Successful Implantation of a Ventricular Shunt With Termination in the Iliac Bone in the Adult Patient With Obstructive Hydrocephalus.

BACKGROUND AND IMPORTANCE: With the exception of the 3 classic shunt placement options (ventriculoperitoneal, ventriculopleural, and ventriculoatrial), surgically feasible alternative sites for distal catheter placement remain limited and often require the assistance of an access surgeon. Tubbs et al suggested the possibility of intraosseous cerebrospinal fluid diversion in the ilium, noting that ilium infusion in cadaveric specimens was possible without the development of body edema or fluid overflow. Since this publication, limited case reports have been published on the success of ventriculo-ilium (VI) shunt placement. Here, we describe the technique used for successful VI shunt placement in 2 adult patients. CLINICAL PRESENTATION: Here, we describe 2 patients with differing etiologies of hydrocephalus (obstructive and nonobstructive) and complex medical and surgical problems precluding traditional distal shunt termini. Both patients underwent successful placement of a VI shunt with distal catheter placement into the right iliac crest using a small right-angle connector and small cranial fixation plate to prevent backout of the catheter. DISCUSSION AND CONCLUSION: We report the first demonstration of successful placement of a VI shunt in 2 adult patients with evidence of shunt functionality and improved neurological outcome. We propose that the placement of a VI shunt is an easy and viable option when more traditional shunt methods are not available for use.

Clinical Guidelines for the Evaluation and Treatment of Lumbar Disc Herniations: How Accurate is the Internet?

OBJECTIVE: To compare information online regarding lumbar disc herniation (LDH) on commonly searched websites and compare those findings with the evidence-based recommendations listed in the North American Spine Society (NASS) clinical practice guidelines. METHODS: NASS Clinical Practice Guidelines, Internet searches were performed utilizing three common search engines (Google, Bing, Yahoo) and keywords associated with LDH. The top 20 websites from each search were selected. The content regarding diagnosis and treatment of LDH was compared to the NASS clinical practice guidelines. RESULTS: On average, websites mentioned only 59% of recommendations supported by Level I evidence. Websites included an average of 3 recommendations not discussed in the NASS guidelines out of an average of 12 total recommendations. Muscle and sensory testing and physical therapy were the most frequent recommendations, appearing on over 80% of websites. Websites were equally likely to contain recommendations backed by high-quality evidence as recommendations not included in NASS guidelines. CONCLUSIONS: This study demonstrates that websites regarding LDH contain a mix of information, with only a fraction of recommendations aligning with NASS clinical guidelines. Patients who use these websites are presented with unsubstantiated information, conceivably impacting their understanding, expectations and decision-making in physician offices.

What is the fate of the adjacent segmental angles 6 months after single-level L3-4 or L4-5 lateral lumbar interbody fusion?

BACKGROUND CONTEXT: Lateral lumbar interbody fusion (LLIF) is an effective technique for fusion and sagittal alignment correction/maintenance. Studies have investigated the impact on the segmental angle and lumbar lordosis (and pelvic incidence-lumbar lordosis mismatch), however not much is documented regarding the immediate compensation of the adjacent angles. PURPOSE: To evaluate acute adjacent and segmental angle as well as lumbar lordosis changes in patients undergoing a L3-4 or L4-5 LLIF for degenerative pathology. STUDY DESIGN/SETTING: Retrospective cohort study. PATIENT SAMPLE: Patients included in this study were analyzed pre- and post-LLIF performed by one of three fellowship-trained spine surgeons, 6 months following surgery. OUTCOME MEASURES: Patient demographics (including body mass index, diabetes diagnosis, age, and sex) as well as VAS and ODI scores were measured. Lateral lumbar radiograph parameters: lumbar lordosis (LL), segmental lordosis (SL), infra and supra-adjacent segmental angle, and pelvic incidence (PI). METHODS: Multiple regressions were applied for the main hypothesis tests. We examined any interactive effects at each operative level and used the 95% confidence intervals to determine significance: a confidence interval excluding zero indicates a significant effect. RESULTS: We identified 84 patients who underwent a single level LLIF (61 at L4-5, 23 at L3-4). For both the overall sample and at each operative level, the operative segmental angle was significantly more lordotic postop compared to preop (all ps≤.01). Adjacent segmental angles were significantly less lordotic postop compared to pre-op overall (p=.001). For the overall sample, greater lordotic change at the operative segment led to more compensatory reduction of lordosis at the supra-adjacent segment. At L4-5, more lordotic change at the operative segment led to more compensatory lordosis reduction at the infra-adjacent segment. CONCLUSION: The present study demonstrated that LLIF resulted in significant increase in operative level lordosis and a compensatory decrease in supra- and infra-adjacent level lordosis, and subsequently no significant impact on spinopelvic mismatch.

