Accuracy of Intraoperative Computed Tomography Assisted Dorsal Instrumentation in Spinal Revision Surgery.

PURPOSE: Instrumentation in spinal revision surgery is considered challenging. Altered or missing anatomical landmarks hinder the surgeons' intraoperative orientation. In recent history, the importance of navigated approaches to spinal screw placement is constantly increasing. A growing number of medical centers have introduced intraoperative CT (iCT) navigation as a new clinical standard. In this study, we compare the accuracy of dorsal iCT-navigated instrumentation in revision surgery versus primary interventions. METHODS: Between September 2017 and January 2019, we prospectively analyzed a consecutive series of dorsal instrumentation using iCT. Patients with previous operative interventions in the relevant spinal segments were included in the revision group and compared with a previously assessed group of primary interventions (nonrevision group). Each screw was assessed individually by an independent observer, making use of a modified Gertzbein and Robbins classification. RESULTS: In this period, 39 patients were treated in the revision group with a total amount of 269 implanted screws. We achieved an overall accuracy of 95.91% compared with 95.12% in the nonrevision group (46 patients, 287 screws). We found no significant difference in accuracy between the two groups or any anatomical region of the spine. CONCLUSION: In summary, iCT-navigated screw placement yields a good accuracy in spinal revision surgery, without significant difference to primary interventions.

Comparison of the Minimally Invasive Tubular Transmuscular Approach with the Conventional Microsurgical Approach for Microsurgical Treatment of Lumbar Disk Herniation: A Prospective Randomized Study.

BACKGROUND: The aim of this study is to compare the outcome of the minimally invasive transmuscular approach using a tubular retractor system (Metrx) with the conventional microsurgical standard approach (CM) for microsurgical treatment of lumbar disk herniation. METHODS: This is a prospective randomized controlled study with a 1:1 distribution of patients in CM and Metrx study groups. Two hundred and twenty-seven (117 CM and 110 Metrx) patients were included. The primary outcome parameters are postoperative pain intensity reduction, length of hospitalization, postoperative quality of life, and daily life performance based on the standardized questionnaires: Visual Analog Scale (VAS), 36-Item Short Form Survey (SF-36), Oswestry Disability Index (ODI), and Prolo scores. The secondary outcome parameters are intraoperative variables: surgery duration, blood loss, and fluoroscopy dose. RESULTS: There were no significant statistical differences in the primary outcome measures between the two groups with respect to postoperative pain relief (median VAS pre-op to 3 months post-op for sciatica: 9-2 [CM] vs. 8-2 [Metrx]; for lumbago: 7-2.5 [CM] vs. 6-3 [Metrx]), the length of hospitalization (median of 5 days), or the frequency of occupational reintegration after 3 months (59.1 vs. 60.7%). CONCLUSION: The microsurgical therapy of lumbar disk herniation via a Metrx approach is a safe and effective treatment option and is equivalent to the CM approach.

Current Practice of Neurosurgical Teleconsultation in Germany.

