Surgical Management of Thoracolumbar Adjacent Segment Disease: Techniques and Outcomes in 107 Patients Undergoing Surgical Intervention.

BACKGROUND: Adjacent segment disease (ASD) is a known sequela of thoracolumbar instrumented fusions. Various surgical options are available to address ASD in patients with intractable symptoms who have failed conservative measures. However, the optimal treatment strategy for symptomatic ASD has not been established. We examined several clinical outcomes utilizing different surgical interventions for symptomatic ASD. METHODS: A retrospective review was performed for a consecutive series of patients undergoing revision surgery for thoracolumbar ASD between October 2011 and February 2022. Patients were treated with endoscopic decompression (N = 17), microdiscectomy (N = 9), lateral lumbar interbody fusion (LLIF; N = 26), or open laminectomy and fusion (LF; N = 55). The primary outcomes compared between groups were re-operation rates and numeric pain scores for leg and back at 2 weeks, 10 weeks, 6 months, and 12 months postoperation. Secondary outcomes included time to re-operation, estimated blood loss, and length of stay. RESULTS: Of the 257 patients who underwent revision surgery for symptomatic ASD, 107 patients met inclusion criteria with a minimum of 1-year follow-up. The mean age of all patients was 67.90 ± 10.51 years. There was no statistically significant difference between groups in age, gender, preoperative American Society of Anesthesiologists scoring, number of previously fused levels, or preoperative numeric leg and back pain scores. The re-operation rates were significantly lower in LF (12.7%) and LLIF cohorts (19.2%) compared with microdiscectomy (33%) and endoscopic decompression (52.9%; P = 0.005). Only LF and LLIF cohorts experienced significantly decreased pain scores at all 4 follow-up visits (2 weeks, 10 weeks, 6 months, and 12 months; P < 0.001 and P < 0.05, respectively) relative to preoperative scores. CONCLUSION: Symptomatic ASD often requires treatment with revision surgery. Fusion surgeries (either stand-alone lateral interbody or posterolateral with instrumentation) were most effective and durable with respect to alleviating pain and avoiding additional revisions within the first 12 months following revision surgery. CLINICAL RELEVANCE: This study emphasizes the importance of risk-stratifying patients to identify the least invasive approach that treats their symptoms and reduces the risk of future surgeries.

Resection of a lumbar intradural tumor.

Background: Myxopapillary ependymomas and schwannomas represent the most common tumors of the conus medullaris and cauda equina. Here, we present the surgical resection of a 64-year-old male with a lumbar intradural tumor. Case Description: A 64-year-old male presented with several months of the lower extremity weakness, pain, and bowel/bladder dysfunction. Magnetic resonance imaging demonstrated a large L3-5 intradural lesion, and surgical resection using intraoperative neuromonitoring with somatosensory evoked potentials (SSEPs), motor evoked potentials (MEPs), free-running electromygraphy (EMGs), and direct sphincter monitoring was recommended. After an L2-S1 laminectomy was performed, intraoperative ultrasound was used to confirm the cranial and caudal extent of the tumor. The dural was opened using a midline approach, and the tumor was quickly visualized. Through careful dissection, the tumor was debulked and gross total resection was ultimately achieved through a piecemeal resection. Hemostasis was frequently required throughout the case, as the tumor was highly vascular. Postoperatively, the patient was at his neurologic baseline and was discharged to rehab on postoperative day 4. The final pathology revealed the intradural lesion was a paraganglioma. Conclusion: Early intervention and gross total resection of spinal intradural tumors are associated with optimal patient outcomes. Additional adjuncts, such as ultrasound, are beneficial and can help achieve gross total tumor resection.

Surgical resection of an intradural extramedullary spinal tumor.

Large ventrally located spinal meningiomas are typically resected via a posterolateral or lateral approach. Optimal outcomes are associated with good preoperative functional status (i.e., modified McCormick grade < 4), while recurrence rates may be predicted by degree and quality of resection (i.e., low Simpson grade). This video describes the operative techniques for resection of a large ventral C2 intradural extramedullary meningioma in a 71-year-old male presenting with hemibody sensory loss and abnormal gait. A paramedian approach was performed, allowing for adequate exposure and gross-total resection. The patient was discharged on postoperative day 2 and showed near-complete resolution of sensory deficits.

The Use of Carbon Fiber-Reinforced Instrumentation in Patients with Spinal Oncologic Tumors: A Systematic Review of Literature and Future Directions.