Incidence, etiology and time course of delays to adult spinal deformity surgery: a single-center experience.

PURPOSE: We sought to determine the incidence, origin, and timeframe of delays to adult spinal deformity surgery so that institutions using preoperative multidisciplinary patient assessment teams might better anticipate and address these potential delays. METHODS: Complex spine procedures for treatment of adult spinal deformity from 1/1/18 to 8/31/21 were identified. Procedures for infection, tumor, and urgent/emergent cases were excluded. Operations delayed due to COVID or those that were performed outside of our established perioperative care pathway were also excluded. The electronic health record was used to identify the etiology and timeline of all pre- and peri-operative delays. RESULTS: Of 235 patients scheduled for complex spine surgery, 193 met criteria for inclusion. Of these patients, 35 patients experienced a surgical delay (18.1%) with a total of 41 delays recorded. Reasons for delay include medically unoptimized (25.6%), intraoperative complication (17.9%), patient directed delay (17.9%), patient illness/injury (15.4%), scheduling complication (10.3%), insurance delay/denial (5.1%), and unknown (2.6%). Twenty-four delays experienced by 22 individuals occurred within 7 days of their scheduled surgery date. CONCLUSION: At a single multidisciplinary center, most delays to adult spinal deformity surgery occur before a patient is admitted to the hospital, and for recommendations of additional medical workup/clearance. We suspect that the preoperative protocol might increase pre-admission delays for unoptimized patients, as the protocol is intended to ensure patients receive surgery only when they are medically ready. Further research is needed to determine the economic and system impact of delays related to a preoperative optimization protocol weighed against the reduction in adverse events these protocols can provide.

Anterior Cervical Corpectomy and Fusion for Degenerative Cervical Spondylotic Myelopathy: Case Presentation With Surgical Technique Demonstration and Review of Literature.

Anterior cervical corpectomy and fusion (ACCF) provides an extensive decompression and provides a large surface area for fusion in patients presenting with cervical spondylotic myelopathy. Unfortunately, this procedure is a more difficult spinal surgery to perform (compared with a traditional anterior cervical discectomy and fusion) and has a higher incidence of overall complications. In literature, ACCF has functional outcomes that seem clinically equivalent to those for multilevel anterior cervical discectomy and fusion, especially when contained to 1 vertebral body level, and in cases, for which both posterior and anterior procedures would be appropriate surgical options, may provide greater long-term clinical benefit than posterior fusion or laminoplasty. In this manuscript, we summarize the indications and outcomes following ACCF for degenerative cervical spondylotic myelopathy. We then describe a case presentation and associated surgical technique with a discussion of complication avoidance with this procedure.

The Impact of Surgical Approach on Sagittal Plane Alignment in Patients Undergoing One- or Two- Level Fusions for Degenerative Pathology: A Multicenter Radiographic Evaluation 6 Months Following Surgery.

OBJECTIVE: Interbody fusion procedures, including transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF), effectively treat lumbar degenerative pathology and provide spinopelvic balance. The objective of this study is to compare changes in spinopelvic parameters 6 months following 1-2 level TLIF, PLIF, ALIF, and LLIF. METHODS: This retrospective study included 18 centers across the United States. Patients were included in the study if they underwent a 1- or 2-level primary lumbar fusion for degenerative pathology. Preoperative and 6-month postoperative lumbar anteroposterior and lateral lumbar plain radiograph measurements included: pelvic incidence, pelvic tilt, lumbar lordosis from L1-S1, and segmental lordosis of each segment between L1 and S1. RESULTS: A total of 474 patients met inclusion criteria, with 632 levels that underwent fusion. Of these, 181 patients underwent an ALIF/LLIF on 381 levels, and 188 underwent a TLIF/PLIF on 252 levels. ALIF/LLIF procedures resulted in significantly more segmental lordosis (P < 0.001) and global lumbar lordotic alignment change (P < 0.01) compared with TLIF/PLIF procedures. Whether patients' alignment was preserved versus worsened was not significantly predicted by type of procedure. Similarly, whether patients' alignment was restored versus not corrected was not significantly predicted by procedure. CONCLUSIONS: In this large-scale multicenter study of lumbar fusion patients presenting with degenerative lumbar pathology, anteriorly placed grafts (ALIF/LLIF) led to a greater likelihood of patients being preserved rather than worsened in their spinopelvic mismatch. Posteriorly placed TLIF or PLIF grafts tended to worsen lordosis both segmentally and globally, yet even the anterior grafts only modestly improved those 2 same measurements.