OBJECTIVE: As neurosurgery is a demanding specialty with services in larger medical centers only, consultation over larger distances plays an important role in health care. In times of digitalization, teleconsultation for medical images and cases plays an increasing role in neurosurgical services. However, no standards and demands have been established for its execution in the subfield of neurosurgery, so far. Therefore, as a first step, we performed a survey about the current state of teleconsultation in neurosurgery in Germany. METHODS: A standardized questionnaire consisting of 20 items was used to investigate the frequency of use and the operating conditions of teleconsultation in the field of neurosurgery. The survey was performed during the annual national German Society of Neurosurgery conference in 2017. Participation in the written survey was on voluntary and anonymous basis. RESULTS: In total, 296 individuals took part in the survey (140 specialists in neurosurgery, 77 residents). Among them, 71% were male and 121 worked at a university medical center. In total, 87.5% of all participants indicated that teleconsultation was used in their institutions (n = 113 in university medical centers and n = 76 in hospitals), and a vast majority stated to have had personal experience with it (88.6% of specialists, 85.5% of residents). The most frequent initial request for a consultation was done by phone call (80.3%). Images or data were then primarily transmitted via an electronic system (77.3%), followed by transmissions via CD or by post. The reply to a consultation was also mainly done by phone call (91.3%), followed by fax, or by e-mail. No standard protocol was followed by 78.6% of the respondents, and they stated not to know about the statutory and legal rules. However, it was stated that the protection of patient data was not endangered by using teleconsultation. The usefulness of teleconsultation and its future relevance were rated highly by the participants. The risk of misinterpretation of image data, especially without having direct access to other patient data, seemed to be a critical and unequivocal challenge. CONCLUSION: The results of the survey demonstrate that teleconsultation for medical images and cases is a frequently used and well-accepted tool in neurosurgical health care. However, a standardized neurosurgical procedure is still lacking and the statutory rules for this field of digital medicine are generally not known in our community. Potential misinterpretation and resulting misjudgment seem to be realistic drawbacks. Thus, we see a necessity for elaboration of guidelines for teleconsultation in neurosurgery on national and European basis.

Patients with degenerative cervical myelopathy have signs of blood spinal cord barrier disruption, and its magnitude correlates with myelopathy severity: a prospective comparative cohort study.

PURPOSE: The aim of this study is to detect the presence of blood spinal cord barrier (BSCB) disruption in patients with degenerative cervical myelopathy (DCM). METHODS: In this prospective non-randomized controlled cohort study, 28 patients with DCM were prospectively included. All patients had indication for neurosurgical decompression. Furthermore, 38 controls with thoracic abdominal aortic aneurysm (TAAA) and indication for surgery were included. All patients underwent neurological examination. Regarding BSCB disruption and intrathecal immunoglobulin (Ig) concentrations, cerebrospinal fluid (CSF) and blood serum were examined for albumin, IgG, IgA and IgM. Quotients (Q) (CSF/serum) were standardized and calculated according to Reibers' diagnostic criteria. RESULTS: Patients and controls distinguished significantly in their clinical status. AlbuminQ, as expression of BSCB disruption, was significantly increased in the DCM patients compared to the controls. Quotients of IgG and IgA differed significantly between the groups as an expression of intrathecal diffusion. In the subgroup analysis of patients with mild/moderate clinical status of myelopathy and patients with severe clinical status, the disruption of the BSCB was significantly increased with clinical severity. Likewise, IgAQ and IgGQ presented increased quotients related to the clinical severity of myelopathy. CONCLUSION: In this study, we detected an increased permeability and disruption of the BSCB in DCM patients. The severity of BSCB disruption and the diffusion of Ig are related to the clinical status in our patient cohort. Having documented this particular pathomechanism in patients with DCM, we suggest that this diagnostic tool cloud be an important addition to surgical decision making in the future. These slides can be retrieved under Electronic Supplementary Material.

Improvement of Back and Leg Pain after Lumbar Spinal Decompression without Fusion.

