TBI patients in the perioperative period. Fifteen articles met search criteria and were reviewed for analysis. Compared to non-transfused, TBI patients who received transfusion tended to be primarily male patients with worse Injury Severity Score (ISS) and Glasgow Coma Scale. Further, the meta-analysis corroborated that transfused TBI patients are older (p = 0.04), have worse ISS scores (p = 0.001), receive more units of RBCs (p = 0.02), and have both higher mortality (p < 0.001) and complication rates (p < 0.0001). There were no differences identified in rates of hypertension, diabetes mellitus, and Abbreviated Injury Scale scores. Additionally, whereas many studies support restrictive (hgb <7 g/dL) transfusion thresholds over liberal (hgb <10 g/dL), our meta-analysis revealed no significant difference in mortality between those thresholds (p = 0.79). Current Class B/C level III evidence predominantly recommends against a liberal transfusion threshold of 10 g/dL for TBI patients (Class B/C level III), but our meta-analysis found no difference in survival between groups. There is evidence suggesting that an intermediate threshold between 7 and 9 g/dL, reflecting the physiological oxygen needs of cerebral tissue, may be worth exploring.

Anticoagulation in Elective Spine Cases: Rates of Hematomas Versus Thromboembolic Disease.

STUDY DESIGN: Retrospective cohort study with propensity matched cohorts. OBJECTIVE: The purpose of this study was to evaluate the association of anticoagulation with VTE and hematoma complications after spine surgery. SUMMARY OF BACKGROUND DATA: One of the major complications of surgery is VTE which can range in presentation. Spine surgery is an especially complex balance between minimizing the risk of a VTE event and also the increased risk of a hematoma which can lead to devastating neurological outcomes. METHODS: The elective spine surgery cases at a single academic center between 2015 and 2017 were identified. A total of 3790 patients were initially identified. Two hundred sixty patients were excluded. The cohort was then matched using a propensity score. This matched a single patient who did not receive anticoagulation to a single patient who did within the institution. This left a total of 1776 patients with 888 patients in each arm. RESULTS: The incidence of VTE, PE, and unplanned reoperation for hematoma in this cohort was 0.96%, 0.34%, and 1.13%, respectively. Predicted odds of VTE and PE were not significantly different; however, the odds of an unplanned reoperation for hematoma (odds ratio [OR] = 7.535, 95% confidence interval [CI]: 2.004-28.340, P = 0.002) were greater for those who received pharmacological anticoagulation in our institutional cohort. CONCLUSION: In this study, anticoagulation does not lead to lower rates of VTE events, but it increases the risk of symptomatic hematomas which require a return trip to the OR. While this was not a randomized controlled trial, we attempted to correct for this with propensity matching. Future randomized control trials would be needed.Level of Evidence: 3.

Bertolotti Syndrome With Articulated L5 Transverse Process Causing Intractable Back Pain: Surgical Video Showcasing a Minimally Invasive Approach for Disconnection: 2-Dimensional Operative Video.

Bertolotti syndrome is a commonly missed cause of intractable back pain that affects 4% to 8% of the general population. It involves the congenital malformation of a transitional lumbosacral vertebra, with total or partial and unilateral or bilateral transverse process (TP) fusion or articulation to the sacrum. The pain can be debilitating, and the tethering of the spine to the sacrum can encourage deformity formation in the coronal plane and lead to early degenerative changes, especially if present only unilaterally. We present the case of a 24-yr-old woman with no notable prior medical history who presented with years of lower axial back pain radiating to her thighs, which limited her activities of daily living and was resistant to conservative management. Her imaging showed an abnormally large left L5 TP, which was articulated to the sacrum, and signs of early coronal deformity. She had responded almost completely to repeated steroid injections into the TP-sacral joint, but that effect was very transient. Informed patient consent was obtained prior to her surgery. She underwent a minimally invasive tube disconnection of the abnormal joint with partial distal resection of the TP, and her symptoms completely resolved. This case highlights the importance of correlating clinical symptoms with aberrant anatomy, and the role of selective surgery in providing symptomatic relief. This case report was written in compliance with our institutional ethical review board approval, and patient consent was waived in light of the retrospective and deidentified nature of the data presented in accordance with the University of Texas Southwestern institutional review board.

Dermoid cysts of the conus medullaris: Clinical review, case series and management strategies.