The impact of interbody approach and lumbar level on segmental, adjacent, and sagittal alignment in degenerative lumbar pathology: a radiographic analysis six months following surgery.

BACKGROUND CONTEXT: Interbody fusion, including: transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF); effectively treat lumbar degenerative pathology and provide spinopelvic balance. Although the decision on surgical approach and technique are multifactorial and patient specific, the impact of the interbody approach on segmental and adjacent level lordosis could be an important factor to consider during pre-operative planning to achieve pre-specified alignment goals. PURPOSE: The purpose of this study is to compare the 6-month postoperative radiographic outcomes in the lumbar spine following 1 to 2 level transforaminal (TLIF), posterior (PLIF), anterior (ALIF), and lateral (LLIF) interbody fusions at the L3-4, L4-5, and L5-S1 levels. As our primary outcome, we evaluated the change in segmental lordosis at the level of fusion in ALIF/LLIF approaches compared to TLIF/PLIF. Secondarily, we evaluated the pelvic incidence to lumbar lordosis (PI-LL) mismatch and examined the compensatory lordotic changes at the adjacent levels 6 months following surgery. STUDY DESIGN: Retrospective cohort. PATIENT SAMPLE: This retrospective study included 18 centers of various practice settings across the United States. Patients were included in the study if they underwent a one- or two-level primary lumbar fusion for degenerative pathology. OUTCOMES MEASURES: Measurements of the pre-operative and 6-month post-operative lumbar AP and lateral lumbar plain radiographs included: pelvic incidence (PI), pelvic tilt, lumbar lordosis from L1-S1 (LL), as well as segmental lordosis (SL) of each segment between L1-S1. METHODS: Due to there being 2 evaluated time points, patients were then grouped based on alignment into categories of preserved, restored, not corrected, and worsened. RESULTS: 474 patients underwent 608 levels of fusion. ALIF/LLIF resulted in significantly more segmental lordosis compared to TLIF/PLIF procedures at both L4-5 and L5-S1 (p<.001). Overall, ALIF/LLIF resulted in significantly more global lumbar lordotic alignment change compared to TLIF/PLIF (p=.01). Whether patients' alignment was preserved versus worsened was not significantly predicted by type of procedure. Similarly, whether patients' alignment was restored versus not corrected was not significantly predicted by type of procedure. Finally, anterior approaches resulted in decreased lordosis at adjacent levels, thus resulting in a more neutral position. CONCLUSION: In this large multicenter retrospective study of 1 to 2 level interbody fusion surgeries, we identified that A/LLIF procedures at L4-L5 and L5-S1 resulted in greater segmental lordosis restoration and PI-LL mismatch improvement compared to T/PLIF procedures. A/LLIF may also significantly reduce lordosis (compared to T/PLIF) at the adjacent levels in a fashion that serves to reduce the lumbar lordosis that may have been increased at the fused level.

Team Approach: Safety and Value in the Practice of Complex Adult Spinal Surgery.

Surgical management of complex adult spinal deformities is of high risk, with a substantial risk of operative mortality. Current evidence shows that potential risk and morbidity resulting from surgery for complex spinal deformity may be minimized through risk-factor optimization. The multidisciplinary team care model includes neurosurgeons, orthopaedic surgeons, physiatrists, anesthesiologists, hospitalists, psychologists, physical therapists, specialized physician assistants, and nurses. The multidisciplinary care model mimics previously described integrated care pathways designed to offer a structured means of providing a comprehensive preoperative medical evaluation and evidence-based multimodal perioperative care. The role of each team member is illustrated in the case of a 66-year-old male patient with previous incomplete spinal cord injury, now presenting with Charcot spinal arthropathy and progressive vertebral-body destruction resulting in lumbar kyphosis.

Outcomes Surrounding Perioperative Transfusion Rates and Hemoglobin Nadir Values Following Complex Spine Surgery.