BACKGROUND: To evaluate whether decompression in lumbar spinal stenosis without fusion leads to sufficient improvement of back pain and leg pain and whether re-decompression alone is sufficient for recurrent lumbar spinal stenosis for patients without signs of instability. MATERIAL AND METHODS: A successive series of 102 patients with lumbar spinal stenosis (with and without previous lumbar surgery) were treated with decompression alone during a 3-year period. Data on pre- and postoperative back pain and leg pain (numerical rating scale [NRS] scale) were retrospectively collected from questionnaires with a return rate of 65% (n = 66). The complete cohort as well as patients with first-time surgery and re-decompression were analyzed separately. Patients were dichotomized to short-term follow-up (< 100 weeks) and long-term follow-up (> 100 weeks) postsurgery. RESULTS: Overall, both back pain (NRS 4.59 postoperative versus 7.89 preoperative; p < 0.0001) and leg pain (NRS 4.09 versus 6.75; p < 0.0001) improved postoperatively. The short-term follow-up subgroup (50%, n = 33) showed a significant reduction in back pain (NRS 4.0 versus 6.88; p < 0.0001) and leg pain (NRS 2.49 versus 6.91: p < 0.0001). Similar results could be observed for the long-term follow-up subgroup (50%, n = 33) with significantly less back pain (NRS 3.94 versus 7.0; p < 0.0001) and leg pain (visual analog scale 3.14 versus 5.39; p < 0.002) postoperatively. Patients with previous decompression surgery benefit significantly regarding back pain (NRS 4.82 versus 7.65; p < 0.0024), especially in the long-term follow-up subgroup (NRS 4.75 versus 7.67; p < 0.0148). There was also a clear trend in favor of leg pain in patients with previous surgery; however, it was not significant. CONCLUSIONS: Decompression of lumbar spinal stenosis without fusion led to a significant and similar reduction of back pain and leg pain in a short-term and a long-term follow-up group. Patients without previous surgery benefited significantly better, whereas patients with previous decompression benefited regarding back pain, especially for long-term follow-up with a clear trend in favor of leg pain.

Anterior Cervical Decompression and Fusion or Posterior Foraminotomy for Cervical Radiculopathy: Results of a Single-Center Series.

BACKGROUND: Anterior cervical diskectomy and fusion (ACDF) or posterior foraminotomy (PF) are standard treatment options for cervical radiculopathy due to disk prolapse. Which method produces superior results has not yet been established. One reason for the dilemma, among others, is a lack of detailed outcome analysis in previous studies. We quantified outcome to compare both methods in our retrospective single-center series. METHOD: We conducted a retrospective analysis of 107 patients with cervical radiculopathy who were operated on via ACDF or via PF. Demographic data, symptoms, neurologic status, and pathology were recorded and correlated to outcome parameters such as Odom's criteria, visual analog scale values of radicular pain, Neck Disability Index values, and subjective satisfaction, which were also compared between both treatment groups. Intraoperative data, early and late complications, and reoperations were recorded and compared between both surgical groups. RESULTS: None of the recorded preoperative data were predictive for postoperative outcome parameters. Patients in the PF group reported better overall outcome (Odom's criteria) and greater relief of radicular and neck pain. Operative time and blood loss were less in the PF group. Both groups showed comparable early complication rates, but PF patients tended to have more late reoperations. CONCLUSION: Due to a better overall outcome as well as greater relief of radicular and neck pain in our cohort, we consider PF the first-line treatment if morphology of the pathology is suitable.

Development of a short scale for assessing economic environmental aspects in patients with spinal diseases using Rasch analysis.

BACKGROUND: Economic environmental factors represent important barriers to participation and have deleterious effects on quality of life (QOL) in persons with spinal diseases (SpD). While economic factors are anchored in the International Classification of Functioning, Disability and Health, their influence on QOL and participation from patients' perspectives is an infrequent focus of research. The aim of the present research is to calibrate a culturally adapted Rasch-based questionnaire assessing economic QOL in patients with SpD. METHODS: The 11-items of the German economic-QOL-scale were answered by 325 patients with SpD on a four-point Likert-scale. Fit to the Rasch measurement model was investigated by testing for stochastic ordering of the items, unidimensionality, local independence, and differential item functioning (DIF). RESULTS: After adjusting for local dependency, fit to the Rasch model was achieved with a non-significant item-trait interaction (chi-squaredf = 20 = 34.8, p = 0.021). The person separation reliability equaled 0.88, the scale was free from age- or gender-related DIF, and unidimensionality could be verified. CONCLUSIONS: The Rasch-based German version of the economic-QOL-scale represents a suitable instrument to investigate the influences of economic factors on patients' QOL at a group and individual level. It can be easily applied in research and practice and may be administered quickly in combination with other instruments. The short test duration implies a low test burden for patients and a minimum of time expenditure by clinicians when evaluating the results.