BACKGROUND: The management of dermoid cysts can be tedious as they have a tendency to recur, and respond poorly to chemotherapy and radiation. Management is especially difficult for tumors involving highly eloquent areas such as the conus medullaris. OBJECTIVE: We aim to provide a summary of the pathology, clinical presentation, and operative management strategies of dermoid cysts involving the conus medullaris. METHODS: Two clinical cases of dermoid cysts of the conus are presented, as well as a commented surgical video. RESULTS: A 33 year-old man with a history of cystic conus medullaris tumor presented with progressive low back pain and loss of bowel and bladder function. His magnetic resonance imaging (MRI) scan showed recurrence of his tumor with tethering of the spinal cord. He was taken for a midline myelotomy that drained yellowish keratinous fluid and decompressed the cyst. No aggressive attempt at complete resection of the cyst wall was undertaken. He made a complete recovery after surgery. A 25 year-old woman with a history of dermoid cyst of the conus that was previously treated surgically, presented with lower extremity weakness and debilitating pain. Her MRI showed significant recurrence of the cystic lesion. She was taken for a midline myelotomy and improved after surgery with complete resolution of her symptoms. CONCLUSION: Dermoid cysts of the conus medullaris are challenging to treat. Surgical control and restraint are key, especially when patients are young and could potentially fully recover and remain in remission for a period of years.

A case series of pulsed radiofrequency treatment of myofascial trigger points and scar neuromas.

INTRODUCTION: Pulsed radiofrequency (PRF) current applied to nerve tissue to treat intractable pain has recently been proposed as a less neurodestructive alternative to continuous radiofrequency lesioning. Clinical reports using PRF have shown promise in the treatment of a variety of focal, neuropathic conditions. To date, scant data exist on the use of PRF to treat myofascial and neuromatous pain. METHODS: All cases in which PRF was used to treat myofascial (trigger point) and neuromatous pain within our practice were evaluated retrospectively for technique, efficacy, and complications. Trigger points were defined as localized, extremely tender areas in skeletal muscle that contained palpable, taut bands of muscle. RESULTS: Nine patients were treated over an 18-month period. All patients had longstanding myofascial or neuromatous pain that was refractory to previous medical management, physical therapy, and trigger point injections. Eight out of nine patients experienced 75-100% reduction in their pain following PRF treatment at initial evaluation 4 weeks following treatment. Six out of nine (67%) patients experienced 6 months to greater than 1 year of pain relief. One patient experienced no better relief in terms of degree of pain reduction or duration of benefit when compared with previous trigger point injections. No complications were noted. DISCUSSION: Our review suggests that PRF could be a minimally invasive, less neurodestructive treatment modality for these painful conditions and that further systematic evaluation of this treatment approach is warranted.

Successful treatment of chronic neuropathic pain with subcutaneous peripheral nerve stimulation: four case reports.

Introduction. Chronic pain is a prevalent medical condition in the general population and is one of the most common reasons patients visit their primary care doctors. When the pain is resistant to the common treatment modalities, it presents a challenge for the physician and may have profound consequences for the quality of life of the patient. Methods. We present four case reports in which subcutaneous peripheral nerve stimulation was successfully used to treat chronic neuropathic pain after all other treatment efforts had failed. Results. In all cases, the patients underwent a trial of peripheral nerve stimulation with good results. The patients reported decreased use of pain medications, increased quality of life, and high satisfaction with the procedure results. Conclusion. The use of subcutaneous peripheral nerve stimulation as a viable treatment alternative in certain cases of chronic neuropathic pain should continue to be rigorously evaluated.

Outcomes of percutaneous disc decompression utilizing nucleoplasty for the treatment of chronic discogenic pain.

BACKGROUND: Percutaneous disc decompression utilizing Nucleoplasty has emerged as one of the minimally invasive techniques for treatment of low back pain and lower extremity pain due to contained herniated discs. Only 1 study to date has examined its effect on functional activity and pain medication use; however, results were not analyzed over time, and recall bias was a limitation. OBJECTIVE: Evaluation of the effect of Nucleoplasty on pain and opioid use in improving functional activity in patients with radicular or axial low back pain secondary to contained herniated discs. DESIGN: Retrospective, non-randomized case series. METHODS: Twenty-two patients who had undergone Nucleoplasty were included in the analysis. Patients were evaluated at 1, 3, 6, and 12 months postoperatively, and were asked to quantify their pain using a visual analog scale ranging from 0 to 10. Patients were also surveyed in regards to their pain medication use, and functional status was quantified by a physical therapist who also used patient reports of ability to perform activities of daily living to assess status. Data were compared between baseline and at 1, 3, 6, and 12 months post-treatment. RESULTS: Reported pain and medication use were significantly decreased and functional status was improved at 1, 3, 6, and 12 months following Nucleoplasty (P values < or = 0.0010 for all outcome measures at all time periods). There were no complications associated with the procedure and we found continued improvements over time. CONCLUSION: Nucleoplasty appears to be safe and effective. Randomized, controlled studies are required to further evaluate its long-term efficacy.