Posterior Transdural Approach for Thoracic Corpectomies in the Setting of Complex Spine Deformity Reconstruction.

BACKGROUND AND OBJECTIVE: There are many surgical approaches for execution of a thoracic corpectomy. In cases of challenging deformity, traditional posterior approaches might not be sufficient to complete the resection of the vertebral body. In this technical note, we describe indications and technique for a transdural multilevel high thoracic corpectomy. METHODS: A 25-year-old man with a history of neurofibromatosis type 1 presented with instrumentation failure after a previous T1-T12 posterior spinal fusion, extensive laminectomy, and tumor resection. The patient presented with progressive back pain, had broad dural ectasia, and a progressive kyphotic rotational and anteriorly translated spinal deformity. To resect the medial-most aspect of the vertebral body, a bilateral extracavitary approach was attempted, but was found insufficient. A transdural approach was subsequently performed. A left paramedian durotomy was made, followed by generous arachnoid dissection, bilateral dentate ligament division, and T4 rootlet sacrifice to mobilize the spinal cord. A ventral durotomy was then made and the ventral dura was reflected over the spinal cord to protect it while drilling. The corpectomy was then completed. The ventral and dorsal durotomies were closed primarily and reinforced with fibrin glue and fibrin sealant patch. The corpectomy defect was filled with nonstructural autograft. RESULTS: The focal kyphosis was corrected with a combination of rod contouring, compression, and in situ bending. During the surgery, the patient had stable neuromonitoring data, and postoperatively had no neurological deficits. On follow-up until 1 year, the patient presented with no signs of cerebrospinal spinal leaks, no motor or sensory deficits, minimal incisional pain, and significantly improved posture. CONCLUSION: Complex high thoracic (T3-5) ventral pathology inaccessible via a bilateral extracavitary approach may be accessed via a transdural approach as opposed to an anterior/lateral transthoracic approach that requires mobilization of cardiovascular structures or scapula.

Transdural Ventral Sling Technique for Calcified Thoracic Disk Herniations.

BACKGROUND: Surgery for thoracic disc herniations remains an ongoing challenge, with numerous surgical approaches, all with their own inherent risks. Discectomy via a posterior laminectomy was historically the treatment of choice; however, it was deemed very high risk with elevated rates of neurologic injury. The posterior transdural approach is an alternative surgical option for soft and calcified thoracic disc herniations. METHODS: A 56-year-old female with many years of numbness/tingling in her hands and difficulty with fine motor tasks presented with progressive weakness and loss of balance in her legs. Imaging revealed a prominent focal central calcified disc herniation at the T5-T6 level causing severe effacement and distortion of the spinal cord. A posterior transdural approach for direct visualization of a large calcified disc herniation was performed, removing the calcified disc without the need for extensive exposure or entry into the thoracic cavity. A ventral sling of the dura was created to allow rotation of the spinal cord while removing the disc. RESULTS: Intraoperative ultrasound confirmed complete disc resection, restoring cerebral spinal fluid flow circumferentially without residual impingement or cerebrospinal fluid leaks. At six months postsurgery, the patient's gait imbalance had resolved, and she had full lower extremity strength (5/5). Radiographic evaluation indicated stable implants without subsidence, pullout, fracture, or alignment loss. CONCLUSIONS: The transdural approach is less invasive in nature, minimizes surgical exposure, patient morbidity, and provides better intraoperative control of the spinal cord. This constitutes an effective alternative surgical approach to both soft and calcified central thoracic disc herniations.

Functional Somatic Syndromes Are Associated With Varied Postoperative Outcomes and Increased Opioid Use After Spine Surgery: A Systematic Review.