BACKGROUND: Optimal transfusion thresholds have been extensively studied for various surgical procedures; however, no transfusion threshold has been set for patients undergoing complex spine surgery. The aim of this study was to compare postoperative outcomes relative to perioperative hemoglobin (Hb) levels for patients undergoing complex spine surgery for adult spinal deformity and to evaluate impact of blood transfusion timing on clinical outcomes. METHODS: Retrospective chart review of patients with adult spinal deformity undergoing spine surgery lasting >6 hours or involving ≥6 levels of fusion was performed. Patients were divided into 2 cohorts based on whole hospitalization Hb nadir <9.0 g/dL versus ≥9.0 g/dL. RESULTS: Among 104 patients, 55 (52.9%) had Hb nadir <9.0 g/dL. Compared with the cohort with higher Hb nadir, patients with Hb nadir <9.0 g/dL were more likely to be female (84.5% vs. 65.3%, P = 0.016), present with lower preoperative Hb (12.6 [1.5] g/dL vs. 13.8 [1.2] g/dL, P < 0.001), experience greater change in Hb after surgery (4.4 [1.5] g/dL vs. 3.7 [1.5] g/dL, P = 0.030), receive a postoperative blood transfusion (69.1% vs. 44.9%, P = 0.013), and have a longer length of stay (9.1 [4.8] days vs. 6.2 [3.2] days, P < 0.001). CONCLUSIONS: In patients with adult spinal deformity undergoing complex spine surgery, earlier targeted blood transfusions during surgery, rather than in the postoperative period, may lead to improved postoperative outcomes.

Effect of Tranexamic Acid on Blood Loss, D-Dimer, and Fibrinogen Kinetics in Adult Spinal Deformity Surgery.

BACKGROUND: Antifibrinolytics such as tranexamic acid reduce operative blood loss and blood product transfusion requirements in patients undergoing surgical correction of scoliosis. The factors involved in the unrelenting coagulopathy seen in scoliosis surgery are not well understood. One potential contributor is activation of the fibrinolytic system during a surgical procedure, likely related to clot dissolution and consumption of fibrinogen. The addition of tranexamic acid during a surgical procedure may mitigate the coagulopathy by impeding the derangement in D-dimer and fibrinogen kinetics. METHODS: We retrospectively studied consecutive patients who had undergone surgical correction of adult spinal deformity between January 2010 and July 2016 at our institution. Intraoperative hemostatic data, surgical time, estimated blood loss, and transfusion records were analyzed for patients before and after the addition of tranexamic acid to our protocol. Each patient who received tranexamic acid and met inclusion criteria was cohort-matched with a patient who underwent a surgical procedure without tranexamic acid administration. RESULTS: There were 17 patients in the tranexamic acid cohort, with a mean age of 60.7 years, and 17 patients in the control cohort, with a mean age of 60.9 years. Estimated blood loss (932 ± 539 mL compared with 1,800 ± 1,029 mL; p = 0.005) and packed red blood-cell transfusions (1.5 ± 1.6 units compared with 4.0 ± 2.1 units; p = 0.001) were significantly lower in the tranexamic acid cohort. In all single-stage surgical procedures that met inclusion criteria, the rise of D-dimer was attenuated from 8.3 ± 5.0 µg/mL in the control cohort to 3.3 ± 3.2 µg/mL for the tranexamic acid cohort (p < 0.001). The consumption of fibrinogen was 98.4 ± 42.6 mg/dL in the control cohort but was reduced in the tranexamic acid cohort to 60.6 ± 35.1 mg/dL (p = 0.004). CONCLUSIONS: In patients undergoing spinal surgery, intravenous administration of tranexamic acid is effective at reducing intraoperative blood loss. Monitoring of D-dimer and fibrinogen during spinal surgery suggests that tranexamic acid impedes the fibrinolytic pathway by decreasing consumption of fibrinogen and clot dissolution as evidenced by the reduced formation of D-dimer. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Multicenter Radiographic Evaluation of the Rates of Preoperative and Postoperative Malalignment in Degenerative Spinal Fusions.