INTRODUCTION: Metastatic spine tumors affect over 30% of patients who have been diagnosed with cancer. While techniques in surgical intervention have undoubtedly evolved, there are some pitfalls when spinal instrumentation is required for stabilization following tumor resection. However, the use of carbon fiber-reinforced polyetheretherketone (CFR-PEEK) implants has become increasingly popular due to improved radiolucency and positive osteobiologic properties. Here, we present a systematic review describing the use of CFR-PEEK-coated instrumentation in the oncologic population while identifying advantages and potential shortcomings of these devices. METHODS: In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic review was conducted in March 2022 to identify articles detailing the use of CFR-PEEK implants for spinal instrumentation in patients with primary and secondary spine tumors. The search was performed using the PubMed, Scopus, and Embase databases. RESULTS: An initial search returned a total of 85 articles among the three databases used. After the exclusion of duplicates and screening of abstracts, 21 full-text articles were examined for eligibility. Eleven articles were excluded due to not fitting our inclusion and exclusion criteria. Ten articles were subsequently eligible for full-text review. CONCLUSIONS: CFR-PEEK possesses a similar safety and efficacy profile to titanium implants but has distinct advantages. It limits artifact, increases early detection of local tumor recurrence, increases radiotherapy dose accuracy, and is associated with low complication rates (9.96%)-making it a promising alternative for the demands unique to the treatment/outcome of spinal oncologic patients.

Size matters - From the working channel to the wavelength of light: Optimizing visualization in endoscopic spine surgery.

BACKGROUND: Minimally invasive surgery bases many of its benefits on decreasing tissue disruption. Endoscopic spine surgery has continued to push the boundaries to accomplish successful clinical outcomes through the evolution of the endoscope and working channel. As the indications for endoscopic spine surgery increase, a more profound discussion of cannula size selection for endoscopic spine surgery is required. The intimate relationship between the working channel, the endoscope and how these choices affect workflow and visualization are paramount to maximize outcomes. METHODS: The authors review the nuances of the endoscopic approaches to the various regions of the spine as it relates to the selection of the working channel. The advantages and limitations of various endoscopic working channels were analyzed as to how they address anatomic regional considerations as well as ultimate goals of surgery. RESULTS: In addition to anatomic regional differences and the goals of the surgery other key elements in endoscopic working channel selection included the amount of tissue disruption, regional risk to the neural elements, impact on visualization, optical physics, and the implications for surgical maneuverability/dexterity. CONCLUSION: Understanding the role and use of the endoscope-working channel combination with its effects on visualization is essential for any surgeon aspiring to perform safe and efficient full endoscopic spine surgery.

Treatment strategies for patients with concurrent blunt cerebrovascular and traumatic brain injury.

Patients who present with traumatic brain injury (TBI) combined with blunt cerebrovascular injuries (BCVI) are difficult to manage, in part because treatment for each entity may exacerbate the other. It is necessary to develop a treatment paradigm that ensures maximum benefit while mitigating the opposing risks. A cohort of 150 patients from 2015 to present, with either internal carotid artery (ICA) and/or vertebral artery (VA) dissections or pseudoaneurysms, was cross-referenced with those who had sustained TBI. Of the 38 patients identified with both TBI and BCVI, 25 suffered ICA injuries, 10 had VA injuries and 3 had combined ICA/VA injuries. Unilateral BCVI occurred in 30 patients, while 8 had bilateral BCVI. Two patients required surgical intervention for TBI, and 5 patients required endovascular intervention for BCVI. Positive emboli detection studies (EDS) on transcranial dopplers (TCD) were demonstrated in 19 patients, with 9 patients having radiographic evidence of stroke. Anti-platelet therapy was initiated in 32 patients, and anti-coagulation in 10 patients, without new or worsening intracranial hemorrhages (ICH). Overall, 76% of patients were able to be discharged home or to rehabilitation, with good recovery demonstrated in 73% of the patients who had appropriate follow-up. In the setting of concurrent TBI and BCVI, use of anti-platelet/coagulation to prevent stroke can be safe if monitored closely. Here we describe a treatment paradigm which weighs the risk and benefits of therapies based on severity of ICH and stroke prevention, which tended to result in good disposition and recovery.

The Effects of Lockdown During the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Pandemic on Neurotrauma-Related Hospital Admissions.

BACKGROUND: The response to the global severe acute respiratory syndrome coronavirus 2 pandemic culminated in mandatory isolation throughout the world, with nationwide confinement orders issued to decrease viral spread. These drastic measures were successful in "flattening the curve" and maintaining the previous rate of coronavirus disease 2019 infections and deaths. To date, the effects of the coronavirus disease 2019 pandemic on neurotrauma has not been reported. METHODS: We retrospectively analyzed hospital admissions from Ryder Trauma Center at Jackson Memorial Hospital, during the months of March and April from 2016 to 2020. Specifically, we identified all patients who had cranial neurotrauma consisting of traumatic brain injury and/or skull fractures, as well as spinal neurotrauma consisting of vertebral fractures and/or spinal cord injury. We then performed chart review to determine mechanism of injury and if emergent surgical intervention was required. RESULTS: Compared with previous years, we saw a significant decline in the number of neurotraumas during the pandemic, with a 62% decline after the lockdown began. The number of emergent neurotrauma surgical cases also significantly decreased by 84% in the month of April. Interestingly, although the number of vehicular traumas decreased by 77%, there was a significant 100% increase in the number of gunshot wounds. CONCLUSIONS: Population seclusion had a direct effect on the frequency of neurotrauma, whereas the change in relative proportion of certain mechanisms may be associated with the psychosocial effects of social distancing and quarantine.