STUDY DESIGN: Systematic Review. OBJECTIVE: To perform a systematic review assessing the relationship between functional somatic syndromes (FSSs) and clinical outcomes after spine surgery. METHODS: A systematic review of online databases (PubMed and Web of Science) through December 2021 was conducted via PRISMA guidelines to identify all studies investigating the impact of at least one FSS (fibromyalgia, irritable bowel syndrome (IBS), chronic headaches/migraines, interstitial cystitis, chronic fatigue syndrome, multiple chemical sensitivity) on outcomes after spine surgery. Outcomes of interest included patient reported outcome measures (PROMs), postoperative opioid use, cost of care, complications, and readmission rates. RESULTS: A total of 207 records were identified. Seven studies (n = 40,011 patients) met inclusion criteria with a mean MINORS score of 16.6 out of 24. Four studies (n = 21,086) reported postoperative opioid use; fibromyalgia was a strong risk factor for long-term opioid use after surgery whereas the association with chronic migraines remains unclear. Two studies (n = 233) reported postoperative patient reported outcome measures (PROMs) with mixed results suggesting a possible association between fibromyalgia and less favorable PROMs. One study (n = 18,692) reported higher postoperative complications in patients with fibromyalgia. CONCLUSION: Patients with fibromyalgia and possibly migraines are at higher risk for prolonged postoperative opioid use and less favorable PROMs after spine surgery. There is limited research on the relationship between other Functional somatic syndromes (FSSs) and outcomes following spine surgery. Growing evidence suggests the variation in outcomes after spine procedures may be attributed to non-identifiable organic patient factors such as FSSs.

Is Patellar Instability a Contraindication to Semiextended Tibial Nailing?: A Case Report.

CASE: We report a 40-year-old woman with undiagnosed patellofemoral instability that worsened 8 months after intramedullary nailing of a distal left tibia fracture in the semiextended position through a partial medial parapatellar approach. Patella stability and asymptomatic knee function were restored after IM nail removal, medial patellofemoral ligament repair, and left tibial tubercle transposition. CONCLUSION: The optimal surgical approach for tibial IM nailing in patients with chronic patellar instability has not been described. Clinicians should be cognizant of the potential for worsening patellofemoral instability in these patients when using the medial parapatellar approach in the semiextended position.

Not All Proximal Humerus Fractures Do Well Without Surgery: Anterior Translation Predicts the Need for Surgery.

OBJECTIVES: To evaluate the effect of translation on a large series of low-energy proximal humerus fractures initially treated nonoperatively. DESIGN: Retrospective multicenter analysis. SETTING: Five level-one trauma centers. PATIENTS/PARTICIPANTS: Two hundred ten patients (152 F; 58 M), average age 64, with 112 left- and 98 right-sided low-energy proximal humerus fractures (OTA/AO 11-A-C). INTERVENTION: All patients were initially treated nonoperatively and were followed for an average of 231 days. Radiographic translation in the sagittal and coronal planes was measured. Patients with anterior translation were compared with those with posterior or no translation. Patients with ≥80% anterior humeral translation were compared with those with <80% anterior translation, including those with no or posterior translation. MAIN OUTCOMES: The primary outcome was failure of nonoperative treatment resulting in surgery and the secondary outcome was symptomatic malunion. RESULTS: Nine patients (4%) had surgery, 8 for nonunion and 1 for malunion. All 9 patients (100%) had anterior translation. Anterior translation compared with posterior or no sagittal plane translation was associated with failure of nonoperative management requiring surgery ( P = 0.012). In addition, of those with anterior translation, having ≥80% anterior translation compared with <80% was also associated with surgery ( P = 0.001). Finally, 26 patients were diagnosed with symptomatic malunion, of whom translation was anterior in 24 and posterior in 2 ( P = 0.0001). CONCLUSIONS: In a multicenter series of proximal humerus fractures, anterior translation of >80% was associated with failure of nonoperative care resulting in nonunion, symptomatic malunion, and potential surgery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Significance of Lateral Pedicle Screw Malposition in Lumbar Spine Fusion.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Our objective was to determine whether lateral pedicle screw breach affects fusion rates and patient-reported outcomes in lumbar fusion surgery. SUMMARY OF BACKGROUND DATA: Although lateral pedicle screw malposition is considered relatively benign, few studies have focused specifically on clinical outcomes or fusion rates associated with lateral screw malposition. METHODS: Twelve-month postoperative computed tomography scans were reviewed for lateral breach, severity of breach, and fusion status. Patients with lateral breach were compared with patients with no breach. Outcome measures included Numerical Pain Rating Scale for back and leg pain, Oswestry Disability Index, and SF-36 physical function (SF-36 PF). Multivariable linear and logistic regression and were adjusted for age, procedure, level, and/or baseline pain score. RESULTS: Forty-five patients (31%) demonstrated 1 or more lateral breaches as compared with 99 patients without breach. After adjusting for baseline scores and fusion level, patients with 2 or more screw breaches experienced SF-36 PF score improvements that were 3.43 points less ( P =0.016) than patients with no lateral breach. After adjusting for baseline Numerical Pain Rating Scale, there was also a significant decrease in the odds of achieving minimally clinical important difference in back pain relief in these patients. There was no observed effect of lateral breach on the odds of successful fusion. CONCLUSIONS: The current study did not observe an association between laterally malpositioned pedicle screws and nonunion. However, results are consistent with a negative effect on SF-36 PF scores and self-reported back pain at 12 months.