STUDY DESIGN: Multicenter, retrospective, institutional-review-board -approved study at 18 institutions in the United States with 24 treating investigators. OBJECTIVE: This study was designed to retrospectively assess the prevalence of spinopelvic malalignment in patients who underwent one- or two-level lumbar fusions for degenerative (nondeformity) indications and to assess the incidence of malalignment after fusion surgery as well as the rate of alignment preservation and/or correction in this population. SUMMARY OF BACKGROUND DATA: Spinopelvic malalignment after lumbar fusion has been associated with lower postoperative health-related quality of life and elevated risk of adjacent segment failure. The prevalence of spinopelvic malalignment in short-segment degenerative lumbar fusion procedures from a large sample of patients is heretofore unreported and may lead to an under-appreciation of these factors in surgical planning and ultimate preservation or correction of alignment. METHODS: Lateral preoperative and postoperative lumbar radiographs were retrospectively acquired from 578 one- or two-level lumbar fusion patients and newly measured for lumbar lordosis (LL), pelvic incidence (PI), and pelvic tilt. Patients were categorized at preop and postop time points as aligned if PI-LL < 10° or malaligned if PI-LL≥10°. Patients were grouped into categories based on their alignment progression from pre- to postoperative, with preserved (aligned to aligned), restored (malaligned to aligned), not corrected (malaligned to malaligned), and worsened (aligned to malaligned) designations. RESULTS: Preoperatively, 173 (30%) patients exhibited malalignment. Postoperatively, 161 (28%) of patients were malaligned. Alignment was preserved in 63%, restored in 9%, not corrected in 21%, and worsened in 7% of patients. CONCLUSION: This is the first multicenter study to evaluate the preoperative prevalence and postoperative incidence of spinopelvic malalignment in a large series of short-segment degenerative lumbar fusions, finding over 25% of patients out of alignment at both time points, suggesting that alignment preservation/restoration considerations should be incorporated into the decision-making of even degenerative lumbar spinal fusions. LEVEL OF EVIDENCE: 3.

Use of patient-reported outcomes and satisfaction for quality assessments.

OBJECTIVES: Recent focus on patient-reported outcomes (PROs) has created a new challenge as we learn how to integrate these outcomes into practice along with other quality metrics. We investigated the relationship between PROs and satisfaction among spine surgery patients. We hypothesized that there would be significant disparities between patient satisfaction and PROs at the 1-year postoperative time point. STUDY DESIGN: Retrospective cohort study of adults undergoing elective lumbar spine surgery at 12 hospitals participating in the Spine Surgical Care and Outcomes Assessment Program. METHODS: Satisfaction, pain, and function scores were collected at 1 year post operation, along with clinical information, to determine the relationship between PROs and satisfaction at the patient level. RESULTS: Among 520 patients (mean age = 63 ± 13 years; 47% male), the majority of patients (82%) reported being satisfied with surgery. Satisfaction was associated with both improvement in pain (odds ratio [OR], 1.33; 95% CI, 1.17-1.51) and function (OR, 1.06; 95% CI, 1.04-1.08). However, even among patients who did not improve in pain or function, more than half (59%) reported being satisfied. CONCLUSIONS: Overall, patients undergoing elective lumbar spine surgery reported being satisfied with outcomes, but the reported responses in PROs were much more variable. As the expectations increase to include PRO measures as valid quality indicators, it is necessary to dedicate time and consideration to understanding the relationships among these measures to support meaningful translations into healthcare policy.

Diagnosis and Treatment of Cervical Radiculopathy and Myelopathy.

This article is a guideline covering a wide array of cervical conditions seen in the workers' compensation, as well as the nonworkers' compensation, population. The guideline is intended to provide a diagnostic and treatment algorithm to commonly seen cervical conditions such as single-level and multilevel radiculopathies and myelopathies.

Choroid plexectomy reduces neurosurgical intervention in patients with hydranencephaly.

INTRODUCTION: The removal of the choroid plexus from the lateral ventricles was attempted by Dandy in the early 20th century but later discarded as complications arose and other methods of cerebrospinal fluid (CSF) diversion were introduced. We compare our experience with a variation of this operation to CSF diversion in patients with hydranencephaly or near hydranencephaly. METHODS: The hospital and office charts of patients with a diagnosis of hydranencephaly were reviewed from the two institutions spanning the career of the senior author. Thirteen patients were identified, of whom 9 underwent CSF diversionary procedures (group A) and 4 underwent choroid plexectomy (group B). RESULTS: The mean number of reoperations (2 in group A, 0 in group B), neurosurgical readmissions (1.5 in group A, 0 in group B) and days of hospitalization related to neurosurgical readmissions (43.5 in group A, 0 in group B) were all less in patients who underwent choroid plexectomy. The total incidence of complications related to surgery was also lower in this group (7 in group A, 0 in group B). CONCLUSION: In our experience, choroid plexectomy in patients with hydranencephaly reduces the incidence of reoperation and readmission, the number of days of hospitalization related to the surgical procedure and the total number of complications in comparison to patients undergoing CSF diversion. Further neurosurgical intervention is minimized as is the financial burden from multiple emergency department visits and radiological procedures for shunt evaluation. Choroid plexectomy is a viable alternative to CSF diversion in patients with hydranencephaly and a rapidly enlarging head. It avoids the chronic issues and complications surrounding CSF diversion in this difficult group of patients.