Comparison of Opioid Consumption Patterns of Three Interbody Fusion Surgical Techniques.

STUDY DESIGN: Retrospective review. OBJECTIVES: With increased awareness of the opioid crisis in spine surgery, the focus postoperatively has shifted to managing surgical site pain while minimizing opioid use. Numerous studies have compared outcomes and fusion status of different interbody fusion techniques; however, there is limited literature evaluating opioid consumption postoperatively between techniques. The aim of this study was to assess in-house and postoperative opioid consumption across 3 surgical techniques. METHODS: Patients were stratified by technique: posterior lumbar interbody fusion (PLIF), minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF), and cortical screw (CS) instrumentation with interbody fusion. Age, ASA, BMI, depression, preoperative opioid use, EBL, and OR time were recorded and compared across surgical groups using Welch's ANOVA and chi-square analysis. Total morphine equivalent dose (MED) was tabulated for both in-house consumption and postoperative prescriptions and was compared across surgical techniques using Welch's ANOVA analysis, Mann Whitney U tests, and linear regression. RESULTS: Two hundred and thirty nine patients underwent one- or two-level posterior lumbar interbody fusion between 2016 and 2020. One hundred and twenty one patients underwent CS instrumentation, 95 underwent PLIF, and 83 underwent MIS-TLIF. There was a significantly higher percentage of patients who had a history of depression and preoperative opioid consumption in the CS group (P = .001, P = .009). CS instrumentation required significantly less total post-op opioids per kilogram bodyweight compared to MIS-TLIF and PLIF surgeries (P = .029). CONCLUSIONS: Patients who underwent CS instrumentation required less opioids postoperatively. CS instrumentation may be associated with less postoperative pain due to the less invasive approach, however, patient education and prescriber practice also play a role in postoperative opioid consumption.

Orthopaedic Trainee Views on Robotic Technologies in Orthopaedics: A Survey-Based Study.

The use of robotics is a growing area within the field of surgery, especially in orthopaedics. To date, there is no literature examining orthopaedic trainee perception of or comfort with robotics in orthopaedics. An assessment of the next generation's attitudes regarding this technology is necessary. An anonymous, national, web-based questionnaire containing 16 multiple-choice questions and 25 5-point Likert's scale questions was sent to 66 Accreditation Council for Graduate Medical Education (ACGME)-approved orthopaedic residency training programs. The survey was designed to discern the attitude of orthopaedic trainees toward robotics. Demographics, extent of exposure and training, and trainee perception regarding robotics were collected. A bivariate analysis using Pearson's Chi-square test or Fisher's was used to determine factors associated with trainee's future plans to use robotics. A total of 280 trainees completed the survey (response rate of 18%). Also, 67.9% have been exposed to and 42.9% trained to use robotics in surgical training. Of those trained, 44.4% were given increasing autonomy to use the technology. Further, 67.1% of trainees do not feel comfortable using robotic technology; however, 71.4% believe robotics has the potential to facilitate their education. Over 90% believe that robotic technology is here to stay. While residents have legitimate concerns about robotic implementation in orthopaedics, the majority of residents and fellows believe robotics will be a part of the future. However, few feel they receive adequate training or experience with the technology.

Gross Trunnion Failure of a Type 1 Taper After Metal-on-Polyethylene Total Hip Arthroplasty: A Report of 2 Cases.

CASE: We describe 2 cases of gross trunnion failure (GTF) in males with Centers for Disease Control and Prevention Class 3 obesity 10 years after metal-on-polyethylene total hip arthroplasty (THA) with a titanium-alloy femoral stem and Type 1 taper. One patient received a large diameter cobalt-chromium femoral head, whereas the other received a smaller diameter head, both with high-offset femoral stems. CONCLUSION: This is the first report of GTF involving the Echo Bi-Metric femoral stem after metal-on-polyethylene THA, and surgeons should consider the potential complication of GTF when using this specific femoral stem with metal heads in obese male patients.

Impact of body mass index on opioid consumption in lumbar spine fusion surgery.

BACKGROUND: in the United States from 1999 to 2000 through 2017-2018, the prevalence of obesity increased from 30.5 to 42.4%, while the prevalence of severe obesity nearly doubled. In lumbar spine surgery, obesity is associated with increased complications, worse perioperative outcomes, and higher costs. The purpose of this study was to examine the association between body mass index (BMI) and opioid consumption in patients undergoing lumbar spine fusion surgery. We hypothesized that obese patients would require more opioids postoperatively. METHODS: retrospective review of 306 patients who underwent one- or two-level posterior lumbar interbody fusion surgery between 2016 and 2020. Patients were stratified by BMI as follows: normal weight (18.5-24.9 kg/m2), overweight (25.0-29.9 kg/m2), obese I (30.0-34.9 kg/m2), and obese II-III (≥ 35.0 kg/m2). Patient demographics and preoperative characteristics were compared across BMI cohorts using one-way ANOVA and chi-square analysis. Patients with prior history of opioid use were excluded. Primary outcome measure was postoperative opioid consumption. Secondary outcomes included operative time, length of stay (LOS), discharge destination, and 30-day re-encounter rates. Outcomes were analyzed using multivariable linear regression adjusted for potential confounders. RESULTS: of 306 total patients, 17.3% were normal weight, 39.9% were overweight, 25.5% were obese I, and 17.3% were obese II-III. Obesity was associated with longer operative times and length of stay (p < 0.001, p = 0.024). For opioid naïve patients, there was no difference in-house opioid consumption when adjusted for kilograms of body mass and LOS (p = 0.083). Classes II-III patients were prescribed more than twice the number of postoperative opioids (p < 0.001) and were on opioids for a longer time postoperatively (p = 0.019). CONCLUSION: obesity is associated with longer operative times, longer LOS, and increased consumption of postoperative opioids. This should be considered when counseling patients preoperatively prior to lumbar spine fusion procedures.

Early Outcome Comparison of the Posterior Approach and the Superior Approach for Primary Total Hip Arthroplasty.

BACKGROUND: The superior approach for total hip arthroplasty (THA) is a minimally invasive, tissue-sparing technique that may have clinical and economic benefits. The purpose of this study was to compare early outcomes between the posterior approach and the superior approach in primary THA. Our hypothesis was that the superior approach would have a noninferior length of stay (LOS), discharge destination, and blood loss compared with the posterior approach. METHODS: All primary THAs performed by a single surgeon at one institution were retrospectively reviewed over a 2-year period (2015-2017). There were 676 patients, 40.4% of whom underwent a posterior approach and 59.6% underwent a superior approach. LOS, discharge destination, blood loss, and operating room time were analyzed. Gender, body mass index, and American Society of Anesthesiologists status were recorded and controlled. RESULTS: The posterior approach was independently associated with an almost threefold higher risk of prolonged LOS (>2 days, P < .001) (odds ratio: 2.90, 95% confidence interval: 1.87-4.49; P < .001). The mean LOS for the superior approach was 1.71 days vs 2.17 days for the posterior group (P < .001). Fewer patients in the superior approach cohort were discharged to a rehabilitation facility (8.9% vs 17.9%, P < .001). The mean operative time was shorter in the superior group (91.8 vs 95.8, P = .001). There was no statistically significant difference in acute postoperative blood loss. There were no dislocations or reoperations in either group. CONCLUSIONS: The superior approach to THA was associated with a significantly shorter length of hospital stay and lower rate of discharge to rehab than the posterior approach. This approach can be used as a safe, minimally invasive, and tissue-sparing variation of a standard posterior approach for THA and has promising early outcomes.